Continuous Subcutaneous Insulin Infusion (CSII)
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Continuous subcutaneous insulin infusion for the treatment of diabetes mellitus - Review of technology appraisal guidance 57
National Institute for Clinical Excellence (NICE) Clinical Guidelines.
The Committee was aware that lower HbA1c levels are associated with a greater risk of episodes of hypoglycaemia and that attempts to achieve target haemoglobin levels with MDI can result in a greater risk of hypoglycaemic episodes. … the Committee considered that there would be a greater quality of life benefit due to the avoidance of the fear of hypoglycaemia by the use of CSII.
Severe hypoglycaemia and glycaemic control in Type 1 diabetes: meta-analysis of multiple daily insulin injections compared with continuous subcutaneous insulin infusion
Pickup JC and Sutton AJ
Diab Med. 2008;25(7):765-774.
Aims
Continuous subcutaneous insulin infusion (CSII) is a recommended treatment for reducing severe hypoglycaemia in Type 1 diabetes, but the change in hypoglycaemia compared with multiple daily insulin injections (MDI) is unclear. We therefore conducted a meta-analysis comparing severe hypoglycaemia and glycaemic control during CSII and MDI.
Methods
Databases and literature (1996–2006) were searched for randomized controlled trials (RCTs) and before/after studies of ≥ 6 months' duration CSII and with severe hypoglycaemia frequency > 10 episodes/100 patient years on MDI.
Results
In 22 studies (21 reports), severe hypoglycaemia during MDI was related to diabetes duration (P = 0.038) and was greater in adults than children (100 vs. 36 events/100 patient years, P = 0.036). Severe hypoglycaemia was reduced during CSII compared with MDI, with a rate ratio of 2.89 (95% CI 1.45 to 5.76) for RCTs and 4.34 (2.87 to 6.56) for before/after studies [rate ratio 4.19 (2.86 to 6.13) for all studies]. The reduction was greatest in those with the highest initial severe hypoglycaemia rates on MDI (P < 0.001). The mean difference in glycated haemoglobin (HbA1c) between treatments was less for RCTs [0.21% (0.13–0.30%)] than in before/after studies [0.72% (0.55–0.90%)] but strongly related to the initial HbA1c on MDI (P < 0.001).
Conclusions
The severe hypoglycaemia rate in Type 1 diabetes was markedly less during CSII than MDI, with the greatest reduction in those with most severe hypoglycaemia on MDI and those with the longest duration of diabetes. The biggest improvement in HbA1c was in those with the highest HbA1c on MDI.
Consensus Statement on the Use of Insulin Pump Therapy in the Pediatric Age-Group
Phillip M, Battelino T, Rodriguez H, Danne T, Kaufman F, in collaboration with the participants in the Consensus Meeting, held in Berlin in April 2006, on the Use of Insulin Pumps Therapy in the Pediatric Age Group organized by the Loop Club on behalf of the European Society for Paediatric Endocrinology (ESPE), the Lawson Wilkins Pediatric Endocrine Society (LWPES) and the International Society for Pediatric and Adolescent Diabetes (ISPAD) and endorsed by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD).
Diab Care. 2007;30(6):1653-1662.
Introduction
Young patients with diabetes, their families and their diabetes care providers continue to be faced with the challenge of striving to maintain blood glucose levels in the near-normal range. High blood glucose with elevated hemoglobin A1c (A1C) levels are associated with long-term microvascular and macrovascular complications. Recurrent episodes of hypoglycemia, especially at young ages, may cause short- and long-term adverse effects on cognitive function, lead to hypoglycemia unawareness, and may be associated with significant emotional morbidity for the child and parents. Fear of hypoglycemia, especially during the night, may compromise quality of life (QOL) for the family, and jeopardize efforts to achieve optimal metabolic control.
Over the past decade, continuous subcutaneous insulin infusion (CSII) has gained increasing popularity amongst patients with diabetes. CSII is the most physiologic method of insulin delivery currently available. It is able to closely simulate the normal pattern of insulin secretion; namely, continuous 24-hour adjustable “basal” delivery of insulin upon which are superimposed prandial "boluses". In addition, CSII offers the possibility of more flexibility and more precise insulin delivery than multiple daily injections (MDI). However, there is sill debate amongst diabetes care practitioners around the world as to whether CSII has advantages over MDI in terms of reduction in A1C levels, occurrence of severe hypoglycemic events, episodes of diabetic ketoacidosis (DKA) and frequency of hospitalizations in young patients. Furthermore, no clear criteria have been established to help the physician choose the "appropriate" patient for CSII therapy.
In order to address these issues, the European Society for Pediatric Endocrinology (ESPE), the Lawson Wilkins Pediatric Endocrine Society (LWPES), and the International Society for Pediatric and Adolescent Diabetes (ISPAD) convened a panel of expert physicians for a consensus conference endorsed by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). For each major topic area, clinical experts were chosen to review the literature and provide evidence-based recommendations according to criteria used by the ADA.
Key citations identified for each topic were assigned a level of evidence (indicated in bold throughout the text) and verified by the expert panel (Table). This article summarizes the consensus recommendations of the expert panel and represents the current state of knowledge about CSII in pediatric and adolescent patients with type I diabetes mellitus (T1DM).