Insulin pump treatment for diabetes: some questions can be answered already

Abstract

With reference to this Journal's recent editorial by Felig and Bergman (1982) on Insulin pump treatment for diabetes: unansweredquestions we would like to state that some of the questions put forward may-at least in part-be answered already. Thus, we wish to add some facts and thoughts to the ideas outlined in the Felig-Bergman editorial (1982), not to quarrel with the substance of any of their well-balanced views on the subject.In essence, these authors have phrased three fundamental questions to which we would like to add our comments. What impact has the normalization of glucose metabolism by insulin pump treatment on the microvascular andneuropathic complications of diabetes ?The evidence that optimal diabetic control may reverse existing micro-vascular lesions appears to be rather shaky. It is our impression, very much like that of Felig and Bergman (1982), that advanced retinopathies and nephropathies do take their natural course irrespective of a normalization of metabolic control-unless optimized treatment is instituted before any or at best only very early (functional) vascular abnormalities have developed. On the other hand, we believe that the evidence from biochemical and animal experimentation, (retrospective) clinical studies and epidemiological investigationsmany of which have been cited by Felig and Bergman (1982)-is convincing to the point that a prospective randomized study on the effects of blood glucose control on the development of these diabetic complications would be unethical (Berger et al., 1982a). However, it is still unclear to what extent hyperglycaemia's detrimental effects are modulated by genetic factors. Neither is it clear just how nearly 'normoglycaemic' metabolic control has to be in order to prevent or delay these diabetic complications, i.e. is a mean blood glucose level during the day of 150 mg/dl sufficient, or do we have to strive for absolute normoglycaemia ? As long as these questions are unanswered, we feel obliged to offer our patients as near to normoglycaemic a control as possible under the present circumstances.

Long-term safety, efficacy and side-effects of continuous subcutaneous insulin infusion treatment for Type 1 (insulin-dependent) diabetes mellitus: a one centre experience

“…Disabling hypoglycaemia was observed at an annual rate of 0.10 DH per patient. This rate is in agreement with previous reports ranging from 0.09 DH per patient year [16] to 0.13 DH per patient year [13], and 0.19 DH per patient year as reported by our group after observation of the first 46 patient years of CSII [9]. Note that the incidence of DH during conventional insulin injection treatment is similar (ranging from 0.16 to 0.4 per patient year as reported by Home et al [54]).…”

“…Improvement in acute metabolic control which may be achieved with CSII compared to conventional insulin therapy [4][5][6][7], as well as side effects of CSII (diabetic ketoacidosis, severe hypoglycaemia and skin complications at the catheter insertion site [4]) have been noted. Little is known as to the long-term efficacy of CSII therapy, most of the previous papers providing intermediate-term observations at best [4][5][6][7][8][9][10][11][12][13]. Only a few studies have reported follow-up results of more than two years [14][15][16][17][18], some of these with rather disappointing results, e.g.…”

Less severe hypoglycaemia, better metabolic control, and improved quality of life in Type 1 diabetes mellitus with continuous subcutaneous insulin infusion (CSII) therapy; an observational study of 100 consecutive patients followed for a mean of 2 years

“…As previously reported [2–4], the experience of this centre with CSII has been largely positive since the technique was introduced in 1980 [5]. In general, we had initiated CSII treatment in patients who already had good metabolic control on conventional intensified insulin therapy, but desired increased flexibility in their daily lives, along with maintaining or even improving their HbA 1c levels.…”

“…Intensified insulin therapy using continuous subcutaneous insulin infusion by external pumps (CSII) has become a therapeutic routine for Type 1 diabetes in a number of diabetes centres since its introduction in 1978 [1]. Its efficacy and safety have been evaluated in several uncontrolled [2][3][4][5][6][7][8][9][10][11][12][13][14] and controlled [15][16][17][18][19][20][21][22][23] trials. The results of these studies have been quite heterogeneous: whereas improvements of metabolic control and the possibility of more flexibility of daily life schedules were reported by some authors, there were also reports of increased complications, e.g.…”

Complications and Fetal Outcome in Diabetic Pregnancy

“…If the basal rate is chosen appropriately, the patient does not need to take her meals at fixed hours, she will be even free to use fast carbohydrates [19]. In some of the patients who do not have regular working or living circumstances, CSII treat ment may be of great value [19].…”