1 The Jesse Z. and Lea Shafer Institute of Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel and Felsenstein Medical Research Center, Petach Tikva, Israel .
Continuous subcutaneous insulin infusion (CSII) mimics physiologic insulin release better than multiple daily injection (MDI) therapy and allows for greater flexibility in food intake and physical activity. Given these benefits, it raises the question "Is it required to wait to offer CSII to patients with type 1 diabetes (T1D) only after MDI therapy has failed"? This study sought to determine if starting CSII in patients with T1D within 1 year of diagnosis results in better long-term glycemic control than starting it later.
This retrospective observational study was conducted in a tertiary-care medical center. The charts of 488 patients with T1D (273 females) 2.6-39 years old (mean, 19.9 ± 7.7 years) who started CSII in 1998-2008 and used it for at least 1 year were reviewed for background, disease-related, and treatment-related variables. Study end points were glycosylated hemoglobin (HbA1c) level, rate of severe hypoglycemia, and diabetic ketoacidosis events during CSII use. Findings were compared between patients who started CSII within 1 year of diagnosis (Group 1, n=93) or later (Group 2, n=395).
Compared with Group 2, Group 1 patients were characterized by a significantly younger age at CSII initiation (10.7±5.7 vs. 16.4±7.0 years, P<0.001), more frequent blood glucose monitoring (5.4 ± 1.8 vs. 3.9 ± 1.5 times per day, P<0.001), and shorter total duration of diabetes (4.3 ± 2.1 vs. 11.9 ± 6.4 years, P<0.001) and of CSII therapy (3.6 ± 2.1 vs. 4.7 ± 2.5 years, P<0.001). There were no significant between-group differences in patient gender or ethnicity, indications for initiating CSII, mean HbA1c level, attainment of target HbA1c, or rates of severe hypoglycemia or ketoacidosis events after CSII initiation.
Starting pump therapy at an early disease stage has no added benefit for glycemic control over time than starting later. The timing of CSII initiation should be tailored to the individual patient by the diabetes care team.
[Show abstract][Hide abstract] ABSTRACT: Continuous subcutaneous insulin infusion (CSII) is generally successful for patients with type 1 diabetes in improving glycaemic control, alleviating the burden of hypoglycaemia and improving the quality of life. There is however, a cohort of patients who fail to thrive on pump therapy and psychological factors or "brittleness" have been posited as a cause for this. We aimed to assess the extent and spectrum of psychological illness in a population of pump patients.
We analysed the patient data and records of 350 patients with type 1 diabetes who formed the insulin pump patient population from a large teaching hospital and compared them with an age and sex matched reference population of patients with type 1 diabetes. We quantified the prevalence of anxiety and depression before and after the initiation of pump therapy and looked to see whether this had implications for changes in glycaemic control and hypoglycaemia reduction.
Mental health problems amongst patients selected for CSII occur significantly more frequently than in a matched population with type 1 diabetes (51% vs 40%, P<0.05). Depression and anxiety were more prevalent in the CSII group. Of those with mental health problems, there is a tendency to do less well in terms of improvements in glycaemic control as indicated by changes in HbA1c and hypoglycaemia reduction - the latter most notable in patients with co-existent depression.
The incidence and prevalence of mental health problems in individuals with diabetes is greater than that of the general population. In patients who are selected to go onto insulin pump therapy, the incidence is again greater. We have shown that in those with psychological illness, they tend to do less well in terms of improving their overall diabetes control. These results suggest that CSII may not be a suitable route of therapy alone for all of those who would fulfill the traditional criteria and suggest that psychological assessment, therapy and intervention may be an altogether more appropriate or alternative or adjunctive course of action in supporting their diabetes self management. The wider implication is that all the patients with diabetes should be regularly assessed for psychological problems and that there needs to be greater psychology/psychiatric support available to intensive diabetes clinics, especially as part of a pre-pump pathway.
[Show abstract][Hide abstract] ABSTRACT: Background:
This study estimated temporal trends of metabolic control over 12 years in a national cohort of childhood-onset type 1 diabetes.
Subjects and methods:
Data from the prospective childhood-onset diabetes register, which included 886 case subjects from 0 to 17.99 years of age at diagnosis and at least 1 year of follow-up until the age of 22.99 years, were analyzed using multivariable linear and logistic regression models in the observational period between 2000 and 2011.
Hemoglobin A1c (HbA1c) significantly decreased over 12 years, from 78 mmol/mol (interquartile range [IQR], 68-88 mmol/mol) (9.26% [IQR, 8.41-10.24%]) in the year 2000 to 61 mmol/mol (IQR, 55-67 mmol/mol) (7.75% [IQR, 7.20-8.30%]) in the year 2011 (P<0.001). HbA1c was significantly associated with age, treatment modality, and duration of diabetes (P<0.001), with females having on average 1.02% higher HbA1c (P=0.01; 95% confidence interval [CI] 1.005-1.035). The overall use of insulin pumps was 74%. The incidence rate of severe acute complications was low: 1.07 per 100 patient-years for severe diabetic ketoacidosis (95% CI 0.81-1.40) and 1.21 per 100 patient-years for severe (requiring intravenous or intramuscular therapy) hypoglycemia (95% CI 0.81-1.40).
The metabolic control of the entire nationwide pediatric type 1 diabetes population significantly improved during the 12-year observational period with a low rate of severe acute complications events. The improvement was associated with the treatment modality. Additional efforts and solutions are necessary to further improve metabolic control and the quality of life of young people with type 1 diabetes.
[Show abstract][Hide abstract] ABSTRACT: Background:
This study evaluated the predictors of effectiveness and durability of insulin pump therapy in children and adolescents who have initiated continuous subcutaneous insulin infusion (CSII) within 2 years after the diagnosis of type 1 diabetes mellitus (T1DM).
Subjects and methods:
The charts of individuals with T1DM using insulin pumps who were treated at our center were reviewed, including subjects with age at onset of <22 years, interval between onset and insulin pump commencement (interval onset-commencement) of <2 years, use of pumps of >1 year, and use of glucose sensors for <4 weeks/year. The primary end point was the mean glycosylated hemoglobin (HbA1c) value (MHbA1c) throughout the follow-up.
From 684 patients treated with insulin pumps, 119 met the inclusion criteria, and 113 were selected for statistical analysis (60 females; age at diabetes onset, 8.9±5.6 years [mean±SD]; follow-up, 4.0±1.8 years; range, 1-8 years; baseline HbA1c, 9.3±1.8%). Only the interval onset-commencement was a linear predictor of the MHbA1c (P=0.01; R(2)=0.089). A significant reduction of the mean yearly HbA1c from baseline throughout all the follow-up was observed (P<0.001). Categorizing the sample into four quartiles on the basis of an increasing interval onset-commencement resulted in levels of MHbA1c significantly lower in the first and second quartiles in comparison with the fourth quartile (7.6±0.8% and 7.8±1.0%, respectively, versus 8.5±0.8%; P<0.001 and P=0.004, respectively).
The present study suggests that early pump commencement in children and adolescents with T1DM provides lower and more durable HbA1c values than a late commencement. It is possible that an early pump commencement could prolong the honeymoon phase, but we cannot confirm or exclude this hypothesis because the lack of data about C-peptide levels during the follow-up.
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