Final

A Review of A Detailed Comparison of Continuous Subcutaneous Insulin Infusion and MultipleDaily Injection Treatments on Type 1 Diabetic Children

Jane Student

Fayetteville Technical Community College

Abstract

A comparison of two different types of insulin therapies in Type 1 diabetic children revealed more than glycemic control and quality of life through data gathered by many health care professionals and etymologists in Poland. Treatment involving continuous subcutaneous insulin infusion (CSII) and multiple daily injections were used to compare glycated hemoglobin levels (HbA1c) in children with Type 1 diabetes. Hospital visits, acute sickness and HbA1c levels were documented within a three year span. The associated risk of hypoglycemia (low blood sugar) and Diabetic Ketoacidosis (severe high blood sugar) in CSII and MDI therapies has been previously documented but were outdated due to the introduction of new types of fast and slow acting insulin along with newer models of insulin pumps (CSII). It made the new study necessary to analyze the risks and benefits of both uses. The new results debunked the previous consensus of CSII insulin pumps having a higher risk of DKA and hypoglycemia. The new pump models were documented for comparison and MDI stood relatively the same as it only uses syringes or pens to insert insulin directly into the bloodstream. Unfortunately there was not enough variables to fine tune MDI usage to improve HbA1c levels and left this particular therapy to feel a bit outdated.

A Detailed Comparison of Continuous Subcutaneous Insulin Infusion and Multiple-Daily Injection Treatments on Type 1 Diabetic Children

With the accessibility of insulin in the 1920s the once deadly Type 1 diabetes has been dramatically changed and has improved the lives of millions. It is commonly confused with Type 2 diabetes, a metabolic disease that accounts for over 90% of diabetics (Chase, 2002). Although the disease itself has not been cured, medical advancements have brought us closer to a future where diabetes related complications are minimized thus vastly improving the lives of diabetics (Russell, 2014). Diabetes Type 1 is a chronic condition that causes the pancreas to produce little to no insulin (Chase, 2002). It was formerly known as insulin-dependent diabetes or juvenile diabetes. Although it is typically discovered during adolescence and childhood, adults are also susceptible to the disease. Various factors that cause the disease have made it difficult to find a cure. These factors range from genetics or an exposure to a certain virus that has not yet been documented. All factors are part of an ongoing study to find a cure and due to these circumstances the current priority is HbA1C (also referred to as hemoglobin A1c or simply A1C) control. For individuals with diabetes this is vital as the higher the HbA1c, the greater the risk of developing diabetes-related complications (Fendler, 2011). There are two main forms of insulin therapy that is used to control the persons A1C. Continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI) are forms of therapy that allow insulin to enter the bloodstream. They have been vastly studied mainly to find the best way possible to treat the disease to an individual. Both have risks and benefits associated with the treatment but it is important to focus on the quality care of these patients. As a mother of a Type 1 diabetic I have 4 used both treatments on my daughter and although I have personal experience to compare the different types of insulin therapies, I want more information using a controlled environment with well documented results to compare my hypothesis to those who have studied the disease for years.

Methods

Patients were treated with CSII or MDI under a controlled three year study that involved 90% of the Polish population’s diabetic children (Fendler, 2011). The study was supervised by the Lodz region center’s diabetes epidemiology database and later manually curated. There were no restrictions to patients and they were given the choice between therapies they or their guardian saw fit, but were later encouraged to CSII if management or related complications became an issue. Candidates were encouraged to used CSII as opposed to MDI when faced with high A1C levels, recurrent hypoglycemia, chronic illness, or willingness to improve their quality of life. The introduction to CSII for parents or patients that were using MDI allowed them to choose a different therapy in view of more freedom in their lifestyles and less scrutiny with food intake to insulin ratios. The CSII patients used insulin pumps manufactured by, Roche, Deltec and Medtronic using either human or analogues insulin. At the end of the three year study HbA1c levels, hospital visits and diabetes related illnesses were documented. Other scholarly journals related to CSII and/or MDI were used to supplement and compare the advancements of current therapies, even those currently going through a trial period. Current advancements are focusing on CSII as opposed to MDI although successful A1C control is based on the individual managing the disease.

Results

231 CSII and 233 MDI patients were studied and documented for any hospitalizations due to A1C control, hyperglycemia with diabetic ketoacidosis (DKA) and hypoglycemia (severe low blood sugar). Assessments were observed solely on age of initial visit. MDI patients saw a rise in their A1C levels while CSII users had no significant change in their A1C. Hospital visit rates due to acute causes did not differ between CSII and MDI treated patients as well as the average duration of their stay although those treated with CSII had significantly less total hospitals visits annually. CSII offered better metabolic control but did not translate into the risk of future hospitalizations. Although earlier studies suggested that CSII added an additional risk to hypoglycemia or DKA (Nathan, 1982), current studies show no difference between those therapies. As the study progressed, some patients using insulin pumps added more challenging approaches like the dual wave bolus, but the effects of the combinations was not studied and the factor was refrained from the CSII group.

Discussion

The study gave me sufficient evidence that shows CSII therapy is beneficial to those suffering from Type 1 diabetes. It has become more common and is now the standard of treatment for young children recently diagnosed (Nabhan, 2008). It proved that CSII is a safe form of intensive insulin therapy with similar A1C glycemic effects as MDI users have, but a significantly lower rate of Hypoglycemia and DKA even with a lower insulin requirement. Even though it is common and almost expected for diabetic patients to increase their insulin dosage (Jakisch, 2008) the CSII patient’s dosage remained significantly less than MDI users. Although it can be argued that the use of dual wave boluses and changes in pump settings to fine tune their 6 insulin needs changed the results in favor of CSII pumps, there was not enough documentation and evidence to make a conclusion based on this particular study. Using other resources further proved the advancements of pump therapy are on the rise and MDI cannot be completely eliminated as they are used by CSII pump users in an emergency in case their pump malfunctions (Chase, 2002). New ways of CSII are being tested at this moment in the form of a bionic pancreas and being introduced through trials and controlled studies (Russell, 2014) but have not been used in unrestricted outpatient conditions. The bionic pancreas would have been a great supplement in favor of CSII, showing glycemic improvement even compared to CSII insulin pumps (Russell, 2014), but could not be included in the study without further studies and approval for public use. There was also a comparison to past uses of CSII using an older model of insulin pumps that were too big and complex to use in an uncontrolled setting (Nathan, 1982). It was often discussed amongst experts if these forms of therapy were vital to the discussion of insulin therapy advancement (Rizza, 1986). It has become apparent to me that CSII is here to stay and new medical advances are making room for a higher quality of life to diabetics and reduced complications caused by this horrible disease.

References

Chase, H. (2002). Understanding diabetes (10th ed.). Denver, Colo.: Barbara Davis Center for Childhood Diabetes, University of Colorado Health Sciences Center:.

Fendler, W., Baranowska, A. I., Mianowska, B., Szadkowska, A., & Mlynarski, W. (2012). Three-year comparison of subcutaneous insulin pump treatment with multi-daily injections on HbA1c, its variability and hospital burden of children with type 1 diabetes. Acta diabetologica, 49(5), 363-370.

Jakisch, B. I., Wagner, V. M., Heidtmann, B., Lepler, R., Holterhus, P. M., Kapellen, T. M., ... & Holl, R. W. (2008). Comparison of continuous subcutaneous insulin infusion (CSII) and multiple daily injections (MDI) in paediatric Type 1 diabetes: a multicentre matched-pair cohort analysis over 3 years. Diabetic Medicine, 25(1), 80-85.

Nabhan, Z. M., Kreher, N. C., Greene, D. M., Eugster, E. A., Kronenberger, W., & DiMeglio, L. A. (2009). A randomized prospective study of insulin pump vs. insulin injection therapy in very young children with type 1 diabetes: 12-month glycemic, BMI, and neurocognitive outcomes. Pediatric diabetes, 10(3), 202-208.

Nathan, D. M., LOU, P., & AVRUCH, J. (1982). Intensive conventional and insulin pump therapies in adult type I diabetes: a crossover study. Annals of internal medicine, 97(1), 31-36.

Rizza, R. A. (1986). New modes of insulin administration: do they have a role in clinical diabetes?. Annals of internal medicine, 105(1), 126-129.

Russell, S. J., El-Khatib, F. H., Sinha, M., Magyar, K. L., McKeon, K., Goergen, L. G., ... & Damiano, E. R. (2014). Outpatient glycemic control with a bionic pancreas in type 1 diabetes. New England Journal of Medicine, 371(4), 313-325.