ESPE Yearbook of Paediatric Endocrinology

d.vanderkaay@erasmusmc.nl or abhimanyu.garg@utsouthwestern.edu.J Clin Endocrinol Metab 2021, 106, 3621–3633. doi: 10.1210/clinem/dgab549

Brief Summary: This expert perspective proposes that a thorough review of medical history and physical examination is generally sufficient to diagnose a child with insulin-resistant diabetes mellitus. This simple approach is especially suitable for low- or middle-income countries.

This article emphasizes the role of medical history, careful physical examination, and basic laboratory investigations in making the diagnosis of severe insulin resistance. In low- and middle-income countries (LMICs), patients and families often must pay for investigations (at diagnosis or for follow up) as well as for medicines. This puts them in a tragic situation: no patient should have to choose between getting the right information and getting the right medicine. Unfortunately, most textbooks and review articles are written by pediatric endocrinologists in high-income countries (HICs) and do not take into account the scarcity of resources. The WHO List of Essential Medicines (EML) and List of Essential diagnostics (EDL) (see Paper 13.1 in this chapter) can help identify the medicines and the diagnostic tests that are most cost-effective. In addition, pediatric endocrinologists from HICs and LMICs could jointly write algorithms that highlight the most cost-effective manner to assess and treat a patient. Medical students and fellows in both HICs and LMICs would highly benefit from this approach.

On a different note, the authors found an undetectable insulin concentration in a patient with severe insulin resistance. They hypothesize that “the low endogenous insulin level can be attributed to the subcutaneous insulin administration 12 hours before the measurement”. This seems unlikely, as the high doses of NPH and of human short-acting insulin administered in this insulin-resistant patient are expected to be detectable in the insulin assay. Another possibility is a technical issue disrupted the assay run. This highlights the fact that, besides their high cost, diagnostic tests need to be reliable.