Building Competency in Diabetes Education THE ESSENTIALS

BASAL-BOLUS INSULIN THERAPY | 12-43 • In 2002, Pickup and Keen also published a systematic review that supported the expanding use of CSII and the covering of pump expenses by third-party payers (78). They suggested that CSII was indicated if poor control persisted after a two- to three- month trial of “optimized insulin injection therapy (including re-education, with attention to SMBG and injection technique) …because of 1) frequent hypoglycemia or 2) a marked dawn blood glucose rise” (78). They pointed out that persons with an erratic lifestyle, marked by variations in meal timing, sleeping patterns, travel and/or activity would have more difficulty achieving optimal control with MDI. Additional evidence supports this view (90,91,92). • In 2004, a second meta-analysis of studies with rapid-acting insulin in pumps (only three studies involving 139 patients) concluded that A1C was reduced by 0.35% with pump use, although there was a greater benefit if the A1C was higher to start (93). • In 2006, Hoogma et al. demonstrated the superiority of CSII with lispro over a lispro/NPH-basedMDI regimen in a randomized, controlled, crossover trial involving 272 adults (12). A1C was reduced by 0.23% (a statistically if not clinically significant amount) while concurrently reducing the rates of mild and severe hypoglycemia (SH) (SH reduced from 0.5 to 0.2 events per patient year [p<0.001]). • Raskin et al. studied 132 persons with type 2 diabetes to compare the use of CSII with aspart to MDI with aspart and NPH (81). The efficacy and safety of both proved to be equal, with an equal improvement in A1C (A1C baseline was 8.2%, reduced to 7.6% with CSII vs. 7.5% with MDI. Weight gain (~1 kg) was equal in both groups. However, participants were more satisfied with CSII therapy than MDI (p <0.001). Satisfaction with treatment improved in both groups during the study. Raskin et al’s conclusion was that pump therapy was equivalent to MDI in type 2 diabetes (94). • An Australian group reported on the use of pump therapy in women with either type 2 or gestational diabetes (95). Between 1991 and 1994, 30 out of 251 Polynesian, European and South Asian women used pump therapy when a single dose of insulin exceeded 100 units. Pump therapy was well tolerated. The women experienced no significant hypoglycemia and control was improved as anticipated compared with regular SC insulin. The authors concluded that CSII was a safe and potentially useful approach when large insulin doses failed to achieve goals. In 2021 Kramer et al reported from their study of 237 patients with type 1 that CSII and Intensified insulin therapy yielded comparable metabolic control. The A1c did not show any significant difference between the use of human short acting insulin and analogue short acting insulin used in BBI or CSII. It was noted that CSII patients tended to have a longer duration of diabetes, were younger and female. Smaller doses of insulin were used in the CSII treated patients. (96)