A cost-benefit comparison of intensive diabetes management with implantable pumps versus multiple subcutaneous injections in patients with type I diabetes

Modeling Intraperitoneal Insulin Absorption in Patients with Type 1 Diabetes

Standard insulin therapy to treat type 1 diabetes (T1D) consists of exogenous insulin administration through the subcutaneous (SC) tissue. Despite recent advances in insulin formulations, the SC route still suffers from delays and large inter/intra-subject variability that limiting optimal glucose control. Intraperitoneal (IP) insulin administration, despite its higher invasiveness, was shown to represent a valid alternative to the SC one. To date, no mathematical model describing the absorption and distribution of insulin after IP administration is available. Here, we aim to fill this gap by using data from eight patients with T1D, treated by implanted IP pump, studied in a hospitalized setting, with frequent measurements of plasma insulin and glucose concentration. A battery of models describing insulin kinetics after IP administration were tested. Model comparison and selection were performed based on model ability to predict the data, precision of parameters and parsimony criteria. The selected model assumed that the insulin absorption from the IP space was described by a linear, two-compartment model, coupled with a two-compartment model of whole-body insulin kinetics with hepatic insulin extraction controlled by hepatic insulin. Future developments include model incorporation into the UVa/Padova T1D Simulator for testing open- and closed-loop therapies with IP insulin administration.

Current treatment options and challenges in patients with Type 1 diabetes: Pharmacological, technical advances and future perspectives

Type 1 diabetes mellitus imposes a significant burden of complications and mortality, despite important advances in treatment: subjects affected by this disease have also a worse quality of life-related to disease management. To overcome these challenges, different new approaches have been proposed, such as new insulin formulations or innovative devices. The introduction of insulin pumps allows a more physiological insulin administration with a reduction of HbA1c level and hypoglycemic risk. New continuous glucose monitoring systems with better accuracy have allowed, not only better glucose control, but also the improvement of the quality of life. Integration of these devices with control algorithms brought to the creation of the first artificial pancreas, able to independently gain metabolic control without the risk of hypo- and hyperglycemic crisis. This approach has revolutionized the management of diabetes both in terms of quality of life and glucose control. However, complete independence from exogenous insulin will be obtained only by biological approaches that foresee the replacement of functional beta cells obtained from stem cells: this will be a major challenge but the biggest hope for the subjects with type 1 diabetes. In this review, we will outline the current scenario of innovative diabetes management both from a technological and biological point of view, and we will also forecast some cutting-edge approaches to reduce the challenges that hamper the definitive cure of diabetes.

The Peripheral Peril: Injected Insulin Induces Insulin Insensitivity in Type 1 Diabetes

Insulin resistance is an underappreciated facet of type 1 diabetes that occurs with remarkable consistency and considerable magnitude. Although therapeutic innovations are continuing to normalize dysglycemia, a sizable body of data suggests a second metabolic abnormality-iatrogenic hyperinsulinemia-principally drives insulin resistance and its consequences in this population and has not been addressed. We review this evidence to show that injecting insulin into the peripheral circulation bypasses first-pass hepatic insulin clearance, which leads to the unintended metabolic consequence of whole-body insulin resistance. We propose restructuring insulin therapy to restore the physiological insulin balance between the hepatic portal and peripheral circulations and thereby avoid the complications of life-long insulin resistance. As technology rapidly advances and our ability to ensure euglycemia improves, iatrogenic insulin resistance will become the final barrier to overcome to restore normal physiology, health, and life in type 1 diabetes.

Favourable serum calcification propensity with intraperitoneal as compared with subcutaneous insulin administration in type 1 diabetes

BACKGROUND

Serum calcification propensity can be monitored using the maturation time of calciprotein particles in serum (T₅₀ test). A shorter T₅₀ indicates greater propensity to calcify; this is an independent determinant of cardiovascular disease. As the intraperitoneal (IP) route of insulin administration mimics the physiology more than the subcutaneous (SC) route in persons with type 1 diabetes (T1DM), we hypothesized that IP insulin influences determinants of calcium propensity and therefore result in a longer T₅₀ than SC insulin administration.

METHODS

Prospective, observational case-control study. Measurements were performed at baseline and at 26 weeks in age and gender matched persons with T1DM.

RESULTS

A total of 181 persons, 39 (21.5%) of which used IP and 142 (78.5%) SC insulin were analysed. Baseline T₅₀ was 356 (45) minutes. The geometric mean T₅₀ significantly differed between both treatment groups: 367 [95% confidence interval (CI) 357, 376] for the IP group and 352 (95% CI 347, 357) for the SC group with a difference of -15 (95% CI -25, -4) minutes, in favour of IP treatment. In multivariable analyses, the IP route of insulin administration had a positive relation on T₅₀ concentrations while higher age, triglycerides and phosphate concentrations had an inverse relation.

CONCLUSION

Among persons with T1DM, IP insulin administration results in a more favourable calcification propensity time then SC insulin. It has yet to be shown if this observation translates into improved cardiovascular outcomes.

Different routes of insulin administration do not influence serum free thiols in type 1 diabetes mellitus

AIMS

Intraperitoneal (IP) insulin administration is a last-resort treatment option for selected patients with type 1 diabetes mellitus (T1DM). As the IP route of insulin administration mimics the physiology more closely than the subcutaneous (SC) route, we hypothesized that IP insulin would result in less oxidative stress (expressed as systemic level of free sulphydryl (R-SH) content) compared to SC insulin in subjects with T1DM.

MATERIALS AND METHODS

Prospective, observational case-control study. Serum thiol measurements were performed at baseline and at 26 weeks in age- and gender-matched patients with T1DM. Serum-free thiols, compounds with a R-SH group that are readily oxidized by reactive oxygen species, are considered to be a marker of systemic redox status.

RESULTS

A total of 176 patients, 39 of which used IP and 141 SC insulin therapy were analysed. Mean baseline R-SH concentration was 248 (31) μmol/L. In multivariable analysis, the route of insulin therapy had no impact on baseline R-SH levels. The estimated geometric mean concentrations of R-SH did not differ significantly between both groups: 264 (95% CI 257, 270) for the IP group and 258 (95% CI 254, 261) for the SC group with a difference of 6 (95% CI -2, 14) μmol/L.

CONCLUSIONS

Based on R-SH as a marker of systemic oxidative stress, these findings demonstrate that the route of insulin administration, IP or SC, does not influence systemic redox status in patients with T1DM.

Multicentre Trial of a Programmable Implantable Insulin Pump in Type I Diabetes

Programmable implantable pumps permitting variable-rate intraperitoneal insulin infusion are currently investigated as a potential alternative to subcutaneous insulin therapy. An improved version of the Siemens implantable system has been evaluated in 6 European centres on 31 type I diabetic patients treated for 10–30 months. Contrary to other pump models there were no proven pump malfunctions and only one no-flow reduction unrelated to catheter obstruction. The latter resulted in 12 surgical catheter replacements. There were 2.0 incidents of programmer malfunctions per patient-year easily managed by reconfiguration or replacement. Insulin remained clear and active in the pump reservoir and glycaemic control remained in the near-normoglycaemic range. Thus, insulin therapy with the Siemens implantable pump is feasible and effective up to 2.5 years.

A New Optimized Percutaneous Access System for CIPII

In recent years, continuous intraperitoneal insulin infusion (CIPII) has become a favored treatment alternative for patients with subcutaneous insulin resistance, mainly due to its ability of mimicking physiological conditions of insulin absorption. CIPII has been shown to improve glycemic control as well as to reduce hypoglycemic events and to lead to increased patient satisfaction and quality of life (QoL). Among CIPII delivery systems, Diaport stands out due to its low side effects, its demonstrated clinical efficacy and the potential for integration into closed-loop systems.

Finding the right route for insulin delivery - an overview of implantable pump therapy

INTRODUCTION

Implantable pump therapy adopting the intraperitoneal route of insulin delivery has been available for the past three decades. The key rationale for implantable pump therapy is the restoration of the portal-peripheral insulin gradient of the normal physiology. Uptake in clinical practice is limited to specialized centers and selected patient populations. Areas covered: Implantable pump therapy is discussed, including technical aspects, rationale for its use, and glycemic and non-glycemic effects. Target populations, summaries of clinical studies and issues related to implantable pump therapy are highlighted. Limitations of implantable pump therapy and its future outlook in clinical practice are presented. Expert opinion: Although intraperitoneal insulin delivery appears closer to the normal physiology, technical, pharmacological, and costs barriers prevent a wider adoption. Evidence from clinical studies remains scarce and inconclusive. As a consequence, the use of implantable pump therapy will be confined to a small population unless considerable technological progress is made and well-conducted studies can demonstrate glycemic and/or non-glycemic benefits justifying wider application.

Continuous intraperitoneal insulin infusion versus subcutaneous insulin therapy in the treatment of type 1 diabetes: effects on glycemic variability

INTRODUCTION

As continuous intraperitoneal insulin infusion (CIPII) results in a more physiologic action of insulin than subcutaneous (SC) insulin administration, we hypothesized that CIPII would result in less glycemic variability (GV) than SC insulin therapy among type 1 diabetes mellitus (T1DM) patients.

MATERIALS AND METHODS

Data from 5-day blind continuous glucose monitoring (CGM) measurements performed during a 26-week, prospective, observational case-control study were analyzed. The coefficient of variation (CV) was the primary measure of GV. In addition, the SD of the mean glucose level, mean of daily differences, and mean amplitude of glycemic excursions were calculated.

RESULTS

In total, 176 patients (36% male; mean age, 49 [SD 13] years; median diabetes duration, 24 [interquartile range, 17, 35] years; glycated hemoglobin level, 63 [10] mmol/mmol), of which 37 used CIPII and 139 SC insulin therapy, were analyzed. CGM data were available for 169 patients at baseline (CIPII, n=35; SC, n=134) and for 164 patients at 26 weeks (CIPII, n=35; SC, n=129). After adjustment for baseline differences, the CV was 4.9% (95% confidence interval, 1.0, 8.8) lower with CIPII- compared with SC-treated patients, irrespective of the use of multiple daily injections or continuous SC insulin infusion. There were no differences in other indices of GV between groups.

CONCLUSIONS

Despite higher blood glucose, the CV was slightly lower with CIPII compared with SC insulin therapy in T1DM patients, and other measures of GV were identical. Future studies are needed to confirm these findings and investigate whether this results in prevention of hypoglycemia and even perhaps (less) microvascular complications.

Report of a 7 year case-control study of continuous intraperitoneal insulin infusion and subcutaneous insulin therapy among patients with poorly controlled type 1 diabetes mellitus: favourable effects on hypoglycaemic episodes

AIMS

Continuous intraperitoneal insulin infusion (CIPII) is a last-resort treatment option for patients with type 1 diabetes mellitus (T1DM) who fail to reach adequate glycaemic control with subcutaneous (SC) insulin therapy. Aim was to compare the long-term effects of CIPII and SC insulin therapy among patients with T1DM in poor glycaemic control.

METHODS

Patients in which CIPII was initiated in 2006 were compared with a control group of T1DM patients who continued SC therapy. Linear mixed models were used to calculate differences between the baseline (2006) and final (2013) measurements within and between groups.

RESULTS

A total of 95 patients of which 21 were using CIPII and 74 using SC insulin were included. Within the CIPII group, the number of hypoglycaemic episodes decreased with -5 (95% CI -8 to -3) per 2 weeks while it remained stable among SC patients. Over time, only the number of hypoglycaemic episodes decreased more with CIPII as compared to SC insulin treatment (difference: -6 (95% CI -9 to -4)). There were no differences between treatment groups regarding clinical parameters and quality of life scores over time. Pump or catheter dysfunction led to ketoacidosis in 6 patients: 2 using CIPII and 4 SC insulin.

CONCLUSIONS

After 7 years of follow-up, there is a persistent decline of hypoglycaemic events among CIPII treated T1DM patients. Besides less hypoglycaemic episodes with CIPII therapy, there are no differences between long-term CIPII and SC insulin therapy.

Intraperitoneal insulin infusion: treatment option for type 1 diabetes resulting in beneficial endocrine effects beyond glycaemia

Continuous intraperitoneal insulin infusion (CIPII) is a treatment option for patients with type 1 diabetes mellitus who fail to reach adequate glycaemic control despite intensive subcutaneous (SC) insulin therapy. CIPII has clear advantages over SC insulin administration in terms of pharmacokinetic and pharmacodynamic properties and has been shown to improve glycaemic regulation. Due to the delivery of insulin predominantly in the portal vein, as opposed to systemically, CIPII offers a unique research model to investigate the effects of insulin on endocrine and metabolic parameters in vivo. The aim of the present article is to provide an overview of the literature with respect to the effects of CIPII on glucose management, quality of life, complications and costs, with additional focus on metabolic and endocrine aspects. Finally, future use and research objectives are discussed.

Assessment of a new insulin preparation for implanted pumps used in the treatment of type 1 diabetes

BACKGROUND

Implanted insulin pumps using the peritoneal route provide long-term improvement of glucose control compared with subcutaneous insulin therapy in type 1 diabetes (T1D) patients. The stability of insulin preparation is critical for a safe use in implanted pumps. Insuman implantable(®) (400 IU/mL) (Sanofi-Aventis Deutschland GmbH, Frankfurt am Main, Germany), a recombinant human insulin, has been developed as a replacement for Insuplant(®) (Aventis Pharma, Frankfurt am Main, Germany), a semisynthetic insulin, the only one used so far. The aim of the study was to demonstrate the noninferiority of Insuman versus Insuplant, in terms of safety and effectiveness when used in implanted pumps.

SUBJECTS AND METHODS

The patients enrolled, currently treated for T1D by the Medtronic MiniMed (Northridge, CA) implantable pump model 2007 with Insuplant, were randomized into two study arms and received either Insuman or Insuplant for four pump refill cycles. Each pump refill cycle was 40±5 days. The co-primary end points included glycated hemoglobin (HbA1c) change from baseline and pump infusion accuracy.

RESULTS

In total, 169 patients were randomized. Noninferiority of Insuman versus Insuplant was demonstrated both for the HbA1c change from baseline (as a percentage) with intergroup difference of 95% confidence interval (-0.36;+0.11) and for the infusion accuracy assessed by the measured percentage of error at pump refill, as shown by intergroup difference of 95% confidence interval (-5.81; -0.50), in per-protocol populations, although the insulin daily dose was similar. Severe hypoglycemia occurred at least once in 12 versus 11 patients, respectively, and metabolic or technical adverse events were comparable.

CONCLUSIONS

Findings suggest that Insuman can safely and effectively replace Insuplant in implanted pumps.

Continuous intraperitoneal insulin infusion in type 1 diabetes: a 6-year post-trial follow-up

BACKGROUND

Continuous intraperitoneal insulin infusion (CIPII) with an implantable pump is a treatment option for patients with type 1 diabetes mellitus (T1DM). Aim of the present study was to describe the long-term course of glycaemic control, complications, health related quality of life (HRQOL) and treatment satisfaction among T1DM patients treated with CIPII.

METHODS

Nineteen patients that participated in a randomized cross-over trial comparing CIPII and subcutaneous (SC) therapy in 2006 were followed until 2012. Laboratory, continuous glucose monitoring, HRQOL and treatment satisfaction measurements were performed at the start of the study, the end of the SC-, the end of the CIPII treatment phase in 2006 and during CIPII therapy in 2012. Linear mixed models were used to calculate estimated values and to test differences between the moments in time.

RESULTS

In 2012, more time was spent in hyperglycaemia than after the CIPII treatment phase in 2006: 37% (95% CI 29, 44) vs. 55% (95% CI 48, 63), mean difference 19.8% (95% CI 3.0, 36.6). HbA1c was 65 mmol/mol (95% CI 60, 71) at the end of the SC treatment phase in 2006, 58 mmol/mol (95% CI 53, 64) at the end of the CIPII treatment phase and 65 mmol/mol (95% CI 60, 71) in 2012, respectively (p > 0.05). In 2012, the median number of grade 2 hypoglycaemic events per week (1 (95% CI 0, 2)) was still significantly lower than during prior SC therapy (3 (95% CI 2, 4)): mean change -1.8 (95% CI -3.4, -0.4). Treatment satisfaction with CIPII was better than with SC insulin therapy and HRQOL remained stable. Pump or catheter dysfunction of the necessitated re-operation in 7 patients. No mortality was reported.

CONCLUSIONS

After 6 years of CIPII treatment, glycaemic regulation is stable and the number of hypoglycaemic events decreased compared to SC insulin therapy. Treatment satisfaction with CIPII is superior to SC insulin therapy, HRQOL is stable and complications are scarce. CIPII is a safe and effective treatment option for selected patients with T1DM, also on longer term.

Current status and future of implantable insulin pumps for the treatment of diabetes

The data from the Diabetes Control and Complications Trial show that control of blood glucose with intensive insulin therapy significantly delays complications of diabetes when compared with conventional therapy consisting of one or two insulin injections per day. However, the subcutaneous intensive insulin therapy, including insulin infusion by external pumps, required to achieve the glycemic goals defined by the Diabetes Control and Complications Trial, led to an increased frequency of severe hypoglycemia. Improvements in parenteral insulin therapy are possible by either modifying subcutaneous insulin kinetics (insulin analogs) or developing better routes of administration. Intraperitoneal insulin infusion offers a more physiologic route of insulin delivery. The ultimate goal for the treatment of diabetes remains the development of a fully automated glucose-controlled device.

Systematic review: continuous intraperitoneal insulin infusion with implantable insulin pumps for diabetes mellitus

Continuous intraperitoneal insulin infusion (CIPII) with implantable insulin pumps (IIPs) is a treatment option for diabetes, which is not widely utilized nor freely accessible in clinical practice. The aim of this study was to summarize available evidence on use of IIPs for CIPII for diabetes treatment, since its introduction to clinical use on the following outcomes: HbA1c, hypoglycaemic events, and complications of treatment.

SECONDARY OUTCOMES

complications of diabetes and treatment satisfaction. Following the procedure for a systematic review this paper may contribute to a balanced evaluation of the need and effectiveness of IIPs. A pre-specified, registered protocol (CRD42012002150) was followed. Studies investigating all diabetes populations and types of IIPs were considered eligible. The sensitive search strategy was developed in collaboration with a clinical librarian and contents experts. PUBMED, MEDLINE, CENTRAL EMBASE, trial registries, and other databases were searched. References were screened independently by two authors, and decisions on study selection were recorded. Of the 1,703 references screened, 362 were assessed as potentially eligible. Ninety-four were identified as studies using IIPs. Fifteen papers, together reporting on four-randomized trials, and eight cohorts were included. Narrative analysis is provided, and data tables are available. CIPII by way of IIPs is effective in lowering HbA1c levels and reducing hypoglycaemic events. Superiority of IIP treatment is likely related to patient characteristics, one subgroup being patients unable to acquire satisfactory glycaemic control with subcutaneous insulin treatment. Higher treatment satisfaction was also reported for this subgroup. For these patients, risk of morbidity may be considered acceptable. Patients' perspectives, influence on quality of life, and possible other outcomes should also be considered important factors in weighing individual benefits and risks. A more uniform method of reporting would help strengthen the evidence base.

Advances in pump technology: insulin patch pumps, combined pumps and glucose sensors, and implanted pumps

This review discusses the most recent developments in insulin pump technology. The benefits of the insulin pump to patients with type 1 diabetes are recognized both for its metabolic effectiveness and its positive effects on quality of life. The current pumps are reliable, small and light, and are becoming more and more sophisticated. Nevertheless, there remain practical and psychological constraints for the patient. However, recent patch-pump advances should simplify the technical aspects of pump treatment and enhance patient comfort. Another advance combines the insulin pump with a glucose sensor. Such a combination is logical for optimizing pump use and, to that end, developing an automated or 'closed-loop'system that permits the delivery of subcutaneous insulin adjusted according to measured levels of subcutaneous glucose. Finally, implanted insulin pumps have proven their worth not only because of their simple use, but also for their contribution in the artificial pancreas project. Indeed, the prompt response with intraperitoneal administration of insulin makes it of interest for use in a closed-loop system.

A recent survey confirms the efficacy and the safety of implanted insulin pumps during long-term use in poorly controlled type 1 diabetes patients

BACKGROUND

This article reports a prolonged trial with insulin pumps implanted in patients with type 1 diabetes showing poor glucose control and a high rate of complications.

METHODS

We reviewed data from 181 patients undergoing implanted insulin pump therapy. Analysis included hemoglobin A1c (HbA1c) values, body weight, and diabetes complications status.

RESULTS

At implantation, the mean age was 43 (range, 19-72) years, mean duration of diabetes was 22.2 (2-52) years, and mean body weight was 68.6 (43-104) kg. The complication status involved retinopathy (62% of patients), neuropathy (34.6%), nephropathy (26%), and cardiovascular disease (14%). Patients' previous insulin treatment regimen was multiple daily injections (17.1%) or continuous subcutaneous insulin infusion (82.9%). HbA1c levels significantly dropped from 7.9 ± 1.2% to 7.6 ± 1.2% after 1 year (P < 0.01) and remained within the range of 7.5-7.6% for up to 5 years. No significant variation of body weight or complications status occurred.

CONCLUSIONS

Implanted insulin pump therapy demonstrates long-term benefits in type 1 diabetes patients who have poor prognosis under intensive subcutaneous treatment.

Improved glycemic control with intraperitoneal versus subcutaneous insulin in type 1 diabetes: a randomized controlled trial

OBJECTIVE Continuous intraperitoneal insulin infusion (CIPII) with an implantable pump has been available for the past 25 years. CIPII, with its specific pharmacodynamic properties, may be a viable treatment alternative to improve glycemic control in patients with type 1 diabetes for whom other therapies have failed. There have been few studies in which CIPII was compared with subcutaneous insulin treatment for patients with type 1 diabetes with poor glycemic control. RESEARCH DESIGN AND METHODS In an open-label, prospective, crossover, randomized, 16-month study, the effects of CIPII and subcutaneous insulin were compared in 24 patients. The primary outcome measure was the incidence of hypoglycemia. Secondary outcome measures were A1C, and glucose profile, including time in euglycemia, as measured by continuous glucose monitoring. RESULTS The incidence of grade 1 hypoglycemic events was 4.0 +/- 2.6 per week with subcutaneous insulin compared with 3.5 +/- 2.3 per week during CIPII (P = 0.13). The absolute mean difference in A1C with CIPII compared with subcutaneous treatment was -0.76% (95% CI -1.41 to -0.11) (P = 0.03). Baseline time spent in euglycemia was 45.2 +/- 12.6% and increased 10.9% (4.6-17.3) with CIPII compared with subcutaneous treatment (absolute value; P = 0.003). There were no differences in the occurrence rate for severe hypoglycemic events, daily insulin use, or BMI. No pump or catheter malfunction was observed during the study. CONCLUSIONS Although we did not observe a significant reduction in hypoglycemic events, improved glycemic control was achieved with the use of CIPII. We saw a 0.8% decrease in A1C and an 11% increase in the time spent in euglycemia.

Surgical aspects and complications of continuous intraperitoneal insulin infusion with an implantable pump

PURPOSE

Continuous intraperitoneal insulin infusion (CIPII) with an implantable pump is safe and effective in selected subjects with diabetes. Our aim was to assess surgical experience and complications with CIPII.

METHODS

We performed a retrospective longitudinal observational cohort study of patients that started with CIPII from 1990 to 2006. Operation free period and complication rate were compared between patients initiating CIPII before 2000 and from 2000 onwards.

RESULTS

In 63 patients, 166 re-operations were performed during 381 patient-years. Re-operations were pump replacement due to end-of-battery life (47%), laparoscopic catheter-related procedures (29%) and other interventions (24%). Median operation free period increased from 21 to 78 months from 2000 onwards (p = 0.039). Nineteen percent of patients developed complications. No operation-related mortality was reported.

CONCLUSIONS

Increased experience together with technical improvements has led to an increase of the operation free period. The absence of procedure-related mortality and a low complication rate makes CIPII feasible for selected patients with diabetes.

Implantable insulin pumps. A position statement about their clinical use

AIM

To review clinical use of implantable insulin pumps and to suggest indications for this therapy.

METHODS

The EVADIAC group performed a review of published reports on implantable insulin pumps for the last 15 years and analyzed its own centralized database. From this update, a position statement on indications of this therapy is drawn.

RESULTS

Published papers mostly report safety and effectiveness data from observational cumulated experiences of 15-350 patient-years. While HbA(1c) reduction does not reach statistical significance in all reported studies, improvement of blood glucose stability and reduction of severe hypoglycaemia appear as constant characteristics of this therapy. When compared to subcutaneous insulin therapy in randomized controlled studies, implantable pumps allow significantly reduced blood glucose fluctuations and improved quality of life in both type 1 and type 2 diabetic patients, and a significant weight decrease in type 2 diabetic patients. While the EVADIAC registry shows the reduced occurrence of pump-pocket complications thanks to preventive measures and a lower incidence of catheter obstructions following improvements of catheter design, underdelivery due to insulin aggregation in pumps remains a recurrent although reversible issue. Determinants of increased anti-insulin antibody production in some patients remain elusive but impact on blood glucose control is limited in most cases.

CONCLUSION

From analyzed data, the EVADIAC group states that implantable pumps can be safely indicated and provide metabolic improvements in type 1 diabetic patients who remain far from targeted HbA(1c) below 7% and/or experience large fluctuations of blood glucose including recurrent severe hypoglycaemia, in spite of intensive follow-up and education when treated by subcutaneous insulin.

Glycemic parameters with multiple daily injections using insulin glargine versus insulin pump

This study compared external insulin pump treatment using insulin lispro or insulin aspart with multiple daily injections (MDI; four or more injections per day) using insulin glargine and insulin lispro or insulin aspart. An electronic database was used to retrieve various parameters of glycemic control for 515 adult patients with type 1 diabetes. An insulin pump was used by 216 patients, and 299 patients were taking insulin glargine for at least 6 months. The mean age (approximately 33 years), duration of diabetes (approximately 16 years), and duration of treatment (approximately 12 months) were similar for both the pump and insulin glargine groups. The mean (+/-SEM) A1C values were significantly reduced in both groups from the baseline to the end of the study (7.7 +/- 0.1% to 7.5 +/- 0.1% for the pump group and 8.0 +/- 0.1% to 7.7 +/- 0.1% for the insulin glargine group, P< 0.001) with similar weight gain (P> 0.05) in both groups. The insulin glargine group significantly reduced basal insulin intake at follow-up. The premeal boluses were similar throughout the study for both groups. The subjects reporting severe hypoglycemic episodes were similar in the two groups; however, there were 12 cases of diabetic ketoacidosis reported in the pump group and none in the insulin glargine group. Patients with type 1 diabetes can achieve similar glycemic control using insulin glargine with premeal insulin lispro or by using an external infusion pump with insulin lispro or insulin aspart. However, costs and episodes of diabetic ketoacidosis are significantly higher for insulin pump users.

Continuous intraperitoneal insulin infusion in patients with 'brittle' diabetes: favourable effects on glycaemic control and hospital stay

AIMS

To evaluate the effects of continuous intraperitoneal insulin infusion (CIPII) using implantable pumps on glycaemic control and duration of hospital stay in poorly controlled 'brittle' Dutch diabetes patients, and to assess their current quality of life.

METHODS

Thirty-three patients were included. Glycaemic control was retrospectively assessed with HbA(1c) levels acquired before implantation, 1 year later and at long-term follow up of 58 months. Duration of hospital stay the year before and the year following first implantation was extracted from hospital records. Determinants of long-term glycaemic response were sought. Self-report questionnaires were administered at 58 months follow-up only, to assess current psychopathology and quality of life.

RESULTS

Mean HbA(1c) decreased from 10.0 +/- 2.3% to 9.0 +/- 1.8% (P = 0.039) 1 year after implantation and stabilized at 9.0 +/- 1.6% (P = 0.023) during long-term follow-up. Median number of hospital days in the 20 patients suffering from hospital admission before implantation decreased from 45 the year before implantation to 13 the year after (P = 0.005). Patients with a higher baseline HbA(1c) showed a larger long-term response (P < 0.001). Relatively low levels for quality of life were found, as well as a higher than expected number of patients with psychiatric symptoms.

CONCLUSIONS

CIPII proved effective in complex patients with a history of poor control and hospital admission. Despite a substantial long-term improvement in glycaemic control and diminished hospital stay, normal levels of glycaemic control and quality of life were not attained.

Current status and future prospects of parenteral insulin regimens, strategies and delivery systems for diabetes treatment

A strong relationship between long term metabolic control and low frequency of chronic diabetes complications was shown in the Diabetes Control Complication Trial (DCCT). However, the subcutaneous intensive insulin therapy required to achieve the glycemic goals defined by the DCCT led to an unacceptable frequency of severe hypoglycemia and a significant weight gain. This limits the benefits of this therapy and excludes groups of patients such as young children, the elderly or hypoglycemia prone patients. The intensive therapy and self blood glucose monitoring (SMBG) necessary to limit hypoglycemia represent a heavy burden for the patients and their family. Improvements in parenteral insulin therapy are possible by either modifying subcutaneous insulin characteristics (analogs, adjunction of peptides such as amylin, GLP1, IGF1), or by developing better routes of administration and making SMBG easier, which is a key to intensive insulin therapy success. The ultimate goal remains the development of an automated, glucose controlled device.

Design of cost-effective packages of care for non-insulin-dependent diabetes mellitus. Defining the information needs

This review concludes that: a) the global burden of disease from non-insulin-dependent diabetes mellitus (NIDDM) cannot be completely estimated at present; b) evidence for the efficacy of key elements of a package of care is still needed; c) generalizing the results of evaluations of costs or effectiveness across different populations is not straightforward; and d) for this complex intervention, the costs and effectiveness of intervention may be highly dependent on methods of organizing care. Addressing this information deficit represents an important task for researchers and health decision makers.

Economic evaluation of interventions in endocrinology

This article provides a review of methods for conducting cost-effectiveness, cost-utility, and cost-benefit studies. Economic evaluations of interventions designed to improve outcomes of patients with diabetes and osteoporosis are reviewed, and key issues for future research are discussed. The role of cost-effectiveness analysis in reimbursement decision making at the public and private levels is explored.

Symptoms, hormones, and glucose fluxes during a gradual hypoglycaemia induced by intraperitoneal vs venous insulin infusion in Type I diabetes

Intraperitoneal (IP) insulin infusion with programmable implantable pumps is associated with a reduction in hypoglycaemic events when compared to intensive diabetes management with subcutaneous insulin in patients with Type 1 diabetes mellitus. The mechanism may involve more physiological insulin kinetics, lower peripheral insulin levels or a specific hepatic action of portal insulin on hypoglycaemic counter regulation. To investigate the latter two hypotheses, we performed two hypoglycaemic clamps (controlled blood glucose decrement to 2.2 mmol l-1) in random order in 12 Type 1 diabetic patients. Insulin was infused either IP or IV for 150 min, at rates chosen to generate similar peripheral insulin levels (1 mU/kg-1 min-1 IV or 2 mU/kg-1 min-1 IP, n = 6) to evaluate direct hepatic action, or at similar rates (1 mU/kg-1 min-1 IV and IP, n = 6) to evaluate IP indirect effects via lower peripheral insulinaemia. Hepatic glucose production and glucose utilization were measured by [6.6 2H] glucose dilution technique. Glucose production was lower (1.7 +/- 0.4 vs 0.5 +/- 0.4 mg kg-1 min-1, p < 0.05), and utilization was similar at the end of the matched-insulinaemia IV and IP clamps, respectively. By contrast, glucose production was higher (1.7 +/- 0.5 IV vs 2.7 +/- 0.3 IP mg kg-1 min-1, p < 0.01) and glucose utilization lower (4.4 +/- 1.0 IV vs 3.3 +/- 0.2 IP mg kg-1 min-1, p < 0.05) with IP delivery at the end of the matched-dose clamps. Counterregulatory hormones and hypoglycaemic symptoms increased similarly in all clamps. In summary, IP insulin, when compared to IV insulin at similar delivery rates, but not at similar insulinaemia, is associated with a less negative glucose balance (glucose production-glucose utilization) during hypoglycaemia. Such a mechanism may play a role in the reduced hypoglycaemic risk seen with IP implantable pumps.