What is the most appropriate recommendation for managing type 1 diabetes mellitus in a 17-year-old patient taking insulin glargine (glargine) and insulin lispro (lispro) who wants to participate in long-distance running, with well-controlled blood glucose levels and a hemoglobin A1c (HbA1c) of 6.5%?

From the Guidelines

The most appropriate recommendation to manage diabetes mellitus during long-distance training for this 17-year-old boy with well-controlled type 1 diabetes is to reduce dosage of basal and bolus insulins (option C). The patient should decrease his insulin glargine (basal) and insulin lispro (bolus) doses by approximately 20-30% on days of prolonged exercise, as recommended by the American Diabetes Association 1. This adjustment is necessary because exercise increases insulin sensitivity and glucose uptake by muscles, which can lead to hypoglycemia if insulin doses remain unchanged. Despite his current good glycemic control (HbA1c 6.5%) and no history of hypoglycemia, marathon training represents a significant increase in physical activity that requires proactive insulin adjustment. Some key points to consider when managing diabetes during exercise include:

• Blood glucose targets prior to exercise should be 90–250 mg/dL (5.0–13.9 mmol/L) 1
• Consider additional carbohydrate intake during and/or after exercise, depending on the duration and intensity of physical activity, to prevent hypoglycemia 1
• Frequent glucose monitoring before, during, and after exercise, with or without use of continuous glucose monitoring, is important to prevent, detect, and treat hypoglycemia and hyperglycemia with exercise 1 Additionally, the patient should carry fast-acting carbohydrates during runs, monitor blood glucose before, during (for longer sessions), and after exercise, and gradually adjust insulin doses based on his individual response to training. This approach allows him to safely participate in marathon training while minimizing the risk of exercise-induced hypoglycemia, which is the primary concern for athletes with type 1 diabetes during endurance activities.

From the FDA Drug Label

14 CLINICAL STUDIES

1. 1 Overview of Clinical Studies The safety and effectiveness of Insulin Glargine given once-daily at bedtime was compared to that of once-daily and twice-daily NPH insulin in open-label, randomized, active-controlled, parallel studies of 2,327 adult patients and 349 pediatric patients with type 1 diabetes mellitus and 1,563 adult patients with type 2 diabetes mellitus

The most appropriate recommendation to manage diabetes mellitus during long-distance training is not directly stated in the provided drug label. Key points to consider in managing diabetes during exercise include:

• Monitoring blood glucose levels
• Adjusting insulin doses
• Consuming carbohydrates before and during exercise However, the label does not provide specific guidance on managing diabetes during long-distance running. Therefore, the best answer choice cannot be determined from the provided information. The FDA drug label does not answer the question.

From the Research

Management of Diabetes Mellitus During Long-Distance Training

The patient in question has a 2-year history of type 1 diabetes mellitus and is planning to run a marathon. To manage his diabetes mellitus during long-distance training, several factors need to be considered:

• The patient's current insulin regimen, which includes insulin glargine at bedtime and insulin lispro before meals
• The patient's blood glucose levels, which range from 90 to 130 mg/dL
• The risk of diabetic ketoacidosis (DKA) and hypoglycemia during intense physical activity

Recommendations for Managing Diabetes Mellitus During Long-Distance Training

Based on the available evidence, the following recommendations can be made:

• Test urine ketones before and after exercise: This is a crucial step in preventing and diagnosing DKA, which can be a life-threatening complication of diabetes mellitus 2, 3, 4, 5.
• Monitor blood glucose levels closely: The patient should monitor his blood glucose levels frequently during exercise to prevent hypoglycemia and hyperglycemia.
• Adjust insulin dosage as needed: The patient's insulin dosage may need to be adjusted based on his blood glucose levels and physical activity level.
• Stay hydrated: The patient should drink plenty of water before, during, and after exercise to prevent dehydration, which can increase the risk of DKA.

Options to Avoid

The following options are not recommended:

• Consume high-protein drink before running: There is no evidence to support the use of high-protein drinks before running in patients with diabetes mellitus.
• Limit training to 30-minute sessions: This may not be necessary or practical for a patient training for a marathon.
• Reduce dosage of basal and bolus insulins: This could increase the risk of DKA and hyperglycemia.
• Stop glargine and continue lispro as sliding scale: This could disrupt the patient's insulin regimen and increase the risk of DKA and hyperglycemia.