Childrens Diabetes: Why a special case

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Childrens Diabetes Why a special case?

• Stephen Greene
• Tayside Institute Child Health
• University of Dundee

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Special Requirements

• Numbers
• Necessity
• Needs
• New

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Type 1 Diabetes The Classic Problem

• A young person
• Commonly under 15 years age
• Rising in the very young
• Incidence prevalence lt 15 yr. Age
• 250-300 new case per year
• 2000 in Scotland
• Primary care
• 0-1 cases per per GP
• Variation of presenting symptoms
• Mild polyuria, polydipsia, general malaise
• Severe Diabetic Ketoacidosis
• Age related

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Increase in Childhood Diabetes Scotland 1960
-1995
Scottish Study Group for the Care of the Young
Diabetic Register

• Per 100,000 pop. lt16 yr. age
• Male
• Female

1960
1995
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Special Case Numbers

• Collection of Patients
• Concentration of expertise
• Economies of scale
• Audit of outcome
• Dispersal of information, technology etc.

Children or Type 1 diabetes?
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The Diabetes Team

• Medical Specialisation
• Paediatric Diabetologists
• Diabetes Nurse Specialists
• Paediatric v. Adult?
• Community v. Hospital Based?
• Dietitian
• Clinical Psychologist
• Social Worker
• Local Family Support Group

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Why the Necessity ?

• Acute General Health
• Diabetic Ketoacidosis
• Hypoglycaemia
• Growth Development
• Schooling
• Family Development

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Why the Necessity ?

• Long-term Health
• Avoidance of the complications of chronic glucose
  toxicty

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The Needs of the Special Case Effective glucose
control
Insulin Profiles Over 24 hours
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Injected Insulin Profiles
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Glycosylated Haemoglobin Distribution of HbA1c
across Scotland

• n 1609
• of patients
• HbA1c

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Insulin Adherence
plt0.001
Morris et al, MEMO/DARTS 1997
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Insulin Adherence
Morris et al, MEMO/DARTS 1997
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Supporting the Diabetes Regimen

• Education
• Practical instruction
• Troubleshooting
• Patient Support Network
• Professional Support Network DiabNet
• Innovative
• Accessible
• Affordable

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Future management of Type 1 diabetes

• New insulin therapies?
• Prevention of IDDM
• Service delivery

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Possible new approaches with insulin?

• Insulin regimens
• Analogues (Fast acting / Slow acting)
• Pumps
• Nasal insulin
• Non-Insulin Therapy
• Insulin like growth factor 1 (IGF-1)
• Islet Cell Transplant

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Continous Subcutaneous Insulin Infusion
(CSII)Pump Insulin
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Prevention of Type 1 diabetes

• Prediction
• HLA Islet cell antibodies GAD antibodies
  Insulin antibodies
• Current studies
• Breast feeding v. cows milk in infancy
• Insulin therapy in pre-diabetes
• Nicotinamide therapy in pre-diabetes

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Prevention studies What if successful?

• Implications for the future
• A new approach
• New skills
• Significant numbers requiring resources
• clinic 100 patients 20 new patients per year
• screening 100 subjects per annum
• 3-5 at risk to be considered for therapy
• routine frequent monitoring
• drug therapy
• beta cell function

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Islet Cell Transplantation

• Previous Studies
• Sustained insulin independence.
• Previously 8 of patients receiving pancreatic
  islet transplantation remain insulin-independent
  for up to 1 year,
• difficulties in obtaining a sufficient number of
  beta cells
• graft rejection. immunosuppressive regimens
  include steroids such as glucocorticoids, induce
  insulin resistance.

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Islet Cell Transplantation

• New England Journal of Medicine July 2000,
  Shapiro et al. (Canada)
• Immunosuppression
• glucocorticoid-free - tacrolimus, sirolimus and
  daclizumab
• Islet cells isolated from cadaver pancreata
• Injected main portal vein of the liver
• Seven patients discontinue insulin therapy for
  an average of 12 months and did not experience
  acute cellular rejection.

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What was new?

• New recipe for islets
• New anti-rejection medicine

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What are the Problems?

• Is it true
• Better statistical tests are required
• How long will the Islets last for?
• Are there any side effects?
• Injections
• Drug therapy

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If it works?..

• Where will the islets come from?

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Islet Cell Production

• Cadaver donors.
• Xenogenic islet cells
• Transgenic Pigs
• Cross-infection
• Pancreatic duct cells
• Long-term cultures
• Unproved
• Fetal pancreas cells
• Long-term production
• Unproved
• Stem Cells / Therapeutic Cloning
• Differentiation
• Genetic Modulation

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