BNF for Children 2011-2012

360 6.1.3 Diabetic ketoacidosis BNFC 2011–20126 Endocrine systemmetformin—see Lactic Acidosis above. Suspend metforminprior to the test; restart no earlier than 48 hours after the testif renal function has returned to baselineHepatic impairment withdraw if tissue hypoxia likelyRenal impairment see under CautionsPregnancy used in pregnancy for both pre-existingand gestational diabetes—see also Pregnancy andBreast-feeding, p. 358Breast-feeding may be used during breast–feeding—see also Pregnancy and Breast-feeding, p. 358Side-effects anorexia, nausea, vomiting, diarrhoea(usually transient), abdominal pain, taste disturbance;rarely lactic acidosis (withdraw treatment), decreasedvitamin-B 12 absorption, erythema, pruritus and urticaria;hepatitis also reportedLicensed use not licensed for use in children under10 yearsIndication and doseDiabetes mellitus (see notes above) specialistsupervision only. By mouthChild 8–10 years initially 200 mg once dailyadjusted according to response at intervals of atleast 1 week; max. 2 g daily in 2–3 divided dosesChild 10–18 years initially 500 mg once dailyadjusted according to response at intervals of atleast 1 week; max. 2 g daily in 2–3 divided dosesMetformin (Non-proprietary) ATablets, coated, metformin hydrochloride 500 mg, netprice 28-tab pack = £1.07, 84-tab pack= £1.57;850 mg, 56-tab pack = £1.67. Label: 21Oral solution, sugar-free, metformin hydrochloride500 mg/5 mL, net price 100 mL = £62.48. Label: 21Brands include Metsol cGlucophage c (Merck Serono) ATablets, f /c, metformin hydrochloride 500 mg, netprice 84-tab pack = £2.88; 850 mg, 56-tab pack =£3.20. Label: 21Oral powder, sugar-free, metformin hydrochloride500 mg/sachet, net price 30-sachet pack = £3.29, 60-sachet pack = £6.58; 1 g/sachet, 30-sachet pack =£6.58, 60-sachet pack = £13.16. Label: 13, 21, counselling,administrationExcipients include aspartame (section 9.4.1)Counselling The contents of each sachet should be mixedwith 150 mL of water and taken immediatelyThe Scottish Medicines Consortium (p. 3) has advised(March 2010) that Glucophage c oral powder is accepted forrestricted use within NHS Scotland for the treatment of type2 diabetes mellitus in patients who are unable to swallow thesolid dosage form.6.1.2.3 Other antidiabetic drugsThere is little experience of the use of acarbose inchildren. It has been used in older children; therapyshould be initiated by an appropriate expert.The use of nateglinide in combination with a sulfonylureais generally reserved for the management of somesubtypes of diabetes resulting from genetic defects ofbeta-cell function or other syndromes of diabetes andrequires specialist management.6.1.3 Diabetic ketoacidosisThe management of diabetic ketoacidosis involves thereplacement of fluid and electrolytes and the administrationof insulin. Guidelines for the Management ofDiabetic Ketoacidosis, published by the British Societyof Paediatric Endocrinology and Diabetes 1 , should befollowed. Clinically well children with mild ketoacidosiswho are dehydrated up to 5% usually respond to oralrehydration and subcutaneous insulin. For those who donot respond, or are clinically unwell, or are dehydratedby more than 5%, insulin and replacement fluids arebest given by intravenous infusion.. To restore circulating volume for children in shock,give 10 mL/kg sodium chloride 0.9% as a rapidinfusion, repeat as necessary up to a maximum of30 mL/kg.. Further fluid should be given by intravenous infusionat a rate that replaces deficit and providesmaintenance over 48 hours; initially use sodiumchloride 0.9%, changing to sodium chloride0.45% and glucose 5% after 12 hours if responseis adequate and plasma-sodium concentration isstable.. Include potassium chloride in the fluids unlessanuria is suspected, adjust according to plasmapotassiumconcentration.. Insulin infusion is necessary to switch off ketogenesisand reverse acidosis; it should not be starteduntil at least 1 hour after the start of intravenousrehydration fluids.. Soluble insulin should be diluted (and mixed thoroughly)with sodium chloride 0.9% intravenousinfusion to a concentration of 1 unit/mL andinfused at a rate of 0.1 units/kg/hour.. Sodium bicarbonate infusion (1.26% or 2.74%) israrely necessary and is used only in cases ofextreme acidosis (blood pH less than 6.9) andshock, since the acid-base disturbance is normallycorrected by treatment with insulin.. Once blood glucose falls to 14 mmol/litre, glucoseintravenous infusion 5% or 10% should be addedto the fluids.. The insulin infusion rate can be reduced to no lessthan 0.05 units/kg/hour when blood-glucose concentrationhas fallen to 14 mmol/litre and blood pHis greater than 7.3 and a glucose infusion has beenstarted (see above); it is continued until the child isready to take food by mouth. Subcutaneous insulincan then be started.. The insulin infusion should not be stopped until 1hour after starting subcutaneous soluble or longactinginsulin, or 10 minutes after starting subcutaneousinsulin aspart, or insulin glulisine, or insulinlispro.Hyperosmolar hyperglycaemic state or hyperosmolarhyperglycaemic nonketotic coma occurs rarely in children.Treatment is similar to that of diabetic ketoacidosis,although lower rates of insulin infusion and slowerrehydration may be required.1. Available at www.bsped.org.uk