ESPE 2018 SATELLITE SYMPOSIUM MEETING REPORT

4 MEETING REPORT – ESPE 2018 SATELLITE SYMPOSIUM Insulin Treatment & Advanced Technology in the Management of Children with Diabetes UPDATE ON INSULIN TREATMENT FOR CHILDREN WITH DIABETES Chiarelli began his presentation with a reminder that the prevalence of type 1 diabetes is currently on the rise, with about half a million children affected worldwide and an additional 85,000 cases diagnosed every year. He described type 1 diabetes as a sword of Damocles, hanging over the heads of children, because of the increased risk of microvascular and macrovascular complications. And the underlying processes leading to beta-cell destruction and diabetes remain unclear, Chiarelli stressed, saying that although our understanding of the pathogenesis has increased over recent years, “we don’t know the beast that kills the beta cells”. With that incomplete understanding in mind, he advised the audience to “be humble” and to reconsider a type 1 diabetes diagnosis if, for example, the required insulin dose remains low after many years. Chiarelli gave a reminder of the internationally agreed staging for type 1 diabetes, with stage 1 defined as positivity for one or more islet autoantibodies, and stages 2 and 3 defined by the onset of asymptomatic and symptomatic hyperglycaemia, respectively. Treating these children is no straightforward matter, because not only do insulin needs vary throughout the day, but insulin sensitivity decreases markedly during puberty, accounting for 30% of children’s basal insulin needs. Insulin sensitivity varies even within a 24-hour period, increasing at night and thereby raising the risk for hypoglycaemia. Other factors, such as food intake and physical activity, also influence children’s insulin requirements, creating a narrow therapeutic margin, and it is very difficult to replicate physiological production of insulin, not least because it must be delivered subcutaneously, increasing the required dose. Also influencing choice of insulin regimen are issues such as the child’s age, duration of diabetes, their lifestyle, and personal and family preferences, as well as their physician’s preferences. Chiarelli reminded the audience that a “conventional” regimen, still to some extent used in developing countries, comprises up to five insulin injections per day, not necessarily timed to meals, whereas modern insulin treatment is based on basal insulin with bolus injections adjusted for carbohydrate intake. A basal–bolus regimen is much more physiological than a conventional regimen, he noted, but also more complex to manage. An extract from Prof Chiarelli ‘s presentation is available here