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.