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Successful Treatment of Type 1 Diabetes and Seizures With Combined Ketogenic
Diet and Insulin
Roxana L. Aguirre Castaneda, Kenneth J. Mack and Aida Lteif
Pediatrics 2012;129;e511; originally published online January 16, 2012;
DOI: 10.1542/peds.2011-0741
The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://pediatrics.aappublications.org/content/129/2/e511.full.html
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
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CASE REPORT
Successful Treatment of Type 1 Diabetes and Seizures
With Combined Ketogenic Diet and Insulin
AUTHORS: Roxana L. Aguirre Castaneda, MD,a Kenneth J.
Mack, MD,b and Aida Lteif, MDa
aPediatric
bChild
Divisions of
Endocrinology and Metabolism and
and Adolescent Neurology, Mayo Clinic College of Medicine,
Rochester, Minnesota
KEY WORDS
diabetes, seizures, ketogenic diet, insulin, diabetic ketoacidosis
ABBREVIATIONS
DKA—diabetic ketoacidosis
KD—ketogenic diet
T1DM—type 1 diabetes mellitus
www.pediatrics.org/cgi/doi/10.1542/peds.2011-0741
doi:10.1542/peds.2011-0741
Accepted for publication Sep 9, 2011
Address correspondence to Roxana L. Aguirre Castaneda, MD,
Division of Pediatric Endocrinology and Metabolism, Mayo Clinic,
200 First St SW, Rochester, MN 55905. E-mail: [email protected]
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
abstract
Diabetic ketoacidosis (DKA) is a life-threatening condition and a major
cause of morbidity and mortality in children with type 1 diabetes
mellitus. The deficiency of insulin leads to metabolic decompensation,
causing hyperglycemia and ketosis that resolves with the administration of insulin and fluids. However, an induced state of ketosis is the
basis for the success of the ketogenic diet (KD), which is an effective
therapy for children with intractable epilepsy. We report the case of
a 2-year-old girl who presented to the emergency department with
1-week history of decreased activity, polyuria, and decreased oral
intake. Her past medical history was remarkable for epilepsy, for
which she was started on the KD with a significant improvement.
Her laboratory evaluation was compatible with DKA, and fluids and
insulin were given until correction. Because of concerns regarding
recurrence of her seizures, the KD was resumed along with the
simultaneous use of insulin glargine and insulin aspart. Urine ketones
were kept in the moderate range to keep the effect of ketosis on
seizure control. Under this combined therapy, the patient remained
seizure-free with no new episodes of DKA. Pediatrics 2012;129:e511–
e514
PEDIATRICS Volume 129, Number 2, February 2012
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e511
Diabetic ketoacidosis (DKA) is a lifethreatening condition and a major
cause of morbidity and mortality in
children with type 1 diabetes mellitus
(T1DM). The frequency of DKA varies
from 15% to 70% at diabetes onset1,2
and has been reported to be 1 to 10 per
100 person-years after the diagnosis
has been established.3,4 The deficiency
of insulin and the subsequent physiologic elevation of counter-regulatory
hormones such as cortisol, glucagon,
epinephrine, and growth hormone leads
to a metabolic decompensation. Gluconeogenesis, glycogenolysis, and ketones
production from fatty acid oxidization, in
addition to impaired peripheral glucose
utilization, result in hyperglycemia and
ketoacidosis, the main features of DKA.
Administration of insulin and fluids improves the cellular glucose uptake and
reverses ketogenesis.
However, although a constant state of
ketosis in children with diabetes causes
metabolic derangement, it turns out
to be the key point in the success of
the ketogenic diet (KD). The KD is an
effective nonpharmacologic therapy for
children with intractable epilepsy.5–7
This high-fat, low-carbohydrate diet
stimulates a ketogenic process that
forces the body to use ketone bodies as
the new source of energy. We report a
girl with DKA and new-onset T1DM treated
with insulin while kept on her KD.
PATIENT PRESENTATION
A 2-year-old girl presented to the
emergency department with a 1-week
history of decreased activity, polyuria,
and decreased oral intake. Her past
medical history was remarkable for
right micro-ophthalmia diagnosed at
birth, bilateral watershed infarcts at
age 3 months, epilepsy since age 4
months, and global developmental delay.
An extensive workup for genetic and
metabolic conditions including plasma
ammonia, lactate, acylcarnitine, carnitine, urine organic acids, plasma amino
e512
acids; mitochondrial DNA screen for
point mutations and deletions; and a
screen for congenital glycosylation defect was unrevealing. Screening performed on cultured fibroblasts for fatty
oxidation defects and mitochondrial
disorders was negative as well. At age
10 months, she experienced between 60
to 80 seizures a day while being on 4
different antiseizure medications. Her
electroencephalogram showed multifocal spikes with a slow background but
not a hypsarrhythmic pattern. Because
of her poor response to conventional
therapy, KD was started with a 4:1 fat to
carbohydrate ratio. The acidotic state
was confirmed and followed with the
presence of urine ketones in the moderate to large range. Four weeks after
the initiation of the KD, the frequency of
seizures decreased to 1 to 15 episodes
per day. After 8 months, no seizures
were reported.
Two days before admission, urine
ketones were constantly in the large
range. On physical examination and
upon her arrival to the emergency department, she was found to be lethargic
and dehydrated. Laboratory studies
showed glucose of 400 mg/dL, pH 7.06,
bicarbonate 6 mEq/L, b-hydroxybutyrate
7.7, and an elevated hemoglobin A1c
at 7.6%. Intravenous fluids and insulin
drip were initially given and sustained
until correction of the DKA. Because of
concerns regarding recurrence of her
seizures, the KD was resumed along
with the simultaneous use of insulin
glargine 0.3 U/kg at bedtime. She also
received insulin aspart before meals if
the blood sugar was .200 mg/dL or if
she had large ketones. Urine ketones
were kept in the moderate range to keep
the effect of ketosis on seizure control
(Table 1).
Over the following 10 months, she
continued with the same insulin regimen and was seizure-free with no new
episodes of DKA. Few mild episodes
of hypoglycemia were reported. The
TABLE 1 Insulin Treatment Used After DK
Resolution and While on the KD
Glucose range (fasting): 100–150 mg/dL
Ketonuria goal: moderate
Glargine insulin: 0.3 U/kg at bedtime (adjusted
to keep glucose within the goal range)
Aspart insulin: with or without large ketonuria
before meals for glucose .200 mg/dL
diagnosis of T1DM was confirmed with
the presence of GAD 65 antibodies and
low levels of C-peptide. DNA sequencing
was performed because of the possibility of DEND syndrome, an association
of developmental delay, neonatal diabetes, and epilepsy, but did not show
any KCNJ11 mutations.
DISCUSSION
The effectiveness of the KD was first
published in a 1921 report by R. Wilder
from Mayo Clinic.8 The mechanism
through which ketosis can control
seizures is not well understood. Reports
indicate that up to one-third of patients
on the KD have a significant decrease in
their seizure frequency, regardless of
the type of their seizure disorder.9,10 In
2006, Henwood et al11 reported a comparable case combining both therapies
in a 4-year-old girl with pyruvate dehydrogenase deficiency. Dressler et al12
recently reported a similar case but
using a continuous subcutaneous insulin infusion.
At age 10 months, our patient was
reported to be on multiple antiseizure
medications with up to 80 episodes of
seizures per day. She was seizure-free
after the introduction of the KD, and
her seizure medications were weaned
to just 1 per day (felbamate). Progress
on achieving developmental milestones
was also observed but with limitation in
the motor area due to right hemiparesis
secondary to brain infarcts. After the
onset of T1DM, there were concerns
regarding the simultaneous use of the
KD because of the risk of developing DKA
and hypoglycemia. A permanent state of
AGUIRRE CASTANEDA et al
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CASE REPORT
ketosis might increase the possibility
of developing severe DKA and could
also reduce the period of time to intervene before the development of severe
ketoacidosis. However, the low carbohydrate content in the KD and the young
age of the patient were important risk
factors for developing hypoglycemia.
Parents were informed of the risks and
benefits of each therapy, but they felt
that the quality of life achieved since the
introduction of the KD outweighed the
possible metabolic complications that
could develop in relation to the new
diagnosis of T1DM. Both treatments
were considered equally important and
necessary. We aimed to reach a balance
between ketosis and insulin treatment
with adequate blood glucose and seizure activity control.
Dealing with a continuous state of ketosis was challenging in this particular
situation, especially when we had to
determine what would be a safe level.
Even when ketosis was the endpoint of
the KD, it could also represent lack of
insulin and be indicative of DKA. Having
trace- to small-level ketones would be
safer from the standpoint of managing
her diabetes while continuing the KD.
However, the seizure control could be
jeopardized. Large ketones may ensure
the effect of the KD but also require
larger insulin amounts. A state of
moderate ketones or an intermediate
level of ketosis could bring together
both treatment goals, and we decided to
keep our patient within this range.
Eventually glucose and ketones were
checked by using a Precision Xtra meter
(Abbott, Abbott Park, IL).
By adding specific glucose targets to
our treatment plan, we intended to
refine our management and provide
better guidance for day-to-day management, including special situations such
as sick-day management. Because of the
low proportion of carbohydrates in the
diet and the young age of the patient, we
used fixed small doses of Aspart insulin
TABLE 2 Aspart Insulin Doses Used With
Meals
Glucose (mg/dL)
Insulin (units)
200–300
301–400
.400
If also b-hydroxybutyrate
.2.5 mmol/L
0.5
1
1.5
+1 extra
for correction of hyperglycemia (Table 2).
Aspart insulin boluses were indicated for hyperglycemia .200 mg/dL
(11 mmol/L) with or without ketonemia
(b-hydroxybutyrate .2.5 mmol/L). An
extra unit of aspart insulin was provided with hyperglycemia .200 mg/dL
(11 mmol/L) and b-hydroxybutyrate .2.5
mmol/L. The dose of insulin glargine
was adjusted to keep the fasting blood
sugars between 100 and 150 mg/dL.
If the levels were above this range
for 3 consecutive days, the dose was
increased.
Managing doses after low glucose levels was more difficult, because it is not
uncommon for children on the KD to
have fasting blood glucose of ,70 mg/
dL. For this reason, and to avoid overtreating lower blood glucose levels,
we decided to decrease the glargine
insulin dose if the fasting glucose
was ,70 mg/dL. The dose would be
decreased after a 3-day pattern if
the glucose was between 70 and 100
mg/dL. During the first 6 months of
combined therapy, her numbers were
between 90 and 180 mg/dL with few
episodes of mild hypoglycemia and
hyperglycemia (.200 mg/dL) per
month probably favored by the honeymoon phase. After this period, her
premeal numbers increased up to the
140 to 280 mg/dL range, requiring 1 to 3
aspart boluses per day, a couple of
times per week. If numbers were consistently high during the day, the glargine dose was increased, on average
once a month.
Data regarding the effect of the KD on
growth are controversial.13 Before the
introduction of the KD and insulin, the
linear growth of our patient was between the 50th and 75th percentiles
and continued the same 1 year after
the combined therapy was started. Her
weight was between the 75th and 90th
percentile during the first year of life,
then it decreased mildly to the 50th to
75th percentile but remained stable
while on the KD and insulin and until
discontinuation of KD. Our patient
remained on both therapies for 10
months with no episodes of seizures or
DKA reported. Patients are usually on
the KD for about 2 years, although
sometimes this is difficult to maintain
because of the restrictions and limitations that the diet requires. After 10
months of the combined therapy, our
patient’s parents found it challenging
to continue the KD because the child
wishes to try other foods; despite the
positive results, they decided to discontinue the KD. Seizures remained
under good control on felbamate alone.
Once on a regular diet, she was placed
on a regular regimen of insulin with
multiple daily injections according to
our clinic protocol. Her hemoglobin A1c
increased but remained acceptable 22
months after her diagnosis of diabetes
(Table 3).
CONCLUSIONS
The simultaneous use of KD and insulin
therapy is feasible and clinically effective according to our results. A safe
balance between the 2 therapies is
challenging and involves a multidisciplinary approach.
TABLE 3 Laboratory Studies at Diagnosis
and Follow-up
On
6
Admission mo
Random glucose
(mg/dL)
Hemoglobin A1c (%)
b-hydroxybutyrate
(mmol/L)
PEDIATRICS Volume 129, Number 2, February 2012
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10
mo
22
mo
362
179 274 300
7.3
7.7
6.8
2.2
7.2
—
8.4
—
e513
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AGUIRRE CASTANEDA et al
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Successful Treatment of Type 1 Diabetes and Seizures With Combined Ketogenic
Diet and Insulin
Roxana L. Aguirre Castaneda, Kenneth J. Mack and Aida Lteif
Pediatrics 2012;129;e511; originally published online January 16, 2012;
DOI: 10.1542/peds.2011-0741
Updated Information &
Services
including high resolution figures, can be found at:
http://pediatrics.aappublications.org/content/129/2/e511.full.h
tml
References
This article cites 12 articles, 4 of which can be accessed free
at:
http://pediatrics.aappublications.org/content/129/2/e511.full.h
tml#ref-list-1
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly
publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2012 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
Downloaded from pediatrics.aappublications.org by guest on September 9, 2014