Continuous Subcutaneous Insulin Infusion Users Research Articles

Experiences and real life management of insulin pump therapy in adults with type 1 diabetes

ObjectiveThere is scarce information regarding the performance of a specific, structured education program addressed to patients with type 1 diabetes (T1D) using continuous subcutaneous insulin infusion (CSII) including both routine use of the therapy and patient experience evaluation. We aimed to assess the routine use of CSII and patient's experience and satisfaction regarding a specific structured patient self-management education and care program. MethodsA retrospective, observational, cross-sectional study collecting CSII routine use downloaded data. Patient experience and satisfaction were evaluated using an anonymous online survey covering different aspects of CSII self-management education and care program. Results380 T1D subjects were included (aged 45.3±12.17 years, 62.1% women, diabetes duration 27.8±10.3 years, 9.7±4.7 years on CSII, HbA1c 7.7+1.0%; 61.0±7.9mmol/mol). Participants with HbA1c≤7.5% (58mmol/mol, n=178) did more SMBGs per day (4.4±2.1 vs. 3.9±1.9); used more boluses (5.0±1.8 vs. 4.5±2.0); the percentage of insulin given as bolus was higher (50.1±12.8 vs. 44.9±13.2%); the night bolus wizard (BW) high glucose target was lower (125.9±4.4 vs. 130.5±12.8mg/dl) and time on CSII therapy was shorter (8.9±4.6 vs. 10.3±4.6 years. p<0.05 all comparisons). More SMBG/day, shorter duration of CSII treatment, a lower BW low glucose target at night, a lower BW high glucose target at night, total insulin dose per day and total number of carbohydrates per day were related with better HbA1c levels. 60% of 373 patients answered the questionnaire. The response to the different aspects of the educational program was homogeneously highly satisfactory. Seventy-seven percent of patients scored the program as very useful. Ninety-three percent of CSII users would not return to their previous insulin treatment. ConclusionsThe analysis of routine clinical use of CSII by T1D patients demonstrates that glucose control may be associated with some pump usage and adherence parameters. The overall user experience and satisfaction with our CSII self-management education and care program was remarkably favorable.

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).

CSII Use in Hospitalized Patients—Adherence to Policy and Safety of Use

Continuous subcutaneous insulin infusion (CSII) therapy is routinely used in diabetes management for patients expecting to use their insulin pumps during hospitalizations. For hospital personnel, this is unfamiliar and complex technology, which necessitates implementing policies and guidelines for standardizing CSII use in the inpatient setting. This study aims to examine adherence to an institutional CSII policy and safety glucometrics for hospitalized patients using CSII. We performed an IRB-exempt retrospective review of CSII user records from January to June 2017. Policy adherence was evaluated for appropriate provider and nurse order set use and documentation in the electronic medical record. 81 patients with 111 admissions on CSII were evaluated. Mean age was 42±16.9 years, 62% were female and 82.7% had type 1 diabetes. Median LOS was 5 days for 788 total patient days, HgbA1c 8.3 ± 1.78, and baseline admission blood glucose (BG) was 175 mg/dL. CSII was continued in 62% of admissions with 12.6% discontinuing use due to medical and surgical contraindications. Overall adherence to the policy was high with documented endocrinology consultations in 100%, provider specified basal rates in 96%, specified bolus doses in 92%, specified correction doses in 83%, specified target BG in 90%, and nurse documented verified doses on the MAR in 93%. Nurse documentation of CSII in the Lines/Drains/Airways flowsheets was 16%. Hypoglycemia (BG&amp;lt;70mg/dL), severe hypoglycemia (BG&amp;lt;40 mg/dL), and uncontrolled hyperglycemia (BG&amp;gt;299mg/dL) were present in 10%, 0.8%, and 10.5% of patient days, respectively. Rates of DKA in CSII users was 0.9%. Policy adherence was effectively achieved for CSII use in hospitals. Rates of hypoglycemia and uncontrolled hyperglycemia were high with very low incidence of severe hypoglycemia or DKA episodes. These results suggest that CSII is possible to safely continue in hospitalized patients, but future studies are necessary to determine how to modify pump rates and optimize glycemic control. Disclosure K. Yang: None. M.B. Ateya: Stock/Shareholder; Self; AbbVie Inc.. R. Gianchandani: None.

Skin Problems Associated with Insulin Pumps and Sensors in Adults with Type 1 Diabetes: A Cross-Sectional Study.

In the future, widespread use of closed-loop infusion (artificial pancreas) systems to treat type 1 diabetes (T1D) may significantly improve glycemic control and enhance treatment flexibility. However, the infusion sets and plasters necessary for these treatments can cause dermatological complications that may hamper the spread of the new technology; few studies have investigated these complications in adults. The aim of this study was to describe the dermatological complications associated with continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) in adults. A total of 118 adult patients from two different diabetes clinics completed a questionnaire concerning the dermatological complications associated with their CSII and/or CGM treatment, other treatment variables, duration of diabetes, allergies, skin care, and other pathologies. CGM or CSII use was associated with current eczema, scars, and wounds. In total, 34% of CSII users and 35% of CGM users currently had one or more skin lesions due to the use of these devices. We found no significant association with glycated hemoglobin (HbA1c) levels, a history of atopic dermatitis, or other skin pathologies. However, multivariate analysis revealed associations with a history of atopy and CSII-associated dermatological complications. Dermatological complications were present in one in every three patients and represent a significant challenge to using CSII and CGM to treat adults with T1D. Prospective studies on the causes of these complications will be required to develop preventive strategies and ensure that optimal diabetes treatment approaches that take advantage of the latest technology can be implemented.

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.

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.

Perspectives on Long-Distance Air Travel with Type 1 Diabetes.

We sought to determine the real-life experiences of individuals traveling long distance (across five or more time-zones) with type 1 diabetes (T1D). Five hundred three members of the T1D Exchange online community ( www.myglu.org ) completed a 45-question survey about their travel experiences flying long distance. The cohort was stratified by duration of T1D and whether or not participants used continuous subcutaneous insulin infusion (CSII) therapy and/or a continuous glucose monitor (CGM). In the last 5 years, 71% of participants had flown long distance. When asked about their perceived "fear of flying," CSII users (with and without a CGM) reported their primary anxiety was "losing supplies," while non-CSII users described concerns over "unstable blood glucose (highs and lows)" (P < 0.05). In addition, 74% of participants reported more hypoglycemia and/or hyperglycemia while traveling overseas and 9% had avoided international travel altogether because of problems related to diabetes management. Furthermore, 22% of participants had run out of insulin at some point during a trip and 37% reported inadequate attention in current sources of information to the unpredictability of self-management needs while traveling. Especially problematic for individuals traveling with T1D are a lack of resources adequately addressing (1) protocols for emergencies while abroad, (2) how to navigate airport security, and (3) managing basal insulin rates when crossing time zones. A strong need exists for easily accessible, free resources for traveling with T1D that is tailored to both device use and duration of the disease.

Continuous subcutaneous insulin infusion (CSII) therapy at Derby Teaching Hospitals: sustained benefits in glucose control.

In the short term, continuous subcutaneous insulin infusion (CSII) has been associated with improved glycaemic control, reduced hypoglycaemia and improved quality of life (QOL). However, limited data are available on its long-term benefits, particularly in the UK. We aimed to assess the impact of CSII on longer term outcomes. Patient-level data were obtained for CSII users at Derby Teaching Hospitals, UK. Patient confidence and satisfaction questionnaires using the Likert scale were used to assess confidence in self-management. Comparative statistics were conducted using Pearson's chi-square and Student's t-tests. Some 258 CSII users were identified (60.1% female, mean age 43.9±13.4years). Overall, there was significant decrease in HbA1c from 78mmol/mol (9.3±2.0%) at baseline, to 69mmol/mol (8.5±1.3%) at 6months [mean difference (md): -0.64; 95% confidence interval (95% CI): -0.91 to -0.37; P<0.0001]; which was sustained at 6years of follow-up (HbA1c : 66mmol/mol, 8.2±1.3%; md: -1.07%; 95% CI: -1.45 to -0.69; P<0.0001). One hundred and twenty-one patients (47%) responded to the survey, of whom 95 (78.5%) reported a reduction in the frequency of hypoglycaemia; 102 (84.3%) were satisfied with the quality of care received in the insulin pump service. CSII therapy led to a sustained long-term improvement in glycaemic control in addition to a reduction in self-reported hypoglycaemia.

Glycemic control and maternal and fetal outcomes in pregnant women with type 1 diabetes according to the type of basal insulin

ObjectiveTo examine the potential role of the type of basal insulin on glycemic control and maternal and foetal outcomes in pregnant women with type 1 diabetes (T1DM). Study designRetrospective cohort study of pregnancies attended at 18 Spanish tertiary hospitals. Inclusion criteriaT1DM, singleton pregnancies, delivery between 2002–2010, and use of the same basal and prandial insulin from before pregnancy until delivery. ResultsA total of 1534 pregnancies were included. The basal insulin most commonly used was Neutral Protamine Hagedorn (NPH) (51.7%), followed by glargine (23.2%) and continuous subcutaneous insulin infusion (CSII) (21.1%). CSII users had longer diabetes duration. Multiple logistic regression analysis showed that CSII was independently associated with lower doses of insulin, higher glycated haemoglobin (HbA1c) in all trimesters, and higher rates of miscarriage, preterm birth and neonatal hypoglycemia. Glargine was related to a higher risk of preterm birth and a small-for-gestational age infant (SGA). The odds ratios (OR) of the associations between insulin type and clinical outcomes (from 0.642 to 4.894) have a relevant magnitude. ConclusionsIn this observational study of pregnant women with T1DM, the type of basal insulin was independently associated with metabolic variables and foetal outcomes.

Differences in Use of Glucose Rate of Change (ROC) Arrows to Adjust Insulin Therapy Among Individuals With Type 1 and Type 2 Diabetes Who Use Continuous Glucose Monitoring (CGM).

To understand differences between individuals with type 1 diabetes (T1D) and type 2 diabetes (T2D) in utilization of continuous glucose monitoring (CGM) data to adjust insulin therapy, either continuous subcutaneous insulin infusion (CSII) or multiple daily insulin injections (MDI). We surveyed 300 individuals who regularly used real-time CGM, using 70 questions to obtain information about general CGM use and response to glucose rate of change (ROC) arrows. The survey was completed by 222 T1D and 78 T2D respondents treated with intensive insulin therapy. T1D respondents included CSII (n = 166) and MDI (n = 56) users. T2D respondents were more balanced: 34 (44%) versus 44 (56%), respectively. A larger percentage of T1D then T2D respondents reported a constant use of CGM (85% vs 61%, P < .001). T1D and T2D respondents reported similar substantial increases in correction dosages in response to rapidly increasing glucose (>3 mg/dL/min; 2 arrows up): +140% versus +136%, P = .4534. However, T1D respondents reported making smaller correction dosage reductions than T2D respondents in response to rapidly decreasing glucose (-42% vs -80%, P < .001). Differences between T1D and T2D respondents were also observed in mealtime dosage adjustments in response to rapidly increasing glucose compared to when glucose is stable (flat arrow) at 110 mg/dl: +81% versus +108%, respectively (P = .003). Although these adjustments are statistically different, both are large. CGM users often rely on ROC information when determining insulin doses and tend to be more aggressive in their insulin adjustments despite differences in type of diabetes.

Characterization of metabolic responders on CSII treatment amongst children and adolescents in Denmark from 2007 to 2013

AimThis prospective study aimed to identify and estimate the frequency of responders offered Continuous subcutaneous insulin infusion (CSII) from baseline data and during follow-up, and secondly to characterize CSII users with good adherence to pump therapy among 463 children and adolescents with Type 1 diabetes mellitus. MethodsA response was defined as lowering HbA1c with 1% or achieving an HbA1c<7.5% (58mmol/mol). Good adherence was defined as measuring ≥7 self monitored blood glucoses (SMBGs) and taking ≥7 boluses daily. Logistic regression was used to estimate the effect of demographic and clinical variables prior to and during pump treatment. ResultsAt 24 months follow-up 32% qualified as responders. Stratifying for age at onset, 45% of the children aged <6yrs qualified as responders vs. 32% and 28% of the youngsters and adolescents aged 6–12yrs. and 12–19 yrs., respectively (p=0.02). Responders were characterized by their HbA1c-level at pump onset (p=0.001), taking more daily boluses (7.64±3.33 vs. 6.40±3.18 p=0.003) and measuring more SMBGs per day at follow-up (6.88±2.35 vs. 6.31±2.54 p=0.03). The incidence of severe hypoglycemia decreased from 14.3 to 3.3 events per 100 person years (p<0.0001). Twenty percent did not respond despite a good adherence toward CSII therapy. ConclusionAge <6 years, high or low HbA1c at pump initiation and number of daily boluses were associated with improved or sustained near-normal metabolic outcome. The incidence of severe hypoglycemia was significantly reduced. Twenty percent of the population had good adherence without any metabolic improvement.

Bolus Guide: A Novel Insulin Bolus Dosing Decision Support Tool Based on Selection of Carbohydrate Ranges

Optimal continuous subcutaneous insulin infusion (CSII) therapy emphasizes the relationship between insulin dose and carbohydrate consumption. One widely used tool (bolus calculator) requires the user to enter discrete carbohydrate values; however, many patients might not estimate carbohydrates accurately. This study assessed carbohydrate estimation accuracy in type 1 diabetes CSII users and compared simulated blood glucose (BG) outcomes using the bolus calculator and the "bolus guide," an alternative system based on ranges of carbohydrate load. Patients (n = 60) estimated the carbohydrate load of a representative sample of meals of known carbohydrate value. The estimated error distribution [coefficient of variation (CV)] was the basis for a computer simulation (n = 1.6 million observations) of insulin recommendations for the bolus guide and bolus calculator, translated into outcome blood glucose (OBG) ranges (< or =60, 61-200, >201 mg/dl). Patients (n = 30) completed questionnaires assessing satisfaction with the bolus guide. The CV of typical meals ranged from 27.9% to 44.5%. The percentage of simulated OBG for the calculator and the bolus guide in the <60 mg/dl range were 20.8% and 17.2%, respectively, and 13.8% and 15.8%, respectively, in the >200 mg/dl range. The mean and median scores of all bolus guide satisfaction items and ease of learning and use were 4.17 and 4.2, respectively (of 5.0). The bolus guide recommendation based on carbohydrate range selection is substantially similar to the calculator based on carbohydrate point estimation and appears to be highly accepted by type 1 diabetes insulin pump users.

Treatment Satisfaction and Quality of Life for an Integrated Continuous Glucose Monitoring/Insulin Pump System Compared to Self-Monitoring plus an Insulin Pump

Little is known about how the most advanced technology affects treatment satisfaction and health-related quality of life (HRQOL) in adults with diabetes. This study was designed to assess treatment satisfaction and HRQOL among users of an integrated real-time (RT) continuous glucose monitoring (CGM)/continuous subcutaneous insulin infusion (CSII) system compared with those using self-monitoring of blood glucose (SMBG) with CSII. Participants were 311 adult respondents to an Internet survey, 162 using RT-CGM/CSII, 149 using SMBG + CSII (median age 43 years; type 1 diabetes 94%; diabetes duration >15 years 61%; median insulin use 15 years). Respondents completed instruments assessing glucose monitoring system and insulin delivery system convenience, interference, burden, glucose control efficacy, cost satisfaction, overall satisfaction, and treatment preference, as well as quality of life (diabetes-related worries, social burden, and psychological well-being). Real-time CGM/CSII users also assessed specific elements of the RT-CGM/CSII system. Group differences were assessed using analysis of covariance controlling for respondent characteristics. The RT-CGM/CSII group gave significantly better ratings than the SMBG + CSII group for their glucose monitoring system's glucose control efficacy, overall satisfaction, desire to switch, and willingness to recommend, and significantly worse ratings for interference with daily activities. The RT-CGM/CSII group gave significantly better ratings than the SMBG + CSII group for their insulin delivery system's convenience and glucose control efficacy, overall satisfaction, desire to switch, and willingness to recommend. Real-time CGM/CSII users gave positive ratings of all system features. Users of the integrated RT-CGM/CSII system reported more benefits of treatment, higher treatment satisfaction and quality of life, and greater preference for this system than SMBG + CSII users.

Prolonged use of continuous glucose monitors in children with type 1 diabetes on continuous subcutaneous insulin infusion or intensive multiple-daily injection therapy

For continuous glucose sensors to improve the treatment of children with type 1 diabetes (T1D), they must be accurate, comfortable to wear, and easy to use. We conducted a pilot study of the FreeStyle Navigator Continuous Glucose Monitoring System (Abbott Diabetes Care) to examine the feasibility of daily use of a continuous glucose monitor (CGM) in an extended ambulatory setting. Following a 13-wk trial of daily Navigator use, 45 children with T1D [10.7 +/- 3.7 yr, range 4.6-17.6, 24 using insulin pumps; continuous subcutaneous insulin infusion (CSII) and 21 using glargine-based multiple daily injections (MDI)] used the Navigator for an additional 13 wk. Navigator use was initially slightly higher in the CSII users than in the MDI users but declined similarly in both groups by 22-26 wk. After 26 wk, 11 (46%) of 24 CSII users and 7 (33%) of 21 MDI users were using the CGM at least 5 d a week. No baseline demographic or clinical factors were predictive of the amount of sensor use at 26 wk. However, Navigator use during weeks 1-13 and scores on a CGM satisfaction survey at 13 wk were predictive of use in weeks 22-26. CGM was generally well-tolerated in children with T1D for more than 6 months, and early acceptance of CGM was predictive of extended use of the device. Although many subjects and parents found CGM valuable, the declining usage over time underscores the need to develop new technologies and strategies to increase acceptance, effectiveness, and long-term use of these devices in youth with T1D.

Review: The pros and cons of continuous subcutaneous insulin infusion (CSII) therapy in the paediatric population and practical considerations when choosing and initiating CSII in children

CSII (continuous subcutaneous insulin infusion), has the potential to improve long-term glycaemic control in many patients with type 1 diabetes. CSII may also reduce the incidence of hypoglycaemic episodes, especially in patients prone to hypoglycaemia, and may reduce glycaemic variability. A pivotal advantage of CSII over MDIs (multiple daily injection), especially in children, is its superior convenience and flexibility. Programmable basal rates are delivered automatically and with unprecedented precision, while bolus doses can easily be used to titrate insulin exposure around meals and activities and to correct hyperglycaemia. The subcutaneous cannula needs to be re-sited only once every 2—3 days. In light of these advantages, CSII is generally preferred by children and parents. Careful patient selection is crucial, however, as CSII users and their carers must be willing and able to use the equipment correctly, as well as to perform general aspects of intensive self-care. Accordingly, CSII should be initiated only by a specialist, multidisciplinary team and in conjunction with a structured, ongoing educational and monitoring programme. Factors affecting the selection of a particular pump include the size and weight of the device, ease of use, range of dose modes and increments, cost, warranty and customer services.

Cross‐sectional study into quality of life issues surrounding insulin pump use in type 1 diabetes

AbstractThis study aimed to determine whether continuous subcutaneous insulin infusion (CSII) is associated with improved quality of life (QoL) in routine care in the UK.We conducted a multiple cohort survey study of individuals with type 1 diabetes (matched for age, gender and frequency of blood glucose testing) using either CSII or multiple daily insulin injections (MDI). The World Health Organization QoL abbreviated questionnaire (WHOQOL‐BREF), the Insulin Delivery System Rating Questionnaire (IDSRQ), the Problem Areas in Diabetes Scale (PAID), and the Hypoglycaemia Fear Scale (HFS) were used to assess QoL.In all, 642 people with type 1 diabetes returned questionnaires: 228 insulin pump users, 332 people using MDI and 82 using non‐intensive insulin delivery. After controlling for confounding variables, CSII users reported that their treatment is more helpful (IDSRQ F = 38.41, p&lt;0.001), that it generates less worry (IDSRQ F = 6.26, p&lt;0.05), and that they are less likely to use hypoglycaemia avoidance behaviours (HFS F = 4.67, p&lt;0.05) and have fewer food‐related problems (PAID p&lt;0.01).In conclusion, even after controlling for self‐care motivation, duration of current therapy and socio‐economic environment, individuals using CSII reported better QoL than a matched cohort of individuals managing their diabetes using MDI. Copyright © 2008 John Wiley &amp; Sons.

Treatment of Danish adolescent diabetic patients with CSII - a matched study to MDI

To compare two intensified insulin therapy regimens - continuous subcutaneous insulin infusion (CSII) against multiple daily insulin injection (MDI) - in Danish adolescents examined in a prospective, matched controlled study design. Thirty type 1 diabetic adolescents at CSII and 26 matched MDI controls were included in this open intention-to-treat study. Actrapid was used in both groups. Before study entry, all participants followed a brush-up course in order to minimize study effect. At each visit, the following parameters were recorded: hemoglobin A1c (HbA1c), insulin dose, weight, number of hypoglycemic and diabetic ketoacidosis (DKA) events, and the time resources used. At entry and exit of the study, diet registration and validated quality-of-life (QoL) questionnaires were filled by the participants. A non-significant decline in HbA1c was seen in both groups (p = 0.468); HbA1c decreased from 9.5 to 8.9% and from 9.7 to 9.5% in the CSII and MDI group, respectively. The insulin dose and the number of severe hypoglycemic events per patient were lower (non-significant) in the CSII group. Both groups showed increased body mass index - highest in the CSII group - and mild to moderate DKA episodes were only seen among CSII users. No differences could be demonstrated within the QoL or diet registrations. CSII treatment is beneficial as an intensified insulin therapy for selected type 1 diabetic patients and both MDI and CSII can be offered by the professional diabetes team to better tailor therapy. In future, there is a strong need to identify the characteristics of responders to CSII treatment in order to increase the efficacy and safety of CSII treatment.

Prevalence and associations of psychological distress in young adults with Type 1 diabetes

To determine the prevalence of psychological distress in young adults with Type 1 diabetes and to explore associated factors. Ninety-two participants with Type 1 diabetes (46 male, 46 female) attending a young adult clinic completed two psychological self-report assessments; the Centre for Epidemiological Studies-Depression Scale (CES-D) and Adult Self-Report Scale (ASR). The mean age was 21.6 +/- 2.8 years (sd) and mean duration of diabetes was 9.3 +/- 5.4 years. A questionnaire identified the method of insulin delivery, the frequency of blood glucose monitoring and hypoglycaemia requiring third-party assistance. HbA(1c) was measured. Of the participants, 35.2% reported depressive symptoms (CES-D > or = 16), 23.1% indicating severe depressive symptoms (CES-D > or = 24), and 32.2, 40.4 and 35.5% of participants reported significant distress (ASR > or = 60) on the ASR total problem scales, ASR internalizing and ASR externalizing scores, respectively. Mean HbA(1c) levels were higher in participants with depressive symptoms compared with those with normal scores (CES-D > or = 16, HbA(1c)= 9.4% vs. CES-D < 16, HbA(1c)= 8.4%, P = 0.01). Factors associated with psychological distress included use of continuous subcutaneous insulin infusion (CSII) (P = 0.02) and increased frequency of hypoglycaemic episodes (P = 0.03). CSII users had higher CES-D (21.3 vs. 11.9, P = 0.001) and ASR-Total (59.7 vs. 53.0, P = 0.02) scores than non-CSII users. Approximately one-third of young adults with Type 1 diabetes experience psychological distress, which is associated with poorer glycaemic control. Psychological distress was related to frequency of hypoglycaemic episodes and method of insulin administration, with significantly greater distress being observed in those using CSII. These findings support inclusion of a psychologist in the diabetes team.

International survey of insulin pump users: Impact of continuous subcutaneous insulin infusion therapy on glucose control and quality of life

To record the characteristics and attitude of patients treated with continuous subcutaneous insulin infusion (CSII), and the impact on glycaemic control in a large number of CSII patients in routine daily life. A structured questionnaire was distributed to 36,450 CSII patients from Europe and North America to determine patient characteristics, therapy characteristics, medical results, complications and treatment satisfaction. A 38% response rate was achieved, 92% from patients with Type 1 diabetes. The responses indicated that CSII users achieved good glycaemic control with a mean HbA(1c) level of 7.0+/-1.1%. A significant correlation was observed between HbA(1c) and the number of blood glucose measurements per day. Four to five blood glucose measurements are needed in a majority of patients to reach optimal glucose control in intensely treated diabetic patients. The clinical benefits of CSII therapy were matched by patient experience and improvements in quality of life. There were 5.74 episodes per patient year of hypoglycaemia needing assistance, although the number of serious adverse effects recorded was dependent on patient's self-reporting. These data suggest patients using CSII therapy achieve good metabolic control, are highly satisfied, and experience an acceptably small number of complications.

Surveillance in Florida of Continuous Subcutaneous Insulin Infusion Use in Cohort

Because of concerns about safety and expense associated with continuous subcutaneous insulin infusion (CSII), all people who had used CSII as of July 1982 were identified. Annual follow-up has resulted in data for up to 61 mo. Of the 92 nonpregnant registrees, 31 were less than 20 yr old, 36 were 20-29, and 25 were 30 yr or older. Two deaths occurred in 1780 person-months of pump use. The cumulative proportion on the pump (CPOP) or actuarial CSII continuance proportion was 11%. There was no significant difference between sexes or between ages for men, but despite eliminating pregnant women, those greater than or equal to 30 yr old had a CPOP of 0.22, compared with 0.11 for those less than 30 yr (P = .03). Continuance curves were no different for those beginning CSII with or without complications or for those with or without good glucose control. Those who began at patient request did have better CPOP than those who began at physician request (P = .05). Physician perception of clinical, mechanical, or psychosocial problems while on the pump was not predictor of continuance curves as measured by CPOP. Of the 17 physicians queried at the latest update, 9 physicians have 16 current CSII users; these 9 have only 14% of their patients in the original cohort currently on CSII. This is compared with the 3 physicians who have 34 current users and 60% of their original cohort on CSII. Four physicians no longer use CSII. Devices for CSII cost +131/person-month of use.(ABSTRACT TRUNCATED AT 250 WORDS)