Background: The effects of metabolic memory highlight the importance of good glycaemic control following diagnosis of type 1 diabetes (T1D). There is relative insulin resistance at diagnosis, particularly in the presence of ketonaemia. Local prescribing guidelines reflect this with higher insulin starting doses with ketonaemia.
Objective and hypotheses: Current insulin dosing guidance for children with newly diagnosed T1D appeared insufficient to achieve optimal glycaemic control prior to discharge. Our objective was to audit initial doses and thus optimise prescribing guidance.
Method: Medical records of children with newly diagnosed T1D presenting to our tertiary paediatric hospital over 6 months were reviewed for data on blood glucose (BG) and insulin dosing at presentation, hospital discharge, and clinic follow-up. This information was used to revise our care pathway dosing guidance. A repeat audit was carried out to determine if the insulin dose change improved glycaemic control.
Results: Audit 1: results were analysed from 23 children in three cohorts: patients in DKA (n=11); those not in DKA with ketones ≥1.5 mmol/l (n=5); and patients with ketones <1.5 mmol/l (n=7). Starting dose of subcutaneous insulin was 0.50.7 units/kg per day depending on ketonaemia as per prescribing guidance. Total daily dose of insulin required to be increased prior to discharge in both cohorts with elevated ketones at presentation. Twenty-four hours mean BG pre-discharge was above target in all cohorts. Guidelines were adjusted to provide insulin starting doses of 0.551.1 units/kg per day depending on degree of ketonaemia. Audit 2: the initial ten patients using this new protocol showed improved mean blood glucose at hospital discharge and less requirement for escalation of insulin dose during admission. Episodes of hypoglycaemia were infrequent (n=2).
Conclusion: Children with significant ketonaemia at diagnosis required more s.c. insulin at initiation of treatment than initially prescribed. Care pathways have been revised to provide 0.551.1 units/kg per day, which has shown improvement in glycaemic control in the early period following diagnosis.
01 - 03 Oct 2015
European Society for Paediatric Endocrinology