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

Insulin Pump Therapy for Patients With Type 2 Diabetes Mellitus: Evidence, Current Barriers, and New Technologies

An increasing number of patients with type 2 diabetes mellitus (T2DM) use insulin pumps. The first insulin pumps especially designed for patients with T2DM have recently become available. However, national guidelines do not primarily recommend the use of continuous subcutaneous insulin infusion (CSII) for this patient group. The effectiveness of CSII in T2DM has not yet been convincingly demonstrated, despite some positive evidence. An overview and an assessment of various studies to date will be given. T2DM is a heterogeneous disease with a substantial phenotypic variability; therefore, it is difficult to provide general conclusions about the effectiveness of CSII in T2DM therapy. The pump types, characteristics, and associated barriers may play a relevant role for therapy outcome. Most advanced functions like various bolus dosages offered by conventional insulin pumps are not needed for T2DM treatment and complicate the device handling for this subject group. Additionally, new technologies like increased connectivity, advanced software features, and interoperability are currently becoming available representing further barriers. The implementation of this technological progress might be a benefit for pumps for T2DM as well. However, these have not been sufficiently examined either and increased security challenges due to integrated peripheral components should not be neglected in terms of a sound cybersecurity. Pump features and handling for patients with T2DM should be as easy as possible, indicating a need for insulin pumps specially designed for patients with T2DM. However, it has to be investigated if pumps designed for T2DM are more effective than other intensified insulin regimens.

Insulin requirement profiles and related factors of insulin pump therapy in patients with type 2 diabetes

Continuous subcutaneous insulin infusion (CSII) is an effective therapy to control hyperglycemia in both patients with type 1 diabetes and type 2 diabetes. However, there is little data investigating the insulin dose setting during CSII therapy in type 2 diabetes to achieve optimal glycemic control and avoid the risk of hypoglycemia. Thus, this study is aimed to assess the dose characteristics of insulin requirement and explore the related clinical factors in patients with type 2 diabetes who were treated with CSII. A total of 327 patients (195 males) aged 52.9±12.5 years old were included in this study. Patients were treated with CSII to achieve the target fasting capillary blood glucose (4.4-7.0 mmol L^-1) and 2-h postprandial capillary blood glucose (4.4-10.0 mmol L^-1) by adjusting insulin infusion according to the seven-point capillary blood glucose profiles. Total daily insulin dose (TDD), total daily insulin dose per kilogram (TDD kg^-1) and the ratio of total basal insulin dose (TBD) to TDD (%TBa) were calculated after patients achieved the glucose targets for at least 3 days via 1-2 weeks of CSII treatment. And insulin dose, insulin dosing patterns and the relevant clinical factors were analyzed. The mean ratio of basal/bolus insulin distribution of all patients was 40%:60%. Patients with central obesity needed more TDD (51.3±17.1 U versus 43.5±14.0 U, P<0.05) and TDD kg^-1 (0.8±0.3 U kg^-1 versus 0.7±0.2 U kg^-1, P<0.05) than those without central obesity. Pearson's correlation analysis demonstrated that TDD was positively correlated with body mass index (BMI), waist circumference (WC), baseline fasting plasma glucose (FPG), fasting C-peptide level, 2 h-postprandial C-peptide level and time to achieve glycemic target (all P<0.05); TDD kg^-1 was positively correlated with waist-to-hip ratio (WHR), baseline FPG, glycosylated hemoglobin A1c (HbA1c), fasting C-peptide level and time to achieve glycemic target, and negatively correlated with BMI (all P<0.05). Multiple linear regression analyses revealed that BMI (β=1.796, P<0.01), WC (β=0.709, P<0.01), baseline FPG (β=1.459, P<0.01) and HbA1c (β=0.930, P=0.021) were independently related to TDD. Gender (β=-0.107, P=0.003), WC (β=0.005, P=0.029), baseline FPG (β=0.025, P<0.01) and HbA1c (β=0.016, P=0.007) were independently associated with TDD kg^-1. Gender (β=-0.015, P=0.048) and disease duration (β=0.134, P=0.029) were independently associated with %TBa. %TBa is around 40% in Chinese patients with type 2 diabetes treated with CSII when glycemic control is achieved. In addition to body weight or BMI, WC and glucose levels before CSII should be considered to set TDD. Patients with central obesity or poor glycemic control might need more TDD. Higher %TBa should be considered in female patients or patients with longer disease duration.

Clinical outcomes of adult inpatients treated with continuous subcutaneous insulin infusion for diabetes mellitus: a systematic review

AIMS

To provide a systematic review of the current evidence concerning the diabetes-related outcomes of patients provided with continuous subcutaneous insulin infusion for treating diabetes mellitus while a hospital inpatient.

METHODS

Relevant publications were obtained from MEDLINE and EMBASE databases concerning hospital inpatients with diabetes being treated with continuous subcutaneous insulin infusion. Studies were assessed independently by two reviewers, and data on the following outcomes were extracted: inpatient mortality; clinical complications, e.g. diabetic ketoacidosis; hyperglycaemia; hypoglycaemia; length of hospital stay; mean bedside glucose level; and glucose level on discharge. Obstetric cases were examined separately to look at maternal and neonatal glycaemic outcomes.

RESULTS

A total of 11 studies met the required criteria and were analysed in detail, 5 of which were predominantly obstetric. No significant complications were reported, with no incidences of death, ketoacidosis or severe hypoglycaemia. Length of hospital stay appeared to be shorter in those patients who remained on continuous subcutaneous insulin infusion, while data on mild hyperglycaemia and hypoglycaemia were inconclusive.

CONCLUSIONS

There are limited data available to form a significant conclusion about the safety of continuous subcutaneous insulin infusion continuation in hospital; however, its use can be justified with the presence of a specialized inpatient diabetes team for advice and support and an alternative treatment regime (e.g. subcutaneous basal bolus) should be accessible if the need were to arise.

Insulin requirement profiles of short-term intensive insulin therapy in patients with newly diagnosed type 2 diabetes and its association with long-term glycemic remission

AIMS

To investigate the insulin requirement profiles during short-term intensive continuous subcutaneous insulin infusion (CSII) in patients with newly diagnosed type 2 diabetes and its relationship with long-term glycemic remission.

METHODS

CSII was applied in 104 patients with newly diagnosed type 2 diabetes. Daily insulin doses were titrated and recorded to achieve and maintain euglycemia for 2 weeks. Measurements of blood glucose, lipid profiles as well as intravenous glucose tolerance tests were performed before and after the therapy. Afterwards, patients were followed up for 1 year.

RESULTS

Total daily insulin dose (TDD) was 56.6±16.1IU at the first day when euglycemia was achieved (TDD-1). Thereafter, TDD progressively decreased at a rate of 1.4±1.0IU/day to 36.2±16.5IU at the end of the therapy. TDD-1 could be estimated with body weight, FPG, triglyceride and waist circumference in a multiple linear regression model. Decrement of TDD after euglycemia was achieved (ΔTDD) was associated with reduction of HOMA-IR (r=0.27, P=0.008) but not with improvement in β cell function. Patients in the lower tertile of ΔTDD had a significantly higher risk of hyperglycemia relapse than those in the upper tertile within 1 year (HR 3.4, 95%CI [1.4, 8.4], P=0.008).

CONCLUSIONS

There is a steady decline of TDD after euglycemia is achieved in patients with newly diagnosed type 2 diabetes treated with CSII, and ΔTDD is associated with a better long-term glycemic outcome.

Insulin requirement profiles in Japanese hospitalized subjects with type 2 diabetes treated with basal-bolus insulin therapy

To assess the total daily inulin dose (TDD) and contribution of basal insulin to TDD and to identify the predictive factors for insulin requirement profiles in subjects with type 2 diabetes, we retrospectively examined insulin requirement profiles of 275 hospitalized subjects treated with basal-bolus insulin therapy (BBT) (mean age, 60.1 ± 12.9 years; HbA1c, 10.2 ± 4.5%). Target plasma glucose level was set between 80 and 129 mg/dL before breakfast and between 80 and 179 mg/dL at 2-hour after each meal without causing hypoglycemia. We also analyzed the relationship between the insulin requirement profiles (TDD and basal/total daily insulin ratio [B/TD ratio]) and insulin-associated clinical parameters. The mean TDD was 0.463 ± 0.190 unit/kg/day (range, 0.16-1.13 unit/kg/day). The mean B/TD ratio was 0.300 ± 0.099 (range, 0.091-0.667). A positive correlation of TDD with B/TD ratio was revealed by linear regression analysis (r=0.129, p=0.03). Stepwise multiple regression analysis identified post-breakfast glucose levels before titrating insulin as an independent determinant of the insulin requirement profile [Std β (standard regression coefficient) = 0.228, p<0.01 for TDD, Std β = -0.189, p<0.01 for B/TD ratio]. The TDD was <0.6 unit/kg/day and the B/TD ratio was <0.4 in the majority (70.2%) of subjects in the present study. These findings may have relevance in improving glycemic control and decreasing the risk of hypoglycemia and weight gain in subjects with type 2 diabetes treated with BBT.

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.