Treatment For Both Types of Diabetes

Treatment for both types of diabetes is aimed at maintaining blood glucose values near normal levels. Additional goals are:

•         Promote normal growth and development and achievement of a healthy weight.

•         Normalize blood glucose levels and minimize hyperglycemia and hypoglycemia.

•         Achieve normal lipid levels.

•         Prevent and delay complications.

•         Promote optimal health and well-being.

Achieving these goals requires insulin or glucose-lowering medications that depend on the type of diabetes, medical nutrition therapy, frequent blood glucose monitoring to identify and evaluate blood glucose patterns, and comprehensive education in diabetes, self-management and decision-making skills at diagnosis and follow-up visits. Target blood glucose goals for teens are listed in Table 4.

TABLE 4

Blood Glucose Goals for Adolescents1

	Biochemical Index	Normal	Goal	Action Indicated2
	Average premeal BG (mg/dl)3	<110	80-120	<80 or >140
	Average 2 hour postmeal BG (mg/dl) for rapid-acting insulin only	3 <120	150-180	>180
	Average bedtime BG (mg/dl)3	<120	100-140	<100 or >160
	Average 3:00 am BG (mg/dl)	<110	80-100	<80 or >120
	HbA1c (%)	<6	<7	>8

1 These values are generally not indicated for preadolescents. The values shown in this table are by necessity generalized to the entire population of individuals with diabetes. Patients with comorbid diseases, the very young and older adults, and others with unusual conditions or circumstances may warrant different treatment goals. These values are for nonpregnant adults.

2  “Action indicated” depends on individual patient circumstances. Such actions may include enhanced diabetes self- management education, comanagement with a diabetes team, referral to an endocrinologist, change in pharmacological therapy, initiation of or increase in SMBG, or more frequent contact with the patient. HbA1c is referenced to a nondiabetic range of 4.0-6.0% (mean, 5.0%, SD 0.5%).

3 Measurement of capillary blood glucose.

Adapted from: Orr, DP. Contemporary management of adolescents with diabetes mellitus. Part 1: Type 1 diabetes. Adolescent Health Update 2000;12(2), Table 1, p 2.

Successful education programs will include the following components:

•         Involvement of the teen, family, key teachers, school nurses and/or coaches.

•         An individualized approach to treatment plans.

•         Culturally appropriate information, educational materials, and treatment plans.

•         Frequent follow-up to evaluate and adjust as needed.

Treatment for Type 1 Diabetes

Insulin Therapy

Insulin is the only medication that is effective in lowering blood glucose levels in type 1 diabetes. The use of insulin requires daily management of those factors that affect the insulin dose (food, physical activity, illness, stress). See Table 5 for common insulin preparations. Rapid-acting insulin may be given before, during, or immediately after a meal. Administration after a meal may help reduce the postprandial hyperglycemia associated with high fat meals. The number of insulin injections/day will vary; insulin may be delivered with insulin syringes, insulin pens or external insulin pumps.

•      Conventional therapy– 2 daily injections of mixed insulin (rapid- or short-acting and intermediate-acting) before breakfast and the evening meal.

•      Conventional therapy with a split night-time dose– 1 injection of mixed insulin (rapid- or short- acting and intermediate-acting) before breakfast, 1 injection of rapid- or short-acting insulin before the evening meal and 1 injection of intermediate-acting insulin before the bedtime snack. This regimen is used to help reduce fasting hyperglycemia associated with the long interval between the evening meal and breakfast and the duration of action of the intermediate-acting insulin and to facilitate management of the dawn phenomenon.

•      Multiple daily injections (MDI) of rapid- or short-acting insulin before every meal (and sometimes large snacks) with intermediate- or long-acting insulin once or twice a day. The addition of rapid- or short-acting insulin before lunch helps reduce pre-supper hyperglycemia with less risk of hypoglycemia associated with very large pre-breakfast doses of intermediate- acting insulin. With the exception of a bedtime snack to prevent hypoglycemia during the night, snacks usually are not required with MDI– an advantage for busy teens and those who wish to maintain a target weight. This may be called intensive therapy depending on the level of glycemic control that is targeted.

•      Intensive therapy with a continuous subcutaneous insulin infusion (CSII or insulin pump)– Rapid-acting insulin is delivered constantly to meet the body’s basal need to suppress hepatic glucose production. A bolus dose of insulin is given before meals and snacks based on the amount of carbohydrate eaten and the measured level of blood glucose. This regimen is for motivated teens who are willing to test frequently (>4 times/day), monitor carbohydrate intake accurately, adjust insulin doses and commit to frequent contact with the diabetes team.

TABLE 5

Description of Commonly Used Insulin Preparations

  Common Description     Name            Onset (hrs)      Peak (hrs)       Effective Duration (hrs)   

Rapid-acting	Lispro	0.25	1-2	2-3
Short-acting	Regular	0.5-1	2-3	3-6
Intermediate-acting	NPH	2-4	4-10	10-16
Intermediate-acting	Lente	3-4	4-12	12-18
Long-acting	Ultralente	6-10	12-18	18-20
Long-acting	Glargine	1	None	24

TO BE CONTINEU

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