Patient case 6.

Poor adherence to treatment and SMBG resulting in DKA

Name: Matthew	A1C: 11.3% (100 mmol/mol)
Age: 10 years
Body weight: 28 kg
Current MDIs: NPH insulin with insulin aspart
Case history   Matthew was been raised under difficult social circumstances and had a troubled relationship with his family. He lived with his mother, step-father, and five half-siblings; despite his young age, he was entrusted with management of his diabetes, with no adult supervision. He experienced an episode of very severe DKA (pH 6.88). Management included standard therapy with IV fluids and insulin and in addition degludec was commenced within 6 h of admission   His DKA episode resulted in him being placed in foster care. It was clear that he was severely neglected, being grossly underweight. His parents had not collected diabetes supplies, including insulin, for several months
Guidance   The PK properties of degludec, described previously, mean that the circulating concentration will not drop quickly and will not drop to zero even if a dose is missed. In fact, a patient would likely have to miss two to three daily doses of degludec to be at any risk of DKA. In addition, in a trial of children with T1D treated with IDet or degludec, degludec resulted in significantly lower rates of hyperglycemia with ketosis [8]   Since degludec is more forgiving regarding missed injections and carries a lower risk of hypoglycemia with ketosis when compared with insulins such as IDet [8], Matthew was switched from NPH insulin to degludec   It was emphasized that his diabetes care be appropriately supervised by a responsible adult