Esnek İnsülin Tedavisi Alan Tip 1 Diyabetli Çocuk ve Adolesanların 2 Yıllık İzlem Sonuçları ve Tedaviye Uyumun Değerlendirilmesi

Abstract

Amaç: Esnek insülin tedavisi, öğünlerin zamanı, yiyecek seçimi ve öğünlerdeki insülin dozunun karbonhidrat sayımı yaparak kişinin yaşam tarzına göre ayarlandığı yoğun insülin tedavisidir. Çalışmamızın amacı tip 1 diyabetli çocuklarda esnek insülin tedavisinin metabolik kontrole, antropometrik özelliklere ve sağlık parametrelerine etkilerinin incelenmesi ve tedaviye uyumun değerlendirilmesidir. Gereç ve Yöntemler: Esnek insülin tedavisini balayı dönemi sonrası en az 2 yıl süre kullanan tip 1 diyabetli 39 hastanın, dosya verileri retrospektif olarak incelendi. İki yıllık izlemde ortalama HbA1c düzeyi >%7.5 olan hastalar grup 1, ≤%7.5 olan hastalar grup 2 olarak tanımlandı. Her grubun 2 yıllık seyri değerlendirildi, gruplar karşılaştırıldı. Bulgular: Hastaların ortanca diyabet süresi 52 (25-152) aydı. Grup 1’de 23 (%59) hasta, grup 2’de 16 (%41) hasta mevcuttu. Gruplar arasında diyabet süresi benzerdi(p>0.05). Grup 2’deki olguların, başlangıç HbA1c düzeyleri daha yüksekti (9.3 vs 11.6, p=0.046). Her iki grubun da tedavinin 1. yılında HbA1c düzeyinin azaldığı (p<0.05); tedavinin 2. yılında grup 2’nin iyi kontrollerini sürdürdükleri, ancak grup 1’de HbA1c düzeyinin arttığı saptandı (p<0.001). Grup 2’deki hastaların boya göre vücut tartı yüzdeleri (%VKİ) tedavinin 2. yılında başlangıca göre artmakla beraber (p=0.031), idealdi. Grup 1’deki hastaların tedavi başlangıcına göre 2 yıllık izlem sonunda %VKİ’leri değişmedi (p>0.05). Her 2 gruptaki olgular da genetiği içinde büyüyen ve yıllık uzamaları normal olan olgulardı. Esnek tedavi alan tüm hastalar değerlendirildiğinde izlemin 2. yılında, ortalama insülin dozlarının arttığı saptandı (p=0). Grup 2’deki hastalar diyetine uyan (p=0.038), karbonhidrat sayımı yapan (p=0.025) ve daha az hazır yemek tüketen (p=0.018) hastalardı. Gruplar arasında ciddi hipoglisemi ve diyabetik ketoasidoz sıklığı benzerdi(p>0.05). Grup 1’deki trigliserid, total kolesterol, LDL, VLDL düzeyleri grup 2’den yüksek, HDL düzeyi düşük olmasına rağmen, fark saptanmadı (p>0.05). Dislipidemi gelişen hastaların ortanca diyabet süresi, dislipidemi gelişmeyen hastalardan daha uzundu(p=0.018). Sonuç: Esnek insülin tedavisi, sağlıklı beslenen ve etkili karbonhidrat sayımı yapan çocuklarda, %VKİ’inde anormal artış yapmadan HbA1c düzeyini ≤%7.5 düşürebilir.

Keywords

• Tip 1 diyabet,esnek insülin tedavisi,karbonhidrat sayımı,HbA1c

Flexible Insulin Therapy of Children and Adolescents with Type 1a Diabetes After 2 Years: Follow-up Results and Compliance of Treatment

Abstract

Objective: Flexible insulin therapy is intensive insulin therapy where the time of meals, food selection, and the dose of insulin in meals are adjusted to the patient’s lifestyle by carbohydrate counting. The aim of our study is to investigate the effects of flexible insulin treatment on metabolic control, anthropometric properties and health parameters in children with type 1 diabetes and to evaluate compliance with treatment. Material and Methods: Medical records of 39 children who used flexible insulin treatment at least 2 years after honeymoon period were retrospectively evaluated. Patients were grouped according to mean HbA1c as group 1 (HbA1c >7.5%) and group 2 (<7.5%). The 2-year follow-up of each group was evaluated, groups were compared. Results: Median diabetes duration was 52 (25-152) months. Group 1 and 2 included 23 (59%) and 16 (41%) patients, respectively. Diabetes duration was similar (p>0.05). Group 2 had higher initial HbA1c levels (9.3 vs 11.6, p=0.046). HbA1c levels of both groups were decreased at first year (p<0.05). In the second year of treatment, group 2 maintained good glycemic control whereas group 1 had increased HbA1c level (p<0.001). Although mean relative weight index ( RWI) increased in the second year of treatment (p=0.031) in group 2, their mean RWI was ideal. RWI did not changed in group 1 after 2 year follow-up of treatment (p>0.05). All patients had normal growth according to their genetic potential. Mean insulin dose of patients was increased in second year (p=0). Compliance of diet (p=0.038), carbohydrate count (p=0.025) and less fast food consumption(p=0.018) were more common in group 2. Conclusion: The frequency of severe hypoglycemia and diabetic ketoacidos were similar (p>0.05). Group 1 had higher triglyceride, total cholesterol, LDL, VLDL and lower HDL levels but not statistically significant (p>0.05). Patients with dyslipidemia had longer median diabetes duration than without dyslipidemia (p=0.018).

Keywords

• Type 1 diabetes,flexible insulin therapy,carbohydrate counting

References

1. Referans 1. Diabetes C, Complications Trial Research G, Nathan DM, Genuth S, Lachin J, Cleary P, et al. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329: 977-86.
2. Referans 2. Kawamura T. The importance of carbohydrate counting in the treatment of children with diabetes. Pediatr Diabetes 2007; 8 Suppl 6: 57-62. Referans 3. Norris A, Wolfsdorf JI. Brook's Clinical Pediatric Endocrinology. NJ, USA: : Wiley-Blackwell.; 2009. 458-504
3. Referans 4. Neu A, Lange K, Barrett T, Cameron F, Dorchy H, Hoey H, et al. Classifying insulin regimens--difficulties and proposal for comprehensive new definitions. Pediatr Diabetes 2015; 16: 402-6.
4. Referans 5. Schmidt S, Schelde B, Norgaard K. Effects of advanced carbohydrate counting in patients with type 1 diabetes: a systematic review. Diabet Med 2014; 31: 886-96.
5. Referans 6. Bizzarri C, Timpanaro TA, Matteoli MC, Patera IP, Cappa M, Cianfarani S. Growth Trajectory in Children with Type 1 Diabetes Mellitus: The Impact of Insulin Treatment and Metabolic Control. Horm Res Paediatr 2018; 89: 172-7.
6. Referans 7. Franc S, Dardari D, Boucherie B, Riveline JP, Biedzinski M, Petit C, et al. Real-life application and validation of flexible intensive insulin-therapy algorithms in type 1 diabetes patients. Diabetes Metab 2009; 35: 463-8.
7. Referans 8. Gokcay G, Furman A, Neyzi O. Updated growth curves for Turkish children aged 15 days to 60 months. Child Care Health Dev 2008; 34: 454-63.
8. Referans 9. Neyzi O, Furman A, Bundak R, Gunoz H, Darendeliler F, Bas F. Growth references for Turkish children aged 6 to 18 years. Acta Paediatr 2006; 95: 1635-41.

9. Referans 10. Chiang JL, Kirkman MS, Laffel LM, Peters AL, Type 1 Diabetes Sourcebook A. Type 1 diabetes through the life span: a position statement of the American Diabetes Association. Diabetes Care 2014; 37: 2034-54.
10. Referans 11. Blasetti A, Di Giulio C, Tocco AM, Verrotti A, Tumini S, Chiarelli F, et al. Variables associated with severe hypoglycemia in children and adolescents with type 1 diabetes: a population-based study. Pediatr Diabetes 2011; 12: 4-10.
11. Referans 12. Bonfig W, Kapellen T, Dost A, Fritsch M, Rohrer T, Wolf J, et al. Growth in children and adolescents with type 1 diabetes. J Pediatr 2012; 160: 900-3 e2.
12. Referans 13. Chemtob CM, Hochhauser CJ, Shemesh E, Schmeidler J, Rapaport R. Does poor early metabolic control predict subsequent poor control in young children with type 1 diabetes: an exploratory study. J Diabetes 2011; 3: 153-7.
13. Referans 14. Dabelea D, Rewers A, Stafford JM, Standiford DA, Lawrence JM, Saydah S, et al. Trends in the prevalence of ketoacidosis at diabetes diagnosis: the SEARCH for diabetes in youth study. Pediatrics 2014; 133: e938-45. Referans 15. Karaguzel G, Simsek S, Deger O, Okten A. Screening of diabetes, thyroid, and celiac diseases-related autoantibodies in a sample of Turkish children with type 1 diabetes and their siblings. Diabetes Res Clin Pract 2008; 80: 238-43.
14. Referans 16. Warncke K, Frohlich-Reiterer EE, Thon A, Hofer SE, Wiemann D, Holl RW, et al. Polyendocrinopathy in children, adolescents, and young adults with type 1 diabetes: a multicenter analysis of 28,671 patients from the German/Austrian DPV-Wiss database. Diabetes Care 2010; 33: 2010-2.
15. Referans 17. Xin Y, Yang M, Chen XJ, Tong YJ, Zhang LH. Clinical features at the onset of childhood type 1 diabetes mellitus in Shenyang, China. J Paediatr Child Health 2010; 46: 171-5.
16. Referans 18. Alemzadeh R, Berhe T, Wyatt DT. Flexible insulin therapy with glargine insulin improved glycemic control and reduced severe hypoglycemia among preschool-aged children with type 1 diabetes mellitus. Pediatrics 2005; 115: 1320-4.
17. Referans 19. Adhikari S, Adams-Huet B, Wang YC, Marks JF, White PC. Institution of basal-bolus therapy at diagnosis for children with type 1 diabetes mellitus. Pediatrics 2009; 123: e673-8.
18. Referans 20. Hayes RL, Garnett SP, Clarke SL, Harkin NM, Chan AK, Ambler GR. A flexible diet using an insulin to carbohydrate ratio for adolescents with type 1 diabetes - a pilot study. Clin Nutr 2012; 31: 705-9.
19. Referans 21. Alemzadeh R, Ellis JN, Holzum MK, Parton EA, Wyatt DT. Beneficial effects of continuous subcutaneous insulin infusion and flexible multiple daily insulin regimen using insulin glargine in type 1 diabetes. Pediatrics 2004; 114: e91-5.
20. Referans 22. Paivarinta M, Tapanainen P, Veijola R. Basal insulin switch from NPH to glargine in children and adolescents with type 1 diabetes. Pediatr Diabetes 2008; 9: 83-90.
21. Referans 23. Goksen D, Atik Altinok Y, Ozen S, Demir G, Darcan S. Effects of carbohydrate counting method on metabolic control in children with type 1 diabetes mellitus. J Clin Res Pediatr Endocrinol 2014; 6: 74-8.
22. Referans 24. Kadlubiska A, Malachowska B, Noiszewska K, Fendler W, Glowinska-Olszewska B, Bossowski A, et al. Five-year observation of the relationship between body mass index and glycated hemoglobin in children with Type 1 diabetes mellitus. Scand J Clin Lab Invest 2018; 78: 398-406.
23. Referans 25. Fu S, Li L, Deng S, Zan L, Liu Z. Effectiveness of advanced carbohydrate counting in type 1 diabetes mellitus: a systematic review and meta-analysis. Sci Rep 2016; 6: 37067.
24. Referans 26. Patton SR, Dolan LM, Powers SW. Dietary adherence and associated glycemic control in families of young children with type 1 diabetes. J Am Diet Assoc 2007; 107: 46-52.
25. Referans 27. Colino E, Lopez-Capape M, Golmayo L, Alvarez MA, Alonso M, Barrio R. Therapy with insulin glargine (Lantus) in toddlers, children and adolescents with type 1 diabetes. Diabetes Res Clin Pract 2005; 70: 1-7.
26. Referans 28. Jackson A, Ternand C, Brunzell C, Kleinschmidt T, Dew D, Milla C, et al. Insulin glargine improves hemoglobin A1c in children and adolescents with poorly controlled type 1 diabetes. Pediatr Diabetes 2003; 4: 64-9.
27. Referans 29. Hochhauser CJ, Rapaport R, Shemesh E, Schmeidler J, Chemtob CM. Age at diagnosis, gender, and metabolic control in children with type 1 diabetes. Pediatr Diabetes 2008; 9: 303-7.
28. Referans 30. Munoz MT, Barrios V, Pozo J, Argente J. Insulin-like growth factor I, its binding proteins 1 and 3, and growth hormone-binding protein in children and adolescents with insulin-dependent diabetes mellitus: clinical implications. Pediatr Res 1996; 39: 992-8.
29. Referans 31. Parthasarathy L, Khadilkar V, Chiplonkar S, Khadilkar A. Longitudinal Growth in Children and Adolescents with Type 1 Diabetes. Indian Pediatr 2016; 53: 990-2.
30. Referans 32. Mao L, Lu W, Ji F, Lv S. Development and linear growth in diabetic children receiving insulin pigment. J Pediatr Endocrinol Metab 2011; 24: 433-6.
31. Referans 33. Plamper M, Gohlke B, Woelfle J, Konrad K, Rohrer T, Hofer S, et al. Interaction of Pubertal Development and Metabolic Control in Adolescents with Type 1 Diabetes Mellitus. J Diabetes Res 2017; 2017: 8615769.
32. Referans 34. Dias VM, Pandini JA, Nunes RR, Sperandei SL, Portella ES, Cobas RA, et al. Effect of the carbohydrate counting method on glycemic control in patients with type 1 diabetes. Diabetol Metab Syndr 2010; 2: 54.
33. Referans 35. Golmayo Gaztelu L, Ros Perez P, Alonso Blanco M, Martin-Frias M, Barrio Castellanos R. [Nine-year longitudinal study of cardiovascular risk factors in Spanish children and adolescents with type 1 diabetes]. An Pediatr (Barc) 2015; 83: 40-6.
34. Referans 36. Hogel J, Grabert M, Sorgo W, Wudy S, Gaus W, Heinze E. Hemoglobin A1c and body mass index in children and adolescents with IDDM. An observational study from 1976-1995. Exp Clin Endocrinol Diabetes 2000; 108: 76-80.
35. Referans 37. Wiegand S, Raile K, Reinehr T, Hofer S, Nake A, Rabl W, et al. Daily insulin requirement of children and adolescents with type 1 diabetes: effect of age, gender, body mass index and mode of therapy. Eur J Endocrinol 2008; 158: 543-9.
36. Referans 38. Bloch CA, Clemons P, Sperling MA. Puberty decreases insulin sensitivity. J Pediatr 1987; 110: 481-7.
37. Referans 39. Demir F. Tip ! diyabetli çocuk ve adolesanların etyolojiden prognoza retrospektif değerlendirilmesi (1985-2004): İstanbul Üniversitesi Tıp Fakültesi; 2004
38. Referans 40. Poyrazoğlu Ş, Bundak R, Baş F, Darendeliler F, Günoz H. Tip 1 diyabetli çocuklarda büyüme ve puberte. Çocuk Dergisi 2004: 83-7.
39. Referans 41. Pereira KC, Pugliese BS, Guimaraes MM, Gama MP. Pubertal development in children diagnosed with diabetes mellitus type 1 before puberty. J Pediatr Adolesc Gynecol 2015; 28: 66-71.
40. Referans 42. Rohrer T, Stierkorb E, Heger S, Karges B, Raile K, Schwab KO, et al. Delayed pubertal onset and development in German children and adolescents with type 1 diabetes: cross-sectional analysis of recent data from the DPV diabetes documentation and quality management system. Eur J Endocrinol 2007; 157: 647-53.
41. Referans 43. Alemzadeh R, Palma-Sisto P, Parton E, Totka J, Kirby M. Beneficial effects of flexible insulin therapy in children and adolescents with type 1 diabetes mellitus. Acta Diabetol 2003; 40: 137-42.
42. Referans 44. Effect of intensive diabetes treatment on the development and progression of long-term complications in adolescents with insulin-dependent diabetes mellitus: Diabetes Control and Complications Trial. Diabetes Control and Complications Trial Research Group. J Pediatr 1994; 125: 177-88.
43. Referans 45. Hypoglycemia in the Diabetes Control and Complications Trial. The Diabetes Control and Complications Trial Research Group. Diabetes 1997; 46: 271-86.
44. Referans 46. Levine BS, Anderson BJ, Butler DA, Antisdel JE, Brackett J, Laffel LM. Predictors of glycemic control and short-term adverse outcomes in youth with type 1 diabetes. J Pediatr 2001; 139: 197-203.
45. Referans 47. Rosenbauer J, Dost A, Karges B, Hungele A, Stahl A, Bachle C, et al. Improved metabolic control in children and adolescents with type 1 diabetes: a trend analysis using prospective multicenter data from Germany and Austria. Diabetes Care 2012; 35: 80-6.
46. Referans 48. Guy J, Ogden L, Wadwa RP, Hamman RF, Mayer-Davis EJ, Liese AD, et al. Lipid and lipoprotein profiles in youth with and without type 1 diabetes: the SEARCH for Diabetes in Youth case-control study. Diabetes Care 2009; 32: 416-20.