insulin-glargine and Diabetic-Ketoacidosis

Diabetes mellitus is a common endocrine disorder in feline practice, affecting approximately 1 in 200 cats. The majority of diabetic cats have type 2 diabetes mellitus, which results from a combination of peripheral insulin resistance and a progressive reduction in insulin production.. While usually easy to diagnose, management of diabetes mellitus presents a number of challenges for practitioners and clients alike. Practitioners must decide on diet, insulin type and dose, monitoring method and intensity, and concomitant therapy, which will vary based on individual patient and client needs, and geographic location. Practitioners may also encounter patients with diabetic ketoacidosis or other diabetic complications, and patients with multiple concurrent diseases. Clients may be challenged by the substantial time and financial commitment involved in owning a diabetic cat.. Understanding the pathophysiology, optimal treatment protocols and current goals of diabetes management will benefit practitioners managing diabetic cats. This article reviews the most current management plans for feline diabetics. It places particular emphasis on best practice for achieving diabetic remission, which is an attainable goal in the majority of newly diagnosed diabetic cats.. The information in this article is drawn from the recent human and veterinary literature, including prospective and retrospective studies. The body of prospective clinical data on the use of newer, long-acting insulins (glargine and especially detemir) in cats is limited, but growing.

Topics: Animals; Cat Diseases; Cats; Diabetes Mellitus, Type 2; Diabetic Ketoacidosis; Drug Administration Schedule; Hypoglycemic Agents; Insulin Detemir; Insulin Glargine; Insulin, Long-Acting

This article reviews our current understanding of the etiology, presentation, and management of type 1 diabetes. The discussion includes a review of the natural history of diabetes, the complex relationship between genetic and environmental risk for type 1 diabetes, and current methods for prediction of type 1 diabetes. The article also reviews the current management of children who have new-onset type 1 diabetes, age-appropriate management goals, and diabetes complications. Finally, the article discusses the future of diabetes screening programs and the progress toward the ultimate goal of curing type 1 diabetes.

Topics: Autoantibodies; Blood Glucose; Child; Diabetes Complications; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Genetic Predisposition to Disease; Humans; Hypoglycemia; Insulin; Insulin Glargine; Insulin, Long-Acting; Nutrition Therapy

To determine the effectiveness and safety of early combination of insulin glargine with intravenous (IV) insulin infusion compared with IV insulin infusion alone in the management of diabetic ketoacidosis (DKA).. This was a single-centre, open-label, randomized controlled trial of adults aged 18 years or older diagnosed with DKA. The 'early glargine' group was given subcutaneous insulin glargine 0.3 units/kg within the first 3 hours of DKA diagnosis, in addition to the standard IV insulin infusion. The control group received standard IV insulin treatment only. The primary outcome was the time to DKA resolution. The other outcomes included rebound hyperglycaemia, mortality, hypoglycaemia and hypokalaemia, as well as the length of hospital stay (LOS).. A total of 60 patients (30 patients per group) were enrolled. Most patients (76.7%) had type 2 diabetes. Both groups were similar in baseline characteristics, except for higher serum beta-hydroxybutyrate and lower pH levels in the early glargine group. The mean ± standard deviation time to DKA resolution in the early glargine group was significantly faster than the control group (9.89 ± 3.81 vs. 12.73 ± 5.37 hours; P = .022). The median (interquartile range) LOS was significantly shorter in the early glargine group than in the control group (4.75 [3.53-8.96] vs. 15.25 [5.71-26.38] days; P = .024). The incidence of rebound hyperglycaemia, all-cause mortality, hypoglycaemia and hypokalaemia was similar between the groups.. Early combination of insulin glargine with IV insulin infusion led to a faster DKA resolution and a shorter LOS, without increasing hypoglycaemia and hypokalaemia.

Topics: Adult; Diabetes Mellitus, Type 2; Diabetic Ketoacidosis; Humans; Hyperglycemia; Hypoglycemia; Hypoglycemic Agents; Hypokalemia; Insulin; Insulin Glargine; Insulin, Regular, Human

In youth with type 1 diabetes (T1D), high haemoglobin A1c (HbA1c) levels are associated with an increased risk for diabetic ketoacidosis (DKA).. This study examined whether daily school-supervised basal insulin injections were feasible and if they reduced the risk of morning ketosis in children and adolescents with high HbA1c levels. We hypothesized that supervised glargine and degludec would reduce the risk of ketosis and that the prolonged action of degludec would protect from ketosis after consecutive days of unsupervised injections.. After a 2-4-week run-in, youth (10-18 years, HbA1c ≥ 8.5%) managing T1D with injections were randomized to school-supervised administration of degludec or glargine for 4 months. School nurses observed daily blood β-hydroxybutyrate (BHB) and glucose checks. During COVID closures, the research team supervised procedures remotely.. Data from 28 youth (age 14.3 ± 2.3 years, HbA1c 11.4 ± 1.9%, 64% F) were analysed. School-supervised injections of both basal insulins for 1-4 days progressively lowered the percent of participants with elevated BHB. The percent of participants with elevated BHB (≥0.6 mmol/L) after 2 days of unsupervised basal insulin doses at home was greater in the glargine than degludec group but had a high p-value (17.2% vs. 9.0%, p = 0.3). HbA1c was unchanged in both groups.. In youth with T1D at high risk for DKA, daily supervised long-acting insulin administration decreased the probability of elevated ketone levels on subsequent school days, regardless of basal insulin type. A larger sample size may have demonstrated that the longer action profile of degludec would offer additional protection from ketosis during days of not attending school.. Engaging school-based caregivers in management of youth with T1D on injected insulin may decrease clinically significant ketosis and minimize acute complications of diabetes.

Topics: Adolescent; Blood Glucose; Child; COVID-19; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Glycated Hemoglobin; Humans; Hypoglycemic Agents; Insulin; Insulin Glargine; Neoplasms; Pilot Projects

To determine whether basal-bolus administration of glargine insulin is a safe and effective alternative treatment compared to the standard continuous rate infusion (CRI) protocol.. Prospective randomized clinical trial.. University teaching hospital.. Twenty cats diagnosed with diabetic ketoacidosis (DKA).. The cats were block-randomized to either a CRI protocol using regular insulin (CRI-group; n = 10) or a basal-bolus SC and IM glargine protocol (glargine-group, n = 10). Baseline blood gases, electrolytes, glucose, and β-hydroxybutyrate (β-OHB) concentrations were measured at the time of admission and later at predefined intervals until reaching the primary endpoint of the study, defined as a β-hydroxybutyrate concentration < 2.55 mmol/L.. The main outcome measure was time (h) to resolution of ketonemia. Secondary outcome measures were time until first improvement of hyperglycemia and ketonemia, decrease of glucose to ≤13.9 mmol/L (250 mg/dL), resolution of acidosis, consumption of first meal, and discharge from hospital. Additionally, occurrence of treatment-associated adverse events and death were compared. Seventeen cats (85%) survived to discharge, with no difference in survival between groups (P = 1.0). Median times to β-OHB < 2.55 mmol/L were 42 (CRI-group) and 30 (glargine-group) hours, respectively (P = 0.114). Median times to first improvement of hyperglycemia (glargine-group: 2 h; CRI-group: 6 h; P = 0.018) and until discharge from hospital (glargine-group: 140 h; CRI-group: 174 h; P = 0.033) were significantly shorter in the glargine-group. No significant differences were observed in any other parameter under investigation (P > 0.05).. Basal-bolus administration of glargine insulin appears to be an effective and safe alternative to the current standard CRI-protocol for the management of DKA in cats. The positive outcomes and simplicity make it a viable option for the treatment of feline DKA.

Topics: Animals; Blood Glucose; Cat Diseases; Cats; Clinical Trials, Veterinary as Topic; Diabetic Ketoacidosis; Hyperglycemia; Hypoglycemic Agents; Insulin; Insulin Glargine; Prospective Studies

The objective was to determine the efficacy of coadministration of subcutaneous (SQ) insulin glargine in combination with intravenous (IV) insulin for treating diabetic ketoacidosis (DKA).. This was a prospective, randomized, controlled trial comparing coadministration of insulin glargine and IV insulin (experimental) with IV insulin (standard care control). The setting was emergency departments (EDs) in two hospitals in Houston, Texas. Patients presenting with blood sugar ≥ 200 mg/dL, pH ≤ 7.3, bicarbonate (HCO3 ) ≤ 18 mg/dL, ketonemia or ketonuria, and anion gap ≥ 16 between November 2012 and April 2013 were enrolled. All patients received IV insulin. Additionally, the experimental group was given SQ insulin glargine within 2 hours of diagnosis. Upon closure of anion gap, patients in the control group were subsequently transitioned to long-acting insulin. In the study group, IV insulin was discontinued and long-acting SQ insulin was reinstituted 24 hours after initial introduction. The primary outcome of time to closure of anion gap (TCAG) was compared between groups using a general linear model (GLM), adjusting for initial anion gap, etiology, and presence of comorbidities. Similarly, the secondary outcome hospital length of stay (LOS) was adjusted for age, etiology, and hospital site in the GLM. Rate of hypoglycemia and intensive care unit (ICU) admission was compared using Fisher's exact test while ICU LOS was compared using Wilcoxon's two-sample test.. A total of 40 patients were enrolled in this pilot trial. The estimated mean TCAG was 10.2 hours (SE ± 6.8 hours) in the experimental group and 11.6 hours (SE ± 6.4 hours) in the control group (p = 0.63). The estimated mean hospital LOS was 3.9 days (SE ± 3.4 days) in the experimental group and 4.8 days (SE ± 3.6 days) in the control group (p = 0.66). Incidents of hypoglycemia, rates of ICU admission, and ICU LOS were similar between the groups.. Coadministration of glargine in combination with an insulin infusion in the acute management of DKA is feasible. Further study is needed to determine the true efficacy in terms of TCAG and hospital LOS.

Topics: Administration, Intravenous; Adult; Blood Glucose; Diabetic Ketoacidosis; Drug Therapy, Combination; Emergency Service, Hospital; Female; Hospitalization; Humans; Injections, Subcutaneous; Insulin; Insulin Glargine; Ketosis; Length of Stay; Male; Middle Aged; Pilot Projects; Prospective Studies; Single-Blind Method; Texas

The aim of this crossover trial was to evaluate the potential of partial substitution of basal insulin with glargine, administered once daily in the morning, to protect against nocturnal ketosis after postprandial interruption of continuous subcutaneous insulin infusion (CSII).. Seven patients with type 1 diabetes received 4 weeks of treatment with insulin lispro, administered by CSII, and 4 weeks of treatment with CSII and a partial basal replacement dose of insulin glargine administered in the morning. On day 28 of each treatment phase, patients were admitted to the research unit where dinner was served and their usual dinner insulin bolus dose given, after which CSII was discontinued at 7 pm. Plasma (p) beta-hydroxybutyrate and p glucose were measured every hour for 12 h thereafter.. Plasma beta-hydroxybutyrate at 7 pm was 0.16+/-0.05 and 0.13+/-0.07 mmol/l with and without glargine, respectively, and increased to 0.17+/-0.10 and 0.60+/-0.3 mmol/l within 6 h (P=0.02). Plasma glucose increased without glargine, from 8.6+/-2.9 to 21.1+/-3.0 mmol/l (P=0.003), but did not rise significantly following glargine (13.6+/-4.7 vs. 12.6+/-5.6 mmol/l; P=0.65).. Partial replacement with a morning dose of insulin glargine protects against the development of ketosis for as much as 12 h after postprandial interruption of CSII. This treatment strategy could, therefore, be useful for patients who are prone to ketosis but, for other reasons, are deemed suitable for CSII.

Topics: Adult; Blood Glucose; C-Peptide; Circadian Rhythm; Cross-Over Studies; Diabetic Ketoacidosis; Female; Glycated Hemoglobin; Humans; Hypoglycemic Agents; Insulin; Insulin Glargine; Insulin Infusion Systems; Insulin Lispro; Insulin, Long-Acting; Male; Middle Aged

To determine whether mixing insulin glargine (IG) with a rapid-acting insulin (RAI) analogue in the same syringe had any deleterious effects on glycemic control in children with type 1 diabetes mellitus.. Data from 55 children mixing the IG with a RAI analogue was collected for 6 months before and 6 months after the insulin mixing began. Data from a control group of 55 children not mixing the insulins was collected at similar intervals. Parameters evaluated included hemoglobin A1c (HbA1c) values, number of non-severe and severe hypoglycemic events, number of diabetic ketoacidosis (DKA) events, and blood glucose distribution patterns.. After 6 months of study, HbA1c values were equivalent for the control and test groups (8.54+/-1.14 vs 8.61+/-1.14, respectively; P=1.0000). Percentages of blood glucose values in, above, and below the target range did not vary significantly in the groups. There were no significant differences in the groups in the occurrence of non-severe or severe hypoglycemic events or of DKA events.. There were no significant differences in glycemic control between children who mixed IG in the same syringe with a RAI analogue compared with children who took separate injections.

Topics: Adolescent; Child; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Drug Combinations; Female; Humans; Hypoglycemia; Injections; Insulin; Insulin Glargine; Insulin, Long-Acting; Male; Matched-Pair Analysis; Patient Compliance; Prospective Studies; Regression Analysis

The pediatric diabetes team at the University of Minnesota made a clinical decision to switch patients with type 1 diabetes with a hemoglobin A1c level greater than 8.0% to insulin glargine in an effort to improve glycemic control. Retrospective chart analysis was performed on 37 patients 6 months after the switch to insulin glargine therapy.. After 6 months, the average hemoglobin A1c level in the entire cohort dropped from 10.1 +/- 2.0 to 8.9 +/- 1.6% (p = 0.001). Thirty patients responded with an average hemoglobin A1c drop of 1.7 +/- 1.5%, from 10.3 +/- 2.2 to 8.6 +/- 1.5% (p < 0.001). Seven patients did not respond to insulin glargine therapy, with an average hemoglobin A1c rise of 1.0 +/- 0.8% from a baseline of 9.5 +/- 1.0% to 10.4 +/- 1.4% (p = 0.01). The greatest response was seen in children with an A1c > 12.0%, who dropped their hemoglobin A1c by 3.5 +/- 1.9%. Compared with responders, non-responders had significantly less contact with the diabetes team in the form of clinic visits and telephone conversations both before and after initiation of glargine therapy. Sixty-two per cent of patients received insulin glargine at lunchtime, when injections could be supervised at school. Three episodes of severe hypoglycemia occurred after initiation of insulin glargine therapy.. Insulin glargine substantially improved glycemic control in children and adolescents with poorly controlled type 1 diabetes. This response was most remarkable in those with a baseline hemoglobin A1c level > 12.0%, and may have been related to increased supervision of injections.

Topics: Adolescent; Child; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Drug Administration Schedule; Female; Glycated Hemoglobin; Humans; Hypoglycemia; Hypoglycemic Agents; Insulin; Insulin Glargine; Insulin, Long-Acting; Male

The Scottish Diabetes Research Network (SDRN)-diabetes research platform was established to combine disparate electronic health record data into research-ready linked datasets for diabetes research in Scotland. The resultant cohort, 'The SDRN-National Diabetes Dataset (SDRN-NDS)', has many uses, for example, understanding healthcare burden and socioeconomic trends in disease incidence and prevalence, observational pharmacoepidemiology studies and building prediction tools to support clinical decision making.. We estimate that >99% of those diagnosed with diabetes nationwide are captured into the research platform. Between 2006 and mid-2020, the cohort comprised 472 648 people alive with diabetes at any point in whom there were 4 million person-years of follow-up. Of the cohort, 88.1% had type 2 diabetes, 8.8% type 1 diabetes and 3.1% had other types (eg, secondary diabetes). Data are captured from all key clinical encounters for diabetes-related care, including diabetes clinic, primary care and podiatry and comprise clinical history and measurements with linkage to blood results, microbiology, prescribed and dispensed drug and devices, retinopathy screening, outpatient, day case and inpatient episodes, birth outcomes, cancer registry, renal registry and causes of death.. There have been >50 publications using the SDRN-NDS. Examples of recent key findings include analysis of the incidence and relative risks for COVID-19 infection, drug safety of insulin glargine and SGLT2 inhibitors, life expectancy estimates, evaluation of the impact of flash monitors on glycaemic control and diabetic ketoacidosis and time trend analysis showing that diabetic ketoacidosis (DKA) remains a major cause of death under age 50 years. The findings have been used to guide national diabetes strategy and influence national and international guidelines.. The comprehensive SDRN-NDS will continue to be used in future studies of diabetes epidemiology in the Scottish population. It will continue to be updated at least annually, with new data sources linked as they become available.

Topics: COVID-19; Diabetes Mellitus, Type 2; Diabetic Ketoacidosis; Humans; Insulin Glargine; Middle Aged; Scotland; Sodium-Glucose Transporter 2 Inhibitors

Topics: Adamantane; Benzhydryl Compounds; Blood Glucose; Diabetic Ketoacidosis; Dipeptides; Dipeptidyl-Peptidase IV Inhibitors; Female; Glucosides; Humans; Hypoglycemic Agents; Insulin Glargine; Male; Middle Aged; Sodium-Glucose Transporter 2 Inhibitors; Treatment Outcome

Few studies have evaluated the early use of insulin glargine in the management of diabetic ketoacidosis (DKA) patients. Early insulin glargine use in DKA was safe and associated with a trend towards faster DKA resolution.. To evaluate the efficacy and safety of early insulin glargine administration for acute management of DKA in critically ill patients.. This single-center retrospective cohort study included patients, who were >18 years of age with DKA, admitted to the intensive care unit (ICU) for at least 12 h, and received intravenous insulin infusion for at least 6 h. The primary endpoint was the association between the time to insulin glargine administration and time to DKA resolution. Linear and logistic regression analyses were performed.. Of the 913 patients evaluated, 380 were included in the study. The overall mean age was 45±17 years, 196 (51.6%) were female, and 262 (70%) patients had type 1 diabetes mellitus. The mean blood glucose level was 584.9±210 mg/dL, pH was 7.16±0.17, anion gap was 28.17±6.9 mEq/L, and serum bicarbonate level was 11.19±5.72 mEq/L. Every 6-h delay in insulin glargine administration was associated with a 26-min increase in time to DKA resolution (95% confidence interval [CI], 14.76-37.44; p<0.0001), 3.2-h increase in insulin infusion duration (95% CI, 28.8-36; p<0.0001), and 6.5-h increase in ICU LOS (95% CI, 5.04-7.92; p<0.0001).. Early administration of insulin glargine is potentially safe and may be associated with a reduction in time to DKA resolution and a shorter duration of insulin infusion.

Topics: Adult; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Female; Humans; Insulin; Insulin Glargine; Middle Aged; Retrospective Studies

Insulin degludec (IDeg) is the longest-acting basal insulin available. Whether IDeg compared to shorter-acting basal insulins like insulin glargine U100 (IGlarU100) reduces the rate of diabetic ketoacidosis (DKA) in adolescents with type 1 diabetes is unknown.. We hypothesized that adolescents with type 1 diabetes would have lower DKA rates and mean hemoglobin A1c (HbA1c) when using IDeg as compared to IGlarU100.. To avoid selection bias, we used self-control case series methodology. Adolescents with type 1 diabetes treated for DKA from January 2015 through December 2018 who switched basal insulin from IGlarU100 to IDeg were eligible for analysis. Thirty-five patients were included, each acting as their own control. Mean HbA1c and DKA rate for the 12 months prior to and after switching to IDeg were compared.. Mean HbA1c prior to and after switching to IDeg was unchanged (97 ± 20 vs. 97 ± 21 mmol/mol [11.0 ± 1.8 vs. 11.0 ± 1.9%]). Median DKA rate (admissions/year) while on IGlar-U100 was 1 with an interquartile range (IQR) of 1-2. After switching to IDeg, median DKA admission rate remained 1, however the IQR decreased to 0-1 (one-sided p value 0.0004). Median change in DKA rate was 1 fewer admission per year, with a maximum reduction of 3 admissions. Higher baseline rates of DKA increased the odds of a patient reducing his/her DKA rate by 1 admission per year or more.. Using IDeg for basal insulin in adolescent patients may decrease the rate of DKA relative to IGlarU100 despite no improvement in HbA1c and may be cost-effective.

Topics: Adolescent; Child; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Female; Glycated Hemoglobin; Humans; Hypoglycemic Agents; Insulin Glargine; Insulin, Long-Acting; Male; Retrospective Studies

We herein present a case of a 20-year-old woman who suffered from type I diabetes mellitus and died from a diabetic ketoacidosis in a context of addiction to hyperglycemia. Diabetic ketoacidosis is a lethal complication of insulin-dependent diabetes mellitus, which can result from insulin therapy stoppage. This can occur voluntarily with suicidal intent or involuntarily due to treatment inaccessibility, forgotten injections, or material deficiency. A new possibility is investigated in our case study: hyperglycemia addiction. The patient was treated by insulin glargine and insulin aspartate. She regularly stopped insulin glargine injections seeking the asthenia sensation produced by hyperglycemia, keeping the insulin aspartate injections to treat the disabling symptom related to hyperketonemia.

Topics: Asthenia; Behavior, Addictive; Depression; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Female; Humans; Hyperglycemia; Hypoglycemic Agents; Insulin Aspart; Insulin Glargine; Medication Adherence; Young Adult

Sodium-glucose cotransporter 2 (SGLT2) inhibitors are new antidiabetic drugs that regulate blood glucose levels by increasing urinary glucose excretion. In May 2015, the U.S. Food and Drug Administration (FDA) issued a warning that SGLT2 inhibitors may lead to ketoacidosis. In this report, we describe a case of life-threatening euglycemic ketoacidosis associated with SGLT2 inhibition and evaluate possible mechanisms and triggers.

Topics: Benzhydryl Compounds; Blood Glucose; Combined Modality Therapy; Diabetes Mellitus, Type 2; Diabetic Ketoacidosis; Drug Therapy, Combination; Glucosides; Humans; Hypoglycemic Agents; Insulin Glargine; Male; Metformin; Middle Aged; Risk Factors; Sodium-Glucose Transporter 2; Sodium-Glucose Transporter 2 Inhibitors

Diabetes ketoacidosis (DKA) is a common presentation and complication of type 1 diabetes (T1D). While intravenous insulin is typically used to treat acute metabolic abnormalities, the transition from intravenous to subcutaneous treatment can present a challenge. We hypothesize that co-administration of glargine, a subcutaneous long-acting insulin analog, during insulin infusion may facilitate a flexible and safe transition from intravenous to subcutaneous therapy.. To determine if the practice of administering subcutaneous glargine during intravenous insulin is associated with an increased risk of hypoglycemia, hypokalemia, or other complications in children with DKA.. Retrospective chart review of patients aged 2 to 21 years, presenting to our center with DKA between April 2012 and June 2014. Patients were divided into two groups: those co-administered subcutaneous glargine with intravenous insulin for over 4 hours (G+); and patients with less than 2 hours of overlap (G-).. We reviewed 149 DKA admissions (55 G+, 94 G-) from 129 unique patients. There was a similar incidence of hypoglycemia between groups (25% G+ vs 20% G-, P = 0.46). Hypokalemia (<3.5 mmol/L) occurred more frequently in the G+ group (OR = 3.4, 95% CI 1.7-7.0, P = 0.001). Cerebral edema occurred in 2/55 (3.6%) of the G- group and none of the G+ subjects.. Co-administration of glargine early in the course of DKA treatment is well tolerated and convenient for discharge planning; however, this approach is associated with an increased risk of hypokalemia.

Topics: Adolescent; Child; Child, Preschool; Diabetic Ketoacidosis; Female; Humans; Hypoglycemia; Hypoglycemic Agents; Hypokalemia; Insulin Glargine; Male; Retrospective Studies; Young Adult

This study investigates the relationship between basal insulin regimen and glycaemic outcomes 12 months after skills-based structured education in the UK Dose Adjustment for Normal Eating (DAFNE) programme for Type 1 diabetes mellitus.. Retrospective analysis of data from 892 DAFNE participants from 11 UK centres.. Mean HbA1c 12 months after DAFNE was lower in those using twice- rather than once-daily basal insulin after correcting for differences in baseline HbA1c , age and duration of diabetes; difference -2 (95% CI -3 to -1) mmol/mol [-0.2 (-0.3 to -0.1)%], P = 0.009. The greatest fall in HbA1c of -5 (-7 to -3) mmol/mol [-0.4 (-0.6 to -0.3)%], P < 0.001 occurred in those with less good baseline control, HbA1c  ≥ 58 mmol/mol, who switched from once- to twice-daily basal insulin. There was no difference in the 12-month HbA1c between users of glargine, detemir and NPH insulin after correcting for other variables. Relative risk of severe hypoglycaemia fell by 76% and ketoacidosis by 63% 12 months after DAFNE. The rate of severe hypoglycaemia fell from 0.82 to 0.23 events/patient year in twice-daily basal insulin users. In the group with greatest fall in HbA1c , the estimated relative risk for severe hypoglycaemia in twice-daily basal insulin users versus once daily at 12 months was 1.72 (0.88-3.36, P = 0.110).. After structured education in adults with Type 1 diabetes mellitus, use of basal insulin twice rather than once daily was associated with lower HbA1c , independent of insulin type, with significant reductions in severe hypoglycaemia and ketoacidosis in all groups.

Topics: Adult; Blood Glucose; Cohort Studies; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Female; Glycated Hemoglobin; Humans; Hypoglycemia; Hypoglycemic Agents; Insulin Detemir; Insulin Glargine; Insulin, Isophane; Insulin, Long-Acting; Logistic Models; Male; Middle Aged; Patient Education as Topic; Retrospective Studies; Self Care; Treatment Outcome

In this study, the authors report a case of new-onset ketosis-prone diabetes in a 21-year-old Chinese woman with H1N1 influenza, who presented with fever, polyuria and loss of appetite for 3 days before admission. She was hospitalized and diagnosed with acute-onset diabetic ketoacidosis for the first time. Her diabetes-associated antibodies were negative. Interestingly, she had an unexplained fever and her white blood cell count was low at admission and remained low for several days. She was believed to have a viral infection, which was found to be H1N1 influenza infection. The literature regarding virus infection and diabetic ketoacidosis is reviewed. The precipitating factors, symptomatology, pathophysiology and management of ketosis-prone diabetes are discussed in the current case report.

Topics: China; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Female; Humans; Hypoglycemic Agents; Influenza A Virus, H1N1 Subtype; Influenza, Human; Infusions, Intravenous; Injections, Intravenous; Injections, Subcutaneous; Insulin; Insulin Glargine; Insulin, Long-Acting; Treatment Outcome; Young Adult

Diabetic ketoacidosis (DKA) is a life-threatening condition and a major cause of morbidity and mortality in children with type 1 diabetes mellitus. The deficiency of insulin leads to metabolic decompensation, causing hyperglycemia and ketosis that resolves with the administration of insulin and fluids. However, an induced state of ketosis is the basis for the success of the ketogenic diet (KD), which is an effective therapy for children with intractable epilepsy. We report the case of a 2-year-old girl who presented to the emergency department with 1-week history of decreased activity, polyuria, and decreased oral intake. Her past medical history was remarkable for epilepsy, for which she was started on the KD with a significant improvement. Her laboratory evaluation was compatible with DKA, and fluids and insulin were given until correction. Because of concerns regarding recurrence of her seizures, the KD was resumed along with the simultaneous use of insulin glargine and insulin aspart. Urine ketones were kept in the moderate range to keep the effect of ketosis on seizure control. Under this combined therapy, the patient remained seizure-free with no new episodes of DKA.

Topics: Child, Preschool; Combined Modality Therapy; Comorbidity; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Diet, Ketogenic; Drug Administration Schedule; Epilepsy; Female; Follow-Up Studies; Humans; Hypoglycemic Agents; Insulin Aspart; Insulin Glargine; Insulin, Long-Acting

To report the first case of fulminant-like type 1 diabetes mellitus in a Hispanic woman from the United States.. The clinical presentation and laboratory data is presented of a Hispanic woman that was diagnosed with fulminant type 1 diabetes mellitus with a review of the literature.. An 18-year-old female presented with 1 week of polydyspea and polyuria. The patient was seen by her primary care doctor and found to have an elevated blood glucose. On presentation to the hospital, she was found to be in diabetic ketoacidosis. The laboratory analysis showed a C-peptide of 0.6 ng/mL and a glycohaemoglobin A(1c) of 6%. The patient had antibodies positive for glutamic acid decarboxylase. The patient was diagnosed with fulminant type 1 diabetes mellitus and was discharged in stable condition on basal/bolus subcutaneous insulin.. Fulminant type 1 diabetes mellitus is a recently described presentation of diabetes mellitus that has been predominately reported in Japan and other Asian countries. The classical presentation includes rapid onset on ketosis within 1 week of symptoms of hyperglycaemia, with a near-normal glycohaemoglobin and absence of C-peptide. With the majority of case being reported from Asia, it has been hypothesized that there is a genetic determent that predisposes Asian individuals to develop fulminant type 1 diabetes mellitus. The addition of the case to the medical literature expands the focus of fulminant type 1 diabetes mellitus beyond the Asian population and supports the need that further research.

Topics: Adolescent; Blood Chemical Analysis; Blood Glucose; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Female; Hispanic or Latino; Humans; Insulin Glargine; Insulin, Long-Acting; United States

Fasting during Ramadan is a major tenet of the Muslim religion. All adults after the age of puberty are required to do so if health permits. However, there are exemptions to this requirement and having a chronic condition such as diabetes is one. Nevertheless, many adults and adolescents feel obliged to fast during Ramadan even though there is no absolute need to do so. This obligation must be respected. There are few data to support this practice in those whose condition, such as diabetes, potentially makes them vulnerable to developing problems during prolonged fasting. This study was designed to examine the ability and safety of young people with diabetes to be able to fast if they so desire. Two groups of patients were studied, those on a multiple injection, so-called basal-bolus, regimen and those on a 'conventional' twice daily pre-mixed insulin regimen. All patients showed a tendency to high blood glucose at the time of commencing their fast. Those on twice daily insulin continued to have hyperglycaemia during the day whilst those on basal-bolus insulin showed a steady fall in blood glucose towards normal by the time of breaking their fast. Although there was a greater tendency to hypoglycaemia in the basal-bolus group, this could be successfully prevented by reducing the dose of basal insulin by 10-20%. We recommend that it is safe for adolescents with diabetes to fast during Ramadan as long as they reduce their basal insulin by this amount and continue to monitor their blood glucose regularly.

Topics: Adolescent; Blood Glucose; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Fasting; Holidays; Humans; Hypoglycemia; Hypoglycemic Agents; Insulin; Insulin Aspart; Insulin Glargine; Insulin, Long-Acting; Islam

OBJECTIVE To investigate if long-acting insulin analogs decrease the risk of diabetic ketoacidosis (DKA) in young individuals with type 1 diabetes. RESEARCH DESIGN AND METHODS Of 48,110 type 1 diabetic patients prospectively studied between 2001 and 2008, the incidence of DKA requiring hospitalization was analyzed in 10,682 individuals aged /=2 years. RESULTS The overall rate of DKA was 5.1 (SE +/- 0.2)/100 patient-years. Patients using insulin glargine or detemir (n = 5,317) had a higher DKA incidence than individuals using NPH insulin (n = 5,365, 6.6 +/- 0.4 vs. 3.6 +/- 0.3, P < 0.001). The risk for DKA remained significantly different after adjustment for age at diabetes onset, diabetes duration, A1C, insulin dose, sex, and migration background (P = 0.015, odds ratio 1.357 [1.062-1.734]). CONCLUSIONS Despite their long-acting pharmacokinetics, the use of insulin glargine or detemir is not associated with a lower incidence of DKA compared with NPH insulin.

Topics: Adolescent; Child; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Female; Humans; Hypoglycemic Agents; Incidence; Insulin; Insulin Detemir; Insulin Glargine; Insulin, Isophane; Insulin, Long-Acting; Male; Risk Factors

Topics: Blood Glucose; Diabetes Mellitus, Type 2; Diabetic Ketoacidosis; Dose-Response Relationship, Drug; Humans; Hypoglycemic Agents; Insulin; Insulin Glargine; Insulin, Long-Acting; Ketones; Male; Middle Aged

To study the effect of subcutaneous administration of insulin glargine on the rate of resolution of acidosis and intravenous insulin infusion requirement in children with moderate and severe diabetic ketoacidosis (DKA).. Retrospective cohort study.. Pediatric intensive care unit of a university-based children's hospital.. Children with moderate to severe DKA admitted between March 2001 and February 2003.. The outcomes of children who received 0.3 units/kg of subcutaneous insulin glargine in the first 6 h of management in addition to the standard treatment (n=12) were compared with those of children who received standard treatment alone (n=59). Measured outcomes included dose of intravenous insulin required, duration of insulin infusion and acidosis correction time. The two groups were similar in demographics and severity of illness. The mean time for acidosis correction (venous pH>or=7.3) in the insulin glargine group was shorter than the standard therapy group (12.4+/-2.9 h and 17.1+/-6.2 h respectively, p<0.001). The insulin infusion time was shorter in the insulin glargine group (14.8+/-6.0 h vs 24.4+/-9.0 h, p<0.001). There was a trend towards shorter total hospital stay in the glargine group (3.2+/-1.0 days vs 3.72+/-1.06 days).. In our small series of children with moderate and severe DKA, supplementing with subcutaneous insulin glargine led to a faster resolution of acidosis without any adverse effects. This could potentially lead to a shorter need for insulin infusion and a shorter ICU length of stay.

Topics: Adolescent; Child; Cohort Studies; Diabetic Ketoacidosis; Female; Humans; Hypoglycemic Agents; Injections, Subcutaneous; Insulin; Insulin Glargine; Insulin, Long-Acting; Intensive Care Units, Pediatric; Length of Stay; Male; Retrospective Studies; Treatment Outcome

This study compared external insulin pump treatment using insulin lispro or insulin aspart with multiple daily injections (MDI; four or more injections per day) using insulin glargine and insulin lispro or insulin aspart. An electronic database was used to retrieve various parameters of glycemic control for 515 adult patients with type 1 diabetes. An insulin pump was used by 216 patients, and 299 patients were taking insulin glargine for at least 6 months. The mean age (approximately 33 years), duration of diabetes (approximately 16 years), and duration of treatment (approximately 12 months) were similar for both the pump and insulin glargine groups. The mean (+/-SEM) A1C values were significantly reduced in both groups from the baseline to the end of the study (7.7 +/- 0.1% to 7.5 +/- 0.1% for the pump group and 8.0 +/- 0.1% to 7.7 +/- 0.1% for the insulin glargine group, P< 0.001) with similar weight gain (P> 0.05) in both groups. The insulin glargine group significantly reduced basal insulin intake at follow-up. The premeal boluses were similar throughout the study for both groups. The subjects reporting severe hypoglycemic episodes were similar in the two groups; however, there were 12 cases of diabetic ketoacidosis reported in the pump group and none in the insulin glargine group. Patients with type 1 diabetes can achieve similar glycemic control using insulin glargine with premeal insulin lispro or by using an external infusion pump with insulin lispro or insulin aspart. However, costs and episodes of diabetic ketoacidosis are significantly higher for insulin pump users.

Topics: Adult; Body Weight; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Female; Glycated Hemoglobin; Humans; Hypoglycemic Agents; Infusion Pumps, Implantable; Injections, Subcutaneous; Insulin; Insulin Aspart; Insulin Glargine; Insulin Infusion Systems; Insulin Lispro; Insulin, Long-Acting; Male; Retrospective Studies

Glargine (Lantus) is a recently approved, long-acting insulin analog that is increasingly being used in children with diabetes. The aim of this retrospective chart review was to summarize our experience in starting glargine in children and adolescents with diabetes. SUBJECTS AND STUDY METHODS: We reviewed the medical records of 71 children with type 1 diabetes (29 boys and 42 girls) who initiated glargine therapy to improve glycemic control between 1 June 2001 and 30 June 2002. Data were collected for 6 months before and 6 months after adding glargine.. Subjects' mean age [+/-standard deviation (SD)] at diagnosis of diabetes was 7.5 +/- 4.1 yr. Mean age at initiation of glargine therapy was 11.5 +/- 4.9 yr. The total daily long-acting insulin dose decreased by about 20% after initiating glargine therapy. There were no significant differences in hemoglobin A1c (HbA1c) and blood glucose control prior to and after initiating glargine therapy (HbA1c at baseline 8.9 +/- 1.6% and HbA1c after 6 months of glargine therapy was 8.9 +/- 1.5%). Overall, blood glucose concentrations did not differ significantly throughout the study. Patients who switched to glargine because of nocturnal hypoglycemia had a 65% decrease in nocturnal blood glucose reading less than 50 mg/dL. There were three seizures in the first week after initiating glargine therapy.. This retrospective study suggests that glargine is at least as effective as other long-acting insulins but that care must be taken during the conversion process to avoid hypoglycemia.

Topics: Adolescent; Blood Glucose; Child; Circadian Rhythm; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Dose-Response Relationship, Drug; Drug Therapy, Combination; Female; Humans; Hypoglycemia; Hypoglycemic Agents; Insulin; Insulin Glargine; Insulin, Isophane; Insulin, Long-Acting; Male; Osmolar Concentration; Retrospective Studies; Seizures; Treatment Outcome

Extreme customization of treatment is even more necessary when dealing with young diabetic patients as compared with adult patients. From diagnosis the pediatrician must introduce treatment in the less traumatic way possible so that the child does not perceive a derangement of his/her life. In order to preserve the quality of life the diabetic child must be able to attend birthday parties, participate in sports, and generally lead a full social life just like his/her friends. In the present paper we evaluate the characteristics of the new insulin analogues and their advantages and disadvantages with respect to the needs of patients. The wide spectrum of available insulin formulations including also the new short- and long- acting insulin analogues are of great help in conceiving a therapeutic plan closely adherent to the patient's needs. As an example, in children aged less than 5-6 years a short acting insulin may be injected immediatly after the meal. The same insulin may be useful in older patients with an incostant style of life due to social activities. On the other hand the "old" insulins may still be used for the therapeutic plan in patients with a more constant life style as to the physical exercise and intervals between the meals. In conclusion, the quality of life in the children and adolescents with diabetes may be accomplished with a flexible and personalized therapeutic plan and a great attention to the education. The latter is a very important tool for the compliance and the reduction of anxiety in patients and their parents.

Topics: Adolescent; Case Management; Child; Delayed-Action Preparations; Diabetes Mellitus, Type 1; Diabetic Ketoacidosis; Drug Administration Schedule; Female; Half-Life; Humans; Insulin; Insulin Aspart; Insulin Glargine; Insulin Lispro; Insulin, Long-Acting; Male; Patient Compliance; Patient Education as Topic; Quality of Life; Social Adjustment; Treatment Outcome