Beneficial Effects of Continuous Subcutaneous Insulin Infusion and Flexible Multiple Daily Insulin Regimen Using Insulin Glargine in Type 1 Diabetes

Abstract

ABSTRACT. Objective. The aim of this study was to evaluate the metabolic effects of continuous subcutaneous insulin infusion (CSII) with flexible multiple daily insulin (FMDI; premeal lispro ؉ bedtime glargine) therapy as determined by glycosylated hemoglobin (HbA 1c ), body mass index (BMI), and hypoglycemic episodes in a group of patients who made the transition from multiple daily insulin (premeal lispro ؉ bid ultralente) to either CSII or FMDI therapy.Methods. Data from 40 (27 female and 13 male) patients (10.1-17.8 years of age) who were on CSII and 40 age-and gender-matched (27 female and 13 male) patients (10.3-17.3 years of age) who were on FMDI were collected during regularly scheduled visits at a similar frequency over a 1-year period.Results. The total daily insulin dose did not change in CSII (0.97 ؎ 0.24 vs 0.91 ؎ 0.22 U/kg) and FMDI (0.98 ؎ 0.21 vs 0.97 ؎ 0.21 U/kg) patients, whereas the bolus: basal insulin ratio was significantly increased in both CSII (1.01 ؎ 0.43 vs 1.32 ؎ 0.52) and FMDI (1.07 ؎ 0.0.41 vs 1.29 ؎ 0.47) patients. The total cohort of CSII patients showed a decrease in HbA 1c from 8.4 ؎ 1.0% to 7.8 ؎ 0.8%, whereas the FMDI cohort did not show a significant change in HbA 1c (8.5 ؎ 1.1% to 8.2 ؎ 0.9%). However, 40% of the CSII group and 22.5% of the FMDI group showed >1.0% improvement in HbA 1c . Also, a similar number of patients in CSII (52.5%; 8.0 ؎ 1.1 to 7.2 ؎ 0.5%) and FMDI (47.5%; 8.0 ؎ 0.5% to 7.5 ؎ 0.4%) maintained or achieved target HbA 1c values <8.0%. The BMI increased significantly in the CSII group (21.6 ؎ 3.2 vs 23.0 ؎ 3.0 kg/m 2 ) but did not change in the FMDI group (21.9 ؎ 3.9 vs 22.6 ؎ 3.8 kg/m 2 ). There was a significant reduction in the rate of severe hypoglycemia (events/100 patientyears) in both cohorts: 20.6 to 8.2 in the CSII and 18.8 to 7.5 in the FMDI. Similarly, the rate of moderate hypoglycemia decreased in both CSII (68.3-35.4) and FMDI (56.3-30.4). I n recent years, significant changes have occurred in the management of type 1 diabetes. 1,2 Insulin replacement regimens now stress the importance of administering smaller doses of insulin throughout the day on the basis of flexibility in making food choices to fit individual lifestyles while focusing on improved metabolic control. 2 The use of carbohydrate counting has been used in a number of diabetic management regimens to aid in this flexibility. 3 Consequently, the goal of physiologic insulin replacement for type 1 diabetes has led to the development of better short-acting insulin analogues (lispro and aspart) that more closely mimic the sharp rise and short duration of pancreatic insulin secreted with nutrient intake. 4,5 Lispro (Humalog; Lilly, Indianapolis, IN) or aspart (Novolog; Novo Nordisk Pharmaceuticals, Princeton, NJ) insulin has been shown, for this purpose, to be an ideal mealtime insulin. [6][7][8][9] The use of the new long-acting basal insulin glargine (Lantus-Aventis Pharmaceuticals, Bridgewater, NJ) in a flexible multiple daily insulin (FMDI) regimen has been shown to enhance further ...

Factors Associated with Adherence to Continuous Subcutaneous Insulin Infusion in Pediatric Diabetes

“…31,32 This may be because our insulin pump candidates routinely undergo extensive screening by our multidisciplinary team before starting CSII. 34,35 We found a higher CSII adherence 36 It is likely that high level of parental involvement in young children enhances CSII adherence rate. 37 Our study did not show any change in BMI z-scores in either group at 12 and 24 months, which is similar to other reports on CSII in children.…”

“…In 1 month the families return for an advanced pump class in which advanced problem solving and specialized features of CSII are discussed with patients and their families. 34 Insulin aspart or lispro is used in all insulin pumps. The pre-pump TDD is divided as basal (30-40%) and bolus (60-70%).…”

“…A diabetes nurse educator has telephone contact with each patient about two or three times per week for the first 2 weeks. 34 Following the pump clinic class series patients return to routine follow-up visits every 3 months. HbA 1c is determined using the DCA 2000 instrument (Bayer Diagnostics Inc., Tarrytown, NY), with a range for those without diabetes of 4.5-5.7%.…”

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

“…Generally children and adolescents on CSII achieve a lower HbA 1c compared to those on MDI, but there is a large inter-individual variation in metabolic outcome. Most previous studies have been retrospective or describing relatively small cohorts [5,6]. One study testing CSII in adolescents in a case-control study in Denmark using basic, non-smarts pumps showed a non-significant decrease in HbA 1c , a tendency toward less severe hypoglycemic events, a decreased need for insulin and a lesser weight gain [7].…”

Continuous Glucose Monitoring–Guided Insulin Adjustment in Children and Adolescents on Near-Physiological Insulin Regimens

“…Intensive insulin treatment regimens designed to mimic physiological insulin production are beneficial in achieving good metabolic control (5,6). Continuous insulin infusion (CSII) and multiple daily doses of insulin (MDI) given with each meal have been shown to improve metabolic control in children without an increased rate of adverse events (7).…”