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Alvarenga CS, La Banca RO, Neris RR, de Cássia Sparapani V, Fuentealba-Torres M, Cartagena-Ramos D, Leal CL, Esper MV, Nascimento LC. Use of continuous subcutaneous insulin infusion in children and adolescents with type 1 diabetes mellitus: a systematic mapping review. BMC Endocr Disord 2022; 22:43. [PMID: 35183150 PMCID: PMC8858488 DOI: 10.1186/s12902-022-00950-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 01/24/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Among the treatments for type 1 diabetes mellitus (T1DM), Continuous Subcutaneous Insulin Infusion (CSII) is a device that infuses insulin through the subcutaneous tissue in an uninterrupted manner and that comes closest to the physiological secretion of insulin. The use of CSII can provide the family with greater security and children and adolescents have more autonomy in relation to the treatment of T1DM. There is a lack of reviews that systematically gather the mounting evidence about the use of CSII in children and adolescents with T1DM. Therefore, the aim of this review was to group and describe primary and secondary studies on the use of CSII in children and adolescents with T1DM. METHODS A systematic mapping review was performed based on searches in the following databases: PubMed, Embase, CINAHL, Lilacs and PsycINFO, using a combination of descriptors and keywords. The screening of the studies was carried out with the aid of the Rayyan software and reading in full was conducted independently by two reviewers. The data extraction of the studies was performed using an extraction tool adapted and validated by researchers specialized in diabetes. The data were analyzed according to the content analysis technique. The map from geocoding of the studies was produced using the ArcGis 10.5 software. RESULTS A total of 113 studies were included in the review, including primary studies, literature reviews and gray literature publications. The content analysis of the results of the studies allowed for the identification of four categories: 1) metabolic control; 2) support networks; 3) benefits of using CSII; and 4) challenges of using CSII, each category having its respective subcategories. The review also made it possible to conduct a rigorous mapping of the literature on the use of CSII considering the location of development and the design of the studies. CONCLUSIONS The use of CSII should be indicated by health professionals able to prepare children, adolescents, and their families for the treatment of T1DM, and, despite being a technological device, it may not be suitable for the entire pediatric population.
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Affiliation(s)
- Carolina Spinelli Alvarenga
- Public Health Nursing Graduate Program, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, SP Brazil
| | | | - Rhyquelle Rhibna Neris
- Public Health Nursing Graduate Program, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, SP Brazil
| | | | | | | | - Camila Lima Leal
- Public Health Nursing Graduate Program, University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, SP Brazil
| | - Marcos Venicio Esper
- Interunit Doctoral Program in Nursing, University of São Paulo College of Nursing and the University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, SP Brazil
| | - Lucila Castanheira Nascimento
- Maternal-Infant and Public Health Nursing Department, University of São Paulo at Ribeirão Preto College of Nursing, PAHO/WHO Collaborating Centre for Nursing Research Development, 3900 Av. Bandeirantes, Campus Universitário - Bairro Monte Alegre, Ribeirão Preto, São Paulo 14040-902 Brazil
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Lindmeyer AM, Meier JJ, Nauck MA. Patients with Type 1 Diabetes Treated with Insulin Pumps Need Widely Heterogeneous Basal Rate Profiles Ranging from Negligible to Pronounced Diurnal Variability. J Diabetes Sci Technol 2021; 15:1262-1272. [PMID: 32806947 PMCID: PMC8655281 DOI: 10.1177/1932296820949939] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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 Pump-treated patients with type 1 diabetes have widely differing basal insulin infusion profiles. We analyzed consequences of such heterogeneity for glycemic control under fasting conditions. METHODS Data from 339 adult patients with type 1 diabetes on insulin pump therapy undergoing a 24-hour fast (basal rate test) were retrospectively analyzed. Hourly programmed basal insulin infusion rates and plasma glucose concentrations as well as their proportions within, below, or above arbitrarily defined target ranges were assessed for specific periods of the day (eg, 1-7 hours, "dawn" period, 16-19 hours, "dusk" period, reference period 20-1 hours/10-14 hours), by tertiles of a predefined "dawn" index (mean basal insulin infusion rate during the "dawn" divided by the reference periods). RESULTS The "dawn" index varied interindividually from 0.7 to 4.4. Basal insulin infusion profiles exhibited substantial differences (P = .011), especially overnight. Despite higher insulin infusion rates at 4 and 6.45 hours, patients with the most pronounced "dawn" phenomenon exhibited higher plasma glucose concentrations at those time points (P < .012). Patients with a marked "dawn" phenomenon exhibited a lower probability for low (<4.4 mmol/L) and a higher probability of high values (>7.2 mmol/L) during the dawn period (all P values <.01). CONCLUSIONS We observe substantial interindividual heterogeneity in the "dawn" phenomenon. However, widely different empirically derived basal insulin infusion profiles appear appropriate for individual patients, as indicated by similar plasma glucose concentrations, mainly in the target range, during a 24-hour fasting period.
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Affiliation(s)
- Anna M. Lindmeyer
- Diabetes Division, Katholisches Klinikum
Bochum, St. Josef-Hospital, Klinikum der Ruhr-Universität Bochum, Germany
- Anna M. Lindmeyer, MD, Department of
Medicine I, Diabetes Division, St. Josef-Hospital (Ruhr University Bochum),
Gudrunstr. 56, Bochum, NRW 44791, Germany.
| | - Juris J. Meier
- Diabetes Division, Katholisches Klinikum
Bochum, St. Josef-Hospital, Klinikum der Ruhr-Universität Bochum, Germany
| | - Michael A. Nauck
- Diabetes Division, Katholisches Klinikum
Bochum, St. Josef-Hospital, Klinikum der Ruhr-Universität Bochum, Germany
- Diabeteszentrum Bad Lauterberg, Bad
Lauterberg im Harz, Germany
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3
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Nauck MA, Kahle-Stephan M, Lindmeyer AM, Wenzel S, Meier JJ. Prediction of Individual Basal Rate Profiles From Patient Characteristics in Type 1 Diabetes on Insulin Pump Therapy. J Diabetes Sci Technol 2021; 15:1273-1281. [PMID: 33251851 PMCID: PMC8655298 DOI: 10.1177/1932296820972691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Basal rate profiles in patients with type 1 diabetes on insulin pump therapy are subject to enormous inter-individual heterogeneity. Tools to predict basal rates based on clinical characteristics may facilitate insulin pump therapy. METHODS Data from 339 consecutive in-patients with adult type 1 diabetes on insulin pump therapy were collected. Basal rate tests were performed over 24 hours. A mathematical algorithm to predict individual basal rate profiles was generated by relating the individual insulin demand to selected clinical characteristics in an exploratory cohort of 170 patients. The predicted insulin pump profiles were validated in a confirmatory cohort of 169 patients. FINDINGS Basal rates (0.27 ± 0.01 IU.d-1.kg-1) showed circadian variations with peaks corresponding to the "dawn" and "dusk" phenomena. Age, gender, duration of pump treatment, body-mass-index, HbA1c, and triacylglycerol concentrations largely predicted the individual basal insulin demand per day (IU/d; exploratory vs prospective cohorts: r2 = 0.518, P < .0001). Model-predicted and actual basal insulin rates were not different (exploratory cohort: Δ 0.1 (95% CI -0.9; 1.0 U/d; P = .95; prospective cohort: Δ -0.5 (95% CI -1.5; 0.6 IU/d; P = .46). Similarly, precise predictions were possible for each hour of the day. Actual and predicted "dawn" index correlated significantly in the exploratory but not in the confirmatory cohort. INTERPRETATION Clinical characteristics predict 52% of the variation in individual basal rate profiles, including their diurnal fluctuations. The multivariate regression model can be used to initiate or optimize insulin pump treatment in patients with type 1 diabetes.
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Affiliation(s)
- Michael A. Nauck
- Diabetes Center Bad Lauterberg, Bad
Lauterberg im Harz, Germany
- Diabetes Division, Katholisches Klinikum
Bochum, St. Josef-Hospital, Klinikum der Ruhr-Universität Bochum, Bochum,
Germany
- Michael A. Nauck, MD, Diabetes Division,
Katholisches Klinikum Bochum, St. Josef-Hospital (Ruhr University Bochum),
Gudrunstr. 56, Bochum, NRW 44791, Germany.
| | - Melanie Kahle-Stephan
- Diabetes Center Bad Lauterberg, Bad
Lauterberg im Harz, Germany
- Diabetes Division, Katholisches Klinikum
Bochum, St. Josef-Hospital, Klinikum der Ruhr-Universität Bochum, Bochum,
Germany
| | - Anna M. Lindmeyer
- Diabetes Division, Katholisches Klinikum
Bochum, St. Josef-Hospital, Klinikum der Ruhr-Universität Bochum, Bochum,
Germany
| | - Sina Wenzel
- Diabetes Division, Katholisches Klinikum
Bochum, St. Josef-Hospital, Klinikum der Ruhr-Universität Bochum, Bochum,
Germany
| | - Juris J. Meier
- Diabetes Division, Katholisches Klinikum
Bochum, St. Josef-Hospital, Klinikum der Ruhr-Universität Bochum, Bochum,
Germany
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4
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Demir G, Atik Altınok Y, Özen S, Darcan Ş, Gökşen D. Initial Basal and Bolus Rates and Basal Rate Variability During Pump Treatment in Children and Adolescents. J Clin Res Pediatr Endocrinol 2021; 13:198-203. [PMID: 33374094 PMCID: PMC8186333 DOI: 10.4274/jcrpe.galenos.2020.2020.0171] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE Pump-treated children with type 1 diabetes (T1DM) have widely differing basal insulin (BI) infusion profiles for specific periods of the day. The pattern of BI requirements depends on the timing and magnitude of cortisol and growth hormone secretion within each age group. In adolescents and young adults, a decreased insulin sensitivity is seen, particularly in the early morning (dawn phenomenon) and to a lesser extent, in the late afternoon (dusk phenomenon). Different approaches exist for the inititation of basal rates. However, there is a lack of evidence-based recommendation, especially in young children. Usually the basal rates are set equally throughout day and night or the day is divided into tertiles. The aim of this study was to analyze the change of the initial, equally distributed, BI rates over the first year of standard insulin pump therapy. METHODS A total of 154 patients with T1DM, aged between 0 and <21 years at diagnosis, from a single center were documented. Patients were divided into five age groups according to age at pump initiation: group 1, <5 years (n=36); group 2, 5-8 years (n=20); group 3, 8-15 years (n=74); group 4, 15-18 years, (n=19); and group 5, >18 years, (n=5). Distribution of hourly basal rates at the initiation of the pump and at the end of first year were evaluated. RESULTS Median (range) age and diabetes duration was 14.46 (1.91-26.15) and 7.89 (1.16-17.15) years, respectively. Forty-four percent were male, 56% were female. Mean total insulin dose/kg in the whole cohort at the initiation and after one year of pump therapy was 0.86±0.23 U/kg and 0.78±0.19 U/kg, respectively and differed significantly between each age group (p<0.001; p<0.001). Mean daily basal rate/kg showed significant differences between the five groups (p<0.001). Circadian distribution of BI differed markedly among the five age groups. CONCLUSION At the initiation of insulin pump therapy, circadian profiles by age group should be taken into account in pediatric patients to optimize basal rate faster and more easily.
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Affiliation(s)
- Günay Demir
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İzmir, Turkey,* Address for Correspondence: Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İzmir, Turkey Phone: +90 232 390 12 30 E-mail:
| | - Yasemin Atik Altınok
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İzmir, Turkey
| | - Samim Özen
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İzmir, Turkey
| | - Şükran Darcan
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İzmir, Turkey
| | - Damla Gökşen
- Ege University Faculty of Medicine, Department of Pediatrics, Division of Pediatric Endocrinology, İzmir, Turkey
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Nimri R, Grosman B, Roy A, Nir J, Fisch Shvalb N, Kurtz N, Loewenthal N, Gillon-Keren M, Muller I, Atlas E, Phillip M. Feasibility Study of a Hybrid Closed-Loop System with Automated Insulin Correction Boluses. Diabetes Technol Ther 2021; 23:268-276. [PMID: 33185480 DOI: 10.1089/dia.2020.0448] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background: The Medtronic MiniMed™ 670G system adjusts basal insulin delivery in response to continuous glucose monitoring levels and is already in use in clinical practice. We tested the home-based feasibility of the new MiniMed advanced hybrid closed-loop (AHCL) system, which includes several algorithm enhancements and an optional autocorrection bolus mode. Methods: Twelve adolescents and young adults (eight females) with type 1 diabetes [median (interquartile range)] aged 16.6 (15.9, 18.2) years and diabetes duration of 7.1 (4.7, 8.8) years] participated in this single-arm study. The first stage was a 6-day open-loop run-in period, with the predictive low-glucose suspend feature on. This was followed by 6 days/5 nights in a supervised hotel setting, using the AHCL system, including closed-loop challenges (missed meal bolus, late meal bolus, and physical activity); and finally, 3 weeks with unrestricted home use. Glycemic parameters were compared between the open-loop and closed-loop periods. Results: Participants spent 93.3% (4.7) of the time in SmartGuard™ Auto Mode. Hemoglobin A1C levels decreased from median (interquartile range) 7.1% (6.7, 7.9) at baseline to 6.8% (6.6, 7.4) at study end, after 4 weeks (P = 0.0027). Time in range (TIR) (70-180 mg/dL) was 68.4% (10.6) and time below 70 mg/dL was 4% (3.5) during open-loop; and 74% (6.1) and 2.6% (1.9), respectively, during the closed-loop at home phase (P = 0.06, P = 0.27). TIR increased during the nighttime, from 64.6% (17.4) to 80.7% (7.8), P = 0.007, without change in time below 70 mg/dL (P = 0.15). No serious adverse events occurred. Conclusions: The new AHCL system demonstrated safety and effectiveness in controlling day and night glucose levels.
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Affiliation(s)
- Revital Nimri
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | | | - Anirban Roy
- Medtronic Diabetes, Northridge, California, USA
| | - Judith Nir
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Naama Fisch Shvalb
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | | | - Neta Loewenthal
- Pediatric Endocrinology Unit, Soroka University Medical Center, Beer Sheva, Israel
- Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Michal Gillon-Keren
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Ido Muller
- DreaMed Diabetes Ltd., Petah Tikvah, Israel
| | - Eran Atlas
- DreaMed Diabetes Ltd., Petah Tikvah, Israel
| | - Moshe Phillip
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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6
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Nauck MA, Lindmeyer AM, Mathieu C, Meier JJ. Twenty-Four Hour Fasting (Basal Rate) Tests to Achieve Custom-Tailored, Hour-by-Hour Basal Insulin Infusion Rates in Patients With Type 1 Diabetes Using Insulin Pumps (CSII). J Diabetes Sci Technol 2021; 15:360-370. [PMID: 31633384 PMCID: PMC8256064 DOI: 10.1177/1932296819882752] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Twenty-four hour fasting periods are being used to scrutinize basal insulin infusion rates for pump-treated patients with type 1 diabetes. METHODS Data from 339 consecutive in-patients with adult type 1 diabetes on insulin pump therapy undergoing a 24-hour fast as a basal rate test were retrospectively analyzed. Hourly programmed basal insulin infusion rates and plasma glucose concentrations within, below, or above arbitrarily defined target ranges were assessed for periods of the day of special interest (eg, 01:00-07:00 am, "dawn" period, 04:00-07:00 pm, and "dusk" period). Statistics: χ2-tests, paired t-tests were used. RESULTS Basal rates (mean: 0.90 ± 0.02 IU/h) showed circadian variations with peaks corresponding to "dawn" (1.07 ± 0.02 IU/h from 01:00 to 07:00 am) and, less prominently, "dusk" (0.95 ± 0.02 IU/h from 03:00 to 07:00 pm). Individual mean plasma glucose concentrations averaged 6.6 ± 0.1 mmol/L, with 53.1% in the predefined "strict" (4.4-7.2 mmol/L) target range. Interestingly, during the "dawn" period, plasma glucose was significantly higher (by 0.5 ± 0.1 mmol/L [95% confidence interval: 0.3-0.8 mmol/L; P < .0001]) and the odds ratio for hypoglycemia was significantly lower compared to the reference period. INTERPRETATION Twenty-four hour fasting periods as basal rate tests frequently unravel periods with inappropriate basal insulin infusion rates potentially responsible for fasting hyper- or hypoglycemia. Notably, the higher basal insulin infusion rate found during the "dawn" period seems to be justified and may need to be accentuated.
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Affiliation(s)
- Michael A. Nauck
- Diabeteszentrum Bad Lauterberg,
Germany
- Diabetes Division, St. Josef-Hospital,
Klinikum der Ruhr-Universität Bochum, Germany
- Michael A. Nauck, MD, Diabetes Division, St.
Josef-Hospital, Ruhr University Bochum, Gudrunstr. 56, Bochum NRW 44791,
Germany.
| | - Anna M. Lindmeyer
- Diabetes Division, St. Josef-Hospital,
Klinikum der Ruhr-Universität Bochum, Germany
| | | | - Juris J. Meier
- Diabetes Division, St. Josef-Hospital,
Klinikum der Ruhr-Universität Bochum, Germany
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7
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Abstract
BACKGROUND Advances in pump technology have increased the popularity of this treatment modality among patients with type 1 diabetes and recently also among patients with type 2 diabetes. AREAS OF UNCERTAINTY Four decades after the incorporation of the insulin pump in clinical use, questions regarding its efficacy, occurrence rate of short-term complications as hypoglycemia and diabetes ketoacidosis, timing of pump initiation, and selected populations for use remain unanswered. DATA SOURCES A review of the literature was performed using the PubMed database to identify all articles published up till December 2018, with the search terms including insulin pump therapy/continuous subcutaneous insulin delivery. The Cochrane database was searched for meta-analysis evaluating controlled randomized trials. Consensuses guidelines published by the International Society for Pediatric and Adolescent Diabetes, American Diabetes Association, and Advanced Technologies and Treatments for Diabetes year books were additionally reviewed for relevant cited articles. THERAPEUTIC ADVANCES Insulin pump therapy offers flexible management of diabetes. It enables adjustment of basal insulin to daily requirements and circadian needs, offers more precise treatment for meals and physical activity, and, when integrated with continuous glucose monitoring, allows glucose responsive insulin delivery. The ability to download and transmit data for analysis allow for treatment optimization. Newer pumps are simple to operate and increase user experience. Studies support the efficacy of pump therapy in improving glycemic control and reducing the occurrence of hypoglycemia without increasing episodes of diabetes ketoacidosis. They also improve quality of life. Recent evidence suggests a role for pump therapy in reducing microvascular and macrovascular diabetes-related complications. CONCLUSIONS Insulin pump therapy appears to be effective and safe in people with T1D regardless of age. Future advancements will include incorporation of closed loop and various decision support systems to aid and improve metabolic control and quality of life.
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8
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Nimri R, Dassau E, Segall T, Muller I, Bratina N, Kordonouri O, Bello R, Biester T, Dovc K, Tenenbaum A, Brener A, Šimunović M, Sakka SD, Nevo Shenker M, Passone CG, Rutigliano I, Tinti D, Bonura C, Caiulo S, Ruszala A, Piccini B, Giri D, Stein R, Rabbone I, Bruzzi P, Omladič JŠ, Steele C, Beccuti G, Yackobovitch-Gavan M, Battelino T, Danne T, Atlas E, Phillip M. Adjusting insulin doses in patients with type 1 diabetes who use insulin pump and continuous glucose monitoring: Variations among countries and physicians. Diabetes Obes Metab 2018; 20:2458-2466. [PMID: 29885025 DOI: 10.1111/dom.13408] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Revised: 05/27/2018] [Accepted: 06/05/2018] [Indexed: 12/14/2022]
Abstract
AIMS To evaluate physicians' adjustments of insulin pump settings based on continuous glucose monitoring (CGM) for patients with type 1 diabetes and to compare these to automated insulin dose adjustments. METHODS A total of 26 physicians from 16 centres in Europe, Israel and South America participated in the study. All were asked to adjust insulin dosing based on insulin pump, CGM and glucometer downloads of 15 patients (mean age 16.2 ± 4.3 years, six female, mean glycated haemoglobin 8.3 ± 0.9% [66.8 ± 7.3 mmol/mol]) gathered over a 3-week period. Recommendations were compared for the relative changes in the basal, carbohydrate to insulin ratio (CR) and correction factor (CF) plans among physicians and among centres and also between the physicians and an automated algorithm, the Advisor Pro (DreaMed Diabetes Ltd, Petah Tikva, Israel). Study endpoints were the percentage of comparison points for which there was full agreement on the trend of insulin dose adjustments (same trend), partial agreement (increase/decrease vs no change) and full disagreement (opposite trend). RESULTS The percentages for full agreement between physicians on the trend of insulin adjustments of the basal, CR and CF plans were 41 ± 9%, 45 ± 11% and 45.5 ± 13%, and for complete disagreement they were 12 ± 7%, 9.5 ± 7% and 10 ± 8%, respectively. Significantly similar results were found between the physicians and the automated algorithm. The algorithm magnitude of insulin dose change was at least equal to or less than that proposed by the physicians. CONCLUSIONS Physicians provide different insulin dose recommendations based on the same datasets. The automated advice of the Advisor Pro did not differ significantly from the advice given by the physicians in the direction or magnitude of the insulin dosing.
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Affiliation(s)
- Revital Nimri
- Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Eyal Dassau
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts
| | | | - Ido Muller
- DreaMed Diabetes Ltd, Petah Tikva, Israel
| | - Natasa Bratina
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre-University Children's Hospital, Ljubljana, Slovenia
| | - Olga Kordonouri
- Diabetes Centre for Children and Adolescents, Auf der Bult, Kinder- und Jugendkrankenhaus, Hannover, Germany
| | - Rachel Bello
- Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Torben Biester
- Diabetes Centre for Children and Adolescents, Auf der Bult, Kinder- und Jugendkrankenhaus, Hannover, Germany
| | - Klemen Dovc
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre-University Children's Hospital, Ljubljana, Slovenia
| | - Ariel Tenenbaum
- Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avivit Brener
- Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Marko Šimunović
- Department of Pediatrics, University Hospital Centre Split, Split, Croatia
| | - Sophia D Sakka
- Department of Endocrinology and Diabetes, Evelina London Children's Hospital, London, UK
| | - Michal Nevo Shenker
- Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | | | - Irene Rutigliano
- Pediatrics IRCCS Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Davide Tinti
- Centre of Pediatric Diabetes, Department of Pediatrics, University of Turin, Turin, Italy
| | - Clara Bonura
- San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Silvana Caiulo
- San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Anna Ruszala
- Department of Pediatric and Adolescent Endocrinology, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Barbara Piccini
- Diabetology Unit, Meyer Children's Hospital, Florence, Italy
| | - Dinesh Giri
- Department of Paediatric Endocrinology and Diabetes, Bristol Royal Hospital for Children, Bristol, UK
| | - Ronnie Stein
- Paediatric Endocrinology and Diabetes Unit, Dana-Dwek Children's Hospital, Sourasky Medical Centre, Tel Aviv, Israel
| | - Ivana Rabbone
- Centre of Pediatric Diabetes, Department of Pediatrics, University of Turin, Turin, Italy
| | - Patrizia Bruzzi
- Departments of Medical and Surgical Sciences of Mothers, Children and Adults, Azienda Ospedaliero-Univeristaria of Modena Policlinico, Paediatric Unit, Modena, Italy
| | - Jasna Šuput Omladič
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre-University Children's Hospital, Ljubljana, Slovenia
| | - Caroline Steele
- Paediatric Endocrinology and Diabetes, Leeds Children's Hospital, Leeds, UK
| | - Guglielmo Beccuti
- Division of Endocrinology, Diabetes and Metabolism, Department of Medical Sciences, University of Turin, Turin, Italy
| | - Michal Yackobovitch-Gavan
- Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Tadej Battelino
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Medical Centre-University Children's Hospital, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Thomas Danne
- Diabetes Centre for Children and Adolescents, Auf der Bult, Kinder- und Jugendkrankenhaus, Hannover, Germany
| | - Eran Atlas
- DreaMed Diabetes Ltd, Petah Tikva, Israel
| | - Moshe Phillip
- Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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9
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Sherr JL, Tauschmann M, Battelino T, de Bock M, Forlenza G, Roman R, Hood KK, Maahs DM. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetes technologies. Pediatr Diabetes 2018; 19 Suppl 27:302-325. [PMID: 30039513 DOI: 10.1111/pedi.12731] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 07/10/2018] [Indexed: 12/12/2022] Open
Affiliation(s)
- Jennifer L Sherr
- Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.,Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Tadej Battelino
- UMC-University Children's Hospital, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Martin de Bock
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Gregory Forlenza
- University of Colorado Denver, Barbara Davis Center, Aurora, Colorado
| | - Rossana Roman
- Medical Sciences Department, University of Antofagasta and Antofagasta Regional Hospital, Antofagasta, Chile
| | - Korey K Hood
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - David M Maahs
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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10
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Haase M, Kahle M, Janert M, Meier JJ, Nauck MA. Basal rate tests (24-hour fasts) performed in type-1 diabetic subjects with either absolute fasting or snacks containing negligible carbohydrate amounts result in similar glucose profiles: A randomized controlled prospective trial. Diabetes Obes Metab 2017; 19:783-790. [PMID: 28058800 DOI: 10.1111/dom.12868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2016] [Revised: 12/19/2016] [Accepted: 12/30/2016] [Indexed: 11/30/2022]
Abstract
AIMS Basal rate tests (24-hour fasting periods) may be necessary to optimize basal insulin replacement in type 1 diabetes. It was the aim of this study to prospectively compare the allowance of negligible carbohydrate snacks vs absolute fasting. METHODS A total of 20 patients with type 1 diabetes (age, 48 ± 15 years (9 women, 11 men); BMI, 28.5 ± 4.5 kg/m2 ; HbA1c, 8.8% ± 2.0% (73.0 ± 21.9 mmol/mol); insulin dose, 0.69 ± 0.31 IU/kg body weight and per day) participated in 2 basal rate tests lasting 24 hours in random order with unchanged basal insulin replacement. On 1 occasion, negligible carbohydrate snacks (salads and vegetables, up to 5.1 g carbohydrate and 276.3 kJ per portion) were allowed; during the second test subjects were obliged to fast absolutely. Plasma glucose profiles were determined using an exact laboratory method. Hypoglycaemic episodes (plasma glucose < 70 mg/dL) were compared. RESULTS Plasma glucose concentrations during fasting periods, with and without negligible carbohydrate snacks, did not differ significantly ( P = .65) and differences were negligible (95% confidence intervals always included a difference of 0 mmol/L). Also, there was no difference in the number of hypoglycaemic plasma glucose values (P = .40) or in compensatory carbohydrate intake. Basal rate testing with negligible carbohydrate snacks was better tolerated (questionnaire, P = .046) and the desire to discontinue the fasting period was significantly reduced (P = .023). CONCLUSIONS Allowing negligible carbohydrate snacks results in unchanged plasma glucose profiles during basal rate testing and is better tolerated by patients with type 1 diabetes.
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Affiliation(s)
- Maike Haase
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany
- Division of Diabetology, Department of Internal Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Melanie Kahle
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany
- Division of Diabetology, Department of Internal Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Martin Janert
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany
| | - Juris J Meier
- Division of Diabetology, Department of Internal Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
| | - Michael A Nauck
- Diabeteszentrum Bad Lauterberg, Bad Lauterberg im Harz, Germany
- Division of Diabetology, Department of Internal Medicine I, St. Josef-Hospital, Ruhr-University Bochum, Bochum, Germany
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11
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Schulten RJ, Piet J, Bruijning PC, de Waal WJ. Lower dose basal insulin infusion has positive effect on glycaemic control for children with type I diabetes on continuous subcutaneous insulin infusion therapy. Pediatr Diabetes 2017; 18:45-50. [PMID: 26880282 DOI: 10.1111/pedi.12352] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 11/29/2015] [Accepted: 12/07/2015] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE The aim of our study was to explore a possible relationship between proportion of basal insulin dose (%BD/T) and glycaemic control in children with type I diabetes on continuous subcutaneous insulin infusion (CSII) therapy. METHODS All patients under the age of 18 with type I diabetes mellitus, treated in a general hospital in Utrecht, The Netherlands, who were on CSII therapy between 2000 and 2011 were selected for inclusion. All data as recorded during outpatient visits were retrospectively collected from patients' charts. Analyses were performed using R Statistical Software. RESULTS Data of 847 outpatient visits of 78 patients [31 males (39.7%) and 47 females (60.3%)] were analyzed. Mean age at diagnosis was 7.1 ± 3.7 yr, mean age at start of pump therapy 10.1 ± 3.8 yr. Mean HbA1c before pump start was 8.3 ± 1.0%, median BMI standard deviation score for age and gender was 0.64 (-1.89-3.79). Median follow-up time per patient was 29 months with an average of 10 visits (range: 3-25). Multivariate analysis revealed that a change of 10% in %BD/T resulted in a decrease or increase of HbA1c of 0.22% [95% confidence interval (CI): 0.15-0.29). No significant effect was observed from SDS BMI, sex, or duration of diabetes. CONCLUSION Low dose basal insulin infusion as a percentage of total insulin dose has a positive effect on metabolic outcome as expressed in HbA1c-levels. A change of 10% in %BD/T results in a decrease or increase of HbA1c of 0.22%. This supports the tendency to aim at the lowest basal insulin requirements in pump setting strategy.
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Affiliation(s)
- Ron J Schulten
- Department of Pediatrics, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Jessica Piet
- Department of Pediatrics, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Patricia Cjl Bruijning
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Wouter J de Waal
- Department of Pediatrics, Diakonessenhuis Utrecht, Utrecht, The Netherlands
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12
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Lau YN, Korula S, Chan AK, Heels K, Krass I, Ambler G. Analysis of insulin pump settings in children and adolescents with type 1 diabetes mellitus. Pediatr Diabetes 2016; 17:319-26. [PMID: 25998469 DOI: 10.1111/pedi.12285] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2014] [Revised: 04/23/2015] [Accepted: 04/28/2015] [Indexed: 11/28/2022] Open
Abstract
AIM To characterize current insulin pump settings used in young patients with type 1 diabetes mellitus (T1DM) and to assess their relationship to glycemic control. METHODS This retrospective study included patients aged <18 yr old with T1DM >1 yr using a Medtronic pump device. Pump data including number of blood glucose (BG) tests per day, basal and bolus insulin parameters, carbohydrate ratio (CR), and insulin sensitivity factors (ISFs) were averaged over 14 d for statistical analyses. Anthropometric data and recent glycosylated hemoglobin A1c (HbA1c) were recorded. RESULTS A total of 292 patients (144 males and 148 females) were included in the study. Participants had a median age (interquartile range, IQR) of 12.9 yr (10.0-15.1 yr) and pump duration of 2.8 yr (1.5-4.2 yr). No significant differences in median HbA1c (IQR) were observed in preschool [n = 14; HbA1c 7.8% (7.3-8.3%)], prepubertal [n = 105; HbA1c 8.1% (7.7-8.9%)], and adolescent subjects [n = 173; HbA1c 8.4% (7.7-9.0%)]. Adolescents took significantly fewer boluses and BG tests per day compared with younger children (p < 0.05). Age-specific diurnal variation in basal insulin delivery was noted. Additionally, stronger carbohydrate cover and weaker corrections were used in real-life compared with theoretical 500 and 100 rules, respectively. Lower HbA1c was associated with higher number of daily boluses, greater number of BG tests per day, lower average CR/500 rule ratio, and higher average ISF/100 rule ratio adjusted for age (R(2) = 0.22; p < 0.01). CONCLUSION Insulin pump therapy requires continuous adjustments and glycemic targets are achieved by a minority. We believe this is the first study in pediatric cohort looking at association between CR and ISF with glycemic control.
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Affiliation(s)
- Yu Ning Lau
- Pharmacy Department, University of Sydney, Sydney, Australia
| | - Sophy Korula
- Insitute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, Australia
| | - Albert K Chan
- Insitute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, Australia
| | - Kristine Heels
- Insitute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, Australia
| | - Ines Krass
- Pharmacy Department, University of Sydney, Sydney, Australia
| | - Geoffrey Ambler
- Insitute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, Australia
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13
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Clinical evaluation of thrice-daily lispro 50/50 versus twice-daily aspart 70/30 on blood glucose fluctuation and postprandial hyperglycemia in patients with type 2 diabetes mellitus. Diabetol Int 2015. [DOI: 10.1007/s13340-014-0196-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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14
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Johansen A, Kanijo B, Fredheim S, Olsen B, Hertz B, Lauridsen MH, Andersen MLM, Mortensen HB, Svensson J. Prevalence and predictors of severe hypoglycemia in Danish children and adolescents with diabetes. Pediatr Diabetes 2015; 16:354-60. [PMID: 25039921 DOI: 10.1111/pedi.12171] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Revised: 05/31/2014] [Accepted: 06/06/2014] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE To investigate the prevalence of severe hypoglycemia in Danish children and adolescents with type 1 diabetes and to pinpoint predictors of this acute complication in children on modern treatment modalities. RESEARCH DESIGN AND METHODS The study is based on data from DanDiabKids, a national diabetes register for children and adolescents. The register contains data on patients with type 1 diabetes with an ascertainment rate of 99%. Data from 3320 patients aged 0-18 yr was included in the study period from 1998 to 2009 and analyzed using a negative binomial model. RESULTS One thousand nine hundred and ninety-nine episodes of severe hypoglycemia in 867 patients were registered conferring an overall incidence of severe hypoglycemia of 15.1 [95% confident interval (CI): 13.8; 16.4] per 100 patient years. This remained unchanged during the study period. Duration of diabetes, age and treatment in centers managing less than 100 patients significantly increased the risk of severe hypoglycemia (p < 0.001). Patients on insulin pump therapy had a 42% reduced risk of severe hypoglycemia compared with pen treated patients (p = 0.01). Patients treated with five or more daily insulin injections had a 31% (95% CI: 17; 49) reduced risk of severe hypoglycemia compared to patients on fewer daily injections (p = 0.015). CONCLUSIONS Despite improvements in metabolic control over a decade the prevalence of severe hypoglycemic events remained unchanged. More intensive treatments such as insulin pump therapy and multiple daily injections on a national level seems to be a protective factor for developing severe hypoglycemia up to 2009.
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Affiliation(s)
- A Johansen
- Department of Pediatrics, Herlev University Hospital, Herlev, Denmark
| | - B Kanijo
- Department of Pediatrics, Herlev University Hospital, Herlev, Denmark
| | - S Fredheim
- Department of Pediatrics, Herlev University Hospital, Herlev, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - B Olsen
- Department of Pediatrics, Herlev University Hospital, Herlev, Denmark
| | - B Hertz
- Department of Pediatrics, Viborg Regional Hospital, Viborg, Denmark
| | - M H Lauridsen
- Department of Pediatrics, Viborg Regional Hospital, Viborg, Denmark
| | - M L M Andersen
- Department of Pediatrics, Herlev University Hospital, Herlev, Denmark
| | - H B Mortensen
- Department of Pediatrics, Herlev University Hospital, Herlev, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - J Svensson
- Department of Pediatrics, Herlev University Hospital, Herlev, Denmark.,Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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15
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Polymorphic basal rates of continuous subcutaneous insulin infusion among Taiwanese children with type 1 diabetes. BIOMED RESEARCH INTERNATIONAL 2015; 2015:250656. [PMID: 25802842 PMCID: PMC4329847 DOI: 10.1155/2015/250656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Revised: 01/13/2015] [Accepted: 01/14/2015] [Indexed: 11/30/2022]
Abstract
Introduction. The basal dose of insulin, proportion of total daily insulin, and circadian variation during continuous subcutaneous insulin infusion (CSII) therapy among children with type 1 diabetes mellitus (T1D) have not been fully elucidated. Materials and Methods. A total of 45 childhood patients with T1D receiving CSII therapy at Pediatrics Department of Chang Gung Memorial Hospital between 2004 and 2012 were analyzed. Patients were classified according to Tanner stage. Results. HbA1c was significantly reduced in all Tanner groups within three months of CSII therapy (from 67 mmol/mol (8.3%) to 54 mmol/mol (7.1%), P < 0.05). The actual basal proportion of total daily insulin use was 34–40%. The circadian distribution of basal insulin differed markedly between the five Tanner groups. Basal insulin requirement was highest between 3:00 and 7:00 h in Tanner stages 1-2. In stages 3-4, a lower nocturnal basal insulin that increased gradually until daytime was noted. Adolescents (stage 5) displayed a high insulin peak between 6:00 and 11:00 h, and a smaller peak between 19:00 and 23:00 h. Conclusions. A smaller proportion of basal insulin to total daily insulin use, as well as varied circadian patterns of insulin use, characterized these children with T1D.
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16
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Cemeroglu AP, Thomas JP, Zande LTV, Nguyen NT, Wood MA, Kleis L, Davis AT. Basal and bolus insulin requirements in children, adolescents, and young adults with type 1 diabetes mellitus on continuous subcutaneous insulin infusion (CSII): effects of age and puberty. Endocr Pract 2014; 19:805-11. [PMID: 23757622 DOI: 10.4158/ep13099.or] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Guidelines for insulin dosing, including the insulin to carbohydrate ratio (I/C), insulin sensitivity factor (ISF), and basal/bolus ratio guidelines, have been well established for adults with type 1 diabetes mellitus (T1DM). However, clinical experience suggests that these guidelines are not appropriate for children. The purpose of this study was to determine the continuous subcutaneous insulin infusion (CSII) settings in children with T1DM at different ages and stages of puberty. METHODS A total of 154 patients data between the ages of 3 and 21 years with well-controlled T1DM according to American Diabetes Association guidelines were reviewed. Only patients on CSII who were not in the honeymoon period were included. RESULTS Patients were divided into 8 groups according to age, gender, and/or pubertal stage. Insulin requirements increased with puberty in both sexes (0.69, 0.97, and 0.90 U/kg/day in children <7 years of age, midpubertal girls, and late-pubertal boys, respectively). Basal insulin requirement was lowest in the youngest group (34%; P<.01). The youngest group had the lowest I/C prediction factor (PF) (mean, 315.7 ± 79.4; P<.01 with all groups), and the ISF-PF was higher than that of the oldest group (mean, 2,588.3 ± 1,101.8; P<.01). CONCLUSION CSII dose calculations vary with age and pubertal status in children with T1DM. These differences must be considered when calculating CSII dosing, especially for younger children.
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Affiliation(s)
- Ayse Pinar Cemeroglu
- Spectrum Health Medical Group, Pediatric Endocrinology and Diabetes Clinic, Helen DeVos Children's Hospital
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17
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Hashimoto T, Kawamura T, Kashihara Y, Hirose M, Higashide T, Tsuruhara A, Fujimoto H, Noi K, Shintaku H. Factors associated with basal insulin dose in Japanese children and young adult type 1 diabetics. J Diabetes Investig 2014; 3:276-82. [PMID: 24843577 PMCID: PMC4014950 DOI: 10.1111/j.2040-1124.2011.00171.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Aims/Introduction: The daily basal insulin doses/body weight and the daily basal insulin doses/total daily insulin doses of Japanese type 1 diabetes mellitus patients are less than those of Western type 1 diabetes mellitus patients. It is known that Western meals are richer in fat than Japanese meals. We speculated that fat intake might be associated with basal insulin dose in type 1 diabetes mellitus patients. Materials and Methods: Forty‐one outpatients with type 1 diabetes mellitus (20 males, 21 females, mean age 15.9) were enrolled. Variables investigated included: gender, SDS‐BMI, HbA1c, duration of diabetes, therapy (MDI or CSII), insulin doses and meal contents. Meal contents were recorded for 3 days using a digital camera. Correlation and multiple regression analyses were performed for all subjects and each age group. Results: The mean daily basal insulin doses/total daily insulin doses was 0.35. In the multiple regression analysis among all subjects, when daily basal insulin doses/body weight was used as a dependent variable, fat energy ratio of the meal was obtained as an entered variable (P = 0.001). This tendency was particularly strong among the patients aged 14 or above (P < 0.001, standardized coefficient β = 0.683). Conclusions: In the type 1 diabetes patients who are aged 14 or above, an association between daily basal insulin doses/body weight and fat energy ratio of meal was suggested. This may explain the aforementioned expectation of increased fat intakes making higher basal insulin doses. (J Diabetes Invest, doi: 10.1111/j.2040‐1124.2011.00171.x, 2011)
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Affiliation(s)
- Tomomi Hashimoto
- Department of Pediatrics, Osaka City University Graduate School of Medicine
| | - Tomoyuki Kawamura
- Department of Pediatrics, Osaka City University Graduate School of Medicine
| | - Yoneo Kashihara
- Department of Pediatrics, Osaka City University Graduate School of Medicine
| | - Masakazu Hirose
- Department of Pediatrics, Osaka City University Graduate School of Medicine
| | | | - Akitoshi Tsuruhara
- Department of Pediatrics, Osaka City University Graduate School of Medicine
| | | | - Kaori Noi
- Nutrition Dietary Section, Osaka City University, Osaka
| | - Haruo Shintaku
- Department of Pediatrics, Osaka City University Graduate School of Medicine
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18
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Abstract
Treatment of type 1 diabetes mellitus (T1DM) requires lifelong administration of exogenous insulin. The primary goal of treatment of T1DM in children and adolescents is to maintain near-normoglycemia through intensive insulin therapy, avoid acute complications, and prevent long-term microvascular and macrovascular complications, while facilitating as close to a normal life as possible. Effective insulin therapy must, therefore, be provided on the basis of the needs, preferences, and resources of the individual and the family for optimal management of T1DM. To achieve target glycemic control, the best therapeutic option for patients with T1DM is basal-bolus therapy either with multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). Many formulations of insulin are available to help simulate endogenous insulin secretion as closely as possible in an effort to eliminate the symptoms and complications of hyperglycemia, while minimizing the risk of hypoglycemia secondary to therapy. When using MDI, basal insulin requirements are given as an injection of long- or intermediate-acting insulin analogs, while meal-related glucose excursions are controlled with bolus injections of rapid-acting insulin analogs. Alternatively, CSII can be used, which provides a 24-h preselected but adjustable basal rate of rapid-acting insulin, along with patient-activated mealtime bolus doses, eliminating the need for periodic injections. Both MDI treatment and CSII therapy must be supported by comprehensive education that is appropriate for the individual needs of the patient and family before and after initiation. Current therapies still do not match the endogenous insulin profile of pancreatic β-cells, and all still pose risks of suboptimal control, hypoglycemia, and ketosis in children and adolescents. The safety and success of a prescribed insulin regimen is, therefore, dependent on self-monitoring of blood glucose and/or a continuous glucose monitoring system to avoid critical hypoglycemia and glucose variability. Regardless of the mode of insulin therapy, doses should be adapted on the basis of the daily pattern of blood glucose, through regular review and reassessment, and patient factors such as exercise and pubertal status. New therapy options such as sensor-augmented insulin pump therapy, which integrates CSII with a continuous glucose sensor, along with emerging therapies such as the artificial pancreas, will likely continue to improve safe insulin therapy in the near future.
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Affiliation(s)
- Faisal S Malik
- Division of Endocrinology and Diabetes, Department of Pediatrics, University of Washington and Seattle Children's Hospital, 4800 Sand Point Way NE, Seattle, WA, 98105, USA
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19
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Urakami T, Kuwabara R, Habu M, Okuno M, Suzuki J, Takahashi S. Basal insulin requirement of youth with type 1 diabetes differs according to age. J Diabetes Investig 2013; 5:442-4. [PMID: 25411604 PMCID: PMC4210068 DOI: 10.1111/jdi.12161] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2013] [Revised: 08/26/2013] [Accepted: 09/01/2013] [Indexed: 11/30/2022] Open
Abstract
We investigated the percentage of total basal insulin dose to total daily insulin dose (%TBD) among Japanese youth of different ages with type 1 diabetes. The study enrolled 69 patients with type 1 diabetes who were treated with multiple daily injections of insulin. The participants were divided into the following age groups: group A, 0 to <10 years (n = 18); group B, 10 to <20 years (n = 31) and group C, 20 to <25 years (n = 20). We found no difference in the sex ratio, body mass index, and glycated hemoglobin and 2-h postprandial C-peptide levels among the three groups. Participants assigned to group B had a significantly higher percentage of total daily insulin dose than those in group A and group C (49.7 ± 10.4% vs 38.5 ± 13.7% and 38.3 ± 8.2%, P = 0.0005). In conclusion, the basal insulin requirements of Japanese youth with type 1 diabetes might have an age effect that is associated with puberty.
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Affiliation(s)
- Tatsuhiko Urakami
- Department of Pediatrics Nihon University School of Medicine Tokyo Japan
| | - Remi Kuwabara
- Department of Pediatrics Nihon University School of Medicine Tokyo Japan
| | - Masako Habu
- Department of Pediatrics Nihon University School of Medicine Tokyo Japan
| | - Misako Okuno
- Department of Pediatrics Nihon University School of Medicine Tokyo Japan
| | - Junichi Suzuki
- Department of Pediatrics Nihon University School of Medicine Tokyo Japan
| | - Shori Takahashi
- Department of Pediatrics Nihon University School of Medicine Tokyo Japan
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20
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Holterhus PM, Bokelmann J, Riepe F, Heidtmann B, Wagner V, Rami-Merhar B, Kapellen T, Raile K, Quester W, Holl RW. Predicting the optimal basal insulin infusion pattern in children and adolescents on insulin pumps. Diabetes Care 2013; 36:1507-11. [PMID: 23404300 PMCID: PMC3661794 DOI: 10.2337/dc12-1705] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE We aimed at developing and cross-validating a mathematical prediction model for an optimal basal insulin infusion pattern for children with type 1 diabetes on continuous subcutaneous insulin infusion therapy (CSII). RESEARCH DESIGN AND METHODS We used the German/Austrian DPV-Wiss database for quality control and scientific surveys in pediatric diabetology and retrieved all CSII patients <20 years of age (November 2009). A total of 1,248 individuals from our previous study were excluded (dataset 1), resulting in 6,063 CSII patients (dataset 2) (mean age 10.6 ± 4.3 years). Only the most recent basal insulin infusion rates (BRs) were considered. BR patterns were identified and corresponding patients sorted by unsupervised clustering. Logistic regression analysis was applied to calculate the probabilities for each BR pattern. Equations were based on both independent datasets separately, and probabilities for BR patterns were cross-validated using typical test patients. RESULTS Of the 6,063 children, 5,903 clustered in one of four major circadian BR patterns, confirming our previous study. The oldest age-group (mean age 12.8 years) was represented by 2,490 patients (42.18%) with a biphasic dawn-dusk pattern (BC). A broad single insulin maximum at 9-10 p.m. (F) was unveiled by 853 patients (14.45%) (mean age 6.3 years). Logistic regression analysis revealed that age, to a lesser extent duration of diabetes, and partly sex predicted BR patterns. Cross-validation revealed almost identical probabilities for BR patterns BC and F in the two datasets but some variation in the remaining two BR patterns. CONCLUSIONS Reconfirmation of four key BR patterns in two very large independent cohorts supports that these patterns are realistic approximations of the circadian distribution of insulin needs in children with type 1 diabetes. Prediction of an optimal pattern a priori can improve initiation and clinical follow-up of CSII in children and adolescents. In addition, these BR patterns represent valuable information for insulin-infusion algorithms in closed-loop CSII.
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Affiliation(s)
- Paul-Martin Holterhus
- Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics,Christian-Albrechts-University of Kiel, University Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany.
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21
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Ramchandani N, Heptulla RA. New technologies for diabetes: a review of the present and the future. INTERNATIONAL JOURNAL OF PEDIATRIC ENDOCRINOLOGY 2012; 2012:28. [PMID: 23098076 PMCID: PMC3541087 DOI: 10.1186/1687-9856-2012-28] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Accepted: 10/15/2012] [Indexed: 11/10/2022]
Abstract
This review summarizes the technologies in use and in the pipeline for the management of diabetes. The review focuses on glucose meters, continuous glucose monitoring devices, insulin pumps, and getting clinicians connected to technologies. All information presented can be found in the public domain, and was obtained from journal articles, websites, product review tables in patient publications, and professional conferences. The technology concerns, ongoing development and future trends in this area are also discussed.
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Affiliation(s)
- Neesha Ramchandani
- The Children's Hospital at Montefiore, Division of Pediatric Endocrinology & Diabetes, 3415 Bainbridge Ave, Bronx, NY, 10467, USA.
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22
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Fendler W, Baranowska AI, Mianowska B, Szadkowska A, Mlynarski W. 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. Acta Diabetol 2012; 49:363-70. [PMID: 21964866 PMCID: PMC3464376 DOI: 10.1007/s00592-011-0332-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2011] [Accepted: 09/14/2011] [Indexed: 11/02/2022]
Abstract
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.
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Affiliation(s)
- Wojciech Fendler
- Department of Paediatrics, Oncology, Haematology and Diabetology, Medical University of Lodz, 36/50 Sporna St., 91-738 Lodz, Poland
| | - Anna Iza Baranowska
- Department of Paediatrics, Oncology, Haematology and Diabetology, Medical University of Lodz, 36/50 Sporna St., 91-738 Lodz, Poland
| | - Beata Mianowska
- Department of Paediatrics, Oncology, Haematology and Diabetology, Medical University of Lodz, 36/50 Sporna St., 91-738 Lodz, Poland
| | - Agnieszka Szadkowska
- Department of Paediatrics, Oncology, Haematology and Diabetology, Medical University of Lodz, 36/50 Sporna St., 91-738 Lodz, Poland
| | - Wojciech Mlynarski
- Department of Paediatrics, Oncology, Haematology and Diabetology, Medical University of Lodz, 36/50 Sporna St., 91-738 Lodz, Poland
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Katz ML, Volkening LK, Anderson BJ, Laffel LM. Contemporary rates of severe hypoglycaemia in youth with type 1 diabetes: variability by insulin regimen. Diabet Med 2012; 29:926-32. [PMID: 22417321 PMCID: PMC3597100 DOI: 10.1111/j.1464-5491.2012.03646.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
AIMS To determine incidence rates of severe hypoglycaemia and compare incidence rates by insulin regimen in a diverse sample of youth with Type 1 diabetes from two sites. METHODS In this observational study, 255 youth (51% female) aged 9-15 years receiving varied insulin regimens provided data prospectively for a median of 1.2 years. Reported episodes of severe hypoglycaemia, defined as episodes requiring help from another person for oral treatment or episodes resulting in seizure/coma, and current insulin regimens were collected systematically. Incidence rates were calculated and compared according to insulin regimen in bivariate and multivariate analyses. RESULTS At first encounter, participants had a median age of 12.2 years (range 9.0-15.0), median diabetes duration of 4.4 years (range 1.0-13.0) and mean HbA(1c) of 67 ± 12 mmol/mol (8.3 ± 1.1%). The incidence rate was 37.6/100 patient-years for all severe hypoglycaemia and 9.6/100 patient-years for seizure/coma. The incidence rate for severe hypoglycaemia was 31.8/100 patient-years on continuous subcutaneous insulin infusion (pump therapy), 34.4/100 patient-years on basal-bolus injections and 46.1/100 patient-years on NPH (NPH vs. pump therapy: P = 0.04). The incidence rate for seizure/coma was 4.5/100 patient-years on pump therapy, 11.1/100 patient-years on basal-bolus injections and 14.4/100 patients-years on NPH (NPH vs. pump therapy: P = 0.004). In the multivariate analysis, the rate of seizure/coma was significantly higher for those on NPH vs. pump therapy (rate ratio 2.9, P = 0.03). CONCLUSIONS Rates of severe hypoglycaemia in youth with Type 1 diabetes remain high. Pump therapy was associated with lower rates of all severe hypoglycaemia and seizure/coma in comparison with NPH.
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Affiliation(s)
- M L Katz
- Genetics and Epidemiology Section, Joslin Diabetes Center, Boston, MA 02215, USA
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24
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Nicolajsen T, Samuelsson A, Hanas R. Insulin doses before and one year after pump start: children have a reversed dawn phenomenon. J Diabetes Sci Technol 2012; 6:589-94. [PMID: 22768890 PMCID: PMC3440064 DOI: 10.1177/193229681200600314] [Citation(s) in RCA: 17] [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] [Indexed: 01/25/2023]
Abstract
OBJECTIVE We aimed to investigate the basal rate and bolus doses in children and adolescents at the start of insulin pump therapy and after 1 year of use. PATIENTS AND METHODS Case records from 29 children and adolescents were examined. All pumps were started with rapid-acting insulin (Humalog). Patients were aged 13.1 ± 3.9 years, with a diabetes duration of 5.4 ± 4.1 years at pump start. Sixteen pumps were started for high hemoglobin A1c (HbA1c; >8.8%, 73 mmol/mol) and 13 for other reasons. RESULTS Basal rates declined in both groups by 20% at 3 days after pump start. The bolus doses were reduced by 25-30% when the indication was high HbA1c and by 15% in the others. After 1 year, there was a significant difference in the basal rate between age groups. The 3-9-year-old age group had higher basal rates during the late evening (10:00 PM-12:00 AM), while the 15-21-year-old age group had higher basal rates in the early morning (3:00 AM-7:00 AM). CONCLUSIONS Insulin doses are reduced considerably when starting with a pump in pediatric practice. Younger children needed higher basal rates late in the evening (reversed dawn phenomenon), while older teenagers seem to need an increase in the morning, which may correspond to a true dawn phenomenon.
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Affiliation(s)
- Tom Nicolajsen
- Department of Pediatrics, NU Hospital GroupUddevalla, Sweden
| | | | - Ragnar Hanas
- Department of Pediatrics, NU Hospital GroupUddevalla, Sweden
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25
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Bachran R, Beyer P, Klinkert C, Heidtmann B, Rosenbauer J, Holl RW. Basal rates and circadian profiles in continuous subcutaneous insulin infusion (CSII) differ for preschool children, prepubertal children, adolescents and young adults. Pediatr Diabetes 2012; 13:1-5. [PMID: 21545675 DOI: 10.1111/j.1399-5448.2011.00777.x] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Initiation of continuous subcutaneous insulin therapy (CSII) requires an appropriate basal rate profile. Different approaches exist; however, there is a lack of evidence-based recommendations, especially in young children. STUDY DESIGN In this large multicenter survey, 5941 CSII patients from the German/Austrian prospective documentation system (DPV) were analyzed. Patients were divided into four age groups: <6 yr (n = 837), 6 to <12 yr (n = 1739), 12 to <18 yr (n = 2985) and 18 to <25 yr (n = 380). Basal insulin requirement and diurnal distribution were evaluated based on the most recent documentation for each patient. RESULTS Basal insulin requirement differed significantly between the four age groups (<6: 0.25 ± 0.12; 6 to <12: 0.33 ± 0.12; 12 to <18: 0.43 ± 0.15; 18 to <25: 0.35 ± 0.13 U/kg; p < 0.001). Circadian insulin profiles were markedly different between the younger and older age groups. In addition to age, longer diabetes duration, female gender, higher HbA1c and lower body mass index standard deviation score (BMI-SDS) were related to higher basal insulin requirement per kilogram of body weight. CONCLUSIONS Age of the patient is the primary factor that influences both total daily requirement and circadian distribution of basal insulin in CSII. Experience from a large database may therefore facilitate the initiation of pump therapy in pediatric patients.
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Hanas R, de Beaufort C, Hoey H, Anderson B. Insulin delivery by injection in children and adolescents with diabetes. Pediatr Diabetes 2011; 12:518-26. [PMID: 21481121 DOI: 10.1111/j.1399-5448.2010.00731.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Type 1 diabetes is treated with insulin, which has traditionally been delivered by vial and syringe. However, for many patients, dosing inaccuracy, pain, anxiety, inconvenience, and social acceptability present barriers to this method of administration (1-5). This has contributed to the increased popularity of alternative insulin delivery systems, including pen delivery devices (4, 6). Evidence suggests that discreet devices, such as insulin pens, facilitate adherence to intensive insulin therapy regimens, help improve lifestyle flexibility, and reduce injection pain compared with the conventional syringe-based regimens, as shown in studies in adults and adolescents (7). In addition, compared with the vial and syringe method of insulin administration, pens may provide more accurate dosing - which is particularly important in children - thereby improving short-term blood glucose control and potentially improving long-term outcomes (5, 8). Children, in particular, may benefit from insulin pens that are simple to use as adherence issues may be more evident in this patient group (9). Pens for insulin delivery in children with type 1 diabetes have been used for a long time in Europe, and have recently gained in popularity in many other places around the world (4, 10). Furthermore, the conventional vial and syringe method of insulin delivery is beginning to be considered as obsolete (11). Moreover, there is a continued drive to improve insulin pen technology, to refine and enhance the functionality and usability of these pens. However, despite recent advances in pen design and function, the selection of pens available especially for children is limited.
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Affiliation(s)
- Ragnar Hanas
- Department of Pediatrics, Uddevalla Hospital, Uddevalla S-451 80, Sweden.
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27
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Kordonouri O, Hartmann R, Danne T. Treatment of type 1 diabetes in children and adolescents using modern insulin pumps. Diabetes Res Clin Pract 2011; 93 Suppl 1:S118-24. [PMID: 21864743 DOI: 10.1016/s0168-8227(11)70027-4] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
In the last decades, we are experiencing an increasing use of insulin pumps for the treatment of type 1 diabetes in children and adolescents. The most frequent reasons for switching from insulin injection schemes to pump therapy are frequent and/or severe hypoglycaemia, dawn phenomenon, poor glycaemic control, wish for more flexibility in daily life, and needle phobia. In toddlers and preschoolers, pumps are frequently introduced from the onset of type 1 diabetes. Pumps offer the possibility of adjusting basal insulin rates individually on an age-depended manner as well as of optimizing meal-related insulin requirements according to the meal composition by using three different kinds of boluses. Structured and intensive education of patients and their families on basics and specific requirements of insulin pump therapy is essential in order to get them familiar with the devices and their features. There is increasing evidence both from multicentre cross-sectional studies as well as from meta-analyses of randomized clinical trials in paediatric populations showing that patients with pump therapy can achieve a more favourable metabolic control accompanied with less hypoglycaemic events than those with multiple daily injections.
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Affiliation(s)
- Olga Kordonouri
- Bult Diabetes Centre for Children and Adolescents, Kinderkrankenhaus auf der Bult, Hannover, Germany.
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28
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Olsen BS, Lilleøre SK, Korsholm CN, Kracht T. Novopen Echo® for the delivery of insulin: a comparison of usability, functionality and preference among pediatric subjects, their parents, and health care professionals. J Diabetes Sci Technol 2010; 4:1468-75. [PMID: 21129343 PMCID: PMC3005058 DOI: 10.1177/193229681000400622] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [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 Despite advances in insulin pen design and functionality, the selection of pens available for children with diabetes is limited. This study assessed the usability, functionality and attitudes towards NovoPen Echo®, a new durable insulin pen designed for pediatric patients that combines a simple memory function with half-increment dosing, versus NovoPen® Junior and HumaPen® Luxura™ HD in pediatric subjects, their parents, and health care professionals (HCPs). METHODS Pens were evaluated in random order during 1:1 interviews in the three target groups (pediatric subjects, parents, and HCPs) in Germany, France, and Canada. Study participants were asked to prepare each pen, perform injections into foam cushions, and provide feedback via a standardized questionnaire. RESULTS In total, 205 participants were included in the study. On a scale of 1-6 (1=most favorable; 6=least favorable regarding overall appearance, shape, colors, thickness and length), NovoPen Echo received the most favorable rating for design and overall appearance (mean±standard deviation=1.71±0.79) compared with NovoPen Junior (2.02±0.93) and HumaPen Luxura HD (2.36±1.01). Furthermore, 89% of pediatric subjects and 94% of parents rated the memory function of NovoPen Echo as very easy/easy to use. When asked to rate the pens overall, 80% of participants preferred NovoPen Echo to the other pens (p<0.0001). CONCLUSIONS The results demonstrate a high overall level of satisfaction with NovoPen Echo among pediatric subjects, parents, and HCPs. The novel design aspects of NovoPen Echo, namely the simple memory function, half-increment units and, ease of use and design, may contribute towards promoting treatment adherence, which is essential in the pediatric setting.
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Affiliation(s)
- Birthe S Olsen
- Department of Pediatrics, Glostrup University Hospital, Glostrup, Denmark.
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29
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Sulmont V, Souchon PF, Gouillard-Darnaud C, Fartura A, Salmon-Musial AS, Lambrecht E, Mauran P, Abely M. Metabolic control in children with diabetes mellitus who are younger than 6 years at diagnosis: continuous subcutaneous insulin infusion as a first line treatment? J Pediatr 2010; 157:103-7. [PMID: 20227730 DOI: 10.1016/j.jpeds.2009.12.034] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2009] [Revised: 11/03/2009] [Accepted: 12/17/2009] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To assess long-term metabolic outcomes in children with diabetes mellitus that was diagnosed when they were <6 years old. STUDY DESIGN A cohort of 66 children with diabetes mellitus that had a duration of at least 5 years and was diagnosed before they were 6 years old. Thirty-four children were treated at diagnosis with multiple daily subcutaneous insulin injections (MDI), and all these children, except 3, were switched to continuous subcutaneous insulin infusion (CSII; group A). Thirty-two children received CSII as initial treatment (group B). RESULTS Hemoglobin A1c values were significantly lower in patients receiving CSII than MDI during all the 8 years of follow-up except one (year 1: 6.9%+/-0.9% versus 7.6%+/-1%, P=.011 ; year 4: 7.4%+/-0.8% versus 8.1%+/-0.9%, P=.006; year 7: 7.6%+/-0.5% versus 8.3%+/-0.8%, P=.001). The incidence of severe hypoglycemia was greatly decreased for the CSII group (9.8 versus 22.3 episodes/100 patient-years, P=.016). In group A, hemoglobin A1c values increased during the study period, and in group B, they increased only during the first 2 years and remained constant thereafter. Only 9.1% of patients did not use or abandoned CSII. CONCLUSION CSII in children<6 years of age enables better long-term metabolic control and lowers the risk of severe hypoglycemia better than MDI, especially when initiated at diagnosis.
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Affiliation(s)
- Veronique Sulmont
- Department of Pediatrics, American Memorial Hospital, University Hospital of Reims, Reims, France.
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30
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Lassmann-Vague V, Clavel S, Guerci B, Hanaire H, Leroy R, Loeuille G, Mantovani I, Pinget M, Renard E, Tubiana-Rufi N. When to treat a diabetic patient using an external insulin pump. Expert consensus. Société francophone du diabète (ex ALFEDIAM) 2009. DIABETES & METABOLISM 2010; 36:79-85. [DOI: 10.1016/j.diabet.2009.09.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/15/2009] [Revised: 09/22/2009] [Accepted: 09/26/2009] [Indexed: 10/20/2022]
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Shashaj B, Sulli N. Difference in insulin usage patterns with pubertal development in children with type 1 diabetes during transition from multiple daily injections to continuous subcutaneous insulin infusion (CSII) and through the CSII treatment. Diabetes Technol Ther 2009; 11:767-74. [PMID: 20001677 DOI: 10.1089/dia.2009.0049] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE This study analyzed the changes in insulin requirement in the transition from multiple daily injections (MDI) to continuous subcutaneous insulin infusion (CSII) and the differences through the CSII treatment in pediatric patients in different pubertal developmental stages. METHODS We analyzed, through a longitudinal retrospective study, the insulin usage patterns and glycemic control of 40 patients with type 1 diabetes on CSII treatment for 12 months. The patients were subdivided in three groups: group A, 13 prepubertal subjects (Tanner stage I); group B, 15 pubertal subjects (Tanner stage II-IV); and group C, 12 postpubertal subjects (Tanner stage V). RESULTS During the transition from MDI to CSII, the insulin requirements decreased significantly by 21 +/- 5% (0.89 +/- 0.26 U/kg/day vs. 0.70 +/- 0.11 U/kg/day). Through the CSII treatment the percentage of total daily insulin delivered as the basal rate in groups A, B, and C was 54-60%, 52-54%, and 52-54%, respectively. The number of basal rates per day was significantly higher in groups A and B. The overall profile of basal rate differed among the groups. During the night, prepubertal patients required more insulin from 12 p.m. to 2 a.m., whereas pubertal and postpubertal patients required more insulin between 2-3 a.m. to 7 a.m. Prepubertal patients had a maximum basal rate between 9 a.m. to 12 a.m. and 2 p.m. to 4 p.m., in contrast to pubertal and postpubertal patients between 2 p.m. to 3 p.m. and 5 p.m. to 6 p.m. The number of "extra" boluses per day was significantly higher in groups B and C compared to group A. CONCLUSIONS Age-related differences exist in insulin usage patterns of pediatric patients on pump treatment. A greater knowledge of these variations may help to obtain optimum conditions in the CSII treatment in pediatric patients.
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Affiliation(s)
- B Shashaj
- Department of Pediatrics, Diabetes Center, University of Rome La Sapienza, Rome, Italy.
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32
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Pańkowska E, Szypowska A, Lipka M, Szpotańska M, Błazik M, Groele L. Application of novel dual wave meal bolus and its impact on glycated hemoglobin A1c level in children with type 1 diabetes. Pediatr Diabetes 2009; 10:298-303. [PMID: 19175902 DOI: 10.1111/j.1399-5448.2008.00471.x] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND An insulin pump is an advanced technology offering new options of bolus - normal (N), dual wave (D-W) or square wave (S-W) bolus to deliver mealtime insulin. OBJECTIVES To assess the impact of D-W/S-W boluses on metabolic control (glycated haemoglobin A1c, HbA1c) and to estimate the paediatric patients compliance with implementation of this system in daily practice. METHODS The cross-sectional study included 499 records of patients aged 0-18 yr. Data from the insulin pump memory provided information on the number of D-W/S-W boluses during a 2-wk period, the insulin requirement (U/kg/d) and the percentage of basal insulin. The HbA1c value (%) and the patient's weight were determined during medical examinations. Mealtime dose of insulin in D-W/S-W bolus was calculated based on the amount of carbohydrate and fat/protein products. RESULTS The number of applied D-W/S-W boluses was 16.6 +/- 0.77/14 d (ranged 0-95), while 18.8% of patients did not program D-W/S-W boluses. The lowest HbA1c value was found in the group using two and/or more D-W/S-W boluses per day (p = 0.001) compared with the group administrating less than one D-W/S-W bolus/d. Patients with HbA1c level <7.5% had a statistically higher relevant number of D-W/S-W boluses, 19.55 (95% CI: 17.44-21.65) vs. 12.42 (95% CI: 10.22-14.61) (p < 0.001), while there was no correlation between the number of boluses and HbA1c in patients in the remission phase (<0.5 IU/kg/d) (r = 0.012, p = 0.930). CONCLUSIONS Patients using at least one D-W/S-W bolus per day achieved a recommended level of HbA1c. Paediatric patients with type 1 diabetes mellitus were found to be able to apply D-W/S-W boluses in daily self-treatment process based on food counting.
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Affiliation(s)
- Ewa Pańkowska
- Second Department of Paediatrics, Medical University of Warsaw, 01-184 Warsaw, Poland.
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Cohen O, Körner A, Chlup R, Zoupas CS, Ragozin AK, Wudi K, Bartaskova D, Pappas A, Niederland T, Taybani Z, Barák L, Vazeou A. Improved glycemic control through continuous glucose sensor-augmented insulin pump therapy: prospective results from a community and academic practice patient registry. J Diabetes Sci Technol 2009; 3:804-11. [PMID: 20144331 PMCID: PMC2769970 DOI: 10.1177/193229680900300429] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Conducted by highly experienced investigators with abundant time and resources, phase III studies of continuous glucose sensing (CGS) may lack generalizability to everyday clinical practice. METHOD Community or academic practices in six Central and Eastern European or Mediterranean countries prospectively established an anonymized registry of consecutive patients with type 1 insulin-dependent diabetes mellitus starting CGS-augmented insulin pump therapy with the Paradigm X22 (Medtronic MiniMed, Northridge, CA) under everyday conditions, without prior CGS with another device. We compared glycosylated hemoglobin (GHb) values before and after 3 months of CGS and assessed relationships between insulin therapy variables and glycemia-related variables at weeks 1, 4, and 12 of CGS. RESULTS Of 102 enrolled patients, 85 (83%) with complete weeks 1, 4, and 12 sensor data and baseline/3-month GHb data were evaluable. Evaluable patients were approximately 54% male and approximately 75% adult (mean age, 33.2 +/- 16.9 years) with longstanding diabetes and high personal/family education levels. Mean GHb declined significantly after 3 months of CGS (7.55 +/- 1.33% at baseline to 6.81 +/- 1.08% after 12 weeks, 0.74% absolute decrease, P < 0.001). The absolute GHb reduction correlated significantly (P < 0.0005) with baseline GHb: larger absolute reductions tended to occur when baseline levels were higher. An increased basal insulin dose as a percentage of the total daily insulin dose and a decreased daily bolus count from week 1 to week 12 of CGS predicted GHb improvement from baseline to week 12. CONCLUSIONS CGS-augmented insulin pump therapy appears to improve glycemic control in type 1 diabetes in varied everyday practice settings.
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Affiliation(s)
- Ohad Cohen
- Institute of Endocrinology, Chaim Sheba Medical Center, Tel Hashomer, Israel.
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34
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El-Khatib FH, Jiang J, Damiano ER. A feasibility study of bihormonal closed-loop blood glucose control using dual subcutaneous infusion of insulin and glucagon in ambulatory diabetic swine. J Diabetes Sci Technol 2009; 3:789-803. [PMID: 20144330 PMCID: PMC2769971 DOI: 10.1177/193229680900300428] [Citation(s) in RCA: 36] [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: 01/29/2023]
Abstract
BACKGROUND We sought to test the feasibility and efficacy of bihormonal closed-loop blood glucose (BG) control that utilizes subcutaneous (SC) infusion of insulin and glucagon, a model-predictive control algorithm for determining insulin dosing, and a proportional-derivative control algorithm for determining glucagon dosing. METHODS Thirteen closed-loop experiments (approximately 7-27 h in length) were conducted in six ambulatory diabetic pigs weighing 26-50 kg. In all experiments, venous BG was sampled through a central line in the vena cava. Efficacy was evaluated in terms of the controller's ability to regulate BG in response to large meal disturbances ( approximately 5 g of carbohydrate per kilogram of body mass per meal) based only on regular frequent venous BG sampling and requiring only the subject's weight for initialization. RESULTS Closed-loop results demonstrated successful BG regulation to normoglycemic range, with average insulin-to-carbohydrate ratios between approximately 1:20 and 1:40 U/g. The total insulin bolus doses averaged approximately 6 U for a meal containing approximately 6 g per kilogram body mass. Mean BG values in two 24 h experiments were approximately 142 and approximately 155 mg/dl, with the total daily dose (TDD) of insulin being approximately 0.8-1.0 U per kilogram of body mass and the TDD of glucagon being approximately 0.02-0.05 mg. Results also affirmed the efficacy of SC doses of glucagon in staving off episodic hypoglycemia. CONCLUSIONS We demonstrate the feasibility of bihormonal closed-loop BG regulation using a control system that employs SC infusion of insulin and glucagon as governed by an algorithm that reacts only to BG without any feed-forward information regarding carbohydrate consumption or physical activity. As such, this study can reasonably be regarded as the first practical implementation of an artificial endocrine pancreas that has a hormonally derived counterregulatory capability.
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Affiliation(s)
- Firas H El-Khatib
- Department of Biomedical Engineering, Boston University, Boston, Massachusetts 02215, USA
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35
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Delvecchio M, Zecchino C, Salzano G, Faienza MF, Cavallo L, De Luca F, Lombardo F. Effects of moderate-severe exercise on blood glucose in Type 1 diabetic adolescents treated with insulin pump or glargine insulin. J Endocrinol Invest 2009; 32:519-24. [PMID: 19474521 DOI: 10.1007/bf03346499] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Few papers focus on exercise-related blood glucose (BG) in patients on continuous sc insulin infusion (CSII) or multiple daily injections (MDI) with glargine. AIM The main objective was to evaluate the degree of glycemic control in Type 1 diabetes mellitus adolescents on CSII doing physical activity with pump switched on or off. These findings were also compared with a small group of patients on MDI with glargine. SUBJECTS AND METHODS Eight patients on CSII (basal rate continued or turned off in alternating sessions) and 5 on MDI joined 4 sessions of moderate-severe exercise. RESULTS Post-exercise BG significantly increased with the pump off and was unchanged/decreased with the pump on and MDI groups vs baseline. The hypoglycemia rate was not different among the 3 groups at any time. Pump on: hypoglycemias more frequent both at bedtime (p=0.031) and at awakening (p<0.001) than before dinner and at awakening than at bed-time (p=0.044). Pump off: hypoglycemias more frequent both at bed-time (p=0.010) and at awakening (p=0.031) than before dinner. MDI: no differences. CONCLUSIONS Glargine is safe and reducing the pre-lunch insulin is unnecessary. Subjects on insulin pump should not stop the basal rate. If they stop the pump, some actions are advisable: pre-exercise insulin bolus, pre-sleeping snack rich in carbohydrates, slight reduction of the overnight basal rate. On the other hand, if the basal rate is unmodified, the ingestion of sugary drinks during the exercise, the reduction of the overnight basal rate, a reduction of the pre-dinner insulin bolus and/or a pre-sleeping snack should be considered.
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Affiliation(s)
- M Delvecchio
- Department of Biomedicine of Developmental Age, University of Bari, Bari, Italy
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Szypowska A, Lipka M, Błazik M, Groele L, Pańkowska E. Insulin requirement in preschoolers treated with insulin pumps at the onset of type 1 diabetes mellitus. Acta Paediatr 2009; 98:527-30. [PMID: 19021593 DOI: 10.1111/j.1651-2227.2008.01142.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
THE AIM The aim of this study is to analyze changes in the basal insulin requirement in preschoolers treated with insulin pump at the onset of T1DM, using system to calculate meal time insulin. METHODS 58 children (31 girls) under 6 years (mean age 3.3 +/- 1.5 years) initiated on insulin pump therapy within 2 months after recognition of T1DM and treated at least for 1 year were analyzed during a follow-up period of 165 patient-years. Data was collected every 6 months: HbA1c, BMI SDS, diabetic ketoacidosis, severe hypoglycaemia, total daily insulin dose (TDD) and basal insulin. RESULTS Basal insulin rose from 10% in the third month and did not exceed 30% of TDD after 12 months (p<0.0001). In the third month, 46% of children were without basal insulin; this group included significantly older children (3.7 +/- 1.4 vs. 2.8 +/- 1.4 years; p = 0.01), which had lower TDD (0.33 +/- 0.18 vs. 0.54 +/- 0.23 u/kg/d; p = 0.0007) than children with basal insulin. HbA1c persisted < or =7.3%. CONCLUSION In preschool children initiated on CSII therapy at the time of T1DM diagnosis the first year of treatment is critical for altering the basal insulin dose. Preschoolers with TDD lower than 0.5 U/kg/d may not require basal insulin. Moreover, basal insulin did not exceed 30% of TDD in the first years after T1DM onset.
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Babar GS, Ali O, Parton EA, Hoffmann RG, Alemzadeh R. Factors associated with adherence to continuous subcutaneous insulin infusion in pediatric diabetes. Diabetes Technol Ther 2009; 11:131-7. [PMID: 19216689 DOI: 10.1089/dia.2008.0042] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND/AIMS Continuous subcutaneous insulin infusion (CSII) is a safe and effective alternative to insulin injections in pediatric type 1 diabetes mellitus. CSII can be associated with an increased risk of hypoglycemia and diabetic ketoacidosis (DKA) in some patients. In our Center, patients/guardians are screened for proficiency in diabetes management skills as a prerequisite to initiation of CSII. We reviewed the clinical data from our patients to assess the predictors associated with nonadherence to CSII therapy. METHODS We retrospectively collected clinical data on all our CSII initiations between July 1999 to June 2003, including: body mass index, hemoglobin A1c (HbA1c), total daily dose, bolus to basal insulin ratio, hypoglycemic episodes (blood glucose <60 mg/dL/week), mean fasting self-monitored blood glucose (SMBG), severity of lipohypertrophy, DKA, and pubertal status. RESULTS Forty-six patients 9.90 +/- 3.4 years old (28 girls and 18 boys) started CSII in the 4-year period. While 39 patients (85%) 9.8 +/- 3.5 years old currently remain on CSII, seven patients (15%) 11.2 +/- 0.9 years old discontinued CSII. Fifteen patients (32.6%) were prepubertal at CSII initiation, and none discontinued CSII in this cohort, whereas seven of 31 (22.6%) pubertal patients discontinued CSII. The patients who continued CSII were similar to the CSII-discontinued cohort at baseline. At 12 months, rising HbA1c was the only predictor of future nonadherence to CSII. At 24 months, the discontinuation group had higher mean fasting SMBG levels and severe lipohypertrophy (P < 0.05). None of the prepubertal patients discontinued CSII, while all seven patients (100%) in the CSII-discontinued group were pubertal (P < 0.001). CONCLUSIONS Extensive screening by a multidisciplinary diabetes team prior to initiation of CSII regimen results in relatively lower discontinuation rates and a higher chance of maintaining optimal glycemic control (HbA1C < 8%) compared to previous studies.
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Affiliation(s)
- Ghufran S Babar
- Children's Hospital of Wisconsin Diabetes Center and Sections of Pediatric Endocrinology & Metabolism and Biostatistics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Szypowska A, Lipka M, Błazik M, Golicka D, Groele L, Pańkowska E. Age-dependent basal insulin patterns in children with type 1 diabetes treated with continuous subcutaneous insulin infusion. Acta Paediatr 2009; 98:523-6. [PMID: 19046348 DOI: 10.1111/j.1651-2227.2008.01151.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS Identifying age-dependent basal rates in type 1 diabetic children treated with continuous subcutaneous insulin infusion (CSII). METHODS CSII-treated children with type 1 diabetes exhibiting insulin requirement > 0.5 U/kg and glycated haemoglobin (HbA1c) < 8%. The study population was composed of 198 Caucasian children (111 girls) with mean age of 9.8 +/- 3.8 years, mean duration of diabetes of 4.3 +/- 3.1 years and mean HbA1c value of 6.7 +/- 0.7%. Data were evaluated for four age groups (0-6; 6-9; 9-12, 12-18 years). Basal rates records were downloaded from pump memory. HbA1c, weight, height were measured at scheduled visits. RESULTS Significant differences in the average hourly basal rate between groups were observed: I gr. 0.14 versus II gr. 0.24 versus III gr. 0.39 versus IV gr. 0.72 units/h; p < 0.0001. The average hourly basal rate correlated with age, body weight, BMI, diabetes duration and total insulin daily dose. Insulin peaks were observed for: I gr. - before midnight, II gr. - before midnight and in the early morning, gr. III and IV - in the early morning. CONCLUSION Basal insulin infusion rate profiles in well-controlled paediatric patients on CSII reflect the age-dependent amount of basal insulin (20-40%) and affect circadian distribution of insulin needs.
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Pańkowska E, Błazik M, Dziechciarz P, Szypowska A, Szajewska H. Continuous subcutaneous insulin infusion vs. multiple daily injections in children with type 1 diabetes: a systematic review and meta-analysis of randomized control trials. Pediatr Diabetes 2009; 10:52-8. [PMID: 18761648 DOI: 10.1111/j.1399-5448.2008.00440.x] [Citation(s) in RCA: 159] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To investigate potential effects of continuous subcutaneous insulin infusion (CSII) compared with multiple daily injections (MDI) on glycemic control in children with type 1 diabetes mellitus (T1DM). STUDY DESIGN Meta-analysis and systematic review of randomized control studies (RCTs). The electronic databases MEDLINE, Cochrane Library, and EMBASE were searched through October 2007. RESULTS Six RCTs involving 165 participants with T1DM met our predefined inclusion criteria. Combined data from all trials showed that the CSII group compared with the MDI group experienced a significant reduction in the level of glycosylated hemoglobin. The pooled weighted mean difference (WMD) was -0.24% [95% confidence interval (95% CI) -0.41 to -0.07, p < 0.001] with a fixed model and remained significant in the random effect model. This effect was reached by slightly decreasing insulin requirement [three RCTs, n = 74, WMD -0.22 IU/kg/d (95% CI -0.31 to -0.14, p < 0.001)]. No differences in the incidences of ketoacidosis and severe hypoglycemic events were found. CONCLUSIONS In short-term insulin therapy, CSII compared with MDI is a more effective form of metabolic control and allows reducing the daily insulin requirement. Yet, no conclusions have been made so far whether this effect holds in later years. These results should be approached with caution because of the methodological limitations of the analyzed studies.
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Affiliation(s)
- Ewa Pańkowska
- The Second Department of Pediatrics, Medical University of Warsaw, Poland.
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Bruttomesso D, Costa S, Baritussio A. Continuous subcutaneous insulin infusion (CSII) 30 years later: still the best option for insulin therapy. Diabetes Metab Res Rev 2009; 25:99-111. [PMID: 19172576 DOI: 10.1002/dmrr.931] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Thirty years after its introduction, the use of continuous subcutaneous insulin infusion (CSII) keeps increasing, especially among children and adolescents. The technique, when used properly, is safe and effective.Compared with traditional NPH-based multiple daily injections (MDI), CSII provides a small but clinically important reduction of HbA(1c) levels, diminishes blood glucose variability, decreases severe hypoglycaemic episodes and offers a better way to cope with the dawn phenomenon.Insulin analogues have improved the treatment of diabetes, eroding part of the place previously occupied by CSII, but CSII still remains the first option for patients experiencing severe hypoglycaemic episodes, high HbA(1c) values or marked glucose variability while being treated with optimized MDI. Furthermore CSII is better than MDI considering the effects on quality of life and the possibility to adjust insulin administration according to physical activity or food intake.CSII may be limited by cost. Present estimates suggest that CSII may be cost-effective just for patients experiencing a marked improvement in HbA(1c) or a decrease in severe hypoglycaemic episodes, but the effects on quality of life are difficult to measure.CSII does not merely imply wearing an external device; it requires a multidisciplinary team, intensive patient education and continuous follow up.
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Affiliation(s)
- Daniela Bruttomesso
- Department of Clinical and Experimental Medicine, Division of Metabolic Diseases, University of Padova, Padova, Italy.
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Danne T, Battelino T, Jarosz-Chobot P, Kordonouri O, Pánkowska E, Ludvigsson J, Schober E, Kaprio E, Saukkonen T, Nicolino M, Tubiana-Rufi N, Klinkert C, Haberland H, Vazeou A, Madacsy L, Zangen D, Cherubini V, Rabbone I, Toni S, de Beaufort C, Bakker-van Waarde W, van den Berg N, Volkov I, Barrio R, Hanas R, Zumsteg U, Kuhlmann B, Aebi C, Schumacher U, Gschwend S, Hindmarsh P, Torres M, Shehadeh N, Phillip M. Establishing glycaemic control with continuous subcutaneous insulin infusion in children and adolescents with type 1 diabetes: experience of the PedPump Study in 17 countries. Diabetologia 2008; 51:1594-601. [PMID: 18592209 DOI: 10.1007/s00125-008-1072-2] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2008] [Accepted: 05/20/2008] [Indexed: 01/15/2023]
Abstract
AIMS/HYPOTHESIS To assess the use of paediatric continuous subcutaneous infusion (CSII) under real-life conditions by analysing data recorded for up to 90 days and relating them to outcome. METHODS Pump programming data from patients aged 0-18 years treated with CSII in 30 centres from 16 European countries and Israel were recorded during routine clinical visits. HbA(1c) was measured centrally. RESULTS A total of 1,041 patients (age: 11.8 +/- 4.2 years; diabetes duration: 6.0 +/- 3.6 years; average CSII duration: 2.0 +/- 1.3 years; HbA(1c): 8.0 +/- 1.3% [means +/- SD]) participated. Glycaemic control was better in preschool (n = 142; 7.5 +/- 0.9%) and pre-adolescent (6-11 years, n = 321; 7.7 +/- 1.0%) children than in adolescent patients (12-18 years, n = 578; 8.3 +/- 1.4%). There was a significant negative correlation between HbA(1c) and daily bolus number, but not between HbA(1c) and total daily insulin dose. The use of <6.7 daily boluses was a significant predictor of an HbA(1c) level >7.5%. The incidence of severe hypoglycaemia and ketoacidosis was 6.63 and 6.26 events per 100 patient-years, respectively. CONCLUSIONS/INTERPRETATION This large paediatric survey of CSII shows that glycaemic targets can be frequently achieved, particularly in young children, and the incidence of acute complications is low. Adequate substitution of basal and prandial insulin is associated with a better HbA(1c).
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Affiliation(s)
- T Danne
- Kinderkrankenhaus auf der Bult, Hanover, Janusz-Korczak-Allee 12, 30173 Hanover, Germany.
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Pańkowska E, Szypowska A, Lipka M. Basal insulin and total daily insulin dose in children with type 1 diabetes using insulin pumps. Pediatr Diabetes 2008; 9:208-13. [PMID: 18547235 DOI: 10.1111/j.1399-5448.2008.00375.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To assess the contribution of basal insulin to the total daily dose (CBITDD) and to identify the determinant factors in children with type 1 diabetes mellitus. STUDY DESIGN Cross-sectional study in which the basal insulin requirement was established based on a memory read-out of insulin delivery from pumps. Factors such as glycated haemoglobin A1c (HbA1c), fasting C-peptide, standard deviation score of body mass index (sdsBMI) and demographic data were determined during routine hospital visits. Study group included a total of 90 well-controlled diabetic children with the mean HbA1c 6.6 +/- 0.7 (5.2-7.9), age 10.4 +/- 4.4 yr (1.1-17.9 yr), diabetes duration 3.0 +/- 2.6 yr (0.3-10.9 yr) and sdsBMI 0.08 (-2.27 to 1.79), excluding patients with ketoacidosis or infectious diseases. RESULTS Correlations between CBITDD and age (r = 0.39 and p < 0.005) and diabetes duration (r = 0.61 and p < 0.0001) and an inverse correlation with C-peptide (r = -0.41 and p = 0.0001) were found. C-peptide-positive patients had a significantly lower percentage of basal insulin compared with C-peptide-negative patients (20.6 +/- 11 vs. 31.6 +/- 11.0%, respectively; p = 0.0004); yet, no significant difference in total insulin daily dose (0.65 +/- 0.3 vs. 0.78 +/- 0.2 U/kg/d, respectively) was observed. CONCLUSIONS The percentage of basal insulin in diabetic children is below 50% and in well-controlled diabetic children is related to the fasting C-peptide level, age of patient and diabetes duration but not to HbA1c and sdsBMI.
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Affiliation(s)
- Ewa Pańkowska
- The Second Department of Paediatrics, Medical University of Warsaw, Warsaw, Poland.
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Kawamura T, Urakami T, Sugihara S, Kim HS, Mochizuki M, Amamiya S. Changes in glycemic control and quality of life in pediatric type 1 diabetics with continuous subcutaneous insulin infusion of insulin aspart following multiple daily injection therapy. Clin Pediatr Endocrinol 2008; 17:39-47. [PMID: 24790361 PMCID: PMC4004922 DOI: 10.1297/cpe.17.39] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2007] [Accepted: 12/10/2007] [Indexed: 11/21/2022] Open
Abstract
The efficacy of continuous subcutaneous insulin infusion (CSII) of the
rapid-acting insulin analogue, insulin aspart, was evaluated in 26 patients with
childhood-onset type 1 diabetes aged between 6 and 18 yr who had been on basal-bolus
therapy (multiple daily injection (MDI) of regular human insulin or rapid-acting insulin
and intermediate/long-acting insulin). The glycemic control in the patients was evaluated
based on changes in the clinical parameters and the patient quality of life (QOL) was
evaluated by using the insulin therapy-related QOL questionnaire. Twenty two patients
continued CSII during the 6-mo study period. The mean HbA1c was 7.8 ± 1.8% at baseline and
it decreased to 7.4 ± 0.8% at 6 mo after the start of the CSII. Overall, no decrease of
the QOL post-CSII initiation was noted. The possible superiority of CSII as compared to
MDI was suggested for patients who “eat out” or “have to look for an appropriate place for
insulin injection.” Aside from an inadequate indwelling needle placement detected after
the initiation of CSII in several patients, no adverse event associated with NovoRapid®
was seen. In conclusion, CSII of rapid-acting insulin appears to be a useful therapy for
patients with childhood-onset type 1 diabetes.
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Affiliation(s)
- Tomoyuki Kawamura
- Department of Pediatrics, Osaka City University School of Medicine, Osaka, Japan
| | - Tatsuhiko Urakami
- Department of Pediatrics, Surugadai Nihon University Hospital, Tokyo, Japan
| | - Shigetaka Sugihara
- Department of Pediatrics, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Hey Sook Kim
- Department of Pediatrics, Tokyo Women's Medical University Medical Center East, Tokyo, Japan
| | - Mie Mochizuki
- Department of Pediatrics, University of Yamanashi School of Medicine, Yamanashi, Japan
| | - Shin Amamiya
- Department of Pediatrics, Saitama Medical University School of Medicine, Saitama, Japan
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Cope JU, Morrison AE, Samuels-Reid J. Adolescent use of insulin and patient-controlled analgesia pump technology: a 10-year Food and Drug Administration retrospective study of adverse events. Pediatrics 2008; 121:e1133-8. [PMID: 18450857 DOI: 10.1542/peds.2007-1707] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES From January 1, 2005, through December 31, 2005, the Food and Drug Administration received 5 adolescent death reports associated with the use of insulin pumps, raising concerns about use of this device in this age group. To understand better the types of infusion pump-related problems in adolescents, we performed a comprehensive evaluation of insulin and patient-controlled analgesic pump-related adverse events reported for adolescents that were received by the Food and Drug Administration from 1996 to 2005. METHODS A search for medical device adverse event reports from January 1, 1996 through December 31, 2005, involving insulin pumps or patient-controlled analgesic pumps used by patients who were aged 12 to 21 years was conducted in the Food and Drug Administration's Manufacturer and User Facility Device Experience Database. Reports were reviewed for demographic characteristics, type of adverse event, and patient morbidity, and potential contributory factors were classified from narratives in the reports. RESULTS A total of 1674 reports were identified: 1594 for insulin pumps and 53 for patient-controlled analgesic pumps. In reports of insulin pump events, there were 13 reported deaths, 2 reports that indicated possible suicide attempts, and several additional reports indicating severe hypoglycemic or hyperglycemic events that seemed to be device-related. A total of 102 (6.4%) insulin-pump reports highlighted factors that may have contributed to the adverse event, including problems associated with compliance, education, sports-related activities, and dropping or damaging the pump. Eighty-two percent of cases involving the insulin pump resulted in hospitalization. Half of the reports involving patient-controlled analgesic pumps indicated that the patient received an excess of medication; tampering and noncompliance were evident in some cases. CONCLUSIONS Adolescents are a special population who deserve careful consideration of risk and benefit for use of device technology. Studies need to further identify safety problems in this age group.
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Affiliation(s)
- Judith U Cope
- Division of Postmarket Surveillance, Office of Surveillance and Biometrics, Food and Drug Administration, Rockville, Maryland 20850, USA.
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Cobry E, Chase HP, Burdick P, McFann K, Yetzer H, Scrimgeour L. Use of CoZmonitor in youth with type 1 diabetes. Pediatr Diabetes 2008; 9:148-51. [PMID: 18221430 DOI: 10.1111/j.1399-5448.2007.00268.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The purpose of this study was to evaluate the effectiveness of directly integrating self-monitoring blood glucose (BG) information with insulin pump therapy on overall glycemic control. METHODS In this randomized trial, 34 youth with type 1 diabetes using insulin pump therapy were trained on the use of the Deltec Cozmo Insulin Pump. Seventeen were randomized to use the CoZmonitor Blood Glucose Module, a device that attaches to the back of the pump using FreeStyle technology to perform BG tests which read directly on the pump screen. The remaining 17 (control group) used a FreeStyle Flash meter, a stand-alone BG meter, for their BG testing. At baseline, 3 and 6 months, the subjects filled out a questionnaire, had a hemoglobin A1c (HbA1c) test, and had pumps and meters downloaded. RESULTS After 3 months of study, there were no changes in mean HbA1c (+/- SD) values for the experimental (8.7 +/- 1.1 to 8.6 +/- 1.1) or the control groups (9.1 +/- 1.4 to 9.2 +/- 1.5). There were also no significant differences in HbA1c values after 6 months. The average number of BG tests per day did not change significantly in either group during the study. After 3 and 6 months, the experimental group rated satisfaction with the use of the CoZmonitor at 4.4 and 3.8 (respectively) on a five-point Likert scale, with 5 being the most satisfied. CONCLUSIONS Although significant changes in HbA1c values or the number of BG tests were not found, use of the BG module had a positive level of satisfaction.
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Affiliation(s)
- Erin Cobry
- Department of Pediatrics, Barbara Davis Center, University of Colorado Health Sciences Center, Aurora, CO 80045-6511, USA
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Affiliation(s)
- Thomas Danne
- Kinderkrankenhaus auf der Bult, Hannover, Germany.
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Abstract
UNLABELLED Both type 1 and type 2 diabetes can occur in children and adolescents. Type 1 diabetes is the most common chronic disease in children in the developed countries and the number of adolescents with type 2 diabetes is rising as a consequence of the obesity epidemic. As they grow, children and adolescents with diabetes have special and changing needs; these must be recognized and addressed as there are major physiological, medical, psychological, social and emotional differences in adults with diabetes. Glycaemic control is important to prevent or delay long-term complications also in the paediatric age group. This goal is often achieved using insulin. However, practical issues associated with insulin use in paediatric patients include attainment of target glycaemic levels without increased risk of hypoglycaemia, hormone-driven fluctuations in insulin requirements, and the psychological and social impacts of weight gain and puberty. This article reviews the advances that are helping to overcome these issues and enable paediatric patients to achieve their treatment goals. CONCLUSION Advanced insulin formulations, particularly insulin analogues, tailored insulin regimens and delivery systems combined with age-appropriate education, patient/carer involvement and ongoing support from the wider diabetes team will assist in the effective management of diabetes among children and adolescents.
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Affiliation(s)
- T Danne
- Diabetes-Zentrum für Kinder und Jugendliche, Kinderkrankenhaus auf der Bult, Hannover, Germany.
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Abstract
Since the findings of the Diabetes Control and Complications Trial became public in 1993, intensive insulin therapy has been recommended for all children. However, successful implementation remains a challenge because of developmental, physiological and cultural, as well as practical issues specific to the pediatric population. This article reviews the different insulin regimens that are currently available, from the short- and intermediate-acting insulins to the newer insulin analogs, focusing on insulin therapies that attempt to provide a more physiologic basal-bolus approach to treatment. More and more children are on multiple daily injection regimens or using continuous subcutaneous insulin infusion to achieve better metabolic control. The achievement of optimal glycemic control in children is complicated by their variability in eating habits and activity levels and perhaps more importantly by the risk of hypoglycemia. The hope is that new technologies including continuous subcutaneous glucose monitoring and perhaps a closed-loop system in the near future will help us achieve more optimal glycemic targets in children without increased side effects. In addition, continuous glucose monitoring may teach us better ways to use insulin in children who do not have the technology available to them.
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Affiliation(s)
- Andrea K Steck
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Denver, CO, USA
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Heidtmann B, Böhle A, Jakisch B, Matheika D, Otto KP, Lepler R. Insulinpumpentherapie in der Pädiatrie. DIABETOLOGE 2007. [DOI: 10.1007/s11428-007-0151-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Pańkowska E, Szypowska A, Lipka M, Skórka A. Sustained metabolic control and low rates of severe hypoglycaemic episodes in preschool diabetic children treated with continuous subcutaneous insulin infusion. Acta Paediatr 2007; 96:881-4. [PMID: 17537017 DOI: 10.1111/j.1651-2227.2007.00301.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To evaluate the safety and efficacy of continuous subcutaneous insulin infusion (CSII) in children under 7 years of age. METHODS One hundred and ten children, aged 0.9-7 years, who had received CSII therapy for at least 6 months, were studied for 237 patient-years by a retrospective chart review. Charts were reviewed for glycosylated hemoglobin (HbA1c), severe hypoglycaemia (SH), ketoacidosis (DKA), height, weight and insulin requirement. In 69 cases (children aged 1.6-7 years) CSII was administered after at least 3 months of insulin therapy with pens. In this group, data from the year from before CSII administration were compared with values recorded during 1 year of CSII treatment. RESULTS Mean HbA1c decreased from 7.8 +/- 0.9 before CSII to 7.5 +/- 1.0 after 6 and 12 months of pump therapy (p = 0.04). In the whole group, the mean HbA1c after 6 months of CSII was 7.5 +/- 1.0 and remained unchanged for up to 4 years of follow-up. Some episodes of SH--4.2 per 100 patient-years, and DKA--5.7 per 100 patient-years were recorded. No increase in BMI z-score occurred. CONCLUSIONS In the youngest children, CSII therapy lowers HbA1c values and provides sustained metabolic control without increases in hypoglycaemia or ketoacidosis episodes.
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Affiliation(s)
- Ewa Pańkowska
- Department of Diabetology and Birth Defects, the Medical University of Warsaw, Poland.
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