MMPAD Munich Meeting Report

MEETING REPORT 14 European Roadshow - Friday 25 th May, 2018 Munich, Germany prior to injection. Peak concentrations are reached after 6 hours, which is, according to Karges, undesirable if one wants to count carbohydrates and calculate dosage. On the other hand, she saw a benefit for school children because they would not need additional injections when snacking in between meals. • Long-acting insulin analogues Insulin glargine U100 was the first basal analogue to be approved in the clinical setting. It was approved for pre-school children (2–6 years). It acts by the insulin being slowly released from microcrystals. Injection techniques must be strictly followed. Karges warned not to inject insulin glargine U100 into the muscle, because this might lead to long-lasting and severe hypoglycaemic events. Insulin glargine U300 is a next generation basal analogue whose action persists for 3–5 days. Its metabolism is similar to that of insulin glargine U100. The benefit of insulin glargine U300 is that it achieves more stable and predictable blood sugar control in type 1 diabetes than insulin glargine U100. Fewer fluctuations in glucose concentrations and hypoglycaemic events were observed. Studies for its approval in paediatric patients are still under way. Insulin detemir achieves its slow dissociation by albumin binding. According to Karges, its use reduces weight gain and lowers the risk for hypoglycaemic episodes compared with NPH and insulin glargine. Yet, higher insulin dosages are required compared with insulin glargine. Among paediatric patients, 70% receive insulin detemir twice daily. • Ultra-long acting insulin analogues have been approved for children of more than 1 year old. For financial reasons, insulin degludec is not currently available in Germany, the speaker explained. Its benefits include a reduction in hyperglycaemia and ketosis. Moreover, it does not need to be administered at the same time every day, as its efficacy lasts up to 40 hours. Ultra-long acting insulin analogues can also be combined with short-acting insulins. • Pre-mixed insulins consist of rapid- acting analogues or regular insulin, mixed with NPH in a 10:90, 15:85, 20:80, 30:70, 40:60 or 50:50 ratio. Fixed preparations may reduce potential mistakes; however, they may also compromise flexibility. Pre- pubertal children receive injections twice a day. In younger children, there is no evidence for reduced efficacy. When and how is insulin absorbed? Insulin absorption depends on many factors. In young children with little subcutaneous fatty tissue, absorption is faster. Subcutaneous insulin is absorbed more rapidly if it is injected into the stomach rather than the upper thigh. If physical exercise is carried out following the injection, circulation in the muscles is increased and insulin may exert its effects more rapidly. An elevated body temperature and ambient air temperature also have similar effects in increasing absorption. Insulin dosage Insulin dose depends on age, bodyweight, pubertal status, diabetes duration, injection site condition, nutrition, physical activity, daily routine and additional illnesses. Since improvements of glycaemic control minimise the risk of complications, the insulin dosage must be adapted according to measured glucose levels. In patients with type 1 diabetes, more frequent self-assessment of glucose levels is associated with lower HbA1c levels. "The more the patient checks glucose levels, the better the HbA1c values are", Karges said. Self-assessment also helps to manage dosing during physical activity. The HbA1c value is a predictor of DKA and a biomarker for long-term complications, although this value does not measure glycaemic variability. An HbA1c value above 9%, for example, is associated with a 20-fold increase in the risk of DKA compared to an HbA1c value of 6%, Karges explained. An increased HbA1c value is also associated with a higher rate and earlier occurrence of retino- and nephropathies.