Continuous Subcutaneous Insulin Infusion In Patients Research Articles

A Systematic Review and Meta-Analysis of Continuous Subcutaneous Insulin Infusion vs. Multiple Daily Injections in Type-2 Diabetes.

Diabetes mellitus (DM) has a growing prevalence worldwide, even in developing countries. Many antidiabetic agents are used to improve glycemic control; however, in cases of an insufficient outcome, insulin is administered. Yet, the timing of proper insulin administration is still a subject of intense research. To date, there have been no recommendations or guidelines for the use of continuous subcutaneous insulin infusion (CSII) in Type 2 Diabetes Mellitus (T2DM). In the present study, we have performed a meta-analysis to evaluate the use of CSII in patients with T2DM. An extensive literature search was conducted through the electronic databases Pubmed, Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials (CENTRAL) from October 2019-May 2022, for interventional studies related to T2DMI and CSII versus multiple daily injections (MDI). We included articles published in the English language only, yielding a total of thirteen studies. We found better outcomes in patients receiving CSII, in regard to glycated hemoglobin (HbA1c) and total insulin dose. In contrast, fasting plasma glucose and body weight did not show statistically significant differences between the two groups. Our analyses showed that CSII could be beneficial in patients with T2DM in order to achieve their glucose targets.

Evaluation of Lipohypertrophy in Patients With Type 1 Diabetes Mellitus on Multiple Daily Insulin Injections or Continuous Subcutaneous Insulin Infusion

ObjectiveTo determine lipohypertrophy (LH) in patients with type 1 diabetes mellitus (T1DM) on multiple daily insulin injections (MDII) or continuous subcutaneous insulin infusion (CSII) and to reveal the factors associated with the development and severity of LH. MethodsSixty-six patients with T1DM treated with MDII (n = 35, 53%) or CSII (n = 31, 47%) for at least 1 year were included. LH localizations were detected with palpation and ultrasonography (USG). ResultsThe LH detection rate with USG was significantly higher than that by palpation in the whole group (P < .001). The LH was detected with USG in 30 (85.7%) patients in the MDII group and 22 (71.0%) patients in the CSII group (P = .144). Advanced LH was detected in 13 (37.1%) of the patients treated with MDII and in 3 (9.7%) of the patients treated with CSII. LH was more severe in the MDII group than in the CSII group (P = .013). Diabetes duration and length of infusion set use were significantly longer and body mass index, hypoglycemia, and complication rates were higher in patients with LH than those in patients without LH (P < .05). A positive correlation was found between LH severity and HbA1C and insulin dose (P < .05, for both). MDII as insulin administration method, incorrect rotation, and a history of ketosis were found to be the most related factors with LH severity in a multiple linear regression analysis (P < .05). ConclusionUSG might be an effective approach for detecting and evaluating the severity of LH. MDII might cause more severe LH than CSII in patients with T1DM. In this study, LH was found to be associated mostly with incorrect rotation technique and a history of ketosis.

The Effectiveness of Insulin Pump Therapy Versus Multiple Daily Injections in Children With Type 1 Diabetes Mellitus in a Specialized Center in Riyadh.

Objectives:Comparison of continuous subcutaneous insulin infusion (CSII) with multiple daily injections (MDI) in achieving glycemic control in youths with type 1 diabetes mellitus (T1DM).Methods:Retrospective cohort study including 2 matched groups of youths with T1DM treated by CSII or MDI in a tertiary specialized children’s hospital in Saudi Arabia. Children and adolescents aged up to 18 years, diagnosed with T1DM and using CSII or MDI, from the period 2016 to 2018. Patients on MDI were newly-diagnosed patients with T1DM who had the disease for only 1 year duration; all CSII patients had at least 1 to 2 years of T1DM but who had just started on pumps in the past 3 months. We excluded patients with other autoimmune diseases, non-ambulatory patients and those admitted to hospital for non-diabetes reasons. Primary outcome was HbA1c at 1, 2, and 3 years, with weight gain as a secondary outcome. Ambulatory glycemic profile was analyzed from a subset of patients using intermittently scanned continuous glucose monitoring (isCGM).Results:A total of 168 youths with T1DM (n = 129 in the MDI group, n = 39 in the CSII group) were included. The CSII group consistently had lower HbA1c levels compared to the MDI group throughout a 3-year follow up period: 8.1% versus 10.1, P-value < .001 at 1 year, 7.5% versus 10.1% at 2 years, P-value < .001, 8.9% versus 10.3% at 3 years, P-value = .033. Body mass index significantly increased in both groups at 1 year, although greater in CSII group. In a subgroup using isCGM (n = 37 on MDI and n = 29 on CSII), the CSII group had a lower average blood glucose (194 mg/dL vs 228 mg/dL, P-value = .028) and a lower estimated HbA1c level (8.4% vs 9.6%, P-value = .022).Conclusion:Treatment with CSII resulted in lower HbA1c compared to MDI in our cohort, which was sustained over a 3-year period.

Continuous glucose monitoring and insulin pump therapy in pregnant women with type 1 diabetes mellitus.

We examined the impact of continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring systems (CGM) during pregnancy in women with pre-gestational type 1 diabetes (T1DM) on glycemic control and subsequent adverse outcomes. In this observational, one-center study we analyzed records of consecutive 109 T1DM pregnancies (2016-2017). The final analyzed group consisted of 81 singleton pregnancies who met inclusion and exclusion criteria. We searched for the association between the use of CSII with or without CGM and pregnancy planning with glycated hemoglobin A1c (HbA1c) through pregnancy and after delivery as well as maternal and infant outcomes. Patients using CSII and CGM vs CSII without CGM and MDI (multiple daily injections) users had the lowest HbA1c levels during and after pregnancy (5.3%, 5.3%, 5.2% and 5,5% in the 1st, 2nd, 3rd trimester and postpartum visit, p = 0.003, p = 0.030, p = 0.039 and p = 0.002, respectively). Patients treated with insulin pumps with CGM and additional functions of automatic insulin delivery suspension on low glucose level (SLG) or predictive low glucose suspend (PLGS) during the third trimester and after pregnancy achieved a significantly lower HbA1c than the other CSII patients. We did not find any differences between the study groups in gestational age at delivery, preterm births, birth weight or macrosomia risk. Despite very good glycemic control, the risk of macrosomia remained high (19.7%). The use of pumps equipped with CGM, especially with automatic insulin delivery suspension, may improve glycemic control in pregnant T1DM women. The proportion of macrosomia remained high.

Vascular and Myocardial Function in Young People with Type 1 Diabetes Mellitus: Insulin Pump Therapy Versus Multiple Daily Injections Insulin Regimen.

Multiple daily injections (MDI) and continuous subcutaneous insulin infusion (CSII) are two modalities of treating type 1 diabetes mellitus (T1DM). The benefits of CSII on long-term metabolic control and outcomes compared to those of MDI are still debated. We investigated both vascular function and myocardial performance in T1DM adolescents on MDI or CSII treatment. One hundred twenty-three T1DM subjects (mean age 14.16±2.55 years), 63 on MDI regimen, 60 on CSII, and 57 controls were enrolled. Anthropometric and biochemical characteristics were evaluated. Ultrasound assessments of carotid intima-media thickness (cIMT), flow-mediated dilatation of brachial artery, anteroposterior diameter of the infrarenal abdominal aorta (APAO), and transthoracic echocardiography were performed. T1DM subjects on the CSII regimen showed better glycemic control than those on MDI, expressed as glycated haemoglobin (HbA1c). c-IMT and APAO were higher in MDI than CSII patients (0.61±0.11 mm vs. 0.56±0.07 mm, p=0.04; 13.61±3.29 mm vs. 11.65±1.84 mm, p=0.01, respectively). Left and right Tei index and left E/e' ratio were higher in MDI than CSII subjects (0.82±0.40 vs. 0.52±0.19, p=0.002; 0.86±0.41 vs. 0.64±0.1, p=0.02; 5.89±2.0 vs. 4.73±1.59, p=0.02, respectively). Multiple regression analyses showed that glucose level, HbA1c and diabetes onset were significantly related to vascular and echocardiographic parameters in MDI and CSII patients. CSII regimen in T1DM adolescents improves glycemic control and seems to ameliorate endothelial function and global myocardial performance as compared to MDI therapy.

Cost-Effectiveness of Sensor-Augmented Insulin Pump Therapy Versus Continuous Insulin Infusion in Patients with Type 1 Diabetes in Turkey.

Background and Aims: Sensor-augmented pump therapy (SAP) combines continuous glucose monitoring with continuous subcutaneous insulin infusion (CSII). SAP is costlier than CSII but provides additional clinical benefits relative to CSII alone. A long-term cost-effectiveness analysis was performed to determine whether SAP is cost-effective relative to CSII in patients with type 1 diabetes (T1D) in Turkey. Methods: Analyses were performed in two different patient cohorts, one with poor glycemic control at baseline (mean glycated hemoglobin 9.0% [75 mmol/mol]) and a second cohort considered to be at increased risk of hypoglycemic events. Clinical input data and direct medical costs were sourced from published literature. The analysis was performed from a third-party payer perspective over patient lifetimes and future costs and clinical outcomes were discounted at 3.5% per annum. Results: In both patient cohorts, SAP was associated with a gain in quality-adjusted life expectancy but higher costs relative to CSII (incremental gain of 1.40 quality-adjusted life years [QALYs] in patients with poor baseline glycemic control and 1.73 QALYs in patients at increased risk of hypoglycemic events). Incremental cost-effectiveness ratios for SAP versus CSII were TRY 76,971 (EUR 11,612) per QALY gained for patients with poor baseline glycemic control and TRY 69,534 (EUR 10,490) per QALY gained for patients at increased risk for hypoglycemia. Conclusions: SAP is associated with improved long-term clinical outcomes versus CSII, and in Turkey, SAP is likely to represent good value for money compared with CSII in T1D patients with poor glycemic control and/or with frequent severe hypoglycemic events.

Risk factors of pathological glycemic variability in pregnant women with type 1 diabetes mellitus

Hypothesis/aims of study. Academician Vasily G. Baranov’s statement that achieving normal glycemia is the main condition for successful pregnancy outcomes in women with diabetes mellitus has already been proven. Unfortunately, these tight glycemic targets are hard to be achieved especially in metabolic changes during pregnancy. Glycemic variability is a new glycemic parameter available due to continuous glucose monitoring (CGM). Pathological glycemic variability can be an important risk factor for oxidative stress along with chronic hyperglycemia in patients with type 1 diabetes mellitus (T1D). However, there is no enough literature confirming the effect of pathological glycemic variability on pregnancy course and outcomes in T1D women. The aim of the study is to analyze different modes of insulin therapy for glycemic targets achievement and glycemic variability reduction in T1D pregnant women.&#x0D; Study design, materials, and methods. 100 women treated with continuous subcutaneous insulin infusion (CSII) and another 100 women treated with multiple daily injections (MDI) of insulin were examined. Indices of glycemic variability were estimated.&#x0D; Results. Glycemic variability was significantly lower in CSII patients compared to the MDI group. The influence of glycemic variability on endothelial dysfunction was confirmed for T1D pregnant women. CSII proved advantages in achieving glycemic targets without increasing glycemic variability and hypoglycemia.&#x0D; Conclusion. CSII combined with CGM is the most optimal insulin therapy for glycemic targets achievement without an increased risk for glycemic variability and hypoglycemia.

Are We Ready to Treat Our Diabetes Patients Using Social Media? Yes, We Are.

The aim of the study was to evaluate Facebook group as possible communication tool to improve glucose control in adolescents and young people with type 1 diabetes (T1D). This retrospective and cross-sectional study included 728 T1D patients (age 11-25) on continuous subcutaneous insulin infusion (CSII) or multiple daily injections (MDI) treated at the center for insulin pump and glucose sensor in Skopje from January 2012 to December 2017. Data were collected through the electronic medical record system and cross-sectional analysis (telephone, social media (Facebook and Viber) or email). Patients were analyzed in two groups: (a) non-Internet group, with 398 patients treated using standard medical protocol with regular clinic visits; (b) Internet group, with 330 patients who, besides standard medical protocol, were active members of a national closed Facebook group on diabetes. Both the non-Internet and Internet groups had regular visits every 2-3 months. Patients from the Internet group were members of the closed Facebook group "Diabetes Macedonia" and had an opportunity to interact with questions, answers, and comments on diabetes care. An additional analysis was performed of the Internet group on combined use of Facebook and Viber. Average HbA1c levels were compared in both groups. Each patient from the Facebook group had 1.5 ± 3.5 posts per day. Hba1c was significantly lower in patients from the Internet group (7.1 ± 3.2%; 54 ± 35 mmol/mol) compared to patients from the non-Internet group (7.6 ± 2.8%; 60 ± 31 mmol/mol). Social media like Facebook and Viber can be additional communication tool in adolescents and young people with T1D and can significantly lower HbA1c compared to patients without social media use. CSII patients are more likely to use both social media (Facebook and Viber) compared with MDI patients (Facebook only).

C-Peptide and Beta-Cell Autoantibody Testing Prior to Initiating Continuous Subcutaneous Insulin Infusion Pump Therapy Did Not Improve Utilization Or Medical Costs Among Older Adults With Diabetes Mellitus

To study the impact of the C-peptide and beta-cell autoantibody testing required by the Center for Medicare and Medicaid Services (CMS) on costs/utilization for patients with diabetes mellitus initiating continuous subcutaneous insulin infusion (CSII) therapy. This retrospective study used propensity score-matched patients. Analysis 1 compared patients 1-year pre- and 2-years post-CSII adoption who met or did not meet CMS criteria. Analysis 2 compared Medicare Advantage patients using CSII or multiple daily injections (MDI) who did not meet CMS criteria for 1-year pre- and 1-year post-CSII adoption. Analysis 3 extended analysis 2 to 2 years postindex and also included a subset of patients ≥55 years old but not yet in Medicare Advantage. Analysis 1 resulted in significantly slower growth in hospital admissions ( P = .0453) in CSII-treated patients who did not meet the criteria. Analyses 2 and 3 showed numerically slower growth in inpatient, outpatient, and emergency department (ED) costs for CSII versus MDI patients (both not meeting criteria). Analysis 3 showed significantly slower growth in ED costs and hospital admissions for CSII versus MDI Medicare Advantage patients before propensity matching (both P<.05). In patients ≥55 years old, ED costs grew more slowly for CSII than MDI therapy ( P = .0678). Numerically slower growth in hospital admissions was seen for pump adopters who did not meet CMS C-peptide criteria, while medical costs growth was similar. For CSII users who did not meet the CMS criteria, numerically slower growth in inpatient, outpatient, ED costs, and hospital admissions occurred versus MDI. CMS = Center for Medicare and Medicaid Services; CSII = continuous subcutaneous insulin infusion; DM = diabetes mellitus; DME = durable medical equipment; ED = emergency department; MDI = multiple daily injections (of insulin).

Prevalence and geographical distribution of insulin pump therapy in the Central Denmark Region and its association with metabolic parameters

AimsInsulin treatment in type 1 diabetes encompasses multiple daily insulin injections (MDI) or continuous subcutaneous insulin infusion (CSII). Both population-based studies and comparative studies regarding CSII use are sparse. The aim of the current study was to describe the prevalence and distribution of CSII use among adults with type 1 diabetes in the Central Denmark Region and to compare metabolic control in CSII-treated patients to those treated with MDI. MethodsA database was constructed using the Danish Adult Diabetes Registry in 2014/2015 in combination with an audit of the patients’ medical records. Results3909 adults with type 1 diabetes patients were included. The proportion of patients treated with CSII differed significantly between the 8 regional hospitals from 12.0% to 31.1%. CSII users had a significantly lower HbA1c compared to MDI treated patients (7.6% (60 mmol/mol) versus 8.0% (64 mmol/mol)) in unadjusted analyses. After adjustment for clinically relevant characteristics the difference between CSII and MDI-treated patients was attenuated, but remained statistically significant. ConclusionThe distribution of CSII differed markedly between hospitals and CSII users had better glycemic control, even after adjustment for sex, age, BMI, diabetes duration, smoking, use of lipid-lowering and blood pressure-lowering medication.

High irisin levels are associated with better glycemic control and bone health in children with Type 1 diabetes

AimIrisin is a new peptide produced mainly by the skeletal muscle playing an important role both in glucose/energy homeostasis and bone metabolism. Childhood type 1 diabetes mellitus (T1DM) is associated with decreased bone mass. We aimed to evaluate irisin levels in TD1M children and their correlation with bone metabolism and glycaemic control. MethodsNinety-six T1DM subjects (12.2 ± 4 years), 56 on multiple daily injections (MDI), 40 on continuous subcutaneous insulin infusion (CSII), and 34 controls were included in the study. Irisin and bone remodeling markers were quantified in sera from patients and controls. Bone mineral density (BMD) was evaluated by QUS. ResultsIncreased irisin levels were found in T1DM patients respect to controls (p < 0.001). With adjustment for age, irisin levels significantly correlated negatively with HbA1c% (r = −0.105, p < 0.001), years of diabetes (r = −0.07, p < 0.04), 25(OH)-Vitamin D (r = −0.175, p < 0.0001), and positively with BTT-Z-score (r = 0.088, p = 0.016), and osteocalcin (r = 0.059, p < 0.04). We detected the highest levels of irisin in CSII patients compared to MDI and controls (p < 0.001 and p < 0.007 respectively). ConclusionsWe demonstrated high irisin levels in T1DM children and the association of highest irisin amounts to a better glycaemic control and bone health in TDM1 subjects on CSII.

Treatment Modality-Dependent Risk of Diabetic Ketoacidosis in Patients with Type 1 Diabetes: Danish Adult Diabetes Database Study.

The aim of this study was to evaluate the incidence rates of diabetic ketoacidosis (DKA) according to treatment modality in patients with type 1 diabetes (T1D) in Denmark, either multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). A total of 20,902 T1D registered in the Danish Adult Diabetes Database were followed for an average of 5.4 years. Poisson regression analyses with risk time as offset were used to compare differences in rates of DKA between CSII and MDI. Model was adjusted for age, sex, diabetes duration, previous DKA events, and hemoglobin A1c (HbA1c). A modifying effect of number of CSII patients on the DKA rates was tested. During 113,731 person-years, 3100 DKA events were registered (53 among CSII). CSII patients were younger (42.3 vs. 47.9 years), a larger proportion was female (59% vs. 43%), had a shorter diabetes duration (19 vs. 21 years), and a lower HbA1c (61.9 vs. 66.6 mmol/mol). There was no significant difference in the incidence rate of DKA between CSII and MDI (rate ratio: 1.30, 95% confidence interval: 0.97-1.76). However, in clinics with at least 250 CSII patients, rates of DKA events were lower among CSII users, while the opposite was true for the smaller clinics (P = 0.016). Delivery of CSII in large diabetes clinics with sufficient support and patient education may ensure that CSII treatment does not lead to an increased risk of DKA.

Impact of Treatments on Diabetic Control and Gastrointestinal Symptoms After Total Pancreatectomy.

The aims of this study were to compare the safety, efficacy, and patients' quality of life with continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDIs) in type 3c diabetes mellitus (T3cDM) following total pancreatectomy (TP) and pancreatic enzyme usage. Thirty-nine patients with T3cDM (18 CSII patients vs 21 MDI patients) who underwent TP between 2000 and 2016 at 3 Harvard-affiliated hospitals and the University of Minnesota returned prospectively obtained questionnaires examining quality of life and both endocrine and exocrine pancreatic functions. Main indications for TP were as follows: chronic pancreatitis (n = 19), intraductal papillary mucinous neoplasm (n = 12), and adenocarcinoma (n = 4). Median hemoglobin A1c using MDIs was 8.1% versus 7.3% in CSII. Severe hypoglycemic events using MDIs were increased compared with CSII (P = 0.02). There were no significant differences in quality-of-life measures with CSII versus MDIs. Pancreatic enzyme dose per meal (P < 0.05) differed between the hospitals. Gastrointestinal symptoms and unintended weight loss (P < 0.01) were more common with low doses of pancreatic enzymes. After TP, CSII therapy is safe compared with MDIs in T3cDM and not associated with an increase in severe hypoglycemic events. Pancreatic enzyme replacement therapy is highly variable with low doses associated with unintentional weight loss and gastrointestinal symptoms.

New technologies and metabolic control in type 1 diabetes mellitus

The introduction of more rigorous criteria of metabolic control, rapid- and long-acting insulin analogues and the advances in diabetes technology (improved insulin deliv­ery systems and blood glucose monitoring) have not been translated into better glycaemic control in patients with type 1 diabetes, which is quite similar to that observed 20–30 years ago in the Diabetes Control and Complica­tions Trial (DCCT). Continuous subcutaneous insulin infusion (CSII) provided by personal insulin pumps may improve glycaemic control; however, observed results are not so good as it has been expected and are only slightly better or similar to these obtained with multiple daily insulin injections (MDII). Real-time continuous glucose monitoring (CGM) seems to be very useful to achieve target glycaemic control and to avoid hypoglycaemia in both CSII and MDII patients. While using CGM, levels of HbA 1c are lower, time spent in hypoglycaemia is shorter and frequency of hypoglycaemia episodes is reduced. To receive optimum benefit, excellent compliance and fre­quent readings of measurements are required. The most common real-time sensors used in Poland are: Medtronic Enlite, Dexcom G4 Platinum and Abbott FreeStyle Libre. Unfortunately, for majority of patients with type 1 diabe­tes CGM devices have no reimbursement. (Clin Diabetol 2017; 6, 3: 111–114)

Budget impact of continuous subcutaneous insulin infusion therapy in patients with type 1 diabetes who experience severe recurrent hypoglycemic episodes in Spain

ObjectiveHypoglycemia is one of the most common complications to achieve a good metabolic control, and has been listed by several scientific associations as a common indication to start treatment with continuous subcutaneous insulin infusion (CSII). Use of CSII is still residual in Spain as compared to neighboring countries, and cost of acquisition cost is one of the main reasons.This study estimates the budget impact of treatment with CSII, as compared to multiple daily insulin injections, of patients with type 1 diabetes mellitus who experience recurrent severe hypoglycemia episodes from the National Healthcare System perspective. MethodsBudget impact was based on a retrospective, observational study evaluating the efficacy of CSII in patients with type 1 diabetes mellitus conducted at Hospital Clínic i Universitari in Barcelona, where one of the main indications for switching to CSII were recurrent severe hypoglycemia episodes. The mean number of annual episodes was 1.33 in the two years prior to CSII start and 0.08 in the last two years of follow up (p=0.003). Costs of treatment and major hypoglycemic events over a four-year period were considered. Costs were taken from different Spanish data sources and expressed in € of 2016. ResultsTreatment with CSII increased costs by €9509 per patient as compared to multiple daily insulin injections (€11,902–€2393). Cost associated to severe hypoglycemic events decreased by €19,330 per patient treated with CSIII (€1371–€20,701). Results suggest mean total savings of €9821 per patient during the four-year study period. ConclusionThe higher costs associated to CSII therapy may be totally offset by the severe hypoglycemic events prevented.

Impacto presupuestario de la infusión subcutánea continua de insulina en el tratamiento de pacientes con diabetes tipo 1 que presentan episodios de hipoglucemia grave recurrente en España

ObjectiveHypoglycemia is one of the most common complications to achieve a good metabolic control, and has been listed by several scientific associations as a common indication to start treatment with continuous subcutaneous insulin infusion (CSII). Use of CSII is still residual in Spain as compared to neighbouring countries, and cost of acquisition cost is one of the main reasons.This study estimates the budget impact of treatment with CSII, as compared to multiple daily insulin injections, of patients with type 1 diabetes mellitus who experience recurrent severe hypoglycemia episodes from the National Healthcare System perspective. MethodsBudget impact was based on a retrospective, observational study evaluating the efficacy of CSII in patients with type 1 diabetes mellitus conducted at Hospital Clínic i Universitari in Barcelona, where one of the main indications for switching to CSII were recurrent severe hypoglycemia episodes. The mean number of annual episodes was 1.33 in the two years prior to CSII start and 0.08 in the last two years of follow up (p=0.003). Costs of treatment and major hypoglycemic events over a four-year period were considered. Costs were taken from different Spanish data sources and expressed in € of 2016. ResultsTreatment with CSII increased costs by €9,509 per patient as compared to multiple daily insulin injections (€11,902-€2,393). Cost associated to severe hypoglycemic events decreased by €19,330 per patient treated with CSIII (€1,371-€20,701). Results suggest mean total savings of €9,821 per patient during the four-year study period. ConclusionThe higher costs associated to CSII therapy may be totally offset by the severe hypoglycemic events prevented.

Tu1381 - Impact of Treatments on Diabetic Control and Gastrointestinal Symptoms after Total Pancreatectomy

OBJECTIVES The aims of this study were to compare the safety, efficacy, and patients' quality of life with continuous subcutaneous insulin infusion (CSII) versus multiple daily injections (MDIs) in type 3c diabetes mellitus (T3cDM) following total pancreatectomy (TP) and pancreatic enzyme usage. METHODS Thirty-nine patients with T3cDM (18 CSII patients vs 21 MDI patients) who underwent TP between 2000 and 2016 at 3 Harvard-affiliated hospitals and the University of Minnesota returned prospectively obtained questionnaires examining quality of life and both endocrine and exocrine pancreatic functions. RESULTS Main indications for TP were as follows: chronic pancreatitis (n = 19), intraductal papillary mucinous neoplasm (n = 12), and adenocarcinoma (n = 4). Median hemoglobin A1c using MDIs was 8.1% versus 7.3% in CSII. Severe hypoglycemic events using MDIs were increased compared with CSII (P = 0.02). There were no significant differences in quality-of-life measures with CSII versus MDIs. Pancreatic enzyme dose per meal (P < 0.05) differed between the hospitals. Gastrointestinal symptoms and unintended weight loss (P < 0.01) were more common with low doses of pancreatic enzymes. CONCLUSIONS After TP, CSII therapy is safe compared with MDIs in T3cDM and not associated with an increase in severe hypoglycemic events. Pancreatic enzyme replacement therapy is highly variable with low doses associated with unintentional weight loss and gastrointestinal symptoms.

Cost-effectiveness of sensor-augmented pump therapy versus standard insulin pump therapy in patients with type 1 diabetes in Denmark.

The use of continuous subcutaneous insulin infusion (CSII) in type 1 diabetes (T1D) has increased in recent years. Sensor-augmented pump therapy (SAP) with low glucose suspend (LGS) (allowing temporary suspension of insulin delivery if blood glucose level falls below a pre-defined threshold level) provides additional benefits over CSII alone, but is associated with higher acquisition costs. Therefore, a cost-effectiveness analysis of SAP+LGS versus CSII in patients with T1D was performed. Analyses were performed using the CORE Diabetes Model in two different patient cohorts in Denmark, one with hyperglycemia at baseline and one with increased risk for hypoglycemic events. Clinical input data were sourced from published literature. The analysis was performed over a lifetime time horizon from a societal perspective. Future costs and clinical outcomes were discounted at 3% per annum. In patients who were hyperglycemic at baseline the use of SAP+LGS versus CSII resulted in improved quality-adjusted life expectancy (12.44 versus 10.99 quality-adjusted life years [QALYs]) but higher mean lifetime costs (DKK 2,027,316 versus DKK 1,801,293) leading to an incremental cost-effectiveness ratio (ICER) of DKK 156,082 per QALY gained. For patients at increased risk for hypoglycemic events the ICER for SAP+LGS versus CSII was DKK 89,868 per QALY gained. The ICER for SAP+LGS versus CSII falls below commonly cited willingness-to-pay thresholds. Therefore, in Denmark, the use of SAP+LGS is likely to be considered cost-effective relative to CSII for patients with T1D who are either hyperglycemic, despite CSII use, or who experience frequent severe hypoglycemic events.

A Comparison of Continuous Subcutaneous Insulin Infusion vs. Multiple Daily Insulin Injection in Children with Type I Diabetes in Kuwait: Glycemic Control, Insulin Requirement, and BMI.

Continuous subcutaneous insulin infusion (CSII) and multiple daily insulin injections (MDI) are two methods currently used to manage type I diabetes mellitus (T1DM). Here we compare our experiences with CSII and MDI in a large cohort of pediatric patients in Kuwait. Data on 326 patients with T1DM who were started on CSII between 2007 and 2012 were retrospectively compared with those of 326 patients on MDI. They were matched for sex, age at diagnosis, T1DM duration, glycemic control, insulin requirement, and body mass index (BMI). Data were collected at baseline and every three months and included glycated hemoglobin (HbA1c), insulin dose, and adverse events (severe hypoglycemia, diabetic ketoacidosis, and skin problems). The main reason for switching to CSII was to achieve better glycemic control (37%), followed by reducing hypoglycemia, and improving the quality of life (13.3% each). Although HbA1c decrease was most significant in the first year, it continued to be significantly lower in the CSII group compared to the MDI throughout the study period. Total daily insulin requirements were significantly lower in the CSII group. BMI increased in both groups, but the difference was significant only at the end of the fifth year. There was no significant change in the rate of diabetic ketoacidosis in either group. The CSII patients had more severe hypoglycemic episodes at baseline; however, it significantly decreased throughout the study period. Only five patients discontinued CSII therapy and two of these restarted within three months. CSII is a safe intensive insulin therapy in youngsters with T1DM and achieved markedly fewer severe hypoglycemic episodes and lower daily insulin requirements.

A Case Report of Continuous Subcutaneous U-500 Insulin Administration in a Patient with Insulin Resistant Lipodystrophy

ABSTRACT Objective: To report the clinical outcome of a patient with lipodystrophy complicated by insulin-resistant diabetes mellitus who was changed from traditional multiple daily injection U-500 dosing to off-label continuous subcutaneous insulin infusion (CSII) of U-500 insulin in a V-Go® Disposable Insulin Delivery device (V-Go®). Methods: Case report with literature review. Results: After initiation of V-Go® the patient was able to reduce her total daily insulin dose from 415 U to 280 U with a concomitant reduction in glycated hemoglobin (HbA1c) from 9.3 to 6.8% over a 3-month period. The reported frequency of hypoglycemia was also significantly reduced. The patient reported increased satisfaction and improved insulin administration compliance. Conclusion: U-500 delivered via CSII in patients with highly resistant type 2 diabetes, as can be seen in lipodystrophy, may be beneficial when patient becomes difficult to manage on insulin administered by multiple daily injections. The use of a V-Go® insulin delivery device can facilitate continuous insulin delivery in patients who are not able to use an insulin pump. Abbreviations: CSII continuous subcutaneous insulin infusion HbA1c glycated hemoglobin A1c