Building Competency in Diabetes Education THE ESSENTIALS

BASAL-BOLUS INSULIN THERAPY | 12-42

Key point: It is the role of the diabetes educator to help inform the patient of options, encourage collaborative decision making and help develop effective problem-solving skills

To pump or not to pump? continuous subcutaneous insulin infusion as basal (andbolus) insulin The difference between BBI and CSII becomes more evident with a comparison of CSII’s ability to more closely mimic physiological basal insulin. According to Bolli, CSII is the gold standard of physiological insulin replacement and should be an option for all persons with type 1 diabetes. The popularity of CSII has risen dramatically in recent years (38,89 However, clinicians and researchers are still engaged in the process of demonstrating a conclusive advantage of CSII alone over BBI. The cost of pump therapy is higher than BBI; patients, providers and third-party payers need to have evidence of the superiority over BBI to make informed decisions about this therapy. What criteria are used to demonstrate superiority of one method over the other? The following criteria are proposed to frame the discussion and evaluate options: • Improved glycemic control sufficient to reduce chronic complications risk (reduction in A1C>0.5%). • Reduction of severe hypoglycemia or hyperglycemia, with concurrently improved A1C. • Reduced glycemic variability (for potential reduction of chronic and acute complications). • Improved quality of life as evidenced by reduced fear of hypoglycemia, decreased burden of disease, and/or reduced psychological distress. In the following discussion, efforts have been made to note whether studies used BBI with NPH or with LAAs. Findings from studies using NPH as basal cannot be generalized to BBI with LAAs as a basal. As further studies are published, a better understanding of how BBI with the newer LAAs compares with CSII will be reported. 1. Improved glycemic control • A 2002 meta-analysis of 12 randomized, controlled trials (1980 to 2000) concluded that CSII therapy does deliver a glycemic advantage over MDI regimens, although this advantage was relatively small (77). With CSII, there were fewer daily glycemic excursions and a reduction in A1C of 0.51%, enough to demonstrate statistical and clinical significance. This difference was “comparable with, or only slightly better than” the control therapy offered by MDI. The authors did not recommend CSII as a superior treatment for all persons with type 1 diabetes, but instead felt that it “should be reserved for those with special problems with optimized insulin injections” (90).