Pros and cons of continuous subcutaneous insulin infusion

Factors associated with adherence to continuous subcutaneous insulin infusion in pediatric diabetes

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.

Recent developments in insulin delivery techniques. Current status and future potential

Although single or multiple daily subcutaneous injections of insulin are the mainstay of insulin delivery techniques, several other methods of insulin delivery are now available or in development, including: (a) continuous subcutaneous insulin infusion by a wearable infusion pump; (b) total or segmental transplantation of a pancreas; (c) transplantation of isolated islet cells; (d) implantation of a programmable insulin pump; (e) oral, nasal, rectal and transdermal mechanisms of insulin delivery; (f) insulin analogues; (g) implantation of polymeric capsules which give continuous or time-pulsed release of insulin; and (h) implantation of a biohybrid artificial pancreas which uses encapsulated islets. Many of these methods of insulin delivery are aimed at achieving a more physiological means of delivery of the insulin, thus to improve glycaemic control and hopefully minimise the secondary complications of diabetes. Techniques of multiple insulin injections and continuous subcutaneous insulin infusion pumps are already in widespread use and are resulting in improved glycaemic control. With the recent increased use of pancreatic transplantation, the rule of establishing euglycaemia will be elucidated in the treatment and prevention of microvascular and macrovascular complications of diabetes mellitus. Despite these advances, the ideal delivery of insulin to patients has yet to be developed. Subcutaneous methods of insulin delivery do not precisely mimic physiological insulin needs and transplantation requires risky immunosuppression. However, the future does look bright as glucose sensors are developed and insulin analogues synthesised.

A primer on insulin use

Insulin treatment, if thoughtfully designed and carefully monitored, can allow the diabetic patient to lead a close-to-normal life. Several types of insulin with varying times of action are available, and regimens can be tailored to a patient's needs and life-style, with alterations made for such things as time changes, exercise, and fasting for surgical procedures. Self-monitoring of blood glucose levels can provide patients with an important measure of independence, as can instruction on recognizing and correcting episodes of hypoglycemia. Insulin is an important part of managing ketoacidosis and hyperosmolar hyperglycemia syndrome, although success depends on overall care.

Insulin pump therapy for older adults: case report

Pump therapy offers some people with insulin-treated diabetes a way to achieve stricter blood glucose con trol and more flexible lives. While strict control may be most important for young people, older adults may benefit from the freedom possible with pump therapy. This case presentation describes the use of an insulin pump by a 68-year-old man whose main goal was to have more flexibility in his meal frequency and timing. Some special con siderations for pump therapy in older adults in clude the use of a sim pler, less expensive in sulin pump, visual aids, and less strict blood glucose targets.