Flexible insulin therapy with glargine insulin improved glycemic control and reduced severe hypoglycemia among preschool-aged children with type 1 diabetes mellitus

Background and Objectives. Insulin replacement regimens now stress the importance of administering throughout the day insulin doses that are based on flexible food choices and focusing on improved metabolic control. A flexible multiple daily insulin (FMDI) regimen (premeal lispro plus bedtime glargine) results in lower hemoglobin A(1c) (HbA(1c)) levels and fewer hypoglycemic episodes than does a multiple daily insulin (MDI) regimen among school-aged children and adolescents with type 1 diabetes mellitus (DM). The purpose of this study was to determine the feasibility of FMDI therapy for a group of preschool-aged children with type 1 DM who were transitioned from MDI therapy ( premeal lispro plus ultralente insulin twice per day), by comparing BMI, total daily insulin requirements, HbA(1c) levels, and episodes of severe hypoglycemia. Research Design and Methods. Data were collected over a 2-year period, during quarterly DM clinic visits, from 35 patients ( 17 female patients and 18 male patients, 4.8 +/- 1.0 years of age) who had received MDI insulin therapy for >= 1 year before being transitioned to a FMDI regimen. Results. Although there was no significant change in BMI with FMDI therapy (17.1 +/- 1.8 kg/m(2) vs 17.0 +/- 1.7 kg/m(2)), 43% of patients (6 female subjects and 9 male subjects) were overweight ( BMI of > 85th percentile for age) both before and after treatment. The total daily insulin requirement (0.67 +/- 0.13 U/kg per day vs 0.78 +/- 0.14 U/kg per day) and bolus/basal insulin ratio (1.1 +/- 0.4 vs 1.9 +/- 0.6) were significantly increased and overall glycemic control was improved after transition to FMDI therapy ( HbA(1c) levels: 8.8 +/- 0.9% vs 8.3 +/- 0.8%). However, HbA(1c) levels improved only among normal-weight subjects (9.0 +/- 1.0% vs 8.3 +/- 1.0%) and not among overweight subjects (8.7 +/- 0.7% vs 8.4 +/- 0.6%) after FMDI therapy. The overall rate of severe hypoglycemia was significantly decreased with the FMDI regimen (25.5 events per 100 patient-years vs 10.6 events per 100 patient-years) but again only for normal-weight children (29.7 events per 100 patient-years vs 7.4 events per 100 patient-years). Conclusions. The use of FMDI therapy with glargine among preschool-aged children with type 1 DM was associated with improved overall glycemic control and decreased frequency of severe hypoglycemia. Although our study did not have a control group, these findings suggest that FMDI regimens may be a feasible therapeutic alternative to MDI treatment for preschool-aged children with type 1 DM. However, excess body weight status appeared to preclude a desirable therapeutic response in this group of patients.