Insulin Therapy and Outpatient Diabetes Management

  • Francine Ratner Kaufman


Over the years since the completion of the Diabetes Control and Complications Trial (DCCT)1,2,3 the benefits for infants, children and youth with type 1 diabetes of following a system of diabetes management that allows for optimal glycemia has become increasingly apparent. Not only is there reduction in long-term diabetes complications, but there is normalization of growth and pubertal development and improvement in physical and psychosocial well-being. Unfortunately, coupled with these benefits is the risk of increased episodes of hypoglycemia that might have neurocognitive consequences, particularly for young children. Therefore, the systems of diabetes management that improve glycemic control must be well-defined and carefully taught to patients and families. Certain aspects of diabetes care must also be conveyed to school personnel and other caregivers if pediatric subjects with type 1 diabetes are to maximally benefit from an intensive management approach. To accomplish this, the family must work in concert with a multidisciplinary diabetes team as well as their primary care provider.


Celiac Disease Insulin Glargine Severe Hypoglycemia Insulin Aspart Insulin Lispro 
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  1. 1.
    Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the long-term development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329, 977–986.CrossRefGoogle Scholar
  2. 2.
    Diabetes Control and Complications Trial Research Group. Effect of intensive diabetes treatment on the development of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial. J Pediatr 1994; 125, 177–188.CrossRefGoogle Scholar
  3. 3.
    Diabetes Control and Complications Trial Research Group. Implementation of treatment protocols in the diabetes control and complications trial. Diabetes Care 1995 18, 361–376.CrossRefGoogle Scholar
  4. 4.
    Chase HP, Lockspeiser T, Perry B, Shepherd M, MacKenzie T, Anderson J, Garg SK. The impact of the diabetes control and complications trial and humalog insulin on glycohemoglobin levels and severe hypoglycemia in type 1 diabetes. Diabetes Care 2001; 24, 430–434.PubMedCrossRefGoogle Scholar
  5. 5.
    Brunner GA, Hirschberger S, Sendhofer G, et al. Post-prandial administration of the insulin analogue insulin aspart in patients with type 1 diabetes mellitus. Diabetic Medicine 2000; 17, 371–375.PubMedCrossRefGoogle Scholar
  6. 6.
    Hedman CA, Lindstrom T, Arnqvist HJ. Direct comparison of insulin lispro and aspart shows small differences in plasma insulin profiles after subcutaneous injection in type 1 diabetes. Diabetes Care 2001; 24, 1120–1121.PubMedCrossRefGoogle Scholar
  7. 7.
    Owens DR, Coates PA, Luzio SD, Tingergen JP, Kurzhals R. Pharmacokinetics of 125I-labeled insulin glargine (HOE 901) in healthy men: Comparison with NPH insulin and the influence on different subcutaneous injection sites. Diabetes Care 2000; 23, 813–819.PubMedCrossRefGoogle Scholar
  8. 8.
    Rosskamp R, Park G. Long-acting insulin analogs. Diabetes Care 1999; 22 (Suppl. 2):B109–B113.PubMedGoogle Scholar
  9. 9.
    Rosenstock J, Park G, Zimmerman J; U.S. Insulin Glargine (HOE 901) Diabetes Investigator Group. Basal insulin glargine (HOE 901) versus NPH insulin in patients with type 1 diabetes on multiple daily insulin regimens. Diabetes Care 2000; 23, 1137–1142.PubMedCrossRefGoogle Scholar
  10. 10.
    Mohn A, Strang S, Lang AM, Edge JA, Dunger DB. Nocturnal glucose control and free insulin levels in children with type 1 diabetes by use of the long-acting insulin HOE 901 as part of a three-injection regimen. Diabetes Care 2000; 23, 557–559.PubMedCrossRefGoogle Scholar
  11. 11.
    Ratner RE, Hirsch IB, Neifing JL, Garg SK, Mecca TE, Wilson CA. Less hypoglycemia with insulin glargine in intensive insulin therapy for type 1 diabetes. U.S. Study Group of Insulin Glargine in Type 1 Diabetes. Diabetes Care 2000; 23, 639–643.PubMedCrossRefGoogle Scholar
  12. 12.
    Brunner GA, Sendlhofer G, Wutte A, et al. Pharmacokinetic and pharmcodynamic properties of long-acting insulin analogue NN304 in comparison to NPH insulin in humans. Exp Clin Endocrinol Diabetes 2000; 108, 100–105.PubMedCrossRefGoogle Scholar
  13. 13.
    ISPAD. Consensus Guidelines 2000, ed, International Society for Pediatric and Adolescent Diabetes, Medical Forum International, Zeist, Netherlands.Google Scholar
  14. 14.
    Skyler J Lancet 2001; 357: 331.Google Scholar
  15. 15.
    American Diabetes Association. Clincial Practice Recommendation 2001. Diabetes Care 2001; 24 (Suppl 1), S1–S126.CrossRefGoogle Scholar
  16. 16.
    White JA, Hirsch IB. Acute complications of diabetes. Endocrinol Metab 2000.Google Scholar
  17. 17.
    American Diabetes Association. Medical management of type 1 diabetes, 3rd edition. American Diabetes Association, Alexandria, VA, 1998.Google Scholar
  18. 18.
    American Diabetes Association. Standards of medical care for patients with diabetes mellitus. Diabetes Care 1997; 20(Suppl 1): S5–S13.Google Scholar
  19. 19.
    Kaufman FR. Diabetes in children and adolescents: Areas of controversy. Med Clin North Am 1998; 82, 721–737.PubMedCrossRefGoogle Scholar
  20. 20.
    Kaufman FR, Halvorson M, Miller D, MacKenzie M, Fisher LK, Pitukcheewanont P. Insulin pump therapy in type 1 pediatric patients: Now and into the year 2000. Diabetes Metab Res Rev 1999; 15, 338–352.CrossRefGoogle Scholar
  21. 21.
    Kaufman FR, Halvorson M, Fisher LK, Pitukcheewanont P. Insulin pump therapy in type 1 pediatric patients. J Pediatr Endocrinol Metab 1999; 12, 759–764.PubMedGoogle Scholar
  22. 22.
    Steindel BS, Roe TF, Costin G, Carlson M, Kaufman FR. Continuous subcutaneous insulin infusion (CSII) in children and adolescents with chronic poorly controlled type 1 diabetes mellitus. Diabetes Res Clin Pract 1995; 27, 199–204.PubMedCrossRefGoogle Scholar
  23. 23.
    Boland EA, Grey M, Oesterle A, Fredrickson L, Tamborlane WV. Continuous subcutaneous insulin infusion. Diabetes Care 1999; 22, 1779–1784.PubMedCrossRefGoogle Scholar
  24. 24.
    Mortensen HB, Hartling SG, Petersen KE, the Danish Study Group of Diabetes in Childhood. A nation-wide cross-sectional study of glycosylated hemoglobin in Danish children with type 1 diabetes. Diabet Med 1998; 5, 871–876.CrossRefGoogle Scholar
  25. 25.
    Mortensen HB, Villumsen J, Volund A, Petersen KE, Nerup J, the Danish Study Group of Diabetes in Childhood. Relationship between insulin injection regimen and metabolic control in young Danish type 1 diabetic patients. Diabet Med 1992; 9, 834–839.PubMedCrossRefGoogle Scholar
  26. 26.
    Mortensen HB, Hougaard P. Comparison of metabolic control in a cross-sectional study of 1,873 children and adolescents with IDDM from 18 countries. Diabetes Care 1997; 20, 714–720.PubMedCrossRefGoogle Scholar
  27. 27.
    Anderson B, Ho J, Brackett J, Finkelstein D, Laffel L. Parental involvement in diabetes management tasks: Relationships to blood glucose monitoring adherence and metabolic control in young adolescents with insulin-dependent diabetes mellitus. J Pediatr 1997; 130, 257–265.PubMedCrossRefGoogle Scholar
  28. 28.
    Nathan DM, McKitrick C, Larkin M, Schaffran R, Singer DE. Glycemic control in diabetes mellitus: Have changes in therapy made a difference? 1996; 100, 157–163.Google Scholar
  29. 29.
    Levine B-S, Anderson BJ, Butler DA, Antisdel JE, Brackett J, Laffel LMB. Predictors of glycemic control and short-term adverse outcomes in youth with type 1 diabetes. J Pediatr 2001; 139, 197–203.PubMedCrossRefGoogle Scholar
  30. 30.
    American Diabetes Association. Postprandial blood glucose. Diabetes Care 2001; 24, 775–778.CrossRefGoogle Scholar
  31. 31.
    Bode BW, Gross TM, Thornton KR, Mastrototoro JM. Continuous glucose monitoring used to adjust diabetes therapy improves glycosylated hemoglobin: A pilot study. Diabetes Research and Clinical Practice 1999; 46, 183–190.PubMedCrossRefGoogle Scholar
  32. 32.
    Chase HP, Kim LM, Owen SL, et al. Continuous subcutaneous glucose monitoring in children with type 1 diabetes. Pediatrics 2001; 107,222–226.PubMedCrossRefGoogle Scholar
  33. 33.
    Garg SK, Potts RO, Ackerman NR, Fermi SI, Tamada JA, Chase HP. Correlation of finger stick blood glucose measurements with glucowatch biographer glucose results in young subjects with type 1 diabetes. Diabetes Care 1999; 22, 1708–1714.PubMedCrossRefGoogle Scholar
  34. 34.
    Pitzer KR, Desai S, Dunn T, Edelman S, Jayalakshmi Y, Kennedy J, Tamada JA, Potts RO. Detection of hypoglycemia with the GlucoWatch Biographer. Diabetes Care 2001; 24, 881–886.PubMedCrossRefGoogle Scholar
  35. 35.
    Lawlor MT, Laffel LMB. New technologies and therapeutic approaches for the management of pediatric diabetes. Current Diabetes Reports 2001; 1, 56–66.PubMedCrossRefGoogle Scholar
  36. 36.
    Byrne HA, Tieszen KL, Hollis S, Doman TL, New JP. Evaluation of an electrochemical sensor for measuring blood ketones. Diabetes Care 2000; 23, 500–503.PubMedCrossRefGoogle Scholar
  37. 37.
    Fulop M, Murphy V, Michilli A, et al. Serum B-hydroxybutyrate measurement in patients with uncontrolled diabetes mellitus. Arch Intern Med 1999; 159, 381–384.PubMedCrossRefGoogle Scholar
  38. 38.
    Cryer PE. Hypoglycemia: The limiting factor in the management of IDDM. Diabetes 1994; 43, 1378–1389.PubMedCrossRefGoogle Scholar
  39. 39.
    Cox DJ, Kovatchev BP, Julian DM, et al. Frequency of severe hypoglycemia in insulin-dependent diabetes mellitus can be predicted from self-monitoring of blood glucose data. J Clin Endocrinol Metab 1994; 79, 1659–1662.PubMedCrossRefGoogle Scholar
  40. 40.
    Bhatia V, Wolfsdorf JI. Severe hypoglycemia in youth with insulin-dependent diabetes mellitus: frequency and causative factors. Pediatrics 1991; 88, 1187–1193.PubMedGoogle Scholar
  41. 41.
    Nordfeldt S, Ludvigsson J. Severe hypoglycemia in children with IDDM: a prospective population study, 1992 - 1994. Diabetes Care 1997; 20, 487–503.CrossRefGoogle Scholar
  42. 42.
    Beregszaszi M, Tubiana-Rufi N, Benali K, Noel M, Bloch J, Czernichow P. Nocturnal hypoglycemia in children and adolescents with insulin-dependent diabetes mellitus. Prevalence and risk factors. J Pediatr 1997; 131, 27–33.PubMedCrossRefGoogle Scholar
  43. 43.
    Kaufman FR. Searching for glycemic control in pediatric type 1 diabetes: A long way to go. J Pediatr 2001; 139, 174–176.PubMedCrossRefGoogle Scholar
  44. 44.
    Danne T, Mortensen HB, Hougaard P, et al. Persistent differences among centers over 3 years in glycemic control and hypoglycemia in a study of 3,805 children and adolescents with type 1 diabetes from the Hvidore study group. Diabetes Care 2001; 24, 1342–1347.PubMedCrossRefGoogle Scholar
  45. 45.
    Kaufman FR. (1997). Diabetes mellitus. Pediatr Res 1997; 18, 383–392.Google Scholar
  46. 46.
    Buckingham BA, Bluck B, Wilson DM. Intensive diabetes management in pediatric patients. Current Diabetes Reports 2001; 1, 11–18.PubMedCrossRefGoogle Scholar
  47. 47.
    Kaufman FR, Halvorson M, Carpenter S. Use of a plastic insulin dosage guide to correct blood glucose levels of the target range and for carbohydrate counting in subjects with type 1 diabetes. Diabetes Care 1999; 22, 1252–1257.PubMedCrossRefGoogle Scholar
  48. 48.
    Skyler JS, Skyler DL, Seigler DE. Algorithms for adjustment of insulin dosage by patients who monitor blood glucose. Diabetes Care 1981; 4, 311–318.PubMedCrossRefGoogle Scholar
  49. 49.
    Kaufman FR, Halvorson M. New trends in managing type 1 diabetes. Contemporary Pediatrics 1999; 16, 112–123.Google Scholar
  50. 50.
    Raymond MW, Schreiner B. Mini-dose glucagons rescue for hypoglycemia in children with type 1 diabetes. Diabetes Care 2001; 24, 643–645.CrossRefGoogle Scholar
  51. 51.
    Jacobson AM, Hauser ST, Willett J, Wolfsdorf JI, Herman L. Consequences of irregular versus continuous medical follow-up in children and adolescents with insulin-dependent diabetes mellitus. J Pediatr 1997; 131, 727–733.PubMedCrossRefGoogle Scholar
  52. 52.
    Kaufman FR, Halvorson M, Carpenter S. Association between diabetes control and visits to a multidisciplinary pediatric diabetes clinic. Pediatrics 1999; 103, 948–951.PubMedCrossRefGoogle Scholar
  53. 53.
    Meltzer LJ, Bennett Johnson S, Prine JM, Banks RA, Desrosiers PM, Silverstein JH. Disordered eating, body mass, and glycemic control in adolescents with type 1 diabetes. Diabetes Care 2001; 24, 678–682.PubMedCrossRefGoogle Scholar
  54. 54.
    Rosenbloom AL. Skeletal and joint manifestations of childhood diabetes. Pediatr Clin North Am 1984; 31, 569–589.PubMedGoogle Scholar
  55. 55.
    Carlsson A, Axelsson IE, Borulf SK, et al. Prevalence of IgA- antiendomysium and IgA-antigliadin autoantibodies at diagnosis of insulin-dependent diabetes mellitus in Swedish children and adolescents. Pediatrics 1999; 103, 1248–1252.PubMedCrossRefGoogle Scholar
  56. 56.
    American Diabetes Association. Care of children with diabetes in the school and day care setting. Diabetes Care 2000; 23 (Suppl 1), S100–103.Google Scholar

Copyright information

© Springer Science+Business Media New York 2003

Authors and Affiliations

  • Francine Ratner Kaufman
    • 1
  1. 1.Childrens Hospital Los AngelesThe Keck School of Medicine of University of Southern CaliforniaLos AngelesUSA

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