t hat is the Question Sanoe Harrison amp Patrick Hanley Autoimmune Diabetes Mellitus Review of Problem Glucose in Healthy Volunteers Day Ave SD 930 70 mg ID: 652010
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Slide1
To Pump OR To Inject … that is the Question … ?
Sanoe
Harrison & Patrick HanleySlide2
Autoimmune Diabetes MellitusReview of ProblemSlide3
Glucose in Healthy Volunteers
Day
Ave ± SD = 93.0
±
7.0
mg/
dl, Night Ave ± SD = 81.8
± 6.3 mg/dl Slide4Slide5Slide6
DCCT
(Diabetes Control and Complication Trial)Slide7
Goals for long term health …A1c < 7.5Absence of severe hypoglycemiaMinimize glucose variability …Normal blood pressure
Normal cholesterol (LDL & HDL)
Normal weight (BMI
<85th percentile for age
& sex)Slide8
Insulin DiscoverySlide9
First glucometer 1968
First insulin syringe 1949Slide10
1963 - Dr. Arnold Kadish
designed the first insulin pump to be worn as a
backpackSlide11
Sanoe’s StorySlide12
Sanoe’s TimelineSlide13
Pat’s StorySlide14
Pat’s TimelineSlide15
Discussion Questions … What made you choose this breakout session?Who uses a pump for insulin?Who uses MDI for insulin?Slide16
Is there research to help us decide … ?We all know the first key is … taking our insulin and checking our blood sugar! But the question is …
with more options today to deliver insulin and monitor glucose is one way better?
Evidence based medicine but also need to consider
…
…
w
hat is best for you the individual patient/family? Slide17
Some Articles Comparing CSII to MDI“Long-term health economic benefits of sensor- augmented pump therapy vs continuous subcutaneous insulin infusion alone in type 1 diabetes: a UK
perspective”
-
Journal of Medical Economics 2016
“
Continuous
subcutaneous insulin infusion therapy and multiple daily insulin injections in type 1 diabetes mellitus: a comparative overview and future
horizons”
-
Expert Opinion on Drug Delivery 2015
“Multiple
Daily Injections OR Insulin Pump Therapy:
Choosing the Best Option for Your Patient—An Evidence-based
Approach”
– Current Diabetes Reports 2015
“Does
treatment with an insulin pump improve
glycaemic
control in children and adolescents with type 1 diabetes? A retrospective case–control study”
- Pediatric Diabetes 2015 Slide18
Articles Comparing CSII to MDI“Insulin pump therapy, multiple daily injections, and cardiovascular mortality in 18,168 people with type 1 diabetes: observational study”
– British Medical Journal 2015
“
Insulin pump use in young children in the T1D Exchange clinic registry is associated with lower hemoglobin A1c levels than injection therapy
” - Pediatric Diabetes 2014
“Long
-term outcome of insulin pump therapy in children with type 1 diabetes assessed in a large population-based case–control
study”
–
Diabetologia
2013
“
A
randomized, prospective trial comparing the efficacy of continuous subcutaneous insulin infusion with multiple daily injections using insulin
glargine
“
– Diabetes Care 2004Slide19Slide20Slide21Slide22Slide23Slide24Slide25Slide26
Major findings of this paper Showed that treatment with CSII resulted in an improvement in HbA1c levels up to 1 year (8.1% vs. 8.3%)
#
of severe
hypoglycaemic
events with
CSII
=
incidence rates of severe
hypoglycaemic
episodes per
100 person
-years were 3 in the CSII group & 6
in the MDI
group
Frequency of ketoacidosis
in CSII group
=
There were
2.8 episodes of
DKA/
100 person-
years
in the CSII group
&
0.5
in
the MDI group
insulin needed in CSII group & no change in weightSlide27
Why do some people stop using pumps?Main reasons found in one study:Greater sense of disease (93%)
Difficulties in doing sports (70%)
W
orse well
-being during pump therapy (63%
)
H
aving
to attach the pump to the body (60%
)
E
mbarrassment
(56%
)
A
dhesions &
pain in the place of needle insertion (50%
)
Difficulties
in controlling
glycemia
during physical
exercise (43%)
Fear
(43%
)
H
igh
levels of HbA1c (36%
)
Frequent
blood glucose monitoring (26%
)
“Reasons
for the discontinuation of therapy of personal insulin pump in children with type 1
diabetes”
Pediatr
Endocrinol
Diabetes
Metab
2015;21,2:65-69Slide28
Pros & Cons of PumpsProsFlexible basal rates Advanced bolus optionsConvenience of giving multiple dosesSlightly decreased total insulin needCons
Risk of DKA with pump malfunction
Hardware attached to body
CostSlide29
Pros & Cons of MDI ProsReliable absorptionNot connected to deviceMore affordable ConsCannot alternate basal rates
Multiple injections
Harder to disguise Slide30
Special Considerations
Image from:
http://
keralaeditor.com
/
kerala
-to-provide-free-insulin-pumps-for-diabetic-kids/Slide31
Case 118 y/o F, got a pump 2yrs ago, and is now going away to collegeAt school she is too busy to test sugar more than 2x per dayShe noticed that her pump insulin reservoir lasts her 5 daysShe usually gets home late, tests, changes her pump sites as needed right before going to bedSlide32
Case 214 year old boy on MDI since diagnosis 2 yrs agoNormally hyperglycemic in the morning despite changing lantus dose Hypoglycemia often with sports
Very active with sports & motivated to do better with his diabetes control
…Slide33
How do you define success with Diabetes?Slide34
Future Directions Slide35
Affreza – Inhaled InsulinSlide36
AbsorptionSlide37
Afrezza – Side EffectsRespiratoryDecreased Lung function in some (6 vs. 3%)Cough ~25 %Cancer
4 cases of lung cancer (2 smokers)Slide38
DegludecSlide39
DegludecPharmacokinetic properties: Long half-life (25 h)Long duration of action (42 h)Lower variability (25% that glarginie) from other basal analogues
Need studies in pediatric patients
… Slide40
A few more questions … Why did you choose your current therapy? Do you want to change?If so why?
Thank you very much for your attention & participation
… any
questions?