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).