Basal Bolus Insulin:
This insulin regimen is useful in case of persistent hyperglycaemia, resulting secondary to long-acting glucocorticoids or intermediate-acting glucocorticoids in divided doses. Usual dose of insulin used in children with Type 1 DM ranges from 0.7-1 U/kg/day (pre pubertal children) to 1-2 U/kg/day (pubertal children). As insulinopenia in DIDM is not expected to be as severe as in Type 1 DM, a lower cumulative dose may be required. However, exact insulin doses to be used in the settings of DIDM among children on ALL directed chemotherapy is not known. In a recent review by Pasqel FJ et al(43), a starting dose of 0.3-0.5 U/kg/day insulin, for basal bolus regimen in hospitalised adult patients with new onset hyperglycaemia is suggested. We suggest to use similar lower dose in children to start with and titrate slowly based on desirable target glucose. Pubertal children and those with insulin resistance may need steep escalation of dose. In this scenario, 25-50 % of basal insulin with 50-75 % of bolus insulin is usually suggested. Higher bolus insulin than usual may be required to compensate for post prandial surge in glucose. Commonly NPH is used as basal insulin, however glargine can also be used especially with dexamethasone (25)(44).
This regimen necessitates close watch for hypoglycaemia, frequent POC glucose monitoring, insulin dose adjustment based on pre-prandial glucose and insulin sensitivity factor, and involvement of parents. However, chance of optimal glucose control is higher in this regimen.