Flexible Insulin Therapy With Glargine an Option in Diabetic Preschoolers

20% of patients showed a 1% or greater improvement in HbA1c levels. In normal-weight preschool-aged children with type 1 diabetes, transition from multiple daily insulin therapy to a more flexible multiple daily insulin regimen that includes glargine insulin may improve overall glycemic control and reduce the frequency of severe hypoglycemia, according to a new study.

Glargine insulin has demonstrated efficacy in school-aged children and adolescents with type 1 diabetes, study investigators note in the May issue of Pediatrics. "Our study extends this observation to include preschool-aged children," they write.

This flexible insulin regimen "may be a feasible therapeutic alternative" to a more rigid multiple daily insulin regimen of premeal lispro plus ultralente insulin twice daily, Dr. Ramin Alemzadeh, director of the children’s diabetes program at the Medical College of Wisconsin in Milwaukee and colleagues write.

The team collected data on 35 preschoolers who completed 1 year or more of premeal lispro plus ultralente insulin twice daily followed by 1 year or more of premeal lispro plus bedtime glargine.

Overall glycemic control improved after transition to flexible insulin therapy, and 20% of patients showed a 1% or greater improvement in HbA1c levels, a level associated with a 21% to 49% decrease in the risk of microvascular complications in the Diabetes Control and Complications trial.

Twenty-two percent of children maintained or achieved optimal HbA1c (less than 8.0%) for their age. However, this was the case only in normal-weight and not in overweight children, despite similar reported levels of energy intake and daily insulin dose, corrected for body weight.

Dr. Alemzadeh stated that, these paradoxical findings suggest "underreporting of food intake by parents," yielding a lispro bolus insulin dose that was not appropriately matched to the actual meal carbohydrate intake, This mismatch may represent an attempt by "fearful parents to prevent hypoglycemia," he said.

With glargine insulin, the rate of severe hypoglycemic episodes was significantly decreased in normal-weight children (29.7 vs 7.4 events per 100 patient-years).

There were no significant changes in weight with premeal lispro and bedtime glargine, although 43% of children were overweight both before and after treatment.

Dr. Alemzadeh and colleagues note in their report that insulin replacement regimens "now stress the importance of administering throughout the day insulin doses that are based on flexible food choices and focusing on improved metabolic control."
Dr. Alemzadeh added that flexible insulin therapy with glargine permits a "less rigid distribution of calories for each meal and, compared to conventional or multiple daily insulin using NPH or ultralents, flexible insulin therapy with glargine is deemed a more physiological way of replacing insulin outside of insulin pump therapy."

Pediatrics 2005;115:1320-1324.

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DID YOU KNOW: Currently, the ADA does not endorse a low-GL or low-GI diet to prevent diabetes, citing insufficient evidence. In its most recent statement on the theory, the association noted the following: "Although some studies have observed an association between glycemic index or glycemic load and type 2 diabetes, this relationship has been equivocal or absent in others."

Diabetes Care 27: 2266–2271, 2004