The suboptimal roadmap to the intensive therapy target.

Abstract

17 THE GOAL OF INTENSIVE THERAPY using either multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII) therapy is to help people with diabetes achieve target A1c values without increasing the frequency of severe hypoglycemia. Under the guidance of the health care provider, patients select a treatment regimen that will match their lifestyle to their diabetes management goals. Often MDI therapy is initially selected because of the perceived greater commitment in terms of initial costs, supplies, and training associated with insulin pump therapy. However, if a patient is unable to meet his or her diabetes management goals with insulin injections, he or she often switches to CSII therapy. In this issue of Diabetes Technology & Therapeutics, Garg et al.1 compared glycemic parameters following 13.1 months of MDI therapy with basal insulin glargine versus 11.6 months of CSII therapy. They demonstrated significant improvements in A1c from baseline values in both the MDI group (8.0 6 0.1% to 7.76 0.1%, P , 0.001) and the CSII group (7.76 0.1% to 7.5 6 0.1%, P , 0.001). Severe hypoglycemia is the most common acute complication of intensive therapy with an average cost of $1,186 per event.2 Garg et al.1 reported that the incidence of severe hypoglycemia in the glargine group was 0.2 episodes per year greater than in the pump group. This translates into 60 cases of severe hypoglycemia, which would have been prevented by placing this group on pump therapy. The statistical methods used did not observe a significant difference between the two groups. No cost data for severe hypoglycemia were included in the analysis, but the added cost would appear to be $71,160, or $238 per patient-year. Garg et al.1 did report more diabetic ketoacidosis (DKA) requiring hospitalization (n5 6) in the CSII group. They used a figure for DKA cost that is based on hospitalization for all types of DKA, not only pump patients. It may be presumed that pump patients are trained to be more sensitive to detecting early signs of DKA and thus be managed more economically. High incidences of DKA with insulin pump therapy have not been reported since the mid-1980s, and it is currently believed that the interruption of insulin is often a result of inadequate patient education3 and now should be recognized very early, thus avoiding hospitalization. The authors concluded that MDI with basal glargine is superior to CSII therapy, considering the increased costs and potential of DKA attributed to the CSII group. A more accurate comparison of the costs of MDI and CSII therapy including both an estimate of costs related to hypoglycemia and those related to DKA is presented in Table 1. The cost analysis reported by Garg et al.1 estimates $9,373 per year for pa-