Jo Ann Ahern

Insulin pump therapy in pediatrics: a therapeutic alternative to safely lower HbA1c levels across all age groups

Abstract: Objective: To examine the efficacy and safety of using continuous subcutaneous insulin infusion (CSII) therapy in a large group of patients 18 months to 18 yr from a single pediatric diabetes program.

A comparison of insulin lispro and buffered regular human insulin administered via continuous subcutaneous insulin infusion pump

This study compared glycemic control achieved with insulin lispro or buffered regular human insulin in patients with Type 1 diabetes treated with continuous subcutaneous insulin infusion (CSII) using an external insulin pump. In this 24-week multicenter, randomized, two-way crossover, open-label trial, 58 patients on CSII with adequate glycemic control received either insulin lispro or buffered regular human insulin for 12 weeks, followed by the alternate treatment for another 12 weeks. Efficacy and safety measures included hemoglobin A(1c) (HbA(1c)) at baseline and endpoint, home blood glucose monitoring, hypoglycemia, and frequency of pump catheter occlusion. Patients consumed a standard test meal on three occasions, with determinations of fasting, 1- and 2-h postprandial glucose values. Insulin lispro use was associated with a significantly lower HbA(1c) than was buffered regular human insulin (7.41+/-0.97 vs. 7.65+/-0.85 mmol/l; P=.004). Fasting serum glucose values before the test meal were similar between the two therapies. The 1-h (11.16+/-4.29 vs. 13.20+/-4.68 mmol/l; P=.012) and 2-h (9.64+/-4.10 vs. 12.53+/-4.64 mmol/l; P=.001) postprandial glucose concentrations were significantly lower during treatment with insulin lispro. No differences between treatments were observed in basal or bolus insulin doses, weight gain, or the incidence and rate of hypoglycemia, hyperglycemia, or pump occlusions. When used in external pumps, insulin lispro provides better glycemic control than buffered regular human insulin with a similar adverse event profile.

Exaggerated Hyperglycemia After A Pizza Meal in Well-Controlled Diabetes

OBJECTIVE To examine whether the postprandial hyperglycemic effect of pizza in well-controlled IDDM patients is related to overeating or to unique properties of this popular food. RESEARCH DESIGN AND METHODS On two evenings, each patient (n = 8) consumed a meal that was similar in macronutrient composition except that one consisted of pizza and the other was a control meal that included high glycemic index foods. The insulin regimen was held constant. RESULTS Postprandial glucose levels were within the target range (< or = 10 mM) after the control meal. Although the initial glucose increase was similar for the two meals, plasma glucose continued to rise and was significantly increased from 4 to 9 h after ingestion of pizza compared with the control meal (P < 0.05). This increase occurred even though free insulin, glucagon, and free fatty acid levels did not differ significantly. CONCLUSIONS Our data suggest that pizza has properties that accentuate and sustain postprandial hyperglycemia.

New developments in treating children with insulin-dependent diabetes mellitus.

A number of new developments in the management of insulin-dependent diabetes mellitus have occurred in the past several years. Primary care providers including pediatric nurse practitioners need to be aware of these developments so that they can work effectively with specialty providers in caring for children with insulin-dependent diabetes mellitus. This article discusses the implications of the Diabetes Control and Complications Trial for children and adolescents, the Diabetes Prevention Trial-Type I, and several other recent developments in caring for children with insulin-dependent diabetes mellitus.

Discrepancies Between Blood Glucose and Glycosylated Hemoglobin in Intensively Treated Diabetic Patients

Self blood glucose monitoring (SBGM) results in nine insulin- dependent diabetic patients who had elevated levels of glycosylated hemoglobin (HbA1 9.8% ±0.4%) despite intensive treatment were compared with those of 11 patients who were able to achieve strict diabetes control (HbA1 8.1% ± 0.2% ; normal 5.6%-8.0%). Surprisingly, both groups reported similar SBGM values and testing frequency, and both groups measured glucose levels accurately when values were checked in the laboratory. On the other hand, laboratory glucose values were lower and correlated with HbA 1 levels only in the group that achieved near normal HbA1 values. These data suggest that problems with SBGM may impede achievement of strict glycemic control during intensive treatment of insulin-dependent diabetes.

Development and Evaluation of a Pediatric Diabetes Program by a Single Provider.

Purpose Although the use of a team approach is ideal for a pediatric population, such an approach is expensive, with programs running at a negative balance of

Insulin Pump Therapy

400,000 to

A Randomized, Prospective Trial Comparing the Efficacy of Continuous Subcutaneous Insulin Infusion With Multiple Daily Injections Using Insulin Glargine

800,000 per year. To address the problem, a “state of the art” pediatric diabetes program was implemented that was cost neutral and did not compromise patient care. Methods Four years after starting a pediatric diabetes program run by a single provider, diabetes goals were evaluated by checking A1C levels while keeping costs in check. A1C levels were obtained every 2 to 3 months and analyzed over several months. Two hundred patients with type 1 diabetes were managed in the program. The cost of the program was analyzed on the basis of rental fees, staff salaries, and basic equipment and supplies required. A1C levels were performed using the Siemens HbA1c DCA Vantage Analyzer. Patients are able to call, fax, text, and e-mail between visits. This has resulted in excellent control and high satisfaction. Results The mean A1C level was 7.2% to 7.4%. The pediatric diabetes program is now cost neutral. Survey results indicated that patients were satisfied with the care they received. Conclusions Children with type 1 diabetes can be managed by a single provider and achieve treatment goals that far exceed those obtained in most pediatric diabetes programs. This can be done at a fiscally responsible cost.

Using a Primary Nurse Manager to Implement DCCT Recommendations in a Large Pediatric Program

Continuous subcutaneous insulin infusion (CSII) pump therapy was introduced to treat patients with type 1 diabetes (T1DM) more than 20 years ago1,2. At that time, most children and adolescents were being treated with one or two daily injections of mixtures of NPH and regular insulin of animal origin and treatment was adjusted based on urinary glucose excretion. With these inadequate methods, it’s not surprising that glucose levels often averaged over 300 mg/dl and that the children were at high risk for the later development of the devastating complications of diabetes. CSII offered the opportunity to more closely simulate the patterns of plasma insulin levels seen in normal children. The more predictable pharmacokinetics of fast-acting versus intermediate-acting insulin3 and the administration of bolus doses immediately prior to each meal were two obvious advantages of this approach to insulin replacement. The development of newer, smaller pumps with variable basal rate profiles allowed for a closer match in insulin needs, particularly overnight, leading to a reduction in nocturnal hypoglycemia.