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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