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van den Boom L, Kostev K. Persistence with insulin pump therapy among children and young adults with type 1 diabetes in Germany: An update. Diabetes Obes Metab 2022; 24:948-950. [PMID: 35014155 DOI: 10.1111/dom.14647] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 12/12/2021] [Accepted: 01/06/2022] [Indexed: 11/26/2022]
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Berget C, Sherr JL, DeSalvo DJ, Kingman RS, Stone SL, Brown SA, Nguyen A, Barrett L, Ly TT, Forlenza GP. Clinical Implementation of the Omnipod 5 Automated Insulin Delivery System: Key Considerations for Training and Onboarding People With Diabetes. Clin Diabetes 2022; 40:168-184. [PMID: 35669307 PMCID: PMC9160549 DOI: 10.2337/cd21-0083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Automated insulin delivery (AID) systems, which connect an insulin pump, continuous glucose monitoring system, and software algorithm to automate insulin delivery based on real-time glycemic data, hold promise for improving outcomes and reducing therapeutic burden for people with diabetes. This article reviews the features of the Omnipod 5 Automated Insulin Delivery System and how it compares to other AID systems available on or currently under review for the U.S. market. It also provides practical guidance for clinicians on how to effectively train and onboard people with diabetes on the Omnipod 5 System, including how to personalize therapy and optimize glycemia. Many people with diabetes receive their diabetes care in primary care settings rather than in a diabetes specialty clinic. Therefore, it is important that primary care providers have access to resources to support the adoption of AID technologies such as the Omnipod 5 System.
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Affiliation(s)
- Cari Berget
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO
| | - Jennifer L. Sherr
- Section of Pediatric Endocrinology, Yale School of Medicine, New Haven, CT
| | - Daniel J. DeSalvo
- Section of Pediatric Diabetes and Endocrinology, Baylor College of Medicine, Houston, TX
| | - Ryan S. Kingman
- Department of Pediatric Endocrinology, Stanford School of Medicine, Palo Alto, CA
| | | | - Sue A. Brown
- Division of Endocrinology, Center for Diabetes Technology, University of Virginia, Charlottesville, VA
| | | | | | | | - Gregory P. Forlenza
- Barbara Davis Center for Childhood Diabetes, University of Colorado, Aurora, CO
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3
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Hartmann B, Tittel SR, Femerling M, Pfeifer M, Meyhöfer S, Lange K, Milek S, Stemler L, Best F, Holl RW. COVID-19 Lockdown Periods in 2020: Good Maintenance of Metabolic Control in Adults with Type 1 and Type 2 Diabetes. Exp Clin Endocrinol Diabetes 2022; 130:621-626. [PMID: 35181878 DOI: 10.1055/a-1743-2537] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
During the COVID-19 pandemic, there were increased concerns about glycemic control in patients with diabetes. Therefore, we aimed to assess changes in diabetes management during the COVID-19 lockdown for patients with type 1 or type 2 diabetes mellitus (T1DM, T2DM) in Germany. We included data from 24,623 patients (age>18 years) with T1DM (N=6,975) or T2DM (N=17,648) with documented data in 2019 and 2020 from the multicenter Diabetes-Prospective Follow-up registry (DPV). We conducted a groupwise comparison of identical patients in 2019 and 2020 for different time periods of pandemia. Pairwise differences of continuous parameters of treatment modalities and metabolic outcome between 2019 and 2020 were adjusted for seasonality, age, and diabetes duration. We presented these outcomes as adjusted medians with 95% confidence intervals. Rates were compared using negative-binomial models, dichotomous outcomes were compared using logistic models. Models were additionally adjusted for age and diabetes duration. These outcomes were presented as least-square means with 95% confidence intervals, p-values of<.05 were considered significant.In participants with T1DM, CGI (combined glucose indicator) increased only by 0.11-0.12% in all time periods of 2020 compared to 2019 (all p<0.001) while BMI decreased slightly by -(0.09-0.10) kg/m² (p<0.0001). In participants with T2DM, HbA1c increased by 0.12%, while BMI decreased slightly by -(0.05-0.06) kg/m² (p<0.0001).During the COVID-19 lockdown period, patients with T1DM and T2DM experienced only clinically insignificant changes in glucose control or body weight. Despite lockdown restrictions, patients were able to maintain metabolic control.
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Affiliation(s)
- B Hartmann
- Heilig-Geist Hospital, Department of Gastroenterology and Diabetology, Bensheim, Germany
| | - S R Tittel
- Institute for Epidemiology and Medical Biometry, ZIBMT, Ulm University, Ulm, Germany.,German Centre for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | | | - M Pfeifer
- Klinik Tettnang GmbH, Tettnang, Germany
| | - S Meyhöfer
- German Centre for Diabetes Research (DZD), Munich-Neuherberg, Germany.,University of Lübeck, Institute for Endocrinology and Diabetes, Lübeck, Germany.,Department of Internal Medicine 1, Endocrinology & Diabetes, University of Lübeck, Lübeck, Germany
| | - K Lange
- Hanover Medical School, Department of Medical Psychology, Hanover, Germany
| | - S Milek
- Diabetes-Schwerpunkt und Schulungspraxis, Hohenmölsen, Germany
| | - L Stemler
- Diabetologikum DDG Ludwigshafen, Ludwigshafen, Germany
| | - F Best
- Specialized diabetes practice, Essen, Germany
| | - R W Holl
- Institute for Epidemiology and Medical Biometry, ZIBMT, Ulm University, Ulm, Germany.,German Centre for Diabetes Research (DZD), Munich-Neuherberg, Germany
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Ju Z, Piarulli A, Bielick L, Marschall S, Brouillard E, Steenkamp D. Advanced Diabetes Technology Remains Underutilized in Underserved Populations: Early Hybrid Closed-Loop System Experience at an Academic Safety Net Hospital. Diabetes Technol Ther 2022; 24:143-147. [PMID: 34569850 DOI: 10.1089/dia.2021.0334] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
We retrospectively evaluated outcomes of the Minimed Medtronic 670G system in an academic urban safety-net population of adults with type 1 diabetes, between September 2016 and January 2020. Among 32 patients prescribed the 670G, the majority were female (69%), white (69%), achieved advanced degrees (56%), were commercially insured (94%), and were experienced pump users (84%). Patients who initiated auto-mode demonstrated significant improvement in A1c after 1 year. However, 31% of patients never initiated auto-mode. Black and Hispanic patients comprised 50% of this group, despite similar insurance coverage, diabetes duration, educational level, and prior pump use. Hence, traditional barriers to technology use do not explain these racial/ethnic disparities. Of 22 patients who initiated auto-mode, 5 discontinued within 1 year. The most common reason for discontinuation was frustration with pump-sensor interactions. Future studies identifying barriers to and strategies for increasing use of advanced insulin delivery systems in underserved populations are needed.
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Affiliation(s)
- Zhihui Ju
- Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center, Boston, Massachusetts, USA
| | - Amanda Piarulli
- Department of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Lauren Bielick
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Shannon Marschall
- Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center, Boston, Massachusetts, USA
| | - Elizabeth Brouillard
- Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center, Boston, Massachusetts, USA
| | - Devin Steenkamp
- Section of Endocrinology, Diabetes and Nutrition, Boston Medical Center, Boston, Massachusetts, USA
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Visser LA, Folcher M, Delgado Simao C, Gutierrez Arechederra B, Escudero E, Uyl-de Groot CA, Redekop WK. The Potential Cost-Effectiveness of a Cell-Based Bioelectronic Implantable Device Delivering Interferon-β1a Therapy Versus Injectable Interferon-β1a Treatment in Relapsing-Remitting Multiple Sclerosis. PHARMACOECONOMICS 2022; 40:91-108. [PMID: 34480325 PMCID: PMC8739553 DOI: 10.1007/s40273-021-01081-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/10/2021] [Indexed: 06/09/2023]
Abstract
BACKGROUND Current first-line disease-modifying therapies (DMT) for multiple sclerosis (MS) patients are injectable or oral treatments. The Optogenerapy consortium is developing a novel bioelectronic cell-based implant for controlled release of beta-interferon (IFNβ1a) protein into the body. The current study estimated the potential cost effectiveness of the Optogenerapy implant (hereafter: Optoferon) compared with injectable IFNβ1a (Avonex). METHODS A Markov model simulating the costs and effects of Optoferon compared with injectable 30 mg IFNβ1a over a 9-year time horizon from a Dutch societal perspective. Costs were reported in 2019 Euros and discounted at a 4% annual rate; health effects were discounted at a 1.5% annual rate. The cohort consisted of 35-year-old, relapsing-remitting MS patients with mild disability. The device is implanted in a daycare setting, and is replaced every 3 years. In the base-case analysis, we assumed equal input parameters for Optoferon and Avonex regarding disability progression, health effects, adverse event probabilities, and acquisition costs. We assumed reduced annual relapse rates and withdrawal rates for Optoferon compared with Avonex. Sensitivity, scenario, value of information, and headroom analysis were performed. RESULTS Optoferon was the dominant strategy with cost reductions (- €26,966) and health gains (0.45 quality-adjusted life-years gained). A main driver of cost differences are the acquisition costs of Optoferon being 2.5 times less than the costs of Avonex. The incremental cost-effectiveness ratio was most sensitive to variations in the annual acquisition costs of Avonex, the annual withdrawal rate of Avonex and Optoferon, and the disability progression of Avonex. CONCLUSION Innovative technology such as the Optoferon implant may be a cost-effective therapy for patients with MS. The novel implantable mode of therapeutic protein administration has the potential to become a new mode of treatment administration for MS patients and in other disease areas. However, trials are needed to establish safety and effectiveness.
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Affiliation(s)
- Laurenske A. Visser
- Erasmus School of Health Policy and Management, Department: Health Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Marc Folcher
- Institute of Molecular and Clinical Opthalmology Basel, Basel, Switzerland
| | - Claudia Delgado Simao
- Functional Printing and Embedded Devices Unit, Eurecat, Centre Tecnològic de Catalunya, 08302 Mataró, Spain
| | | | - Encarna Escudero
- Plastic Materials Unit, Eurecat, Centre Tecnològic de Catalunya, Cerdanyola de Valles, Spain
| | - Carin A. Uyl-de Groot
- Erasmus School of Health Policy and Management, Department of Health Technology Assessment, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - William Ken Redekop
- Erasmus School of Health Policy and Management, Department: Health Technology Assessment, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Gargouri I, Hadja Inna AA, Franc S, Picaud P, Penfornis A, Amadou C. Factors associated with insulin pump discontinuation in adults with diabetes: a time-to-invent analysis and prediction model Early insulin pump discontinuation. Endocr Pract 2021; 28:185-190. [PMID: 34920110 DOI: 10.1016/j.eprac.2021.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 11/15/2021] [Accepted: 12/09/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Insulin pump discontinuation has mostly been studied in children and adolescents living with diabetes. We aimed to assess the rate of insulin pump continuation in a population of adult patients with diabetes, at 18 months after initiation, to determine the factors associated with pump discontinuation, and to develop a simple prediction model. METHODS This single-center, retrospective study included all adult patients with type 1 (T1D) or type 2 (T2D) diabetes, who started insulin pump treatment between January 2015 and June 2018. Exclusion criteria were pregnancy, short-term pregnancy plans, and insulin pump discontinuation within the previous six months. The probability of insulin pump continuation after 18 months was estimated using the Kaplan-Meier method. Factors associated with insulin pump discontinuation were studied using a Cox regression model and an exponentia model was built for prediction purposes. RESULTS The study included 315 patients. Mean age was 41 years; mean duration of diabetes was 16 years; 50% were men; 74% had T1D; mean HbA1c was 9.1% (76 mmol/mol). After 18 months, the rate of insulin pump continuation was 0.80 (95%CI: 0.76-0.85). By multivariate analysis, the occurrence of severe hypoglycemia in the previous year was associated with insulin pump discontinuation (HR 2.42; 95%CI 1.30-4.51) while other factors did not reach statistical significance. CONCLUSION Insulin pump discontinuation occurred in 20% of patients at 18 months after initiation and was mainly associated with a recent history of severe hypoglycemia. The type of diabetes and glycemic control at baseline were not associated with treatment discontinuation.
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Affiliation(s)
- Imen Gargouri
- Diabetes department Sud-Francilien Hôpital, Corbeil Essonnes, France
| | | | - Sylvia Franc
- Diabetes department Sud-Francilien Hôpital, Corbeil Essonnes, France; CERITD (Center for Study and Research for the Intensification of diabetes treatment), Bioparc-Génopole, Évry, France; LBEPS, Univ Evry, IRBA, Université Paris Saclay, 91025 Evry, France
| | - Pascale Picaud
- CERITD (Center for Study and Research for the Intensification of diabetes treatment), Bioparc-Génopole, Évry, France
| | - Alfred Penfornis
- Diabetes department Sud-Francilien Hôpital, Corbeil Essonnes, France; Paris-Saclay University
| | - Coralie Amadou
- Diabetes department Sud-Francilien Hôpital, Corbeil Essonnes, France; Paris-Saclay University.
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Hennessy LD, De Lange M, Wiltshire EJ, Jefferies C, Wheeler BJ. Youth and non-European ethnicity are associated with increased loss of publicly funded insulin pump access in New Zealand people with type 1 diabetes. Diabet Med 2021; 38:e14450. [PMID: 33131079 DOI: 10.1111/dme.14450] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 10/23/2020] [Accepted: 10/29/2020] [Indexed: 12/21/2022]
Abstract
AIMS Continuous subcutaneous insulin infusion (CSII) has been publicly funded in New Zealand for people living with type 1 diabetes since 2012. The aim of the current study was to investigate the loss of access, once obtained, to public-funded CSII. The frequency and socio-demographics of access, and loss, to CSII spanning the period 2012 to 2018 were examined. METHODS Nationally held data collections including the New Zealand Virtual Diabetes Register were used to calculate the overall and subgroup proportions using and ceasing CSII. A logistic regression model was used to estimate odds ratios for pump use for the predictor variables (sex, age group, ethnicity and deprivation index) and to calculate odds ratios for pump cessation for the same demographic factors. RESULTS Once CSII access is obtained, approximately 4% per year cease CSII in a subsequent year. This cessation of publicly funded CSII was not distributed equally among the population, showing over-representation in youth (aged 10-29 years) and non-Europeans, in particular Māori and Pasifika. Compounding this, it remains less likely for people with diabetes to initially access publicly funded CSII in New Zealand if they are non-European and more socio-economically deprived. CONCLUSIONS In New Zealand, Māori and Pasifika, as well as youth, are over-represented in the cessation of CSII in comparison with Europeans and all other age groups. These groups are also less likely to gain initial access to public funding. Efforts to understand and reduce these disparities are needed, including review of current public funding access criteria.
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Affiliation(s)
| | - Michel De Lange
- Biostatistics Centre, University of Otago, Dunedin, New Zealand
| | - Esko J Wiltshire
- Paediatrics and Child Health, University of Otago Wellington, Wellington, New Zealand
| | - Craig Jefferies
- Paediatric Endocrinology, Starship Children's Health, Auckland, New Zealand
| | - Benjamin J Wheeler
- Paediatric Endocrinology, Southern District Health Board, Dunedin, New Zealand
- Department of Women's and Children's Health, University of Otago, Dunedin, New Zealand
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Lee YJ, Lee YA, Kim JH, Chung HR, Gu MJ, Kim JY, Shin CH. The durability and effectiveness of sensor-augmented insulin pump therapy in pediatric and young adult patients with type 1 diabetes. Ann Pediatr Endocrinol Metab 2020; 25:248-255. [PMID: 33401881 PMCID: PMC7788343 DOI: 10.6065/apem.2040048.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 05/19/2020] [Indexed: 01/11/2023] Open
Abstract
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.
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Affiliation(s)
- Yun Jeong Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Young Ah Lee
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea
| | - Jae Hyun Kim
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Hye Rim Chung
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Min Jeong Gu
- Pediatric Diabetes Education Unit, Seoul National University Children’s Hospital, Seoul, Korea
| | - Ji Young Kim
- Department of Food Nutrition Service and Nutrition Care, Seoul National University Children's Hospital, Seoul, Korea
| | - Choong Ho Shin
- Department of Pediatrics, Seoul National University Children's Hospital, Seoul, Korea,Address for correspondence: Choong Ho Shin, MD, PhD Department of Pediatrics, Seoul National University Children's Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea Tel: +82-2-2072-3357 Fax: +82-743-3455 E-mail:
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Abstract
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.
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Moreno-Fernandez J, Gomez FJ, Pinés P, González J, López J, López LM, Blanco B, Roa C, Herranz S, Muñoz-Rodríguez JR. Continuous Subcutaneous Insulin Infusion in Adult Type 1 Diabetes Mellitus Patients: Results from a Public Health System. Diabetes Technol Ther 2019; 21:440-447. [PMID: 31199682 DOI: 10.1089/dia.2019.0097] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
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 HbA1c 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 HbA1c 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.
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Affiliation(s)
- Jesus Moreno-Fernandez
- 1Service of Endocrinology and Nutrition, Ciudad Real General University Hospital, Ciudad Real, Spain
| | - Francisco Javier Gomez
- 2Service of Endocrinology and Nutrition, La Mancha-Centro General Hospital, Ciudad Real, Spain
| | - Pedro Pinés
- 3Service of Endocrinology and Nutrition, Albacete University Hospital, Albacete, Spain
| | - Javier González
- 4Service of Endocrinology and Nutrition, Virgen de la Luz Hospital, Cuenca, Spain
| | - José López
- 5Service of Endocrinology and Nutrition, Virgen de la Salud Hospital, Toledo, Spain
| | - Luz María López
- 3Service of Endocrinology and Nutrition, Albacete University Hospital, Albacete, Spain
| | - Benito Blanco
- 6Service of Endocrinology and Nutrition, Nuestra Señora del Prado Hospital, Toledo, Spain
| | - Carlos Roa
- 7Service of Endocrinology and Nutrition, Santa Barbara Hospital, Ciudad Real, Spain
| | - Sandra Herranz
- 8Service of Endocrinology and Nutrition, Guadalajara University Hospital, Guadalajara, Spain
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Berget C, Messer LH, Forlenza GP. A Clinical Overview of Insulin Pump Therapy for the Management of Diabetes: Past, Present, and Future of Intensive Therapy. Diabetes Spectr 2019; 32:194-204. [PMID: 31462873 PMCID: PMC6695255 DOI: 10.2337/ds18-0091] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IN BRIEF Insulin pump therapy is advancing rapidly. This article summarizes the variety of insulin pump technologies available to date and discusses important clinical considerations for each type of technology.
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12
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Thalange N, Biester T, Danne T. Clinical Use of Degludec in Children and Adolescents with T1D: A Narrative Review with Fictionalized Case Reports. Diabetes Ther 2019; 10:1219-1237. [PMID: 31187420 PMCID: PMC6612349 DOI: 10.1007/s13300-019-0641-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Indexed: 12/11/2022] Open
Abstract
The use of insulin in children and adolescents with type 1 diabetes (T1D) is a challenge because of the heterogeneity of these patients and their lifestyles, with consequent unpredictability in blood glucose levels. A new ultra-long-acting basal insulin, insulin degludec (degludec), has the potential to mitigate some of these challenges, notably variability in the glucose-lowering action of the basal insulin component of an insulin regimen, and consequent risks of hypo- and hyperglycemia. However, the protracted half-life and steady state pharmacokinetics of degludec potentially bring some new challenges. In particular, the adjustment of therapy in response to commonly encountered clinical situations might require a different approach when degludec is used in place of other currently used basal insulins in this challenging patient population. The purpose of this article is to guide clinicians through a series of case histories in the use of this insulin. These include, but are not limited to, how to initiate, titrate, switch from other basal insulin or pump therapy; how to alleviate difficulties arising as a result of unpredictable lifestyle/habits; and how to maintain treatment following diabetic ketoacidosis. The guidance presented in this review illustrates that degludec is a good option for a diverse range of children and adolescents with T1D, providing much needed flexibility in the treatment of this challenging patient population.Funding Novo Nordisk.
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Affiliation(s)
- Nandu Thalange
- Al Jalila Children's Specialty Hospital, Al Jaddaf, Dubai, United Arab Emirates.
| | - Torben Biester
- Diabetes Centre for Children and Adolescents, AUF DER BULT, Hannover, Germany
| | - Thomas Danne
- Diabetes Centre for Children and Adolescents, AUF DER BULT, Hannover, Germany
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Blair J, McKay A, Ridyard C, Thornborough K, Bedson E, Peak M, Didi M, Annan F, Gregory JW, Hughes D, Gamble C. Continuous subcutaneous insulin infusion versus multiple daily injections in children and young people at diagnosis of type 1 diabetes: the SCIPI RCT. Health Technol Assess 2019; 22:1-112. [PMID: 30109847 DOI: 10.3310/hta22420] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
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 (HbA1c) concentration at 12 months. The secondary outcomes were (1) HbA1c 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 HbA1c 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 HbA1c 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.
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Affiliation(s)
- Joanne Blair
- Department of Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Andrew McKay
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Colin Ridyard
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Keith Thornborough
- Department of Diabetes, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Emma Bedson
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
| | - Matthew Peak
- Department of Research, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Mohammed Didi
- Department of Endocrinology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Francesca Annan
- Paediatric and Adolescent Division, University College Hospital, London, UK
| | - John W Gregory
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Dyfrig Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - Carrol Gamble
- Clinical Trials Research Centre, University of Liverpool, Liverpool, UK
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14
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Maffeis C, Birkebaek NH, Konstantinova M, Schwandt A, Vazeou A, Casteels K, Jali S, Limbert C, Pundziute-Lycka A, Toth-Heyn P, de Beaufort C, Sumnik Z, Cherubini V, Svensson J, Pacaud D, Kanaka-Gantenbein C, Shalitin S, Bratina N, Hanas R, Alonso GT, Poran L, Pereira AL, Marigliano M. Prevalence of underweight, overweight, and obesity in children and adolescents with type 1 diabetes: Data from the international SWEET registry. Pediatr Diabetes 2018; 19:1211-1220. [PMID: 30033651 DOI: 10.1111/pedi.12730] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 07/08/2018] [Accepted: 07/11/2018] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVE To assess the prevalence of underweight (UW), overweight (OW), and obesity in children and adolescents with type 1 diabetes (T1D). METHODS An international cross-sectional study including 23 026 T1D children (2-18 years, duration of diabetes ≥1 year) participating in the SWEET prospective, multicenter diabetes registry. Body mass index SD score (BMI-SDS) was calculated using the World Health Organization BMI charts. Children were categorized as UW (BMI-SDS < -2SD), OW (+1SD < BMI-SDS ≤ +2SD), and obese (OB) (BMI-SDS > +2SD). Hierarchic regression models were applied with adjustment for sex, age, and duration of diabetes. RESULTS The prevalence of UW, OW, and obesity was: 1.4%, 22.3%, and 7.3% in males and 0.6%, 27.2%, and 6.8% in females. Adjusted BMI-SDS was significantly higher in females than in males (mean ± SEM: 0.54 ± 0.05 vs 0.40 ± 0.05, P < 0.0001). In males, BMI-SDS significantly decreased by age (P < 0.0001) in the first three age categories 0.61 ± 0.06 (2 to <10 years), 0.47 ± 0.06 (10 to <13 years), 0.34 ± 0.05 (13 to <16 years). In females, BMI-SDS showed a U-shaped distribution by age (P < 0.0001): 0.54 ± 0.04 (2 to <10 years), 0.39 ± 0.04 (10 to <13 years), 0.55 ± 0.04 (13 to <16 years). BMI-SDS increased by diabetes duration (<2 years: 0.38 ± 0.05, 2 to <5 years: 0.44 ± 0.05, and ≥5 years: 0.50 ± 0.05, P < 0.0001). Treatment modality did not affect BMI-SDS. Adjusted HbA1c was significantly higher in females than in males (8.20% ± 0.10% vs 8.06% ± 0.10%, P < 0.0001). In both genders, the association between HbA1c and BMI-SDS was U-shaped with the highest HbA1c in the UW and obesity groups. CONCLUSIONS The high rate of OW and obesity (31.8%) emphasize the need for developing further strategies to prevent and treat excess fat accumulation in T1D.
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Affiliation(s)
- Claudio Maffeis
- Pediatric Diabetes and Metabolic Disorders Unit, University of Verona, University City Hospital, Verona, Italy
| | - Niels H Birkebaek
- Department of Pediatrics, Aarhus University Hospital, Aarhus, Denmark
| | - Maia Konstantinova
- Clinic for Endocrinology, Diabetes and Genetics, Medical University Sofia, University Pediatric Hospital, Sofia, Bulgaria
| | - Anke Schwandt
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany.,German Center for Diabetes Research (DZD), Munich-Neuherberg, Germany
| | - Andriani Vazeou
- Diabetes Center, P & A Kyriakou Children's Hospital, Athens, Greece
| | - Kristina Casteels
- Department of Pediatrics, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, University of Leuven, Leuven, Belgium
| | - Sujata Jali
- KLE Diabetes Centre, KLE University JNMC and KLE'S Dr. Prabhakar Kore Hospital & MRC, Belagavi, India
| | - Catarina Limbert
- Hospital Dona Estefânia, Unit of Pediatric Endocrinology and Diabetes, Lisbon, Portugal
| | - Auste Pundziute-Lycka
- Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Peter Toth-Heyn
- Ist. Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Carine de Beaufort
- Deccp, Pediatric Clinic/Centre Hospitalier de Luxembourg, Luxembourg, Grand Duche de Luxembourg
| | - Zdenek Sumnik
- Department of Pediatrics, Motol University Hospital, Prague, Czech Republic
| | | | - Jannet Svensson
- Department of Pediatric and adolescents, Copenhagen University hospital, Herlev, Denmark
| | - Daniele Pacaud
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Christina Kanaka-Gantenbein
- Diabetes Center, First Department of Pediatrics, Medical School,National and Kapodistrian University of Athens, Agia Sophia Children's Hospital, Athens, Greece
| | - Shlomit Shalitin
- The Jesse Z. and Lea Shafer Institute of Endocrinology and Diabetes, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Natasa Bratina
- University Children's Hospital, Department of Endocrinology, Diabetes and Metabolic Diseases, Ljubljana, Slovenia
| | - Ragnar Hanas
- The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden and NU Hospital Group, Uddevalla, Sweden
| | - Guy T Alonso
- Barbara Davis Center, University of Colorado, Aurora, Colorado
| | - Luxmi Poran
- General Private Practitioner at T1diams, Mauritius, Island
| | - Ana L Pereira
- APDP-Diabetes Portugal, Department of Pediatric and adolescents, Lisbon, Portugal
| | - Marco Marigliano
- Pediatric Diabetes and Metabolic Disorders Unit, University of Verona, University City Hospital, Verona, Italy
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15
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Sherr JL, Tauschmann M, Battelino T, de Bock M, Forlenza G, Roman R, Hood KK, Maahs DM. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetes technologies. Pediatr Diabetes 2018; 19 Suppl 27:302-325. [PMID: 30039513 DOI: 10.1111/pedi.12731] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 07/10/2018] [Indexed: 12/12/2022] Open
Affiliation(s)
- Jennifer L Sherr
- Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.,Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Tadej Battelino
- UMC-University Children's Hospital, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Martin de Bock
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Gregory Forlenza
- University of Colorado Denver, Barbara Davis Center, Aurora, Colorado
| | - Rossana Roman
- Medical Sciences Department, University of Antofagasta and Antofagasta Regional Hospital, Antofagasta, Chile
| | - Korey K Hood
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - David M Maahs
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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16
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Affiliation(s)
- Laurel H Messer
- CU School of Medicine, Barbara Davis Center for Diabetes , Aurora, Colorado
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17
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Berg AK, Olsen BS, Thyssen JP, Zachariae C, Simonsen AB, Pilgaard K, Svensson J. High frequencies of dermatological complications in children using insulin pumps or sensors. Pediatr Diabetes 2018; 19:733-740. [PMID: 29484783 DOI: 10.1111/pedi.12652] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 01/08/2018] [Accepted: 01/22/2018] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Dermatological complications in children and adolescents that are related to continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) have not been well-characterized. This study examined the prevalence and characteristics of different types of dermatological complications. METHODS Online questionnaires regarding dermatological complications related to CSII and/or CGM were returned from a total of 144 children and adolescents, aged 2 to 20 years. Both previous and current skin problems were reported along with their clinical characteristics. Descriptive statistics, χ2 tests, and multivariate analyses were used to evaluate the data. RESULTS Of 143 patients using CSII, 90% had previous and 63% reported current dermatological complications. Non-specific eczema was most frequently reported and was currently present in 25.7% of the patients. These results were independent of age and current CGM use. Among the 76 patients using CGM, 46% reported current dermatological complications. A history of atopy was associated with dermatological complications in individuals using CSII, but not CGM. The patients rated CGM-related dermal issues as significantly worse than those associated with CSII (P < .05). CONCLUSIONS Dermatological complications can be a serious problem in treating pediatric and adolescent patients of all ages with CSII and/or CGM. Only a few clinical characteristics associated with these complications were identified in this study, highlighting the need for prospective studies that might lead to improvements in the prevention and treatment of dermatological problems.
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Affiliation(s)
- Anna Korsgaard Berg
- Department of Pediatrics, Copenhagen Diabetes Research Center (CPH-DIRECT), Copenhagen University Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
| | - Birthe Susanne Olsen
- Department of Pediatrics, Copenhagen Diabetes Research Center (CPH-DIRECT), Copenhagen University Hospital, Copenhagen, Denmark
| | - Jacob P Thyssen
- Department of Dermatology and Allergy, Copenhagen University Hospital, Copenhagen, Denmark
| | - Claus Zachariae
- Department of Dermatology and Allergy, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anne Birgitte Simonsen
- Department of Dermatology and Allergy, Copenhagen University Hospital, Copenhagen, Denmark
| | - Kasper Pilgaard
- Pediatric and Adolescent Department, Nordsjaellands Hospital, Hillerød, Denmark
| | - Jannet Svensson
- Department of Pediatrics, Copenhagen Diabetes Research Center (CPH-DIRECT), Copenhagen University Hospital, Copenhagen, Denmark.,Faculty of Health and Medical Science, University of Copenhagen, Copenhagen, Denmark
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18
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Beato-Víbora P, Chico-Ballesteros A, Giménez M, Guerrero-Vázquez R, Barrio-Castellanos R, Goñi-Iriarte MJ, Díaz-Soto G, Merino-Torres JF, Moreno-Fernández J, Martínez-Brocca MA. A national survey on the efficacy and safety of continuous subcutaneous insulin infusion in patients with type 1 diabetes in Spain. Diabetes Res Clin Pract 2018; 137:56-63. [PMID: 29278712 DOI: 10.1016/j.diabres.2017.12.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 11/29/2017] [Accepted: 12/12/2017] [Indexed: 11/15/2022]
Abstract
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), HbA1c 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 HbA1c ≤ 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%. HbA1c 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.
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19
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Altmann E, Stirling C, Broad L. Experiences and decision making during paediatric transitions to continuous sub-cutaneous insulin infusion (CSII): A mixed method study. Digit Health 2018; 4:2055207618806083. [PMID: 30364424 PMCID: PMC6196618 DOI: 10.1177/2055207618806083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 09/19/2018] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES We aimed to improve the decision quality and outcomes for families with children or adolescents with diabetes considering continuous sub-cutaneous insulin infusion (CSII). METHODS A mixed method study involved three focus groups with youth, parents and clinicians to provide experience information as background to the development of a decision aid (DA). A pre-test (T1) and post-test (T2) evaluation of the DA with a convenience sample of five families considering initiating CSII. RESULTS The focus group data showed that families found the move to CSII to be generally empowering with adolescents engaging with the technology quickly, and that experiential information from others was important in the process. Participants increased their knowledge and decreased decisional conflict after using the DA from T1 to T2. Preferred option measurement indicated that at T1, three participants were 'unsure' and two participants' preferred option was CSII. After exposure to the DA at T2, those who were previously unsure had a preferred option of CSII with a resulting five people with a preferred option of CSII. CONCLUSIONS The results from this study suggest that transitioning to CSII for paediatric and adolescent patients and their carers may be assisted by a DA and that participants felt empowered to a make decision regarding CSII when using the PANDANI DA. The quasi-experimental design without randomisation or control group was a study limitation caused by the small number of participants. Expanding this pilot research into a randomised control trial would decrease the threat to validity from other possible explanations for the improvement in decisional conflict, such as nurse educators.
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Affiliation(s)
- Erika Altmann
- School of Social Sciences, University of Tasmania, Hobart, Australia
| | - Christine Stirling
- School of Health Sciences, College of Health and Medicine, University of Tasmania, Hobart, Australia
| | - Liz Broad
- Women, Adolescent and Children and Services, Department of Health & Human Services, Hobart, Australia
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20
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Weissberg-Benchell J, Hessler D, Fisher L, Russell SJ, Polonsky WH. Impact of an Automated Bihormonal Delivery System on Psychosocial Outcomes in Adults with Type 1 Diabetes. Diabetes Technol Ther 2017; 19:723-729. [PMID: 29106311 DOI: 10.1089/dia.2017.0174] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVES The study assessed the psychosocial impact of the bihormonal bionic pancreas (BP) on adults in a real-world outpatient setting. RESEARCH DESIGN AND METHODS Thirty-nine adults with type 1 diabetes at four study centers across the U.S. participated in a two-arm, random-order, crossover design study: 11 days with the BP and 11 days with their usual care (UC). Psychosocial questionnaires were administered before the first study arm, at the end of the first study arm, and at the end of the second study arm. RESULTS The mean age of participants was 33 years; mean diabetes duration was 17 years; and 84% were non-Hispanic Caucasian. Significantly greater improvements in psychosocial outcomes were found following the use of BP versus UC; these included reductions in diabetes-related distress (P < 0.001) with the greatest drops in distress related to hypoglycemia and to eating constraints, and greater treatment satisfaction (P < 0.05). The majority of BP users described their experience as positive with a reduction in worrying about low (72%) and high (69%) blood sugars. The majority reported trusting the device (69%) and feeling less burdened by the BP than their usual method of diabetes care (64%). Concerns about the burden of the BP were also expressed, with >75% of users highlighting the burden of carrying around the equipment and the need to change glucagon daily, and more than half of the participants reporting concerns about wearability, discomfort, the time it took to correct out-of-range numbers, and "glitches" in the system. CONCLUSIONS Overall, participants report substantial psychosocial benefits accruing from the BP relative to their usual method of diabetes care. However, participants also reported a number of burdens associated with the system. Future versions of the BP device should be designed with the goal of addressing these concerns, and studies with larger, more diverse samples, and with more technology-naive participants are needed.
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Affiliation(s)
| | - Danielle Hessler
- 2 University of California , Department of Family and Community Medicine, San Francisco, San Francisco, California
| | - Lawrence Fisher
- 2 University of California , Department of Family and Community Medicine, San Francisco, San Francisco, California
| | - Steven J Russell
- 3 Massachusetts General Hospital Diabetes Research Center , Boston, Massachusetts
| | - William H Polonsky
- 2 University of California , Department of Family and Community Medicine, San Francisco, San Francisco, California
- 4 Behavioral Diabetes Institute , San Diego, California
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21
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Karges B, Schwandt A, Heidtmann B, Kordonouri O, Binder E, Schierloh U, Boettcher C, Kapellen T, Rosenbauer J, Holl RW. Association of Insulin Pump Therapy vs Insulin Injection Therapy With Severe Hypoglycemia, Ketoacidosis, and Glycemic Control Among Children, Adolescents, and Young Adults With Type 1 Diabetes. JAMA 2017; 318:1358-1366. [PMID: 29049584 PMCID: PMC5818842 DOI: 10.1001/jama.2017.13994] [Citation(s) in RCA: 257] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE Insulin pump therapy may improve metabolic control in young patients with type 1 diabetes, but the association with short-term diabetes complications is unclear. OBJECTIVE To determine whether rates of severe hypoglycemia and diabetic ketoacidosis are lower with insulin pump therapy compared with insulin injection therapy in children, adolescents, and young adults with type 1 diabetes. DESIGN, SETTING, AND PARTICIPANTS Population-based cohort study conducted between January 2011 and December 2015 in 446 diabetes centers participating in the Diabetes Prospective Follow-up Initiative in Germany, Austria, and Luxembourg. Patients with type 1 diabetes younger than 20 years and diabetes duration of more than 1 year were identified. Propensity score matching and inverse probability of treatment weighting analyses with age, sex, diabetes duration, migration background (defined as place of birth outside of Germany or Austria), body mass index, and glycated hemoglobin as covariates were used to account for relevant confounders. EXPOSURES Type 1 diabetes treated with insulin pump therapy or with multiple (≥4) daily insulin injections. MAIN OUTCOMES AND MEASURES Primary outcomes were rates of severe hypoglycemia and diabetic ketoacidosis during the most recent treatment year. Secondary outcomes included glycated hemoglobin levels, insulin dose, and body mass index. RESULTS Of 30 579 patients (mean age, 14.1 years [SD, 4.0]; 53% male), 14 119 used pump therapy (median duration, 3.7 years) and 16 460 used insulin injections (median duration, 3.6 years). Patients using pump therapy (n = 9814) were matched with 9814 patients using injection therapy. Pump therapy, compared with injection therapy, was associated with lower rates of severe hypoglycemia (9.55 vs 13.97 per 100 patient-years; difference, -4.42 [95% CI, -6.15 to -2.69]; P < .001) and diabetic ketoacidosis (3.64 vs 4.26 per 100 patient-years; difference, -0.63 [95% CI, -1.24 to -0.02]; P = .04). Glycated hemoglobin levels were lower with pump therapy than with injection therapy (8.04% vs 8.22%; difference, -0.18 [95% CI, -0.22 to -0.13], P < .001). Total daily insulin doses were lower for pump therapy compared with injection therapy (0.84 U/kg vs 0.98 U/kg; difference, -0.14 [-0.15 to -0.13], P < .001). There was no significant difference in body mass index between both treatment regimens. Similar results were obtained after propensity score inverse probability of treatment weighting analyses in the entire cohort. CONCLUSIONS AND RELEVANCE Among young patients with type 1 diabetes, insulin pump therapy, compared with insulin injection therapy, was associated with lower risks of severe hypoglycemia and diabetic ketoacidosis and with better glycemic control during the most recent year of therapy. These findings provide evidence for improved clinical outcomes associated with insulin pump therapy compared with injection therapy in children, adolescents, and young adults with type 1 diabetes.
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Affiliation(s)
- Beate Karges
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Anke Schwandt
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Neuherberg
| | | | - Olga Kordonouri
- Diabetes Center for Children and Adolescents, Children's Hospital Auf Der Bult, Hannover, Germany
| | - Elisabeth Binder
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Ulrike Schierloh
- Department of Pediatrics, Centre Hospitalier de Luxembourg, Luxembourg City, Luxembourg
| | - Claudia Boettcher
- Division of Paediatric Endocrinology and Diabetology, Center of Child and Adolescent Medicine, Justus Liebig University Giessen, Giessen, Germany
| | - Thomas Kapellen
- Hospital for Children and Adolescents, University of Leipzig, Leipzig, Germany
| | - Joachim Rosenbauer
- German Center for Diabetes Research (DZD), Neuherberg
- Institute for Biometrics and Epidemiology, German Diabetes Center, Leibniz Center at the University of Düsseldorf, Düsseldorf, Germany
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Neuherberg
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22
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Perry L, James S, Steinbeck K, Dunbabin J, Lowe J. Young people with type 1 diabetes mellitus: Attitudes, perceptions, and experiences of diabetes management and continuous subcutaneous insulin infusion therapy. J Eval Clin Pract 2017; 23:554-561. [PMID: 28052468 DOI: 10.1111/jep.12670] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 09/11/2016] [Accepted: 10/05/2016] [Indexed: 01/22/2023]
Abstract
RATIONALE, AIMS, AND OBJECTIVES Continuous subcutaneous insulin infusion (CSII; insulin pump) use is increasing. However, there is little information about how this technology is used compared with other insulin delivery methods (ie, injections) by young people with type 1 diabetes mellitus in Australia. This study explored young people's attitudes, perceptions, and experiences with diabetes management comparing those using with those not using CSII, and proportions likely to transition to adult services requiring initiation and/or support for CSII use. METHODS A survey was undertaken of young people (aged 12 to 18 years) with type 1 diabetes mellitus and their parents/guardians living in Hunter New England, Australia, using a questionnaire designed to collect quantitative, descriptive, and demographic data. Most questions were based on previously developed and validated instruments. In total, 107 respondents returned partially or fully completed questionnaires. RESULTS Respondents had positive attitudes and perceptions of their self-efficacy and diabetes management, but were moderately disturbed by their diabetes and reported experiencing suboptimal management outcomes. Patterns of associations were demonstrated between knowledge, attitudes, and experiences of diabetes modeled by regression analysis. There were no statistically significant differences in responses between users and nonusers of CSII. Over 40% indicated their intention to use the technology as adults. CONCLUSIONS Opportunities for enhanced diabetes service support were clear, and CSII did not appear to be used to its full potential. Service redesign could enhance support for this young population using all preferred insulin delivery methods and should align to patients' goals and preferences to maximize service and patient gain.
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Affiliation(s)
- Lin Perry
- Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia.,South Eastern Sydney Local Health District, Prince of Wales Hospital, Randwick, New South Wales, Australia
| | - Steven James
- Faculty of Health, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Katharine Steinbeck
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia.,Academic Department of Adolescent Medicine, The Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Janet Dunbabin
- Faculty of Health and Medicine, University of Newcastle, Callaghan, New South Wales, Australia
| | - Julia Lowe
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Endocrinology and Metabolism, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Wong JC, Boyle C, DiMeglio LA, Mastrandrea LD, Abel KL, Cengiz E, Cemeroglu PA, Aleppo G, Largay JF, Foster NC, Beck RW, Adi S. Evaluation of Pump Discontinuation and Associated Factors in the T1D Exchange Clinic Registry. J Diabetes Sci Technol 2017; 11:224-232. [PMID: 27595711 PMCID: PMC5478021 DOI: 10.1177/1932296816663963] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND The objectives of this study were to examine factors associated with insulin pump discontinuation among children and adults followed longitudinally for 1 year in the multicenter T1D Exchange clinic registry, and to provide participant-reported reasons for stopping pump therapy. METHODS We longitudinally followed 8935 participants of all ages using an insulin pump at the time of registry enrollment. Logistic regressions were used to identify demographic and clinical factors associated with pump discontinuation. Pump discontinuation was self-reported by participants on a first annual follow-up survey. RESULTS The overall frequency of pump discontinuation was 3%. Discontinuation was higher in adolescents (4%) and young adults (4%) than in younger children (3%) or older adults (1%). In multivariate analysis of children between 6 and <13 and 13 and <18 years, participants who discontinued pump use were more likely to have higher HbA1c levels at baseline (adjusted P < .001 for both). The top participant-reported reasons for discontinuing the pump included problems with wearability (57%), disliking the pump or feeling anxious (44%), and problems with glycemic control (30%). CONCLUSIONS In T1D Exchange registry participants, insulin pump discontinuation is uncommon, but more prevalent among adolescents and young adults, and youth with poor glycemic control. Given the known benefits of pump therapy, these populations should be targeted for support and education on troubleshooting pump use. Common reasons for discontinuation should also be considered in future device design and technological improvement.
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Affiliation(s)
- Jenise C. Wong
- University of California, San Francisco, San Francisco, CA, USA
- Jenise C. Wong, MD, PhD, University of California, San Francisco, 550 16th St, 4th Floor Box 0434, San Francisco, CA 94143-0434, USA.
| | | | | | | | - Kimber-Lee Abel
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Eda Cengiz
- Yale School of Medicine, New Haven, CT, USA
| | | | | | | | | | - Roy W. Beck
- Jaeb Center for Health Research, Tampa, FL, USA
| | - Saleh Adi
- University of California, San Francisco, San Francisco, CA, USA
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24
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Shulman R, Stukel TA, Miller FA, Newman A, Daneman D, Guttmann A. Insulin pump use and discontinuation in children and teens: a population-based cohort study in Ontario, Canada. Pediatr Diabetes 2017; 18:33-44. [PMID: 26748950 DOI: 10.1111/pedi.12353] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2015] [Revised: 12/04/2015] [Accepted: 12/12/2015] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To describe insulin pump use by youth since introduction of universal funding in Ontario, Canada and to explore the relationship between pump use and pediatric diabetes center characteristics and the relationship between discontinuation and center and patient characteristics. RESEARCH DESIGN AND METHODS Observational, population-based cohort study of youth with type 1 diabetes (<19 yr) who received pump funding from 2006 to 2013 (n = 3700). We linked 2012 survey data from 33 pediatric diabetes centers to health administrative databases. We tested the relationship between center-level pump uptake and center characteristics (center type, physician model, and availability of 24-h support) using an adjusted negative binomial model; we studied center- and patient-level factors (socioeconomic status and baseline glycemic control) associated with discontinuation using a Cox proportional hazards model with generalized estimating equations. RESULTS Pump users were more likely to be in the highest income quintile than non-pump users (29.6 vs. 19.1%, p < 0.0001). In 2012, mean percent pump use was 38.0% with variability across centers. There was no association between uptake and center characteristics. Discontinuation was low (0.42/100 person-yr) and was associated with being followed at a small community center [hazard ratio (HR): 2.24 (1.05-4.76)] and being more deprived [HR: 2.36 (1.14-1.48)]. Older age was associated with a lower rate of discontinuation [HR: 0.31 (0.14-0.66)]. CONCLUSIONS Rates of pump use have increased since 2006 and discontinuation is rare. Large variation in uptake across centers was not explained by the factors we examined but may reflect variation in patient populations or practice patterns, and should be further explored.
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Affiliation(s)
- Rayzel Shulman
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Therese A Stukel
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Fiona A Miller
- Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Canada.,Toronto Health Economics and Technology Assessment (THETA) Collaborative, Toronto, Canada
| | - Alice Newman
- Institute for Clinical Evaluative Sciences, Toronto, Canada
| | - Denis Daneman
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Astrid Guttmann
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Health Sciences Building, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Canada
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25
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Tauschmann M, Allen JM, Wilinska ME, Thabit H, Acerini CL, Dunger DB, Hovorka R. Home Use of Day-and-Night Hybrid Closed-Loop Insulin Delivery in Suboptimally Controlled Adolescents With Type 1 Diabetes: A 3-Week, Free-Living, Randomized Crossover Trial. Diabetes Care 2016; 39:2019-2025. [PMID: 27612500 PMCID: PMC5079605 DOI: 10.2337/dc16-1094] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/18/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study evaluated the feasibility, safety, and efficacy of day-and-night hybrid closed-loop insulin delivery in adolescents with type 1 diabetes under free-living conditions. RESEARCH DESIGN AND METHODS In an open-label randomized crossover study, 12 suboptimally controlled adolescents on insulin pump therapy (mean ± SD age 14.6 ± 3.1 years; HbA1c 69 ± 8 mmol/mol [8.5 ± 0.7%]; duration of diabetes 7.8 ± 3.5 years) underwent two 21-day periods in which hybrid closed-loop insulin delivery was compared with sensor-augmented insulin pump therapy in random order. During the closed-loop intervention, a model predictive algorithm automatically directed insulin delivery between meals and overnight. Participants used a bolus calculator to administer prandial boluses. RESULTS The proportion of time that sensor glucose was in the target range (3.9-10 mmol/L; primary end point) was increased during the closed-loop intervention compared with sensor-augmented insulin pump therapy by 18.8 ± 9.8 percentage points (mean ± SD; P < 0.001), the mean sensor glucose level was reduced by 1.8 ± 1.3 mmol/L (P = 0.001), and the time spent above target was reduced by 19.3 ± 11.3 percentage points (P < 0.001). The time spent with sensor glucose levels below 3.9 mmol/L was low and comparable between interventions (median difference 0.4 [interquartile range -2.2 to 1.3] percentage points; P = 0.33). Improved glucose control during closed-loop was associated with increased variability of basal insulin delivery (P < 0.001) and an increase in the total daily insulin dose (53.5 [39.5-72.1] vs. 51.5 [37.6-64.3] units/day; P = 0.006). Participants expressed positive attitudes and experience with the closed-loop system. CONCLUSIONS Free-living home use of day-and-night closed-loop in suboptimally controlled adolescents with type 1 diabetes is safe, feasible, and improves glucose control without increasing the risk of hypoglycemia. Larger and longer studies are warranted.
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Affiliation(s)
- Martin Tauschmann
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K.,Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Janet M Allen
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K.,Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Malgorzata E Wilinska
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K.,Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Hood Thabit
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
| | - Carlo L Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - David B Dunger
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K.,Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Roman Hovorka
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K. .,Department of Paediatrics, University of Cambridge, Cambridge, U.K
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26
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Moser C, Maurer K, Binder E, Meraner D, Steichen E, Abt D, Freund-Unsinn K, Hofer SE. Needle detachment in a slim and physically active child with insulin pump treatment. Pediatr Diabetes 2016. [PMID: 26201949 DOI: 10.1111/pedi.12297] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Insulin pump therapy (CSII) is well established in pediatric patients with type 1 diabetes. In childhood diabetes, insulin pump treatment shows considerable advantages such as fewer injections, increased flexibility, fewer hypoglycemic events and lower HbA1c levels. Side effects such as catheter obstruction, technical pump failure, and dermatological complications have been observed, but are rarely reported. The reported patient is a physically very active and slim 10-year-old boy with reduced subcutaneous fatty tissue. After strong muscular activity an accidental rupture of the infusion set and needle detachment occurred in October 2013. X-ray and ultrasound imaging localized the needle in the musculus rectus femoris dexter. The needle was kept in situ and oral antibiotic treatment to prevent inflammatory reaction was prescribed. Repeated ultrasound measurements documented that the needles position had remained unchanged. Steel needle catheters (Sure-T infusion set, 6 mm) positioned in a thin layer of subcutaneous fat tissue of the thigh, combined with intense sports activity can result in a needle rupture and penetration into the muscle. Careful monitoring provides an alternative to surgery and lowers the risk of muscular necrosis. Because of differences in the distribution of subcutaneous fat tissue, an individualized catheter selection is necessary in pump treatment for children and adolescents, requiring a variety of different catheter sets.
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Affiliation(s)
- Christine Moser
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Kathrin Maurer
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Elisabeth Binder
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Dagmar Meraner
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Elisabeth Steichen
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniela Abt
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
| | - Karin Freund-Unsinn
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Sabine E Hofer
- Department of Pediatrics, Medical University of Innsbruck, Innsbruck, Austria
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27
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Tauschmann M, Allen JM, Wilinska ME, Thabit H, Stewart Z, Cheng P, Kollman C, Acerini CL, Dunger DB, Hovorka R. Day-and-Night Hybrid Closed-Loop Insulin Delivery in Adolescents With Type 1 Diabetes: A Free-Living, Randomized Clinical Trial. Diabetes Care 2016; 39:1168-74. [PMID: 26740634 PMCID: PMC4915556 DOI: 10.2337/dc15-2078] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 11/13/2015] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To evaluate feasibility, safety, and efficacy of day-and-night hybrid closed-loop insulin delivery in adolescents with type 1 diabetes under free-living conditions without remote monitoring or supervision. RESEARCH DESIGN AND METHODS In an open-label, randomized, free-living, crossover study design, 12 adolescents receiving insulin pump therapy (mean [±SD] age 15.4 ± 2.6 years; HbA1c 8.3 ± 0.9%; duration of diabetes 8.2 ± 3.4 years) underwent two 7-day periods of sensor-augmented insulin pump therapy or hybrid closed-loop insulin delivery without supervision or remote monitoring. During the closed-loop insulin delivery, a model predictive algorithm automatically directed insulin delivery between meals and overnight; prandial boluses were administered by participants using a bolus calculator. RESULTS The proportion of time when the sensor glucose level was in the target range (3.9-10 mmol/L) was increased during closed-loop insulin delivery compared with sensor-augmented pump therapy (72 vs. 53%, P < 0.001; primary end point), the mean glucose concentration was lowered (8.7 vs. 10.1 mmol/L, P = 0.028), and the time spent above the target level was reduced (P = 0.005) without changing the total daily insulin amount (P = 0.55). The time spent in the hypoglycemic range was low and comparable between interventions. CONCLUSIONS Unsupervised day-and-night hybrid closed-loop insulin delivery at home is feasible and safe in young people with type 1 diabetes. Compared with sensor-augmented insulin pump therapy, closed-loop insulin delivery may improve glucose control without increasing the risk of hypoglycemia in adolescents with suboptimally controlled type 1 diabetes.
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Affiliation(s)
- Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K. Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Janet M Allen
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K. Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Malgorzata E Wilinska
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K. Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Hood Thabit
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
| | - Zoë Stewart
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
| | | | | | - Carlo L Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - David B Dunger
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K. Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, U.K. Department of Paediatrics, University of Cambridge, Cambridge, U.K.
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28
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Abstract
The majority of people with type 1 diabetes have suboptimal glycemic control, increasing their complication risk. Technology to support diabetes self-care has advanced significantly and includes self-monitoring of blood glucose (SMBG), insulin pump therapy (IPT), continuous glucose monitoring (CGM), and sensor-augmented pump therapy (SAPT), which are stepping stones toward the "artificial pancreas" using closed-loop technology. Use of these technologies improves clinical outcomes for patients with the appropriate skills and motivation. This review addresses the psychosocial factors that influence both technology provision and clinical outcome and also how technology impacts on psychological outcomes. Optimal use of the various diabetes self-management technologies is influenced by previous self-care behaviors, demographic and psychological factors. Provision of IPT is also influenced by the same factors. Despite technology increasing the complexity of treatment, the lack of evidence for adverse psychological outcomes is reassuring. Treatment satisfaction is high, and discontinuation rates are low. However, technology will widen the health inequality gap if its use is limited to motivated patients who demonstrate good self-care behaviors. Pivotal to the success of the various technologies is provision of appropriate education at initiation of the technology, regular ongoing contact for treatment adjustments and trouble-shooting device issues plus access to psychological support when required. Additional support strategies may be required to help patients struggling with their diabetes to benefit from the available technology, recognizing that they may have most to gain.
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Affiliation(s)
- Victoria Franklin
- Raigmore Hospital, Inverness, Scotland, UK University of Aberdeen, Scotland, UK
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29
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Wong JC, Dolan LM, Yang TT, Hood KK. Insulin pump use and glycemic control in adolescents with type 1 diabetes: Predictors of change in method of insulin delivery across two years. Pediatr Diabetes 2015; 16:592-9. [PMID: 25387433 PMCID: PMC4458222 DOI: 10.1111/pedi.12221] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 08/29/2014] [Accepted: 09/02/2014] [Indexed: 01/21/2023] Open
Abstract
Few studies have explored durability of insulin pump use, and none have explored the link between depression and pump discontinuation. To examine the relationship between depressive symptoms [measured by the Children's Depression Inventory (CDI)], method of insulin delivery, and hemoglobin A1c (A1c), mixed models were used with data from 150 adolescents with type 1 diabetes (T1D) and visits every 6 months for 2 years. Of the 63% who used a pump, compared with multiple daily injections (MDI) at baseline, there were higher proportions who were non-minorities, had caregivers with a college degree, private insurance, and two caregivers in the home (p ≤ 0.01). After adjusting for time, sex, age, T1D duration, frequency of blood glucose monitoring, ethnicity, insurance, and caregiver number and education, baseline pump use was associated with -0.79% lower mean A1c [95% confidence interval (CI): -1.48, -0.096; p = 0.03]. For those using a pump at baseline, but switching to MDI during the study (n = 9), mean A1c was 1.38% higher (95% CI: 0.68, 2.08; p < 0.001) than that for those who did not switch method of delivery. A 10-point increase in CDI was associated with a 0.39% increase in A1c (95% CI: 0.16, 0.61; p = 0.001), independent of pump use. Regarding the temporal relationship between CDI score and changing method of insulin delivery, prior higher CDI score was associated with switching from pump to MDI (odds ratio = 1.21; 95% CI: 1.05, 1.39; p = 0.007). Clinicians should be aware of the associations between depressive symptoms, change in insulin delivery method, and the effect on glycemic control.
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Affiliation(s)
- Jenise C. Wong
- Division of Endocrinology, Department of Pediatrics, University of California San Francisco, San Francisco, CA 94158
| | - Lawrence M. Dolan
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH 45229 and Division of Endocrinology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH 45229
| | - Tony T. Yang
- Division of Child and Adolescent Psychiatry, Department of Psychiatry, University of California San Francisco, San Francisco, CA 94143
| | - Korey K. Hood
- Division of Endocrinology, Department of Pediatrics, University of California San Francisco, San Francisco, CA 94158
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30
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Richter H, Dombrowski S, Hamer H, Hadji P, Kostev K. Use of a German longitudinal prescription database (LRx) in pharmacoepidemiology. GERMAN MEDICAL SCIENCE : GMS E-JOURNAL 2015; 13:Doc14. [PMID: 26339224 PMCID: PMC4549652 DOI: 10.3205/000218] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 07/23/2015] [Indexed: 11/30/2022]
Abstract
Large epidemiological databases are often used to examine matters pertaining to drug utilization, health services, and drug safety. The major strength of such databases is that they include large sample sizes, which allow precise estimates to be made. The IMS® LRx database has in recent years been used as a data source for epidemiological research. The aim of this paper is to review a number of recent studies published with the aid of this database and compare these with the results of similar studies using independent data published in the literature. In spite of being somewhat limited to studies for which comparative independent results were available, it was possible to include a wide range of possible uses of the LRx database in a variety of therapeutic fields: prevalence/incidence rate determination (diabetes, epilepsy), persistence analyses (diabetes, osteoporosis), use of comedication (diabetes), drug utilization (G-CSF market) and treatment costs (diabetes, G-CSF market). In general, the results of the LRx studies were found to be clearly in line with previously published reports. In some cases, noticeable discrepancies between the LRx results and the literature data were found (e.g. prevalence in epilepsy, persistence in osteoporosis) and these were discussed and possible reasons presented. Overall, it was concluded that the IMS® LRx database forms a suitable database for pharmacoepidemiological studies.
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Affiliation(s)
- Hartmut Richter
- IMS Health, Real World Evidence Solutions, Frankfurt, Germany
| | | | - Hajo Hamer
- Department of Neurology, Epilepsy Center, University of Erlangen, Germany
| | - Peyman Hadji
- Department of Women's Health, North West Hospital, Frankfurt, Germany
| | - Karel Kostev
- Fresenius University of Applied Sciences, Idstein, Germany
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31
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Abstract
Technological innovations have revolutionized the treatment of type 1 diabetes. Although technological advances can potentially improve diabetes outcomes, maintenance of target glycemic control, at the present time, remains largely dependent on patient and family motivation, competence, and adherence to daily diabetes care requirements. Trials of closed loop or "artificial pancreas" technology show great promise to automate insulin delivery and achieve near normal glucose control and reduced hypoglycemia with minimal patient intervention.
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Affiliation(s)
- Katharine Garvey
- Division of Endocrinology, Department of Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Pediatrics, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA.
| | - Joseph I Wolfsdorf
- Division of Endocrinology, Department of Medicine, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Department of Pediatrics, Harvard Medical School, 25 Shattuck St, Boston, MA 02115, USA
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32
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Heinemann L, Fleming GA, Petrie JR, Holl RW, Bergenstal RM, Peters AL. Insulin pump risks and benefits: a clinical appraisal of pump safety standards, adverse event reporting and research needs. A joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group. Diabetologia 2015; 58:862-70. [PMID: 25784563 DOI: 10.1007/s00125-015-3513-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2014] [Accepted: 12/30/2014] [Indexed: 10/23/2022]
Abstract
Insulin pump therapy, also known as continuous subcutaneous insulin infusion (CSII), is an important and evolving form of insulin delivery, which is mainly used for people with type 1 diabetes. However, even with modern insulin pumps, errors of insulin infusion can occur due to pump failure, insulin infusion set (IIS) blockage, infusion site problems, insulin stability issues, user error or a combination of these. Users are therefore exposed to significant and potentially fatal hazards: interruption of insulin infusion can result in hyperglycaemia and ketoacidosis; conversely, delivery of excessive insulin can cause severe hypoglycaemia. Nevertheless, the available evidence on the safety and efficacy of CSII remains limited. The European Association for the Study of Diabetes (EASD) and American Diabetes Association (ADA) have therefore joined forces to review the systems in place for evaluating the safety of pumps from a clinical perspective. We found that useful information held by the manufacturing companies is not currently shared in a sufficiently transparent manner. Public availability of adverse event (AE) reports on the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database is potentially a rich source of safety information but is insufficiently utilised due to the current configuration of the system; the comparable database in Europe (European Databank on Medical Devices, EUDAMED) is not publicly accessible. Many AEs appear to be attributable to human factors and/or user error, but the extent to which manufacturing companies are required by regulators to consider the interactions of users with the technical features of their products is limited. The clinical studies required by regulators prior to marketing are small and over-reliant on bench testing in relation to 'predicate' products. Once a pump is available on the market, insufficient data are made publicly available on its long-term use in a real-world setting; such data could provide vital information to help healthcare teams to educate and support users, and thereby prevent AEs. As well as requiring more from the manufacturing companies, we call for public funding of more research addressing clinically important questions in relation to pump therapy: both observational studies and clinical trials. At present there are significant differences in the regulatory systems between the USA and European Union at both pre- and post-marketing stages; improvements in the European system are more urgently required. This statement concludes with a series of recommended specific actions for 'meknovigilance' (i.e. a standardised safety approach to technology) which could be implemented to address the shortcomings we highlight.
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33
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Heinemann L, Fleming GA, Petrie JR, Holl RW, Bergenstal RM, Peters AL. Insulin pump risks and benefits: a clinical appraisal of pump safety standards, adverse event reporting, and research needs: a joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group. Diabetes Care 2015; 38:716-22. [PMID: 25776138 DOI: 10.2337/dc15-0168] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Insulin pump therapy, also known as continuous subcutaneous insulin infusion (CSII), is an important and evolving form of insulin delivery, which is mainly used for people with type 1 diabetes. However, even with modern insulin pumps, errors of insulin infusion can occur due to pump failure, insulin infusion set (IIS) blockage, infusion site problems, insulin stability issues, user error, or a combination of these. Users are therefore exposed to significant and potentially fatal hazards: interruption of insulin infusion can result in hyperglycemia and ketoacidosis; conversely, delivery of excessive insulin can cause severe hypoglycemia. Nevertheless, the available evidence on the safety and efficacy of CSII remains limited. The European Association for the Study of Diabetes (EASD) and the American Diabetes Association (ADA) have therefore joined forces to review the systems in place for evaluating the safety of pumps from a clinical perspective. We found that useful information held by the manufacturing companies is not currently shared in a sufficiently transparent manner. Public availability of adverse event (AE) reports on the US Food and Drug Administration's Manufacturer and User Facility Device Experience (MAUDE) database is potentially a rich source of safety information but is insufficiently utilized due to the current configuration of the system; the comparable database in Europe (European Databank on Medical Devices [EUDAMED]) is not publicly accessible. Many AEs appear to be attributable to human factors and/or user error, but the extent to which manufacturing companies are required by regulators to consider the interactions of users with the technical features of their products is limited. The clinical studies required by regulators prior to marketing are small and over-reliant on bench testing in relation to "predicate" products. Once a pump is available on the market, insufficient data are made publicly available on its long-term use in a real-world setting; such data could provide vital information to help health care teams to educate and support users and thereby prevent AEs. As well as requiring more from the manufacturing companies, we call for public funding of more research addressing clinically important questions in relation to pump therapy: both observational studies and clinical trials. At present, there are significant differences in the regulatory systems between the US and European Union at both pre- and postmarketing stages; improvements in the European system are more urgently required. This statement concludes with a series of recommended specific actions for "meknovigilance" (i.e., a standardized safety approach to technology) that could be implemented to address the shortcomings we highlight.
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Affiliation(s)
| | | | - John R Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Reinhard W Holl
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
| | | | - Anne L Peters
- Keck School of Medicine of the University of Southern California, Los Angeles, CA
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Lange K, Ziegler R, Neu A, Reinehr T, Daab I, Walz M, Maraun M, Schnell O, Kulzer B, Reichel A, Heinemann L, Parkin CG, Haak T. Optimizing insulin pump therapy: the potential advantages of using a structured diabetes management program. Curr Med Res Opin 2015; 31:477-85. [PMID: 25597225 DOI: 10.1185/03007995.2015.1006355] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Use of continuous subcutaneous insulin infusion (CSII) therapy improves glycemic control, reduces hypoglycemia and increases treatment satisfaction in individuals with diabetes. As a number of patient- and clinician-related factors can hinder the effectiveness and optimal usage of CSII therapy, new approaches are needed to address these obstacles. Ceriello and colleagues recently proposed a model of care that incorporates the collaborative use of structured SMBG into a formal approach to personalized diabetes management within all diabetes populations. We adapted this model for use in CSII-treated patients in order to enable the implementation of a workflow structure that enhances patient-physician communication and supports patients' diabetes self-management skills. We recognize that time constraints and current reimbursement policies pose significant challenges to healthcare providers integrating the Personalised Diabetes Management (PDM) process into clinical practice. We believe, however, that the time invested in modifying practice workflow and learning to apply the various steps of the PDM process will be offset by improved workflow and more effective patient consultations. This article describes how to implement PDM into clinical practice as a systematic, standardized process that can optimize CSII therapy.
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Affiliation(s)
- Karin Lange
- Department of Medical Psychology, Hannover Medical School , Hannover , Germany
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Scheuing N, Badenhoop K, Borkenstein M, Konrad K, Lilienthal E, Laubner K, Naeke A, Rami-Merhar B, Thon A, Wiemann D, Holl RW. Why is insulin pump treatment rarely used in adolescents and young adults with cystic fibrosis-related diabetes? Pediatr Diabetes 2015; 16:10-5. [PMID: 24984902 DOI: 10.1111/pedi.12158] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 04/11/2014] [Accepted: 05/06/2014] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND In type 1 diabetes (T1D), the use of continuous subcutaneous insulin infusion (CSII) has increased steadily in the last years. Compared with conventional insulin injection regimes, major advantages might be a nearly physiological insulin secretion, lower rates of hypoglycemia, higher flexibility in daily life, and increased quality of life. Data on CSII in cystic fibrosis-related diabetes (CFRD) are scarce. OBJECTIVE To analyze current use of insulin pumps in CFRD and compare demographics of pump-treated patients between CFRD and T1D. METHODS Data from the prospective German/Austrian diabetes patient registry on insulin-treated patients with either CFRD (n = 515) or T1D (n = 43 165) aged >10 yr at manifestation of diabetes were analyzed. RESULTS A total of 4.1% (n = 21) of CFRD and 17.7% (n = 7647) of T1D patients received insulin pump treatment within the recent year of care (p < 0.001). Pump-treated patients with CFRD had a significantly shorter duration of diabetes [median (Q1 ; Q3 ): 5.8 (2.9; 9.5) vs. 7.8 (4.3; 20.4) yr, p = 0.026] and tended to be younger [22.0 (18.2; 30.1) vs. 24.9 (17.3; 45.9) yr] than pump-treated T1D patients. Age at initiation of CSII seemed to be lower in CFRD [19.2 (16.5; 29.2) vs. 23.3 (14.8; 43.5) yr]. Insulin pump therapy was used slightly more often in male CFRD patients than females (4.7 vs. 3.6%), whereas in T1D the opposite was observed (14.9 vs. 21.2%, p < 0.001). Discontinuation rate of CSII was higher in CFRD than T1D (30.0 vs. 12.7%, p = 0.005). CONCLUSIONS Despite potential advantages, insulin pump therapy was rarely used among adolescent and young adult CFRD patients.
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Affiliation(s)
- Nicole Scheuing
- Institute of Epidemiology and Medical Biometry, ZIBMT, University of Ulm, Ulm, Germany
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Ziegler C, Liberman A, Nimri R, Muller I, Klemenčič S, Bratina N, Bläsig S, Remus K, Phillip M, Battelino T, Kordonouri O, Danne T, Lange K. Reduced Worries of Hypoglycaemia, High Satisfaction, and Increased Perceived Ease of Use after Experiencing Four Nights of MD-Logic Artificial Pancreas at Home (DREAM4). J Diabetes Res 2015; 2015:590308. [PMID: 26581230 PMCID: PMC4637058 DOI: 10.1155/2015/590308] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Accepted: 03/05/2015] [Indexed: 01/08/2023] Open
Abstract
AIMS This study assesses the impact of using an AP-system at home on fear of hypoglycaemia. In addition, satisfaction and acceptance of the new technology are evaluated. METHODS In a multicentre, multinational study of 75 patients using the MD-Logic AP during four consecutive nights in home setting 59 of them (aged 10-54 years, 54% male, HbA1c 7.89 ± 0.69% [62.72 ± 7.51 mmol/mol], diabetes duration 11.6 ± 8.4 yrs) answered standardized questionnaires (HFS, adapted TAM, and AP satisfaction) before and after using the AP. RESULTS After experiencing the AP in home setting worries of hypoglycaemia were significantly reduced (before 1.04 ± 0.53 versus after 0.90 ± 0.63; P = 0.017). Perceived ease of use as a measure of acceptance with the AP significantly increased after personal experience (before 4.64 ± 0.94 versus after 5.06 ± 1.09; P = 0.002). The overall satisfaction mean score after using the AP was 3.02 ± 0.54 (range 0-4), demonstrating a high level of satisfaction with this technology. CONCLUSIONS The four-night home-based experience of using MD Logic AP was associated with reduced worries of hypoglycaemia, high level of satisfaction, and increased perceived ease of use of the new technology in children, adolescents, and adults.
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Affiliation(s)
- Claudia Ziegler
- Diabetes Centre for Children and Adolescents, Kinder- und Jugendkrankenhaus AUF DER BULT, 30173 Hannover, Germany
- *Claudia Ziegler:
| | - Alon Liberman
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, 49202 Petah Tikva, Israel
| | - Revital Nimri
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, 49202 Petah Tikva, Israel
| | - Ido Muller
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, 49202 Petah Tikva, Israel
| | - Simona Klemenčič
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre-University Children's Hospital, 1000 Ljubljana, Slovenia
| | - Nataša Bratina
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre-University Children's Hospital, 1000 Ljubljana, Slovenia
| | - Sarah Bläsig
- Diabetes Centre for Children and Adolescents, Kinder- und Jugendkrankenhaus AUF DER BULT, 30173 Hannover, Germany
| | - Kerstin Remus
- Diabetes Centre for Children and Adolescents, Kinder- und Jugendkrankenhaus AUF DER BULT, 30173 Hannover, Germany
| | - Moshe Phillip
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, 49202 Petah Tikva, Israel
| | - Tadej Battelino
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre-University Children's Hospital, 1000 Ljubljana, Slovenia
| | - Olga Kordonouri
- Diabetes Centre for Children and Adolescents, Kinder- und Jugendkrankenhaus AUF DER BULT, 30173 Hannover, Germany
| | - Thomas Danne
- Diabetes Centre for Children and Adolescents, Kinder- und Jugendkrankenhaus AUF DER BULT, 30173 Hannover, Germany
| | - Karin Lange
- Department of Medical Psychology, Hannover Medical School, 30625 Hannover, Germany
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Kostev K, Rockel T, Rosenbauer J, Rathmann W. Risk factors for discontinuation of insulin pump therapy in pediatric and young adult patients. Prim Care Diabetes 2014; 8:346-351. [PMID: 24735947 DOI: 10.1016/j.pcd.2014.03.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 03/13/2014] [Accepted: 03/19/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND Previous studies have shown that only a small number of pediatric and young adult patients discontinue pump therapy, but risk factors for discontinuation are unclear. OBJECTIVE To identify characteristics of pediatric and young adult patients with pump therapy which are associated with discontinuation of treatment. SUBJECTS AND METHODS Retrospective cohort study using a representative nationwide database (LRx; IMS Health) in Germany covering >80% of all prescriptions to members of statutory health insurances in 2008-2011. All patients (age group <25 years) with new prescriptions of insulin pumps were identified (2009-2010) and were followed for 12 months. RESULTS Overall, 2452 new pump users were identified, of whom 177 (7.2%) switched to other forms of insulin therapy within 12 months. In multivariate logistic regression, younger age (<6 years; reference 18 to <25 years: Odds ratio, OR, 95% CI: 0.36; 0.17-0.74) and use of teflon needles (reference steel needles: OR, 95% CI: 0.59; 0.41-0.83) were related to a lower odds of pump discontinuation. A non-significant trend was found for male sex (OR, 95% CI: 0.75; 0.52-1.08). Prescriptions of thyroid therapeutics (ATC H03A: OR, 95% CI: 1.79; 1.23-2.61) and antiepileptics (N03: OR, 95% CI: 3.14; 1.49-6.59) were significantly associated with discontinuation of pump therapy. CONCLUSIONS About 93% of pediatric and young adult patients maintained insulin pump therapy within 12 months. Age <6 years, male sex and teflon needle use were associated with a lower risk of discontinuation. Thyroid therapy (indicating autoimmunity) and antiepileptic drug prescriptions were associated with a higher likelihood for discontinuation of insulin pump treatment.
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Affiliation(s)
| | | | - Joachim Rosenbauer
- Institute for Biometrics and Epidemiology, German Diabetes Center, D-40225 Duesseldorf, Germany
| | - Wolfgang Rathmann
- Institute for Biometrics and Epidemiology, German Diabetes Center, D-40225 Duesseldorf, Germany
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Parkin CG, Mlinac A, Hinzmann R. 7(th) Annual Symposium on Self-Monitoring of Blood Glucose (SMBG), May 8-10, 2014, Helsinki, Finland. Diabetes Technol Ther 2014; 16:794-815. [PMID: 25211215 PMCID: PMC4201241 DOI: 10.1089/dia.2014.0239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
International experts in the fields of diabetes, diabetes technology, endocrinology, mobile health, sport science, and regulatory issues gathered for the 7(th) Annual Symposium on Self-Monitoring of Blood Glucose (SMBG). The aim of this meeting was to facilitate new collaborations and research projects to improve the lives of people with diabetes. The 2014 meeting comprised a comprehensive scientific program, parallel interactive workshops, and two keynote lectures.
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Tauschmann M, Hovorka R. Insulin pump therapy in youth with type 1 diabetes: toward closed-loop systems. Expert Opin Drug Deliv 2014; 11:943-55. [PMID: 24749563 DOI: 10.1517/17425247.2014.910192] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Insulin pump technology has advanced considerably over the past three decades, leading to more favorable metabolic control and less hypoglycemic events when compared with multiple daily injection therapy. The use of insulin pumps is increasing, particularly in children and adolescents with type 1 diabetes. AREAS COVERED This review outlines recent developments in insulin pump therapy from a pediatric perspective. 'Smart' pumps, sensor-augmented pump therapy and threshold-suspend feature of insulin pumps are reviewed in terms of efficacy, safety and psychosocial impact. The current status of closed-loop systems focusing on clinical outcomes is highlighted. EXPERT OPINION Closed-loop insulin delivery is gradually progressing from bench to the clinical practice. Longer and larger studies in home settings are needed to expand on short- to medium-term outpatient evaluations. Predictive low glucose management and overnight closed-loop delivery may be the next applications to be implemented in daily routine. Further challenges include improvements of control algorithms, sensor accuracy, duration of insulin action, integration and size of devices and connectivity and usability. Gradual improvements and increasing sophistication of closed-loop components lie on the path toward unsupervised hands-off fully closed-loop system.
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Affiliation(s)
- Martin Tauschmann
- University of Cambridge, Wellcome Trust-MRC Institute of Metabolic Science , Cambridge , UK
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40
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Neylon OM, O'Connell MA, Skinner TC, Cameron FJ. Demographic and personal factors associated with metabolic control and self-care in youth with type 1 diabetes: a systematic review. Diabetes Metab Res Rev 2013; 29:257-72. [PMID: 23364787 DOI: 10.1002/dmrr.2392] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Revised: 12/02/2012] [Accepted: 01/02/2013] [Indexed: 11/11/2022]
Abstract
Optimal use of recent technological advances in insulin delivery and glucose monitoring remain limited by the impact of behaviour on self-care. In recent years, there has been a resurgence of interest in psychosocial methods of optimizing care in youth with type 1 diabetes. We therefore sought to examine the literature for demographic, interpersonal and intrapersonal correlates of self-care and/or metabolic control. Studies for this systematic review were obtained via an electronic search of Medline, Embase, Cumulative Index to Nursing and Allied Health Literature and PsycINFO databases. Seventy studies fulfilled the inclusion criteria. These studies have indicated that identifiable individual characteristics in each domain are robustly associated with metabolic control and/or self-care in children and adolescents. We present these characteristics and propose a theoretical model of their interactions and effect on diabetes outcomes. There is currently no consensus regarding patient selection for insulin pump therapy. In this era of scarce healthcare resources, it may be prudent to identify youth requiring increased psychosocial support prior to regimen intensification. The importance of this review lies in its potential to create a framework for rationally utilizing resources by stratifying costly therapeutic options to those who, in the first instance, will be most likely to benefit from them.
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Affiliation(s)
- Orla M Neylon
- University of Tasmania, Burnie, Tasmania, Australia.
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Lombardo F, Scaramuzza AE, Iafusco D. Failure of glycated hemoglobin drop after continuous subcutaneous insulin infusion initiation may indicate patients who discontinue: a 4-year follow-up study in children and adolescents with type 1 diabetes. Acta Diabetol 2012; 49 Suppl 1:S99-105. [PMID: 22008950 DOI: 10.1007/s00592-011-0344-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2011] [Accepted: 10/05/2011] [Indexed: 01/09/2023]
Abstract
Continuous subcutaneous insulin infusion (CSII) is effective and safe in children and adults with type 1 diabetes. Notwithstanding, some patients decide to discontinue using CSII. We evaluated the discontinuation rate, and its related factors, in a large group of children and adolescents with type 1 diabetes using CSII in Italy. Data on all patients with type 1 diabetes younger than 18 years were collected by 28 Pediatric Diabetologic referral Centers located throughout Italy. The primary endpoint was to measure the discontinuation rate using CSII. Among the study population (n = 6,644), 985 (14.8%) were using CSII. Sixty patients discontinued using CSII, representing the 6.1%. The discontinuation rate significantly increased (P = 0.002) with age: 0-6 years, 1/84 (1.2%), 7-11 years, 8/262 (3.1%), 12-18 years, 51/579 (8.8%). The average time to discontinuation was 1.8 ± 1.4 years. The average age of patients who discontinued using CSII was higher than in patients still on CSII (12.1 ± 3.2 vs. 10.3 ± 3.8, P = 0.0001), while their diabetes duration was significantly shorter (8.6 ± 2.7 vs. 10.2 ± 3.7, P = 0.0001). HbA1c decreased only in patients still on CSII (8.7 ± 1.3% vs. 7.8 ± 1.3%, P = 0.02), but not in patients who discontinued using CSII (8.5 ± 1.6% vs. 8.2 ± 1.3%, P = 0.213). HbA1c might be one important indicator helpful to identify patients at higher risk discontinuing using CSII.
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Affiliation(s)
- Fortunato Lombardo
- Department of Pediatric Sciences, University of Messina, 98123 Messina, Italy
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Ramchandani N, Heptulla RA. New technologies for diabetes: a review of the present and the future. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2012; 2012:28. [PMID: 23098076 PMCID: PMC3541087 DOI: 10.1186/1687-9856-2012-28] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Accepted: 10/15/2012] [Indexed: 11/10/2022]
Abstract
This review summarizes the technologies in use and in the pipeline for the management of diabetes. The review focuses on glucose meters, continuous glucose monitoring devices, insulin pumps, and getting clinicians connected to technologies. All information presented can be found in the public domain, and was obtained from journal articles, websites, product review tables in patient publications, and professional conferences. The technology concerns, ongoing development and future trends in this area are also discussed.
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Affiliation(s)
- Neesha Ramchandani
- The Children's Hospital at Montefiore, Division of Pediatric Endocrinology & Diabetes, 3415 Bainbridge Ave, Bronx, NY, 10467, USA.
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Thorpe CT, Fahey LE, Johnson H, Deshpande M, Thorpe JM, Fisher EB. Facilitating healthy coping in patients with diabetes: a systematic review. DIABETES EDUCATOR 2012; 39:33-52. [PMID: 23073967 DOI: 10.1177/0145721712464400] [Citation(s) in RCA: 96] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
PURPOSE The purpose of this study is to summarize recent literature on approaches to supporting healthy coping in diabetes in 2 specific areas: (1) the impact of different approaches to diabetes treatment on healthy coping and (2) the effectiveness of interventions specifically designed to support healthy coping. METHODS A PubMed search identified 129 articles published August 1, 2006, to April 30, 2011, addressing diabetes in relation to emotion, quality of life, depression, adjustment, anxiety, coping, family therapy, behavior therapy, psychotherapy, problem solving, couples therapy, or marital therapy. RESULTS Evidence suggests that treatment choice may significantly influence quality of life, with treatment intensification in response to poor metabolic control often improving quality of life. The recent literature provides support for a variety of healthy coping interventions in diverse populations, including diabetes self-management education, support groups, problem-solving approaches, and coping skills interventions for improving a range of outcomes; cognitive behavior therapy and collaborative care for treating depression; and family therapy for improving coping in youths. CONCLUSIONS Healthy coping in diabetes has received substantial attention in the past 5 years. A variety of approaches show positive results. Research is needed to compare the effectiveness of different approaches in different populations and determine how to overcome barriers to intervention dissemination and implementation.
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Affiliation(s)
- Carolyn T Thorpe
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (Dr C. Thorpe, Dr J. Thorpe),University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania (Dr C. Thorpe, Dr J. Thorpe)
| | - Lauren E Fahey
- Department of Population Health Sciences, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (Ms Fahey)
| | - Heather Johnson
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin (Dr Johnson)
| | - Maithili Deshpande
- University of Wisconsin School of Pharmacy, Madison, Wisconsin (Ms Deshpande)
| | - Joshua M Thorpe
- Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania (Dr C. Thorpe, Dr J. Thorpe),University of Pittsburgh School of Pharmacy, Pittsburgh, Pennsylvania (Dr C. Thorpe, Dr J. Thorpe)
| | - Edwin B Fisher
- University of North Carolina School of Public Health, Chapel Hill, North Carolina (Dr Fisher)
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Ricotti L, Assaf T, Dario P, Menciassi A. Wearable and implantable pancreas substitutes. J Artif Organs 2012; 16:9-22. [PMID: 22990986 DOI: 10.1007/s10047-012-0660-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Accepted: 08/27/2012] [Indexed: 01/08/2023]
Abstract
A lifelong-implanted and completely automated artificial or bioartificial pancreas (BAP) is the holy grail for type 1 diabetes treatment, and could be a definitive solution even for other severe pathologies, such as pancreatitis and pancreas cancer. Technology has made several important steps forward in the last years, providing new hope for the realization of such devices, whose feasibility is strictly connected to advances in glucose sensor technology, subcutaneous and intraperitoneal insulin pump development, the design of closed-loop control algorithms for mechatronic pancreases, as well as cell and tissue engineering and cell encapsulation for biohybrid pancreases. Furthermore, smart integration of the mentioned components and biocompatibility issues must be addressed, bearing in mind that, for mechatronic pancreases, it is most important to consider how to recharge implanted batteries and refill implanted insulin reservoirs without requiring periodic surgical interventions. This review describes recent advancements in technologies and concepts related to artificial and bioartificial pancreases, and assesses how far we are from a lifelong-implanted and self-working pancreas substitute that can fully restore the quality of life of a diabetic (or other type of) patient.
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Affiliation(s)
- Leonardo Ricotti
- The Biorobotics Institute, Scuola Superiore Sant'Anna, Viale Rinaldo Piaggio 34, 56025, Pontedera (Pisa), Italy.
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Shulman R, Palmert MR, Daneman D. Insulin pump therapy in youths with Type 1 diabetes: uptake and outcomes in the ‘real world’. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/dmt.12.1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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de Bock M, Gunn AJ, Holt JA, Derraik JGB, Reed P, Cutfield W, Mouat F, Hofman P, Jefferies C. Impact of insulin pumps on glycaemic control in a pump-naïve paediatric regional population. J Paediatr Child Health 2012; 48:247-52. [PMID: 22085335 DOI: 10.1111/j.1440-1754.2011.02245.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM To examine the clinical impact of insulin-pump therapy for children with type 1 diabetes mellitus (T1DM) in a regional paediatric service, Auckland, New Zealand. METHODS Retrospective analysis of children with T1DM from the Starship paediatric diabetes database who started on insulin-pump therapy from 2002 to 2008 compared with the whole T1DM population and with an equal number of non-pump patients matched by age, sex, ethnicity and duration of diabetes. RESULTS From 621 subjects with 6680 clinic visits, 75 children were treated with insulin-pump therapy for more than 12 months. Transitioning to insulin-pump treatment was associated with an improvement in HbA1c compared with baseline (-0.3%/year, P < 0.001) for up to 3 years. In contrast, despite similar deprivation scores, non-pump controls showed a continuing trend to higher HbA1C values (+0.2%/year, P < 0.01). The risk of severe hypoglycaemia fell after pump start (from 27 (0-223) to 5 (0-0.91) events/100 patient years) with no change in non-pump controls; the rate of diabetic ketoacidosis remained low in both groups. CONCLUSIONS In a pump-naïve regional paediatric population, insulin-pump therapy for T1DM was safe and effective, and associated with sustained improvements in HbA1c and lower risk of hypoglycaemia.
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Affiliation(s)
- Martin de Bock
- The Liggins Institute Department of Physiology, University of Auckland, Auckland, New Zealand.
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Bachran R, Beyer P, Klinkert C, Heidtmann B, Rosenbauer J, Holl RW. Basal rates and circadian profiles in continuous subcutaneous insulin infusion (CSII) differ for preschool children, prepubertal children, adolescents and young adults. Pediatr Diabetes 2012; 13:1-5. [PMID: 21545675 DOI: 10.1111/j.1399-5448.2011.00777.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Initiation of continuous subcutaneous insulin therapy (CSII) requires an appropriate basal rate profile. Different approaches exist; however, there is a lack of evidence-based recommendations, especially in young children. STUDY DESIGN In this large multicenter survey, 5941 CSII patients from the German/Austrian prospective documentation system (DPV) were analyzed. Patients were divided into four age groups: <6 yr (n = 837), 6 to <12 yr (n = 1739), 12 to <18 yr (n = 2985) and 18 to <25 yr (n = 380). Basal insulin requirement and diurnal distribution were evaluated based on the most recent documentation for each patient. RESULTS Basal insulin requirement differed significantly between the four age groups (<6: 0.25 ± 0.12; 6 to <12: 0.33 ± 0.12; 12 to <18: 0.43 ± 0.15; 18 to <25: 0.35 ± 0.13 U/kg; p < 0.001). Circadian insulin profiles were markedly different between the younger and older age groups. In addition to age, longer diabetes duration, female gender, higher HbA1c and lower body mass index standard deviation score (BMI-SDS) were related to higher basal insulin requirement per kilogram of body weight. CONCLUSIONS Age of the patient is the primary factor that influences both total daily requirement and circadian distribution of basal insulin in CSII. Experience from a large database may therefore facilitate the initiation of pump therapy in pediatric patients.
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de Vries L, Grushka Y, Lebenthal Y, Shalitin S, Phillip M. Factors associated with increased risk of insulin pump discontinuation in pediatric patients with type 1 diabetes. Pediatr Diabetes 2011; 12:506-12. [PMID: 20723097 DOI: 10.1111/j.1399-5448.2010.00701.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND There are few reports on rates and predictors for pump discontinuation in the pediatric population. OBJECTIVE To study the rate of and predictors for insulin pump discontinuation among pediatric patients with type 1 diabetes. METHODS Medical chart review of 530 patients with type 1 diabetes who had started pump therapy between 2000 and 2008 in our center revealed that 11.3% had discontinued pump use after 3 d to 5 yr; of these, 9.1% discontinued pump use at least 3 months after initiation. Relevant data were retrieved from the files of these patients and from those of 100 randomly assigned pump-treated patients. RESULTS The pump discontinuation group had a significantly higher proportion of female patients (75 vs. 46%, p = 0.001) and patients above 10 yr of age (93.8 vs. 80%, p = 0.03) than the reference group. Comparable findings were noted for age at diagnosis, pubertal stage, anthropometric data and duration of diabetes at pump initiation, rate of severe hypoglycemic and diabetic ketoacidosis episodes. There were no between-group differences in number of daily insulin injections and blood glucose measurements before pump treatment. At pump initiation, HbA(1c) was significantly higher in patients discontinuing pump therapy than in the controls (8.6 ± 1.4 vs. 8.1 ± 1.0, p = 0.02). This difference was maintained at the last follow-up visit recorded. CONCLUSIONS Almost 90% of our cohort maintained pump therapy. Female gender, age older than 10 years in girls and poor metabolic control at pump initiation were associated with higher risk for pump discontinuation - for such patients intensified individual and family support may serve to maximize persistent pump therapy.
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Affiliation(s)
- Liat de Vries
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tiqva, Israel Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
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