Insulin pump therapy: then and now. Multiple cardiovascular risk intervention. Oxford Medicine Online

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1 Oxford Medicine Online You are looking at 1-10 of 28 items for: evidence-based AND medicine MED00250 oxford_diabetes_library Insulin pump therapy: then and now John Pickup (ed.) DOI: /med/ Continuous subcutaneous insulin infusion (CSII) is also known as insulin pump therapy CSII is a form of intensified insulin treatment, mostly used for selected patients with type 1 diabetes Insulin pump therapy was originally developed as a research tool, but is now part of routine clinical practice In CSII, short-acting (monomeric) insulin is infused subcutaneously at variable rates (basal and prandial) from a portable infusion pump The main clinical indications are frequent and disabling hypoglycaemia and/or a continued elevated HbA1c in spite of best attempts with insulin injection therapy (usually multiple daily insulin injections, MDI) Multiple cardiovascular risk intervention Miles Fisher DOI: /med/ Cardiovascular disease is a common cause of morbidity and mortality in people with type 2 diabetes. Some guidelines define diabetes as a coronary heart disease equivalent, requiring multiple cardiovascular risk factor reduction The treatment of hyperglycaemia in type 2 diabetes reduces cardiovascular events, and on long-term follow up reduces cardiovascular and total mortality. Metformin and pioglitazone have advantages in subgroups of patients There is a large evidence base for the treatment of hypertension in people with type 2 diabetes, using multiple antihypertensive drugs, and for the use of statins. The results of studies of other lipid-regulating drugs have been disappointing Benefits of other methods to reduce cardiovascular risk, such as antiplatelet drugs and antioxidants, have yet to be established in people with type 2 diabetes. Diabetes is a state of premature cardiovascular death which is associated with chronic hyperglycaemia and may also be associated with blindness and renal failure. Miles Fisher, British Diabetic Association meeting Dublin, Page 1 of 5

2 The future of pumps and sensors: research and development Lutz Heinemann DOI: /med/ Current pumps are already highly technical and are expected to develop further Pumps that receive information from continuous glucose monitoring (CGM) systems are likely to be in increasing use in the coming years. The first type is a version that automatically suspends insulin delivery in the event of hypoglycaemia, the first step towards an artificial pancreas A fully closed-loop insulin delivery device with a glucose sensor coupled to a computer-controlled insulin infusion pump is being actively researched. It is a complex problem that may require some years of development. A hybrid system with patientactivated meal-time insulin and closing-the-loop only in the basal state is a likely first development for clinical use Smaller, simpler patch pumps with integrated cannulae and novel pumping mechanisms are under development. Some may be used in type 2 diabetes Fully implantable insulin pumps have been in the research phase for some decades and, as yet, have significant problems for transfer to widespread routine clinical use CSII and continuous glucose monitoring in children and adolescents Tadej Battelino DOI: /med/ Continuous subcutaneous insulin infusion (CSII) and real-time continuous glucose monitoring (RT-CGM) is safe, feasible, and effective in all age groups Most infants, toddlers, children, and adolescents are eligible candidates Thorough education and monitoring of patients, families, and caregivers are paramount CSII significantly increases patients flexibility and quality of life RT-CGM improves metabolic control without increasing the risk of hypoglycaemia The evidence base for insulin pump therapy John Pickup (ed.) DOI: /med/ All grades of hypoglycaemia are less during continuous subcutaneous insulin infusion (CSII) than during multiple daily insulin injections (MDI) treatment. The mean frequency of severe hypoglycaemia is about 75% less on CSII vs. MDI, with the greatest reduction occurring in those with most hypoglycaemia on MDI Meta-analysis of randomized controlled trials (RCTs) and before/after studies shows that the mean difference in HbA1c between MDI and CSII is about 0.5% 0.6%, but the worst controlled subjects on MDI Page 2 of 5

3 enjoy the greatest improvement on switching to CSII. Those with an HbA1c of 9% 10% on MDI may see a reduction of 3% 4% on CSII. Glycaemic variability is also improved on switching to CSII Other benefits of CSII include a reduction in the dawn phenomenon, reduced daily insulin dosage, and improved quality of life Health economic studies indicate that CSII is a cost-effective use of resources Pharmacotherapy in type 2 diabetes: clinical evidence Gayatri Sreemantula, Santosh Shankarnarayan, and Jiten P Vora DOI: /med/ Patients with type 2 diabetes demonstrate increased cardiovascular risk; this risk is significantly reduced by improved glycaemic control Recent trials have demonstrated that both low and high mean HbA values are associated with increased all-cause mortality and cardiac events UKPDS and further Cochrane analysis showed that metformin improves glycaemia, is weight neutral and possesses positive cardiovascular profile. Lactic acidosis, in one systematic analysis, is proved to be extremely rare and prevalence may be similar to placebo in low risk groups Thiazolidinediones are efficacious, combine well with other agents for diabetes and show good durability, They are associated with weight gain, increase risk of (non-fatal) heart failure and increase risk of small bone fracture in women. Rosiglitazone (but not pioglitazone) has been associated with increased risk of myocardial infarction and the European Medicines Agency has recently recommended suspension of all authorization of its use Sulfonylureas are efficacious, with rapid onset of action and combine well with other agents for diabetes in the European Union diabetes. They are associated with weight gain and increased risk of hypoglycaemia Initial addition of basal insulin to oral therapy followed by subsequent intensification to a basal-prandial regimen would be the ideal insulin treatment strategy Current evidence is suggestive of a potential association between use of analogue insulins and increased cancer incidence and would warrant further investigations. Gestational diabetes: management in pregnancy Robert Lindsay (ed.) Print Publication Year: 2011 Published Online: Jan 2012 ISBN: eisbn: DOI: /med/ Two recent large trials demonstrate that detection and management of gestational diabetes improves outcomes. While gestational diabetes is predominantly managed by diet and lifestyle change use of glibenclamide and metformin can be considered as second-line therapy. Page 3 of 5

4 Running an insulin pump service John Pickup, Siobhan Pender, Julia Kidd, and Nardos Yemane DOI: /med/ Patients are selected for continuous subcutaneous insulin infusion (CSII) because they meet clinical criteria (e.g. disabling hypoglycaemia and/or elevated HbA1c on multiple daily insulin injections [MDI]), general requireents (e.g. willing and able to perform pump procedures), and have no obvious contraindications, for example, unwilling or unable to perform pump procedures A sequential approach to treatment by CSII is recommended where patients first undergo a pre-pump assessment (including renewed diabetes education, optimization on MDI, for at least adults), with only those not achieving good control being offered a trial of pump therapy Basal insulin rates are about 50% of the total daily dose and meal boluses are set by the insulin: carbohydrate ratio and a correction factor based on the insulin sensitivity factor for the individual Dietitians play a crucial role in the pump service in teaching carbohydrate counting, preventing weight gain, treating and avoiding hypoglycaemia, and promoting healthy eating CSII is typically started as an outpatient; education and training are vital Management of type 2 diabetes and insulin Rajesh Peter, Richard A Chudleigh, David R Owens, and Anthony Barnett DOI: /med/ Since type 2 diabetes is a progressive disease many patients will eventually require insulin therapy Initiation of insulin is often inappropriately delayed resulting in adverse health consequences Several different types of insulin are available and the regime used should be tailored to the needs of the individual patient, but informed by recent clinical trial data Early and efffective use of insulin will commonly improve symptoms and help to achieve better glycaemic control thereby reducing the risk of longterm vascular complications. Hyperglycaemia and weight management Miles Fisher Print Publication Year: 2012 Published Online: Jan 2012 ISBN: eisbn: DOI: /med/ Intensive insulin therapy in patients with type 1 diabetes reduces cardiovascular outcomes on long-term follow up The treatment of hyperglycaemia in type 2 diabetes reduces cardiovascular events, and on long-term follow up reduces cardiovascular and total mortality. Metformin reduces myocardial infarctions separate from an effect on glycaemia Pioglitazone reduces recurrent myocardial infarctions and strokes in type 2 diabetic patients Page 4 of 5

5 with established cardiovascular disease, but at the expense of increased fluid retention Newer antidiabetic drugs have some favourable effects on cardiovascular risk factors In patients with type 2 diabetes bariatric surgery reduces weight and leads to remission of diabetes in many patients, with favourable effects on cardiovascular risk factors. Page 5 of 5