ABSTRACT
Introduction: Neonatal diabetes mellitus (NDM) is a rare monogenic form of diabetes occurring mainly in the first 6 months of life. Approximately 30% of transient NDM cases have an activating mutation in the KATP channel genes ABCC8 and KCNJ11. The majority of transfers from insulin to sulfonylureas in patients with KCNJ11 mutations are done inside the hospital. Objectives: To report a case of transient neonatal diabetes mellitus (TNDM) where precision medicine, defining treatment based on molecular diagnosis and technology (intermittent continuous glucose monitoring-iCGM) allowed to make treatment adjustments with the patient safely at home, in times of COVID-19 pandemic. Methods: Case report of a patient with TNDM in use of iCGM. Results: A boy with transient NDM due to the p.E227K mutation in the KCNJ11 gene. Diabetes remitted at 30 months and relapsed at 6 years of age. Insulin was initiated and soon transition to glibenclamide was proposed with the use of iCGM, which allowed the patient to safely stay at home during the transition, especially important in the context of the COVID-19 pandemic. The data was uploaded to an online platform that allowed the medical team to perform remote daily checks on glucose levels and suggest treatment changes. During insulin therapy, the device's 14-day analysis revealed a glucose management index (GMI) of 7,2% and 72% of time in range (TIR). Patient's glucose profile improved rapidly after SU was initiated so that insulin therapy was discontinued. After four months of SU treatment, GMI was 6,2% with 93% of TIR (Figure 1). Conclusions: NDM is a model of a genetic disease that can benefit from precision medicine, where treatment is defined after molecular diagnosis, and that iCGM is a valuable tool that should be considered to monitor glucose, increase safety and speed up dose adjustments in outpatient transition from insulin to glibenclamide. As far as we understand the use of iCGM was not reported in this situation previously.
ABSTRACT
Introduction: In March 2020 diabetes outpatient clinics were closed and consultations suspended due to the restrictions imposed by authorities in the context of the COVID-19 pandemic. Telemedicine in Brazil was then urgently officialized. Considering that the majority of our patients come from a low socioeconomic background, the only alternative of communication was through a free mobile app via cell phone. Objectives: The aim of this study was to evaluate patient satisfaction and the effectiveness of care delivered by teleconsultations via cell phone in this population. Methods: This was a questionnaire-based cross-sectional study, completed using Google forms, offered to every patient/carer from the Pediatric Diabetes Outpatient Clinic of Santa Casa de São Paulo who received telemedicine care during this period. Complementary data were obtained from patients' electronic medical records. Results: In 12 weeks (between March and June 2020), from a total of 154 appointments, 83%(n=88) of patients were attended via asynchronous teleconsultations using a mobile app, 16%(n=17) were in-person and 31.2%(n=48) did not attend the consultation. The great majority of patients had their insulin dose adjusted (87.6%;n=85). From those who answered the questionnaire (87%;n=77), 93%(n=72) approved the telemedicine consultation and 59% said that glycemic control improved afterward. There were also economic benefits and less waste of time reported. Only 3 patients declared that they did not feel safe without face-to-face care. 60% declared they would like to continue alternating presential with online consultations after the end of the pandemic. Conclusions: During COVID-19 pandemics, the transition to telemedicine was associated with patients' satisfaction and efficacy in treatment adjustments. Considering the socioeconomic characteristics of this population, telemedicine via mobile app was a good option for offering diabetes care during a period of isolation.