The effectiveness and durability of an early insulin pump therapy in children and adolescents with type 1 diabetes mellitus

The Current Status of Bioartificial Pancreas Devices

Type 1 diabetes mellitus is a common and highly morbid disease for which there is no cure. Treatment primarily involves exogenous insulin administration, and, under specific circumstances, islet or pancreas transplantation. However, insulin replacement alone fails to replicate the endocrine function of the pancreas and does not provide durable euglycemia. In addition, transplantation requires lifelong use of immunosuppressive medications, which has deleterious side effects, is expensive, and is inappropriate for use in adolescents. A bioartificial pancreas that provides total endocrine pancreatic function without immunosuppression is a potential therapy for treatment of type 1 diabetes. Numerous models are in development and take different approaches to cell source, encapsulation method, and device implantation location. We review current therapies for type 1 diabetes mellitus, the requirements for a bioartificial pancreas, and quantitatively compare device function.

The durability and effectiveness of sensor-augmented insulin pump therapy in pediatric and young adult patients with type 1 diabetes

PURPOSE

Despite the prevalent use of insulin pump therapy worldwide, few studies have been conducted among young patients with type 1 diabetes (T1D) in Korea. We investigated the durability and effectiveness of insulin pump therapy among Korean pediatric and young adult patients with T1D.

METHODS

This study included 54 patients with T1D diagnosed at pediatric ages (range, 1.1-14.1 years) who initiated insulin pump therapy during 2016-2019 at Seoul National University Children's Hospital and Seoul National University Bundang Hospital. Clinical and biochemical data, including anthropometric measurements, insulin dose, and glycated hemoglobin (HbA1c) levels were obtained from T1D diagnosis to last follow-up.

RESULTS

Forty-four patients (81.5%) continued insulin pump therapy with a median pump use duration of 2.9 years (range, 0.2-3.5 years); 10 discontinued the therapy within 12 months (<1 month, n=6; 1-6 months, n=1; and 6-12 months, n=3) due to physical interferences or financial problems. Older age (≥10 years of age) and longer diabetes duration (≥2 years) at the initiation of pump therapy were associated with discontinuation (P<0.05 for both). For patients continuing pump therapy, HbA1c levels significantly decreased after 1 year of therapy (from 8.9% to 8.1%, P<0.001) without changes in the body mass index z-scores or insulin dose. Although 4 patients experienced diabetic ketoacidosis, all recovered without complications.

CONCLUSION

Insulin pump therapy was effective in improving glycemic control in T1D patients during 12 months of treatment. Early initiation of insulin pump therapy after T1D diagnosis was helpful for continuing therapy.

Early versus delayed insulin pump therapy in children with newly diagnosed type 1 diabetes: results from the multicentre, prospective diabetes follow-up DPV registry

BACKGROUND

Although continuous subcutaneous insulin infusion therapy (ie, insulin pump therapy) is associated with improved metabolic control compared with multiple daily insulin injections in children with type 1 diabetes, it is unclear when it is best to start it after diagnosis. In this study, we aimed to compare the outcomes between early and delayed start of insulin pump therapy in young patients with type 1 diabetes.

METHODS

We based the current study on data from the multicentre, prospective diabetes follow-up registry (ie, Diabetes-Patienten-Verlaufsdokumentation [DPV]). The DPV registry comprises 501 diabetes centres from Germany, Austria, Switzerland, and Luxembourg. We included patients diagnosed with type 1 diabetes between 2004 and 2014, who were aged between 6 months and 15 years at the time of diagnosis, who had started insulin pump therapy either within the first 6 months (ie, the early treatment group) or in the second to third year (ie, the delayed treatment group) after diabetes diagnosis, and who were treated with insulin pump therapy for at least 1 year. The outcome parameters included the glycated haemoglobin (HbA_1c) values, the cardiovascular risk profile, and rates of acute complications and diabetes-associated hospital admissions (ie, hospitalisation) during the most recent documented treatment year with insulin pump therapy. Statistical models were adjusted for age at diabetes diagnosis, year of diagnosis, sex, immigrant background, use of continuous glucose monitoring, centre size, and the German Index of Socioeconomic Deprivation 2012 terciles.

FINDINGS

Our study sample comprised 8332 patients from 311 diabetes centres in Germany, Austria, Switzerland, and Luxembourg. The early treatment group consisted of 4004 (48·1%) of 8332 patients, and the delayed treatment group consisted of 4328 (51·9%). The median diabetes duration during follow-up was 6·7 years (IQR 5·1-8·7 in the early group; 5·0-8·7 in the delayed group) in both groups. Patients with early initiation of insulin pump therapy compared with those with delayed initiation of insulin pump therapy had significantly lower estimated mean HbA_1c values (7·9% [95% CI 7·8-7·9] and 62·6 mmol/mol [95% CI 62·1-63·2] vs 8·0% [8·0-8·1] and 64·1 mmol/mol [63·6-64·6]; p=0·0006), and lower rates of hypoglycaemic coma (incidence risk ratio 0·44 [95% CI 0·24-0·79]; p=0·0064) and hospitalisation (0·86 [95% CI 0·78-0·94]; p=0·0016). A better cardiovascular risk profile was observed in patients with early initiation of insulin pump therapy than in those with delayed initiation: an estimated mean systolic blood pressure of 117·6 mm Hg (95% CI 117·2-117·9) versus 118·5 mm Hg (118·2-118·9), p=0·0007; and HDL cholesterol of 62·8 mg/dL (95% CI 62·2-63·5) versus 60·6 mg/dL (60·0-61·2), p<0·0001; however, diastolic blood pressure; concentrations of LDL cholesterol, non-HDL cholesterol, and triglycerides; and estimated body-mass index standard deviation scores during follow-up did not differ significantly between both groups.

INTERPRETATION

Our findings provide evidence for improved clinical outcomes associated with the early initiation of insulin pump therapy in children with type 1 diabetes.

FUNDING

The German Center for Diabetes Research (Deutsches Zentrum für Diabetesforschung), German Robert Koch Institute, German Diabetes Association, and Diabetes Agenda 2010.

Insulin Pump Therapy

BACKGROUND

Advances in pump technology have increased the popularity of this treatment modality among patients with type 1 diabetes and recently also among patients with type 2 diabetes.

AREAS OF UNCERTAINTY

Four decades after the incorporation of the insulin pump in clinical use, questions regarding its efficacy, occurrence rate of short-term complications as hypoglycemia and diabetes ketoacidosis, timing of pump initiation, and selected populations for use remain unanswered.

DATA SOURCES

A review of the literature was performed using the PubMed database to identify all articles published up till December 2018, with the search terms including insulin pump therapy/continuous subcutaneous insulin delivery. The Cochrane database was searched for meta-analysis evaluating controlled randomized trials. Consensuses guidelines published by the International Society for Pediatric and Adolescent Diabetes, American Diabetes Association, and Advanced Technologies and Treatments for Diabetes year books were additionally reviewed for relevant cited articles.

THERAPEUTIC ADVANCES

Insulin pump therapy offers flexible management of diabetes. It enables adjustment of basal insulin to daily requirements and circadian needs, offers more precise treatment for meals and physical activity, and, when integrated with continuous glucose monitoring, allows glucose responsive insulin delivery. The ability to download and transmit data for analysis allow for treatment optimization. Newer pumps are simple to operate and increase user experience. Studies support the efficacy of pump therapy in improving glycemic control and reducing the occurrence of hypoglycemia without increasing episodes of diabetes ketoacidosis. They also improve quality of life. Recent evidence suggests a role for pump therapy in reducing microvascular and macrovascular diabetes-related complications.

CONCLUSIONS

Insulin pump therapy appears to be effective and safe in people with T1D regardless of age. Future advancements will include incorporation of closed loop and various decision support systems to aid and improve metabolic control and quality of life.

Serum C-peptide and osteocalcin levels in children with recently diagnosed diabetes

BACKGROUND

We explored the association of C-peptide (marker of secreted insulin), proinsulin and proinsulin ⁄C-peptide ratio (PI/C) (markers of beta-cell endoplasmic reticulum [ER] stress) with undercarboxylated (uOC) and carboxylated osteocalcin (cOC) and their ratio (uOC/cOC) in children with recently diagnosed type 1 (T1D) or type 2 diabetes (T2D), and the correlation of these variables with partial remission (PR) in children with T1D.

METHODS

Demographic and clinical data of children with new-onset diabetes (n = 68; median age = 12.2 years; 33.8% non-Hispanic White, 45.6% Hispanic/Latino, 16.2% African American and 4.4% other) were collected at diagnosis and during the first (V1), second (V2) and third clinical visits at 9.0, 32.0 and 175.7 weeks, respectively. Serum proinsulin, C-peptide, uOC and cOC values were measured 7.0 weeks after diagnosis. PR was defined as insulin dose-adjusted HbA1c (IDAA1c) ≤9.

RESULTS

In children with new-onset T1D with DKA (33.3%) or T2D (29.4%), Spearman's correlation coefficient revealed a positive association between the C-peptide levels and both uOC and uOC/cOC ratio. In T1D (n = 48), both higher serum C-peptide levels and low PI:C ratio were associated with higher BMI percentile (β = 0.02, P = .001; β = -0.01, P = .02, respectively) and older age at diagnosis (β = 0.13, P = .001; β = -0.12, P = .001, respectively). Furthermore, in children with T1D, C-peptide levels at V1 correlated with IDAA1c ≤ 9 at V1 (P = .04).

CONCLUSION

C-peptide levels are associated with a higher uOC and uOC/cOC ratio in paediatric diabetes. In new-onset T1D children, older age and higher BMI were associated with lower beta-cell stress and higher preserved function, which was predictive of PR on follow-up.

Using insulin pump with a remote-control system in young patients with diabetes improves glycemic control and enhances patient satisfaction

Background

Insulin delivery triggered by a remote control is an advanced feature offered by newer insulin pump systems. These remote-integrated pump systems might further improve glycemic control and patient satisfaction. This study aims at assessing the effects of advanced insulin pump system on patients with type 1 diabetes mellitus (T1DM).

Methods

The prospective, observational study in two centers addressed patients on multiple daily injection (MDI) switching to an integrated pump system (primary: adolescents and young adults, secondary: school-children). Treatment and patient satisfaction parameters were recorded at baseline and at two visits at 12 and 24 weeks.

Results

Thirty-eight patients were analyzed; primary n = 24 (mean-age 16) and secondary n = 14 (mean-age 9). From baseline to visit2, the mean decrease of HbA1c was 1.09% (p = 0.00009) and 0.79% (p = 0.09) for the primary and secondary group, respectively. Patient satisfaction rate was favorable. Exploratory analyses revealed patients favoring the use of the remote control achieved best reductions in HbA1c (p = 0.0174). Safety was encouraging with no adverse events in the period from visit1 to visit2.

Conclusions

Switching young T1DM patients from MDI to a remote control-integrated pump system achieved a reductions in HbA1c and insulin dose. Positive attitude towards remote operating enhanced these effects. Patient satisfaction has markedly improved.

Electronic supplementary material

The online version of this article (10.1186/s40842-019-0081-z) contains supplementary material, which is available to authorized users.

Is insulin pump therapy effective in Type 1 diabetes?

There continues to be uncertainty about the effectiveness in Type 1 diabetes of insulin pump therapy (continuous subcutaneous insulin infusion, CSII) vs. multiple daily insulin injections (MDI). This narrative review discusses the reasons for this uncertainty, summarizes the current evidence base for CSII and suggests some future research needs. There are difficulties in interpreting trials of CSII because effectiveness varies widely due to factors such as differing baseline control, suboptimal use of best CSII practices, and psychological factors, for example, high external locus of control, non-adherence and lack of motivation. Many summary meta-analyses are also misleading because of poor trial selection (e.g. short duration, obsolete pumps, low baseline rate of hypoglycaemia) and reliance on mean effect size for decision-making. Both MDI and CSII can achieve strict glycaemic control without hypoglycaemia in some people with Type 1 diabetes, especially those who are motivated and have undergone structured diabetes education, and with high levels of ongoing input from healthcare professionals. CSII is particularly effective in those people with Type 1 diabetes who have not achieved target HbA_1c levels without disabling hypoglycaemia using best attempts with MDI, and here there can be valuable and substantial improvement. Insulin pumps are safe, effective and accepted when used in newly diagnosed diabetes, particularly in children, where MDI may not be practicable. Future research needs include more studies on mortality associated with insulin pumps where registry data have suggested lower rates vs. MDI; and psychological strategies to improve non-adherence and suboptimal glycaemic outcomes on CSII.

HbA1c values and hospital admissions in children and adolescents receiving continuous subcutaneous insulin infusion therapy

AIMS

To assess HbA_1c values and hospitalization rates before, during and after continuous subcutaneous insulin infusion (CSII) therapy.

METHODS

Demographic and hospitalization data were extracted from 161 individuals with Type 1 diabetes who received continuous subcutaneous insulin infusion (CSII) therapy between 2002 and 2013 at the Leeds Children and Young People's Diabetes Service for those aged < 20 years. The median (range) age at CSII start was 11.9 (1.1-17.6) years. The median (range) follow-up time was 2.3 (0-8.1) years. Random intercept models were used to compare HbA_1c values before and during CSII initiation (and after CSII for those who discontinued it). Hospitalization rates were calculated for diabetic ketoacidosis and severe hypoglycaemia.

RESULTS

The mean HbA_1c concentration decreased by 7 mmol/mol [95% CI 6-8; 0.6% (95% CI 0.5-0.7%)]. For the discontinued group (n=30), mean HbA_1c decreased by 5 mmol/mol [95% CI 2-8; 0.4% (95% CI 0.2-0.7%)]. HbA_1c returned to pre-CSII start levels at the end of this therapy. Diabetic ketoacidosis admissions increased threefold during CSII compared with before CSII start [2.2 per 100 person-years (95% CI 1.3 to 3.6) vs 7.4 per 100 person-years (95% CI 5.1 to 10.8)] and was highest during the first year of CSII. No difference in severe hypoglycaemia incidence rate was found during CSII compared with the pre-CSII period.

CONCLUSIONS

Despite significant reductions in HbA_1c levels for individuals treated with CSII, improvements are needed to reduce diabetic ketoacidosis hospitalizations for those new to the therapy.

Physiological factors influencing diabetes control in type 1 diabetes children with insulin pumps from diagnosis

BACKGROUND

The aim of this study was to identify the physiological factors influencing diabetes control in children with type 1 diabetes (T1D) using continuous subcutaneous insulin infusion (CSII) from diabetes diagnosis.

METHODS

This study focused on 163 children (81 boys) initiated with CSII within 2 weeks after T1D recognition and treated for at least 3 years. We analysed fasting C-peptide, GADA, ICA, IA2A, BMI z-score, total daily dose, and basal insulin. Patients were divided into groups according to their metabolic control: 7.5% > HbA1c ≥ 7.5% at the end of the study.

RESULTS

At the end of the follow-up, patients with HbA1c <7.5%, had a lower HbA1c level at diagnosis (11.7% vs 12.6%; P = 0.018), lower HbA1c level at both the first-year (6.7% vs 7.3%; P = 0.000) and the second-year (6.8% vs.7.7%; P = 0.000) follow-up, and a lower GADA level (P = 0.001). A multiple logistic regression analysis showed that HbA1c at diagnosis (P = 0.012), HbA1c at first year (P = 0.000), HbA1c at second year (P = 0.000), age at diagnosis (P = 0.047), GADA (P = 0.031), and basal insulin at third year (P = 0.032), influenced HbA1c <7.5% at the third year of follow-up. At the end of the study, 76% of patients started with CSII at the age <10 years and 49% of subjects initiated with CSII at the age ≥10 years achieved HbA1c ≤7.5%.

CONCLUSIONS

This study shows that for those who initiated CSII at T1D onset, younger age, less intense autoimmune process, a low HbA1c at recognition, and good diabetes control during the first year of treatment were associated with long-term optimal glycaemic control.

A systematic review of non-genetic predictors and genetic factors of glycated haemoglobin in type 1 diabetes one year after diagnosis

Type 1 diabetes (T1D) results from autoimmune destruction of the pancreatic βcells. Although all T1D patients require daily administration of exogenous insulin, their insulin requirement to achieve good glycaemic control may vary significantly. Glycated haemoglobin (HbA1c) level represents a stable indicator of glycaemic control and is a reliable predictor of long-term complications of T1D. The purpose of this article is to systematically review the role of non-genetic predictors and genetic factors of HbA1c level in T1D patients after the first year of T1D, to exclude the honeymoon period. A total of 1974 articles published since January 2011 were identified and 78 were finally included in the analysis of non-genetic predictors. For genetic factors, a total of 277 articles were identified and 14 were included. The most significantly associated factors with HbA1c level are demographic (age, ethnicity, and socioeconomic status), personal (family characteristics, parental care, psychological traits...) and features related to T1D (duration of T1D, adherence to treatment …). Only a few studies have searched for genetic factors influencing HbA1c level, most of which focused on candidate genes using classical genetic statistical methods, with generally limited power and incomplete adjustment for confounding factors and multiple testing. Our review shows the complexity of explaining HbA1c level variations, which involves numerous correlated predictors. Overall, our review underlines the lack of studies investigating jointly genetic and non-genetic factors and their interactions to better understand factors influencing glycaemic control for T1D patients.

Initiation of insulin pump therapy in children at diagnosis of type 1 diabetes resulted in improved long-term glycemic control

BACKGROUND

Insulin pump therapy (IPT) is increasingly used in children and young people with type 1 diabetes. There are limited studies evaluating the optimal time to start IPT.

OBJECTIVE

The aim of this study was to determine if early initiation of IPT in children with type 1 diabetes leads to improved glycaemic control and quality of life (QOL) compared with the later introduction of IPT.

SUBJECTS

There were 38 subjects in the early pump group (EPG) (age 12.6 + 4.9 yr, 23 male) and 37 in the later pump group (LPG) (age 13.1 + 4.1 yr, 19 male).

METHODS

Hemoglobin A1c (HbA1c), rate of severe hypoglycemia, and diabetic ketoacidosis (DKA) were collected retrospectively over a 48-month period. Eligible subjects and/or their parents completed both a Paediatric and Paediatric Diabetes-specific Quality of Life Inventory.

RESULTS

HbA1c measurements were lower in the EPG (6.8%; 51 mmol/mol) compared to the LPG (7.9%; 63 mmol/mol), across the 48 months of the study (p < 0.0001). There was no significant difference in the rate (per patient years) of severe hypoglycaemia (0.02; 0.07) p = 0.075 between the two groups. There were no episodes of DKA in either group. There was no significant difference in QOL between the groups with both having high satisfaction rates.

CONCLUSIONS

Initiation of IPT at diagnosis of type 1 diabetes in children resulted in consistently lower HbA1c with no apparent change in hypoglycemia, DKA, or QOL.