Flexible Intensive Insulin Therapy in Adults With Type 1 Diabetes and High Risk for Severe Hypoglycemia and Diabetic Ketoacidosis

Abstract

OBJECTIVE -Diabetes treatment and teaching programs (DTTPs) for type 1 diabetes, which teach flexible intensive insulin therapy to enable dietary freedom, have proven to be safe and effective in routine care. This study evaluates DTTP outcomes in patients at high risk for severe hypoglycemia and severe ketoacidosis.RESEARCH DESIGN AND METHODS -There were 96 diabetes centers that participated between 1992 and 2004. A total of 9,583 routine-care patients with type 1 diabetes were examined before and 1 year after a DTTP. History of repeated severe hypoglycemia/severe ketoacidosis was an indication for DTTP participation. Before-after analyses were performed for subgroups of patients with three or more episodes of severe hypoglycemia or two or more episodes of severe ketoacidosis during the year before a DTTP. Main outcome measures were GHb, severe hypoglycemia, severe ketoacidosis, and hospitalization.RESULTS -A total of 341 participants had three or more episodes of severe hypoglycemia the year before a DTTP. Mean baseline GHb was 7.4 vs. 7.2% after the DTTP, incidence of severe hypoglycemia was 6.1 vs. 1.4 events ⅐ patient Ϫ1 ⅐ year Ϫ1 , and hospitalization was 8.6 vs. 3.9 days ⅐ patient Ϫ1 ⅐ year Ϫ1 . In mixed-effects models taking effects of centers and diabetes duration into account, mean difference was Ϫ0.3% (95% CI Ϫ0.5 to Ϫ0.1%; P ϭ 0.0006) for GHb and Ϫ4.7 events ⅐ patient Ϫ1 ⅐ year Ϫ1 (Ϫ5.4 to Ϫ4; P Ͻ 0.0001) for severe hypoglycemia. A total of 95 patients had two or more episodes of severe ketoacidosis. GHb was 9.4% at baseline versus 8.7% after DTTP; incidence of severe ketoacidosis was 3.3 vs. 0.6 events ⅐ patient Ϫ1 ⅐ year Ϫ1 , and hospitalization was 19.4 vs. 10.2 days ⅐ patient Ϫ1 ⅐ year Ϫ1 . In linear models with diabetes duration as the fixed effect, the adjusted mean difference was Ϫ2.7 events ⅐ patient Ϫ1 ⅐ year Ϫ1(95% CI Ϫ3.3 to Ϫ2.1; P Ͻ 0.0001) for severe ketoacidosis and Ϫ8.1 days (Ϫ12.9 to Ϫ3.2; P ϭ 0.0014) for hospitalization.CONCLUSIONS -Patients at high risk for severe hypoglycemia or severe ketoacidosis may benefit from participation in a standard DTTP for intensive insulin therapy and dietary freedom.

Twice‐ rather than once‐daily basal insulin is associated with better glycaemic control in Type 1 diabetes mellitus 12 months after skills‐based structured education in insulin self‐management

“…These data confirm earlier reports of a major reduction in severe hypoglycaemia 12 months after the ITTP and DAFNE 6, 10, 11, which is largely independent of HbA 1c (above or below 58 mmol/mol, 7.5%), insulin type or injection frequency. We propose the 76% reduced risk of severe hypoglycaemia arises from the total DAFNE education package, not just the basal insulin regimen.…”

A rapid synthesis of the evidence on interventions supporting self-management for people with long-term conditions: PRISMS – Practical systematic RevIew of Self-Management Support for long-term conditions

“…Five papers reporting three studies focused on T1DM, [251][252][253][254][255] eight focused on T2DM, [246][247][248][249][250]260,261,264 the remaining 15 included mixed populations. [237][238][239][240][241][242][243][244][245][256][257][258][259]262,263 Thirteen of the studies were conducted in the USA, [237][238][239][244][245][246][247][248][256][257][258][259]262 one in the UK, 240 three from Germany (in five papers), 251,[253][254][255]260 three from Austria, 250,…”

“…Participating populations ranged from 85 to 9583 participants. One study in three papers, [253][254][255] reported a decade of data on nearly 10,000 patients involved in a national programme of inpatient self-management education to teach people with T1DM to adjust insulin dose according to expected food intake and pre-meal blood sugar.…”

“…Five papers reported the outcomes of national programmes (in Germany [251][252][253][254][255] and Austria…”

“…[238][239][240][241][242][243][244][245][246][247][248][249][250][251][252][253][254][255] Education programmes encompassed interventions delivered by MCOs, 238,240,244,245 in primary 241 …”