Insulin analogues in children and teens with type 1 diabetes: Advantages and caveats

Insulin analogues have been developed in response to the increasing demand for the achievement and maintenance of meticulous glycemic control starting at the onset of diabetes. Results of the Diabetes Control and Complications Trial in T1D demonstrate unequivocally the need for near normoglycemia as the best means of delaying the onset or slowing the progression of diabetes-related complications. The rapid-acting and very long-acting analogues provide the potential to meet the bolus (meal-related or prandial) and basal demands for physiologic insulin delivery. Data accumulated so far suggest that use of these analogues can decrease the risk of hypoglycemia significantly and may facilitate achievement of lower HbA1c levels. A word of caution is warranted, however. Although studies of these analogues have been somewhat disappointing with respect to glycemic outcomes (lower HbA1c levels in the range of 0.1%-0.2% may have limited clinical significance), one must remember that many of the studies were performed for safety purposes before clinicians and investigators had acquired any experience in their use. Longer term use of these analogues may allow better outcomes to be achieved. With respect to analogue use, specifically in children and teens with diabetes, two issues are worthy of comment. First, there have been few clinical trials in these populations. The lack of adequate studies in the pediatric population is a common experience when new medications are introduced into clinical care. Second, regimens that aim to achieve and maintain meticulous glycemia with either the new analogues or even with traditional insulins make therapeutic demands that some children or teens who have T1D and their families may find difficult, if not impossible, to meet for various reasons, many of which are related to psychosocial or socioeconomic factors. The health care providers involved with these families must remain sensitive to these issues and not forget the multifaceted nature of diabetes management.