Prandial insulin:
In this regimen, short acting/ rapid acting insulin is used to curtail post prandial glucose surge secondary to defective post prandial insulin secretion. Regular insulin, 0.1 U/kg/dose (for people who eat snack in between meal) or rapid acting insulin (for people who do not eat snack in between meal) is used with each meal. Additional supplemental dose is used based on pre-prandial glucose levels and insulin sensitivity factor. Persistent elevation of pre-prandial glucose beyond the target necessitates increase in previous insulin dose. However, this scheme doesn’t account to progressive increase in insulin resistance which is often seen and not suitable when hyperglycaemia is persistent throughout the day. As of now no study has demonstrated that post-prandial defective insulin secretion as the only mechanism of hyperglycaemia, hence this strategy is often questioned and not suitable in many instances(42). Utility of standalone insulin pumps or insulin pumps with Continuous Glucose Monitoring Systems (CGMS) is limited considering scarcity of data and concerns about general wellbeing of children with leukaemia.
At present, there are no studies to prove superiority of one regimen over other. Considering mechanism of glucocorticoid induced hyperglycaemia, pharmacokinetics of steroid and insulin, it is reasonable to use NPH alone in the presence of predominant post lunch hyperglycaemia with falling glucose levels by the end of the day. Similarly, basal bolus regimen is preferable in the presence of persistent hyperglycaemia throughout the day with long acting steroid or intermediate acting steroid in divided doses.