Embedding CSII therapy in the routine management of diabetes in children: a clinical audit of this service in Leeds

Abstract

The aim of this study was to document the clinical and secondary care cost benefit of continuous subcutaneous insulin infusion (CSII) over a five‐year period in the Leeds Paediatric Diabetes Service. Patients with type 1 diabetes treated using CSII therapy since 2002 who attended the paediatric diabetes clinics in Leeds, UK, were eligible for inclusion. Information on glycaemic control (HbA1c) and frequency/type of hospital admission was collected during the 12‐month period before CSII was initiated and compared prospectively after the transition to pump therapy. Multi‐level regression modelling was used to assess the change in HbA1c levels and the effect of patient characteristics. Data were included on 84 individuals ranging in age from 0 to 18 years, 54% of whom were female. Mean (SD) HbA1c levels improved from a baseline of 9.4 ± 1.7% to 8.9 ± 1.5%, with a significant overall reduction of 0.53% within the first year (95% CI 0.29‐0.78%). The improvement in HbA1c levels was sustained for up to five years after CSII therapy commenced. Regression modelling showed that age, sex and duration of diabetes were not significantly associated with change in HbA1c levels. Hospital admission rates fell for severe hypoglycaemia from 8.9 to 2.4 per 100 patient years although hyperglycaemia admissions remained largely the same (7.6 vs 7.3 on CSII per 100 patient years). We concluded that patients treated using CSII appear to exhibit both improved glycaemic control, which is sustained over the short/medium term, and lower hospital admission rates for hypoglycaemia. Copyright © 2009 John Wiley & Sons.

HbA1c values and hospital admissions in children and adolescents receiving continuous subcutaneous insulin infusion therapy

“…In the present study we observed a greater HbA 1c reduction within 1 year of CSII therapy compared with our previous study [11]. Other studies have also shown short-term improvements in glycaemic control, particularly within the first year of CSII [4,7,[17][18][19].…”

“…In the present study, we found that severe hypoglycaemia incidence did not change and DKA increased with CSII therapy. The median (range) pre-CSII start follow-up period (time between earliest recorded HbA 1c to CSII start date) was shorter than the follow-up period after CSII initiation [0.8 (0.01-2) years vs 2.3 (0.1-8.1) years], which may indicate that there was less opportunity for a hospitalization pre-CSII start; however, when comparing pre-CSII start incidence rates between the two studies, severe hypoglycaemia admissions decreased eightfold (8.8 per 100 person-years in the previous study [11] to 1.1 per 100 person-years in the present study) and DKA decreased nearly fourfold (7.6 per 100 person-years in the previous study [11] to 2.2 per 100 person-years), whilst during-CSII incidence rates remained similar. This may reflect improved MDI treatment within the LCYPDS; however, it is disappointing that improvements have not been matched with CSII therapy.…”

“…Campbell et al [11] used a multi-level modelling approach to account for repeated data and found an overall reduction in mean HbA 1c of [6 mmol/mol (95% CI 3-9); 0.5% (95% CI 0.3 to 0.8%] after 1 year of starting CSII therapy in the Leeds Children and Young People's Diabetes Service (LCYPDS) [11]. They also found a reduction in hospital admissions incidence for severe hypoglycaemia from 8.9 to 2.4 per 100 person-years, whilst hospital admissions for hyperglycaemia remained stable with an incidence rate of 7.6 vs 7.3 per 100 person-years [11]. Data from the LCYPDS now include individuals starting CSII therapy up to 2013, allowing analysis over a longer follow-up period.…”

Sustained benefits of continuous subcutaneous insulin infusion

“…However, results are inconsistent in children. Only one randomised controlled trial has shown benefit, although many observational studies have demonstrated improved glycaemic control 2 3. Unfortunately, many of these studies are of limited duration.…”

Uso do sistema de infusão contínua de insulina em crianças e adolescentes com diabetes mellitus tipo 1: revisão de mapeamento sistemático

“…No entanto, outros dois artigos descreveram que tais episódios podem ocorrer mesmo em uso do SICI (60,65). De acordo com alguns estudos, as hiperglicemias apresentam diferentes causas, como bloqueio da infusão de insulina por desalojamento da cânula (59,60,95,103,105,(118)(119)(120); programações incorretas das taxas basais ou não administração dos bolus (60); término da quantidade de insulina no reservatório (60); descarregamento da bateria ( 60); e oclusão de sistema (68,103,(120)(121)(122)(123). Segundo as evidências apresentadas nos estudos, as causas para oclusão de sistema podem envolver: falta de troca do conjunto de infusão conforme as recomendações; dobra da extensão do sistema de infusão; sangue ou ar no conjunto de infusão; irritação dermatológica no local de inserção (58,60,(126)(127)(128)61,62,65,95,105,118,124,125); insulina turva ( 60); e exposição da insulina em extremos de temperatura (60).…”