BNF for Children 2011-2012

BNFC 2011–2012 6.1.1 Insulins 349Treatment of diabetes Treatment should be aimed atalleviating symptoms and minimising the risk of longtermcomplications (see below).Diabetes is a strong risk factor for cardiovascular diseaselater in life. Other risk factors for cardiovasculardisease (smoking, hypertension, obesity and hyperlipidaemia)should be addressed. The use of an ACE inhibitor(section 2.5.5.1) and of a lipid-regulating drug (section2.12) can be beneficial in children with diabetes and ahigh cardiovascular disease risk. For reference to the useof an ACE inhibitor in the management of diabeticnephropathy, see section 6.1.5.Prevention of diabetic complications Althoughrare, retinopathy, neuropathy and nephropathy canoccur in children with diabetes. Screening for complicationsshould begin 5 years after diagnosis of diabetes orfrom 12 years of age. Optimal glycaemic control in bothtype 1 diabetes and type 2 diabetes reduces, in the longterm, the risk of microvascular complications includingretinopathy, development of proteinuria and to someextent neuropathy.A measure of the total glycosylated (or glycated) haemoglobin(HbA 1 ) or a specific fraction (HbA 1c ) providesa good indication of long-term glycaemic control. Overallit is ideal to aim for an HbA 1c concentration of 48–59 mmol/mol or less (reference range 20–42 mmol/mol), but this cannot always be achieved and for thoseusing insulin there is a significantly increased risk ofdisabling hypoglycaemia.Measurement of HbA 1cHbA 1c values were previously aligned to the assayused in the Diabetes Control and ComplicationsTrial (DCCT) and expressed as a percentage. Anew standard, specific for HbA 1c , has been createdby the International Federation of Clinical Chemistryand Laboratory Medicine (IFCC), whichexpresses HbA 1c values in mmol of glycosylatedhaemoglobin per mol of haemoglobin. From 1June 2011 UK laboratories will only express resultsin IFCC-standardised units (mmol/mol).Equivalent valuesIFCC-HbA 1c (mmol/mol) DCCT-HbA 1c (%)42 6.048 6.553 7.059 7.564 8.075 9.0Laboratory measurement of serum-fructosamine concentrationis technically simpler and cheaper than themeasurement of HbA 1c and can be used to assesscontrol over short periods of time, particularly whenHbA 1c monitoring is invalid (e.g. disturbed erythrocyteturnover or abnormal haemoglobin type).Tight control of blood pressure in hypertensive childrenwith type 2 diabetes may reduce mortality significantlyand protects visual acuity (by reducing considerably therisks of maculopathy and retinal photocoagulation) (seealso section 2.5).Driving Information on the requirements for drivingvehicles by individuals receiving treatment for diabetesis available in the BNF (section 6.1) or from the DVLA atwww.dvla.gov.uk/medical.aspx.6.1.1 InsulinsInsulin is a polypeptide hormone that plays a key role inthe regulation of carbohydrate, fat, and protein metabolism.There are differences in the amino-acid sequenceof animal insulins, human insulins, and the human insulinanalogues. Human sequence insulin may be producedsemisynthetically by enzymatic modification ofporcine insulin (emp) or biosynthetically by recombinantDNA technology using bacteria (crb, prb) or yeast(pyr).Immunological resistance to insulin action is uncommon.Preparations of human sequence insulin shouldtheoretically be less immunogenic than other insulinpreparations, but no real advantage has been shown intrials.Insulin is inactivated by gastro-intestinal enzymes, andmust therefore be given by injection; the subcutaneousroute is ideal in most circumstances. Insulin is usuallyinjected into the thighs, buttocks, or abdomen; absorptionfrom a limb site can be increased if the limb is usedin strenuous exercise after the injection. Generally, subcutaneousinsulin injections cause few problems; lipodystrophymay occur and is a factor in poor glycaemiccontrol. Lipodystrophy can be minimised by using differentinjection sites in rotation. Local allergic reactionsare rare.Insulin should be given to all children with type 1diabetes; it may also be needed to treat type 2 diabeteseither when other methods cannot control the conditionor during periods of acute illness or peri-operatively.Insulin is required in all instances of ketoacidosis (section6.1.3), which can develop rapidly in children.NHS Diabetes guidanceSafe and Effective Use of Insulin inHospitalised Patients (March 2010)Available at www.diabetes.nhs.ukManagement of diabetes with insulin The aim oftreatment is to achieve the best possible control ofblood-glucose concentration without making the childor carer obsessional and to avoid disabling hypoglycaemia;close co-operation is needed between the childor carer and the medical team to achieve good controland thereby reduce the risk of complications.Insulin preparations can be divided into 3 types:. those of short duration which have a relativelyrapid onset of action, namely soluble insulin andthe rapid-acting insulin analogues, insulin aspart,insulin glulisine, and insulin lispro (section 6.1.1.1);. those with an intermediate action, e.g. isophaneinsulin (section 6.1.1.2); and. those whose action is slower in onset and lasts forlong periods, e.g. protamine zinc insulin, insulindetemir, and insulin glargine (section 6.1.1.2).6 Endocrine system