Suspension of basal insulin to avoid hypoglycemia in type 1 diabetes treated with insulin pump

Abstract

SummaryTreatment with continuous s.c. insulin infusion (CSII) provides better glycemic control and lower risk of hypoglycemia than conventional therapy with multiple daily insulin injections. These benefits have been related to a more reliable absorption and an improved pharmacokinetic profile of insulin delivered through CSII therapy. However, even for patients treated with CSII, exaggerated postmeal hyperglycemic excursions and late postabsorptive hypoglycemia can still constitute a therapeutic challenge. Two female patients with type 1 diabetes who began treatment with CSII required to increase their previous breakfast insulin-to-carbohydrate ratio in order to achieve postprandial glycemic goals. However, they simultaneously presented recurrent episodes of late hypoglycemia several hours after breakfast bolus. Advancing the timing of the bolus was ineffective and bothersome for patients. In both cases, the best therapeutic option was to set a basal insulin rate of zero units per hour during 6 h after breakfast. Even so, they need to routinely take a midmorning snack with 10–20 g of carbohydrates to avoid late postabsorptive hypoglycemia. They have been using this insulin schedule for about 3 years without complications. The action of prandial insulin delivered through insulin pumps can be inappropriately delayed for the requirements of some patients. Although suspension of basal rate can be an acceptable therapeutic alternative for them, these cases demonstrate that new strategies to improve the bioavailability of prandial insulin infused through CSII are still needed.Learning points CSII remains the most physiologically suitable system of insulin delivery available today.Additionally, the duration of action of prandial insulin delivered through insulin pumps can be excessively prolonged in some patients with type 1 diabetes.These patients can present recurrent late episodes of hypoglycemia several hours after the administration of insulin boluses.The routine suspension of basal insulin for several hours, leaving meal bolus to cover both prandial and basal insulin requirements, can be a therapeutic option for these subjects.

Experiences of Adults Using Continuous Subcutaneous Insulin Infusion: A Qualitative Study

“…Advantages of CSII include delivering doses more accurately, reducing blood glucose variability, reducing the risk of hypoglycemia and severe hypoglycemia, improving glycemic control, and eliminating the need for multiple daily injections (MDIs). CSII also allows flexibility in bolusing insulin, exercising, eating scheduling, varying carbohydrate intake, and eliminating the unpredictable effects of longacting insulin using different basal rates [2]. In fact, the hourly basal rate imitates the physiological requirements [3].…”

Insulin pumps in children - a systematic review

“…However, the insulin-to-carbohydrate ratio and ISF should be revised when the blood glucose variation (hypo/hyperglycemia) occurs within four hours of the bolus or meal or after giving a correction insulin bolus. To test the basal rate, we should eliminate the influence of other factors that could affect it by dividing the day into windows, testing the basal rate for each window on different days, and ensuring that the tested person follows his/her usual routine without strenuous activity before the test by 24 h and during the test period[ 49 , 50 ]. Hypoglycemia should not present during the last 12 h before testing, and the patients should be fasting for the tested period except for water.…”

Modelado y simulación de tecnologías para el tratamiento de la diabetes

“…Las altas excursiones hiperglucémicas después de las comidas y la hipoglucemia postabsortiva tardía siguen constituyendo un desafío terapéutico [128]. Para evitar estos síntomas, algunas personas con DMT1 confían en la rutina de la suspensión de insulina basal durante varias horas, dejando que el bolo de la comida cubra las necesidades de insulina tanto prandial como basal [129]. Además, hay tanto ensayos comparativos in-silico [130] y clínicos [131] donde muestran un mejor control de la glucosa posprandial usando otras combinaciones de basal-bolo que la estándar.…”