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Abstract
Diabetic ketoacidosis (DKA) is the most common acute hyperglycaemic emergency in people with diabetes mellitus. A diagnosis of DKA is confirmed when all of the three criteria are present - 'D', either elevated blood glucose levels or a family history of diabetes mellitus; 'K', the presence of high urinary or blood ketoacids; and 'A', a high anion gap metabolic acidosis. Early diagnosis and management are paramount to improve patient outcomes. The mainstays of treatment include restoration of circulating volume, insulin therapy, electrolyte replacement and treatment of any underlying precipitating event. Without optimal treatment, DKA remains a condition with appreciable, although largely preventable, morbidity and mortality. In this Primer, we discuss the epidemiology, pathogenesis, risk factors and diagnosis of DKA and provide practical recommendations for the management of DKA in adults and children.
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Affiliation(s)
- Ketan K Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Colney Lane, Norwich, Norfolk, UK.,Norwich Medical School, University of East Anglia, Norfolk, UK
| | - Nicole S Glaser
- Department of Pediatrics, University of California Davis, School of Medicine, Sacramento, CA, USA
| | - Ethel Codner
- Institute of Maternal and Child Research, School of Medicine, University of Chile, Santiago, Chile
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Moreno-Fernandez J, Gomez FJ, Pinés P, González J, López J, López LM, Blanco B, Roa C, Herranz S, Muñoz-Rodríguez JR. Continuous Subcutaneous Insulin Infusion in Adult Type 1 Diabetes Mellitus Patients: Results from a Public Health System. Diabetes Technol Ther 2019; 21:440-447. [PMID: 31199682 DOI: 10.1089/dia.2019.0097] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Aims: To analyze prevalence and clinical effect of continuous subcutaneous insulin infusion (CSII) in adult type 1 diabetes mellitus (T1DM) patients in a public health system real-world scenario. Materials and Methods: All adult T1DM patients on CSII being followed at Castilla-La Mancha Health Public Service were included. Primary efficacy outcome was the change in HbA1c during the follow-up. Secondary efficacy outcomes included evaluation of the following variables: insulin pump indications, diabetes complication rates, insulin and pump use, continuous glucose monitoring use, patients achieving an HbA1c decrease ≥6 mmol/mol (0.5%) with or without severe hypoglycemia, and discontinuations. Direct patient data were typed through the web-based Spanish national registry on CSII therapy by nine diabetologists from eight different health care areas. Results: A total of 7% of T1DM adult patients were treated with insulin pumps in our region, with a regional prevalence of 18.7 CSII patients/100,000 inhabitants. Three hundred thirteen patients were analyzed with a mean age of 34.1 ± 11.0 years and T1DM duration of 16.6 ± 9.7 years. Mean duration of CSII therapy was 6.2 ± 4.0 years. Data completion was 91.2%. Main indications for treatment were high glucose variability (36%) and suboptimal glycemic control (32%). Mean duration of CSII therapy was 6.2 ± 4.0 years. Sensor-augment pump therapy was used by 26% of the patients. Glycated hemoglobin decreased to -5 mmol/mol (95% CI -6 to -3 mmol/mol; P < 0.001) during the follow-up (Mean difference in change -0.4%, 95% CI -0.5 to -0.2; P < 0.001). Percentage of patients with severe hypoglycemia decreased from 32% to 13% (P < 0.001). Frequent nonsevere hypoglycemia, severe hypoglycemia, and diabetic ketoacidosis were less frequent among patients using higher number of daily basal rates at the study end. The rate of CSII interruption was 3.8%. Conclusions: Prevalence of CSII therapy in our region remains under 10% of adult T1DM patients, although CSII treatment was associated with a sustained improvement in glycemic control.
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Affiliation(s)
- Jesus Moreno-Fernandez
- 1Service of Endocrinology and Nutrition, Ciudad Real General University Hospital, Ciudad Real, Spain
| | - Francisco Javier Gomez
- 2Service of Endocrinology and Nutrition, La Mancha-Centro General Hospital, Ciudad Real, Spain
| | - Pedro Pinés
- 3Service of Endocrinology and Nutrition, Albacete University Hospital, Albacete, Spain
| | - Javier González
- 4Service of Endocrinology and Nutrition, Virgen de la Luz Hospital, Cuenca, Spain
| | - José López
- 5Service of Endocrinology and Nutrition, Virgen de la Salud Hospital, Toledo, Spain
| | - Luz María López
- 3Service of Endocrinology and Nutrition, Albacete University Hospital, Albacete, Spain
| | - Benito Blanco
- 6Service of Endocrinology and Nutrition, Nuestra Señora del Prado Hospital, Toledo, Spain
| | - Carlos Roa
- 7Service of Endocrinology and Nutrition, Santa Barbara Hospital, Ciudad Real, Spain
| | - Sandra Herranz
- 8Service of Endocrinology and Nutrition, Guadalajara University Hospital, Guadalajara, Spain
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Kampmann U, Madsen LR, Bjerg L, Witte DR, Hasselstrøm K, Østergård T, Alstrup K, Møller MK, Dylmer D, Hansen KW. Prevalence and geographical distribution of insulin pump therapy in the Central Denmark Region and its association with metabolic parameters. Diabetes Res Clin Pract 2018; 141:148-155. [PMID: 29733870 DOI: 10.1016/j.diabres.2018.04.042] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 04/10/2018] [Accepted: 04/26/2018] [Indexed: 10/17/2022]
Abstract
AIMS Insulin treatment in type 1 diabetes encompasses multiple daily insulin injections (MDI) or continuous subcutaneous insulin infusion (CSII). Both population-based studies and comparative studies regarding CSII use are sparse. The aim of the current study was to describe the prevalence and distribution of CSII use among adults with type 1 diabetes in the Central Denmark Region and to compare metabolic control in CSII-treated patients to those treated with MDI. METHODS A database was constructed using the Danish Adult Diabetes Registry in 2014/2015 in combination with an audit of the patients' medical records. RESULTS 3909 adults with type 1 diabetes patients were included. The proportion of patients treated with CSII differed significantly between the 8 regional hospitals from 12.0% to 31.1%. CSII users had a significantly lower HbA1c compared to MDI treated patients (7.6% (60 mmol/mol) versus 8.0% (64 mmol/mol)) in unadjusted analyses. After adjustment for clinically relevant characteristics the difference between CSII and MDI-treated patients was attenuated, but remained statistically significant. CONCLUSION The distribution of CSII differed markedly between hospitals and CSII users had better glycemic control, even after adjustment for sex, age, BMI, diabetes duration, smoking, use of lipid-lowering and blood pressure-lowering medication.
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Affiliation(s)
- Ulla Kampmann
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Denmark.
| | - Lene Ring Madsen
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Denmark
| | - Lasse Bjerg
- Department of Public Health, Section of General Practice, Aarhus University, Denmark; Department of Clinical Epidemiology, Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | - Daniel R Witte
- Department of Public Health, Section of General Practice, Aarhus University, Denmark; Danish Diabetes Academy, Odense, Denmark
| | | | - Torben Østergård
- Department of Internal Medicine, Viborg Regional Hospital, Denmark
| | - Kirsten Alstrup
- Department of Internal Medicine, Randers Regional Hospital, Denmark
| | | | - Dorrit Dylmer
- Department of Internal Medicine, Holstebro Regional Hospital, Denmark
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Beato-Víbora P, Chico-Ballesteros A, Giménez M, Guerrero-Vázquez R, Barrio-Castellanos R, Goñi-Iriarte MJ, Díaz-Soto G, Merino-Torres JF, Moreno-Fernández J, Martínez-Brocca MA. A national survey on the efficacy and safety of continuous subcutaneous insulin infusion in patients with type 1 diabetes in Spain. Diabetes Res Clin Pract 2018; 137:56-63. [PMID: 29278712 DOI: 10.1016/j.diabres.2017.12.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2017] [Revised: 11/29/2017] [Accepted: 12/12/2017] [Indexed: 11/15/2022]
Abstract
AIMS To assess safety and benefits of continuous subcutaneous insulin infusion (CSII) therapy in a cohort of type 1 diabetes patients in Spain. METHODS A web-based national registry was created by the Working Group of the Spanish Diabetes Association. All patients on CSII being followed at selected referral centers were included. A cross-sectional analysis was performed. RESULTS A total of 1275 patients were included. Data completion for patients on CSII was 67 ± 32%. Indications for treatment were suboptimal glycemic control (32%), high glucose variability (24%), preconception care (14%) and hypoglycemia (11%). In the patients on CSII for ≥1 year (n = 843, mean CSII duration of 5 years), HbA1c decreased by 5 mmol/mol (0.5%) in the whole population and by 8 mmol/mol (0.7%) in subjects with suboptimal glycemic control as CSII indication. Percentage of patients achieving HbA1c ≤ 53 mmol/mol (7%) increased from 20% before CSII to 34% at the end of follow-up. Severe hypoglycemia decreased from 29% to 5%. The rate of discontinuation was 9.5%. HbA1c was lower in patients using bolus advisor and temporary basal rates. CONCLUSIONS CSII was associated with a sustained improvement in glycemic control and a reduction in severe hypoglycemia. The use of advanced CSII settings was related to better glycemic control.
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Dogan ADA, Jørgensen UL, Gjessing HJ. Diabetic Ketoacidosis Among Patients Treated With Continuous Subcutaneous Insulin Infusion. J Diabetes Sci Technol 2017; 11:631-632. [PMID: 27595713 PMCID: PMC5505411 DOI: 10.1177/1932296816668375] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | - Hans Jørgen Gjessing
- Medical Department, Fredericia Hospital, Fredericia, Denmark
- Hans Jørgen Gjessing, MD, PhD, Medical Department, Fredericia Hospital, 7000 Fredericia, Denmark.
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Lessons from type 1 diabetes for understanding natural history and prevention of autoimmune disease. Rheum Dis Clin North Am 2014; 40:797-811. [PMID: 25437293 DOI: 10.1016/j.rdc.2014.07.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Type 1 diabetes (T1D) is a chronic autoimmune disorder resulting from immune-mediated destruction of insulin-producing beta cells within the pancreatic islets. Prediction of T1D is now possible, as having 2 or more islet autoantibodies confers a 100% risk of diabetes development. With the ability to predict disease development, clinical trials to prevent diabetes onset have been completed and are currently under way. This review focuses on the natural history, prediction, and prevention trials in T1D. We review the lessons learned from these attempts at preventing a chronic autoimmune disease and apply the paradigm from T1D prevention to other autoimmune disorders.
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Joubert M, Morera J, Vicente A, Rod A, Parienti JJ, Reznik Y. Cross-sectional survey and retrospective analysis of a large cohort of adults with type 1 diabetes with long-term continuous subcutaneous insulin infusion treatment. J Diabetes Sci Technol 2014; 8:1005-10. [PMID: 24876454 PMCID: PMC4455364 DOI: 10.1177/1932296814537040] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. Continuous subcutaneous insulin infusion (CSII) is an established modality for intensive insulin treatment of type 1 diabetes (T1D), but long-term data concerning satisfaction, CSII function use, safety, and efficacy in real-life conditions are scarce. Methods. We analyzed a cohort of adult patients with T1D treated with CSII for more than 1 year in a single diabetes center. We performed a cross-sectional survey in 2010 (tolerance/satisfaction and behavior forms) and a retrospective analysis of medical records (including HbA1c level, hospitalization, and catheter infections). The primary objective was to assess long-term tolerance/satisfaction, and secondary objectives were safety and efficacy. Results. There were 295 patients analyzed. After a median duration of CSII use of 5 years, overall satisfaction was high for about 90% of patients. Mean CSII-related discomfort scores were low for work, recreation, and sleep and moderate for sport and sexual activity (2.5 ± 1.9, 2.6 ± 1.8, 2.6 ± 2.1, 3.4 ± 2.3, and 4.0 ± 2.9 of 10, respectively). Despite a high level of diabetes education, only one third of patients were using advanced CSII functions. During long-term follow-up, the safety of CSII treatment was good; the hospitalization rate was 0.18 patients/year, and catheter infections were scarce. The HbA1c level dropped about -0.5% independently from CSII duration (P < .05). Conclusions. In this adult cohort, satisfaction and tolerance, together with safety, of CSII were maintained at long-term follow up. The sole basic functions of CSII were currently used by patients. A 0.5% decrease in the HbA1c level was maintained during the study period.
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Affiliation(s)
- Michael Joubert
- Endocrinology Department, Caen University Hospital, Caen, France
| | - Julia Morera
- Endocrinology Department, Caen University Hospital, Caen, France University of Caen (UNICAEN), Caen, France
| | - Angel Vicente
- Endocrinology Department, Caen University Hospital, Caen, France
| | - Anne Rod
- Endocrinology Department, Caen University Hospital, Caen, France
| | - Jean-Jacques Parienti
- University of Caen (UNICAEN), Caen, France Research and Biostatistic Department, Caen University Hospital, Caen, France
| | - Yves Reznik
- Endocrinology Department, Caen University Hospital, Caen, France University of Caen (UNICAEN), Caen, France
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Janez A. Continuous subcutaneous insulin infusion in adult type 1 diabetes mellitus: data from a registry at the University Medical Centre Ljubljana, Slovenia. J Int Med Res 2013; 40:1546-51. [PMID: 22971507 DOI: 10.1177/147323001204000434] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To evaluate the treatment indications, effectiveness and adverse events of continuous subcutaneous insulin infusion (CSII) in adults with type 1 diabetes mellitus using data from a registry at the University Medical Centre Ljubljana, Ljubljana, Slovenia. METHODS The registry included patients with type 1 diabetes who had converted from multiple daily injection (MDI) to CSII. Patients with complete data sets covering a period of ≥3 years were included in the study (n=184). Complications, glycaemic control and insulin dose during CSII were compared with data obtained during MDI. RESULTS CSII resulted in significant reductions in glycosyated haemoglobin level and total daily insulin dose. The mean number of severe hypoglycaemic episodes during CSII was 0.17 per patient per year. CONCLUSIONS Treatment of adults with type 1 diabetes mellitus by CSII can improve glycaemic control and reduce insulin requirements compared with MDI, however patient selection, education and continuous care are important parts of this therapy.
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Affiliation(s)
- A Janez
- Department of Endocrinology, Diabetes and Metabolic Diseases, University Medical Centre Ljubljana, Zaloska 7, SI-1000 Ljubljana, Slovenia.
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Jankovec Z, Hahn M, Grunder S, Lacigova S, Cechurova D, Krcma M, Zourek M, Haladova I, Rusavy Z. Analysis of continuous patient data from the Czech National Register of patients with type 1 and type 2 diabetes using insulin pump therapy. Diabetes Res Clin Pract 2010; 87:219-23. [PMID: 19853948 DOI: 10.1016/j.diabres.2009.09.028] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Revised: 09/24/2009] [Accepted: 09/28/2009] [Indexed: 12/01/2022]
Abstract
AIM Patient data from the Czech National Register of patients treated with Continuous Subcutaneous Insulin Infusion (CSII) were evaluated to compare treatment indication, efficacy and safety with specific regard to the type of diabetes (T1 vs. T2). METHODS Evaluation was done on complete data sets of at least 3 years from patients with either T1 diabetes (n=730, 93.1%) or T2 diabetes (n=54, 6.9%) between 1995 and 2006. RESULTS HbA(1c) decreased from 9.65 (+/-0.07) and 9.66 (+/-0.05) for T1 and T2 respectively to 8.24 (+/-0.07) for T1 and 8.52 (+/-0.27) for T2 after 1 year of treatment, 8.34 (+/-0.07) and 8.54 (+/-0.26) after 2 years and 8.44 (+/-0.07) and 8.71 (+/-0.25) after 3 years (adjusted mean values, +/-SEM). This reduction is significant for both diabetes types. Results gathered from the safety analysis revealed almost comparable results for both patient groups (rates of adverse events of 42.5 and 34.8 for T1 and T2, per 100 patients and year). CONCLUSION Both patient groups achieved substantial reduction of HbA(1c). Safety evaluation showed that fewer patients with T2 diabetes were affected by adverse events. According to that CSII treatment for patients with T2 diabetes is similarly effective with a slightly better safety profile.
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Affiliation(s)
- Z Jankovec
- Medical Department I, University Hospital and Medical Faculty of Charles University, Plzen, Czech Republic.
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Al Hemaidi N, Wagdi M, Al Ali M, Soliman A, Al Zyoud M. Use of Insulin Pump in Children with Type I Diabetes Mellitus: Effect on Glycemic Control and Body Mass Indices (BMI). Qatar Med J 2008. [DOI: 10.5339/qmj.2008.2.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
To assess the effect of an insulin pump on the glycemic control as well as the body mass index (BMI) of children with type 1 diabetes mellitus (DM1), 23 patients under the age of 18 years were monitored for one year or more. HbAlc concentration decreased from 9.36+/- 2.02% to 8.54+/-1.149%. The BMI increased significantly from 17.12+/- 2.236 to 20.4+1- 2.93. No hypoglycemia was reported in any of the patients after using the pump. Three incidences of diabetic-ketoacidosis (DKA) were reported due to two pump malfunctions and one patient error. All except two wanted to continue with the pump because of the desirable flexibility of their lifestyle including activity and meal times.
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Affiliation(s)
- N. Al Hemaidi
- Pediatrics Department, Hamad Medical Corporation Doha, Qatar
| | - M. Wagdi
- Pediatrics Department, Hamad Medical Corporation Doha, Qatar
| | - M. Al Ali
- Pediatrics Department, Hamad Medical Corporation Doha, Qatar
| | - A. Soliman
- Pediatrics Department, Hamad Medical Corporation Doha, Qatar
| | - M. Al Zyoud
- Pediatrics Department, Hamad Medical Corporation Doha, Qatar
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Hanas R, Ludvigsson J. Hypoglycemia and ketoacidosis with insulin pump therapy in children and adolescents. Pediatr Diabetes 2006; 7 Suppl 4:32-8. [PMID: 16774616 DOI: 10.1111/j.1399-543x.2006.00169.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
This review deals with the two most serious side effects encountered with insulin pump therapy, severe hypoglycemia and diabetic ketoacidosis (DKA). Although clinical follow-up studies reported decreased rates of severe hypoglycemia, randomized studies have not confirmed this, showing no difference between the pump and injection groups. Less-severe hypoglycemia (mild/moderate/symptomatic hypoglycemia) was found to be more common with pump use. Some patients have inadvertently dosed or overdosed while awake or during sleep, causing fatal outcome in rare cases. Population-based or retrospective clinical studies reported a low rate of DKA in pump users that was still a higher rate than those using injection therapy, at least in some countries. In research settings and for patients with good compliance and adequate family support, the risk of DKA seems lower; many short-term studies report no DKA at all, possibly due to the increased attention given to participants. The use of continuous subcutaneous insulin infusion (CSII) seems to decrease the risk in patients who had recurrent DKA before pump start. Most episodes of DKA occur early after pump start, suggesting a learning curve occurs in all new forms of treatment. Increased teaching and awareness programs are vital to prevent severe hypoglycemia and DKA in children and adolescents using insulin pumps.
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Affiliation(s)
- Ragnar Hanas
- Department of Pediatrics, Uddevalla Hospital, Uddevalla, Sweden.
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Poulsen C, Langkjaer L, Worsøe C. Precipitation of insulin products used for continuous subcutaneous insulin infusion. Diabetes Technol Ther 2005; 7:142-50. [PMID: 15738712 DOI: 10.1089/dia.2005.7.142] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Commercially available insulin products used for continuous subcutaneous insulin infusion have been compared with respect to resistance towards isoelectric insulin precipitation. METHODS The degree of isoelectric insulin precipitation of insulin aspart injection (IAsp), insulin lispro injection (ILis), and buffered human regular insulin injection (BHR) was examined while reducing pH through addition of diluted HCl or exposure to CO2. RESULTS The pH at which defined fractions of the insulins precipitated differed among the three products; 10% and 90% precipitation, respectively, was observed at pH 6.41 and pH 6.30 for ILis, pH 6.18 and pH 5.95 for BHR, and pH 5.90 and pH 5.67 for IAsp, in accordance with the isoelectric points of these insulin species. The amount of H(+)-equivalents per microliter of product to reach 10% precipitation was found to be highest for IAsp (5.49 nmol of H(+)-equivalents), with ILis and BHR almost equivalent to each other (4.46 and 4.32 nmol of H(+)-equivalents, respectively). Exposure to a CO2-enriched environment resulted in the same order of insulin precipitation of the three products as tested with HCl. CONCLUSIONS Resistance towards isoelectric precipitation is highest for IAsp, lowest for ILis, and intermediate for BHR. Isoelectric precipitation will alter the pharmacokinetic properties of the insulin and could lead to occlusion of the infusion catheter, causing elevated blood glucose and ultimately causing diabetic ketoacidosis if no intervention is made. Causal relationships between the observed differences in resistance towards isoelectric precipitation of the insulin products, the mechanism behind catheter occlusion, and the clinical relevance of the observations require further studies.
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Affiliation(s)
- Christian Poulsen
- Department of Pharmaceutics, Ba., Novo Nordisk A/S, Bagsvaerd, Denmark.
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Current literature in diabetes. Diabetes Metab Res Rev 2003; 19:333-40. [PMID: 12879412 DOI: 10.1002/dmrr.349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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