ESPE Abstracts (2018) 89 S5.2

Re-defining Targets for Optimal T1D Control

Ragnar Hanas

Department of Pediatrics, NU Hospital Group, Uddevalla, Sweden

HbA1c reflects mean glucose levels over 2–3 months. ISPAD’s and ADA’s HbA1c target level is <7.5% (58 mmol/mol) in all pediatric age groups, but UK and Sweden have adopted ≤6.5% based on NICE Guidelines and DCCT results, provided that the person does not have hypoglycemia problems. NICE states: ‘Explain to children and young people with type 1 diabetes and their family members or carers (as appropriate) that an HbA1c target level of 48 mmol/mol (6.5%) or lower is ideal to minimize the risk of long-term complications.’ Longitudinal data clearly show that it is very important to reach an HbA1c within target during the pediatric years. Improving HbA1c as a young adult is not enough to avoid complications. The current practice of tolerating some hyperglycemia to minimize the risk of hypoglycemia in young children with T1D may not be optimal for the developing brain. Diabetes onset is a ‘window of opportunity’ when the family is open for change. We used to say that diabetes is a difficult condition that you gradually need to adjust to, but in later years we are much stricter with intensive therapy right from the onset, teaching carbohydrate counting, insulin always given before meals and recording of mean glucose levels. All are started on MDI; if <10 years with an injection aid (i-port) to reduce injection pain, and if <7 we start a pump and CGM within a few weeks. Older children get CGM (Libre) within a week to alleviate the pain of finger pricking. We stress that these routines need to be continued throughout the remission phase with close follow-up and instructions to contact us if BG is > 8 mmol/l (145 mg/dl) for 2 weeks in a row. At this time, the introduction of a target HbA1c of ≤ 6.5% is readily accepted by the family, and can be achieved by most, if not all families. The most critical period is actually when the child or teenager goes out of the remission phase and needs a quick increase in insulin doses. If you do not catch them in time, they will come back to clinic some months later with a high HbA1c, which will be difficult to bring down. HbA1c during the first 2 years determines long-term levels both individually and on a clinic level. It is therefore vital to achieve and maintain optimal control already from the onset of diabetes.

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