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Umpierrez GE, Klonoff DC. Diabetes Technology Update: Use of Insulin Pumps and Continuous Glucose Monitoring in the Hospital. Diabetes Care 2018; 41:1579-1589. [PMID: 29936424 PMCID: PMC6054505 DOI: 10.2337/dci18-0002] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 04/20/2018] [Indexed: 02/03/2023]
Abstract
The use of continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) systems has gained wide acceptance in diabetes care. These devices have been demonstrated to be clinically valuable, improving glycemic control and reducing risks of hypoglycemia in ambulatory patients with type 1 diabetes and type 2 diabetes. Approximately 30-40% of patients with type 1 diabetes and an increasing number of insulin-requiring patients with type 2 diabetes are using pump and sensor technology. As the popularity of these devices increases, it becomes very likely that hospital health care providers will face the need to manage the inpatient care of patients under insulin pump therapy and CGM. The American Diabetes Association advocates allowing patients who are physically and mentally able to continue to use their pumps when hospitalized. Health care institutions must have clear policies and procedures to allow the patient to continue to receive CSII treatment to maximize safety and to comply with existing regulations related to self-management of medication. Randomized controlled trials are needed to determine whether CSII therapy and CGM systems in the hospital are associated with improved clinical outcomes compared with intermittent monitoring and conventional insulin treatment or with a favorable cost-benefit ratio.
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Affiliation(s)
- Guillermo E Umpierrez
- Division of Endocrinology, Metabolism and Lipids, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - David C Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA
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2
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Rajput R, Sinha B, Majumdar S, Shunmugavelu M, Bajaj S. Consensus statement on insulin therapy in chronic kidney disease. Diabetes Res Clin Pract 2017; 127:10-20. [PMID: 28315574 DOI: 10.1016/j.diabres.2017.02.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 02/16/2017] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Diabetes mellitus (DM) is one of the leading causes of chronic kidney disease (CKD) which eventually leads to insulin resistance and decreased insulin degradation. In patients with diabetic kidney disease (DKD), the overall insulin requirement declines which necessitates the reassessment for individualization, adjustment and titration of insulin doses depending on the severity of kidney disease. OBJECTIVE To provide simple and easily implementable guidelines to primary care physicians on appropriate insulin dosing and titration of various insulin regimens in patients with DKD. METHODS Each insulin regimen (basal, prandial, premix and basal-bolus) was presented and evaluated for dosing and titration based on data from approved medical literatures on chronic kidney disease. These evaluations were then factored into the national context based on the expert committee representatives' and key opinion leaders' clinical experience and common therapeutic practices followed in India. RESULTS Recommendations based on dosing and titration of insulins has been developed. Moreover, the consensus group also recommended the strategy for dose estimation of insulin, optimal glycaemic targets and self-monitoring in patients with DKD. CONCLUSION The consensus based recommendations will be a useful reference tool for health care practitioners to initiate, optimise and intensify insulin therapy in patients with DKD.
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Affiliation(s)
| | | | - Sujoy Majumdar
- G D Diabetes Institute & Peerless Hospital Kolkata, India
| | - M Shunmugavelu
- Trichy Diabetes Speciality Centre (P) Ltd, Trichy, Tamil Nadu, India
| | - Sarita Bajaj
- Dept of Medicine, MLN Medical College, Allahabad, India
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3
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Bode BW, Kaufman FR, Vint N. An Expert Opinion on Advanced Insulin Pump Use in Youth with Type 1 Diabetes. Diabetes Technol Ther 2017; 19:145-154. [PMID: 28135116 DOI: 10.1089/dia.2016.0354] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Among children and adolescents with type 1 diabetes mellitus, the use of insulin pump therapy has increased since its introduction in the early 1980s. Optimal management of type 1 diabetes mellitus depends on sufficient understanding by patients, their families, and healthcare providers on how to use pump technology. The goal for the use of insulin pump therapy should be to advance proficiency over time from the basics taught at the initiation of pump therapy to utilizing advanced settings to obtain optimal glycemic control. However, this goal is often not met, and appropriate understanding of the full features of pump technology can be lacking. The objective of this review is to provide an expert perspective on the advanced features and use of insulin pump therapy, including practical guidelines for the successful use of insulin pump technology, and other considerations specific to patients and healthcare providers.
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Affiliation(s)
- Bruce W Bode
- 1 Atlanta Diabetes Associates , Atlanta, Georgia
| | - Francine R Kaufman
- 2 The Center for Endocrinology, Diabetes and Metabolism, Children's Hospital Los Angeles , Los Angeles, California
- 3 Medtronic , Northridge, California
| | - Nan Vint
- 4 Lilly USA, LLC, Lilly Corporate Center , US Medical Affairs, Indianapolis, Indiana
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4
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Pecoits-Filho R, Abensur H, Betônico CCR, Machado AD, Parente EB, Queiroz M, Salles JEN, Titan S, Vencio S. Interactions between kidney disease and diabetes: dangerous liaisons. Diabetol Metab Syndr 2016; 8:50. [PMID: 27471550 PMCID: PMC4964290 DOI: 10.1186/s13098-016-0159-z] [Citation(s) in RCA: 93] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 07/10/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Type 2 diabetes mellitus (DM) globally affects 18-20 % of adults over the age of 65 years. Diabetic kidney disease (DKD) is one of the most frequent and dangerous complications of DM2, affecting about one-third of the patients with DM2. In addition to the pancreas, adipocytes, liver, and intestines, the kidneys also play an important role in glycemic control, particularly due to renal contribution to gluconeogenesis and tubular reabsorption of glucose. METHODS In this review article, based on a report of discussions from an interdisciplinary group of experts in the areas of endocrinology, diabetology and nephrology, we detail the relationship between diabetes and kidney disease, addressing the care in the diagnosis, the difficulties in achieving glycemic control and possible treatments that can be applied according to the different degrees of impairment. DISCUSSION Glucose homeostasis is extremely altered in patients with DKD, who are exposed to a high risk of both hyperglycemia and hypoglycemia. Both high and low glycemic levels are associated with increased morbidity and shortened survival in this group of patients. Factors that are associated with an increased risk of hypoglycemia in DKD patients include decreased renal gluconeogenesis, deranged metabolic pathways (including altered metabolism of medications) and decreased insulin clearance. On the other hand, decrease glucose filtration and excretion, and inflammation-induce insulin resistance are predisposing factors to hyperglycemic episodes. CONCLUSION Appropriate glycaemic monitoring and control tailored for diabetic patients is required to avoid hypoglycaemia and other glycaemic disarrays in patients with DM2 and kidney disease. Understanding the renal physiology and pathophysiology of DKD has become essential to all specialties treating diabetic patients. Disseminating this knowledge and detailing the evidence will be important to initiate breakthrough research and to encourage proper treatment of this group of patients.
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Affiliation(s)
- Roberto Pecoits-Filho
- School of Medicine, Pontificia Universidade Católica do Paraná, Imaculada Conceição, 1155, Curitiba, PR 80215-901 Brazil
| | - Hugo Abensur
- School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Carolina C. R. Betônico
- Hospital Regional de Presidente Prudente, Universidade do Oeste Paulista, Presidente Prudente, São Paulo, Brazil
| | | | | | - Márcia Queiroz
- School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Silvia Titan
- School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Sergio Vencio
- Institute of Pharmaceutical Sciences, Goiania, Brazil
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5
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Betônico CCR, Titan SMO, Correa-Giannella MLC, Nery M, Queiroz M. Management of diabetes mellitus in individuals with chronic kidney disease: therapeutic perspectives and glycemic control. Clinics (Sao Paulo) 2016; 71:47-53. [PMID: 26872083 PMCID: PMC4732385 DOI: 10.6061/clinics/2016(01)08] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Revised: 11/26/2015] [Accepted: 11/26/2015] [Indexed: 12/16/2022] Open
Abstract
The purpose of this study was to evaluate the therapeutic options for diabetes treatment and their potential side effects, in addition to analyzing the risks and benefits of tight glycemic control in patients with diabetic kidney disease. For this review, a search was performed using several pre-defined keyword combinations and their equivalents: "diabetes kidney disease" and "renal failure" in combination with "diabetes treatment" and "oral antidiabetic drugs" or "oral hypoglycemic agents." The search was performed in PubMed, Endocrine Abstracts and the Cochrane Library from January 1980 up to January 2015. Diabetes treatment in patients with diabetic kidney disease is challenging, in part because of progression of renal failure-related changes in insulin signaling, glucose transport and metabolism, favoring both hyperglycemic peaks and hypoglycemia. Additionally, the decline in renal function impairs the clearance and metabolism of antidiabetic agents and insulin, frequently requiring reassessment of prescriptions. The management of hyperglycemia in patients with diabetic kidney disease is even more difficult, requiring adjustment of antidiabetic agents and insulin doses. The health team responsible for the follow-up of these patients should be vigilant and prepared to make such changes; however, unfortunately, there are few guidelines addressing the nuances of the management of this specific population.
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Affiliation(s)
- Carolina C R Betônico
- Universidade Oeste Paulista, Hospital Regional de Presidente Prudente, Divisão de Endocrinologia, Presidente Prudente/, SP, Brazil
| | - Silvia M O Titan
- Faculdade de Medicina da Universidade de São Paulo, Departamento de Medicina Interna, Divisão de Nefrologia
| | | | - Márcia Nery
- Divisão de Endocrinologia, São Paulo/, SP, Brazil
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Schaschkow A, Mura C, Dal S, Langlois A, Seyfritz E, Sookhareea C, Bietiger W, Peronet C, Jeandidier N, Pinget M, Sigrist S, Maillard E. Impact of the Type of Continuous Insulin Administration on Metabolism in a Diabetic Rat Model. J Diabetes Res 2016; 2016:8310516. [PMID: 27504460 PMCID: PMC4967706 DOI: 10.1155/2016/8310516] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Revised: 05/26/2016] [Accepted: 06/14/2016] [Indexed: 02/07/2023] Open
Abstract
Exogenous insulin is the only treatment available for type 1 diabetic patients and is mostly administered by subcutaneous (SC) injection in a basal and bolus scheme using insulin pens (injection) or pumps (preimplanted SC catheter). Some divergence exists between these two modes of administration, since pumps provide better glycaemic control compared to injections in humans. The aim of this study was to compare the impacts of two modes of insulin administration (single injections of long-acting insulin or pump delivery of rapid-acting insulin) at the same dosage (4 IU/200 g/day) on rat metabolism and tissues. The rat weight and blood glucose levels were measured periodically after treatment. Immunostaining for signs of oxidative stress and for macrophages was performed on the liver and omental tissues. The continuous insulin delivery by pumps restored normoglycaemia, which induced the reduction of both reactive oxygen species and macrophage infiltration into the liver and omentum. Injections controlled the glucose levels for only a short period of time and therefore tissue stress and inflammation were elevated. In conclusion, the insulin administration mode has a crucial impact on rat metabolic parameters, which has to be taken into account when studies are designed.
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Affiliation(s)
- A. Schaschkow
- UMR DIATHEC, EA 7294, Centre Européen d'Etude du Diabète, Université de Strasbourg (UdS), Boulevard René Leriche, 67200 Strasbourg, France
| | - C. Mura
- UMR DIATHEC, EA 7294, Centre Européen d'Etude du Diabète, Université de Strasbourg (UdS), Boulevard René Leriche, 67200 Strasbourg, France
| | - S. Dal
- UMR DIATHEC, EA 7294, Centre Européen d'Etude du Diabète, Université de Strasbourg (UdS), Boulevard René Leriche, 67200 Strasbourg, France
| | - A. Langlois
- UMR DIATHEC, EA 7294, Centre Européen d'Etude du Diabète, Université de Strasbourg (UdS), Boulevard René Leriche, 67200 Strasbourg, France
| | - E. Seyfritz
- UMR DIATHEC, EA 7294, Centre Européen d'Etude du Diabète, Université de Strasbourg (UdS), Boulevard René Leriche, 67200 Strasbourg, France
| | - C. Sookhareea
- UMR DIATHEC, EA 7294, Centre Européen d'Etude du Diabète, Université de Strasbourg (UdS), Boulevard René Leriche, 67200 Strasbourg, France
| | - W. Bietiger
- UMR DIATHEC, EA 7294, Centre Européen d'Etude du Diabète, Université de Strasbourg (UdS), Boulevard René Leriche, 67200 Strasbourg, France
| | - C. Peronet
- UMR DIATHEC, EA 7294, Centre Européen d'Etude du Diabète, Université de Strasbourg (UdS), Boulevard René Leriche, 67200 Strasbourg, France
| | - N. Jeandidier
- UMR DIATHEC, EA 7294, Centre Européen d'Etude du Diabète, Université de Strasbourg (UdS), Boulevard René Leriche, 67200 Strasbourg, France
- Department of Endocrinology, Diabetes, and Metabolic Diseases, Pôle NUDE, Hôpitaux Universitaires de Strasbourg (HUS), 67000 Strasbourg Cedex, France
| | - M. Pinget
- UMR DIATHEC, EA 7294, Centre Européen d'Etude du Diabète, Université de Strasbourg (UdS), Boulevard René Leriche, 67200 Strasbourg, France
- Department of Endocrinology, Diabetes, and Metabolic Diseases, Pôle NUDE, Hôpitaux Universitaires de Strasbourg (HUS), 67000 Strasbourg Cedex, France
| | - S. Sigrist
- UMR DIATHEC, EA 7294, Centre Européen d'Etude du Diabète, Université de Strasbourg (UdS), Boulevard René Leriche, 67200 Strasbourg, France
| | - E. Maillard
- UMR DIATHEC, EA 7294, Centre Européen d'Etude du Diabète, Université de Strasbourg (UdS), Boulevard René Leriche, 67200 Strasbourg, France
- *E. Maillard:
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7
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Lin CH, Hsieh SH, Sun JH, Tsai JS, Huang YY. Glucose Variability and β- Cell Response by GLP-1 Analogue added-on CSII for Patients with Poorly Controlled Type 2 Diabetes. Sci Rep 2015; 5:16968. [PMID: 26607841 PMCID: PMC4660278 DOI: 10.1038/srep16968] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Accepted: 10/22/2015] [Indexed: 12/24/2022] Open
Abstract
The effects of twice-daily GLP-1 analogue injections added on continuous subcutaneous insulin infusion (CSII) in patients with poorly controlled type 2 diabetes (T2DM) were unknown. After optimization of blood glucose in the first 3 days by CSII during hospitalization, patients with poorly controlled T2DM were randomized to receive CSII combined with injections of exenatide or placebo for another 3 days. A total of 51 patients (30 in exenatide and 21 in placebo groups) with mean A1C 11% were studied. There was no difference in mean glucose but a significant higher standard deviation of plasma glucose (SDPG) was found in the exenatide group (50.51 ± 2.43 vs. 41.49 ± 3.00 mg/dl, p = 0.027). The improvement of incremental area under the curve (AUC) of glucose and insulinogenic index (Insulin0–peak/ Glucose0–peak) in 75 g oral glucose tolerance test was prominent in the exenatide group (p < 0.01). The adiponectin level was significantly increased with exenatide added on (0.39 ± 0.32 vs. −1.62 ± 0.97 μg/mL, in exenatide and placebo groups, respectively, p = 0.045). In conclusion, the add-on of GLP-1 analogue to CSII increased glucose variability and the β - cell response in patients with poorly controlled T2DM.
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Affiliation(s)
- Chia-Hung Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan.,Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, Taiwan
| | - Sheng-Hwu Hsieh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Jui-Hung Sun
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
| | | | - Yu-Yao Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou, Taiwan
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8
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New Insulins and New Aspects in Insulin Delivery. Can J Diabetes 2015; 39:335-43. [DOI: 10.1016/j.jcjd.2015.04.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 03/23/2015] [Accepted: 04/13/2015] [Indexed: 12/13/2022]
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9
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Lin CH, Lee YS, Huang YY, Hsieh SH, Chen ZS, Tsai CN. Polymorphisms of GLP-1 receptor gene and response to GLP-1 analogue in patients with poorly controlled type 2 diabetes. J Diabetes Res 2015; 2015:176949. [PMID: 25785276 PMCID: PMC4345081 DOI: 10.1155/2015/176949] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2014] [Revised: 12/22/2014] [Accepted: 01/05/2015] [Indexed: 02/01/2023] Open
Abstract
AIM The relationship between genetic polymorphisms of the glucagon-like peptide-1 (GLP-1) receptor (GLP1R) gene and unresponsiveness to GLP-1 analogue treatment in patients with poorly controlled type 2 diabetes mellitus (DM) is unclear. METHODS Thirty-six patients with poorly controlled type 2 DM were enrolled and they received six days of continuous subcutaneous insulin infusion for this study. After the normalization of blood glucose in the first 3 days, the patients then received a combination therapy with injections of the GLP-1 analogue, exenatide, for another 3 days. All 13 exons and intron-exon boundaries of the GLP1R gene were amplified to investigate the association. RESULTS The short tandem repeat at 8GA/7GA (rs5875654) had complete linkage disequilibrium (LD, with r2 = 1) with single nucleotide polymorphism (SNP) rs761386. Quantitative trait loci analysis of GLP1R gene variation with clinical response of GLP1 analogue showed the missense rs3765467 and rs761386 significantly associated with changes in the standard deviation of plasma glucose (SDPG(baseline) - SDPG(treatment with GLP-1 analogue)) (P = 0.041 and 0.019, resp.). The reported P values became insignificant after multiple testing adjustments. CONCLUSION The variable response to the GLP-1 analogue was not statistically correlated with polymorphisms of the GLP1R gene in patients with poorly controlled type 2 DM.
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Affiliation(s)
- Chia-Hung Lin
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan 333, Taiwan
| | - Yun-Shien Lee
- Department of Biotechnology, Ming Chuan University, Taoyuan 333, Taiwan
- Genomic Medicine Research Core Laboratory, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Yu-Yao Huang
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Sheng-Hwu Hsieh
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Chang Gung Memorial Hospital, Taoyuan 333, Taiwan
| | - Zih-Syuan Chen
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan 333, Taiwan
| | - Chi-Neu Tsai
- Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan 333, Taiwan
- *Chi-Neu Tsai:
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Gough SCL, Harris S, Woo V, Davies M. Insulin degludec: overview of a novel ultra long-acting basal insulin. Diabetes Obes Metab 2013; 15:301-9. [PMID: 23240573 DOI: 10.1111/dom.12052] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Revised: 11/19/2012] [Accepted: 12/11/2012] [Indexed: 11/27/2022]
Abstract
All the basal insulin products currently available have suboptimal pharmacokinetic (PK) properties, with none reliably providing a reproducible and peakless pharmacodynamic (PD) effect that endures over 24 h from once-daily dosing. Insulin degludec is a novel acylated basal insulin with a unique mechanism of protracted absorption involving the formation of a depot of soluble multihexamer chains after subcutaneous injection. PK/PD studies show that insulin degludec has a very long duration of action, with a half-life exceeding 25 h. Once-daily dosing produces a steady-state profile characterized by a near-constant effect, which varies little from injection to injection in a given patient. Clinically, insulin degludec has been shown consistently to carry a lower risk of nocturnal hypoglycaemia than once-daily insulin glargine, in both basal+bolus and basal-only insulin regimens. The constancy of the steady-state profile of insulin degludec also means that day-to-day irregularities at the time of injection have relatively little PD influence, thereby offering the possibility of greater treatment flexibility for patients.
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Affiliation(s)
- S C L Gough
- Oxford Centre for Diabetes, Endocrinology and Metabolism and NIHR Oxford Biomedical Research Centre, Oxford, UK.
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11
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Dokken BB. How insulin analogues can benefit patients. Nurse Pract 2013; 38:44-48. [PMID: 23344228 DOI: 10.1097/01.npr.0000425828.67564.10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Primary care providers offer diabetes care for many patients in the United States. Primary care nurse practitioners can benefit from an understanding of effective administration of insulin therapy. This review will outline suggestions for the effective use of insulin analogues in clinical practice.
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12
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Abstract
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.
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Affiliation(s)
- Masakazu Hirose
- Joslin Diabetes Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Elizabeth A. Beverly
- Joslin Diabetes Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Katie Weinger
- Joslin Diabetes Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Jin X, Zeng L, Zhang S, He S, Ren Y, Chen Y, Wei L, Wang L, Li H, Cheng J, Lu Y. Human insulin versus porcine insulin in rhesus monkeys with diabetes mellitus. J Med Primatol 2012; 42:1-9. [PMID: 23106308 DOI: 10.1111/jmp.12025] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/20/2012] [Indexed: 02/05/2023]
Abstract
BACKGROUND Monkeys with insulin-dependent diabetes are important preclinical animal models for islet transplantation. Exogenous insulin should be administered to achieve good glycemic control and minimize the long-term vascular complications associated with diabetes until the graft function recovered completely. However, the effect of multiple daily injections of porcine or human insulin and the long-term effects of porcine insulin have not been studied in diabetic rhesus monkeys. METHODS Diabetic rhesus monkeys, using a 6-month self-control insulin comparison experiment, were used to detect the incidence of adverse events and long-term diabetes complication events after long-term administration of porcine insulin. RESULTS In this study, we found that a 20% higher dose of porcine insulin results in similar glycemic control as the human insulin regimen, and adverse events were seldom reported when porcine insulin was administered. Moreover, long-term injection with porcine insulin could delay the rate and severity of diabetes-related complications. CONCLUSIONS Porcine insulin as a competent candidate for regular insulin therapy to maintain blood glucose levels in insulin-dependent diabetic monkeys during preclinical studies of islet transplantation.
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Affiliation(s)
- Xi Jin
- Key Laboratory of Transplant Engineering and Immunology, Ministry of Health, Regenerative Medicine Research Center, West China Hospital, Sichuan University, Chengdu, China
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Sharrow SD, Glass LC, Dobbins MA. 14-day in vitro chemical stability of insulin lispro in the MiniMed Paradigm pump. Diabetes Technol Ther 2012; 14:264-70. [PMID: 22107252 DOI: 10.1089/dia.2011.0125] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Insulin lispro was subjected to a simulated in-use study in the Medtronic MiniMed Paradigm(®) pump system (Medtronic, Northridge, CA) under stressed conditions over 14 days. METHODS Basal and bolus insulin doses were delivered under conditions of elevated temperature (37°C) and continuous shaking over 14 days. The simulation included a study arm with infusion set changes every 3 days and an arm with no infusion set changes over the entire study period. Analyses were performed on samples pumped through the infusion system and on samples retained in the pump reservoir. RESULTS Results met U.S. Pharmacopeia criteria for insulin lispro potency through the entire testing period. No precipitation was observed on visual inspection, and no occlusion alarms were noted. CONCLUSIONS Insulin lispro demonstrated appropriate physicochemical stability for up to 14 days in the MiniMed Paradigm pump system.
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15
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Bode BW. Comparison of pharmacokinetic properties, physicochemical stability, and pump compatibility of 3 rapid-acting insulin analogues-aspart, lispro, and glulisine. Endocr Pract 2011; 17:271-80. [PMID: 21134878 DOI: 10.4158/ep10260.ra] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To compare how the rapid-acting insulin analogues (RAIAs) aspart, lispro, and glulisine perform in continuous subcutaneous insulin infusion (CSII) therapy regarding (1) pharmacokinetic properties, (2) chemical and physical stability, and (3) pump compatibility. METHODS PubMed was searched for articles pertaining to the use of RAIAs in CSII, without a restriction on the time period. RESULTS These RAIAs have pharmacokinetic profiles that more closely mimic endogenous insulin in comparison with regular human insulin and tend to produce less hypoglycemia. Among these RAIAs, the rates of absorption and clinical efficacy in terms of glycemic control were similar. Although glulisine showed a faster onset of action in some studies with aspart and lispro, this advantage lasted only for a maximum of 1 hour, after which results were similar for glulisine and aspart or lispro. Each RAIA is created by making minor amino acid substitutions to the regular human insulin molecule and adding a stabilizer to help prevent fibrillation. A series of chemical and covalent changes affecting the primary structure of an insulin preparation, however, may cause decomposition during storage, handling, and use, diminishing the potency of the insulin molecule while contained in an insulin pump. Precipitation, fibrillation, and occlusion may ensue, undermining compatibility for CSII pump use. Aspart has demonstrated the greatest chemical and physical stability in the insulin pump, with the lowest rates of overall occlusion in comparison with lispro and glulisine (aspart 9.2%, lispro 15.7%, and glulisine 40.9%; P<.01). CONCLUSION Aspart is the most compatible of the 3 RAIAs for pump use.
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Affiliation(s)
- Bruce W Bode
- Atlanta Diabetes Associates, Atlanta, Georgia, USA.
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16
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Abstract
Drugs are the most frequent cause of hypoglycaemia in adults. Although hypoglycaemia is a well known adverse effect of antidiabetic agents, it may occasionally develop in the course of treatment with drugs used in everyday clinical practice, including NSAIDs, analgesics, antibacterials, antimalarials, antiarrhythmics, antidepressants and other miscellaneous agents. They induce hypoglycaemia by stimulating insulin release, reducing insulin clearance or interfering with glucose metabolism. Several drugs may also potentiate the hypoglycaemic effect of antidiabetic agents. Administration of these agents to individuals with diabetes mellitus is of most concern. Many of these drugs, and depending on clinical setting, may also induce hyperglycaemia. Drug-induced hepatotoxicity and nephrotoxicity may lead in certain circumstances to hypoglycaemia. Some drugs may also induce hypoglycaemia by causing pancreatitis. Drug-induced hypoglycaemia is usually mild but may be severe. Effective clinical management can be handled through awareness of this drug-induced adverse effect on blood glucose levels. Herein, we review pertinent clinical information on the incidence of drug-induced hypoglycaemia and discuss the underlying pathophysiological mechanisms, and prevention and management.
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Affiliation(s)
- Chaker Ben Salem
- Department of Clinical Pharmacology, Faculty of Medicine of Sousse, and Medical Intensive Care Unit, Sahloul University Hospital, Sousse, Tunisia.
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17
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Kesavadev J, Das AK, Unnikrishnan R, Joshi SR, Ramachandran A, Shamsudeen J, Krishnan G, Jothydev S, Mohan V. Use of insulin pumps in India: suggested guidelines based on experience and cultural differences. Diabetes Technol Ther 2010; 12:823-31. [PMID: 20807118 PMCID: PMC2956384 DOI: 10.1089/dia.2010.0027] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
All type 1 diabetes mellitus (T1DM) subjects and the majority of type 2 diabetes mellitus (T2DM) subjects at one time or another require insulin to sustain life. Syringes and pens are presently the most popular insulin delivery devices. Though in use for more than 3 decades, insulin pumps are now being more commonly used because of their unique ability to continuously infuse insulin, closely mimicking that of physiological secretion from a normal pancreas. Unlike insulin shots with syringes, pump infusion sites need to be changed less frequently. Scientific evidence from published studies have proven added benefit of insulin pumps in improving quality of life, normalizing sugars in recalcitrant diabetes, improving sexual function, and relieving the intractable pain of neuropathy. In the western world, pumps are commonly used with T1DM subjects, whereas in India 80% of pumpers are T2DM subjects. The success of insulin pump therapy depends on selection of the right candidate, extensive education, motivation, and implementing the sophisticated programs with skill. However, all affordable patients are not ideal candidates for pump therapy because for successful continuation of pump therapy other inclusion criteria should also be fulfilled. Among the other indications discussed are a high level of insulin resistance, brittle diabetes, chronic kidney disease on renal replacement therapy, and continuous glucose monitoring pattern strongly suggesting need for a variable basal insulin infusion rate. In International Diabetes Foundation data released in 2009, estimated diabetes prevalence for 2010 is 285 million, representing 6.4% of the world's adult population, with a prediction that by 2030 the number of people with diabetes will have increased to 438 million. Considering this massive growth in T2DM and its propensity after 10–15 years to lead to an insulin-deficient state, available evidence from studies is a compelling indication not to deny the benefits of continuous subcutaneous insulin infusion in selected T2DM subjects. This article aims at suggesting guidelines based on clinical experience and cultural diversity for India and developing countries.
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18
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Abstract
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.
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19
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Anarte M, Ruiz de Adana M, Carreira M, Domínguez-López M, Machado A, González-Molero I, Caballero F, de la Higuera M, González-Romero S, Sánchez I, Soriguer F. Estudio longitudinal del impacto del tratamiento con infusores de insulina en variables psicológicas, la calidad de vida el control glucémico de pacientes con diabetes mellitus tipo 1. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/s1134-3230(10)62008-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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20
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Scaramuzza AE, Iafusco D, Santoro L, Bosetti A, De Palma A, Spiri D, Mameli C, Zuccotti GV. Timing of bolus in children with type 1 diabetes using continuous subcutaneous insulin infusion (TiBoDi Study). Diabetes Technol Ther 2010; 12:149-52. [PMID: 20105045 DOI: 10.1089/dia.2009.0117] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Continuous subcutaneous insulin infusion is considered a safe and effective way to administer insulin in pediatric patients with type 1 diabetes, but achieving satisfactory and stable glycemic control is difficult. Several factors contribute to control, including fine-tuning the basal infusion rate and bolus timing. We evaluated the most effective timing of a pump-delivered, preprandial bolus in children with type 1 diabetes. METHODS We assessed the response of 30 children with type 1 diabetes to a standard meal after different timing of a bolus dose. RESULTS The glucose levels for 3 h after the meal were lower (i.e., closer to the therapeutic target of <140 mg/dL) when the bolus doses were administered 15 min or immediately before the meal, rather than after the meal. However, these differences were not statistically significant, except at the 1-h postprandial time point: bolus just after meal, 177 +/- 71 mg/dL (9.83 +/- 3.94 mmol/L); 15 min before meal, 136 +/- 52 mg/dL (7.55 +/- 2.89 mmol/L) (P = 0.044); and just before meal, 130 +/- 54 mg/dL (7.22 +/- 3.00 mmol/L) (P = 0.024). The area under the curve (AUC) (in mg/min) did not differ significantly with different bolus times, but the SD of the AUC was the lowest with the bolus given 15 min before the meal. CONCLUSIONS These data support injection of the bolus before, rather than after, eating, even if the patient is hypoglycemic before meals.
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Affiliation(s)
- Andrea E Scaramuzza
- Department of Paediatrics, University of Milano, Ospedale Luigi Sacco, 20154 Milan, Italy.
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21
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Drab S. Translating clinical guidelines into clinical practice: Role of the pharmacist in type 2 diabetes management. J Am Pharm Assoc (2003) 2009; 49:e152-62. [DOI: 10.1331/japha.2009.08181] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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22
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Abstract
Insulin analogues were developed to try and achieve more physiological insulin replacement from injection in the subcutaneous site. Their pharmacokinetics and pharmacodynamics differ from human insulin when injected subcutaneously because of alterations in the amino acid sequence of the insulin molecule. The rapid-acting insulin analogues, lispro, aspart and glulisine, have a rapid onset of action and shorter duration of action because of changes to the B26-30 portion of insulin inhibiting formation of dimers and hexamers. They appear to improve postprandial glucose, incidence of hypoglycaemia and patient satisfaction and, when used in combination with basal insulin analogues, improve glycosylated haemoglobin in comparison to conventional insulin therapy. Additionally, they have been successfully used in children, pregnant women, in pump therapy and as part of premixed biphasic regimens. The two basal insulin analogues, glargine and detemir, developed by adjusting the isoelectric point and adding a fatty acid residue, respectively, have a protracted duration of action and a relatively smooth profile. Their pharmacokinetic and pharmacodynamic profiles have been assessed using euglycaemic clamp protocols. Both analogues have a longer duration of action, less of a peak of activity and a reduced variability with repeated injection. There is some evidence to suggest that detemir may have a slight hepatoselective effect. Clinical studies have shown a lower relative risk of hypoglycaemia and detemir appears to have a weight-sparing action. Insulin analogues represent a successful example of applied medical science.
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Affiliation(s)
- B Sheldon
- Centre for Diabetes, Endocrinology & Research (CEDAR), Royal Surrey County Hospital, University of Surrey, Guildford, UK.
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