Treating the Spectrum of Type 2 Diabetes

Continuous subcutaneous insulin infusions: Closing the loop

CONTEXT

Continuous subcutaneous insulin infusions (CSIIs) and continuous glucose monitors (CGMs) have revolutionized the management of diabetes mellitus (DM). Over the last two decades the development of advanced, small, and user-friendly technology has progressed substantially, essentially closing the loop in the fasting and post-absorptive state, nearing the promise of an artificial pancreas. The momentum was mostly driven by the diabetes community itself, to improve its health and quality of life.

EVIDENCE ACQUISITION

Literature regarding CSII and CGM was reviewed.

EVIDENCE SYNTHESIS

Management of DM aims to regulate blood glucose to prevent long term micro and macrovascular complications. CSIIs combined with CGMs provide an integrated system to maintain tight glycemic control in a safe and uninterrupted fashion, while minimizing hypoglycemic events. Recent advances have allowed to 'close the loop' by better mimicking endogenous insulin secretion and glucose level regulation. Evidence supports sustained improvement in glycemic control with reduced episodes of hypoglycemia using these systems, while improving quality of life. Ongoing work in delivery algorithms with or without counterregulatory hormones will allow for further layers of regulation of the artificial pancreas.

CONCLUSION

Ongoing efforts to develop an artificial pancreas have created effective tools to improve the management of DM. CSIIs and CGMs are useful in diverse populations ranging from children to the elderly, as well as in various clinical contexts. Individually and more so together, these have had a tremendous impact in the management of DM, while avoiding treatment fatigue. However, cost and accessibility are still a hindrance to its wider application.

Insulin requirement profiles of short-term intensive insulin therapy in patients with newly diagnosed type 2 diabetes and its association with long-term glycemic remission

AIMS

To investigate the insulin requirement profiles during short-term intensive continuous subcutaneous insulin infusion (CSII) in patients with newly diagnosed type 2 diabetes and its relationship with long-term glycemic remission.

METHODS

CSII was applied in 104 patients with newly diagnosed type 2 diabetes. Daily insulin doses were titrated and recorded to achieve and maintain euglycemia for 2 weeks. Measurements of blood glucose, lipid profiles as well as intravenous glucose tolerance tests were performed before and after the therapy. Afterwards, patients were followed up for 1 year.

RESULTS

Total daily insulin dose (TDD) was 56.6±16.1IU at the first day when euglycemia was achieved (TDD-1). Thereafter, TDD progressively decreased at a rate of 1.4±1.0IU/day to 36.2±16.5IU at the end of the therapy. TDD-1 could be estimated with body weight, FPG, triglyceride and waist circumference in a multiple linear regression model. Decrement of TDD after euglycemia was achieved (ΔTDD) was associated with reduction of HOMA-IR (r=0.27, P=0.008) but not with improvement in β cell function. Patients in the lower tertile of ΔTDD had a significantly higher risk of hyperglycemia relapse than those in the upper tertile within 1 year (HR 3.4, 95%CI [1.4, 8.4], P=0.008).

CONCLUSIONS

There is a steady decline of TDD after euglycemia is achieved in patients with newly diagnosed type 2 diabetes treated with CSII, and ΔTDD is associated with a better long-term glycemic outcome.

Insulin requirement profiles in Japanese hospitalized subjects with type 2 diabetes treated with basal-bolus insulin therapy

To assess the total daily inulin dose (TDD) and contribution of basal insulin to TDD and to identify the predictive factors for insulin requirement profiles in subjects with type 2 diabetes, we retrospectively examined insulin requirement profiles of 275 hospitalized subjects treated with basal-bolus insulin therapy (BBT) (mean age, 60.1 ± 12.9 years; HbA1c, 10.2 ± 4.5%). Target plasma glucose level was set between 80 and 129 mg/dL before breakfast and between 80 and 179 mg/dL at 2-hour after each meal without causing hypoglycemia. We also analyzed the relationship between the insulin requirement profiles (TDD and basal/total daily insulin ratio [B/TD ratio]) and insulin-associated clinical parameters. The mean TDD was 0.463 ± 0.190 unit/kg/day (range, 0.16-1.13 unit/kg/day). The mean B/TD ratio was 0.300 ± 0.099 (range, 0.091-0.667). A positive correlation of TDD with B/TD ratio was revealed by linear regression analysis (r=0.129, p=0.03). Stepwise multiple regression analysis identified post-breakfast glucose levels before titrating insulin as an independent determinant of the insulin requirement profile [Std β (standard regression coefficient) = 0.228, p<0.01 for TDD, Std β = -0.189, p<0.01 for B/TD ratio]. The TDD was <0.6 unit/kg/day and the B/TD ratio was <0.4 in the majority (70.2%) of subjects in the present study. These findings may have relevance in improving glycemic control and decreasing the risk of hypoglycemia and weight gain in subjects with type 2 diabetes treated with BBT.

Insulin requirement profiles of patients with type 2 diabetes after achieving stabilized glycemic control with short-term continuous subcutaneous insulin infusion

BACKGROUND

As in type 1 diabetes, continuous subcutaneous insulin infusion (CSII) therapy is emerging as a promising therapeutic option in type 2 diabetes. However, the insulin requirement profiles of patients with type 2 diabetes when treated via CSII with rapid-acting insulin analogs have not been well investigated.

METHODS

We examined insulin requirement profiles of type 2 diabetes patients (n = 300; age, 57.9 +/- 11.4 years; hemoglobin A1c [HbA(1c)], 9.1 +/- 2.2%) for 3 days after achieving normoglycemia via 1-2 weeks of CSII therapy. We also analyzed the total daily dose (TDD) of insulin-associated clinical and laboratory parameters at baseline.

RESULTS

The mean TDD was 45.1 +/- 24.7 IU/day (range, 4.8-145.8 IU/day). The total daily bolus (TBo) (range 2.8-111.3 IU/day) was 64.1 +/- 12.1% of the TDD. The rates of infusion for day and night in total daily basal dose (TBa) were 0.74 +/- 0.35 and 0.41 +/- 0.32 IU/h, respectively. The dose ratio (in IU/day) was 2.7 : 1.9 : 1.6 : 1.8 : 1 (breakfast, lunch, and dinner bolus and day and night basal, respectively). After adjusting for age, gender, and body mass index, TDD was associated with HbA(1c), fasting and 2-h postprandial plasma glucose, fasting C-peptide, and carbohydrate-to-insulin ratio (P < 0.05).

CONCLUSIONS

Initial TDD in type 2 diabetes patients on CSII showed a wide range of distribution with a TBo-to-TBa ratio >2.0 and was associated with parameters indicating glycemic control but not with body weight, suggesting that the currently used protocol in dose determination of insulin, including allocation of half of the TDD to TBa or weight-based determination of initial TDD, may need to be reexamined when treating type 2 diabetes with CSII therapy.

Evaluation of treatment satisfaction associated with the use of insulin aspart in continuous subcutaneous insulin infusion

BACKGROUND

The purpose of this study was to compare treatment satisfaction among people with type 1 and type 2 diabetes after switching from insulin lispro to insulin aspart in continuous subcutaneous insulin infusion (CSII). Efficacy of glycemic control between treatments was also investigated.

METHODS

Subjects using CSII with insulin lispro for 6 months or longer continued this therapy over a 4-week period and then switched to insulin aspart in CSII for 12 weeks. The Diabetes Treatment Satisfaction Questionnaire (DTSQ) and Insulin Treatment Satisfaction Questionnaire (ITSQ) were administered immediately prior to the switch and again at the end of 12 weeks of therapy with insulin aspart. Hemoglobin A(1c)(A1C) and fasting blood glucose (FBG) levels, insulin dose, and body weight were recorded at the same time points.

RESULTS

Although average overall DTSQ score did not change significantly, average overall ITSQ score was significantly improved following the insulin aspart treatment. There was a small but statistically significant reduction in mean A1C and FBG following 12 weeks of CSII using insulin aspart.

CONCLUSIONS

Both insulin aspart and insulin lispro are appropriate for CSII. ITSQ improvements suggest that aspects of CSII therapy with insulin aspart positively impact treatment satisfaction.