Pharmacotherapy of type 1 diabetes in children and adolescents: more than insulin?
By Dr Torben Biester, Pediatrician and Pediatric Diabetologist at the The Kinder und Jugendkrankenhaus Auf der Bult in Hannover, Germany.
For pediatric patients with type 1 diabetes, intensified insulin therapy, with either multiple daily injections or insulin pump therapy, is currently the only method of treatment. To optimize this therapy, insulin analogues are fixed parts of all therapy regimens. Analogue insulin is a laboratory-grown sub-group of human insulin. It is genetically altered to create either a more rapid-acting or a more uniformly-acting form of insulin. These analogues are advantageous for patients with poor blood sugar management.
The individual decision on the type of insulin used should be based on personal preferences, the same as with daily routines such as sports, school etc. Kids in primary school might prefer to use human insulin, so there is no need to give a breakfast injection in the break, while adolescents like to be flexible on every meal and prefer to use analogues.
New ultra-rapid insulins seem to be beneficial not only in adults but also in the adolescent age group, and are going to be approved soon to reduce postprandial rising of glucose levels.
New developments in long-acting analogues have demonstrated safety and will be regular in pediatrics, we hope, soon. Furthermore, the psychosocial approach for consideration of real-life aspects becomes more the focus of therapeutic regimens and is implemented into international guidelines. Technical improvements, such as continuous glucose monitoring, particularly in combination with pump therapy, support the great success of rapid-acting analogues by reducing hypoglycemia. Insulin pumps that can interrupt insulin administration in prediction of hypoglycemia are standard of care, especially in preschool kids. In Germany, more than 50 % of the pediatric population uses insulin pumps, so insulin pumps are standard in that age group. Glucose sensor therapy is increasing rapidly and gives more insights into glycemic profiles, which allows a more precise treatment and counselling.
Non-insulin agents such as SGLT2-inhibitors show beneficial aspects in people with type 1 diabetes. For outpatient care, with these currently off-label-used drugs, special training for measurement of ketones should be imperative. As it stands today, whether this will be a part of regular T1D therapy in the future is under discussion.
Apart from all medical and technical improvements, psychosocial care and age appropriate education is a must for all families to enable them to give patients a self-led lifestyle with the least possible burden.
Torben Biester, Olga Kordonouri and Thomas Danne
Dr Torben Biester is a Pediatrician and Pediatric Diabetologist at the The Kinder und Jugendkrankenhaus Auf der Bult in Hannover, Germany.