Subcutaneous versus intraperitoneal insulin for patients with diabetes mellitus on continuous ambulatory peritoneal dialysis: Meta-analysis of non-randomized clinical trials.

Abstract

Background: Diabetes mellitus is one of the leading causes of end stage renal disease. Use of intraperitoneal (IP) nsulin in diabetic patients on peritoneal dialysis (PD) can restore glucose control to near normal values. The safety and efficacy of this method is unclear. Methods: We performed a meta-analysis to study the safety and efficacy of IP insulin administration in diabetic patients on PD. The primary outcome measures is glycemic control: secondary outcome measures were plasma lipids, insulin dose requirement/day and the risk of peritonitis and hepatic subcapsular steatosis. Medline, EMBASE, Cochrane Central Register of Controlled Trials, and reference lists of eligible studies were searched. Eligible studies included randomized and non-randomized controlled trials that allocated adult PD diabetic patients to IP insulin and subcutaneous (SC) insulin. Results: Twenty one citations were identified and three met the eligibility criteria. Glycemic control with IP insulin, as assessed with HbA1C, was equal to or better than that obtained with SC insulin: weighted mean difference was −1.49 % (95% CI: -2.17 to - 0.27, p=0.0001). The insulin dose required was more than two-fold higher in the IP treatment. Serum HDL-cholesterol decreased during IP insulin therapy while serum triglyceride (TG) concentration tended to increase, in comparison with levels seen in patients treated with SC insulin. Conclusions: Use of IP insulin provides adequate glycemic control, which appears superior to that seen following treatment with conventional SC insulin. The plasma lipids are adversely affected by IP insulin, possibly contributing to increased cardiovascular risk. Data are limited and further studies are needed to assess for the long-term safety of this approach.

Effect of poly(ethylene glycol) content and formulation parameters on particulate properties and intraperitoneal delivery of insulin from PLGA nanoparticles prepared using the double-emulsion evaporation procedure

“…These polymers have been used to encapsulate inter alia 83 lysozyme, recombinant human epidermal growth factor and luteinising hormone-releasing 84 hormone agonist, leading to improvement of pharmacokinetic profiles and minimising 85 frequency of administration (8,9). They are generally fabricated using emulsion solvent superior to that seen following treatment with conventional SC insulin (19). However, the 120 approach is not without its clinical difficulties and more data is needed to assess long-term 121 safety, which will include evaluation of novel delivery strategies, such as nanoparticulate 122 platforms (19).…”

Disinfection of the peritoneal dialysis bag medication port: Comparison of disinfectant agent and disinfection time

“…17 There is no evidence to link contamination through the MP with the development of peritonitis, however, there is a need to perform this disinfection, since contamination may happen following handling. Other than antibiotics, 18 the most commonly used intraperitoneal medications are heparin 7 and insulin, 19 however, reports linking the association between peritonitis and MP manipulation are contradictory. Selgas et al 20 reported the occurrence of 4 times more…”

When ESKD complicates the management of diabetes mellitus

“…In a meta‐analysis studying the safety and efficacy of IP insulin administration, the insulin dose required was more than twofold higher in the IP treatment, but glycemic control measured by hemoglobin A1C was equal to or better than the control obtained by SC insulin 105 . Increased IP insulin requirements of two‐ to threefold have been confirmed in multiple studies 103,106‐108 .…”

“…Some have advocated for the administration of insulin into an empty peritoneum to improve the efficacy of IP insulin, 111 but this procedure increases the number of times the peritoneal space is accessed which, in turn, increases the risk for peritonitis. Furthermore, the lipid profile appeared to be adversely affected, with decreased HDLs and increased triglycerides, potentially increasing cardiovascular risk 105,112,113 . The disadvantages of IP administration of insulin are many and include increased risk of peritonitis, 106,114 risk of development of hepatic subcapsular steatonecrosis, 115 malignant omentum syndrome, 116 and increased costs incurred from higher insulin doses.…”