Continuous subcutaneous insulin infusion (CSII) in the Veneto region: efficacy, acceptability and quality of life

Continuous Subcutaneous Insulin Infusion in Type 1 Diabetes Mellitus Patients: Results from the Spanish National Registry

Aim: To analyze the clinical effect of continuous subcutaneous insulin infusion (CSII) in type 1 diabetes mellitus (T1D) patients in the Spanish real-world scenario. Methods: All T1D patients on CSII registered in the SPAnish Insulin Pump (SPAIP) registry were included. The primary efficacy outcome was change in HbA1c during follow-up. Secondary efficacy outcomes included: insulin pump indications, diabetes complication rates, insulin and pump use, and continuous glucose monitoring (CGM) glycometrics. Patient data were typed through the web-based SPAIP registry. Results: Data from 2979 T1D patients treated with CSII were analyzed. The median age was 44 years (interquartile range [IQR] 34-52 years), and T1D duration was 27 years (IQR 18-35 years). The median duration of CSII therapy was 6 years (IQR 3-10 years). The main indications for treatment were suboptimal glycemic control (33.8%), hypoglycemia (22.1%), and increased glycemic variability (18.8%). Glycated hemoglobin decreased by 6 mmol/mol (95% CI, -5 to -6 mmol/mol, P < 0.001) [-0.5%, 95% CI, -0.4 to -0.5, P < 0.001] during the follow-up. The percentage of patients with severe hypoglycemia decreased from 14.9% to 0.9% (P < 0.001). We observed an inverse correlation between final HbA1c levels and CGM adherence (R = -0.24, P < 0.001) or percentage of time with active hybrid closed-loop functions (R = -0.25, P < 0.001). Conclusions: CSII treatment was associated with a sustained improvement in glycemic control in the Spanish population. This benefit was greater among patients with higher CGM or active hybrid closed-loop functions adherence. The protocol was publicly registered at ClinicalTrials.gov (NCT04761094).

Highlighting the Role of Obesity and Insulin Resistance in Type 1 Diabetes and Its Associated Cardiometabolic Complications

PURPOSE OF REVIEW

This narrative review appraises research data on the potentially harmful effect of obesity and insulin resistance (IR) co-existence with type 1 diabetes mellitus (T1DM)-related cardiovascular (CVD) complications and evaluates possible therapeutic options.

RECENT FINDINGS

Obesity and IR have increasingly been emerging in patients with T1DM. Genetic, epigenetic factors, and subcutaneous insulin administration are implicated in the pathogenesis of this coexistence. Accumulating evidence implies that the concomitant presence of obesity and IR is an independent predictor of worse CVD outcomes. The prevalence of obesity and IR has increased in patients with T1DM. This increase can be partly attributed to general population trends but, additionally, to iatrogenic weight gain caused by insulin treatment. This association might be the missing link explaining the excess CVD burden observed in patients with T1DM despite optimal glycemic control. Data on newer agents for type 2 diabetes mellitus (T2DM) treatment are unraveling novel ways to challenge this aggravating coexistence.

Quality of Life in Children With Diabetes Treated With Insulin Pump Compared With Multiple Daily Injections in Tertiary Care Center

Background:

Continuous Subcutaneous Insulin Infusion (CSII) and Multiple Daily Injections (MDI) have been widely used as options in treating diabetes in childhood. Glycemic control is important to reduce diabetes complications; however, more focus needs to be on patients’ Quality of Life (QoL). Diabetes and QoL have strong associations in terms of patients’ overall health including their psychology, physical well-being, compliance with medication. A previous systematic review stressed that strong evidence to deny or prove the benefits of insulin pump therapy on health-related quality of life is deficient. The aim of this study is to assess the health-related quality of life and the psychological impacts of children with diabetes who use CSII and MDI treatment.

Methods:

A cross-sectional study included 68 pediatric patients with type 1 Diabetes (T1DM) who were treated in a tertiary center in Jeddah, Saudi Arabia. We used the Pediatric Quality of Life Inventory 3.0 Diabetes Module and this module assesses the health-related quality of life of children with diabetes.

Results:

Thirty-four (50%) participants found to be on MDI, of which 21 (61.8%) are males, compared to 34 (50%) patients using CSII, of which 12 (35.2%) are females. Participants using CSII had statistically significant better symptom control, less treatment difficulties but were more worrisome than MDI participants.

Conclusion:

CSII group had better quality of life in almost all aspects even though they were more worrisome. Further studies with a larger sample size are needed to give comprehensive generalizations.

Continuous subcutaneous insulin infusion reduces the risk of postoperative infection

BACKGROUND

Perioperative hyperglycemia was associated with postoperative infection, and proper management of perioperative glucose has become critical in improving the prognosis of patients.

METHODS

A total of 1015 diabetic patients who underwent surgery and received insulin treatment for their hyperglycemia in our hospital were retrospectively reviewed. According to propensity matching, we obtained 253 pairs of patients from the group which received continuous subcutaneous insulin infusion (CSII) therapy (CSII group) and the group which received insulin injection therapy (non-CSII group). Perioperative glucose levels and corresponding outcomes were compared between the two groups.

RESULTS

Compared with the non-CSII group, the CSII group had lower fasting and mean glucose levels, lower incidence of fever (operation day: 18.6% vs 10.2%; P = .014; first postoperative day: 55.1% vs 34.7%; P < .001), a positive rate of postoperative secretion culture (6.3% vs 1.2%; P = .004), and a shorter time of antibiotics use (total antibiotics use: P = .002; postoperative antibiotics use: P < .001) and hospital stays (P < .001). However, there was no difference in the total medical expenditure between the two groups (P = .499). Further analysis showed that CSII therapy was superior to multiple daily insulin injection (MDI) therapy in its effect on infection and other postoperative outcomes when 64 pairs of patients from the CSII group and MDI group were compared.

CONCLUSIONS

CSII therapy provides better perioperative glucose control and a lower risk of postoperative infection without increasing the total medical expenditure.

Experiences of Adults Using Continuous Subcutaneous Insulin Infusion: A Qualitative Study

OBJECTIVES

We aimed to determine the quality of life (QoL) of Kuwaiti adults with type 1 diabetes mellitus (T1DM) who used continuous subcutaneous insulin infusions (CSIIs) and to understand their perception of this treatment.

BACKGROUND

CSII is an effective and safe alternative to multiple daily injections for T1DM, with the potential to improve both glycemic control and QoL. Although CSII has been widely used in Kuwait, its effectiveness and benefits have not been properly evaluated. Healthcare providers and patients need more information on CSII before its initiation.

METHODS

In this qualitative case study, semi-structured individual interviews were performed using a topic guide. Interviews were stopped at data saturation point. Subsequently, a thematic analysis of transcripts was performed.

RESULTS

Eighteen adults with T1DM (8 males and 10 females; age 31.4 ± 6.4 years; diabetes duration 17.7 ± 9.5 years; CSII duration 3.6 ± 2.4 years) were recruited from the CSII clinic. Six main themes were studied: health benefits, lifestyle flexibility, improvement of mood and emotion, practical problems, physical and personal effects, and self-confidence to manage diabetes. CSII positively affected the QoL of participants', most notably by enhancing lifestyle flexibility; however, important negative qualities were also reported.

CONCLUSION

The identified themes highlight the complexity of the experiences of participants, and can be used to provide a framework to help healthcare providers understand how people with T1DM become aware of their treatment regimens. It is important to identify the positive aspects of CSII and not focus only on its negative effects.

Continuous Subcutaneous Insulin Infusion in Adult Type 1 Diabetes Mellitus Patients: Results from a Public Health System

Aims: To analyze prevalence and clinical effect of continuous subcutaneous insulin infusion (CSII) in adult type 1 diabetes mellitus (T1DM) patients in a public health system real-world scenario. Materials and Methods: All adult T1DM patients on CSII being followed at Castilla-La Mancha Health Public Service were included. Primary efficacy outcome was the change in HbA_1c during the follow-up. Secondary efficacy outcomes included evaluation of the following variables: insulin pump indications, diabetes complication rates, insulin and pump use, continuous glucose monitoring use, patients achieving an HbA_1c decrease ≥6 mmol/mol (0.5%) with or without severe hypoglycemia, and discontinuations. Direct patient data were typed through the web-based Spanish national registry on CSII therapy by nine diabetologists from eight different health care areas. Results: A total of 7% of T1DM adult patients were treated with insulin pumps in our region, with a regional prevalence of 18.7 CSII patients/100,000 inhabitants. Three hundred thirteen patients were analyzed with a mean age of 34.1 ± 11.0 years and T1DM duration of 16.6 ± 9.7 years. Mean duration of CSII therapy was 6.2 ± 4.0 years. Data completion was 91.2%. Main indications for treatment were high glucose variability (36%) and suboptimal glycemic control (32%). Mean duration of CSII therapy was 6.2 ± 4.0 years. Sensor-augment pump therapy was used by 26% of the patients. Glycated hemoglobin decreased to -5 mmol/mol (95% CI -6 to -3 mmol/mol; P < 0.001) during the follow-up (Mean difference in change -0.4%, 95% CI -0.5 to -0.2; P < 0.001). Percentage of patients with severe hypoglycemia decreased from 32% to 13% (P < 0.001). Frequent nonsevere hypoglycemia, severe hypoglycemia, and diabetic ketoacidosis were less frequent among patients using higher number of daily basal rates at the study end. The rate of CSII interruption was 3.8%. Conclusions: Prevalence of CSII therapy in our region remains under 10% of adult T1DM patients, although CSII treatment was associated with a sustained improvement in glycemic control.

Continuous subcutaneous insulin infusion versus multiple daily injections in children and young people at diagnosis of type 1 diabetes: the SCIPI RCT

BACKGROUND

The risk of developing long-term complications of type 1 diabetes (T1D) is related to glycaemic control and is reduced by the use of intensive insulin treatment regimens: multiple daily injections (MDI) (≥ 4) and continuous subcutaneous insulin infusion (CSII). Despite a lack of evidence that the more expensive treatment with CSII is superior to MDI, both treatments are used widely within the NHS.

OBJECTIVES

(1) To compare glycaemic control during treatment with CSII and MDI and (2) to determine safety and cost-effectiveness of the treatment, and quality of life (QoL) of the patients.

DESIGN

A pragmatic, open-label randomised controlled trial with an internal pilot and 12-month follow-up with 1 : 1 web-based block randomisation stratified by age and centre.

SETTING

Fifteen diabetes clinics in hospitals in England and Wales.

PARTICIPANTS

Patients aged 7 months to 15 years.

INTERVENTIONS

Continuous subsutaneous insulin infusion or MDI initiated within 14 days of diagnosis of T1D.

DATA SOURCES

Data were collected at baseline and at 3, 6, 9 and 12 months using paper forms and were entered centrally. Data from glucometers and CSII were downloaded. The Health Utilities Index Mark 2 was completed at each visit and the Pediatric Quality of Life Inventory (PedsQL, diabetes module) was completed at 6 and 12 months. Costs were estimated from hospital patient administration system data.

OUTCOMES

The primary outcome was glycosylated haemoglobin (HbA_1c) concentration at 12 months. The secondary outcomes were (1) HbA_1c concentrations of < 48 mmol/mol, (2) severe hypoglycaemia, (3) diabetic ketoacidosis (DKA), (4) T1D- or treatment-related adverse events (AEs), (5) change in body mass index and height standard deviation score, (6) insulin requirements, (7) QoL and (8) partial remission rate. The economic outcome was the incremental cost per quality-adjusted life-year (QALY) gained.

RESULTS

A total of 293 participants, with a median age of 9.8 years (minimum 0.7 years, maximum 16 years), were randomised (CSII, n = 149; MDI, n = 144) between May 2011 and January 2015. Primary outcome data were available for 97% of participants (CSII, n = 143; MDI, n = 142). At 12 months, age-adjusted least mean squares HbA_1c concentrations were comparable between groups: CSII, 60.9 mmol/mol [95% confidence interval (CI) 58.5 to 63.3 mmol/mol]; MDI, 58.5 mmol/mol (95% CI 56.1 to 60.9 mmol/mol); and the difference of CSII - MDI, 2.4 mmol/mol (95% CI -0.4 to 5.3 mmol/mol). For HbA_1c concentrations of < 48 mmol/mol (CSII, 22/143 participants; MDI, 29/142 participants), the relative risk was 0.75 (95% CI 0.46 to 1.25), and for partial remission rates (CSII, 21/86 participants; MDI, 21/64), the relative risk was 0.74 (95% CI 0.45 to 1.24). The incidences of severe hypoglycaemia (CSII, 6/144; MDI, 2/149 participants) and DKA (CSII, 2/144 participants; MDI, 0/149 participants) were low. In total, 68 AEs (14 serious) were reported during CSII treatment and 25 AEs (eight serious) were reported during MDI treatment. Growth outcomes did not differ. The reported insulin use was higher with CSII (mean difference 0.1 unit/kg/day, 95% CI 0.0 to 0.2 unit/kg/day; p = 0.01). QoL was slightly higher for those randomised to CSII. From a NHS perspective, CSII was more expensive than MDI mean total cost (£1863, 95% CI £1620 to £2137) with no additional QALY gains (-0.006 QALYs, 95% CI -0.031 to 0.018 QALYs).

LIMITATIONS

Generalisability beyond 12 months is uncertain.

CONCLUSIONS

No clinical benefit of CSII over MDI was identified. CSII is not a cost-effective treatment in patients representative of the study population.

FUTURE WORK

Longer-term follow-up is required to determine if clinical outcomes diverge after 1 year. A qualitative exploration of patient and professional experiences of MDI and CSII should be considered.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN29255275 and EudraCT 2010-023792-25.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 42. See the NIHR Journals Library website for further project information. The cost of insulin pumps and consumables supplied by F. Hoffman-La Roche AG (Basel, Switzerland) for the purpose of the study were subject to a 25% discount on standard NHS costs.

Skin-Related Complications Among Adolescents With Type 1 Diabetes Using Insulin Pump Therapy

Background

To identify the skin-related complications in adolescents with type 1 diabetes (T1D) using the insulin pump therapy (IPT).

Methods

A total of 64 T1D adolescents (between ages 13 and 19) using the insulin pump were included in this cross-sectional study. They had visited the Diabetes Clinic at Diabetes Treatment Center, Prince Sultan Military Medical City, Saudi Arabia, for treatment from January 2018 to March 2018. Data on the prior and present skin-related complications, for a 6-month interval, were gathered via a closed/structured questionnaire. Besides this, demographic information was also recorded.

Results

From the patients in this study (n = 64), 9.3% experienced 3 or more skin-related complications, whereas 7.8% patients registered 2 and 25% had only 1 such disorder. However, in 37 patients (51.8%), there was no evidence of skin-related complications. Significantly, the female revealed a higher level of issues (P = .036), >3 years on IPT (P = .039), negligence of infusion set rotation (P = .001), needle length of 9 mm (P = .021), and beyond 3 days for catheter replacement (P = .022). The factors age, body mass index, diabetes duration, and insulin dosage remained quite unaffected. From the regression analysis, the factors female gender, catheter replacement, and infusion set rotation showed up as the independent risk factors for the skin complications.

Conclusions

The IPT users invariably experience dermatologic conditions. Through this study, female gender, length of IPT usage time, and infusion set rotations were identified as the independent risk factors responsible for the skin issues.

Duration of Catheter Use in Patients with Diabetes Using Continuous Subcutaneous Insulin Infusion: A Review

Increasing proportions of patients with diabetes use continuous subcutaneous insulin infusion (CSII) therapy mostly due to its clinical efficacy and flexibility for insulin dosing and adjustments. Some challenges are nevertheless associated with this technology. A key and underlooked component of CSII technical difficulties is the subcutaneous catheter used to infuse insulin. Several adverse events (AEs) have been experienced by patients in relation to catheters, such as blockage, kinking, and insertion site reactions, including irritation, infections, lipohypertrophies etc., all of which could compromise the metabolic control. With the objective of minimizing these AEs, recommendations for changing catheters every 2-3 days have historically been provided by manufacturers based on reports derived from small studies and anecdotal data. The aim of this review was to provide an updated analysis of current recommendations and patients' practices in relation to frequency of catheter change. Our main findings are: (1) adequately designed and powered studies investigating optimal catheter wearing time are still lacking; (2) increasing catheter wearing time is generally associated with increased frequency of catheter AEs; (3) however, interpatient variability is large, with some individuals needing to change their catheters every 2-3 days, whereas others probably being able to keep them in place for longer periods without problems. Further research is thus warranted to provide more solid and evidence-based recommendations while exploring personalized approaches at the same time. Increasing catheter wear life without significant side effects is an important goal to simplify CSII therapy and reduce its associated costs and burdens.

Prevalence and geographical distribution of insulin pump therapy in the Central Denmark Region and its association with metabolic parameters

AIMS

Insulin treatment in type 1 diabetes encompasses multiple daily insulin injections (MDI) or continuous subcutaneous insulin infusion (CSII). Both population-based studies and comparative studies regarding CSII use are sparse. The aim of the current study was to describe the prevalence and distribution of CSII use among adults with type 1 diabetes in the Central Denmark Region and to compare metabolic control in CSII-treated patients to those treated with MDI.

METHODS

A database was constructed using the Danish Adult Diabetes Registry in 2014/2015 in combination with an audit of the patients' medical records.

RESULTS

3909 adults with type 1 diabetes patients were included. The proportion of patients treated with CSII differed significantly between the 8 regional hospitals from 12.0% to 31.1%. CSII users had a significantly lower HbA1c compared to MDI treated patients (7.6% (60 mmol/mol) versus 8.0% (64 mmol/mol)) in unadjusted analyses. After adjustment for clinically relevant characteristics the difference between CSII and MDI-treated patients was attenuated, but remained statistically significant.

CONCLUSION

The distribution of CSII differed markedly between hospitals and CSII users had better glycemic control, even after adjustment for sex, age, BMI, diabetes duration, smoking, use of lipid-lowering and blood pressure-lowering medication.

Cost-effectiveness of insulin pumps compared with multiple daily injections both provided with structured education for adults with type 1 diabetes: a health economic analysis of the Relative Effectiveness of Pumps over Structured Education (REPOSE) randomised controlled trial

OBJECTIVES

To assess the long-term cost-effectiveness of insulin pumps and Dose Adjustment for Normal Eating (pumps+DAFNE) compared with multiple daily insulin injections and DAFNE (MDI+DAFNE) for adults with type 1 diabetes mellitus (T1DM) in the UK.

METHODS

We undertook a cost-utility analysis using the Sheffield Type 1 Diabetes Policy Model and data from the Relative Effectiveness of Pumps over Structured Education (REPOSE) trial to estimate the lifetime incidence of diabetic complications, intervention-based resource use and associated effects on costs and quality-adjusted life years (QALYs). All economic analyses took a National Health Service and personal social services perspective and discounted costs and QALYs at 3.5% per annum. A probabilistic sensitivity analysis was performed on the base case. Further uncertainties in the cost of pumps and the evidence used to inform the model were explored using scenario analyses.

SETTING

Eight diabetes centres in England and Scotland.

PARTICIPANTS

Adults with T1DM who were eligible to receive a structured education course and did not have a strong clinical indication or a preference for a pump.

INTERVENTION

Pumps+DAFNE.

COMPARATOR

MDI+DAFNE.

MAIN OUTCOME MEASURES

Incremental costs, incremental QALYs gained and incremental cost-effectiveness ratios (ICERs).

RESULTS

Compared with MDI+DAFNE, pumps+DAFNE was associated with an incremental discounted lifetime cost of +£18 853 (95% CI £6175 to £31 645) and a gain in discounted lifetime QALYs of +0.13 (95% CI -0.70 to +0.96). The base case mean ICER was £142 195 per QALY gained. The probability of pump+DAFNE being cost-effective using a cost-effectiveness threshold of £20 000 per QALY gained was 14.0%. All scenario and subgroup analyses examined indicated that the ICER was unlikely to fall below £30 000 per QALY gained.

CONCLUSIONS

Our analysis of the REPOSE data suggests that routine use of pumps in adults without an immediate clinical need for a pump, as identified by National Institute for Health and Care Excellence, would not be cost-effective.

TRIAL REGISTRATION NUMBER

ISRCTN61215213.

A national survey on the efficacy and safety of continuous subcutaneous insulin infusion in patients with type 1 diabetes in Spain

AIMS

To assess safety and benefits of continuous subcutaneous insulin infusion (CSII) therapy in a cohort of type 1 diabetes patients in Spain.

METHODS

A web-based national registry was created by the Working Group of the Spanish Diabetes Association. All patients on CSII being followed at selected referral centers were included. A cross-sectional analysis was performed.

RESULTS

A total of 1275 patients were included. Data completion for patients on CSII was 67 ± 32%. Indications for treatment were suboptimal glycemic control (32%), high glucose variability (24%), preconception care (14%) and hypoglycemia (11%). In the patients on CSII for ≥1 year (n = 843, mean CSII duration of 5 years), HbA_1c decreased by 5 mmol/mol (0.5%) in the whole population and by 8 mmol/mol (0.7%) in subjects with suboptimal glycemic control as CSII indication. Percentage of patients achieving HbA_1c ≤ 53 mmol/mol (7%) increased from 20% before CSII to 34% at the end of follow-up. Severe hypoglycemia decreased from 29% to 5%. The rate of discontinuation was 9.5%. HbA_1c was lower in patients using bolus advisor and temporary basal rates.

CONCLUSIONS

CSII was associated with a sustained improvement in glycemic control and a reduction in severe hypoglycemia. The use of advanced CSII settings was related to better glycemic control.

A cluster randomised trial, cost-effectiveness analysis and psychosocial evaluation of insulin pump therapy compared with multiple injections during flexible intensive insulin therapy for type 1 diabetes: the REPOSE Trial

BACKGROUND

Insulin is generally administered to people with type 1 diabetes mellitus (T1DM) using multiple daily injections (MDIs), but can also be delivered using infusion pumps. In the UK, pumps are recommended for patients with the greatest need and adult use is less than in comparable countries. Previous trials have been small, of short duration and have failed to control for training in insulin adjustment.

OBJECTIVE

To assess the clinical effectiveness and cost-effectiveness of pump therapy compared with MDI for adults with T1DM, with both groups receiving equivalent structured training in flexible insulin therapy.

DESIGN

Pragmatic, multicentre, open-label, parallel-group cluster randomised controlled trial, including economic and psychosocial evaluations. After participants were assigned a group training course, courses were randomly allocated in pairs to either pump or MDI.

SETTING

Eight secondary care diabetes centres in the UK.

PARTICIPANTS

Adults with T1DM for > 12 months, willing to undertake intensive insulin therapy, with no preference for pump or MDI, or a clinical indication for pumps.

INTERVENTIONS

Pump or MDI structured training in flexible insulin therapy, followed up for 2 years. MDI participants used insulin analogues. Pump participants used a Medtronic Paradigm^® Veo^TM (Medtronic, Watford, UK) with insulin aspart (NovoRapid, Novo Nordisk, Gatwick, UK).

MAIN OUTCOME MEASURES

Primary outcome - change in glycated haemoglobin (HbA_1c) at 2 years in participants whose baseline HbA_1c was ≥ 7.5% (58 mmol/mol). Key secondary outcome - proportion of participants with HbA_1c ≤ 7.5% at 2 years. Other outcomes at 6, 12 and 24 months - moderate and severe hypoglycaemia; insulin dose; body weight; proteinuria; diabetic ketoacidosis; quality of life (QoL); fear of hypoglycaemia; treatment satisfaction; emotional well-being; qualitative interviews with participants and staff (2 weeks), and participants (6 months); and ICERs in trial and modelled estimates of cost-effectiveness.

RESULTS

We randomised 46 courses comprising 317 participants: 267 attended a Dose Adjustment For Normal Eating course (132 pump; 135 MDI); 260 were included in the intention-to-treat analysis, of which 235 (119 pump; 116 MDI) had baseline HbA_1c of ≥ 7.5%. HbA_1c and severe hypoglycaemia improved in both groups. The drop in HbA_1c% at 2 years was 0.85 on pump and 0.42 on MDI. The mean difference (MD) in HbA_1c change at 2 years, at which the baseline HbA_1c was ≥ 7.5%, was -0.24% [95% confidence interval (CI) -0.53% to 0.05%] in favour of the pump (p = 0.098). The per-protocol analysis showed a MD in change of -0.36% (95% CI -0.64% to -0.07%) favouring pumps (p = 0.015). Pumps were not cost-effective in the base case and all of the sensitivity analyses. The pump group had greater improvement in diabetes-specific QoL diet restrictions, daily hassle plus treatment satisfaction, statistically significant at 12 and 24 months and supported by qualitative interviews.

LIMITATION

Blinding of pump therapy was not possible, although an objective primary outcome was used.

CONCLUSION

Adding pump therapy to structured training in flexible insulin therapy did not significantly enhance glycaemic control or psychosocial outcomes in adults with T1DM.

RESEARCH PRIORITY

To understand why few patients achieve a HbA_1c of < 7.5%, particularly as glycaemic control is worse in the UK than in other European countries.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN61215213.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 20. See the NIHR Journals Library website for further project information.

Changes in HbA1c and Weight Following Transition to Continuous Subcutaneous Insulin Infusion Therapy in Adults With Type 1 Diabetes

BACKGROUND

Historically, intensive insulin therapy for type 1 diabetes (T1D) has improved glycemic control at the risk of adverse weight gain. The impact of continuous subcutaneous insulin infusion therapy (CSII) on weight in the current era remains unknown. We assessed changes in hemoglobin A1c (HbA1c) and weight in adults with T1D transitioning to CSII at 2 diabetes centers in Denmark and the United States.

METHODS

Patients with T1D, aged ≥18 years, managed with multiple daily injections (MDI) who transitioned to CSII between 2002 and 2013 were identified using electronic health record data from the Steno Diabetes Center (n = 600) and Joslin Diabetes Center (n = 658). Changes in HbA1c and weight after 1 year was assessed overall and by baseline HbA1c cut points. Multivariate regression assessed correlates of HbA1c reduction.

RESULTS

In adults with T1D transitioning to CSII, clinically significant HbA1c reductions were found in patients with baseline HbA1c 8.0-8.9% (Steno, -0.7%; Joslin, -0.4%) and baseline HbA1c ≥9.0% (Steno, -1.1%; Joslin, -0.9%) ( P < .005 for all). Overall, there was no significant change in weight after 1 year at either center. Modest (<2%) weight gain was noted in patients with baseline HbA1c ≥9% at Steno (1.1 ± 0.3 kg, P < .0001) and Joslin (1.7 ± 1.1, P < .005). In multivariate models, HbA1c reduction was associated with higher HbA1c, older age, female sex at Steno ( R² = .28, P < .005), but only higher baseline HbA1c at Joslin ( R² = .19, P < .005).

CONCLUSION

Adults with T1D with suboptimal glycemic control significantly improved HbA1c without a negative impact on weight 1 year after transitioning from MDI to CSII.

The role of insulin pump therapy for type 2 diabetes mellitus

Many patients with type 2 diabetes fail to achieve adequate glucose control despite escalation of treatment and combinations of multiple therapies including insulin. Patients with long-standing type 2 diabetes often suffer from the combination of severe insulin deficiency in addition to insulin resistance, thereby requiring high doses of insulin delivered in multiple injections to attain adequate glycemic control. Insulin-pump therapy was first introduced in the 1970s as an approach to mimic physiological insulin delivery and attain normal glucose in patients with type 1 diabetes. The recent years have seen an increase in the use of this technology for patients with type 2 diabetes. This article summarizes the clinical studies evaluating insulin pump use in patients with type 2 diabetes and discusses the benefits and shortcomings of pump therapy in this population. Copyright © 2016 John Wiley & Sons, Ltd.

Continuous subcutaneous insulin infusion: short-term benefits apparent, long-term benefits speculative

Continuous subcutaneous insulin infusion (CSII) is increasingly used as a means of insulin delivery for those with type 1 diabetes, and has recently been endorsed by NICE for this purpose. CSII improves glycaemic control compared to other intensified insulin regimens, with a small decrease in HbA1C and mean blood glucose, and a larger reduction in glucose fluctuation. This improved control is not associated with an increased risk of hypoglycaemia and CSII probably results in significantly lower rates of severe hypoglycaemia. There is no evidence that those using CSII are at increased risk of diabetic ketoacidosis. CSII is uniquely associated with a small risk of application site infection. CSII has a positive impact on quality of life. There is much less evidence concerning the benefits of CSII in reducing microvascular or macrovascular complication rates. Small studies, mostly from the 1980s, show improvements in markers of early nephropathy, retinopathy progression and neuropathy, but the potential long-term impact of CSII has not been proven. Recently CSII has been used in the management of those Br J Diabetes Vasc Dis 2004;4:104—08 with type 2 diabetes but evidence is lacking with regard to the benefits of using it in this group.

Sustained benefit of continuous subcutaneous insulin infusion on glycaemic control and hypoglycaemia in adults with Type 1 diabetes

AIM

To evaluate the sustainability of the benefits of continuous subcutaneous insulin infusion therapy in routine practice in a cohort of adults with diabetes.

METHODS

The clinical records of all adults starting continuous subcutaneous insulin infusion over 12 years at our centre were included in this study. Baseline and mean annual HbA(1c) levels were recorded. The frequency of mild-to-moderate and severe hypoglycaemia and hypoglycaemia awareness were analysed in a subgroup.

RESULTS

Adequate data were available from 327 patients, of whom 71% were female. The patients' mean ± sd age was 41 ± 14 years, the mean ± sd (range) follow-up for continuous subcutaneous insulin infusion was 4.3 ± 2.7 (1-12) years. The mean ± sd HbA(1c) concentration fell by 8 ± 5 mmol/mol (0.7 ± 0.5%) at year 1 [to 63 ± 12 mmol/mol from 70 ± 18 mmol/mol (7.9 ± 1.1% from 8.6 ± 1.6%); P < 0.0005], sustained to year 5. In patients with initial poor control, HbA(1c) dropped by 12 ± 11 mmol/mol (1.1 ± 1.0%; P < 0.0005) at year 1, sustained to year 6. The percentage of patients with ≥ 5 mild to moderate hypoglycaemic episodes per week fell from 29 to 12% (n = 163; P = 0.006). In the subgroup (n = 87; follow-up 2.5 ± mean ± sd 1.1 years), the frequency of severe hypoglycaemia fell from 0.6 ± 1.7 episodes per patient per year to 0.3 ± 0.9 (P = 0.047). Of 24 patients with impaired awareness of hypoglycaemia (Gold score ≥ 4), the mean ± sd Gold score improved from 4.9 ± 0.9 to 3.8 ± 1.7 (P = 0.011). Nine people regained awareness. No deterioration in HbA(1c) was seen in the hypoglycaemia-prone groups.

CONCLUSIONS

The benefits of continuous subcutaneous insulin infusion with regard to improving glycaemic control and reducing hypoglycaemia frequency, along with improvement in hypoglycaemia awareness without deterioration in glycaemic control, can be sustained over several years in clinical practice.

Drug-related risk of severe hypoglycaemia in observational studies: a systematic review and meta-analysis

BACKGROUND

Diabetes mellitus (DM) leads to multiple complications, including severe hypoglycaemia events (SHEs). SHEs can impact a patient's quality of life and compliance and may directly result in additional costs to the health care system. The aim of this review was to evaluate the risk of severe hypoglycaemia in patients with type 1 (T1) and 2 (T2) DM as observed in everyday clinical practice for various drug regimens.

METHODS

We conducted a systematic review of observational (retrospective or prospective) studies in the MEDLINE, Embase, and Cochrane Library databases that covered at least 100 children or adults with T1/T2 DM. In T1 DM, basal-bolus/pre-mix insulin (human or analogue) and insulin pump were reviewed, and in T2 DM, basal-bolus/pre-mix insulin (human or analogue), oral antidiabetic drugs supported with basal insulin (human or analogue), sulfonylureas in monotherapy, and combined oral treatment were reviewed. In order to estimate SHE rates, we extracted data on the time horizon of the study, number of patients, number of SHEs, and number of patients experiencing at least one SHE. We used a random effects model to estimate the annual SHE rate. We considered the risk for other antidiabetic medications in T2 DM to be negligible and the results of our main review yielded no observational data for premixes in T1 DM so they were assessed based on relative rates taken from additional systematic reviews. The study, being a desk research, did not involve any human subjects (including human material or human data) and no ethical committee approval was asked for. For the same reason there was no need to collect informed consent for participation in the study.

RESULTS

We identified 76 observational studies encompassing 707,722.30 patient-years. The estimated annual SHE rate varied from 0.168 (95 % CI 0.123-0.237) for insulin pump up to 1.628 for biphasic human insulin in T1 DM patients, and from 0.0035 for oral antidiabetic drugs up to 0.554 (95 % CI 0.157-7.534) for basal-bolus with human insulin in T2 DM patients.

CONCLUSIONS

Our review indicates that SHE rates differ between patients depending on treatment regimen. However, SHEs are also driven by other factors. Proper modelling techniques are needed to use various types of information in published studies.

Insulin pump therapy, multiple daily injections, and cardiovascular mortality in 18,168 people with type 1 diabetes: observational study

OBJECTIVE

To investigate the long term effects of continuous subcutaneous insulin infusion (insulin pump therapy) on cardiovascular diseases and mortality in people with type 1 diabetes.

DESIGN

Observational study.

SETTING

Swedish National Diabetes Register, Sweden 2005-12.

PARTICIPANTS

18,168 people with type 1 diabetes, 2441 using insulin pump therapy and 15,727 using multiple daily insulin injections.

MAIN OUTCOME MEASURES

Cox regression analysis was used to estimate hazard ratios for the outcomes, with stratification of propensity scores including clinical characteristics, risk factors for cardiovascular disease, treatments, and previous diseases.

RESULTS

Follow-up was for a mean of 6.8 years until December 2012, with 114,135 person years. With multiple daily injections as reference, the adjusted hazard ratios for insulin pump treatment were significantly lower: 0.55 (95% confidence interval 0.36 to 0.83) for fatal coronary heart disease, 0.58 (0.40 to 0.85) for fatal cardiovascular disease (coronary heart disease or stroke), and 0.73 (0.58 to 0.92) for all cause mortality. Hazard ratios were lower, but not significantly so, for fatal or non-fatal coronary heart disease and fatal or non-fatal cardiovascular disease. Unadjusted absolute differences were 3.0 events of fatal coronary heart disease per 1000 person years; corresponding figures were 3.3 for fatal cardiovascular disease and 5.7 for all cause mortality. When lower body mass index and previous cardiovascular diseases were excluded, results of subgroup analyses were similar to the results from complete data. A sensitivity analysis of unmeasured confounders in all individuals showed that an unmeasured confounders with hazard ratio of 1.3 would have to be present in >80% of the individuals treated with multiple daily injections versus not presence in those treated with pump therapy to invalidate the significantly lower hazard ratios for fatal cardiovascular disease. Data on patient education and frequency of blood glucose monitoring were missing, which might have influenced the observed association.

CONCLUSION

Among people with type 1 diabetes use of insulin pump therapy is associated with lower cardiovascular mortality than treatment with multiple daily insulin injections.

Initiating insulin therapy in children and adolescents with type 1 diabetes mellitus

The primary clinical goals to be achieved with insulin initiation are elimination of ketosis and hyperglycemia with prevention of chronic complications. Insulin therapy is the mainstay in management of type 1 diabetes, which should be aimed at achieving good glycemic control, with achievement of hemoglobin A1c (HbA1c) <7.5%, pre-meal self-monitored blood glucose (SMBG) of 90-130 mg/dL, bed time SMBG of 100-140 mg/dL, mean blood glucose level of 120-160 mg/dL and no ketonuria. Two classes of insulin are available for use in T1DM viz. bolus/prandial insulins (rapid-acting insulins and short-acting insulins) and basal insulins (intermediate-acting insulin and long-acting insulin). Insulin glargine and glulisine can be used in children above 6 years, lispro in children above 3 years and detemir and aspart in children above 2 years. The caution for hypoglycemia should be exercised while prescribing them. Degludec is currently not approved for pediatric use. The initial insulin regimen should comprise of ≥2 daily bolus and ≥1 basal insulin injections. Insulin intensification would be required if the initial regimen fails, which can be achieved by increasing frequency of long and rapid acting insulin analogues. The American Diabetes Association guidelines recommend HbA1c targets of <8.0% for children <6 years of age, ≤7.5% for children 6 to 12 years of age, and ≤7.0% for adolescents, 12-18 years of age. However, the evidence is now in favor of a single target HbA1c of ≤7.5% for all children and adolescents <19 years of age.

Predicting the effectiveness of insulin pump therapy on glycemic control in clinical practice: a retrospective study of patients with type 1 diabetes from 10 outpatient diabetes clinics in Sweden over 5 years

BACKGROUND

Multicenter long-term studies of predictors for the effectiveness of continuous subcutaneous insulin infusion (CSII) in clinical practice are lacking. We hypothesized that there are substantially greater reductions in hemoglobin A1c (HbA1c) in patients with poor glycemic control and that other predictors may also exist.

SUBJECTS AND METHODS

We used data from 10 outpatient diabetic clinics in Sweden and studied CSII treatment over 5 years. Patients with HbA1c values available ≤ 6 months before starting CSII and at 5 years were included (n = 272, 82% of CSII patients) along with 2,437 contemporaneous controls on multiple daily insulin injections (MDI). Baseline variables evaluated were age, sex, diabetes duration, insulin dose, body mass index (BMI), HbA1c at baseline, and outpatient clinical care unit.

RESULTS

At 5 years, significantly greater reductions in HbA1c by CSII compared with MDI were found for patients with higher baseline HbA1c (P = 0.032) and lower baseline BMI (P = 0.013). For baseline HbA1c levels of 7.0%, 8.0%, and 9.0% and a BMI of 25 kg/m(2), the reduction in HbA1c level by CSII was 0.08% (difference not significant), 0.16% (95% confidence interval, 0.03-0.29%), and 0.25% (95% confidence interval, 0.11-0.39%), respectively. Corresponding analyses for the change in HbA1c level from start to 1 and 2 years revealed a significant interaction of insulin pump therapy only with baseline HbA1c levels (P < 0.001 and P = 0.030, respectively). The interaction term between outpatient clinical care unit and CSII treatment was statistically significant for some care units, with some care units demonstrating a benefit from CSII and others demonstrating a detriment.

CONCLUSIONS

Patients with high HbA1c levels have a greater probability of improved HbA1c after initiating pump therapy, but effects remain relatively modest even for patients with poor control. Factors predicting successful insulin pump use need further study.

Variations in the quality and sustainability of long-term glycaemic control with continuous subcutaneous insulin infusion

AIMS

To investigate the pattern of changes in HbA1c in people with Type 1 diabetes managed by long-term Continuous subcutaneous insulin infusion.

METHODS

We studied HbA1c changes using computerized clinic records in 35 adult people with Type 1 diabetes and an elevated HbA1c (≥ 64 mmol/mol, 8.0%) on multiple daily insulin injections, who were then switched to continuous subcutaneous insulin infusion for at least 5 years.

RESULTS

We identified three subgroups with similar baseline HbA1c but different long-term responses to pump therapy: group A--those with improvement followed by deterioration (57%); group B--those with improvement that was sustained throughout the 5 years (31%); and group C-those where HbA1c did not change significantly from baseline (12%). The patients in group C had a higher BMI: 31.0 ± 5.2 vs. 25.9 ± 3.3 vs. 25.2 ± 3.1 kg/m² (group C vs. group A and group B; P = 0.02).

CONCLUSIONS

Improved glycaemic control with continuous subcutaneous insulin infusion was maintained over 5 years by 88% of people with Type 1 diabetes in this study, but there were variations in the long-term efficacy, with some people improving and worsening, others maintaining strict control and a few subcutaneous insulin infusion 'non-responders'.

Comparison of continuous subcutaneous insulin infusion and insulin glargine-based multiple daily insulin aspart injections with preferential adjustment of basal insulin in patients with type 2 diabetes

The purpose of this study was to evaluate and compare multiple daily injection (MDI) therapy of bolus insulin aspart and basal insulin glargine with continuous subcutaneous insulin infusion (CSII) with aspart in patients with type 2 diabetes mellitus (T2DM). It was assessed whether MDI was capable of controlling glycemic index with a higher efficacy than CSII by preferential adjustment of basal insulin with a lower total daily insulin dosage in T2DM. Two hundred patients with T2DM were enrolled in the study and randomly assigned to CSII (n=100) and MDI (n=100; aspart immediately prior to each meal and glargine at bedtime) groups for 12 weeks of therapy. During the last week of each treatment period, the subjects wore a continuous glucose monitoring system for 2–3 days. The dosage of basal insulin was preferentially adjusted to control prior-meal blood glucose levels, and the characteristics of insulin dosage were analyzed. No statistically significant differences were observed between the two groups in hemoglobin A1c (HbA1c), which dropped from 10–11% prior to therapy to 7–7.5% after 12 weeks. After 12 weeks, good glycemic level control was achieved in all patients in the MDI and CSII groups. A statistically significant difference in the dose of insulin between the CSII and MDI groups was observed (P<0.001). In conclusion, no significant differences were found between the two therapies in the incidence of hypoglycemia and HbA1c for the 12 weeks. The basal insulin dosage was significantly decreased in the MDI group compared with that in the CSII group, but the CSII group was superior to MDI group in decreasing fasting blood glucose and shortening the time required for hypoglycemia to meet the targeted level.

Comparison of continuous subcutaneous insulin infusion and multiple daily insulin injections in Chinese patients with type 2 diabetes mellitus

Objective

To investigate prospectively the insulin dose requirements of Chinese patients with type 2 diabetes mellitus treated with either multiple daily insulin injections (MDI) or continuous subcutaneous insulin infusion (CSII) therapy during a 2-week therapeutic intervention.

Methods

Patients with type 2 diabetes mellitus were randomly assigned to MDI or CSII therapy. The effects of the two treatment methods were determined based on blood glucose parameters, total daily insulin dose and rates of hypoglycaemia.

Results

A total of 609 patients were enrolled in the study. Glycaemic goals were achieved after a mean ± SD of 6.90 ± 2.10 and 5.44 ± 2.22 days’ treatment in the MDI and CSII groups, respectively. Once stabilized, the mean ± SD total daily insulin doses were 37.12 ± 10.19 IU and 32.58 ± 8.78 IU for the MDI and CSII groups, respectively. Once stabilized, the mean ± SD total basal and bolus doses were 19.46 ± 7.95 IU/day and 17.66 ± 3.53 IU/day for the MDI group, and 22.79 ± 7.55 IU/day and 9.81 ± 2.64 IU/day for the CSII group, respectively. There were significant differences in the total, basal and bolus insulin doses between the two groups.

Conclusion

CSII therapy may be considered as an effective method to achieve good glycaemic control in Chinese patients with type 2 diabetes mellitus.

Nonmetabolic complications of continuous subcutaneous insulin infusion: a patient survey

BACKGROUND

Little is known about the frequencies and types of nonmetabolic complications occurring in type 1 diabetes patients being treated by modern insulin pump therapy (continuous subcutaneous insulin infusion [CSII]), when recorded by standardized questionnaire rather than clinical experience.

SUBJECTS AND METHODS

A self-report questionnaire was completed by successive subjects with type 1 diabetes attending an insulin pump clinic, and those with a duration of CSII of ≥6 months were selected for analysis (n=92). Questions included pump manufacturer, insulin, infusion set type and duration of use, frequency of infusion set and site problems, pump malfunctions, and patient-related problems such as weight change since starting CSII.

RESULTS

Median (range) duration of CSII was 3.3 (0.5-32.0) years, and mean ± SD duration of infusion set use was 3.2 ± 0.7 (range 2-6) days. The commonest infusion set problems were kinking (64.1% of subjects) and blockage (54.3%). Blockage was associated with >3 days of use of infusion sets plus lispro insulin in the pump (relative risk [95% confidence interval], 1.71 [1.03-2.85]; P=0.07). The commonest infusion site problem was lipohypertrophy (26.1%), which occurred more often in those with long duration of CSII (4.8 [2.38-9.45] vs. 3.0 [1.50-4.25] years; P=0.01). Pump malfunction had occurred in 48% of subjects (43% in the first year of CSII), with "no delivery," keypad, and battery problems commonly occurring. Although some patients reported weight gain (34%) and some weight loss (15%) on CSII, most patients (51%) reported no change in weight.

CONCLUSIONS

Pump, infusion set, and infusion site problems remain common with CSII, even with contemporary technology.

Short-term effects of continuous subcutaneous insulin infusion therapy in perioperative patients with diabetes mellitus

BACKGROUND

Hyperglycemia is common and hard to control in surgical patients with diabetes. We retrospectively investigated short-term effects of continuous subcutaneous insulin infusion (CSII) in perioperative patients with diabetes.

PATIENTS AND METHODS

Perioperative patients with diabetes discharged between January 1, 2006 and January 1, 2012 were included. Glucose control and postoperative outcomes were compared between the patients using CSII or non-CSII insulin therapy.

RESULTS

We identified 108 pairs of patients matched by propensity and surgical category who were using CSII therapy (CSII group) or non-CSII insulin therapy (control group). The CSII group had significantly lower fasting glucose levels (on the first postoperative day, 9.06±3.09 mmol/L vs. 11.05±4.19 mmol/L; P=0.003) and lower mean glucose levels (on the operation day, 9.93±2.65 mmol/L vs. 12.05±3.86 mmol/L; P=0.001). The CSII group also had a lower incidence of fever (on the first postoperative day, 30.4% vs. 53.2%; P=0.005). Furthermore, patients in the CSII group experienced significantly shorter postoperative intervals for suture removal (P=0.02) and hospital discharge (P=0.03). No significant difference in the total medical expenditure was observed between the two groups (P=0.47). We also made a comparison between the 30 pairs of patients who were using CSII or multiple daily insulin injection therapy but observed no significant difference between these two therapies in glucose control or postoperative outcomes.

CONCLUSIONS

Compared with non-CSII insulin therapy, even short-term implementation of CSII can improve the postoperative control of glucose, reduce the incidence of postoperative fever, and shorten the time for suture removal and discharge in surgical patients with diabetes.

Long-term outcome of insulin pump therapy in children with type 1 diabetes assessed in a large population-based case-control study

AIMS/HYPOTHESIS

We determined the impact of insulin pump therapy on long-term glycaemic control, BMI, rate of severe hypoglycaemia and diabetic ketoacidosis (DKA) in children.

METHODS

Patients on pump therapy at a single paediatric tertiary hospital were matched to patients treated by injections on the basis of age, duration of diabetes and HbA1c at the time of pump start. HbA1c, anthropometric data, episodes of severe hypoglycaemia and rates of hospitalisation for DKA were collected prospectively.

RESULTS

A total of 345 patients on pump therapy were matched to controls on injections. The mean age, duration of diabetes at pump start and length of follow-up were 11.4 (± 3.5), 4.1 (± 3.0) and 3.5 (± 2.5) years, respectively. The mean HbA1c reduction in the pump cohort was 0.6% (6.6 mmol/mol). This improved HbA1c remained significant throughout the 7 years of follow-up. Pump therapy reduced severe hypoglycaemia from 14.7 to 7.2 events per 100 patient-years (p < 0.001). In contrast, severe hypoglycaemia increased in the non-pump cohort over the same period from 6.8 to 10.2 events per 100 patient-years. The rate of hospitalisation for DKA was lower in the pump cohort (2.3 vs 4.7 per 100 patient-years, p = 0.003) over the 1,160 patient-years of follow-up.

CONCLUSIONS/INTERPRETATION

This is the longest and largest study of insulin pump use in children and demonstrates that pump therapy provides a sustained improvement in glycaemic control, and reductions of severe hypoglycaemia and hospitalisation for DKA compared with a matched cohort using injections.

Insulin pump-long-term effects on glycemic control: an observational study at 10 diabetes clinics in Sweden

AIM

This study examined long-term effects of continuous subcutaneous insulin infusion (CSII) in clinical practice on glycemic control in patients with type 1 diabetes.

SUBJECTS AND METHODS

We evaluated all type 1 diabetes patients at 10 diabetes outpatient clinics in Sweden who had been treated with CSII for at least 5.5 years and had valid glycated hemoglobin (HbA1c) data before starting pump use and at 5 years ± 6 months. Controls treated with multiple daily insulin injections (MDI) over a time-matched period were also evaluated.

RESULTS

There were 331 patients treated with CSII at least 5.5 years at the 10 clinics. Of these, 272 (82%) fulfilled the inclusion criteria. Patients treated with CSII were younger than those treated with MDI (mean age, 38.6 vs. 45.6 years; P<0.001), more were women (56% vs. 43%; P<0.001), and diabetes duration was shorter (mean, 15.1 years vs. 20.1 years; P<0.001). After adjusting for variables differing at baseline and influencing the change in HbA1c over the study period, the reduction in HbA1c remained statistically significant at 5 years and was estimated to be 0.20% (95% confidence interval [CI] 0.07-0.32) (2.17 mmol/mol [95% CI 0.81-3.53]) (P=0.002). The corresponding adjusted reduction at years 1 and 2 was 0.42% (95% CI 0.31-0.53) (4.59 mmol/mol [95% CI 3.41-5.77]) (P<0.001) and 0.43% (95% CI 0.31-0.55) (4.71 mmol/mol [95% CI 3.38-6.04]) (P<0.001), respectively. The effect of insulin pump use versus controls on HbA1c decreased significantly with time (P<0.001).

CONCLUSIONS

Use of CSII in clinical practice in Sweden is associated with an approximately 0.2% (2 mmol/mol) reduction in HbA1c after 5 years.

Insulin infusion set: the Achilles heel of continuous subcutaneous insulin infusion

Continuous subcutaneous insulin infusion from an insulin pump depends on reliable transfer of the pumped insulin to the subcutaneous insulin depot by means of an insulin infusion set (IIS). Despite their widespread use, the published knowledge about IISs and related issues regarding the impact of placement and wear time on insulin absorption/insulin action is relatively small. We also have to acknowledge that our knowledge is limited with regard to how often patients encounter issues with IISs. Reading pump wearer blogs, for instance, suggests that these are a frequent source of trouble. There are no prospective clinical studies available on current IIS and insulin formulations that provide representative data on the type and frequency of issues with infusion sets. The introduction of new IISs and patch pumps may foster a reassessment of available products and of patient problems related to their use. The aim of this review is to summarize the current knowledge and recommendations about IISs and to highlight potential directions of IIS development in order to make insulin absorption safer and more efficient.

Management of diabetes mellitus: is the pump mightier than the pen?

Continuous subcutaneous insulin infusion (CSII, or insulin pump therapy) reduces HbA1c levels and hypoglycaemia in patients with type 1 diabetes mellitus (T1DM) compared with multiple daily insulin injections (MDI). The greatest reduction in HbA(1c) levels with CSII occurs in patients with the worst glycaemic control; therefore, the most appropriate and cost-effective use of CSII in adults with T1DM is in those who have continued, elevated HbA(1c) levels or disabling hypoglycaemic episodes with MDI (including the use of long-acting insulin analogues and structured patient education). The disadvantages of CSII include higher costs than MDI and the risk of ketosis in the event of pump failure. In children with T1DM, CSII may be used when MDI is considered impractical or inappropriate. Pumps are not generally recommended for patients with type 2 diabetes mellitus but may improve control in some subgroups. A new generation of smaller insulin infusion pumps with an integrated cannula, called patch pumps, could improve uptake of CSII in general. The important clinical question is not whether CSII is more efficacious than MDI in general adult T1DM, but whether CSII further improves glycaemic control when this control continues to be poor with MDI, and evidence exists that in most cases it does.

Investigation of the insulin dose and characteristics of continuous subcutaneous insulin infusion in Chinese people with type 2 diabetes

BACKGROUND

Continuous subcutaneous insulin infusion (CSII) for type 2 diabetes mellitus (T2DM) is a promising therapy. CSII therapy is flexible, but the required insulin dose for different people may vary. Few studies have investigated the insulin dose and characteristics of CSII for T2DM, and none has focused on an Asian Chinese population.

METHODS

In total, 171 subjects with T2DM were using CSII and divided into different groups according to their body mass index (BMI) and the course of disease, respectively. The basal rate of CSII was set for four periods per day. We preferentially adjusted the basal insulin dose to control fasting and preprandial blood glucose.

RESULTS

Good glycemic control was achieved after 4.8±2.5 days. The mean total daily insulin dose was 31.66±9.85 IU, and the dose per unit body weight was 0.48±0.19 IU/kg/day. The total daily basal and bolus doses were 21.14±7.64 IU and 10.38±3.62 IU, respectively (i.e., about 66.7±6.8% and 33.3±6.8% of the total daily dose). We did not observe any significant difference in total dose of insulin or basal and bolus doses of insulin per day among different groups divided by BMI. Only in the group with BMI of <23 kg/m(2) was the insulin dose of per kilogram of body weight (0.60±0.25 IU/kg/day) significantly higher than in the other two groups (P=0.0001). There was no relationship between the insulin dose and the course of disease.

CONCLUSIONS

In individuals with T2DM on CSII short-term intensive therapy, proper increase of basal dose of insulin and preferential adjustment of the basal rate may be the effective method that can achieve good glycemic control with a lower total daily dose.

Treatment satisfaction and quality of life for an integrated continuous glucose monitoring/insulin pump system compared to self-monitoring plus an insulin pump

BACKGROUND

Little is known about how the most advanced technology affects treatment satisfaction and health-related quality of life (HRQOL) in adults with diabetes. This study was designed to assess treatment satisfaction and HRQOL among users of an integrated real-time (RT) continuous glucose monitoring (CGM)/continuous subcutaneous insulin infusion (CSII) system compared with those using self-monitoring of blood glucose (SMBG) with CSII.

METHODS

Participants were 311 adult respondents to an Internet survey, 162 using RT-CGM/CSII, 149 using SMBG + CSII (median age 43 years; type 1 diabetes 94%; diabetes duration >15 years 61%; median insulin use 15 years). Respondents completed instruments assessing glucose monitoring system and insulin delivery system convenience, interference, burden, glucose control efficacy, cost satisfaction, overall satisfaction, and treatment preference, as well as quality of life (diabetes-related worries, social burden, and psychological well-being). Real-time CGM/CSII users also assessed specific elements of the RT-CGM/CSII system. Group differences were assessed using analysis of covariance controlling for respondent characteristics.

RESULTS

The RT-CGM/CSII group gave significantly better ratings than the SMBG + CSII group for their glucose monitoring system's glucose control efficacy, overall satisfaction, desire to switch, and willingness to recommend, and significantly worse ratings for interference with daily activities. The RT-CGM/CSII group gave significantly better ratings than the SMBG + CSII group for their insulin delivery system's convenience and glucose control efficacy, overall satisfaction, desire to switch, and willingness to recommend. Real-time CGM/CSII users gave positive ratings of all system features.

CONCLUSIONS

Users of the integrated RT-CGM/CSII system reported more benefits of treatment, higher treatment satisfaction and quality of life, and greater preference for this system than SMBG + CSII users.

Effect of insulin catheter wear-time on subcutaneous adipose tissue blood flow and insulin absorption in humans

BACKGROUND

Insertion of an insulin catheter for continuous subcutaneous insulin infusion into the subcutaneous adipose tissue (SAT) causes a tissue trauma that may have consequences for insulin absorption. We evaluated the importance of insulin catheter wear-time on subcutaneous adipose tissue blood flow (ATBF) and absorption of the rapid-acting insulin analog insulin aspart over a period of 4 days.

METHODS

Teflon insulin catheters (Medtronic, Minneapolis, MN) were inserted into the abdominal SAT of 10 healthy men without diabetes (mean +/- SEM age, 23.0 +/- 1.1 years; body mass index, 22.1 +/- 0.7 kg/m(2)) and connected to an insulin pump delivering a constant rate of isotonic saline for 4 days. Subjects participated in four study days (days 0, 1, 2, and 4) during which ATBF around the catheter tip was measured by (133)Xe clearance and absorption of an insulin aspart bolus (0.1 U/kg) was measured for 4 h.

RESULTS

ATBF increased from day 0 to day 2 after catheter insertion (2.6 +/- 0.6 to 4.5 +/- 0.8 mL/100 g/min; P = 0.030). By day 4, ATBF had returned to day 0 level. Time to peak plasma insulin aspart concentration after bolus administration decreased with catheter wear-time from 55 +/- 3 min on day 0 to 45 +/- 4 min on day 4 (P = 0.019). Neither peak plasma concentration nor area under the curve of insulin aspart changed significantly.

CONCLUSIONS

Insertion of a Teflon insulin catheter into the SAT results in increased ATBF and faster absorption of insulin aspart in a period of 4 days without any change in the total amount of insulin aspart absorbed.

A cost-effectiveness analysis of continuous subcutaneous insulin injection versus multiple daily injections in type 1 diabetes patients: a third-party US payer perspective

OBJECTIVE

To estimate the long-term cost-effectiveness of using continuous subcutaneous insulin infusion (CSII) compared with multiple daily injections (MDI) of insulin in adult and child/young adult type 1 diabetes mellitus (T1DM) patients from a third-party payer perspective in the United States.

METHOD

A previously validated health economic model was used to determine the incremental cost-effectiveness ratio (ICER) of CSII compared with MDI using published clinical and cost data. The primary input variable was change in HbA(1c), and was assumed to be an improvement of -0.9% to -1.2% for CSII compared with MDI for child/young adult and adults, respectively. A series of Markov constructs simulated the progression of diabetes-related complications.

RESULTS

CSII was associated with an improvement in quality-adjusted life-years (QALYs) gained of 1.061 versus MDI for adults and 0.799 versus MDI for children/young adults. ICERs were $16,992 and $27,195 per QALY gained for CSII versus MDI in adults and children/young adults, respectively. Improved glycemic control from CSII led to a lower incidence of diabetes complications, with the most significant reduction in proliferative diabetic retinopathy (PDR), end stage renal disease (ESRD), and peripheral vascular disease (PVD). The number needed to treat (NNT) for PDR was nine patients, suggesting that only nine patients need to be treated with CSII to avoid one case of PDR. The NNT for ESRD and PVD was 19 and 41, respectively.

CONCLUSIONS

Setting the willingness to pay at $50,000/QALY, the analysis demonstrated that CSII is a cost-effective option for patients with T1DM in the United States.

Continuous subcutaneous insulin infusion (CSII) 30 years later: still the best option for insulin therapy

Thirty years after its introduction, the use of continuous subcutaneous insulin infusion (CSII) keeps increasing, especially among children and adolescents. The technique, when used properly, is safe and effective.Compared with traditional NPH-based multiple daily injections (MDI), CSII provides a small but clinically important reduction of HbA(1c) levels, diminishes blood glucose variability, decreases severe hypoglycaemic episodes and offers a better way to cope with the dawn phenomenon.Insulin analogues have improved the treatment of diabetes, eroding part of the place previously occupied by CSII, but CSII still remains the first option for patients experiencing severe hypoglycaemic episodes, high HbA(1c) values or marked glucose variability while being treated with optimized MDI. Furthermore CSII is better than MDI considering the effects on quality of life and the possibility to adjust insulin administration according to physical activity or food intake.CSII may be limited by cost. Present estimates suggest that CSII may be cost-effective just for patients experiencing a marked improvement in HbA(1c) or a decrease in severe hypoglycaemic episodes, but the effects on quality of life are difficult to measure.CSII does not merely imply wearing an external device; it requires a multidisciplinary team, intensive patient education and continuous follow up.

Severe hypoglycaemia and glycaemic control in Type 1 diabetes: meta-analysis of multiple daily insulin injections compared with continuous subcutaneous insulin infusion

AIMS

Continuous subcutaneous insulin infusion (CSII) is a recommended treatment for reducing severe hypoglycaemia in Type 1 diabetes, but the change in hypoglycaemia compared with multiple daily insulin injections (MDI) is unclear. We therefore conducted a meta-analysis comparing severe hypoglycaemia and glycaemic control during CSII and MDI.

METHODS

Databases and literature (1996-2006) were searched for randomized controlled trials (RCTs) and before/after studies of > or = 6 months' duration CSII and with severe hypoglycaemia frequency > 10 episodes/100 patient years on MDI.

RESULTS

In 22 studies (21 reports), severe hypoglycaemia during MDI was related to diabetes duration (P = 0.038) and was greater in adults than children (100 vs. 36 events/100 patient years, P = 0.036). Severe hypoglycaemia was reduced during CSII compared with MDI, with a rate ratio of 2.89 (95% CI 1.45 to 5.76) for RCTs and 4.34 (2.87 to 6.56) for before/after studies [rate ratio 4.19 (2.86 to 6.13) for all studies]. The reduction was greatest in those with the highest initial severe hypoglycaemia rates on MDI (P < 0.001). The mean difference in glycated haemoglobin (HbA(1c)) between treatments was less for RCTs [0.21% (0.13-0.30%)] than in before/after studies [0.72% (0.55-0.90%)] but strongly related to the initial HbA(1c) on MDI (P < 0.001).

CONCLUSIONS

The severe hypoglycaemia rate in Type 1 diabetes was markedly less during CSII than MDI, with the greatest reduction in those with most severe hypoglycaemia on MDI and those with the longest duration of diabetes. The biggest improvement in HbA(1c) was in those with the highest HbA(1c) on MDI.

Continuous subcutaneous insulin infusion leads to immediate, stable and long-term changes in metabolic control

BACKGROUND

Evaluations of continuous subcutaneous insulin infusion (CSII) usually focus on one pre- and one post-CSII measurement to assess metabolic therapy outcome.

AIM

Extending this research, the aim of the present study was to provide a more fine-grained analysis of achieved glycaemic control.

METHODS

In 52 patients with type 1 diabetes (mean age of 37.85 years at CSII begin; s.d. +/- 12.41), haemoglobin A(1c) (HbA(1c)) levels were assessed every 3 months over a period of 5 years (1 year before and 4 years after the introduction of CSII). Mixed models were utilized to describe changes in glycaemic control.

RESULTS

The pre-post course showed that already in the first quarter, a statistically significant lower HbA(1c) level was obtained [7.30%, in contrast to 8.21% at the last quarter with intensified conventional therapy (ICT)]. In the following 15 quarters, the mean HbA(1c) levels remained constantly lower than that with ICT. Overall, the aggregated mean HbA(1c) level of patients with CSII therapy was 7.19%, in contrast to 8.08% with ICT; thus, an overall decrease by 11% was achieved. In addition, individual differences in blood glucose level and age of diabetes onset as a predictor for therapy success were analysed.

CONCLUSIONS

The data show an immediate, stable and long-term effect of CSII on HbA(1c). In addition, a significant relationship between metabolic control and age of diabetes onset was found, as well as a reduction of variance in HbA(1c) levels between subjects after change to CSII.

Long-acting insulin analogs versus insulin pump therapy for the treatment of type 1 and type 2 diabetes

Insulin pump therapy (continuous subcutaneous insulin infusion [CSII]) is now an established form of intensive insulin treatment. It is pertinent to ask, however, if multiple daily injection (MDI) regimens based on new long-acting insulin analogs such as glargine and detemir have now replaced the need for CSII. In type 1 diabetes, CSII reduces the frequency of severe hypoglycemia compared with isophane-based MDIs, but the rate of severe hypoglycemia is usually similar on glargine- or detemir-based MDIs compared with isophane-based MDIs. CSII reduces A1C and glycemic variability compared with isophane-based MDIs; but glargine and detemir do not improve A1C or variability in many patients, particularly those who are prone to hypoglycemia. Head-to-head comparisons of CSII with MDI based on glargine indicate lower A1C, fructosamine, or glucose levels on CSII. It can be concluded that long-acting insulin analogs have not yet replaced the need for insulin pump therapy in type 1 diabetes, and CSII is the best current therapeutic option for some type 1 diabetic subjects. In type 2 diabetes, CSII and MDI produce similar glycemic control, although there is little study of MDI based on long-acting analogs compared with pumps. It is possible that CSII will be beneficial in selected patient groups with type 2 diabetes, but this requires further study.

Treatment of Danish adolescent diabetic patients with CSII - a matched study to MDI

OBJECTIVE

To compare two intensified insulin therapy regimens - continuous subcutaneous insulin infusion (CSII) against multiple daily insulin injection (MDI) - in Danish adolescents examined in a prospective, matched controlled study design.

RESEARCH DESIGN AND METHODS

Thirty type 1 diabetic adolescents at CSII and 26 matched MDI controls were included in this open intention-to-treat study. Actrapid was used in both groups. Before study entry, all participants followed a brush-up course in order to minimize study effect. At each visit, the following parameters were recorded: hemoglobin A1c (HbA1c), insulin dose, weight, number of hypoglycemic and diabetic ketoacidosis (DKA) events, and the time resources used. At entry and exit of the study, diet registration and validated quality-of-life (QoL) questionnaires were filled by the participants.

RESULTS

A non-significant decline in HbA1c was seen in both groups (p = 0.468); HbA1c decreased from 9.5 to 8.9% and from 9.7 to 9.5% in the CSII and MDI group, respectively. The insulin dose and the number of severe hypoglycemic events per patient were lower (non-significant) in the CSII group. Both groups showed increased body mass index - highest in the CSII group - and mild to moderate DKA episodes were only seen among CSII users. No differences could be demonstrated within the QoL or diet registrations.

CONCLUSIONS

CSII treatment is beneficial as an intensified insulin therapy for selected type 1 diabetic patients and both MDI and CSII can be offered by the professional diabetes team to better tailor therapy. In future, there is a strong need to identify the characteristics of responders to CSII treatment in order to increase the efficacy and safety of CSII treatment.

Quality of life and treatment satisfaction in adults with Type 1 diabetes: a comparison between continuous subcutaneous insulin infusion and multiple daily injections

AIMS

The aim of this case-control study was to compare quality of life (QoL) and treatment satisfaction in adults with Type 1 diabetes (T1DM) treated with either continuous subcutaneous insulin infusion (CSII) or multiple daily injections (MDI).

METHODS

Consecutive patients aged between 18 and 55 years, and attending diabetes clinics for a routine visit, completed the Diabetes-Specific Quality-of-Life Scale (DSQOLS), the Diabetes Treatment Satisfaction Questionnaire (DTSQ) and the SF-36 Health Survey (SF-36). Case (CSII) and control subjects (MDI) were recruited in a 1 : 2 ratio.

RESULTS

Overall, 1341 individuals were enrolled by 62 diabetes clinics; 481 were cases and 860 control subjects. Cases had a longer diabetes duration and were more likely to have eye and renal complications. Age, school education, occupation and HbA(1c) were similar. Of control subjects, 90% followed glargine-based MDI regimens and 10% used NPH-based MDI regimens. On multivariate analysis, after adjusting for socioeconomic and clinical characteristics, scores in the following areas of the DSQOLS were higher in cases than control subjects: diet restrictions (beta = 5.96; P < 0.0001), daily hassles (beta = 3.57; P = 0.01) and fears about hypoglycaemia (beta = 3.88; P = 0.006). Treatment with CSII was also associated with a markedly higher DTSQ score (beta = 4.13; P < 0.0001) compared with MDI. Results were similar when CSII was compared separately with glargine- or NPH-based MDI regimens.

CONCLUSIONS

This large, non-randomized, case-control study suggests quality of life gains deriving from greater lifestyle flexibility, less fear of hypoglycaemia, and higher treatment satisfaction, when CSII is compared with either glargine-based or NPH-based MDI regimens.

Prevalence and associations of psychological distress in young adults with Type 1 diabetes

AIMS

To determine the prevalence of psychological distress in young adults with Type 1 diabetes and to explore associated factors.

METHODS

Ninety-two participants with Type 1 diabetes (46 male, 46 female) attending a young adult clinic completed two psychological self-report assessments; the Centre for Epidemiological Studies-Depression Scale (CES-D) and Adult Self-Report Scale (ASR). The mean age was 21.6 +/- 2.8 years (sd) and mean duration of diabetes was 9.3 +/- 5.4 years. A questionnaire identified the method of insulin delivery, the frequency of blood glucose monitoring and hypoglycaemia requiring third-party assistance. HbA(1c) was measured.

RESULTS

Of the participants, 35.2% reported depressive symptoms (CES-D > or = 16), 23.1% indicating severe depressive symptoms (CES-D > or = 24), and 32.2, 40.4 and 35.5% of participants reported significant distress (ASR > or = 60) on the ASR total problem scales, ASR internalizing and ASR externalizing scores, respectively. Mean HbA(1c) levels were higher in participants with depressive symptoms compared with those with normal scores (CES-D > or = 16, HbA(1c)= 9.4% vs. CES-D < 16, HbA(1c)= 8.4%, P = 0.01). Factors associated with psychological distress included use of continuous subcutaneous insulin infusion (CSII) (P = 0.02) and increased frequency of hypoglycaemic episodes (P = 0.03). CSII users had higher CES-D (21.3 vs. 11.9, P = 0.001) and ASR-Total (59.7 vs. 53.0, P = 0.02) scores than non-CSII users.

CONCLUSIONS

Approximately one-third of young adults with Type 1 diabetes experience psychological distress, which is associated with poorer glycaemic control. Psychological distress was related to frequency of hypoglycaemic episodes and method of insulin administration, with significantly greater distress being observed in those using CSII. These findings support inclusion of a psychologist in the diabetes team.

Insulin-associated weight gain in diabetes--causes, effects and coping strategies

Insulin therapy or intensification of insulin therapy commonly results in weight gain in both type 1 and type 2 diabetes. This weight gain can be excessive, adversely affecting cardiovascular risk profile. The spectre of weight gain can increase diabetic morbidity and mortality when it acts as a psychological barrier to the initiation or intensification of insulin, or affects adherence with prescribed regimens. Insulin-associated weight gain may result from a reduction of blood glucose to levels below the renal threshold without a compensatory reduction in calorie intake, a defensive or unconscious increase in calorie intake caused by the fear or experience of hypoglycaemia, or the 'unphysiological' pharmacokinetic and metabolic profiles that follow subcutaneous administration. There is, however, scope for limiting insulin-associated weight gain. Strategies include limiting dose by increasing insulin sensitivity through diet and exercise or by using adjunctive anorectic or insulin-sparing pharmacotherapies such as pramlintide or metformin. Insulin replacement regimens that attempt to mimic physiological norms should also enable insulin to be dosed with maximum efficiency. The novel acylated analogue, insulin detemir, appears to lack the usual propensity for causing weight gain. Elucidation of the pharmacological mechanisms underlying this property might help clarify the mechanisms linking insulin with weight regulation.

Systematic literature review: quality of life associated with insulin pump use in Type 1 diabetes

AIM

To review systematically the published literature addressing whether continuous subcutaneous insulin infusion (CSII) provides any quality of life benefits to people with Type 1 diabetes.

METHODS

Electronic databases and published references were searched and a consultation with two professional groups was undertaken to identify relevant studies published up to July 2005. A multistep selection process was then undertaken to identify those articles which met the specific selection criteria, which were then critically reviewed.

RESULTS

Eighty-four potential relevant articles were identified from examination of titles and abstracts published during the specified time frame. Of these, 28 articles were retrieved in full text, of which 17 fulfilled the specific criteria for inclusion. Mixed results emerged from existing literature. Of the five randomized controlled trials, three reported mixed results, with one study reporting quality of life benefits and one reporting no evidence of quality of life benefits.

CONCLUSIONS

There is conflicting evidence reported in the various studies on the quality of life benefits of CSII in Type 1 diabetes. Existing research is flawed, making a judgement about the quality of life benefits of insulin pump use difficult. There is no strong evidence against quality of life benefits associated with CSII or otherwise, with poor methodology and inconsistent assessment of quality of life clouding the issue. The lack of reported benefit is probably a function of this rather than pump therapy not offering any quality of life benefits.

Precipitation of insulin aspart and insulin glulisine products used for continuous subcutaneous insulin infusion

BACKGROUND

The commercially available insulin products insulin aspart injection (IAsp) and insulin glulisine injection (IGlu), used for continuous subcutaneous insulin infusion (CSII), have been compared with respect to resistance towards isoelectric insulin precipitation. Additionally, a hybrid product consisting of the insulin aspart analogue in an IGlu product composition (the hybrid product was termed IAsp (Apidra)) has been examined.

METHODS

The degree of isoelectric insulin precipitation was examined by reverse-phase high performance liquid chromatography while reducing pH through addition of diluted HCl.

RESULTS

The pH at which isoelectric precipitation occurred differed between IAsp and IGlu as reflected by the pH level at which 50% of the insulin precipitated (IAsp, pH 5.86; IGlu, pH 6.64). The amount of H(+)-equivalents per microliter of product required to induce isoelectric precipitation differed between IAsp and IGlu as reflected by the amount of acid required to cause 50% insulin precipitation (5.27 and 4.14 nmol of H(+)-equivalents, respectively). Data from IAsp(Apidra) suggest that the observed difference between IAsp and IGlu can be attributed to a combination of the different insulin analogue molecules and different product compositions of IAsp and IGlu.

CONCLUSIONS

Resistance towards isoelectric precipitation is highest for IAsp and lowest for IGlu because of the lower pH and higher amount of acid required to induce isoelectric insulin precipitation of IAsp. Isoelectric precipitation will alter the pharmacokinetic properties of the insulin and could lead to occlusion of the infusion catheter during CSII. However, further studies are required to elucidate the potential clinical relevance of the observed differences in in vitro resistance towards isoelectric precipitation between IAsp and IGlu.