Patient case 4.

Titration of degludec after switching due to prior hypoglycemia

Name: Michael	A1C: 8.5% (69.4 mmol/mol)
Age: 4 years
Body weight: 14 kg
Previous MDIs: Biphasic lispro and neutral protamine Hagedorn (NPH) insulin (25:75) given as 7 U (am) and 4 U (pm)
Case history   Michael was diagnosed with T1D when he was 3 years old and has been treated with biphasic lispro (25:75 for insulin lispro/insulin lispro protamine) twice daily. Initially, he was very well controlled with a low insulin requirement, but over the last year his control has deteriorated, partly because his parents were unwilling to consider a more intensive insulin regimen. However, he recently experienced an episode of severe nocturnal hypoglycemia and professional CGM documented previously unsuspected nocturnal hypoglycemia, persuading his parents that for their son’s safety, a change was required. Additionally, he consistently had elevated fasting glucose potentially due to previously unrecognized nocturnal hypoglycemia and rebound morning hyperglycemia (Somogyi phenomenon) or the “dawn phenomenon” [42]. CGM confirmed that he was experiencing reactive hyperglycemia secondary to unsuspected hypoglycemia, demonstrating that the basal insulin component within his fixed biphasic insulin mixture was too high
Guidance
Michael’s parents were advised to increase the frequency of BG monitoring, especially at bedtime and overnight (3–4 h after bedtime) to minimize risk of nocturnal hypoglycemia and a switch to degludec was proposed   The initial dose of degludec (based on his total daily requirement) was reduced from the level used with NPH insulin and set to 30% of his daily dose (0.3 U/kg)   Beginning on 4 U/day (0.29 units/kg) of degludec, the titration algorithm of the BEGIN: Young 1 was applied [8] and on the basis of his lowest pre-breakfast fasting plasma glucose of 10.9 mmol/L (196 mg/dL), his first dose adjustment was an increase of 1 U to 5 U/day   Over the course of 2 weeks, Michael reached his new target of 4–8 mmol/L (70–145 mg/dL), achieved with 4.5 U (0.32 units/day) of degludec and he experienced no recurrence of nocturnal severe hypoglycemia