Building Competency in Diabetes Education THE ESSENTIALS

BASAL-BOLUS INSULIN THERAPY | 12-48 Bergenstal et al compared the efficacy of sensor-augmented pump (SAP) therapy with that of BBI and found a significant improvement in A1c. In this study there were 485 patients (329 adults and 156 children) with inadequately controlled type 1 diabetes. All patients used recombinant insulin analogues. At one year, the SAP group showed a 0.8% reduction in their A1c (8.3%- 7.5%) versus a 0.2% reduction in the injection therapy group (8.3%- 8.1%)(103). Referred to as ‘open loop’ therapy, SAP requires the wearer to make manual adjustments to their insulin dosage. The robust information supplied by the continuous monitoring system allows for more timely and insightful changes. With the CGM’s ability to talk to the pump, features such as low glucose suspend and predictive low glucose suspend have helped to prevent more frequent and severe hypoglycemic events (105,108,109). In his study of type 1 patients Garg found that by using the automatic suspension of insulin delivery the duration and severity of induced hypoglycemia could be significantly reduced without causing rebound hyperglycemia (110). Ly et al looked at the effects of sensor- augmented insulin pump therapy and automated insulin suspension versus standard insulin pump therapy on hypoglycemia rates in patients with type 1 diabetes. Following 6 months of treatment and adjusting for the baseline hypoglycemia rate, their findings indicated the number of severe and moderate events in the low-glucose suspension group decreased from 175 to 35, whereas the number of events decreased from 28 to 16 in the pump-only group (111l). With the increasing accuracy, durability and usability of these sensing systems in combination with CSII it is expected that more patients will be advocating for their use. As the evidence suggests, these systems are proving to be revolutionary for diabetes management. Use of Hybrid (HCL) and Closed loop (CL) pump therapy Further to the development of SAP is the hybrid closed loop system eventually leading to the entire closed looped pump system. The hybrid closed loop systems currently available have an automated insulin delivery program which supplies insulin for basal needs. The system reads the rtCGM and delivers basal insulin according to a developed algorithm adjusting the dosage every five minutes. The patient remains responsible for their mealtime bolus insulin needs(112). To date, these systems are the most advanced government approved form of insulin delivery resulting in a reduced risk of hypoglycemia and improved glycemic control (112). With the use of HCL, studies have shown an average time in range from 65-76% with a low burden of hypoglycemia (112). McAuley and colleagues investigated glycemic and psychosocial outcomes with hybrid closed-loop (HCL) versus user-determined insulin dosing with multiple daily injections (MDI) or insulin pump in patients with type 1 diabetes. Their findings after a 26 week trial period, showed that HCL improved TIR, A1C c , and increased the patients’ sense of satisfaction from managing their diabetes compared with those continuing with user-determined insulin dosing