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Ye Y, Acevedo-Mendez BA, Izard S, Myers AK. Differences in Glycemic Control for Inpatients with Type 1 Diabetes on Insulin Pump Versus Subcutaneous Insulin Therapy. J Gen Intern Med 2024:10.1007/s11606-024-08736-4. [PMID: 38587726 DOI: 10.1007/s11606-024-08736-4] [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: 11/09/2023] [Accepted: 03/18/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Inpatient use of insulin pump therapy has been increasing due to greater availability of this technology, however there is a paucity of research that investigates glycemic control of inpatient insulin pump users. OBJECTIVE To compare the glycemic control of hospitalized patients with type 1 diabetes (T1D) who used insulin pump vs. multiple daily injections (MDI). DESIGN Retrospective chart review. PARTICIPANTS Patients with T1D who were hospitalized between January 1, 2017, and December 31, 2019, in an academic medical center in the New York metropolitan area. MAIN MEASURES Patients were categorized into three groups based on their method of insulin administration: "pump only" group used insulin pump exclusively, "MDI only" group used MDI only, and "intermittent pump" group used a combination of both methods. The primary endpoints are mean blood glucose, rates of hypoglycemic events (blood glucose < 70 mg/dL), and rates of hyperglycemic events (blood glucose > 250 mg/dL). Separate multivariable Poisson regressions were performed to determine the association between the type of insulin administration and rate outcomes (i.e., rate of hypoglycemic events and rate of hyperglycemic events). RESULTS The study included 78 patients with a mean age of 51, who were mostly male (54%), and white (72%). The average proportion of glucose measurements that were hyperglycemic for the "pump only", "MDI only", and "intermittent pump" groups were 0.11 (SD = 0.11), 0.25 (SD = 0.19), and 0.24 (SD = 0.25), respectively. The "pump only" group has a significantly lower proportion of hyperglycemic events as compared to the "MDI only" group (p = 0.0227). CONCLUSIONS In this sample, patients who exclusively used their insulin pump while inpatient had a lower rate of hyperglycemic events than patients who used MDI only; suggesting that select patients can safely continue their insulin pump therapy in the inpatient setting.
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Affiliation(s)
- Yuting Ye
- Department of Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA.
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, North Shore University Hospital, 300 Community Drive, Manhasset, NY, 11030, USA.
| | - Bernardo A Acevedo-Mendez
- Department of Medicine, North Shore University Hospital, Northwell Health, Manhasset, NY, USA
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, North Shore University Hospital, 300 Community Drive, Manhasset, NY, 11030, USA
| | - Stephanie Izard
- Quantitative Intelligence, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Alyson K Myers
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, North Shore University Hospital, 300 Community Drive, Manhasset, NY, 11030, USA
- Division of Endocrinology, Department of Medicine, Montefiore Einstein, Bronx, NY, USA
- Albert Einstein College of Medicine, Bronx, NY, USA
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2
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Suto H, Kamei K, Kato H, Misawa T, Unno M, Nitta H, Satoi S, Kawabata Y, Ohtsuka M, Rikiyama T, Sudo T, Matsumoto I, Hirao T, Okano K, Suzuki Y, Sata N, Isaji S, Sugiyama M, Takeyama Y. Risk factors associated with hypoglycemic events after total pancreatectomy: A nationwide multicenter prospective study in Japan. Surgery 2022; 172:962-967. [PMID: 35820975 DOI: 10.1016/j.surg.2022.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/27/2022] [Accepted: 04/25/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND The number of total pancreatectomy cases have increased worldwide, expanding the need for new insulin products and high-titer pancrelipases. However, the current data that is focused on hypoglycemic events after a total pancreatectomy from large nationwide series are still lacking. This study is aimed to assess the risk factors associated with hypoglycemic events after a total pancreatectomy. METHODS Data were prospectively collected from 216 consecutive patients who underwent total pancreatectomies between August 2015 and December 2017 from 68 Japanese centers. Of the 216 patients, 166 with a follow-up period of 1 year were analyzed. The risk factors for hypoglycemic events at 6 and 12 months (postoperative months 6 and 12) were investigated based on the results of a nationwide multicenter prospective study. RESULTS Of the 166 patients, 57 (34%) and 70 (42%) experienced moderate or severe hypoglycemic events or hypoglycemia unawareness on a monthly basis at postoperative months 6 and 12, respectively. Multivariate analysis revealed that body weight loss after surgery ≥0.3 kg and total cholesterol level ≤136 mg/dL at postoperative month 6, and glycated hemoglobin level ≤8.9% and rapid-acting insulin use at postoperative month 12 were independent risk factors for hypoglycemic events after a total pancreatectomy. There were different independent risk factors depending on the postoperative period. CONCLUSION Patients with body weight loss after surgery, low total cholesterol level, strict glycemic control, and using rapid-acting insulin should be aware of the occurrence of hypoglycemic events after their total pancreatectomy. In order to prevent hypoglycemic events after a total pancreatectomy, we need to consider optimal nutritional and glycemic control according to the postoperative period.
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Affiliation(s)
- Hironobu Suto
- Department of Gastroenterological Surgery, Kagawa University, Kagawa, Japan.
| | - Keiko Kamei
- Department of Surgery, Kindai University, Osaka, Japan
| | - Hiroyuki Kato
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Takeyuki Misawa
- Department of Surgery, The Jikei University Kashiwa Hospital, Chiba, Japan
| | - Michiaki Unno
- Department of Surgery, Tohoku University, Miyagi, Japan
| | - Hiroyuki Nitta
- Department of Surgery, Iwate Medical University, Iwate, Japan
| | - Sohei Satoi
- Department of Surgery, Kansai Medical University, Osaka, Japan
| | - Yasunari Kawabata
- Department of Digestive and General Surgery, Faculty of Medicine, Shimane University, Shimane, Japan
| | - Masayuki Ohtsuka
- Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Toshiki Rikiyama
- Department of Surgery, Saitama Medical Center, Jichi Medical University, Saitama, Japan
| | - Takeshi Sudo
- Department of Surgery, Kure Medical Center and Chugoku Cancer Center, Hiroshima, Japan
| | | | - Tomohiro Hirao
- Department of Public Health, Kagawa University, Kagawa, Japan
| | - Keiichi Okano
- Department of Gastroenterological Surgery, Kagawa University, Kagawa, Japan
| | - Yasuyuki Suzuki
- Department of Gastroenterological Surgery, Kagawa University, Kagawa, Japan
| | - Naohiro Sata
- Department of Surgery, Jichi Medical University, Tochigi, Japan
| | - Shuji Isaji
- Director of Mie University Hospital, Mie, Japan
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3
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Masuda T, Katakami N, Taya N, Miyashita K, Takahara M, Kato K, Kuroda A, Matsuhisa M, Shimomura I. Comparison of continuous subcutaneous insulin infusion treatment and multiple daily injection treatment on the progression of diabetic complications in Japanese patients with juvenile-onset type 1 diabetes mellitus. J Diabetes Investig 2022; 13:1528-1532. [PMID: 35474612 PMCID: PMC9434575 DOI: 10.1111/jdi.13819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/14/2022] [Accepted: 04/25/2022] [Indexed: 11/28/2022] Open
Abstract
To evaluate whether continuous subcutaneous insulin infusion attenuates the progression of diabetic complications, we retrospectively extracted data from 35 individuals who had developed type 1 diabetes mellitus aged ≤20 years and whose treatment had been changed from multiple daily injections to continuous subcutaneous insulin infusion. The annual changes in estimated glomerular filtration rate, urinary albumin excretion rate, carotid intima‐media thickness and brachial‐ankle pulse wave velocity during each treatment period were calculated. Although mean glycated hemoglobin under the continuous subcutaneous insulin infusion treatment was lower than that under the multiple daily injection treatment, there were no significant differences in annual changes in diabetic nephropathy and atherosclerosis between the two treatment periods. This pilot study showed that, in Japanese patients with juvenile‐onset type 1 diabetes mellitus, there was no significant difference in the progression of diabetic nephropathy and atherosclerosis, at least in the early stage, between the two treatments.
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Affiliation(s)
| | | | | | | | - Mitsuyoshi Takahara
- Department of Metabolic Medicine.,Department of Diabetes Care Medicine, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita City, Osaka, 565-0871, Japan
| | - Ken Kato
- Diabetes center, NHO, National Hospital, 2-1-14 Hoenzaka, Chuo-ku Osaka City, Osaka, Osaka, 540-0006, Japan
| | - Akio Kuroda
- Diabetes Therapeutics and Research Center, Institute of Advance Medical Sciences, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
| | - Munehide Matsuhisa
- Diabetes Therapeutics and Research Center, Institute of Advance Medical Sciences, Tokushima University, 3-18-15 Kuramoto-cho, Tokushima City, Tokushima, 770-8503, Japan
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4
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Walsh J, Roberts R, Bailey TS, Heinemann L. Insulin Titration Guidelines for Patients With Type 1 Diabetes: It Is About Time! J Diabetes Sci Technol 2022:19322968221087261. [PMID: 35369773 DOI: 10.1177/19322968221087261] [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] [Indexed: 10/18/2022]
Abstract
PURPOSE A proposal that an Insulin Advisory Committee develop insulin titration guidelines 100 years after its discovery. FINDINGS Glucose control metrics remain poor despite significant advances in diabetes technology. SUMMARY A century after the introduction of insulin, health care providers and patients with type 1 diabetes have worldwide access to a variety of insulin delivery devices (IDDs), glucose monitors, bolus calculators (BCs), continuous glucose monitors (CGMs), and automated insulin delivery (AID) systems. However, these advances have not enabled most patients to achieve today's clear A1c and time-in-range goals. Much of this failure arises from the lack of clear insulin titration guidelines for determining appropriate insulin doses. The lack of dosing clarity results in local physicians, clinics, and individual patients managing insulin titrations as they see fit, creating significant inefficiencies for reaching recommended glycemic goals. This review (1) details the widespread problems generated by nonphysiological dose settings in today's BCs, insulin pumps, and AID systems; (2) presents a method to develop and implement optimized total daily doses of insulin to correct the most common problem of hyperglycemia; (3) discusses using large device databases to provide clear insulin titration guidelines that optimize BC settings from an optimized total daily dose (TDD) of insulin for patients with T1D; and (4) recommends the formation of an Insulin Advisory Committee to clarify the steps to take toward universal insulin titration guidelines, optimized BC settings, and a systematic logic for their use in insulin delivery devices.
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Affiliation(s)
- John Walsh
- Advanced Metabolic Care and Research, Escondido, CA, USA
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5
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Effects of continuous subcutaneous insulin infusion on clinical parameters in patients with different sociodemographic and clinical characteristics. Int J Diabetes Dev Ctries 2021. [DOI: 10.1007/s13410-021-01025-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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6
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Thomas MG, Avari P, Godsland IF, Lett AM, Reddy M, Oliver N. Optimizing type 1 diabetes after multiple daily injections and capillary blood monitoring: Pump or sensor first? A meta-analysis using pooled differences in outcome measures. Diabetes Obes Metab 2021; 23:2521-2528. [PMID: 34286892 DOI: 10.1111/dom.14498] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Revised: 07/05/2021] [Accepted: 07/16/2021] [Indexed: 12/25/2022]
Abstract
AIMS Most people living with type 1 diabetes self-manage using multiple daily injection (MDI) insulin regimens and self-monitoring of blood glucose (SMBG). Continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) are adjuncts to education and support self-management optimization. The aim of this systematic review and meta-analysis was to assess which first-line technology is most effective. METHODS Electronic databases (MEDLINE, EMBASE and WEB OF SCIENCE) were systematically searched from 1999 to September 2020. Randomized controlled trials comparing either CSII with MDI or CGM with SMBG in adults with type 1 diabetes were included. Data were extracted in duplicate by two reviewers, and were analysed to assess individual and overall treatment effect measures (PROSPERO registration: CRD42020149915). RESULTS Glycated haemoglobin was significantly reduced for CGM when compared with SMBG [Cohen's d - 0.62 (95% CI -0.79 to -0.45)] and for CSII when compared with MDI [Cohen's d - 0.44 (95% CI -0.67 to -0.22)]. Rates of severe hypoglycaemia were significantly reduced with CGM compared with SMBG, but did not change for CSII when compared with MDI. Episodes of diabetic ketoacidosis were more likely to occur with CSII than MDI. Both CSII and CGM reduced glucose standard deviation, compared with MDI and SMBG respectively. CONCLUSIONS Both CGM and CSII remain impactful interventions compared with SMBG and MDI but in adults with type 1 diabetes and in the contexts in which they have been studied, CGM might have a greater positive impact on glycaemic variability and severe hypoglycaemia than CSII, when added to MDI and SMBG. A head-to-head study, including patient reported outcomes, is required to explore these findings further.
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Affiliation(s)
- Maria G Thomas
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Parizad Avari
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Ian F Godsland
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Aaron M Lett
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Monika Reddy
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Nick Oliver
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
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7
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Aleppo G, Parkin CG, Carlson AL, Galindo RJ, Kruger DF, Levy CJ, Umpierrez GE, Forlenza GP, McGill JB. Lost in Translation: A Disconnect Between the Science and Medicare Coverage Criteria for Continuous Subcutaneous Insulin Infusion. Diabetes Technol Ther 2021; 23:715-725. [PMID: 34077674 PMCID: PMC8573795 DOI: 10.1089/dia.2021.0196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Numerous studies have demonstrated the clinical value and safety of insulin pump therapy in type 1 diabetes and type 2 diabetes populations. However, the eligibility criteria for insulin pump coverage required by the Centers for Medicare & Medicaid Services (CMS) discount conclusive evidence that supports insulin pump use in diabetes populations that are currently deemed ineligible. This article discusses the limitations and inconsistencies of the insulin pump eligibility criteria relative to current scientific evidence and proposes workable solutions to address this issue and improve the safety and care of all individuals with diabetes.
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Affiliation(s)
- Grazia Aleppo
- Division of Endocrinology, Metabolism and Molecular Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Christopher G. Parkin
- Clinical Research, CGParkin Communications, Inc., Henderson, Nevada, USA
- Address correspondence to: Christopher G. Parkin, MS, Clinical Research, CGParkin Communications, Inc., 2352 Martinique Avenue, Henderson, NV 89044, USA.
| | - Anders L. Carlson
- International Diabetes Center, Endocrinologist, Regions Hospital & HealthPartners Clinics, Minneapolis, Minnesota, USA
- Diabetes Education Programs, HealthPartners and Stillwater Medical Group, Minneapolis, Minnesota, USA
- University of Minnesota Medical School, Minneapolis, Minnesota, USA
| | - Rodolfo J. Galindo
- Emory University School of Medicine, Atlanta, Georgia, USA
- Center for Diabetes Metabolism Research Emory University Hospital Midtown, Atlanta, Georgia, USA
- Hospital Diabetes Taskforce, Emory Healthcare System, Atlanta, Georgia, USA
| | - Davida F. Kruger
- Division of Endocrinology, Diabetes, Bone & Mineral, Henry Ford Health System, Detroit, Michigan, USA
| | - Carol J. Levy
- Division of Endocrinology, Diabetes, and Metabolism, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
- Mount Sinai Diabetes Center and T1D Clinical Research, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Guillermo E. Umpierrez
- Division of Endocrinology, Metabolism Emory University School of Medicine, Atlanta, Georgia, USA
- Diabetes and Endocrinology, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Gregory P. Forlenza
- Barbara Davis Center, Division of Pediatric Endocrinology, Department of Pediatrics, University of Colorado Denver, Denver, Colorado, USA
| | - Janet B. McGill
- Division of Endocrinology, Metabolism and Lipid Research, Washington University in St. Louis, School of Medicine, St. Louis, Missouri, USA
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8
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Real-world outcomes of insulin pump compared to multiple daily injection therapy in adult type 1 diabetes mellitus patients in a Mediterranean scenario. Int J Diabetes Dev Ctries 2020. [DOI: 10.1007/s13410-020-00887-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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9
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Osaki A, Yamada E, Nakajima Y, Kasai Y, Shimoda Y, Toki A, Horiguchi K, Yoshino S, Inoue M, Saito T, Kameda T, Okada S, Yamada M. Insulin pump therapy would be favored by pregnant women with diabetes. COGENT PSYCHOLOGY 2020. [DOI: 10.1080/23311908.2020.1801221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Affiliation(s)
- Aya Osaki
- Center of Regional Medical Research and Education, Gunma University Hospital, Maebashi 371-8511, Japan
- Department of Endocrinology and Diabetes, Gunma University Graduate School of Medicine, Maebashi 371-8511, Japan
| | - Eijiro Yamada
- Center for Patients Support and Community Service, Gunma University Hospital, Maebashi 371-8511, Japan
| | - Yasuyo Nakajima
- Center for Patients Support and Community Service, Gunma University Hospital, Maebashi 371-8511, Japan
| | - Yuko Kasai
- Center for Patients Support and Community Service, Gunma University Hospital, Maebashi 371-8511, Japan
| | - Yoko Shimoda
- Center for Patients Support and Community Service, Gunma University Hospital, Maebashi 371-8511, Japan
| | - Akiko Toki
- Department of Endocrinology and Diabetes, Gunma University Graduate School of Medicine, Maebashi 371-8511, Japan
- Center for Patients Support and Community Service, Gunma University Hospital, Maebashi 371-8511, Japan
| | - Kazuhiko Horiguchi
- Center for Patients Support and Community Service, Gunma University Hospital, Maebashi 371-8511, Japan
| | - Satoshi Yoshino
- Center for Patients Support and Community Service, Gunma University Hospital, Maebashi 371-8511, Japan
| | - Maki Inoue
- Department of Obstetrics and Gynecology, Gunma University Graduate School of Medicine, Maebashi 371-8511, Japan
| | - Tsugumichi Saito
- Center for Patients Support and Community Service, Gunma University Hospital, Maebashi 371-8511, Japan
- Center for Medical Education, Gunma University Graduate School of Medicine, Maebashi 371-8511, Japan
| | - Takashi Kameda
- Center for Medical Education, Gunma University Graduate School of Medicine, Maebashi 371-8511, Japan
| | - Shuichi Okada
- Center for Patients Support and Community Service, Gunma University Hospital, Maebashi 371-8511, Japan
| | - Masanobu Yamada
- Center for Patients Support and Community Service, Gunma University Hospital, Maebashi 371-8511, Japan
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10
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Dicembrini I, Pala L, Caliri M, Minardi S, Cosentino C, Monami M, Mannucci E. Combined continuous glucose monitoring and subcutaneous insulin infusion versus self-monitoring of blood glucose with optimized multiple injections in people with type 1 diabetes: A randomized crossover trial. Diabetes Obes Metab 2020; 22:1286-1291. [PMID: 32166907 DOI: 10.1111/dom.14028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 11/30/2022]
Abstract
AIM To investigate the efficacy of a combination of continuous glucose monitoring (CGM) and continuous subcutaneous insulin infusion (CSII) versus an optimized degludec-based multiple daily injections (MDI) regimen + self-monitoring of blood glucose (SMBG) in people with type 1 diabetes with regard to optimizing glucose control. MATERIAL AND METHODS The trial included 28 individuals who underwent a 4-week run-in phase, and were then randomized 1:1 to: (a) CSII + CGM followed by MDI + SMBG or (b) an MDI basal-bolus regimen followed by CSII + CGM. RESULTS In patients randomized to the CSII + CGM → MDI + SMBG arm, a significant reduction in glycated haemoglobin (HbA1c) versus baseline was found at the end of the first phase (CSII + CGM) without significant variation in the following MDI + SMBG phase. In the arm randomized to the MDI + SMBG → CSII + CGM sequence, a significant improvement in HbA1c was observed in the first phase (MDI + SMBG), together with a further decrease in the following CSII + CGM phase. In the comparison of the two treatments using a mixed linear model, CSII + CGM was superior to MDI + SMBG with respect to change in HbA1c (P = 0.001). CONCLUSIONS This study suggests that CSII + CGM improves glycaemic control without relevant safety issues in type 1 diabetes, in comparison with MDI + SMBG.
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Affiliation(s)
- Ilaria Dicembrini
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Laura Pala
- Diabetes Unit, Careggi Teaching Hospital, Florence, Italy
| | - Mariasmeralda Caliri
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Silvia Minardi
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Claudia Cosentino
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
| | - Matteo Monami
- Diabetes Unit, Careggi Teaching Hospital, Florence, Italy
| | - Edoardo Mannucci
- Department of Experimental and Clinical Biomedical Sciences, University of Florence, Florence, Italy
- Diabetes Unit, Careggi Teaching Hospital, Florence, Italy
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11
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Mou Y, Ma D, Zhang J, Tao J, He W, Li W, Mu Y, Yu X. Continuous subcutaneous insulin infusion reduces the risk of postoperative infection. J Diabetes 2020; 12:396-405. [PMID: 31697444 DOI: 10.1111/1753-0407.13008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 10/26/2019] [Accepted: 11/01/2019] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Perioperative hyperglycemia was associated with postoperative infection, and proper management of perioperative glucose has become critical in improving the prognosis of patients. METHODS A total of 1015 diabetic patients who underwent surgery and received insulin treatment for their hyperglycemia in our hospital were retrospectively reviewed. According to propensity matching, we obtained 253 pairs of patients from the group which received continuous subcutaneous insulin infusion (CSII) therapy (CSII group) and the group which received insulin injection therapy (non-CSII group). Perioperative glucose levels and corresponding outcomes were compared between the two groups. RESULTS Compared with the non-CSII group, the CSII group had lower fasting and mean glucose levels, lower incidence of fever (operation day: 18.6% vs 10.2%; P = .014; first postoperative day: 55.1% vs 34.7%; P < .001), a positive rate of postoperative secretion culture (6.3% vs 1.2%; P = .004), and a shorter time of antibiotics use (total antibiotics use: P = .002; postoperative antibiotics use: P < .001) and hospital stays (P < .001). However, there was no difference in the total medical expenditure between the two groups (P = .499). Further analysis showed that CSII therapy was superior to multiple daily insulin injection (MDI) therapy in its effect on infection and other postoperative outcomes when 64 pairs of patients from the CSII group and MDI group were compared. CONCLUSIONS CSII therapy provides better perioperative glucose control and a lower risk of postoperative infection without increasing the total medical expenditure.
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Affiliation(s)
- Yune Mou
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Delin Ma
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jianhua Zhang
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jing Tao
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wentao He
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wenjun Li
- Department of Computer Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yiming Mu
- Department of Endocrinology, Chinese PLA General Hospital, Beijing, China
| | - Xuefeng Yu
- Division of Endocrinology, Department of Internal Medicine, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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12
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Markakis K, Alam T, Jinadev P, Chapman A, Urwin A, Thabit H, Boulton AJM, Rutter MK, Leelarathna L. Continuous Subcutaneous Insulin Infusion Initiation Is Associated With Blood Pressure Reduction in Adults With Type 1 Diabetes. J Diabetes Sci Technol 2019; 13:691-697. [PMID: 30636544 PMCID: PMC6610598 DOI: 10.1177/1932296818822818] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND In type 1 diabetes (T1D) continuous subcutaneous insulin infusion (CSII) use has been associated with lower risks for mortality and diabetes-related complications when compared to multiple daily injections. There are limited data on the effect of CSII on blood pressure (BP). We aimed to evaluate the relationship between CSII initiation and BP changes. METHODS We performed a retrospective, single-center, observational study including all adults with T1D who initiated CSII between 2001 and 2014. Mean systolic BP levels were calculated from values obtained up to 15 months before and up 15 months after CSII initiation. RESULTS We studied 436 adults (46% male; mean [95% CI] age: 45 [36, 54] years, duration of diabetes: 20.3 [19.1, 21.5] years). CSII was associated with the following changes (post minus pre CSII levels) in mean (95% CI) SBP and DBP levels, respectively: whole cohort (N = 436): -2 (-1, -3), P < .001 and -2 (-1, -2), P < .001; those taking stable antihypertensive medication (n = 118): -4 (-6, -2), P < .001 and -2 (-3, -1), P < .001; antihypertensive treatment-naïve patients (n = 279): -1 (-2, 0), P = .147 and -1 (-2, 0), P = .002. In multivariate regression analysis including age, sex, diabetes duration, pre-CSII BP, HbA1c and weight changes, only pre-CSII BP showed an independent association with BP drop in all patients' groups. Once adjusted for pre-CSII BP there was no significant difference between those on antihypertensive drugs and antihypertensive treatment-naïve individuals. CONCLUSIONS We showed BP reduction in association with CSII therapy particularly in those on antihypertensive medication. These original findings may partly explain the cardiovascular and mortality benefits associated with CSII therapy.
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Affiliation(s)
- Konstantinos Markakis
- Manchester Diabetes Centre, Manchester
University NHS Foundation Trust, Manchester Academic Health Science Centre,
Manchester, UK
| | - Tayiba Alam
- School of Medical Sciences, University
of Manchester, Manchester, UK
| | - Pushpa Jinadev
- Manchester Diabetes Centre, Manchester
University NHS Foundation Trust, Manchester Academic Health Science Centre,
Manchester, UK
| | - Alyson Chapman
- Manchester Diabetes Centre, Manchester
University NHS Foundation Trust, Manchester Academic Health Science Centre,
Manchester, UK
| | - Andrea Urwin
- Manchester Diabetes Centre, Manchester
University NHS Foundation Trust, Manchester Academic Health Science Centre,
Manchester, UK
| | - Hood Thabit
- Manchester Diabetes Centre, Manchester
University NHS Foundation Trust, Manchester Academic Health Science Centre,
Manchester, UK
- School of Medical Sciences, University
of Manchester, Manchester, UK
| | - Andrew J. M. Boulton
- Manchester Diabetes Centre, Manchester
University NHS Foundation Trust, Manchester Academic Health Science Centre,
Manchester, UK
- Division of Diabetes, Endocrinology and
Gastroenterology, University of Manchester, Manchester, UK
| | - Martin K. Rutter
- Manchester Diabetes Centre, Manchester
University NHS Foundation Trust, Manchester Academic Health Science Centre,
Manchester, UK
- Division of Diabetes, Endocrinology and
Gastroenterology, University of Manchester, Manchester, UK
| | - Lalantha Leelarathna
- Manchester Diabetes Centre, Manchester
University NHS Foundation Trust, Manchester Academic Health Science Centre,
Manchester, UK
- Division of Diabetes, Endocrinology and
Gastroenterology, University of Manchester, Manchester, UK
- Lalantha Leelarathna, PhD, Manchester
Diabetes Centre, Hathersage Rd, Manchester, M13 9WL, UK.
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13
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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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Heller S, White D, Lee E, Lawton J, Pollard D, Waugh N, Amiel S, Barnard K, Beckwith A, Brennan A, Campbell M, Cooper C, Dimairo M, Dixon S, Elliott J, Evans M, Green F, Hackney G, Hammond P, Hallowell N, Jaap A, Kennon B, Kirkham J, Lindsay R, Mansell P, Papaioannou D, Rankin D, Royle P, Smithson WH, Taylor C. A cluster randomised trial, cost-effectiveness analysis and psychosocial evaluation of insulin pump therapy compared with multiple injections during flexible intensive insulin therapy for type 1 diabetes: the REPOSE Trial. Health Technol Assess 2018; 21:1-278. [PMID: 28440211 DOI: 10.3310/hta21200] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Insulin is generally administered to people with type 1 diabetes mellitus (T1DM) using multiple daily injections (MDIs), but can also be delivered using infusion pumps. In the UK, pumps are recommended for patients with the greatest need and adult use is less than in comparable countries. Previous trials have been small, of short duration and have failed to control for training in insulin adjustment. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of pump therapy compared with MDI for adults with T1DM, with both groups receiving equivalent structured training in flexible insulin therapy. DESIGN Pragmatic, multicentre, open-label, parallel-group cluster randomised controlled trial, including economic and psychosocial evaluations. After participants were assigned a group training course, courses were randomly allocated in pairs to either pump or MDI. SETTING Eight secondary care diabetes centres in the UK. PARTICIPANTS Adults with T1DM for > 12 months, willing to undertake intensive insulin therapy, with no preference for pump or MDI, or a clinical indication for pumps. INTERVENTIONS Pump or MDI structured training in flexible insulin therapy, followed up for 2 years. MDI participants used insulin analogues. Pump participants used a Medtronic Paradigm® VeoTM (Medtronic, Watford, UK) with insulin aspart (NovoRapid, Novo Nordisk, Gatwick, UK). MAIN OUTCOME MEASURES Primary outcome - change in glycated haemoglobin (HbA1c) at 2 years in participants whose baseline HbA1c was ≥ 7.5% (58 mmol/mol). Key secondary outcome - proportion of participants with HbA1c ≤ 7.5% at 2 years. Other outcomes at 6, 12 and 24 months - moderate and severe hypoglycaemia; insulin dose; body weight; proteinuria; diabetic ketoacidosis; quality of life (QoL); fear of hypoglycaemia; treatment satisfaction; emotional well-being; qualitative interviews with participants and staff (2 weeks), and participants (6 months); and ICERs in trial and modelled estimates of cost-effectiveness. RESULTS We randomised 46 courses comprising 317 participants: 267 attended a Dose Adjustment For Normal Eating course (132 pump; 135 MDI); 260 were included in the intention-to-treat analysis, of which 235 (119 pump; 116 MDI) had baseline HbA1c of ≥ 7.5%. HbA1c and severe hypoglycaemia improved in both groups. The drop in HbA1c% at 2 years was 0.85 on pump and 0.42 on MDI. The mean difference (MD) in HbA1c change at 2 years, at which the baseline HbA1c was ≥ 7.5%, was -0.24% [95% confidence interval (CI) -0.53% to 0.05%] in favour of the pump (p = 0.098). The per-protocol analysis showed a MD in change of -0.36% (95% CI -0.64% to -0.07%) favouring pumps (p = 0.015). Pumps were not cost-effective in the base case and all of the sensitivity analyses. The pump group had greater improvement in diabetes-specific QoL diet restrictions, daily hassle plus treatment satisfaction, statistically significant at 12 and 24 months and supported by qualitative interviews. LIMITATION Blinding of pump therapy was not possible, although an objective primary outcome was used. CONCLUSION Adding pump therapy to structured training in flexible insulin therapy did not significantly enhance glycaemic control or psychosocial outcomes in adults with T1DM. RESEARCH PRIORITY To understand why few patients achieve a HbA1c of < 7.5%, particularly as glycaemic control is worse in the UK than in other European countries. TRIAL REGISTRATION Current Controlled Trials ISRCTN61215213. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 20. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Simon Heller
- Academic Unit of Diabetes, Endocrinology and Metabolism, University of Sheffield, Sheffield, UK
| | - David White
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Ellen Lee
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Julia Lawton
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Daniel Pollard
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Norman Waugh
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Katharine Barnard
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Anita Beckwith
- King's College Hospital NHS Foundation Trust, London, UK
| | - Alan Brennan
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Michael Campbell
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Cindy Cooper
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | | | - Simon Dixon
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jackie Elliott
- Academic Unit of Diabetes, Endocrinology and Metabolism, University of Sheffield, Sheffield, UK
| | - Mark Evans
- Institute of Metabolic Science, University of Cambridge, Cambridge, UK.,Wolfson Diabetes Clinic, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Fiona Green
- Dumfries Royal Infirmary NHS Trust, Dumfries, UK
| | - Gemma Hackney
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Peter Hammond
- Harrogate and District NHS Foundation Trust, Harrogate, UK
| | - Nina Hallowell
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Alan Jaap
- Edinburgh Centre for Endocrinology and Diabetes, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Brian Kennon
- Queen Elizabeth University Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Jackie Kirkham
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Robert Lindsay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Peter Mansell
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Diana Papaioannou
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - David Rankin
- Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Pamela Royle
- Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry, UK
| | - W Henry Smithson
- Department of General Practice, University College Cork, Cork, Ireland
| | - Carolin Taylor
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Abstract
OBJECTIVES The aims of this study were to compare the safety, efficacy, and patients' quality of life with continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDIs) in type 3c diabetes mellitus (T3cDM) following total pancreatectomy (TP) and pancreatic enzyme usage. METHODS Thirty-nine patients with T3cDM (18 CSII patients vs 21 MDI patients) who underwent TP between 2000 and 2016 at 3 Harvard-affiliated hospitals and the University of Minnesota returned prospectively obtained questionnaires examining quality of life and both endocrine and exocrine pancreatic functions. RESULTS Main indications for TP were as follows: chronic pancreatitis (n = 19), intraductal papillary mucinous neoplasm (n = 12), and adenocarcinoma (n = 4). Median hemoglobin A1c using MDIs was 8.1% versus 7.3% in CSII. Severe hypoglycemic events using MDIs were increased compared with CSII (P = 0.02). There were no significant differences in quality-of-life measures with CSII versus MDIs. Pancreatic enzyme dose per meal (P < 0.05) differed between the hospitals. Gastrointestinal symptoms and unintended weight loss (P < 0.01) were more common with low doses of pancreatic enzymes. CONCLUSIONS After TP, CSII therapy is safe compared with MDIs in T3cDM and not associated with an increase in severe hypoglycemic events. Pancreatic enzyme replacement therapy is highly variable with low doses associated with unintentional weight loss and gastrointestinal symptoms.
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Haase M, Kahle M, Janert M, Meier JJ, Nauck MA. Basal rate tests (24-hour fasts) performed in type-1 diabetic subjects with either absolute fasting or snacks containing negligible carbohydrate amounts result in similar glucose profiles: A randomized controlled prospective trial. Diabetes Obes Metab 2017; 19:783-790. [PMID: 28058800 DOI: 10.1111/dom.12868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 12/19/2016] [Accepted: 12/30/2016] [Indexed: 11/30/2022]
Abstract
AIMS Basal rate tests (24-hour fasting periods) may be necessary to optimize basal insulin replacement in type 1 diabetes. It was the aim of this study to prospectively compare the allowance of negligible carbohydrate snacks vs absolute fasting. METHODS A total of 20 patients with type 1 diabetes (age, 48 ± 15 years (9 women, 11 men); BMI, 28.5 ± 4.5 kg/m2 ; HbA1c, 8.8% ± 2.0% (73.0 ± 21.9 mmol/mol); insulin dose, 0.69 ± 0.31 IU/kg body weight and per day) participated in 2 basal rate tests lasting 24 hours in random order with unchanged basal insulin replacement. On 1 occasion, negligible carbohydrate snacks (salads and vegetables, up to 5.1 g carbohydrate and 276.3 kJ per portion) were allowed; during the second test subjects were obliged to fast absolutely. Plasma glucose profiles were determined using an exact laboratory method. Hypoglycaemic episodes (plasma glucose < 70 mg/dL) were compared. RESULTS Plasma glucose concentrations during fasting periods, with and without negligible carbohydrate snacks, did not differ significantly ( P = .65) and differences were negligible (95% confidence intervals always included a difference of 0 mmol/L). Also, there was no difference in the number of hypoglycaemic plasma glucose values (P = .40) or in compensatory carbohydrate intake. Basal rate testing with negligible carbohydrate snacks was better tolerated (questionnaire, P = .046) and the desire to discontinue the fasting period was significantly reduced (P = .023). CONCLUSIONS Allowing negligible carbohydrate snacks results in unchanged plasma glucose profiles during basal rate testing and is better tolerated by patients with type 1 diabetes.
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Affiliation(s)
- Maike Haase
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany
- Division of Diabetology, Department of Internal Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Melanie Kahle
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany
- Division of Diabetology, Department of Internal Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Martin Janert
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany
| | - Juris J Meier
- Division of Diabetology, Department of Internal Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Michael A Nauck
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany
- Division of Diabetology, Department of Internal Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
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17
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Landau Z, Raz I, Wainstein J, Bar-Dayan Y, Cahn A. The role of insulin pump therapy for type 2 diabetes mellitus. Diabetes Metab Res Rev 2017; 33. [PMID: 27189155 DOI: 10.1002/dmrr.2822] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2015] [Revised: 04/11/2016] [Accepted: 05/04/2016] [Indexed: 11/10/2022]
Abstract
Many patients with type 2 diabetes fail to achieve adequate glucose control despite escalation of treatment and combinations of multiple therapies including insulin. Patients with long-standing type 2 diabetes often suffer from the combination of severe insulin deficiency in addition to insulin resistance, thereby requiring high doses of insulin delivered in multiple injections to attain adequate glycemic control. Insulin-pump therapy was first introduced in the 1970s as an approach to mimic physiological insulin delivery and attain normal glucose in patients with type 1 diabetes. The recent years have seen an increase in the use of this technology for patients with type 2 diabetes. This article summarizes the clinical studies evaluating insulin pump use in patients with type 2 diabetes and discusses the benefits and shortcomings of pump therapy in this population. Copyright © 2016 John Wiley & Sons, Ltd.
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Affiliation(s)
- Zohar Landau
- Pediatric Endocrine and Diabetes Unit, E. Wolfson Medical Center, Holon, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Itamar Raz
- Diabetes Unit, Department of Internal Medicine, Hadassah University Hospital, Jerusalem, Israel
| | - Julio Wainstein
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Diabetes Unit, Wolfson Medical Center, Holon, Israel
| | - Yosefa Bar-Dayan
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Diabetes Unit, Wolfson Medical Center, Holon, Israel
| | - Avivit Cahn
- Diabetes Unit, Department of Internal Medicine, Hadassah University Hospital, Jerusalem, Israel
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18
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Hammond P. Continuous subcutaneous insulin infusion: short-term benefits apparent, long-term benefits speculative. ACTA ACUST UNITED AC 2016. [DOI: 10.1177/14746514040040020701] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Continuous subcutaneous insulin infusion (CSII) is increasingly used as a means of insulin delivery for those with type 1 diabetes, and has recently been endorsed by NICE for this purpose. CSII improves glycaemic control compared to other intensified insulin regimens, with a small decrease in HbA1C and mean blood glucose, and a larger reduction in glucose fluctuation. This improved control is not associated with an increased risk of hypoglycaemia and CSII probably results in significantly lower rates of severe hypoglycaemia. There is no evidence that those using CSII are at increased risk of diabetic ketoacidosis. CSII is uniquely associated with a small risk of application site infection. CSII has a positive impact on quality of life. There is much less evidence concerning the benefits of CSII in reducing microvascular or macrovascular complication rates. Small studies, mostly from the 1980s, show improvements in markers of early nephropathy, retinopathy progression and neuropathy, but the potential long-term impact of CSII has not been proven. Recently CSII has been used in the management of those Br J Diabetes Vasc Dis 2004;4:104—08 with type 2 diabetes but evidence is lacking with regard to the benefits of using it in this group.
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Affiliation(s)
- Peter Hammond
- Harrogate District Hospital, Lancaster Park Road, HG2 7SX, UK,
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19
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Glycaemic control using different regimens of intermediate- and short-acting insulin in childhood type 1 diabetes mellitus: an experience from a tertiary care centre. Int J Diabetes Dev Ctries 2016. [DOI: 10.1007/s13410-016-0509-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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Ribeiro MEB, Del Roio Liberatore Junior R, Custodio R, Martinelli Junior CE. [Continuous insulin therapy versus multiple insulin injections in the management of type 1 diabetes: a longitutinal study]. REVISTA PAULISTA DE PEDIATRIA 2016; 34:86-90. [PMID: 26826879 DOI: 10.1016/j.rpped.2015.06.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Revised: 06/08/2015] [Accepted: 06/09/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare multiple doses of insulin and continuous insulin infusion therapy as treatment for type 1 diabetes melito. METHODS 40 patients with type 1 diabetes melito (21 female) with ages between 10 and 20 years (mean=14.2) and mean duration of diabetes of 7 years used multiple doses of insulin for at least 6 months and after that, continuous insulin infusion therapy for at least 6 months. Each one of the patients has used multiple doses of insulin and continuous insulin infusion therapy. For analysis of HbA1c, mean glycated hemoglobin levels (mHbA1c) were obtained during each treatment period (multiple doses of insulin and continuous insulin infusion therapy period). RESULTS Although mHbA1c levels were lower during continuous insulin infusion therapy the difference was not statistically significant. During multiple doses of insulin, 14.2% had mHbA1c values below 7.5% vs. 35.71% while on continuous insulin infusion therapy; demonstrating better glycemic control with the use of continuous insulin infusion therapy. During multiple doses of insulin, 15-40 patients have severe hypoglycemic events versus 5-40 continuous insulin infusion therapy. No episodes of ketoacidosis events were recorded. CONCLUSIONS This is the first study with this design comparing multiple doses of insulin and continuous insulin infusion therapy in Brazil showing no significant difference in HbA1c; hypoglycemic events were less frequent during continuous insulin infusion therapy than during multiple doses of insulin and the percentage of patients who achieved a HbA1c less than 7.5% was greater during continuous insulin infusion therapy than multiple doses of insulin therapy.
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21
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Ribeiro MEB, Del Roio Liberatore Junior R, Custodio R, Martinelli Junior CE. [Continuous insulin therapy versus multiple insulin injections in the management of type 1 diabetes: a longitutinal study]. ACTA ACUST UNITED AC 2016. [PMID: 26826879 PMCID: PMC4795726 DOI: 10.1016/j.rppede.2015.06.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To compare multiple doses of insulin and continuous insulin infusion therapy as treatment for type 1 diabetes melito. METHODS 40 patients with type 1 diabetes melito (21 female) with ages between 10 and 20 years (mean=14.2) and mean duration of diabetes of 7 years used multiple doses of insulin for at least 6 months and after that, continuous insulin infusion therapy for at least 6 months. Each one of the patients has used multiple doses of insulin and continuous insulin infusion therapy. For analysis of HbA1c, mean glycated hemoglobin levels (mHbA1c) were obtained during each treatment period (multiple doses of insulin and continuous insulin infusion therapy period). RESULTS Although mHbA1c levels were lower during continuous insulin infusion therapy the difference was not statistically significant. During multiple doses of insulin, 14.2% had mHbA1c values below 7.5% vs. 35.71% while on continuous insulin infusion therapy; demonstrating better glycemic control with the use of continuous insulin infusion therapy. During multiple doses of insulin, 15-40 patients have severe hypoglycemic events versus 5-40 continuous insulin infusion therapy. No episodes of ketoacidosis events were recorded. CONCLUSIONS This is the first study with this design comparing multiple doses of insulin and continuous insulin infusion therapy in Brazil showing no significant difference in HbA1c; hypoglycemic events were less frequent during continuous insulin infusion therapy than during multiple doses of insulin and the percentage of patients who achieved a HbA1c less than 7.5% was greater during continuous insulin infusion therapy than multiple doses of insulin therapy.
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22
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McAdams BH, Rizvi AA. An Overview of Insulin Pumps and Glucose Sensors for the Generalist. J Clin Med 2016; 5:jcm5010005. [PMID: 26742082 PMCID: PMC4730130 DOI: 10.3390/jcm5010005] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2015] [Revised: 12/16/2015] [Accepted: 12/24/2015] [Indexed: 01/22/2023] Open
Abstract
Continuous subcutaneous insulin, or the insulin pump, has gained popularity and sophistication as a near-physiologic programmable method of insulin delivery that is flexible and lifestyle-friendly. The introduction of continuous monitoring with glucose sensors provides unprecedented access to, and prediction of, a patient’s blood glucose levels. Efforts are underway to integrate the two technologies, from “sensor-augmented” and “sensor-driven” pumps to a fully-automated and independent sensing-and-delivery system. Implantable pumps and an early-phase “bionic pancreas” are also in active development. Fine-tuned “pancreas replacement” promises to be one of the many avenues that offers hope for individuals suffering from diabetes. Although endocrinologists and diabetes specialists will continue to maintain expertise in this field, it behooves the primary care physician to have a working knowledge of insulin pumps and sensors to ensure optimal clinical care and decision-making for their patients.
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Affiliation(s)
- Brooke H McAdams
- Fellow in Endocrinology, University of South Carolina School of Medicine, Columbia, SC 29203, USA.
| | - Ali A Rizvi
- Medicine and Director, Endocrinology Division, University of South Carolina School of Medicine, Two Medical Park, Suite 502, Columbia, SC 29203, USA.
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23
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Abstract
While being physically active bestows many health benefits on individuals with type 1 diabetes, their overall blood glucose control is not enhanced without an effective balance of insulin dosing and food intake to maintain euglycemia before, during, and after exercise of all types. At present, a number of technological advances are already available to insulin users who desire to be physically active with optimal blood glucose control, although a number of limitations to those devices remain. In addition to continued improvements to existing technologies and introduction of new ones, finding ways to integrate all of the available data to optimize blood glucose control and performance during and following exercise will likely involve development of "smart" calculators, enhanced closed-loop systems that are able to use additional inputs and learn, and social aspects that allow devices to meet the needs of the users.
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Affiliation(s)
- Sheri R Colberg
- Human Movement Sciences Department, Old Dominion University, Norfolk, VA, USA
| | - Remmert Laan
- William Sansum Diabetes Center, Santa Barbara, CA, USA
| | - Eyal Dassau
- Department of Chemical Engineering, University of California, Santa Barbara, CA, USA
| | - David Kerr
- William Sansum Diabetes Center, Santa Barbara, CA, USA
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24
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Borot S, Franc S, Cristante J, Penfornis A, Benhamou PY, Guerci B, Hanaire H, Renard E, Reznik Y, Simon C, Charpentier G. Accuracy of a new patch pump based on a microelectromechanical system (MEMS) compared to other commercially available insulin pumps: results of the first in vitro and in vivo studies. J Diabetes Sci Technol 2014; 8:1133-41. [PMID: 25079676 PMCID: PMC4455475 DOI: 10.1177/1932296814543946] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The JewelPUMP™ (JP) is a new patch pump based on a microelectromechanical system that operates without any plunger. The study aimed to evaluate the infusion accuracy of the JP in vitro and in vivo. For the in vitro studies, commercially available pumps meeting the ISO standard were compared to the JP: the MiniMed® Paradigm® 712 (MP), Accu-Chek® Combo (AC), OmniPod® (OP), Animas® Vibe™ (AN). Pump accuracy was measured over 24 hours using a continuous microweighing method, at 0.1 and 1 IU/h basal rates. The occlusion alarm threshold was measured after a catheter occlusion. The JP, filled with physiological serum, was then tested in 13 patients with type 1 diabetes simultaneously with their own pump for 2 days. The weight difference was used to calculate the infused insulin volume. The JP showed reduced absolute median error rate in vitro over a 15-minute observation window compared to other pumps (1 IU/h): ±1.02% (JP) vs ±1.60% (AN), ±1.66% (AC), ±2.22% (MP), and ±4.63% (OP), P < .0001. But there was no difference over 24 hours. At 0.5 IU/h, the JP was able to detect an occlusion earlier than other pumps: 21 (19; 25) minutes vs 90 (85; 95), 58 (42; 74), and 143 (132; 218) minutes (AN, AC, MP), P < .05 vs AN and MP. In patients, the 24-hour flow error was not significantly different between the JP and usual pumps (-2.2 ± 5.6% vs -0.37 ± 4.0%, P = .25). The JP was found to be easier to wear than conventional pumps. The JP is more precise over a short time period, more sensitive to catheter occlusion, well accepted by patients, and consequently, of potential interest for a closed-loop insulin delivery system.
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Affiliation(s)
- Sophie Borot
- Department of Endocrinology-Metabolism and Diabetology-Nutrition, University Hospital of Besançon and University of Franche-Comte, Besançon, France
| | - Sylvia Franc
- Centre Hospitalier Sud-Francilien, Department of Diabetes and Endocrinology, Corbeil-Essonne, France Centre d'Etudes et de Recherche pour l'Intensification du Traitement du Diabète, Corbeil-Essonnes, France
| | - Justine Cristante
- Department of Endocrinology, Pôle DigiDune, Grenoble University Hospital, Joseph-Fourier University, Grenoble, France
| | - Alfred Penfornis
- Department of Endocrinology-Metabolism and Diabetology-Nutrition, University Hospital of Besançon and University of Franche-Comte, Besançon, France
| | - Pierre-Yves Benhamou
- Department of Endocrinology, Pôle DigiDune, Grenoble University Hospital, Joseph-Fourier University, Grenoble, France
| | - Bruno Guerci
- University of Lorraine and the Department of Diabetology, Metabolic Diseases and Nutrition, Brabois Adult Hospital, Vandoeuvre les Nancy, France
| | - Hélène Hanaire
- Cardiovascular and Metabolic Unit, Department of Diabetology, University Hospital of Toulouse, Toulouse, France
| | - Eric Renard
- Department of Endocrinology, Diabetes, and Nutrition and Clinical Investigation Centre, Montpellier University Hospital, Montpellier, France
| | - Yves Reznik
- Endocrinology and Diabetes Department, Côte de Nacre, Caen, France
| | - Chantal Simon
- Hospices Civils de Lyon, University of Lyon, Lyon, France
| | - Guillaume Charpentier
- Centre Hospitalier Sud-Francilien, Department of Diabetes and Endocrinology, Corbeil-Essonne, France Centre d'Etudes et de Recherche pour l'Intensification du Traitement du Diabète, Corbeil-Essonnes, France
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Middelbeek RJW, Brown FM. Comment on Brethauer et al. Bariatric surgery improves the metabolic profile of morbidly obese patients with type 1 diabetes. Diabetes care 2014;37:e51-e52. Diabetes Care 2014; 37:e250. [PMID: 25342845 PMCID: PMC4876668 DOI: 10.2337/dc14-1116] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Roeland J W Middelbeek
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center; Joslin Diabetes Center; and Harvard Medical School, Boston, MA
| | - Florence M Brown
- Division of Endocrinology, Diabetes and Metabolism, Beth Israel Deaconess Medical Center; Joslin Diabetes Center; and Harvard Medical School, Boston, MA
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Walsh J, Roberts R, Heinemann L. Confusion Regarding Duration of Insulin Action: A Potential Source for Major Insulin Dose Errors by Bolus Calculators. J Diabetes Sci Technol 2014; 8:170-178. [PMID: 24876553 PMCID: PMC4454113 DOI: 10.1177/1932296813514319] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
People with diabetes on insulin pumps often use a bolus calculator (BC) to obtain insulin dose recommendations. After the first bolus of the day, residual insulin activity, called bolus insulin on board (BOB), must be correctly accounted for to reduce the size of subsequent boluses and minimize the insulin stacking that would otherwise occur. Critical to achieving this calculation is having an appropriate duration of insulin action (DIA) setting in the BC. Unfortunately, the widespread use of inappropriately short DIAs may be causing unrecognized "stacking" of insulin that leads to unexplained hypoglycemic events. Currently, there is no widely accepted definition or value of the DIA for use in a BC. Various shortcomings regarding the selection of an appropriate DIA setting have led to considerable confusion among clinicians and insulin pump users about this important concept. Traditional pharmacological studies used to determine the pharmacodynamic (PD) properties of rapid-acting insulins create a misleading impression that insulin action times (IATs) in daily life vary from 3 to 5 hours and cause IATs to appear more variable than they actually are. These IAT time ranges are not appropriate for use as the DIA time value required to obtain an accurate bolus recommendation from a BC. We highlight the problems that arise when an inappropriately short DIA leads to excessive bolus recommendations, provide a research protocol to accurately measure DIA, and suggest appropriate DIA time recommendations for use in current clinical practice.
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Affiliation(s)
- John Walsh
- Advanced Metabolic Care + Research, Escondido, CA, USA
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27
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Ma D, Chen C, Lu Y, Ma J, Yin P, Xie J, Yang Y, Shao S, Liu Z, Zhou X, Yuan G, Yu X. Short-term effects of continuous subcutaneous insulin infusion therapy in perioperative patients with diabetes mellitus. Diabetes Technol Ther 2013; 15:1010-8. [PMID: 23971526 PMCID: PMC3868275 DOI: 10.1089/dia.2013.0117] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Hyperglycemia is common and hard to control in surgical patients with diabetes. We retrospectively investigated short-term effects of continuous subcutaneous insulin infusion (CSII) in perioperative patients with diabetes. PATIENTS AND METHODS Perioperative patients with diabetes discharged between January 1, 2006 and January 1, 2012 were included. Glucose control and postoperative outcomes were compared between the patients using CSII or non-CSII insulin therapy. RESULTS We identified 108 pairs of patients matched by propensity and surgical category who were using CSII therapy (CSII group) or non-CSII insulin therapy (control group). The CSII group had significantly lower fasting glucose levels (on the first postoperative day, 9.06±3.09 mmol/L vs. 11.05±4.19 mmol/L; P=0.003) and lower mean glucose levels (on the operation day, 9.93±2.65 mmol/L vs. 12.05±3.86 mmol/L; P=0.001). The CSII group also had a lower incidence of fever (on the first postoperative day, 30.4% vs. 53.2%; P=0.005). Furthermore, patients in the CSII group experienced significantly shorter postoperative intervals for suture removal (P=0.02) and hospital discharge (P=0.03). No significant difference in the total medical expenditure was observed between the two groups (P=0.47). We also made a comparison between the 30 pairs of patients who were using CSII or multiple daily insulin injection therapy but observed no significant difference between these two therapies in glucose control or postoperative outcomes. CONCLUSIONS Compared with non-CSII insulin therapy, even short-term implementation of CSII can improve the postoperative control of glucose, reduce the incidence of postoperative fever, and shorten the time for suture removal and discharge in surgical patients with diabetes.
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Affiliation(s)
- Delin Ma
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Cai Chen
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Yu Lu
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Jingdong Ma
- Department of Health Information Management, Tongji Medical College, Huazhong University of Science & Technology, Wuhan, Hubei Province, China
| | - Ping Yin
- Department of Epidemiology and Biostatistics, School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Junhui Xie
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Yan Yang
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Shiying Shao
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Zhelong Liu
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Xinrong Zhou
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Gang Yuan
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Xuefeng Yu
- Department of Endocrinology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
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Abstract
When we are interested in making decisions about best use, comparative therapeutic efficacy, or cost-effectiveness of diabetes technologies such as insulin pump therapy [continuous subcutaneous insulin infusion (CSII)] or continuous glucose monitoring, meta-analysis for the purpose of literature summary is inappropriate and may be misleading. Instead, "decision-making meta-analysis" is more appropriate and should involve either preselection of trials based on intended use [e.g., elevated baseline hemoglobin A1c or hypoglycemia rate for trials of multiple daily injections (MDI) versus CSII] or metaregression of summary effect sizes in different trials against potential effect-modifying covariates such as baseline risk, or models of the covariates that determine effect size using individual patient data. Appropriate meta-analysis should also only include trials that are of sufficient duration to accurately measure outcomes such as severe hypoglycemia, and they should not use obsolete technology that is of proven inferiority to current technology. The use of appropriate decision-making meta-analysis is illustrated by the change in the rate ratio for severe hypoglycemia in randomized controlled trials of MDI versus CSII in type 1 diabetes from 1.56 (95% confidence interval 0.96-2.55; p = .074) for literature-summary meta-analysis to 2.0 (1.08-3.69; p = .027) for decision-making meta-analysis of all patients and 3.91 (1.35-11.36; p = .01) for trials in children.
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Affiliation(s)
- John C Pickup
- Diabetes Research Group, King's College London School of Medicine, Guy's Hospital, London SE1 1UL, United Kingdom.
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29
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Lian G, Yue X, Xianxiang Z, Yong L, Weijuan L, Bing C. Insulinization: A promising strategy for the treatment of type 2 diabetes mellitus. Exp Ther Med 2013; 6:1300-1306. [PMID: 24223662 PMCID: PMC3820840 DOI: 10.3892/etm.2013.1300] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 08/19/2013] [Indexed: 12/19/2022] Open
Abstract
The aim of the present study was to assess the efficiency of the long-term use of continuous subcutaneous insulin infusion (CSII), a novel regimen known as insulinization, for the treatment of type 2 diabetes mellitus. A total of 150 subjects who fulfilled the diagnostic criteria for type 2 diabetes were included in the study. The patients were divided into eight groups according to the treatment regimens they received and were monitored for 3 months. Insulin doses were adjusted to optimize glycemic control with the simplest possible insulin regimen. The outcomes studied included the time required for glycemic control and insulin dose reduction, the total daily insulin dose, the ratio of patients not requiring the administration of oral antidiabetic drugs (OADs), the rate of hypoglycemia, and hemoglobin A1c (HbA1c) and fasting plasma insulin (FinS) levels. Patients receiving insulinization required less time to achieve optimal glycemic control and insulin decrement compared with patients receiving other treatments. The total daily insulin dose for patients receiving insulinization therapy was 0.23±0.07 U/kg/day, which was lower than that in any other group. In patients receiving insulinization, the ratio of patients that did not require OADs (43.3%) and the concentration of FinS A were higher than those in the other groups. Furthermore, insulinization resulted in a greater reduction in HbA1c levels, as well as a reduced incidence of severe hypoglycemia. Insulinization may mimic physiological insulin secretion more effectively than other therapies. This regimen is more efficient and reduces the incidence of hypoglycemia in patients with type 2 diabetes, indicating that it is likely to be a promising treatment strategy for the disease.
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Affiliation(s)
- Guo Lian
- Departments of Endocrinology, Chongqing Three Gorges Central Hospital, Chongqing 404000
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30
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Drever E, Feig DS. Novel Insulin Delivery Technologies in Women with Pregestational Type 1 Diabetes: A Review of the Literature. Obstet Med 2013; 6:8-12. [PMID: 27757145 DOI: 10.1258/om.2012.120026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2012] [Indexed: 11/18/2022] Open
Abstract
Pregnancy in the setting of type 1 diabetes is associated with an increased risk of adverse outcomes for both mother and fetus. Adequate glycaemic control has been shown to result in improved outcomes, but the strict glycaemic targets required in pregnancy are often difficult to achieve. The development of novel technologies for insulin delivery aim to assist in achieving excellent glycaemic control, while attempting to minimize the significant risk of hypoglycaemia that exists in pregnancy. This review will discuss the use of insulin pump therapy, continuous glucose monitoring and closed loop insulin delivery in the setting of pregestational diabetes, highlighting some of the potential advantages of these technologies. Novel insulin delivery devices have been shown to be safe in the setting of pregnancy, but proper randomized controlled trials are still needed to determine if they are superior to traditional insulin delivery mechanisms.
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Affiliation(s)
- Erin Drever
- Department of Medicine, University of Toronto
| | - Denice S Feig
- Department of Medicine, University of Toronto; Division of Endocrinology and Metabolism, Mount Sinai Hospital, Toronto; Institute for Clinical and Evaluative Sciences, Toronto; Department of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
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31
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Leitlinien Insulinpumpentherapie bei Kindern und Erwachsenen (Für den Ausschuss Insulinpumpentherapie der Österreichischen Diabetesgesellschaft). Wien Klin Wochenschr 2013; 124 Suppl 2:123-8. [DOI: 10.1007/s00508-012-0287-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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32
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Prieto-Tenreiro A, Villar-Taibo R, Pazos-Couselo M, González-Rodríguez M, Casanueva F, García-López JM. [Benefits of subcutaneous continuous insulin infusion in type 1 diabetic patients with high glycemic variability]. ACTA ACUST UNITED AC 2012; 59:246-53. [PMID: 22440045 DOI: 10.1016/j.endonu.2012.02.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2011] [Revised: 02/02/2012] [Accepted: 02/13/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Hypoglycemia limits the efficacy of intensive insulin therapy, especially in patients with great glucose variability. The extent to which continuous subcutaneous insulin infusion (CSII) overcomes this limitation is unclear. Our aim was to determine whether CSII is helpful for decreasing glucose variability and hypoglycemia, mainly in patients with the greatest variability. METHOD Twenty-four patients with type 1 diabetes wore a continuous glucose monitoring system sensor for three days before starting therapy with CSII and 6 months later. Glucose variability (SD, MAGE, M) and hypoglycemia duration (area under the curve (AUC) <70mg/dL) were compared in all patients and in those with the greatest MAGE (highest quartile). RESULTS At 6 months, a decreased glucose variability was seen, as measured by MAGE, M, and SD (median: -28mg/dL (interquartile range, -48 to 1), p=0.03; -22(-40 to 0), p=0.04; -11(-23 to 0), p=0.009; respectively). Patients with the greatest initial glucose variability (MAGE quartile 4) showed a greater decrease in both MAGE (-47mg/dL (-103 to -34) vs -20 (-36 to 17), p=0.01) and AUC <70 (-10.7mg/dL x day (-15 to 0) vs -1.1 (-4.7 to 3.8), p=0.03) as compared to all others. Patients with longer initial hypoglycemia (AUC quartile 4) achieved a greater reduction in AUC <70 (-9.7mg/dL x day(-15 to -6.5) vs -0.08 (-2.9 to 3.8), p=0.003). A correlation was found between ΔMAGE-ΔAUC (r 0.4, p=0.03). CONCLUSIONS During CSII, glucose variability significantly decreased, especially in patients with the greatest initial variability. Hypoglycemia was also markedly less in patients with greater variability, with the greatest reduction occurring in those who experienced more marked hypoglycemia with CSII.
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33
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External insulin pump treatment in the day-to-day management of diabetes: benefits and future prospectives. DIABETES & METABOLISM 2011; 37 Suppl 4:S40-7. [DOI: 10.1016/s1262-3636(11)70964-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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34
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Zisser H, Breton M, Dassau E, Markova K, Bevier W, Seborg D, Kovatchev B. Novel methodology to determine the accuracy of the OmniPod insulin pump: a key component of the artificial pancreas system. J Diabetes Sci Technol 2011; 5:1509-18. [PMID: 22226273 PMCID: PMC3262722 DOI: 10.1177/193229681100500627] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND This article describes two novel and easy approaches for assessing the accuracy of insulin pumps as implemented within the artificial pancreas system. The approaches are illustrated by data testing the OmniPod Insulin Management System at its lowest delivery volume (0.05 U) and at doses of 0.1, 0.2, 1, and 6U. METHOD In method 1, a pipette, digital microscope, and imaging software were used to measure average bolus delivery on a linear scale for multiple volumes. In method 2, a digital microscope and imaging software were used to measure the volume of a spherical bolus of 0.05 U of insulin. RESULTS Bench testing results using the two novel methods demonstrated that the OmniPod is extremely accurate, with a relative error ranging from -0.90% to +0.96% for all measured doses (0.05, 0.1, 0.2, 1, and 6 U). In method 1, at target bolus dose of 0.05 U, the mean delivered dose (± standard deviation) was 0.0497 ± 0.003 U, 0.099 ± 0.005 U at 0.1 U, 0.2 ± <1e-5 U at 0.2 U, 1.001 ± 0.018 U at 1 U, and 6.03 ± 0.04 U at 6 U. In method 2, at target bolus dose of 0.5 ml, the mean delivered dose for both OmniPods was 0.505 ± 0.014. CONCLUSIONS Both methods confirmed a high degree of accuracy for the OmniPod insulin pump. These techniques can be used to estimate delivery volume in other infusion pumps as well.
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Affiliation(s)
- Howard Zisser
- Sansum Diabetes Research Institute, Santa Barbara, California 93105, USA.
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35
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Continuous subcutaneous insulin infusion vs. multiple daily injections. Open Med (Wars) 2011. [DOI: 10.2478/s11536-011-0064-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Abstract
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36
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Abstract
Restoration of the physiological insulin secretion is a current medical challenge and a dream for patients with Diabetes Mellitus. Continuous insulin therapy using pumps was the first step to the development of artificial pancreas. The aim of diabetes treatment is to achieve strict glycemic control in order to avoid the development of long-term diabetic complications while reducing the frequency of hypoglycemic episodes. Continuous subcutaneous insulin infusion (CSII) using an external pump, offers both a better blood glucose stability as compared to multiple daily injections and a broader flexibility in life mode, and reduces the frequency of severe hypoglycemia. The advantages of the insulin pump (consistency of basal delivery, adjustable basal rates, and low insulin depots allowing the reduction of glycemic variability) have contributed to its reported superiority compared with multiple daily injections (MDI). However, experience with CSII indicates that candidates for insulin pump therapy must be carefully selected and strongly motivated to improve their glucose control. Finally, the use of CSII in patients with Diabetes Mellitus type 2 now appears to be a good alternative to the ineffective MDI regimens observed in some of these patients.
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Affiliation(s)
- Triantafillos Didangelos
- Diabetes Division, 1st Propeudetic Department of Internal Medicine, Medical School, Aristotle University of Thessaloniki, AHEPA Hospital, Thessaloniki, Greece.
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37
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Bode BW. Comparison of pharmacokinetic properties, physicochemical stability, and pump compatibility of 3 rapid-acting insulin analogues-aspart, lispro, and glulisine. Endocr Pract 2011; 17:271-80. [PMID: 21134878 DOI: 10.4158/ep10260.ra] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare how the rapid-acting insulin analogues (RAIAs) aspart, lispro, and glulisine perform in continuous subcutaneous insulin infusion (CSII) therapy regarding (1) pharmacokinetic properties, (2) chemical and physical stability, and (3) pump compatibility. METHODS PubMed was searched for articles pertaining to the use of RAIAs in CSII, without a restriction on the time period. RESULTS These RAIAs have pharmacokinetic profiles that more closely mimic endogenous insulin in comparison with regular human insulin and tend to produce less hypoglycemia. Among these RAIAs, the rates of absorption and clinical efficacy in terms of glycemic control were similar. Although glulisine showed a faster onset of action in some studies with aspart and lispro, this advantage lasted only for a maximum of 1 hour, after which results were similar for glulisine and aspart or lispro. Each RAIA is created by making minor amino acid substitutions to the regular human insulin molecule and adding a stabilizer to help prevent fibrillation. A series of chemical and covalent changes affecting the primary structure of an insulin preparation, however, may cause decomposition during storage, handling, and use, diminishing the potency of the insulin molecule while contained in an insulin pump. Precipitation, fibrillation, and occlusion may ensue, undermining compatibility for CSII pump use. Aspart has demonstrated the greatest chemical and physical stability in the insulin pump, with the lowest rates of overall occlusion in comparison with lispro and glulisine (aspart 9.2%, lispro 15.7%, and glulisine 40.9%; P<.01). CONCLUSION Aspart is the most compatible of the 3 RAIAs for pump use.
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Affiliation(s)
- Bruce W Bode
- Atlanta Diabetes Associates, Atlanta, Georgia, USA.
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38
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Monami M, Lamanna C, Marchionni N, Mannucci E. Continuous subcutaneous insulin infusion versus multiple daily insulin injections in type 1 diabetes: a meta-analysis. Acta Diabetol 2010; 47 Suppl 1:77-81. [PMID: 19504039 DOI: 10.1007/s00592-009-0132-5] [Citation(s) in RCA: 78] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2009] [Accepted: 05/12/2009] [Indexed: 11/26/2022]
Abstract
Continuous subcutaneous insulin infusion (CSII) is considered an option for type 1 diabetic patients unsatisfactorily controlled with multiple daily injections (MDI). Short-acting analogs are superior to regular human insulin in CSII. This meta-analysis is aimed at assessing the advantages of short-acting analog-based CSII over MDI in type 1 diabetes. Randomized clinical trials (RCTs) comparing CSII (with analogs) and MDI for at least 12 weeks in type 1 diabetic patients were retrieved, assessing between-group differences in HbA1c and incidence of hypoglycemia. A total of 11 RCTs was included in the analysis. CSII was associated with a significant improvement of HbA1c in comparison with MDI (standardized difference in mean: -0.3 [-0.4;-0.1]%; P < 0.001). No significant difference was observed in the rate of severe hypoglycemic episodes. The reduction of HbA1c with CSII was evident in trials enrolling patients with mean age greater than 10 years, but not in younger children. Available data justify the use of CSII for basal-bolus insulin therapy in type 1 diabetic patients unsatisfactorily controlled with MDI.
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Affiliation(s)
- Matteo Monami
- Section of Geriatric Cardiology, Department of Cardiovascular Medicine, Azienda Ospedaliero-Universitaria Careggi, Via delle Oblate 4, 50141 Florence, Italy.
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Benhamou PY, Garnier C, Debaty I, Rueff A, Gilbert C, Ressel M, Siaud C, Boudrot E, Carpentier B, Boizel R, Nasse L, Halimi S. Basal insulin dose in 40 type 1 diabetic patients remains stable 1year after educational training in flexible insulin therapy. DIABETES & METABOLISM 2010; 36:369-74. [DOI: 10.1016/j.diabet.2010.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/22/2009] [Revised: 03/19/2010] [Accepted: 03/20/2010] [Indexed: 11/30/2022]
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40
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Brown L, Edelman ER. Optimal control of blood glucose: the diabetic patient or the machine? Sci Transl Med 2010; 2:27ps18. [PMID: 20393187 DOI: 10.1126/scitranslmed.3001083] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In this issue of Science Translational Medicine, El-Khatib et al. describe a "closed-loop" bihormonal artificial pancreas, designed to avert episodes of low blood sugar in patients with insulin-dependent diabetes. We discuss the benefits and challenges of therapy directed at tight control of blood glucose and ask whether this and similar technological breakthroughs can address as yet unanswered questions in the biology of diabetes.
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Affiliation(s)
- Larry Brown
- Harvard MIT Division of Health Sciences and Technology, Massachusetts Institute of Technology, E25-438, 77 Massachusetts Avenue, Cambridge, MA 02139, USA
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Schmid V, Hohberg C, Borchert M, Forst T, Pfützner A. Pilot study for assessment of optimal frequency for changing catheters in insulin pump therapy-trouble starts on day 3. J Diabetes Sci Technol 2010; 4:976-82. [PMID: 20663464 PMCID: PMC2909532 DOI: 10.1177/193229681000400429] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Continuous subcutaneous insulin infusion (CSII) by means of insulin pump devices is considered to be one of the most optimal therapies to achieve treatment targets in patients with diabetes mellitus. In CSII, the insulin is delivered through Teflon catheters or steel needle infusion sets, which need to be renewed on a regular basis. This pilot study was performed to investigate the optimal change frequency in daily practice and to explore potential problems that may occur when the sets are used for a more prolonged time than the recommended up to 72 hours of usage (Teflon catheters). METHOD Twelve patients with type 1 diabetes participated in the trial [age (mean +/- STD): 40.3 +/- 12.6 years, body mass index: 26.2 +/- 3.3 kg/m(2), hemoglobin A1c: 6.7 +/- 0.6%]. They were asked to wear their infusion set (Comfort or Silhouette) for increasing periods of 1, 2, 3, 4, and 5 days. After each use, patients completed standardized questionnaires regarding technical and medical issues associated with infusion set use. A health care professional investigated the infusion sites and infusion sets and completed an "infusion set inspection" questionnaire. Blood glucose was measured and recorded to assess a potential influence of duration of catheter use on glycemic control. RESULTS Infusion set and injection site problems (itching, bruising, swelling, and pain) started to occur in measurable amounts on the 3rd day of catheter use, and about 40% of patients reported significant issues when using a catheter for 5 days. In parallel, there was a consistent increase in mean daily blood glucose levels that correlated with the number of days of catheter use (e.g., day 1: 7.5 +/- 3.8 mmol/liter, day 3: 8.4 +/- 4.2 mmol/liter, day 5: 9.0 +/- 4.0 mmol/liter, day 7: 11.6 +/- 2.2 mmol/liter, p < 0.05 vs day 1). CONCLUSIONS Using the catheters for 2 days resulted in a safe and well-tolerated therapy. Clinically relevant adverse events started to occur during the 3rd day and their incidence increased constantly with longer use. This was associated with undesired changes in mean glycemic control. Data support the recommendation by the drug and device manufacturers that insulin pump catheters should only be used for 48-72 hours to avoid adverse events and potential metabolic deterioration.
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Petersen SB, Kildegaard J, Nielsen FS, Søndergaard E, Parkner T, Laursen T, Lauritzen T, Skyggebjerg O, Christiansen JS. Pharmacokinetics following continuous subcutaneous insulin infusion of insulin aspart with or without initial subcutaneous bolus. Diabetes Obes Metab 2010; 12:334-40. [PMID: 20380654 DOI: 10.1111/j.1463-1326.2009.01168.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIM To evaluate time to steady state insulin concentration (C(ss)) following continuous subcutaneous insulin infusion (CSII) of insulin aspart (IAsp) with or without an initial s.c. bolus. METHODS In random order 10 healthy volunteers were given a basal insulin infusion rate (0.5 U/h) for 8 h with or without an initial s.c. bolus (1.4 U). Serum IAsp was measured until 3 h after infusion was stopped. RESULTS An overshoot of IAsp was seen before C(ss) was achieved following an initial bolus of insulin as compared to no bolus. The apparent half-life (t((1/2))) with or without bolus did not differ (p = 0.15). Time to steady state (T(ss)) was evaluated in two ways: (1) T(ss) defined as the first point within an interval of C(ss)+/- 2 x CV was 233 vs. 166 min with and without a bolus respectively (p = 0.068). (2) A t-test was performed for each concentration-time point vs. mean C(ss), and the first point with no significance was defined, T(ss). This gave 208 (p = 0.09) and 178 min (p = 0.24) with and without bolus respectively. Mathematical modelling suggests that an ideal mean bolus should be 0.89 U, and that this bolus dose may result in a shorter T(ss). CONCLUSION A bolus of 1.4 U resulted in an overshoot of serum IAsp before C(ss) and a longer period before C(ss) is achieved. Mathematical modelling suggests that a mean bolus of 0.89 U would result in a faster achievement of C(ss) compared to no bolus.
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Affiliation(s)
- S B Petersen
- Novo Nordisk A/S, Diabetes Research Unit, 2760 Maaloev, Denmark
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Riveline JP, Franc S, Biedzinski M, Jollois FX, Messaoudi N, Lagarde F, Lormeau B, Pichard S, Varroud-Vial M, Deburge A, Dresco E, Charpentier G. Sexual activity in diabetic patients treated by continuous subcutaneous insulin infusion therapy. DIABETES & METABOLISM 2010; 36:229-33. [PMID: 20303814 DOI: 10.1016/j.diabet.2010.01.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2009] [Revised: 12/31/2009] [Accepted: 01/06/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND AIMS As concerns over interference with sexual activity may be an obstacle to initiating pump therapy in diabetic patients, the aim of the study was to assess the impact of continuous subcutaneous insulin infusion (CSII) therapy on sexual activity. PATIENTS AND METHODS Patients filled out a questionnaire on their demographic data, diabetes history, pump-treatment history, metabolic control, inconvenience/convenience of the pump and catheter, and information on sexual activity. RESULTS A total of 271 diabetic patients (aged 44+/-17 years, 51% women, 22% single), treated with CSII for 4.2+/-5.9 years and with a diabetes duration of 19+/-11 years, filled out the questionnaire. Their HbA(1c) was 7.7+/-1.1%, with 2.4+/-2.1 mild hypoglycaemic episodes over the past week, and their frequency of sexual activity was: never 29.9%; <1/month 12.3%; >1/month and <1/week 18.2%; and >1/week 39.6%. Age and cohabitation were independently correlated with frequency of sexual activity (P<0.0001 and P<0.0003, respectively), but not diabetes duration or complications. To the question "Does the pump have an influence on your sexual activity?", The answer was "no" in 90% and "yes" in 10%. However, intercourse frequency was significantly decreased in the latter (P=0.04). On multivariate analyses, this negative influence of CSII was correlated with HbA(1c) (P<0.05), discomfort with the pump (P<0.05) and the number of mild hypoglycaemic episodes (P<0.01). CONCLUSION Frequency of sexual activity appears to be unaffected by pump therapy or diabetes, but is decreased by the expected characteristics-namely, age and being single. Also, only 10% of patients believe that CSII is an obstacle during sexual activity and, in particular, because of the catheter.
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Affiliation(s)
- J-P Riveline
- Service de diabétologie, centre hospitalier Sud-Francilien, 59, boulevard Henri-Dunant, 91100 Corbeil-Essonnes, France.
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Misso ML, Egberts KJ, Page M, O'Connor D, Shaw J. Continuous subcutaneous insulin infusion (CSII) versus multiple insulin injections for type 1 diabetes mellitus. Cochrane Database Syst Rev 2010:CD005103. [PMID: 20091571 DOI: 10.1002/14651858.cd005103.pub2] [Citation(s) in RCA: 174] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Type 1 diabetes is a metabolic disorder resulting from a defect in insulin secretion. Onset of type 1 diabetes mellitus may occur at any age and it is one of the most common chronic diseases of childhood and adolescence. Since there are no interventions known to prevent onset, it is vital that effective treatment regimes are available. Glycaemic control is maintained by replacement of insulin and may be in the form of 'conventional' insulin therapy (multiple injections per day) or continuous subcutaneous insulin infusion (CSII). OBJECTIVES To assess the effects of CSII compared to multiple insulin injections (MI) in people with type 1 diabetes mellitus. SEARCH STRATEGY Studies were obtained from electronic searches of The Cochrane Library, MEDLINE, EMBASE and CINAHL. SELECTION CRITERIA Studies were included if they were randomised controlled trials comparing CSII with three or more insulin injections per day (MI) in people with type 1 diabetes mellitus. DATA COLLECTION AND ANALYSIS Two authors independently assessed risk of bias and extracted characteristics of included studies. Authors contacted study investigators to obtain missing information. Generic inverse variance meta-analyses using a random-effects model were performed. MAIN RESULTS Twenty three studies randomised 976 participants with type 1 diabetes to either intervention. There was a statistically significant difference in glycosylated haemoglobin A1c (HbA1c) favouring CSII (weighted mean difference -0.3% (95% confidence interval -0.1 to -0.4). There were no obvious differences between the interventions for non-severe hypoglycaemia, but severe hypoglycaemia appeared to be reduced in those using CSII. Quality of life measures suggest that CSII is preferred over MI. No significant difference was found for weight. Adverse events were not well reported, no information is available on mortality, morbidity and costs. AUTHORS' CONCLUSIONS There is some evidence to suggest that CSII may be better than MI for glycaemic control in people with type 1 diabetes. Non-severe hypoglycaemic events do not appear to be reduced with CSII. There is insufficient evidence regarding adverse events, mortality, morbidity and costs.
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Affiliation(s)
- Marie L Misso
- Australasian Cochrane Centre, Monash Institute of Health Services Research, Monash University, 43-51 Kanooka Grove, Clayton, Victoria, Australia, 3168
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Cyganek K, Hebda-Szydlo A, Katra B, Skupien J, Klupa T, Janas I, Kaim I, Sieradzki J, Reron A, Malecki MT. Glycemic control and selected pregnancy outcomes in type 1 diabetes women on continuous subcutaneous insulin infusion and multiple daily injections: the significance of pregnancy planning. Diabetes Technol Ther 2010; 12:41-7. [PMID: 20082584 DOI: 10.1089/dia.2009.0081] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Two regimens are used to achieve excellent glycemic control during pregnancy in type 1 diabetes mellitus (T1DM): continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI). We assessed their efficacy and safety and the effect of pregnancy planning. METHODS We examined 269 pregnant T1DM women: 157 treated with MDI (MDI group), 42 with CSII (CSII group), and 70 who switched from MDI to CSII in the first trimester (MDI/CSII group). There were 116 women who planned pregnancy: 58 in the MDI group, 38 in the CSII group, and 20 in the MDI/CSII group. The estimated differences in glycemic control and maternal and fetal outcomes were adjusted for baseline characteristics. RESULTS Mean glycated A1c (HbA1c) in the first trimester in the whole group was 6.9%, and the women differed depending on whether they planned pregnancy or not (P < 0.0001). A multiple regression model showed an average difference of about 0.9% in favor of pregnancy planning, with no interaction between the planning and treatments. In the second trimester, HbA1c decreased to a mean value of 5.8%, with improvement of HbA1c across all treatments: by 1.5% in not-planning and 0.9% in planning women. Despite greater improvement, not-planning women still had a higher HbA1c (by 0.3%, P = 0.05). In the third trimester, there was no further significant changes; nevertheless, women who planned pregnancy still had a lower HbA1c (by 0.5%, P = 0.02). There were 14 malformations, stillbirths, and perinatal infant deaths in the not-planning versus five in the planning group (P = 0.07). Patients in the CSII group had a 2 kg greater weight gain compared to the MDI group (15.0 kg vs. 13.0 kg; P = 0.005). CONCLUSIONS In pregnancy with T1DM, both MDI and CSII can provide excellent glycemic control. Pregnancy planning has a beneficial effect on glycemic control, independent from the therapy model. CSII seems to predispose to a larger weight gain in mothers.
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Affiliation(s)
- Katarzyna Cyganek
- Department of Metabolic Diseases, Jagiellonian University Medical College, 31-511 Krakow, Poland
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Clausen TS, Kaastrup P, Stallknecht B. Effect of insulin catheter wear-time on subcutaneous adipose tissue blood flow and insulin absorption in humans. Diabetes Technol Ther 2009; 11:575-80. [PMID: 19764836 DOI: 10.1089/dia.2009.0058] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Insertion of an insulin catheter for continuous subcutaneous insulin infusion into the subcutaneous adipose tissue (SAT) causes a tissue trauma that may have consequences for insulin absorption. We evaluated the importance of insulin catheter wear-time on subcutaneous adipose tissue blood flow (ATBF) and absorption of the rapid-acting insulin analog insulin aspart over a period of 4 days. METHODS Teflon insulin catheters (Medtronic, Minneapolis, MN) were inserted into the abdominal SAT of 10 healthy men without diabetes (mean +/- SEM age, 23.0 +/- 1.1 years; body mass index, 22.1 +/- 0.7 kg/m(2)) and connected to an insulin pump delivering a constant rate of isotonic saline for 4 days. Subjects participated in four study days (days 0, 1, 2, and 4) during which ATBF around the catheter tip was measured by (133)Xe clearance and absorption of an insulin aspart bolus (0.1 U/kg) was measured for 4 h. RESULTS ATBF increased from day 0 to day 2 after catheter insertion (2.6 +/- 0.6 to 4.5 +/- 0.8 mL/100 g/min; P = 0.030). By day 4, ATBF had returned to day 0 level. Time to peak plasma insulin aspart concentration after bolus administration decreased with catheter wear-time from 55 +/- 3 min on day 0 to 45 +/- 4 min on day 4 (P = 0.019). Neither peak plasma concentration nor area under the curve of insulin aspart changed significantly. CONCLUSIONS Insertion of a Teflon insulin catheter into the SAT results in increased ATBF and faster absorption of insulin aspart in a period of 4 days without any change in the total amount of insulin aspart absorbed.
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Goykhman S, Drincic A, Desmangles JC, Rendell M. Insulin Glargine: a review 8 years after its introduction. Expert Opin Pharmacother 2009; 10:705-18. [PMID: 19284367 DOI: 10.1517/14656560902775677] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Insulin Glargine was the first long-acting insulin analog produced by recombinant DNA technology, approved for use by the US FDA in April 2000 and by the European Agency for the Evaluation of Medicinal Products in June, 2000. It has become the most widely used insulin in the USA owing to its long duration of action without a pronounced peak. The principal advantage of insulin Glargine over neutral protamine Hagedorn (NPH) insulin is in a lower frequency of hypoglycemic reactions, thus affording improved safety. It is used in both type 1 and type 2 diabetes, usually as a single daily dose. In type 2 patients, it is often the first insulin introduced as a single daily dose. Although insulin Glargine is typically administered as a single nighttime dose, it can be given in the morning or at any other time convenient for the patient. In labile type 1 diabetes, it is often most effective given as two daily injections. In obese, insulin-resistant patients, it may be best to administer insulin Glargine in two separate doses, owing to the high volumes of injected insulin required. Insulin Glargine does not treat postprandial hyperglycemia. It is necessary to supplement with short-acting insulin at mealtimes to control glucose surges after meals. Insulin Glargine is effective in hospitalized and postsurgical patients on account of its lack of pronounced insulin peaks and long duration of action. Although there is considerable use of Glargine in pregnant diabetic women, there is no definitive study to confirm its benefits. Insulin Glargine is thought to coprecipitate supplementary short-acting insulins when co-administered in the same syringe. Therefore, more injections are typically needed in the usual treatment regimen for insulin requiring diabetes. In many cases, constant basal insulin levels may be achieved with multiple overlapping doses of NPH insulin given together with short-acting insulin at mealtimes. Such a therapy may be less costly, but the major advantage of insulin Glargine remains the greater safety of a lower frequency of hypoglycemic reactions.
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Affiliation(s)
- Stanislav Goykhman
- Creighton University School of Medicine, Children's Hospital, Diabetes Center, Divisions of Adult and Pediatric Endocrinology, Omaha, NE 68131, USA
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Consequences of delayed pump infusion line change in patients with type 1 diabetes mellitus treated with continuous subcutaneous insulin infusion. J Diabetes Complications 2009; 24:73-8. [PMID: 19395280 DOI: 10.1016/j.jdiacomp.2009.03.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2008] [Revised: 02/16/2009] [Accepted: 03/19/2009] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To systematically investigate the effect of lack of adherence to the recommended change in insulin pump infusion line use beyond 48 h and determine whether the type of insulin made a difference. RESEARCH DESIGN AND METHODS This was a double-blind, randomized, crossover trial with 20 patients with diabetes mellitus I using insulins aspart and lispro without a line change for up to 100 h. Using retrospective continuous glucose monitoring, we analyzed the average glucose over the day. Changes in serum 1,5-anhydroglucitol, carboxymethyllysine, and free 15-F(2t) isoprostane were also studied. RESULTS From Day 2 to Day 5 of the pump line use, the daily average glucose level increased from 122.7 to 163.9 mg/dl (P<.05), fasting glucose from 120.3 to 154.5 mg/dl (P<.05), postprandial glucose from 114.6 to 172.1 mg/dl (P<.05), and the daily maximum glucose from 207.7 to 242.8 dl (P<.05 for the trend). Time period that the glucose was >180 mg/dl increased from 14.5% to 38.3% (P<.05). Loss of control occurred despite increase in total daily insulin dose from 48.5+/-11.8 to 55.3+/-17.9 U (P=.05). There was no difference in loss of control between insulin types, and biomarkers measured did not change significantly. CONCLUSIONS The insulin pump infusion should be changed every 48 h in patients using continuous subcutaneous insulin infusion (CSII), to avoid loss of glycemic control. In the short-term, this loss of glycemic control has no impact on oxidative stress and glycation.
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Pańkowska E, Błazik M, Dziechciarz P, Szypowska A, Szajewska H. Continuous subcutaneous insulin infusion vs. multiple daily injections in children with type 1 diabetes: a systematic review and meta-analysis of randomized control trials. Pediatr Diabetes 2009; 10:52-8. [PMID: 18761648 DOI: 10.1111/j.1399-5448.2008.00440.x] [Citation(s) in RCA: 159] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To investigate potential effects of continuous subcutaneous insulin infusion (CSII) compared with multiple daily injections (MDI) on glycemic control in children with type 1 diabetes mellitus (T1DM). STUDY DESIGN Meta-analysis and systematic review of randomized control studies (RCTs). The electronic databases MEDLINE, Cochrane Library, and EMBASE were searched through October 2007. RESULTS Six RCTs involving 165 participants with T1DM met our predefined inclusion criteria. Combined data from all trials showed that the CSII group compared with the MDI group experienced a significant reduction in the level of glycosylated hemoglobin. The pooled weighted mean difference (WMD) was -0.24% [95% confidence interval (95% CI) -0.41 to -0.07, p < 0.001] with a fixed model and remained significant in the random effect model. This effect was reached by slightly decreasing insulin requirement [three RCTs, n = 74, WMD -0.22 IU/kg/d (95% CI -0.31 to -0.14, p < 0.001)]. No differences in the incidences of ketoacidosis and severe hypoglycemic events were found. CONCLUSIONS In short-term insulin therapy, CSII compared with MDI is a more effective form of metabolic control and allows reducing the daily insulin requirement. Yet, no conclusions have been made so far whether this effect holds in later years. These results should be approached with caution because of the methodological limitations of the analyzed studies.
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Affiliation(s)
- Ewa Pańkowska
- The Second Department of Pediatrics, Medical University of Warsaw, Poland.
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Treatment of diabetes mellitus using an external insulin pump in clinical practice. DIABETES & METABOLISM 2008; 34:425-38. [PMID: 18951117 DOI: 10.1016/s1262-3636(08)73973-9] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Before the initiation of insulin pump therapy, patients must be aware of the different aspects of this form of intensive insulin therapy. Most healthcare professionals recommend a sequential approach to inform patients about CSII. Factors that need to be considered in choosing an insulin pump include its safety features, durability of the device, tolerability and comfort of the catheter, user-friendliness, technical features and appearance. The initial insulin requirements need to be individualized for the given patient, using different methods to determine the appropriate dosages for the basal rate and prandial boluses. Glycaemic targets and algorithms for insulin dose adaptation need to be learned by the patients to enable them to avoid and/or correct hypo- and hyperglycaemia/ketosis episodes. Patients are also advised on how to carry out frequent self-monitoring of blood glucose-and of ketone bodies, if necessary. Insulin pumps are now able to deliver a range of basal rates and boluses that increase the flexibility of CSII. One specific issue is the approach to meal-planning, based on carbohydrate-counting or the equivalent: this method of so-called 'flexible insulin therapy' can improve metabolic control (for instance, by diminishing postprandial excursions) as well as the quality of life of patients. Evaluation of the knowledge and practices of the patient can be made through a continuous educational programme carried out by experienced nurses and physicians at the start of therapy and during follow-up. In addition, it may be necessary to identify the reasons for lack of improvement in metabolic control after several months of therapy, which include pump malfunction, cannula problems, miscalculated insulin dosages and insufficient metabolic control in specific clinical situations with a high risk of metabolic deterioration (illness, exercise, concomitant drugs). Annual assessment of the patient using an itemized checklist is required to verify the continued efficacy and safety of insulin pump therapy, two main factors of success with CSII treatment.
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