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

Psychopathology and continuous subcutaneous insulin infusion in type 1 diabetes

Aim. Continuous subcutaneous insulin infusion (CSII) is used as an option in patients with diabetes failing to multiple daily injections (MDI). Psychological factors may play a relevant role in the failure to attain therapeutic goals in patients on MDI. This could lead to an overrepresentation of psychopathology in patients treated with CSII. Methods. A consecutive series of 100 patients with type 1 diabetes was studied, collecting main clinical parameters and assessing psychopathology with the self-reported questionnaire Symptom Checklist 90-revised. Patients on CSII were then compared with those on MDI. Results. Of the 100 enrolled patients, 44 and 56 were on CSII and MDI, respectively. Among men, those on CSII were younger than those on MDI; conversely, no difference in age was observed in women. Women on CSII showed higher scores on most Symptom Checklist 90 subscales than those on MDI, whereas no differences were observed in men. Conclusion. Women with type 1 diabetes treated with CSII display higher levels of psychopathology than those on MDI. This is probably the consequence of the fact that patients selected for CSII are those failing to MDI. Higher levels of psychopathology could represent a limit for the attainment and maintenance of therapeutic goals with CSII.

Glucose variability assessed by low blood glucose index is predictive of hypoglycemic events in patients with type 1 diabetes switched to pump therapy

OBJECTIVE

To determine whether subgroups of type 1 diabetic patients with different glucose variability indices respond differently to continuous subcutaneous insulin infusion (CSII) in terms of reduced hypoglycemic events.

RESEARCH DESIGN AND METHODS

We studied 50 adults with long-standing type 1 diabetes switched to CSII because of persistently high A1C or frequent hypoglycemia despite well-managed intensive basal-bolus therapy. We compared A1C, hypoglycemic events, and glucose variability from self-monitoring of blood glucose profiles at baseline and after 6 months of CSII. Regression analysis was performed to identify predictors of response.

RESULTS

In multivariate analysis, baseline low blood glucose index (LBGI) was the best independent predictor of hypoglycemia outcome on CSII (R(2) = 0.195, P = 0.0013). An ROC curve analysis demonstrated a sensitivity of 70.8% (95% CI 48.9-87.4) and specificity of 73.1% (52.2-88.4) by using the LBGI cutoff of 3.34 as predictor of reduction of hypoglycemia on CSII. By grouping patients by LBGI tertiles, we found a 23.3% reduction in hypoglycemic events (<60 mg/dL [3.3 mmol/L]) in the third tertile (range 4.18-9.34) without change in A1C (P < 0.05). Conversely, the first tertile (range 0.62-2.05) demonstrated the greatest A1C reduction, -0.99% (P = 0.00001), but with increasing hypoglycemia.

CONCLUSIONS

Baseline LBGI predicts the outcome of type 1 diabetic patients who switch to CSII in terms of hypoglycemia.

Improved glycemic control and acute complications among children with type 1 diabetes mellitus in Moshi, Tanzania

OBJECTIVE

There are an estimated 1000 children with diabetes in Tanzania. Recently, the first two pediatric endocrinologists, trained in the European Society for Paediatric Endocrinology (ESPE)/International Society for Paediatric and Adolescent Diabetes (ISPAD) program in Nairobi, Kenya, entered practice. The purpose of this study was to prospectively assess the impact of a 6-month diabetes management and education program on glycemic control and acute complications in children and adolescents in Tanzania.

RESEARCH DESIGN AND METHODS

Eighty-one patients aged 3-19 yr were enrolled. All were on split-dose Insulatard (Neutral Protamine Hagedorn) and Actrapid (soluble, regular) insulin, and were given three glucose test strips per week. Children were seen in clinic an average of six times over 6 months and received 3 h of diabetes education. A structured questionnaire evaluated social demographic data and acute complications.

RESULTS

Despite regular clinic attendance, diabetes education, and provision of insulin, hemoglobin A1c (HbA1c) levels did not improve. Four children (5%) had HbA1c 7.5%, 22 (28%) HbA1c 7.5-10%, 9 (24%) HbA1c 11-12.5%, and 36 (44%) HbA1c >12.5%. There was a substantial reduction in severe hypoglycemia, with 17% of subjects experiencing this acute complication compared to 52% in the 6 months prior to study enrolment. Six children were admitted in diabetic ketoacidosis during the study compared to three during the previous 6 months. Twenty-six children (36%) reported missing >6 doses of insulin (but only two lacked insulin).

CONCLUSIONS

Diabetes education significantly reduced the risk of severe hypoglycemia, but better glycemic control of diabetes was not attained. Further study is needed to explore factors to improve glycemic control including increased testing, or perhaps different insulin regimens.

Insulin pump-long-term effects on glycemic control: an observational study at 10 diabetes clinics in Sweden

AIM

This study examined long-term effects of continuous subcutaneous insulin infusion (CSII) in clinical practice on glycemic control in patients with type 1 diabetes.

SUBJECTS AND METHODS

We evaluated all type 1 diabetes patients at 10 diabetes outpatient clinics in Sweden who had been treated with CSII for at least 5.5 years and had valid glycated hemoglobin (HbA1c) data before starting pump use and at 5 years ± 6 months. Controls treated with multiple daily insulin injections (MDI) over a time-matched period were also evaluated.

RESULTS

There were 331 patients treated with CSII at least 5.5 years at the 10 clinics. Of these, 272 (82%) fulfilled the inclusion criteria. Patients treated with CSII were younger than those treated with MDI (mean age, 38.6 vs. 45.6 years; P<0.001), more were women (56% vs. 43%; P<0.001), and diabetes duration was shorter (mean, 15.1 years vs. 20.1 years; P<0.001). After adjusting for variables differing at baseline and influencing the change in HbA1c over the study period, the reduction in HbA1c remained statistically significant at 5 years and was estimated to be 0.20% (95% confidence interval [CI] 0.07-0.32) (2.17 mmol/mol [95% CI 0.81-3.53]) (P=0.002). The corresponding adjusted reduction at years 1 and 2 was 0.42% (95% CI 0.31-0.53) (4.59 mmol/mol [95% CI 3.41-5.77]) (P<0.001) and 0.43% (95% CI 0.31-0.55) (4.71 mmol/mol [95% CI 3.38-6.04]) (P<0.001), respectively. The effect of insulin pump use versus controls on HbA1c decreased significantly with time (P<0.001).

CONCLUSIONS

Use of CSII in clinical practice in Sweden is associated with an approximately 0.2% (2 mmol/mol) reduction in HbA1c after 5 years.

Novel Insulin Delivery Technologies in Women with Pregestational Type 1 Diabetes: A Review of the Literature

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.

Continuous subcutaneous insulin infusion (CSII) pumps

Optimal blood glucose control and the restoration of the physiological insulin secretion is a current medical challenge andwill account for an overall cardiovascular morbidity and mortality related to diabetes mellitus complications. Continuous Subcutaneous Insulin Infusion (CSII) is the first step to the development of the so-called "artificial pancreas" and is intended to restore blood glucose levels and the frequency of hypoglycemic episodes. CSII using an external pump, offers both a better glycemic profile compared to multiple daily insulin injections (MDI) and a broader flexibility in everyday activities. The advantages of insulin pumps, i.e., basal delivery consistency, adjustable basal rates and low insulin depots also contribute to its reported clinical superiority. However, experience with CSII indicates that candidate patients should be carefully selected, thoroughly educated and vividly motivated to improve their blood glucose control.

Insulin pump therapy is associated with less post-exercise hyperglycemia than multiple daily injections: an observational study of physically active type 1 diabetes patients

BACKGROUND

Aerobic exercise typically decreases blood glucose levels in individuals with type 1 diabetes. It is currently unknown if glucose responses to exercise and recovery differ between patients on multiple daily insulin injections (MDI) and continuous subcutaneous insulin infusion (CSII).

SUBJECTS AND METHODS

Nineteen (16 male, three female) physically active individuals with type 1 diabetes took part in this observational study. Interstitial glucose levels (blinded) were compared during 45 min of standardized aerobic exercise (cycling or running at 60% peak aerobic capacity) and during 6 h of postexercise recovery between individuals using MDI (n=9) and CSII (n=10) therapy.

RESULTS

Both MDI and CSII groups had similar reductions in glucose levels during exercise, but responses in early and late recovery differed (group × time interaction, P<0.01). Participants using MDI had greater increases in glucose throughout recovery compared with individuals with CSII. Two-thirds of the MDI patients experienced late-onset post-exercise hyperglycemia (blood glucose >12 mmol/L) compared with only 1/10(th) of the CSII patients (P<0.01).

CONCLUSIONS

Among individuals performing regular moderate-to-heavy intensity aerobic exercise, use of CSII helped to limit post-exercise hyperglycemia compared with MDI therapy and is not associated with increased risk for post-exercise late-onset hypoglycemia.

Benefits of continuous subcutaneous insulin infusion on quality of life

PURPOSE

The aim of this study was to compare the general health-related quality of life (HRQoL), the metabolic control (HbA1c), the anthropometric measurement, and the cardiorespiratory fitness (expressed by VO2max) in youths with type 1 diabetes treated with continuous subcutaneous insulin infusion (CSII) to those receiving multiple daily injections (MDI). We looked for factors influencing the HRQoL and metabolic control.

METHODS

A total of 239 patients treated with CSII (51 girls and 53 boys) or MDI (64 girls and 71 boys) between ages 8 and 18 years were assessed with the Pediatric Quality of Life Inventory, Generic Core Scales, and Diabetes Module. VO2max was evaluated using the 20-meter shuttle run test.

RESULTS

CSII group had significantly better HRQoL according to both child self-report and parent proxy-report. Youths with CSII reported better physical, emotional, and school-related functioning, and had less diabetes-related fear and symptoms than the MDI group. There were no significant differences in body mass index z-scores, insulin doses, HbA1c, and VO2max between the groups. HRQoL was predicted by the CSII therapy (β = -0.220; p = .000) and the VO2max (β = 0.386; p = .000), other clinical and anthropometric parameters had no effect; the HbA1c was predicted only by VO2max (β = -0.353; p = .000).

CONCLUSIONS

Diabetic youths treated with CSII therapy have better HRQoL than those treated with MDI. There are no differences between the investigated groups in anthropometric data, glycated hemoglobin, and physical fitness. Moreover, good physical fitness has an important role in achieving better metabolic control and HRQoL, which underlines the importance of regular aerobic exercise in the treatment and care of type 1 diabetes in childhood.

Comparison of arterial and mixed venous blood glucose levels in hemodynamically unstable pigs: implications for location of a continuous glucose sensor

One of several unsolved challenges in the construction of an artificial endocrine pancreas (a system for automatically adjusting the blood glucose level) is the positioning of the glucose sensor. We believe the best positioning to be either intraarterial or in a central vein. It is therefore important to know whether the glucose content in these blood locations is the same. We conducted a post hoc analysis of previously collected data from pigs exposed to gross inflammatory and circulatory stress. Paired arterial and mixed venous glucose values were compared with a mixed effects model. We found the blood glucose values from the arterial and mixed venous blood to be the same.

Failure of glycated hemoglobin drop after continuous subcutaneous insulin infusion initiation may indicate patients who discontinue: a 4-year follow-up study in children and adolescents with type 1 diabetes

Continuous subcutaneous insulin infusion (CSII) is effective and safe in children and adults with type 1 diabetes. Notwithstanding, some patients decide to discontinue using CSII. We evaluated the discontinuation rate, and its related factors, in a large group of children and adolescents with type 1 diabetes using CSII in Italy. Data on all patients with type 1 diabetes younger than 18 years were collected by 28 Pediatric Diabetologic referral Centers located throughout Italy. The primary endpoint was to measure the discontinuation rate using CSII. Among the study population (n = 6,644), 985 (14.8%) were using CSII. Sixty patients discontinued using CSII, representing the 6.1%. The discontinuation rate significantly increased (P = 0.002) with age: 0-6 years, 1/84 (1.2%), 7-11 years, 8/262 (3.1%), 12-18 years, 51/579 (8.8%). The average time to discontinuation was 1.8 ± 1.4 years. The average age of patients who discontinued using CSII was higher than in patients still on CSII (12.1 ± 3.2 vs. 10.3 ± 3.8, P = 0.0001), while their diabetes duration was significantly shorter (8.6 ± 2.7 vs. 10.2 ± 3.7, P = 0.0001). HbA1c decreased only in patients still on CSII (8.7 ± 1.3% vs. 7.8 ± 1.3%, P = 0.02), but not in patients who discontinued using CSII (8.5 ± 1.6% vs. 8.2 ± 1.3%, P = 0.213). HbA1c might be one important indicator helpful to identify patients at higher risk discontinuing using CSII.

A discovery-phase urine proteomics investigation in type 1 diabetes

Diabetes is a chronic metabolic disease which can lead to serious health problems particularly in and to the development of cardiovascular and renal complications. The aim of this study is to possibly identify distinctive molecular features in urine samples which might correlate to the progression and complications of type 1 diabetes. Diabetic patients with normo- and micro-albuminuria have been analyzed and compared to a group of control subjects. Urine proteins of control and type 1 diabetes subjects were investigated in their proteome profiles, using high-resolution two-dimensional gel electrophoresis separation and protein identifications by MALDI-TOF-MS and LC-MS/MS analysis. Proteomics analysis highlighted differential expression of several proteins between control and type 1 diabetes subjects. In particular, five proteins were found to be down-regulated and four proteins up-regulated. Lower protein representations in diabetic subjects were associated with Tamm-Horsfall urinary glycoprotein, apolipoprotein A-I, apolipoprotein E, α2-thiol proteinase inhibitor, and human complement regulatory protein CD59, while higher protein representations were found for α-1-microglobulin, zinc-α2 glycoprotein, α-1B glycoprotein, and retinol-binding protein 4. These differences were maintained comparing control subjects with type 1 diabetes normo-albuminuric and micro-albuminuric subjects. Furthermore, these proteins are correlated to glycosylated hemoglobin and microalbuminuria, confirming their role in diabetic pathology. This study gives new insights on potential molecular mechanisms associated with the complications of type 1 diabetic disease providing evidences of urine proteins potentially exploitable as putative prognostic biomarkers.

Quality of life and technology: impact on children and families with diabetes

Ensuring quality of life (QOL) while maintaining glycemic control within targets is an important challenge in type 1 and type 2 diabetes treatment. For children with diabetes, QOL includes enjoying meals, feeling safe in school, and perceiving positive, supportive relationships with parents, siblings, and friends. Yet many treatment-related and psychosocial barriers can interfere with a child's QOL and their ability to manage diabetes effectively. Diabetes management also imposes considerable lifestyle demands that are difficult and often frustrating for children to negotiate at a young age. Recent advances in diabetes medications and technologies have improved glycemic control in children with diabetes. Two widely used technologies are the insulin pump and continuous glucose monitoring (CGM) system. These technologies provide patients with more flexibility in their daily life and information about glucose fluctuations. Several studies report improvements in glycemic control in children with type 1 diabetes using the insulin pump or sensor-augmented pump therapy. Importantly, these technologies may impact QOL for children and families with diabetes, although they are rarely used or studied in the treatment of children with type 2 diabetes. Further, emerging closed loop and web- and phone-based technologies have great potential for supporting diabetes self-management and perhaps QOL. A deeper understanding and appreciation of the impact of diabetes technology on children's and parents' QOL is critical for both the medical and psychological care of diabetes. Thus, the purpose of this review is to discuss the impact of new diabetes technologies on QOL in children, adolescents and families with type 1 diabetes.

Three-year comparison of subcutaneous insulin pump treatment with multi-daily injections on HbA1c, its variability and hospital burden of children with type 1 diabetes

Treatment with continuous subcutaneous insulin infusion (CSII) allows a large degree of treatment individualization and intensification in children with diabetes. The study's aim was to evaluate the impact of treatment with CSII on glycated haemoglobin level (HbA1c) in children with diabetes and investigate whether introduction of CSII is associated with an increased risk of acute complications of diabetes. Patients treated throughout the recruitment period exclusively with multiple daily injections (MDI) were matched for duration of diabetes and HbA1c level at baseline with patients treated exclusively with CSII in a 1:1 group ratio (n = 223 and 231 for MDI and CSII, respectively). The CSII group showed lower HbA1c after the observation period (7.98 ± 1.38 vs. 7.56 ± 0.97; P = 0.002). HbA1c variability measured as standard deviations of average values was also lower in the CSII group (0.73 ± 0.45 vs. 0.84 ± 0.54; P = 0.049). The rate of hospitalization due to acute events was similar in both groups (14.7/100 vs. 14.0/100 person/years in the MDI and CSII group, P = 0.72). Duration of hospital stay per year was on average 1.25 days shorter in the CSII group (P = 0.0004), but the risk of acute complications resulting in hospitalization did not differ between the groups (hazard ratio (HR) 1.16; 95% confidence interval (95% CI) 0.68-1.63). The most significant risk factor for hospitalization due to acute complications was baseline HbA1c concentration (HR 1.25; 95% CI 1.14-1.37). In conclusion, CSII treatment may improve glycemic control and reduce its variability. Change of MDI to CSII does not alter the risk of hospitalization and may reduce the annual duration of hospitalization in children with diabetes.

Availability of insulin pump therapy in clinical practice

AIM

To examine the availability of insulin pump therapy in patients with Type 1 diabetes.

METHODS

Patients using insulin pumps among a cohort of 7224 patients with Type 1 diabetes were studied.

RESULTS

In logistic regression, used to evaluate variables not changing over time among the total cohort, use of insulin pumps varied by outpatient clinic (P<0.001) and sex (P<0.001). Cox regression analysis in 5854 patients with detailed patient data prior to use of an insulin pump showed higher HbA(1c) (P<0.0001), lower creatinine (P=0.002), high and low insulin doses (P<0.0001), younger age (P<0.0001) and female sex (P<0.0001) to be associated with use of an insulin pump. Women were 1.5-fold more likely to start using an insulin pump (hazard ratio 1.52, 95% confidence interval 1.29-1.79) and patients in the 20- to 30-years age range were more than twice as likely to begin use of an insulin pump than patients aged 40-50 years (hazard ratio 8.63, 95% confidence interval 5.91-12.59 and hazard ratio 3.98, 95% confidence interval 2.80-5.64, respectively). A 10-μmol/l higher level of creatinine was associated with a hazard ratio of 0.56 (95% confidence interval 0.39-0.81) of starting use of an insulin pump.

CONCLUSIONS

At 10 hospital outpatient clinics in Sweden, use of insulin pumps therapy varied by clinic. A higher proportion of women began using insulin pumps. Younger patients and patients with fewer complications were also more likely to start using an insulin pump. Further research is needed to confirm these findings in other geographical regions and to understand whether the availability of insulin pumps today is optimized.

Does the timing of insulin pump therapy initiation after type 1 diabetes onset have an impact on glycemic control?

BACKGROUND

Continuous subcutaneous insulin infusion (CSII) mimics physiologic insulin release better than multiple daily injection (MDI) therapy and allows for greater flexibility in food intake and physical activity. Given these benefits, it raises the question "Is it required to wait to offer CSII to patients with type 1 diabetes (T1D) only after MDI therapy has failed"? This study sought to determine if starting CSII in patients with T1D within 1 year of diagnosis results in better long-term glycemic control than starting it later.

METHODS

This retrospective observational study was conducted in a tertiary-care medical center. The charts of 488 patients with T1D (273 females) 2.6-39 years old (mean, 19.9 ± 7.7 years) who started CSII in 1998-2008 and used it for at least 1 year were reviewed for background, disease-related, and treatment-related variables. Study end points were glycosylated hemoglobin (HbA1c) level, rate of severe hypoglycemia, and diabetic ketoacidosis events during CSII use. Findings were compared between patients who started CSII within 1 year of diagnosis (Group 1, n=93) or later (Group 2, n=395).

RESULTS

Compared with Group 2, Group 1 patients were characterized by a significantly younger age at CSII initiation (10.7±5.7 vs. 16.4±7.0 years, P<0.001), more frequent blood glucose monitoring (5.4 ± 1.8 vs. 3.9 ± 1.5 times per day, P<0.001), and shorter total duration of diabetes (4.3 ± 2.1 vs. 11.9 ± 6.4 years, P<0.001) and of CSII therapy (3.6 ± 2.1 vs. 4.7 ± 2.5 years, P<0.001). There were no significant between-group differences in patient gender or ethnicity, indications for initiating CSII, mean HbA1c level, attainment of target HbA1c, or rates of severe hypoglycemia or ketoacidosis events after CSII initiation.

CONCLUSIONS

Starting pump therapy at an early disease stage has no added benefit for glycemic control over time than starting later. The timing of CSII initiation should be tailored to the individual patient by the diabetes care team.

Effect on glycemic control by short- and long-term use of continuous glucose monitoring in clinical practice

BACKGROUND

In Sweden, patients with diabetes mellitus frequently receive short-term (<3 months) continuous glucose monitoring (CGM) to study glucose patterns or long-term CGM to treat poor glycemic control or severe hypoglycemia. The effects of CGM on glycemic control in clinical practice in relation to indication and duration of use has not been completely studied.

METHODS

Patients with diabetes, among which 99% were diagnosed as type 1, receiving CGM at 10 outpatient clinics in Sweden were studied retrospectively. Long-term use of CGM was defined as ≥ 3 months use of CGM and short-term as <3 months. A control group matched on start date and date of latest value 3 months after the start was selected for both long- and short-term groups.

RESULTS

In 34 long-term users of CGM, over a mean follow-up of 1.1 years, the adjusted mean difference of hemoglobin A1c (HbA1c) compared with controls (n = 408) was -0.76 (95% confidence interval -1.17; -0.33, p < .001). Long-term users with indications for high HbA1c (n = 15) had a reduction of 1.2% in HbA1c from 10.1 to 8.9% (p = .003), whereas patients with hypoglycemia as their indication (n = 16) decreased by 0.3% (p = .17). Nonsevere hypoglycemic events decreased in long-term users within the same follow-up period (p = .004). Short-term users showed no statistically significant improvement in HbA1c compared with controls at 1.1 years (n = 41), p = .85 or at 2.6 years (n = 43), p = .19.

CONCLUSION

Long-term CGM use was associated with improved glycemic control in clinical practice and a reduction in nonsevere hypoglycemic events, whereas short-term use had no effect on HbA1c. The effect on glycemic control varied by indication.

Comparison of pharmacokinetic properties, physicochemical stability, and pump compatibility of 3 rapid-acting insulin analogues-aspart, lispro, and glulisine

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.

Overweight, obesity and features of metabolic syndrome in children with diabetes treated with insulin pump therapy

There has been no specific evaluation of atherogenic risk factors in children with type 1 diabetes mellitus (T1DM) treated with continuous subcutaneous insulin infusion (CSII). We, therefore, studied the prevalence of overweight/obesity and metabolic syndrome among these patients. Five hundred children with T1DM treated with CSII and multiple daily insulin (MDI) regimen were included in the study. Anthropometric data/physical examination, data concerning diabetes, and a lipid profile were assessed in this group, and compared with respect to treatment method (CSII vs. MDI). Almost one-third (30.2%) of the children were overweight/obese. The body mass index (BMI) values at the time of the present evaluation were significantly higher in comparison with the BMI values 3-6 months after the diagnosis. Dyslipidemia was recognized in 51.6%, hypertension in 4.8%, and the metabolic syndrome in 3.2%. of the subjects. The overweight/obese children differed from their normal-weight counterparts with respect to metabolic control, the incidence of hypertension, dyslipidemia, and metabolic syndrome. The girls showed higher prevalence of overweight/obesity and higher BMI values compared to the boys. The children treated with CSII had the same prevalence of overweight/obesity, but a lower incidence of dyslipidemia, and a better metabolic control compared to the children treated with MDI regimen. Our study shows a high prevalence of overweight/obesity and dyslipidemia in children with T1DM including those treated with an insulin pump.

Effect of the sensor site-insulin injection site distance on the dynamics of local glycemia in the minipig model

BACKGROUND

Previous studies have shown that at the near steady state attained by slow insulin infusion, the local glycemia of subcutaneous fluid tracks the venous glucose concentration (i.e., it is not perturbed by the infusion of insulin). Here we test whether the subcutaneous glycemia near the site of injection of a bolus of insulin is perturbed by the injection in the minipig model without diabetes.

METHODS

A bolus of short-acting diluted insulin was administered in the animal's flank while three to five continuous glucose monitoring systems measured the subcutaneous glucose concentrations at 0.5, 1, 2, and 3 cm ("near sensors") and at 10-15 cm ("far sensors") from the injection site.

RESULTS

We found no statistically significant (P < 0.05) evidence that near and far sensors differ in response time, that is, the elapsed time to onset of signal drop or the elapsed time to minimum signal following insulin injection. We found mixed evidence that near and far sensors differ in the percentage drops at the glycemic minimum. The near versus far difference for near sensors at 0.5 and 3 cm from the injection site was statistically significant (P < 0.05): the average percentage drops for these near sensors were 3% and 11%, respectively, below those for far sensors. We did not find evidence of a difference for near sensors at 1 and 2 cm.

CONCLUSIONS

Because there is some evidence that insulin injection can cause a minor perturbation (about ≤10%) in the local glycemia, caution is warranted when co-locating glucose sensing and insulin injection sites.

Evolution of diabetes insulin delivery devices

The first manufactured insulin pump was introduced in the 1970s and the first insulin pens in 1985; since then, many improvements have been made to both devices. The advantages of pens over syringes have been confirmed in numerous studies and include greater accuracy, ease of use, patient satisfaction, quality of life, and adherence. United States claims database analyses indicate that the improved adherence made possible by use of an insulin pen has the potential to reduce diabetes care costs when compared with using a vial and syringe. Features of certain advanced pump models include the ability to connect wirelessly to a blood glucose meter or to a subcutaneous interstitial glucose sensor for semicontinuous glucose-driven insulin rate adjustment. A new trend in the design of insulin pumps is the tubing-free patch pump that adheres directly to the skin. The low rate of insulin pen usage in the United States compared with European countries and the fact that many patients report that they are not offered the option of an insulin pen by their physician suggest that there is a need to increase patient and provider awareness of the currently available devices for insulin administration.

STAR 3 randomized controlled trial to compare sensor-augmented insulin pump therapy with multiple daily injections in the treatment of type 1 diabetes: research design, methods, and baseline characteristics of enrolled subjects

BACKGROUND

Sensor-augmented pump therapy (SAPT) integrates real-time continuous glucose monitoring (RT-CGM) with continuous subcutaneous insulin infusion (CSII) and offers an alternative to multiple daily injections (MDI). Previous studies provide evidence that SAPT may improve clinical outcomes among people with type 1 diabetes. Sensor-Augmented Pump Therapy for A1c Reduction (STAR) 3 is a multicenter randomized controlled trial comparing the efficacy of SAPT to that of MDI in subjects with type 1 diabetes.

METHODS

Subjects were randomized to either continue with MDI or transition to SAPT for 1 year. Subjects in the MDI cohort were allowed to transition to SAPT for 6 months after completion of the study. SAPT subjects who completed the study were also allowed to continue for 6 months. The primary end point was the difference between treatment groups in change in hemoglobin A1c (HbA1c) percentage from baseline to 1 year of treatment. Secondary end points included percentage of subjects with HbA1c < or =7% and without severe hypoglycemia, as well as area under the curve of time spent in normal glycemic ranges. Tertiary end points include percentage of subjects with HbA1c < or =7%, key safety end points, user satisfaction, and responses on standardized assessments.

RESULTS

A total of 495 subjects were enrolled, and the baseline characteristics similar between the SAPT and MDI groups. Study completion is anticipated in June 2010.

CONCLUSIONS

Results of this randomized controlled trial should help establish whether an integrated RT-CGM and CSII system benefits patients with type 1 diabetes more than MDI.