10 / 16
Insulin infusion and glucose monitoring: a guideline for
diabetes technologies
Comment by Jennifer Sherr,
MD, PhD
In this modern day of diabetes management, healthcare providers are faced with a vast array of tools to assist our patients
as we strive to help themmeet prescribed glycaemic targets. Yet, determination of who would benefit from the application
of diabetes technologies to their regimens is, at times, less clear.
T
o help address this question,
the Endocrine Society ap-
pointed a Task Force of seven
experts, a methodologist, and a
medical writer. Use of two diabe-
tes technologies was considered:
continuous subcutaneous insulin
infusions (insulin pumps) and real-
time continuous glucose monitors
(RT-CGM). To quantify the degree
with which the task force endorsed a
certain recommendation, the terms
“we recommend” was indicative of
a strong recommendation, whereas
a weak recommendation was identi-
fied by the phrase “we suggest.”
For those with type 1 diabetes
(T1D), the guidelines recommend
consideration of pump use in those
who have not achieved their A1c
goal and in those who have reached
target but experience severe hypo-
glycaemia or high glucose variability.
Both of these recommendations
were qualified by the statement that
the patient needed to be “willing and
able to use the device.”
Most individuals living with T1D
would fall into one of these two
categories, and thus be considered
a candidate for pump therapy. Pump
use was suggested to be considered
in those with type 2 diabetes (T2D)
who failed to achieve targeted gly-
caemic control despite adherence
to a prescribed medical regimen, in-
cluding glucose monitoring, lifestyle
modifications, and use of intensive
insulin therapy in conjunction with
oral or injectable agents. Addition-
ally, continuation of pumps during
hospitalisation is also feasible, as
long as a protocol for this and safety
measures are in place.
In the case of RT-CGM, for those
with T1D, the same criteria for the
use of pumps was applied to sensor
use contingent on the patient being
willing to use the device on a nearly
daily basis. However, in those with
T2D, only short-term, intermittent
use of these devices for those with
A1c >7% was suggested.
Educating patients on the various
features that pumps and RT-CGM
is essential. Indeed, the guidelines
highlight that the use of bolus cal-
culators is suggested for those on
pump therapy. Only by educating
our patients on pump features (bo-
lus calculators, advanced boluses,
the ability to have multiple basal
rates, temporary basal rates, etc) and
RT-CGM features (real time alarms
and retrospective review of reports),
can we expect them to reap the full
benefit of these technologies. If one
were to merely manually bolus with
an insulin pump, it would be like
using a smartphone simply to make
calls.
Determination of who would be
an acceptable candidate and thus
benefit from these technologies is
essential, especially due to the cost
associated with their use. Impor-
tantly, based on the guidelines it
seems most adults with T1D who
are motivated and willing to use
them would be candidates for both
pump and RT-CGM use. Preparing
patients by integrating use of these
technologies into their daily lives
now will be critical as we move to-
wards the marriage of these devices
through closed loop insulin delivery
systems.
Dr Sherr is Instructor, Pediatrics
(Endocrinology), Yale University
School of Medicine, New
Haven, Connecticut.
JOURNAL SCAN
Increased mortality in people with impaired glucose tolerance after the onset of diabetes
Diabetes Care
Take-home message
•
This study included 542 patients with impaired glucose tolerance participating in a lifestyle diabetes prevention trial who were
followed for 23 years. Of these patients, 174 died during follow-up. The overall death rate was 15.9/1000 person-years, with age-
adjusted death rates of 11.1/1000 person-years before development of type 2 diabetes and 19.4/1000 person-years after diabetes
development. An adjusted, time-dependent multivariate analysis revealed that development of type 2 diabetes was associated
with a 73% increased risk of death.
•
This study demonstrates that a large portion of the increased mortality risk in patients with impaired glucose tolerance is attribut-
able to development of type 2 diabetes.
Abstract
OBJECTIVE
People with impaired glucose tolerance (IGT) have in-
creased risk of mortality and a high risk of progression to diabetes,
but the extent that the excess mortality is associated with IGT per se
or is the result of subsequent diabetes is unclear.
RESEARCH DESIGN AND METHODS
We compared mortality before and
after the development of diabetes among 542 persons with IGT
initially who participated in a 6-year lifestyle diabetes prevention
trial and were followed-up from 1986 to 2009.
RESULTS
During the 23-year follow-up, 174 (32.1%) died, with an overall
death rate of 15.9/1,000 person-years. The majority of deaths (74.7%;
130 of 174) occurred after progression to type 2 diabetes, with age-
adjusted death rates of 11.1/1,000 person-years (95% CI 8.2–12.0)
before and 19.4/1,000 person-years (95% CI 11.9–23.3) after the de-
velopment of type 2 diabetes. The cumulative mortality was 37.8%
(95% CI 33.1–42.2%) in participants who developed type 2 diabetes
during first 10 years of follow-up, 28.6% (95% CI 21.6–35.0%) in those
who progressed to type 2 diabetes in 10–20 years, and 13.9% (95%
CI 7.0–20.3%) in those who did not develop to type 2 diabetes within
20 years. Time-dependent multivariate Cox proportional hazards
analyses, with adjustment for baseline age, sex, intervention, and
other potential confounding risk factors, showed that the development
of type 2 diabetes was associated with a 73% higher risk of death
(hazard ratio 1.73 [95% CI 1.18–2.52]).
CONCLUSIONS
As elsewhere, IGT is associated with increased risk of
mortality in China, but much of this excess risk is attributable to the
development of type 2 diabetes.
Changes in mortality in people with IGT before and after the
onset of diabetes during the 23-year follow-up of the Da Qing
Diabetes Prevention Study
Diabetes Care
2016;39:1550-1555,
Gong Q, Zhang V, Wang J, et al.
Diabetes technology – continuous subcutaneous
insulin infusion therapy and continuous glucose
monitoring in adults: an Endocrine Society
clinical practice guideline
The Journal of Clinical Endocrinology and Metabolism
Take-home message
•
Current treatments such as continuous subcutaneous insulin infusion and
continuous glucose monitoring play an important part in the manage-
ment of diabetes. This evidence-based, clinical practice guideline offers
a literature review and recommendations for use in adult patients.
•
Data on the use of medical devices are limited. However, current studies
do support the use of technology for the treatment of diabetes.
Abstract
OBJECTIVE
To formulate clinical practice
guidelines for the use of continuous
glucose monitoring and continuous
subcutaneous insulin infusion in adults
with diabetes.
PARTICIPANTS
The participants include
an Endocrine Society-appointed Task
Force of seven experts, a methodolo-
gist, and a medical writer. The Ameri-
can Association for Clinical Chemistry,
the American Association of Diabetes
Educators, and the European Society
of Endocrinology co-sponsored this
guideline.
EVIDENCE
The Task Force developed
this evidence-based guideline using
the Grading of Recommendations, As-
sessment, Development, and Evalua-
tion system to describe the strength
of recommendations and the quality
of evidence. The Task Force commis-
sioned one systematic review and
used the best available evidence from
other published systematic reviews
and individual studies.
CONSENSUS PROCESS
One group meet-
ing, several conference calls, and
e-mail communications enabled con-
sensus. Committees and members of
the Endocrine Society, the American
Association for Clinical Chemistry, the
American Association of Diabetes
Educators, and the European Society
of Endocrinology reviewed and com-
mented on preliminary drafts of these
guidelines.
CONCLUSIONS
Continuous subcutane-
ous insulin infusion and continuous
glucose monitoring have an important
role in the treatment of diabetes. Data
from randomized controlled trials are
limited on the use of medical devices,
but existing studies support the use of
diabetes technology for a wide variety
of indications. This guideline presents
a review of the literature and practice
recommendations for appropriate
device use.
J Clin Endocrinol Metab
2016 Sep
02;[Epub ahead of print], Peters AL,
Ahmann AJ, Battelino T, et al.
DIABETES
PRACTICEUPDATE ENDOCRINOLOGY
10