Intensive insulin therapy with insulin lispro: a randomized trial of continuous subcutaneous insulin infusion versus multiple daily insulin injection

Proof-of-concept Study of Using Supervised Machine Learning Algorithms to Predict Self-care and Glycemic Control in Type 1 Diabetes Patients on Insulin Pump Therapy

OBJECTIVE

Using supervised machine learning algorithms (SMLAs), we built models to predict the probability of type 1 diabetes mellitus (T1DM) patients on insulin pump therapy for meeting insulin pump self-management behavioral (IPSMB) criteria and achieving good glycemic response within six months.

METHODS

This was a single-center retrospective chart review of 100 adult T1DM patients on insulin pump therapy (>6 months). Three SMLAs were deployed: multivariable logistic regression (LR), random forest (RF), and K-nearest neighbor (k-NN); validated using repeated three-fold cross-validation. Performance metrics included AUC-ROC for discrimination and Brier scores for calibration.

RESULTS

Variables predictive of adherence with IPSMB criteria were baseline HbA1c, continuous glucose monitoring (CGM), and sex. The models had comparable discriminatory power (LR=0.74; RF=0.74; k-NN=0.72), with the random forest model showing better calibration (Brier=0.151). Predictors of the good glycemic response included baseline HbA1c, entering carbohydrates, and following the recommended bolus dose, with models comparable in discriminatory power (LR=0.81, RF=0.80, k-NN=0.78) but the random forest model being better calibrated (Brier=0.099).

CONCLUSION

These proof-of-concept analyses demonstrate the feasibility of using SMLAs to develop clinically relevant predictive models of adherence with IPSMB criteria and glycemic control within six months. Subject to further study, non-linear prediction models may perform better.

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

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.

Hollow fiber-combined glucose-responsive gel technology as an in vivo electronics-free insulin delivery system

Accumulating evidence demonstrates that not only sustained elevation of blood glucose levels but also the glucose fluctuation represents key determinants for diabetic complications and mortality. Current closed-loop insulin therapy option is limited to the use of electronics-based systems, although it poses some technical issues with high cost. Here we demonstrate an electronics-free, synthetic boronate gel-based insulin-diffusion-control device technology that can cope with glucose fluctuations and potentially address the electronics-derived issues. The gel was combined with hemodialysis hollow fibers and scaled suitable for rats, serving as a subcutaneously implantable, insulin-diffusion-active site in a manner dependent on the subcutaneous glucose. Continuous glucose monitoring tests revealed that our device not only normalizes average glucose level of rats, but also markedly ameliorates the fluctuations over timescale of a day without inducing hypoglycemia. With inherent stability, diffusion-dependent scalability, and week-long & acute glucose-responsiveness, our technology may offer a low-cost alternative to current electronics-based approaches.

Here, the authors develop an in vivo insulin delivery system which consists of a glucose responsive gel combined with hemodialysis hollow fibers. This system is electronics-free, temperature independent, and can stably sustain acute glucose-responsiveness in rats.

The continuing quest for better subcutaneously administered prandial insulins: a review of recent developments and potential clinical implications

The class of rapid-acting insulin analogues were introduced more than 20 years ago to control postprandial plasma glucose (PPG) excursions better than unmodified regular human insulin. Insulins, lispro, aspart and glulisine all achieved an earlier onset of action, greater peak effect and shorter duration of action resulting in lower PPG levels and a reduced risk of late postprandial hypoglycaemia. However, the subcutaneous absorption rate of these analogues still fails to match the physiological profile of insulin in the systemic circulation following a meal. Recent reformulations of aspart and lispro have generated a second generation of more rapid-acting insulin analogue candidates, including fast-acting aspart (faster aspart), ultra-rapid lispro and BioChaperone Lispro. These modifications have the potential to mimic physiological prandial insulin secretion better with an even earlier onset of action with improved PPG control, shorter duration of effect and reduced risk of hypoglycaemia. Recent phase 3 trials in type 1 and type 2 diabetes show that faster aspart and ultra-rapid lispro compared with conventional aspart and lispro, achieved fewer PPG excursions with a small increase in post-meal hypoglycaemia but similar or marginally superior glycated haemoglobin levels, and suggest the need for parallel optimization of basal insulin replacement. Phase 1 trials for BioChaperone Lispro are equally encouraging with phase 3 trials yet to be initiated. Comparative analysis of the clinical and pharmacological evidence for these new prandial insulin candidates in the treatment of type 1 and type 2 diabetes is the main focus of this review.

Psychosocial Aspects of Diabetes Technology: Adult Perspective

The success of diabetes technologies depends on the attitudes and behavior of the individuals who choose to adopt them. Real-time continuous glucose monitoring, continuous subcutaneous insulin infusion, and sensor-augmented pump systems may positively affect diabetes-related quality of life (QOL), although the influence on QOL outcomes seems to be modest and the results from randomized controlled trials are limited and controversial. In contrast, more consistently positive QOL-related responses are apparent from observational data. The newer generations of devices hold the promise for more strongly enhancing diabetes-related QOL. Appropriate training and ongoing support are likely to be the key to successful uptake.

Continuous subcutaneous insulin infusion versus multiple daily injections in children and young people at diagnosis of type 1 diabetes: the SCIPI RCT

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 (HbA_1c) concentration at 12 months. The secondary outcomes were (1) HbA_1c 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 HbA_1c 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 HbA_1c 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.

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

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^® Veo^TM (Medtronic, Watford, UK) with insulin aspart (NovoRapid, Novo Nordisk, Gatwick, UK).

MAIN OUTCOME MEASURES

Primary outcome - change in glycated haemoglobin (HbA_1c) at 2 years in participants whose baseline HbA_1c was ≥ 7.5% (58 mmol/mol). Key secondary outcome - proportion of participants with HbA_1c ≤ 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 HbA_1c of ≥ 7.5%. HbA_1c and severe hypoglycaemia improved in both groups. The drop in HbA_1c% at 2 years was 0.85 on pump and 0.42 on MDI. The mean difference (MD) in HbA_1c change at 2 years, at which the baseline HbA_1c 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 HbA_1c 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.

ViDa1: The Development and Validation of a New Questionnaire for Measuring Health-Related Quality of Life in Patients with Type 1 Diabetes

This study describes the development of a new questionnaire to measure health-related quality of life (HRQoL) in patients with type 1 diabetes (the ViDa1 questionnaire) and provides information on its psychometric properties. For its development, open interviews with patients took place and topics relevant to patients' HRQoL were identified and items were generated. Qualitative analysis of items, expert review, and refinement of the questionnaire followed. A pilot study (N = 150) was conducted to explore the underlying structure of the 40-item ViDa1 questionnaire. A Principal Component Analysis (PCA) was performed and six of the items that did not load on any of the factors were eliminated. The results supported a four-dimensional structure for ViDa1, the dimensions being Interference of diabetes in everyday life, Self-care, Well-being, and Worry about the disease. Subsequently, the PCA was repeated in a larger sample (N = 578) with the reduced 34-item version of the questionnaire, and a Confirmatory Factor Analysis (CFA) was performed (N = 428). Overall fit indices obtained presented adequate values which supported the four-factor model initially proposed [([Formula: see text] 2601.93) (p < 0.001); Root Mean Square Error of Approximation = 0.060 (CI = 0.056 -0.064)]. As regards reliability, the four dimensions of the ViDa1 demonstrated good internal consistency, with Cronbach's alphas ranging between 0.71 and 0.86. Evidence of convergent-discriminant validity in the form of high correlations with another specific HRQoL questionnaire for diabetes and low correlations with other constructs such as self-efficacy, anxiety, and depression were presented. The ViDa1 also discriminated between different aspects of clinical interest such as type of insulin treatment, presence of chronic complications, and glycemic control, temporal stability, and sensitivity to change after an intervention. In conclusion, the ViDa1 questionnaire presents adequate psychometric properties and may represent a good alternative for the evaluation of HRQoL in type 1 diabetes.

Integrated sensor-augmented pump therapy systems [the MiniMed® Paradigm™ Veo system and the Vibe™ and G4® PLATINUM CGM (continuous glucose monitoring) system] for managing blood glucose levels in type 1 diabetes: a systematic review and economic evaluation

BACKGROUND

In recent years, meters for continuous monitoring of interstitial fluid glucose have been introduced to help people with type 1 diabetes mellitus (T1DM) to achieve better control of their disease.

OBJECTIVE

The objective of this project was to summarise the evidence on the clinical effectiveness and cost-effectiveness of the MiniMed(®) Paradigm™ Veo system (Medtronic Inc., Northridge, CA, USA) and the Vibe™ (Animas(®) Corporation, West Chester, PA, USA) and G4(®) PLATINUM CGM (continuous glucose monitoring) system (Dexcom Inc., San Diego, CA, USA) in comparison with multiple daily insulin injections (MDIs) or continuous subcutaneous insulin infusion (CSII), both with either self-monitoring of blood glucose (SMBG) or CGM, for the management of T1DM in adults and children.

DATA SOURCES

A systematic review was conducted in accordance with the principles of the Centre for Reviews and Dissemination guidance and the National Institute for Health and Care Excellence Diagnostic Assessment Programme manual. We searched 14 databases, three trial registries and two conference proceedings from study inception up to September 2014. In addition, reference lists of relevant systematic reviews were checked. In the absence of randomised controlled trials directly comparing Veo or an integrated CSII + CGM system, such as Vibe, with comparator interventions, indirect treatment comparisons were performed if possible.

METHODS

A commercially available cost-effectiveness model, the IMS Centre for Outcomes Research and Effectiveness diabetes model version 8.5 (IMS Health, Danbury, CT, USA), was used for this assessment. This model is an internet-based, interactive simulation model that predicts the long-term health outcomes and costs associated with the management of T1DM and type 2 diabetes. The model consists of 15 submodels designed to simulate diabetes-related complications, non-specific mortality and costs over time. As the model simulates individual patients over time, it updates risk factors and complications to account for disease progression.

RESULTS

Fifty-four publications resulting from 19 studies were included in the review. Overall, the evidence suggests that the Veo system reduces hypoglycaemic events more than other treatments, without any differences in other outcomes, including glycated haemoglobin (HbA1c) levels. We also found significant results in favour of the integrated CSII + CGM system over MDIs with SMBG with regard to HbA1c levels and quality of life. However, the evidence base was poor. The quality of the included studies was generally low, often with only one study comparing treatments in a specific population at a specific follow-up time. In particular, there was only one study comparing Veo with an integrated CSII + CGM system and only one study comparing Veo with a CSII + SMBG system in a mixed population. Cost-effectiveness analyses indicated that MDI + SMBG is the option most likely to be cost-effective, given the current threshold of £30,000 per quality-adjusted life-year gained, whereas integrated CSII + CGM systems and Veo are dominated and extendedly dominated, respectively, by stand-alone, non-integrated CSII with CGM. Scenario analyses did not alter these conclusions. No cost-effectiveness modelling was conducted for children or pregnant women.

CONCLUSIONS

The Veo system does appear to be better than the other systems considered at reducing hypoglycaemic events. However, in adults, it is unlikely to be cost-effective. Integrated systems are also generally unlikely to be cost-effective given that stand-alone systems are cheaper and, possibly, no less effective. However, evidence in this regard is generally lacking, in particular for children. Future trials in specific child, adolescent and adult populations should include longer term follow-up and ratings on the European Quality of Life-5 Dimensions scale at various time points with a view to informing improved cost-effectiveness modelling.

STUDY REGISTRATION

PROSPERO Registration Number CRD42014013764.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Impact of the Omnipod® Insulin Management System on Quality of Life: A Survey of Current Users

BACKGROUND

Few recent studies have examined the impact of continuous subcutaneous insulin infusion systems on patient-reported quality of life (QOL). We explored QOL changes resulting from treatment with the Omnipod^® Insulin Management System (Insulet Corp., Billerica, MA).

METHODS

One thousand two hundred forty-five adults (>18 years) with type 1 diabetes and current Omnipod users completed an online questionnaire examining perceived changes in QOL and glycemic control since Omnipod initiation. The QOL dimensions included overall well-being (World Health Organization-5, modified to examine changes retrospectively), diabetes distress (Type 1 Diabetes Distress Scale, current distress and a modified retrospective version), and psychosocial impact (two subscales from the Diabetes Technology Impact Measure, perceived control over diabetes, and hypoglycemic safety). Regression analyses examined associations between demographics, key psychological factors, and perceived change in glycemic control with the QOL dimensions.

RESULTS

Broad QOL and clinical benefits associated with Omnipod use were common. The majority reported positive changes in the following: overall well-being (53.5%), perceived control over diabetes (72.5%), hypoglycemic safety (50.6%), and diabetes distress (69.6%). Worsening in any of these areas was uncommon. In addition, 64.2% of patients reported glycemic improvement post-Omnipod initiation, while 35.2% reported a decrease in severe hypoglycemic episodes. Trust in one's Omnipod, perceived improvement in glycemic control, and reductions in severe hypoglycemia independently predicted benefits in all QOL measures (all P < 0.001).

CONCLUSIONS

These findings suggest that Omnipod users perceived substantial QOL benefits from the device; benefits are more apparent in those who trust the device and have noted positive changes in glycemic control.

[Insulin pump therapy in children, adolescents and adults]

This position statement is based on the current evidence available on the safety and benefits of continuous subcutaneous insulin pump therapy (CSII) in diabetes with an emphasis on the effects of CSII on glycemic control, hypoglycaemia rates, occurrence of ketoacidosis, quality of life and the use of insulin pump therapy in pregnancy. The current article represents the recommendations of the Austrian Diabetes Association for the clinical praxis of insulin pump treatment in children, adolescents and adults.

7(th) Annual Symposium on Self-Monitoring of Blood Glucose (SMBG), May 8-10, 2014, Helsinki, Finland

International experts in the fields of diabetes, diabetes technology, endocrinology, mobile health, sport science, and regulatory issues gathered for the 7(th) Annual Symposium on Self-Monitoring of Blood Glucose (SMBG). The aim of this meeting was to facilitate new collaborations and research projects to improve the lives of people with diabetes. The 2014 meeting comprised a comprehensive scientific program, parallel interactive workshops, and two keynote lectures.

Comparison of continuous subcutaneous insulin infusion and insulin glargine-based multiple daily insulin aspart injections with preferential adjustment of basal insulin in patients with type 2 diabetes

The purpose of this study was to evaluate and compare multiple daily injection (MDI) therapy of bolus insulin aspart and basal insulin glargine with continuous subcutaneous insulin infusion (CSII) with aspart in patients with type 2 diabetes mellitus (T2DM). It was assessed whether MDI was capable of controlling glycemic index with a higher efficacy than CSII by preferential adjustment of basal insulin with a lower total daily insulin dosage in T2DM. Two hundred patients with T2DM were enrolled in the study and randomly assigned to CSII (n=100) and MDI (n=100; aspart immediately prior to each meal and glargine at bedtime) groups for 12 weeks of therapy. During the last week of each treatment period, the subjects wore a continuous glucose monitoring system for 2–3 days. The dosage of basal insulin was preferentially adjusted to control prior-meal blood glucose levels, and the characteristics of insulin dosage were analyzed. No statistically significant differences were observed between the two groups in hemoglobin A1c (HbA1c), which dropped from 10–11% prior to therapy to 7–7.5% after 12 weeks. After 12 weeks, good glycemic level control was achieved in all patients in the MDI and CSII groups. A statistically significant difference in the dose of insulin between the CSII and MDI groups was observed (P<0.001). In conclusion, no significant differences were found between the two therapies in the incidence of hypoglycemia and HbA1c for the 12 weeks. The basal insulin dosage was significantly decreased in the MDI group compared with that in the CSII group, but the CSII group was superior to MDI group in decreasing fasting blood glucose and shortening the time required for hypoglycemia to meet the targeted level.

Retrospective cohort study evaluating exenatide twice daily and long-acting insulin analogs in a Veterans Health Administration population with type 2 diabetes

AIM

This was a retrospective cohort study that evaluated the differences in glycated haemoglobin (HbA1c) and body mass index (BMI) in veterans with type 2 diabetes mellitus (T2DM), prescribed exenatide twice daily (BID) versus long-acting insulin analog (LAIA) two years after initiation in the United States (US) veteran population.

MATERIALS AND METHODS

Patients were included if they were ≥ 18 years old with T2DM, and initiated exenatide BID or LAIA at the Veterans Health Administration between January 1, 2006 and December 31, 2010. Multivariate models were used to evaluate the changes in HbA1c and BMI between groups, controlling for potential confounders. Logistic regression was used to evaluate the odds of achieving ≥ 0.5% HbA1c reduction based on baseline HbA1c stratifications: low,<7%; moderate, 7% to<9%; and high,≥ 9%.

RESULTS

A total of 446 exenatide BID and 51,531 LAIA patients met inclusion/exclusion criteria. On average, exenatide BID patients were significantly older (64 versus 60 years) with a higher BMI (37.8 versus 32.9 kg/m(2)). Baseline HbA1c was 8.2% and 8.8% for exenatide BID and LAIA patients, respectively (P<0.001); otherwise, patients were similar for all other characteristics. Exenatide BID treatment was significantly associated with a 0.32% (95%CI: 0.18-0.47%) greater reduction in HbA1c at two years compared with LAIA. Similar findings were observed for BMI reduction (0.68 kg/m(2); 95%CI: 0.42-0.95 kg/m(2)). Exenatide BID patients with moderate baseline HbA1c had significantly higher odds of achieving ≥ 0.5% HbA1c reduction compared with LAIA patients (OR=1.5; 95%CI: 1.2-2.0).

CONCLUSIONS

Veterans treated with exenatide BID had significantly greater reduction in HbA1c and BMI compared with patients treated with LAIA patients two years after initiation.

An observational 7-year study of continuous subcutaneous insulin infusion for the treatment of type 1 diabetes mellitus

This work reports the experience with use of continuous subcutaneous insulin infusion (CSII) in 112 type 1 diabetic patients followed up for 7 years and previously treated with multiple daily insulin injections (MDII).

MATERIAL AND METHODS

A retrospective, observational study in 112 patients with diabetes mellitus treated with CSII from 2005 to 2012, previously treated with MDII and receiving individualized diabetic education with a specific protocol. Variables analyzed included: prevalence of the different indications of pump treatment; mean annual HbA1c and fructosamine values before and after CSII treatment; and hypoglycemia frequency and symptoms.

RESULTS

The most common reason for pump treatment was brittle diabetes (74.1%), followed by frequent or severe hypoglycemia or hypoglycemia unawareness (44.6%). Other indications were irregular food intake times for professional reasons (20.2%), dawn phenomenon (15.7%), pregnancy (12.3%), requirement of very low insulin doses (8.9%), and gestational diabetes (0.9%). HbA1c decreased by between 0.6% and 0.9%, and fructosamine by between 5.1% and 12.26%. Nine percent of patients experienced hypoglycemia weekly, 24% every two weeks, and 48% monthly. No hypoglycemia occurred in 19% of patients. Only 10% had neuroglycopenic symptoms. Hypoglycemia unawareness was found in 21%. Hypoglycemia was more common at treatment start, and its frequency rapidly decreased thereafter.

CONCLUSION

CSII therapy provides a better glycemic control than MDII treatment. Specific patient training and fine adjustment of insulin infusion doses are required to prevent hypoglycemic episodes, which are the most common complications, mainly at the start of treatment.

The evidence base for diabetes technology: appropriate and inappropriate meta-analysis

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.

[Satisfaction and quality of life evaluation in patients with type 1 diabetes mellitus treated using continuous subcutaneous insulin infusion compared with multiple daily injections]

OBJECTIVE

To assess the quality of life (QOL) and satisfaction (SF) in patients with type 1 diabetes mellitus (T1DM) treated with continuous subcutaneous insulin infusion (CSII) compared with multiple daily insulin injections (MDI).

METHOD

A descriptive study was conducted to assess the QOL and SF of 68 patients on CSII or MDI treatment (1:2). The instruments used were, the Spanish version of the Diabetes Quality of Life (EsDQOL) specific for diabetes related QOL, SF-36 for general QOL, and the Diabetes Treatment Satisfaction Questionnaire (DTSQ) for SF evaluation.

RESULTS

The EsDQOL scores for patients on CSII therapy were similar to those treated with MDI (87.20±21.11 vs 86.83±20.7, P=.86), with lower scores in the SF-36 questionnaire (66.91±15.76 vs 75.90±14.56, P=.03) except in Health Transition section, where patients treated with CSII showed higher scores (68.75±19.66 vs 57.93±17.18, p=.02). The values obtained in the DTSQ questionnaire were higher in CSII patients compared with the MDI group in last weeks (31.50±4.66 vs 27.83±6.06, p=.01) and last three months periods (13.2±6.73 vs 8.77±7.40, p=.01).

CONCLUSIONS

Patients with T1DM on CSII therapy showed a poorer global QOL, although they felt more satisfied with their treatment than those treated with MDI. No differences in diabetes related QOL were detected between groups.

Frequent insulin dosage adjustments based on glucose readings alone are sufficient for a safe and effective therapy

PROBLEM

Frequent dosage adjustments are necessary to achieve effective insulin therapy. However, a controversy surrounds the pertinent clinical parameters required to make effective and safe insulin titrations. We hypothesize that glucose readings are sufficient to adjust insulin dosage provided that it is done on a weekly basis.

METHODS

In a prospective pilot study, we recruited 14 subjects with suboptimally controlled insulin-treated Type-2 and Type-1 diabetes. Subjects were treated with basal-bolus insulin therapy that was titrated weekly for 12 weeks. Dosage adjustments were made by the study Endocrinologist by reviewing subjects' glucose readings, exclusively based on logsheets and contingent upon the approval of the on-site study team. To corroborate that the glucose readings were sufficient for making dosage adjustments, we used software to process only glucose readings and recommend insulin dosage adjustments. The recommendations made by the software were retrospectively compared to the ones made by the study Endocrinologist.

RESULTS

All N=568 recommendations were approved by the study team and in 99.3% of the cases the recommendations were clinically similar to the ones made by the software. No hazardous disagreements were found. The mean A1C improved from 9.8% (± 2.0) to 7.9% (± 1.3) (p=0.001) in 12 weeks and the weekly mean glucose progressively improved from 220.3 mg/dl (± 51.9) to 151.5 mg/dl (± 19.2) (p<0.0001). The frequency of minor hypoglycemia was 22.7 per patient-year in subjects with Type-2 diabetes and 42.7 in the subjects with Type-1 diabetes. No severe hypoglycemic events occurred.

CONCLUSIONS

Glucose readings are sufficient to adjust insulin therapy in a safe and effective manner, when adjustments are made on a weekly basis. Thus, dedicated software may help adjust insulin dosage between clinic visits.

Management of diabetes mellitus: is the pump mightier than the pen?

Continuous subcutaneous insulin infusion (CSII, or insulin pump therapy) reduces HbA1c levels and hypoglycaemia in patients with type 1 diabetes mellitus (T1DM) compared with multiple daily insulin injections (MDI). The greatest reduction in HbA(1c) levels with CSII occurs in patients with the worst glycaemic control; therefore, the most appropriate and cost-effective use of CSII in adults with T1DM is in those who have continued, elevated HbA(1c) levels or disabling hypoglycaemic episodes with MDI (including the use of long-acting insulin analogues and structured patient education). The disadvantages of CSII include higher costs than MDI and the risk of ketosis in the event of pump failure. In children with T1DM, CSII may be used when MDI is considered impractical or inappropriate. Pumps are not generally recommended for patients with type 2 diabetes mellitus but may improve control in some subgroups. A new generation of smaller insulin infusion pumps with an integrated cannula, called patch pumps, could improve uptake of CSII in general. The important clinical question is not whether CSII is more efficacious than MDI in general adult T1DM, but whether CSII further improves glycaemic control when this control continues to be poor with MDI, and evidence exists that in most cases it does.

The effort required to achieve and maintain optimal glycemic control

BACKGROUND

Insulin therapy is most effective when dosage is frequently adjusted. We sought to evaluate the effort required to maintain A1C below 7% once attained in older patients with type 2 diabetes.

METHODS

A total of 2380 insulin dosage adjustment episodes were analyzed for their intensity and frequency. The data were divided into an "induction period" (n=608), defined as the time before subjects' A1C dropped below 7% for the first time, and a "maintenance period" (n=1772), defined as the remaining study period. The data originated from a published study and included 26 older subjects with suboptimally controlled type 2 diabetes treated for a year with intensive insulin therapy. To achieve therapy goals, the study team contacted the subjects once every few weeks, reviewed records and optimized the insulin dosage.

RESULTS

During both the induction and maintenance periods, insulin dosage (both long-acting and fast-acting) was adjusted by more than 20%. Maintaining A1C below 7% required dosage adjustments every 2.7(±1.0) weeks, averaging 11.4% (±4.0) in 2.0 (±0.3) different components of insulin dosage (i.e., two of either long-acting or short-acting for breakfast, lunch or dinner) per contact.

CONCLUSIONS

Considerable effort was required to maintain optimal A1C levels in older patients with type 2 diabetes. Since the full benefit of insulin therapy is attained only when multiple components of insulin dosage are frequently adjusted and given the growing shortage of care providers' availability, innovative approaches are needed to empower patients to safely make their own insulin adjustments.

Insulin pump therapy in adults

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.

Are glucose readings sufficient to adjust insulin dosage?

AIMS/HYPOTHESIS

insulin therapy is effective predominantly when dosage is frequently adjusted. However, a controversy surrounds the pertinent clinical parameters required to make effective and safe frequent dosage adjustments. We hypothesize that glucose readings are sufficient to adjust insulin dosage provided that dosage is adjusted every 1-4 weeks.

METHODS

to test the hypothesis, we generated several algorithms implemented in software to process glucose readings and recommend insulin dosage adjustments. A post hoc analysis was made on 630 log sheets (2,520 insulin dosage adjustments) from 26 older adults with suboptimally controlled type 2 diabetes. The subjects were followed for a year and treated with intensive insulin therapy that was titrated every 1-4 weeks by a trained study team. More than 88% of subjects attained the treatment goal (hemoglobin A1c <7%) without excessive hypoglycemia. Glucose readings from each log sheet were used as an input to the software, and its recommendations for insulin dosage adjustments were compared to the original ones made by the study team. While the study team could have been exposed to multiple clinical parameters, the software relied solely on glucose readings.

RESULTS

the software recommendations for dosage adjustments were clinically equivalent to the original study team's recommendations in more than 95% of the cases, unrelated to patients' insulin sensitivity. The remaining 4.4% (n = 111) were thoroughly examined, yet we did not find any recommendations suggested by the software to be unsafe or unreasonable.

CONCLUSIONS/INTERPRETATION

glucose readings are sufficient to effectively adjust insulin dosage provided that adjustments are made every 1-4 weeks. Therefore, dedicated software can help adjusting insulin dosage between clinic visits.

Continuous subcutaneous insulin infusion versus multiple daily insulin injections in type 1 diabetes: a meta-analysis

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.

Is insulin pump therapy better than injection for adolescents with diabetes?

BACKGROUND AND AIMS

Insulin pump therapy is a commonly used alternative to multiple daily injections (MDI) in the treatment of pediatric type 1 diabetes. The aim of the current study was to examine whether there are different medical and psychosocial outcomes for adolescents using MDI versus pump therapy as experienced in a naturally occurring context of self- or doctor-chosen insulin regimens.

METHODS

Adolescents and their parents completed questionnaires assessing quality of life and parenting stress. A1C levels were obtained from the medical record.

RESULTS

Metabolic and psychosocial outcomes did not differ significantly between adolescents using pump therapy and adolescents using MDI. Higher parental stress was associated with older children, lower quality of life, and higher A1C levels.

CONCLUSIONS

Physicians might present this information to families along with the potential advantages and disadvantages of pumps and injections.

Insulin pump use in adults with type 1 diabetes--practical issues

In recent years continuous subcutaneous insulin infusion pumps have become widely adopted in many parts of the world in the treatment of type 1 diabetes in adults. A comprehensive summary of all aspects of pump therapy is beyond the scope of this article, and in this review we will focus on several practical issues that in our experience are of clinical importance in the care of patients using insulin pumps. These include: benefits and risks of pump therapy, including the use of pumps to limit hypoglycemia; individual patient considerations in choosing between pump therapy and multiple daily injections; common pump-specific etiologies of erratic glucose control, including routine clinical practices that can assist with the detection of these problems; and the use of different pump bolus types for prandial insulin coverage.

Continuous subcutaneous insulin infusion (CSII) versus multiple insulin injections for type 1 diabetes mellitus

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.

Psychosocial problems in adolescents with type 1 diabetes mellitus

Adolescents with diabetes are at increased risk of developing psychiatric (10-20%) or eating disorders (8-30%), as well as substance abuse (25-50%), leading to non-compliance with treatment and deterioration of diabetic control. At high risk are female adolescents with family problems and other comorbid disorders. Impaired cognitive function has also been reported among children with diabetes, mainly in boys, and especially in those with early diabetes diagnosis (< 5 years), or with episodes of severe hypoglycaemia or prolonged hyperglycaemia. Type 1 diabetes mellitus contributes to the development of problems in parent-child relationships and employment difficulties, and negatively affects the quality of life. However, insulin pumps appear to improve patients' metabolic control and lifestyle. The contributions of family and friends to the quality of metabolic control and emotional support are also crucial. In addition, the role of the primary-care provider is important in identifying patients at high risk of developing psychosocial disorders and referring them on to health specialists. At high risk are patients in mid-adolescence with comorbid disorders, low socioeconomic status or parental health problems. Multisystem therapy, involving the medical team, school personnel, family and peer group, is also essential. The present review focuses on the prevalence of nutritional and psychosocial problems among adolescents with diabetes, and the risk factors for its development, and emphasizes specific goals in their management and prevention.

Not all roads lead to Rome-a review of quality of life measurement in adults with diabetes

AIMS

Quality of life (QoL) is recognized widely as an important health outcome in diabetes, where the burden of self-management places great demands on the individual. However, the concept of QoL remains ambiguous and poorly defined. The aim of our review is to clarify the measurement of QoL in terms of conceptualization, terminology and psychometric properties, to review the instruments that have been used most frequently to assess QoL in diabetes research and make recommendations for how to select measures appropriately.

METHODS

A systematic literature search was conducted to identify the ten measures most frequently used to assess QoL in diabetes research (including clinical trials) from 1995 to March 2008.

RESULTS

Six thousand and eight-five abstracts were identified and screened for instrument names. Of the ten instruments most frequently used to assess 'QoL', only three actually do so [i.e. the generic World Health Organization Quality of Life (WHOQOL) and the diabetes-specific Diabetes Quality of Life (DQOL) and Audit of Diabetes-Dependent Quality of Life (ADDQoL)]. Seven instruments more accurately measure health status [Short-Form 36 (SF-36), EuroQoL 5-Dimension (EQ-5D)], treatment satisfaction [Diabetes Treatment Satisfaction Questionnaire (DTSQ)] and psychological well-being [Beck Depression Inventory (BDI), Hospital Anxiety and Depression Scale (HADS), Well-Being Questionnaire (W-BQ), Problem Areas in Diabetes (PAID)].

CONCLUSIONS

No single measure can suit every purpose or application but, when measures are selected inappropriately and data misinterpreted, any conclusions drawn are fundamentally flawed. If we value QoL as a therapeutic goal, we must ensure that the instruments we use are both valid and reliable. QoL assessment has the proven potential to identify ways in which treatments can be tailored to reduce the burden of diabetes. With careful consideration, appropriate measures can be selected and truly robust assessments undertaken successfully.

Treatment of diabetes mellitus using an external insulin pump: the state of the art

The aim of diabetes treatment is to achieve tight glucose control to avoid the development of chronic diabetic complications while reducing the frequency of hypoglycaemic episodes. Continuous subcutaneous insulin infusion (CSII) using an external pump is an intensive diabetes therapy recognized to improve metabolic control and glycaemic instability, and to reduce the frequency of severe hypoglycaemia. For years, the theoretical advantages of the insulin pump (constancy of basal delivery, adjustable basal rates, and low insulin depots allowing the reduction of glycaemic variability) have contributed to its reported superiority compared with multiple daily injections (MDI). However, insulin pump therapy is now challenged by new MDI regimens based on long-acting insulin analogues that could replace the use of CSII. As a consequence, health professionals now have to determine which patients are likely to benefit the most from CSII. Recently, several studies reported that children and adolescents, and patients whose blood glucose imbalance was initially the most pronounced with basal-bolus regimens, would particularly benefit from CSII. Other indications were also proposed in marginal clinical situations with highly selected patients in whom a significant improvement of blood glucose was demonstrated. Finally, the use of CSII in type 2 diabetic patients now appears to be a good alternative to the ineffective MDI regimens observed in some of these patients. However, past experience with CSII indicates that candidates for insulin pump therapy must be carefully selected and strongly motivated to improve their glucose control. Use of CSII also requires strict medical supervision by physicians and a regular programme of patient education by paramedical teams, to ensure optimal responsible use of this technique by healthcare professionals.

A comparison of glycaemic variability in CSII vs. MDI treated type 1 diabetic patients using CGMS

OBJECTIVE

To evaluate and compare glucose variability, hypoglycaemic events and daily glycaemic control in well-controlled (HbA1c <or= 7%), type 1 diabetic patients treated with either continuous subcutaneous insulin infusion (CSII) using lispro or multiple daily insulin injection (MDI) using glargine once daily and lispro with meals.

RESEARCH DESIGN AND METHODS

A total of 16 patients with type 1 diabetes receiving treatment with either CSII (eight patients) or MDI (eight patients), all with HbA1c levels < 7%, wore a continuous glucose monitoring system sensor for 3 days to compare the number, duration, timing and severity of hyperglycaemic and hypoglycaemic episodes.

RESULTS

There were several more episodes of hyperglycaemic [blood glucose (BG) >or= 180 mg/dl] and hypoglycaemic (BG <or= 60 mg/dl) excursions observed in patients treated with CSII than MDI. Glycaemic exposure over 150 mg/dl was similar between the two groups. Maintenance of near-euglycaemia as determined by the average amount of time spent within the glucose range of 80-140 mg/dl was marginally significantly better for the MDI than for the CSII group. Although the CSII group had significantly more hypoglycaemic episodes below 60 mg/dl, the average duration of hypoglycaemia was not significantly different for the two groups. Similar percentages of nocturnal hypoglycaemia were seen. There were no reported major adverse events throughout the duration of the study.

CONCLUSION

Well-controlled type 1 diabetic patients treated with MDI had fewer hyperglycaemic and hypoglycaemic excursions than patients treated with CSII.

Continuous subcutaneous insulin infusion versus multiple daily insulin injections in patients with diabetes mellitus: systematic review and meta-analysis

AIMS

We compared the effects of continuous subcutaneous insulin infusion (CSII) with those of multiple daily insulin (MDI) injections on glycaemic control, risk of hypoglycaemic episodes, insulin requirements and adverse events in type 1 and type 2 diabetes mellitus.

METHODS

The electronic databases MEDLINE, EMBASE and CENTRAL were systematically searched for randomised controlled trials up to March 2007. A systematic review and meta-analysis were performed.

RESULTS

Overall, 22 studies were included (17 on type 1 diabetes mellitus, two on type 2 diabetes mellitus, three on children). With regard to adults with type 1 diabetes mellitus, our meta-analysis found a between-treatment difference of -0.4% HbA(1c) (six studies) in favour of CSII therapy. Available median rates of mild or overall hypoglycaemic events were comparable between the different interventions (1.9 [0.9-3.1] [CSII] vs 1.7 [1.1-3.3] [MDI] events per patient per week). Total daily insulin requirements were lower with CSII than with MDI therapy. In patients with type 2 diabetes mellitus, CSII and MDI treatment showed no statistically significant difference for HbA(1c). The incidence of mild hypoglycaemic events was comparable between the treatment groups. In adolescents with type 1 diabetes mellitus, glycated haemoglobin and insulin requirements were significantly lower in the CSII groups; no data were available on hypoglycaemic events. The only study performed in younger children did not provide enough data for conclusive inferences. No overall conclusions were possible for severe hypoglycaemia and adverse events for any of the different patient groups due to rareness of such events, different definitions and insufficient reporting.

CONCLUSIONS/INTERPRETATION

CSII therapy in adults and adolescents with type 1 diabetes mellitus resulted in a greater reduction of glycated haemoglobin, in adult patients without a higher rate of hypoglycaemia. No beneficial effect of CSII therapy could be detected for patients with type 2 diabetes mellitus.

Changes in glycemic control and quality of life in pediatric type 1 diabetics with continuous subcutaneous insulin infusion of insulin aspart following multiple daily injection therapy

The efficacy of continuous subcutaneous insulin infusion (CSII) of the rapid-acting insulin analogue, insulin aspart, was evaluated in 26 patients with childhood-onset type 1 diabetes aged between 6 and 18 yr who had been on basal-bolus therapy (multiple daily injection (MDI) of regular human insulin or rapid-acting insulin and intermediate/long-acting insulin). The glycemic control in the patients was evaluated based on changes in the clinical parameters and the patient quality of life (QOL) was evaluated by using the insulin therapy-related QOL questionnaire. Twenty two patients continued CSII during the 6-mo study period. The mean HbA1c was 7.8 ± 1.8% at baseline and it decreased to 7.4 ± 0.8% at 6 mo after the start of the CSII. Overall, no decrease of the QOL post-CSII initiation was noted. The possible superiority of CSII as compared to MDI was suggested for patients who “eat out” or “have to look for an appropriate place for insulin injection.” Aside from an inadequate indwelling needle placement detected after the initiation of CSII in several patients, no adverse event associated with NovoRapid^® was seen. In conclusion, CSII of rapid-acting insulin appears to be a useful therapy for patients with childhood-onset type 1 diabetes.

[Types of insulin therapy]

Diabetes mellitus is a chronic disease associated with a series of long-term microvascular and macrovascular complications that requires continuing therapeutic control. In recent years, the pharmaceutical industry has developed new types of insulin and administration systems in order to more closely mimic human insulin secretion. In this way, insulin therapy is divided into conventional and intensive regimens according to their complexity. In type 1 diabetes mellitus (T1DM) patients, the treatment of choice is the one which achieves intensive glycemic control. In type 2 diabetes mellitus, we can start with a simplified conventional regimen which could progress into an intensive one similar to that of T1DM treatment. Both types of diabetes require an individualized treatment prescription based on the needs and characteristics of each patient.

Quality of life and treatment satisfaction in adults with Type 1 diabetes: a comparison between continuous subcutaneous insulin infusion and multiple daily injections

AIMS

The aim of this case-control study was to compare quality of life (QoL) and treatment satisfaction in adults with Type 1 diabetes (T1DM) treated with either continuous subcutaneous insulin infusion (CSII) or multiple daily injections (MDI).

METHODS

Consecutive patients aged between 18 and 55 years, and attending diabetes clinics for a routine visit, completed the Diabetes-Specific Quality-of-Life Scale (DSQOLS), the Diabetes Treatment Satisfaction Questionnaire (DTSQ) and the SF-36 Health Survey (SF-36). Case (CSII) and control subjects (MDI) were recruited in a 1 : 2 ratio.

RESULTS

Overall, 1341 individuals were enrolled by 62 diabetes clinics; 481 were cases and 860 control subjects. Cases had a longer diabetes duration and were more likely to have eye and renal complications. Age, school education, occupation and HbA(1c) were similar. Of control subjects, 90% followed glargine-based MDI regimens and 10% used NPH-based MDI regimens. On multivariate analysis, after adjusting for socioeconomic and clinical characteristics, scores in the following areas of the DSQOLS were higher in cases than control subjects: diet restrictions (beta = 5.96; P < 0.0001), daily hassles (beta = 3.57; P = 0.01) and fears about hypoglycaemia (beta = 3.88; P = 0.006). Treatment with CSII was also associated with a markedly higher DTSQ score (beta = 4.13; P < 0.0001) compared with MDI. Results were similar when CSII was compared separately with glargine- or NPH-based MDI regimens.

CONCLUSIONS

This large, non-randomized, case-control study suggests quality of life gains deriving from greater lifestyle flexibility, less fear of hypoglycaemia, and higher treatment satisfaction, when CSII is compared with either glargine-based or NPH-based MDI regimens.

A randomized trial comparing continuous subcutaneous insulin infusion of insulin aspart versus insulin lispro in children and adolescents with type 1 diabetes

OBJECTIVE

The safety and efficacy of insulin aspart continuous subcutaneous insulin infusion (CSII) was compared with that of insulin lispro CSII in children and adolescents with type 1 diabetes.

RESEARCH DESIGN AND METHODS

Children and adolescents aged 4-18 years with diagnosed type 1 diabetes >or=1 year previously and treated with insulin analog in a CSII >or=3 months were randomly assigned 2:1 to 16 weeks of insulin aspart CSII (n = 198) or insulin lispro CSII (n = 100) in this open-label, parallel-group, multicenter study. Standard diabetes safety and efficacy parameters were assessed.

RESULTS

Baseline demographics, subject characteristics, and diabetes history were similar between treatment groups. After 16 weeks of treatment, insulin aspart CSII was noninferior to insulin lispro CSII as measured by change in A1C from baseline (aspart, -0.15 +/- 0.05%; lispro, -0.05 +/- 0.07% [95% CI of the treatment difference -0.27 to 0.07]; P = 0.241). No significant differences between treatment groups were observed in fasting plasma glucose, hyperglycemia, and rates of hypoglycemic episodes. At week 16, 59.7% of subjects in the aspart group and 43.8% of subjects in the lispro groups achieved age-specific American Diabetes Association A1C goals (<8.5% for subjects aged <6 years; <8% for subjects aged 6-18 years) (P = 0.040, corrected for baseline). Daily insulin dose (units per kilogram) was significantly lower at week 16 for subjects treated with aspart compared with those treated with lispro (0.86 +/- 0.237 vs. 0.94 +/- 0.233, P = 0.018).

CONCLUSIONS

Insulin aspart was as safe and effective as insulin lispro for use in a CSII in children and adolescents with type 1 diabetes.

Systematic literature review: quality of life associated with insulin pump use in Type 1 diabetes

AIM

To review systematically the published literature addressing whether continuous subcutaneous insulin infusion (CSII) provides any quality of life benefits to people with Type 1 diabetes.

METHODS

Electronic databases and published references were searched and a consultation with two professional groups was undertaken to identify relevant studies published up to July 2005. A multistep selection process was then undertaken to identify those articles which met the specific selection criteria, which were then critically reviewed.

RESULTS

Eighty-four potential relevant articles were identified from examination of titles and abstracts published during the specified time frame. Of these, 28 articles were retrieved in full text, of which 17 fulfilled the specific criteria for inclusion. Mixed results emerged from existing literature. Of the five randomized controlled trials, three reported mixed results, with one study reporting quality of life benefits and one reporting no evidence of quality of life benefits.

CONCLUSIONS

There is conflicting evidence reported in the various studies on the quality of life benefits of CSII in Type 1 diabetes. Existing research is flawed, making a judgement about the quality of life benefits of insulin pump use difficult. There is no strong evidence against quality of life benefits associated with CSII or otherwise, with poor methodology and inconsistent assessment of quality of life clouding the issue. The lack of reported benefit is probably a function of this rather than pump therapy not offering any quality of life benefits.

[Sub-cutaneous closed-loop: continuous glucose measurement and external insulin pump: hope in treatment of type 1 diabetes]

The development of an artificial pancreas allowing a continuous insulin infusion according to glucose measurement is closed to be an ideal device for type 1 diabetic patients and for the diabetologits. The development of miniaturized external pumps infusing short acting analogues with pharmacokinetic profile closer to physiology, and the availability of accurate continuous glucose sensors has led to the development of closed-loop subcutaneous system. The feasibility of this solution as been proven at a small scale but remains to be confirmed in a home setting. Intermediate solutions, such as semi-automatic systems might be immediately valuable.

Reduction in hemoglobin A1C with real-time continuous glucose monitoring: results from a 12-week observational study

BACKGROUND

Real-time continuous glucose monitoring (CGM) was studied in 140 adults with diabetes over a 12-week period of home use. Hemoglobin A(1c)(HbA1c) was measured on day 1 (baseline) and at weeks 6 and 12.

METHODS

On day 1, participants received the CGM device (STS(R) System, DexCom, Inc., San Diego, CA) and underwent training on proper use. Insertion of the first sensor was performed under staff supervision. Subjects inserted subsequent sensors on their own. After calibration, the device (a 3-day sensor, receiver, and transmitter) provided users with real-time glucose values updated at 5-min intervals, glucose trend graphs, configurable high/low alerts, and a hypoglycemia alarm (<or=55 mg/dL). Study participants were given supplies sufficient for 3 weeks of device use. Follow-up visits were performed at 3-week intervals for resupply and to download CGM data, with a final visit at the end of week 12.

RESULTS

Overall, a reduction in HbA1c of 0.4 +/- 0.05% (least squares mean +/- SE) was observed, P < 0.0001. Significant HbA1c reductions were observed across subgroups of subjects with both type 1 and 2 diabetes, and those delivering insulin by multiple daily injections and pumps. The largest HbA1c reduction (1.4 +/- 0.4%) was observed in subjects with baseline HbA1c >9.0%. Increased CGM use was associated with greater reductions in HbA1c.

CONCLUSIONS

This observational study showed that home use of real-time GCM was safe and well tolerated and associated with a clinically and statistically significant reduction in HbA1c. Large-scale randomized, controlled outcome studies of CGM are indicated.