Continuous Subcutaneous Insulin Infusion Pump Research Articles

Role of Continuous Subcutaneous Insulin Infusion in Patients with Recalcitrant Diabetes in South India

We aimed to assess the effect of continuous subcutaneous insulin infusion (CSII) therapy in patients with "recalcitrant diabetes" whose glycemia had not been controlled adequately with multiple daily injections of insulin or insulin plus oral hypoglycemic agents. We retrospectively analyzed the medical records of patients with diabetes who were initiated on insulin pump therapy at our center in India between 2002 and 2007. Data analysis included fasting and postprandial blood glucose and glycated hemoglobin (HbA1c) values, insulin requirement, body weight, and the occurrence of hypoglycemia and diabetic ketoacidosis. We studied 33 patients with diabetes (type 1 [n = 17] and type 2 [n = 16]) who were on CSII therapy for a mean duration of 3.4 years. A statistically significant reduction in HbA1c was found after initiating CSII (prepump 10.7% vs. postpump 8.3%, P < 0.001). The reduction was greater in type 1 patients (10.6 +/- 2.1 vs. 8.0 +/- 1.6%) than in type 2 patients (11.0 +/- 2.1 vs. 8.8 +/- 1.4%). There was a reduction in frequency of severe hypoglycemia after starting the CSII pump, and there were no instances of diabetic ketoacidosis. Although HbA1c levels did not reach optimal targets, our data indicate that CSII is an effective therapy for patients with diabetes having recalcitrant diabetes who can afford this treatment and whose glycemia is poorly controlled with conventional therapies.

Breastfeeding and the Basal Insulin Requirement in Type 1 Diabetic Women

To evaluate whether breastfeeding in women with type 1 diabetes mellitus is associated with a decreased insulin requirement. In this prospective study conducted between September 2006 and August 2008, type 1 diabetic pregnant women were recruited before the third trimester of pregnancy. Eligible women had no evidence of diabetes-related complications and were treated with continuous subcutaneous insulin infusion pump therapy. During pregnancy and in the first 8 weeks of the postpartum period, participants performed daily fingerstick blood glucose monitoring with at least 12 measurements per day; insulin dosages were adjusted to maintain normoglycemia. Participant characteristics, diabetic parameters, and neonatal growth were compared between women who breastfed exclusively and women who did not breastfeed. Of 18 women, 12 breastfed and 6 did not. Compared with nonbreastfeeding mothers, breastfeeding mothers showed a decreased need for total daily basal insulin (0.21 +/- 0.05 units/kg per day vs 0.33 +/- 0.02 units/kg per day). The mean value of total daily basal insulin was significantly lower in the breastfeeding group than in the non-breastfeeding group. The mean number of hyperglycemic episodes in the first 2 weeks post partum and during the third to eighth weeks was not different between the groups. However, the mean number of hypoglycemic episodes in the first 2 weeks post partum in the breastfeeding group was significantly higher than in the nonbreastfeeding group (11.9 +/- 2.6 episodes vs 5.5 +/- 1.6 episodes, P<.001). No differences were observed between the groups in neonatal birth weight or infant weight after 8 weeks of age. Decreased need in total daily basal insulin is caused by increased glucose use during lactation. We recommend that the starting total daily basal insulin dosage for type 1 diabetic women who breastfeed be calculated as 0.21 units times the weight in kg per day. This regimen results in normoglycemia and minimizes the risk of severe hypoglycemia associated with lactation.

Patient-Reported Outcomes for an Integrated Real-Time Continuous Glucose Monitoring/Insulin Pump System

A 16-week, two-site study evaluated outcomes for a new device (the Paradigm 722 System, Medtronic MiniMed, Northridge, CA) that combines a "smart" continuous subcutaneous insulin infusion (CSII) pump with real-time (RT) continuous glucose monitoring (CGM) and CareLinktrade mark data management software (DMS). CSII-naive adults with type 1 diabetes in suboptimal control (mean glycosylated hemoglobin [A1C] = 8.6%) were randomized to the control arm, consisting of multiple daily injections (MDI) and self-monitoring of blood glucose (SMBG), or the study arm (CSII with RT-CGM as an adjunct to SMBG). Participants (n = 28) completed the validated Insulin Delivery System Rating Questionnaire (IDSRQ) and the parallel Blood Glucose (BG) Monitoring System Rating Questionnaire (BGMSRQ) at study start and end. Participants in the study arm (n = 14) also completed newly developed User Acceptance Questionnaires (UAQs) for CSII, RT-CGM, and DMS at study end. A1C reduction from study start to end was significant (P < 0.05) in both arms (-1.7% for study arm;-1.0% for control arm); there was no significant change in weight in either arm. The IDSRQ showed significantly (P < 0.05) greater benefit for the study arm in convenience, acceptability of BG monitoring requirements, BG control efficacy, diabetes worries, and interpersonal hassles, as well as higher overall satisfaction/preference. The BGMSRQ showed significantly (P < 0.05) greater benefit for the study arm in the BG monitoring system's ability to help manage glycemic control and less interest in changing to another BG monitoring system. The Study Arm UAQs showed positive ratings of system features. Several patient-reported outcomes were significantly more positive in the study arm than the control arm; none was significantly more positive in the control arm. The features of the integrated RT-CGM/CSII system were frequently used and highly rated by participants, with high user satisfaction.

Bolus Calculator: A Review of Four “Smart” Insulin Pumps

Abstract The use of continuous subcutaneous insulin infusion (CSII) pumps has been gaining popularity since 1979, when the first research report on insulin pumps was published. Insulin pumps-small medical devices that are programmed to infuse insulin through a catheter placed under the skin-are a replacement for multiple daily injections of insulin. They are currently being used by 375,000 people with type 1 diabetes, many of whom prefer CSII to multiple daily injections because of the increased flexibility of diet and exercise, increased convenience and precision when dosing, and better predictability of blood glucose levels that insulin pumps can provide when used correctly. Recent pump manufacturers have engineered a new feature called a bolus calculator, which calculates bolus insulin doses based on input from the pump wearer, which functions to help patients obtain optimum control over blood glucose levels. The bolus calculator takes into account the patient's current blood glucose, target blood glucose, amount of carbohydrate consumed, and other factors such as insulin sensitivity and insulin-to-carbohydrate ratio as well as duration of insulin action ("insulin on board"). Each pump company calculates insulin doses in a slightly different way. This article will review differences in bolus calculator recommendations between four insulin pumps, as well as errors that may occur when using bolus calculators. It will also include an in silico simulation of a meal followed by a snack using multiple insulin decay curves.

Use of Continuous Glucose Monitoring to Estimate Insulin Requirements in Patients with Type 1 Diabetes Mellitus during a Short Course of Prednisone

Insulin requirements to maintain normoglycemia during glucocorticoid therapy and stress are often difficult to estimate. To simulate insulin resistance during stress, adults with type 1 diabetes mellitus (T1DM) were given a three-day course of prednisone. Ten patients (7 women, 3 men) using continuous subcutaneous insulin infusion pumps wore the Medtronic Minimed CGMS (Northridge, CA) device. Mean (standard deviation) age was 43.1 (14.9) years, body mass index 23.9 (4.7) kg/m(2), hemoglobin A1c 6.8% (1.2%), and duration of diabetes 18.7 (10.8) years. Each patient wore the CGMS for one baseline day (day 1), followed by three days of self-administered prednisone (60 mg/dl; days 2-4), and one post-prednisone day (day 5). Analysis using Wilcoxon signed rank test (values are median [25th percentile, 75th percentile]) indicated a significant difference between day 1 and the mean of days on prednisone (days 2-4) for average glucose level (110.0 [81.0, 158.0] mg/dl vs 149.2 [137.7, 168.0] mg/dl; p = .022), area under the glucose curve and above the upper limit of 180 mg/dl per day (0.5 [0, 8.0] mg/dl.d vs 14.0 [7.7, 24.7] mg/dl.d; p = .002), and total daily insulin dose (TDI) , (0.5 [0.4, 0.6] U/kg.d vs 0.9 [0.8, 1.0] U/kg.d; p = .002). In addition, the TDI was significantly different for day 1 vs day 5 (0.5 [0.4, 0.6] U/kg.d vs 0.6 [0.5, 0.8] U/kg.d; p = .002). Basal rates and insulin boluses were increased by an average of 69% (range: 30-100%) six hours after the first prednisone dose and returned to baseline amounts on the evening of day 4. For adults with T1DM, insulin requirements during prednisone induced insulin resistance may need to be increased by 70% or more to normalize blood glucose levels.

A evolução da insulinoterapia no diabetes melito tipo 1

The discovery of insulin can be considered the milestone of diabetes mellitus history and a great achievement for its treatment. The first insulin available was the regular. Afterwards, Hagedorn added the protamine to the insulin, thus, creating the NPH insulin. In the 1950s an insulin free of protamine was synthesized: the lente insulin. With the advent of molecular biology, synthetic human insulin was synthesized using recombinant DNA technology. Most recently several types of insulin analogues were available, providing the patients with better metabolic control. Type 1 diabetes mellitus treatment includes plain substitution and individualization for short-acting plus long-acting insulin according to the physician's assistance, besides regular practice of physical activities and diet orientations. In type 1 diabetes mellitus the insulin of low variability is the best choice since basal/bolus insulin therapy or continuous subcutaneous insulin infusion pump can mimetize the physiological release of insulin by beta cells.

Restoring Euglycemia in the Basal State Using Continuous Glucose Monitoring in Subjects with Type 1 Diabetes Mellitus

Our objective was to use continuous glucose monitoring to derive the optimal basal insulin infusion rates in adults with type 1 diabetes and using continuous subcutaneous insulin infusion (CSII) pumps. In an effort to mimic euglycemia during the basal state, we used a standard protocol to adjust basal insulin infusion rates in 16 subjects with type 1 diabetes mellitus who were using CSII pumps. All subjects wore Continuous Glucose Monitoring System sensors (CGMS), Medtronic Minimed, Northridge, CA) in order to obtain around-the-clock tracings of their glucose measurements. Subjects were asked to skip meals periodically in order to optimize basal insulin infusion rates, defined as the basal infusion rates that maintained glucose levels in the range of 65-120 mg/dL during the fasting state or between meals. In order to demonstrate improved glycemic control, with blunting of glucose excursion, we compared the baseline CGMS area under the curve (AUC) to the AUC obtained after optimizing the basal insulin dosages. We analyzed the curves by determining the AUC for glucose excursions above 110 mg/dL. The AUC for glucose excursions above 110 mg/dL was significantly smaller after optimization (19 +/- 13 mg/dL.day) compared to the baseline AUC (50 +/- 31 mg/dL.day) (P < 0.001). Using both a standard protocol for initial basal insulin infusion rates and CGMS curves to optimize basal infusion rates, one can improve glycemia in subjects with type 1 diabetes using CSII.

New Technology, New Errors: How to Prime an Upgrade of an Insulin Infusion Pump

A series of use errors occurred when switching an ambulatory care clinic patient from an older model to a newer model of an ambulatory continuous subcutaneous insulin infusion pump. The nurse practitioner (N.P.) reviewed the new pump's mechanics with the patient, who had a 26-year history of Type 1 diabetes mellitus, and supervised the patient's programming of the pump. At bedtime, a blood sugar of > 250 mg/dL prompted the patient to give herself insulin via the pump. The next morning, she was treated at the emergency department for diabetic ketoacidosis. The pump had been improperly primed, resulting in no insulin delivery. The incident also reflected the absence of a fail-safe mechanism(s) on the pump to alert the user to the improper priming and inappropriate handoff of the patient's care. Unlike the old pump, the new pump did not require manual priming. The lack of delivery of insulin resulted in DKA, a potentially life-threatening complication of diabetes. A root cause analysis suggested several important safety issues, including skipping of steps on the patient training checklist and other shortcuts in patient training. The clinic developed policies and procedures, including mandatory formal training for each pump model by the certified pump trainer and for initiation of insulin pump therapy. This case illustrates the importance of a structured device selection process, provider education, patient education, and monitoring for safety and effectiveness of technological devices in care.

Use of rapid-acting insulin analogues in the treatment of patients with type 1 and type 2 diabetes mellitus: Insulin pump therapy versus multiple daily injections

Background: Replicating endogenous insulin production is the goal of treatment for diabetes mellitus (DM) and is necessary to minimize the risk of vascular complications. The 2 main methods of achieving this goal are continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDIs) comprising basal and prandial injections. Objective: The objective of this article was to discuss the use of a rapid-acting insulin analogue, insulin aspart, in CSII and MDI compared with other insulins in adult patients with type 1 or type 2 DM. Methods: This article was based on a presentation given by the author at a satellite symposium entitled “Realising the Value of Modern Insulins: Reaching Further with Rapid-Acting Insulin Analogues” that was convened during the XIXth World Diabetes Congress, December 3, 2006, in Cape Town, South Africa. Results: In patients with type 1 DM, CSII using the rapid-acting insulin analogue insulin aspart has been reported in clinical trials to improve glycemic control compared with MDI therapy using neutral protamine Hagedorn plus insulin aspart (for basal and mealtime coverage, respectively). In patients with type 2 DM, the CSII and MDI regimens offered similar efficacy and tolerability; CSII therapy may be less burdensome, however, with fewer social limitations than MDIs. Not all insulins are equally suited for use in CSII treatment. Although the efficacy of insulin aspart in CSII was comparable to other rapid-acting insulins, the frequency of hypoglycemia was shown to be significantly lower with insulin aspart compared with human insulin or insulin lispro in patients with type 1 DM. The compatibility of insulin aspart and insulin lispro for use in CSII pumps was compared in an 8-week, double-blind, 2-period, crossover study of patients with type 1 DM. The overall adverse-effect score was significantly lower ( P < 0.005) with insulin aspart than with insulin lispro, as were scores for pain/burning and inflammation (both, P < 0.01) and dermal redness ( P < 0.001). Furthermore, a stability study reported on the suitability of insulin aspart for use in CSII pumps. Quality-of-life scores with CSII have been reported to be higher than with MDI therapy. Conclusion: CSII with the rapid-acting insulin analogue insulin aspart is a viable choice for patients with type 1 or type 2 DM who want close-to-physiologic insulin treatment.

Flexibility of rapid-acting insulin analogues in children and adolescents with diabetes mellitus

Background: Every year, ~70,000 children aged <15 years develop type 1 diabetes mellitus (DM) worldwide. Achieving glycosylated hemoglobin control is a very important aim, but quality-of-life concerns for the child and the family should also have high priority in the management of pediatric DM. Objective: This review outlines some of the issues involved in treating type 1 DM in children and adolescents, as well as the use of rapid-acting insulin analogues in basal-bolus therapy and continuous subcutaneous insulin infusion pumps. Methods: This review article was based on a presentation at a satellite symposium entitled “Realising the Value of Modern Insulins: Reaching Further with Rapid-ActingInsulinAnalogues”that was convenedduring the XIXth World Diabetes Congress, December 3, 2006, in Cape Town, South Africa. Results: Treating children and adolescents with DM is a challenge that should not be ignored. Furthermore, DM in children is quite different from that in adults. Numerous factors have to be taken into account when evaluating treatment for children with DM in comparison with treatment for adult DM: sleep patterns; unpredictable activities, especially eating behaviors; limited size of injection sites, making it difficult to rotate injections; higher insulin sensitivity; and frequent infectious diseases. In addition, achieving normal psychosocial development may be just as important as achieving strict metabolic control in this population. Rapid-acting insulin analogues can be used effectively in these individuals with type 1 DM. The pharmacokinetic profile of insulin aspart suggests that it is suitable for flexible mealtime administration in children and adolescents. Indeed, clinical studies in children and adolescents have shown the efficacy and tolerability of postprandial administration of insulin aspart, particularly in comparison with soluble human insulin. Postprandial administration of insulin aspart, compared with preprandial soluble human insulin, has alsobeenstudiedinveryyoungchildren(aged2-6years); similar metabolic control and increased parent preference for insulin aspart were reported. Conclusions: Rapid-acting insulin analogues in children and adolescents with type 1 DM are effective and well tolerated; they can be injected postprandially, and this is a reliable option that can be recommended to patients and their families.

Calculating the insulin to carbohydrate ratio using the hyperinsulinaemic-euglycaemic clamp—a novel use for a proven technique

In patients with type 1 diabetes, three main variables need to be assessed to optimize meal-related insulin boluses: pre-meal blood glucose (BG), insulin to carbohydrate ratio (I : C), and basal insulin. We are presenting data for a novel use of the hyperinsulinaemic-euglycaemic clamp (HEC) in patients with type 1 diabetes that minimizes the impact of these variables and can be used to determine the I : C. Ten subjects (six men and four women) using continuous subcutaneous insulin infusion (CSII) pumps were recruited for this study [24-65 years; BMI 27.1 +/- 4.9 kg/m(2); A1C 7.2 +/- 1.4% (mean +/- SD)]. The HEC used a primed continuous intravenous insulin infusion of 40 mU/m(2)/min and a variable infusion of 20% glucose to maintain BG at 90 mg/dL. After subjects were in steady state (SS) for 50 min, a standardized meal (40% of total calories/day - 30% carbohydrate, 30% protein, 40% fat) was consumed. Subjects gave the insulin bolus with their CSII pump. No changes were made in the glucose infusion rate. Mean BG at SS was 85.7 +/- 10.4 mg/dL. Peak BG was 115.0 +/- 12.7 mg/dL at 68.5 +/- 8.8 min after the meal. Mean I : C was 1 : 9.3 +/- 1.7 (range 1 : 7-1 : 12). Insulin sensitivity varied from 1.9 to 9.1 mg/kg/min. The HEC can be used to reduce confounding factors and to determine the I : C. As a first estimate of the I : C in patients with type 1 diabetes, it is recommended to start with a ratio of 1 : 9.3 and to measure post-prandial BG at 70 min.

The Experiences of School Nurses Caring for Students Receiving Continuous Subcutaneous Insulin Infusion Therapy

Diabetes mellitus is the most common metabolic disorder in childhood. Today, children with diabetes are receiving new technologically advanced treatment options, such as continuous subcutaneous insulin infusion (CSII) therapy. School nurses are the primary health caregivers of children with diabetes during school hours. Therefore, it is important to determine their perceptions, resources, and resource needs when caring for students with continuous subcutaneous insulin infusion or insulin pump therapy. This study uses a phenomenological approach to examine the experiences of school nurses caring for students receiving insulin pump therapy. Eleven school nurses were interviewed using semistructured taped interviews. The nurses' responses indicated that they were "scared" when first caring for students with continuous subcutaneous insulin infusion therapy. However, they were able to work through their fear by using their resources and gaining more knowledge and hands-on experience with insulin pumps. The data also revealed that school nurses who were able to learn the language of continuous subcutaneous insulin infusion therapy and successfully deal with pump problems developed trusting and knowing relationships with students, teachers, and parents.

Safety Issues: Use of Continuous Subcutaneous Insulin Infusion (CSM) Pumps in Hospitalized Patients

— The use of continuous subcutaneous insulin infusion (CSII) pump therapy is increasing. Patients on CSII at admission whose current admission diagnosis is not expected to affect their blood sugar, who are competent to manage their pumps, and who are in good control of their diabetes at the time of hospital admission may benefit from the good control of continued use of CSII during their stay. However, as with any insulin therapy, CSII can be dangerous if not managed appropriately. Hospitals should be prepared to safely manage these patients by having protocols in place to carefully select those suitable to continue their pumps and to discontinue CSII when criteria are no longer met. All caregivers of the patient, including physicians, nurses, pharmacists, operating room and emergency staffs, and radiology technicians, must have an appropriate level of education on CSII. Hospitals not prepared to manage these patients may need to consider disconnection of the pump at admission. There are few publications addressing management of CSII in the hospital setting. We review published reports and describe our approach to the management of CSII during hospitalization that includes: a case analysis of our experiences; the development of a policy and procedure, standardized physician order form, standardized pharmacy order entry, and educational programs for medical, nursing, radiology, and pharmacy staff; and physician credentialing.

Safety Issues: Use of Continuous Subcutaneous Insulin Infusion (CSII) Pumps in Hospitalized Patients

The use of continuous subcutaneous insulin infusion (CSII) pump therapy is increasing. Patients on CSII at admission whose current admission diagnosis is not expected to affect their blood sugar, who are competent to manage their pumps, and who are in good control of their diabetes at the time of hospital admission may benefit from the good control of continued use of CSII during their stay. However, as with any insulin therapy, CSII can be dangerous if not managed appropriately.Hospitals should be prepared to safely manage these patients by having protocols in place to carefully select those suitable to continue their pumps and to discontinue CSII when criteria are no longer met. All caregivers of the patient, including physicians, nurses, pharmacists, operating room and emergency staffs, and radiology technicians, must have an appropriate level of education on CSII. Hospitals not prepared to manage these patients may need to consider disconnection of the pump at admission.There are few publications addr...

A patient with severe, recurrent hypoglycemia and glycemic lability who underwent islet transplantation

A 48-year-old woman who was diagnosed with type 1 diabetes at 5 years of age presented to our Clinical Islet Transplant Program with severe, recurrent hypoglycemia and glycemic lability. She was diligent with her diet, used a continuous subcutaneous insulin infusion pump (32 U per day), and monitored her glucose levels typically eight times a day. The patient usually had one hypoglycemic reaction a day, experienced a severe reaction once a month, and had marked variability of her glucose values. On presentation, her HYPO score was 584 and her lability index was 868 mmol/l(2)/h per week. HYPO score, lability index score, screening for diabetes complications, and routine pretransplant evaluation. Severe, recurrent hypoglycemia and glycemic lability associated with type 1 diabetes. The patient underwent islet transplantation. Post-transplant, the problems with hypoglycemia abated and excellent stable glycemic control was attained, although some side effects from the immunosuppressive drug, sirolimus, were evident. Insulin was reinstituted 2.5 years after surgery, at lower doses than before the transplant because of deterioration in graft function. Occasional episodes of hypoglycemia have occurred and some glycemic lability has recurred, although endogenous insulin secretion is still preserved.

Meal challenge during a hyperinsulinemic euglycemic clamp – new protocol for a proven technique

To optimize meal-related insulin doses in diabetic patients, 3 variables need to be assessed: pre-meal blood glucose (BG), insulin to carbohydrate ratio (I:CHO) and basal insulin. When any of these variables are miscalculated, postprandial glucose is affected. We are presenting preliminary data for a novel use of the hyperinsulinemic euglycemic clamp (HEC) technique in patients with type 1 diabetes which minimizes the impact of these variables. Six subjects (3 men, 3 women) treated with continuous subcutaneous insulin infusion pumps were recruited for this study (24–65 yrs; BMI 26.4±15.8 kg/m2; A1c 7.0 ±1.4%). Subjects started the HEC after an overnight fast. A cannula was inserted for infusions and another cannula was inserted in the warmed contralateral arm for sampling of arterialized venous blood. To achieve euglycemia an insulin (Humulin R; Eli Lilly) infusion was started at t=0 using a primed continuous intravenous infusion of 40mU/m2/min. Whole BG was measured every 5 mins and a variable infusion of 20% glucose was used to maintain BG at 90mg/dl. When subjects were in a euglycemic steady state (SS) for 50 mins a standardized meal (40% of total calories/day − 30% carbohydrate, 30% protein, 40% fat) was consumed. Subjects gave the insulin bolus with their insulin pump and used their usual I:CHO ratio. No changes were made in the glucose and insulin infusion rates. The BG excursion was observed, and, using the peak excursion from SS, the correct I:CHO was isolated. Mean BG at SS was 83.3±4.7 and at peak was 117.3±16.3 mg/dl. This novel use of the HEC can be used to determine the I:CHO ratio and obliterate any interfering factors. (The study is supported by NIDDK 1R01DK068663)

267 Treatment with continuous subcutaneous insulin infusion (CSII) pump in Cystic Fibrosis during pregnancy

267 Treatment with continuous subcutaneous insulin infusion (CSII) pump in Cystic Fibrosis during pregnancy

Use of Continuous Subcutaneous Insulin Infusion Pump in Patients With Type 2 Diabetes Mellitus

In patients with type 2 diabetes, the control of hyperglycemia is often difficult despite full doses of oral hypoglycemic agents and extremely large doses of insulin. These patients pose a major management problem. The authors therefore investigated whether insulin given as a subcutaneous continuous infusion of insulin (CSII) would result in an improvement in glucose homeostasis. Four patients with badly controlled type 2 diabetes, on treatment with extremely high doses of insulin and oral hypoglycemic agents, were started on CSII. All four patients had a marked improvement in plasma glucose concentrations with a corresponding fall in HbA1c levels. This improvement was associated with a marked fall in the insulin doses necessary to maintain adequate glucose homeostasis. Since HbA1c levels fell from levels that would be associated with diabetic complications to those at which complications are markedly reduced, we recommend that patients with type 2 diabetes uncontrolled on extremely high doses of insulin be given a trial of treatment with CSII.

Contrasting Challenges of Insulin Pump Therapy in a Toddler and Adolescent With Type 1 Diabetes

To describe the challenges and outcomes of continuous subcutaneous insulin infusion (CSII) pump therapy in a toddler and adolescent with type 1 diabetes. Insight into patient-family aspects motivating pump use is provided. Two cases treated at the Pediatric Diabetes Clinic at Yale University. Upon parental request, CSII was initiated to improve glycemic control in a 4-year-old boy (case 1) with unpredictable food intake. During 68 months of CSII therapy, hemoglobin A1C levels averaged 6.3% +/- 0.6%. Severe hypoglycemic episodes ceased 36 months ago, and occasional postprandial hyperglycemia during early school years was corrected with school nurses' reminders about premeal insulin bolus doses. Currently 9.5 years old, he independently manages all his insulin injections with parental assistance only to change the catheter site. Case 2 is a girl who was nearly 12 years of age when diagnosed with type 1 diabetes. Initially managed with daily injections, hypoglycemic episodes were interfering with her physically active lifestyle. At age 13 years, she elected CSII therapy, and glycemic control improved. Temporarily erratic in the immediate period pre- and postmenarche, metabolic control has since stabilized. At 15 years old, she successfully manages her diabetes independently. To optimize glycemic control, CSII can be initiated and used effectively, both in children of all ages and in adolescents with type 1 diabetes. CSII may be ideal therapy for toddlers, with no apparent lower age boundary for initiating CSII; however, the parenting challenges and requirements for supportive education differ between toddlers and adolescents. When disease and pump management are appropriately individualized, CSII therapy can help children with diabetes achieve and sustain glycemic control. Lifestyle flexibility, quality-of-life improvement, and independence can thus begin early in childhood and be maintained throughout young adulthood.

Basal Bolus Dosing: A Clinical Experience

Basal bolus insulin dosing (BBD) may be defined as the physiological replacement of basal and bolus insulin to achieve near normal glycemia without hypoglycemia and loss of life quality. Normally, continuous and variable basal insulin release provides partial suppression of hepatic glucose production to maintain euglycemia during the fasting period. With meals, additional insulin is released in a biphasic pattern to further suppress hepatic glucose production and to increase glucose transport into muscle, fat and liver. Newer subcutaneous insulins for bolus and basal mimic near normal secretion. In addition, improvements in continuous subcutaneous insulin infusion pump features such as dual wave insulin delivery allow improved postprandial glycemia. Insulin dosing is done in a three step process. Firstly, the dosage is estimated based on formulas derived from body weight or previous insulin requirements. Secondly, pre-dosing adjustments modify these formulas by considering estimations of insulin sensitivity based on clinical judgment and laboratory evaluations. Lastly, post-dosage adjustments are based on timed, self-monitored, blood glucose determinations assisted by overall average glucose determinations such as hemoglobin A1c. Continuous glucose monitoring systems have provided a more insightful tool for dosage adjustments. Daily consecutive intensive glucose evaluations using a continuous glucose monitoring system and corresponding dosage adjustments may offer an even better tool for insulin dosing selection.