409during hypoglycemia is reduction in intra-islet insulin which is a signal to
α-cell to secrete glucagon; this is defective in patients with T1DM as a
result of absolute insulin deficiency. In addition, autonomic neuropathy due
to long-standing diabetes also impairs glucagon secretion and predisposes
for neuroglycopenia.- A 25-year-old man with T1DM who is on basal–bolus insulin regimen (lispro
and glargine) had a glucose profile: FPG 200 mg/dl, post-breakfast 180 mg/dl,
post-lunch 140 mg/dl, and post-dinner 130 mg/dl. He denies any episode of
hypoglycemia. How to proceed further?
Predominant abnormality in glucose profile of the index patient is fasting
hyperglycemia. Fasting hyperglycemia may occur as a result of early morn-
ing hypoglycemia (Somogyi phenomenon) or hyperglycemia (dawn
phenomenon). Therefore, 0300–0400h blood glucose estimation is recom-
mended to differentiate between them. Fasting hyperglycemia due to
Somogyi phenomenon requires reduction in insulin doses, whereas exag-
gerated dawn phenomenon needs an increase in insulin doses. The index
patient had 0300h blood glucose of 60 mg/dl suggestive of Somogyi phe-
nomenon as a cause for the fasting hyperglycemia; hence, the dose of
glargine was reduced.- When should treatment be initiated for hypertension in children and adoles-
cents with T1DM?
In children and adolescents with T1DM having systolic or diastolic BP con-
sistently ≥ 90 th percentile for age, sex, and height, lifestyle modification
including dietary intervention and exercise should be initiated. If target
blood pressure is not achieved within 3–6 months, pharmacological inter-
vention should be considered. If SBP or DBP is consistently ≥ 95 th percentile
for age, sex, and height, pharmacological treatment along with lifestyle
modification should be initiated. ACE inhibitors are the drug of choice for
hypertension in patients with T1DM; however, if not tolerated, ARBs should
be considered.- When to add statin in children and adolescents with T1DM?
Lipid profile should be measured in children and adolescents with T1DM
≥2 years of age after optimum blood glucose control. If LDL-C is <100 mg/
dl, then five yearly monitoring is recommended. In children between 2 and
10 years of age having LDL-C>100 mg/dl, medical nutrition therapy
(MNT) aimed at restricting saturated fat and dietary cholesterol intake
(7 % of total calories and 200 mg/day, respectively) is indicated. Statin
therapy is recommended in children older than 10 years (paucity of data
<10 years), if LDL-C is >160 mg/dl or >130 mg/dl with one or more12 Diabetes in the Young