The influence of patient variables on insulin total daily dose in paediatric inpatients with new onset type 1 diabetes mellitus

Abstract

Purpose Insulin dose requirements at new diagnosis of type 1 diabetes mellitus (T1DM) vary widely. Current guidelines recommend an initial total daily dose (TDD) ranging from 0.5 to 1.0 IU/kg/day. It often takes several days of frequent dose adjustments before an optimal insulin dose is achieved. The aim of this study was to identify the influence of patient variables on the dose-requirement of insulin in newly diagnosed children with T1DM. Methods A retrospective chart review of children (≤ 18 years old) admitted to hospital between 2010 and 2016 due to new onset T1DM was undertaken. Demographic, clinical, insulin dosing, and laboratory data were recorded. The influence of patient characteristics on insulin TDD was analysed statistically by performing univariate and multivariate linear regression analyses. Results Complete clinical records for 70 patients were available for analysis. The median insulin TDD on first day of admission was 21 (4.5 to 75 units) and that on the day before discharge was 27 (5.5 to 124 units). In the multivariate regression analysis, body size (total body weight and fat-free mass), glycated haemoglobin (HbA1C), and blood ketone concentration were found to be significant predictors of optimal insulin TDD (p < 0.05). Conclusion In addition to body size, HbA1c and ketone concentrations are useful in calculating initial TDD in newly diagnosed children with T1DM. This could potentially decrease the number of days needed to reach a stable dose and result in improved early glycaemic control.

Catabolism of fats and branched‐chain amino acids in children with Type 1 diabetes: Association with glycaemic control and total daily insulin dose

“… 49 , 50 , 51 The ratio of TG to HDL has previously been associated with IR in obese adolescents. 52 Total daily insulin dose (TDD, units/kg/d) correlates inversely with whole body insulin sensitivity 12 , 13 but is influenced by various other factors, including patient age, macronutrient intake, energy expenditure and pubertal stage, given that increases in sex steroids and growth hormone are associated with decreased insulin sensitivity and consequent increases in insulin. 12 , 13 About 80% of our subjects were prepubertal, and the remaining were in early puberty.…”

“… 52 Total daily insulin dose (TDD, units/kg/d) correlates inversely with whole body insulin sensitivity 12 , 13 but is influenced by various other factors, including patient age, macronutrient intake, energy expenditure and pubertal stage, given that increases in sex steroids and growth hormone are associated with decreased insulin sensitivity and consequent increases in insulin. 12 , 13 About 80% of our subjects were prepubertal, and the remaining were in early puberty. Although there was a significant positive correlation between pubertal status and HbA1c, there were no significant correlations between pubertal status and other metrics of glycaemic control (TIR), insulin sensitivity (total and HMW adiponectin, TG/HDL ratio) or TDD (units/kg/d).…”

“…Surrogate measures of IR included total and high molecular weight adiponectin, and the triglyceride (TG) to high‐density lipoprotein (HDL) ratio. We also measured total daily insulin dose (TDD, units/kg/d), which can reflect in part the sensitivity to insulin action 12,13 as well as the daily macronutrient intake and energy expenditure. In poorly controlled individuals with T1D, hypercortisolaemia and elevated cytokines can induce proteolysis and muscle catabolism and reduce muscle protein synthesis 18,19 .…”

“…2,3 Factors postulated to contribute to IR in T1D include free fatty acidaemia, 2 growth hormone (GH) hypersecretion, [4][5][6][7][8] hypercortisolaemia, 4,9,10 excess adiposity 11 and pubertal progression, especially in girls. 12,13 While the prevalence of obesity is increasing in individuals with T1D, studies have also demonstrated that normalweight adolescents and adults with T1D are less sensitive to insulin than controls without T1D with similar BMI. 3,[14][15][16] We previously showed that IR in adolescents with obesity is associated with sex-dependent derangements in the catabolism of branched-chain amino acids (BCAA) and fatty acids.…”

“… 2 , 3 Factors postulated to contribute to IR in T1D include free fatty acidaemia, 2 growth hormone (GH) hypersecretion, 4 , 5 , 6 , 7 , 8 hypercortisolaemia, 4 , 9 , 10 excess adiposity 11 and pubertal progression, especially in girls. 12 , 13 While the prevalence of obesity is increasing in individuals with T1D, studies have also demonstrated that normal‐weight adolescents and adults with T1D are less sensitive to insulin than controls without T1D with similar BMI. 3 , 14 , 15 , 16 …”