Monitoring while on insulin therapy, glycaemic control targets, dose modification:
After initiation of insulin therapy, all pre-meals and bed-time glucose measurements should be done routinely. In addition, post-meal glucose values give idea about adequacy of bolus insulin. Experience with CGMS in acute hospital setting is scarce, more so with children. Also acute physiological state (dehydration, catabolic state, infection) of children with ALL raises concerns about the accuracy of CGMS. Close watch for hypoglycaemia symptoms and monitoring with POC testing to pick up hypoglycaemia throughout duration of insulin therapy is mandatory. Prompt treatment of hypoglycaemia should be done as per standard protocols and necessary change in the dose of insulin should be made if necessary(45).
As DIDM is known to be transient in majority of cases, intention of treatment is largely to reduce acute metabolic complications and improve outcome of ALL directed therapy. Hence a tight control of glucose is not always mandated in contrast to Type 1 DM. Also, tight glucose control comes with the risk of hypoglycaemia especially in young children. After NICE-SUGAR trial(46) ADA has recommended glycaemic targets of 140-180 mg/dl in critically ill and non-critically ill hospitalised adult patients with diabetes(43)(47). We suggest to follow the same cut offs in children on ALL directed chemotherapy with DIDM than strict glucose control targets used in Type 1 DM(47).
In addition to bolus insulin, supplemental prandial bolus insulin (correction bolus for elevated pre-meal blood sugar) to be administered based on Insulin Sensitivity Factor and pre-meal blood glucose. Correction bolus is calculated by dividing 1500 (1800 in case of rapid acting insulin) by total daily insulin dose, to get the mg/dL of glucose that is lowered by 1 unit of regular insulin(48).
Insulin doses have to be titrated to achieve target glucose. Based on POC capillary blood glucose values over 2-3 days, basal and bolus insulin dose can be adjusted up to 15-20 % at a time(49). So, detailed glucose profiling while on insulin treatment is very useful to monitor, titrate and optimise the treatment. Changes in dose of glucocorticoid mandates the necessary change in insulin dose. Roughly, 50% of change in glucocorticoid dose (increase or decrease), should follow 25 % change in insulin dose.
Most of the time, hyperglycaemia settles within 2 days of stopping steroids(25), hence majority of the cases can be discharged without insulin. In case of continuing insulin therapy, necessary diabetic education to be provided to parents for domiciliary management(49)(50).