Search

Objective: To identify characteristics of adult patients at baseline associated with duration of subsequent, continuous, subcutaneous infusion of insulin treatment (pump therapy) of type I diabetes., Research Design and Methods: For 6 wk, patients followed a standardized conventional therapy and kept a record of insulin dosages, capillary blood glucose concentrations, and symptomatic hypoglycemia. They were then hospitalized. Additional baseline data were obtained and pump therapy was started. Survival analysis was used to determine the relationship between baseline independent variables or risk factors and duration of pump therapy, which is the dependent variable., Results: Of the 68 participants, 33 (49%) terminated pump therapy after an average of 9.9 mo of treatment. Two models (each P < 0.00005) were developed that exhibited a high degree of consistency. Of the 6 variables, 5 were common to both models (HbA1, autonomic neuropathy, mean amplitude of glycemic excursions, frequency of symptoms of hypoglycemia when blood glucose was < 70 mg/dl, and erythema at injection sites). The sixth variable in model 1 (insulin dosage) was replaced in model 2 by a variable, Adult Self-Efficacy for Diabetes, which was obtained on the 33 more recently enrolled patients; this variable related to patient perceptions of self-care behaviors., Conclusions: We found that, at baseline, the presence of a high concentration of HbA1 and a low estimation by the patient of their ability to treat the disease portend failure of insulin pump therapy as evidenced by its discontinuation. This effect is accentuated when clinical evidence of autonomic neuropathy is observed. These findings offer guidance in selecting patients with type I diabetes for insulin pump therapy.

Type II (non-insulin-dependent) diabetes accounts for most of the diabetes morbidity and expense, yet no systematic study of the effects of intensification of treatment by such patients who require insulin treatment has been conducted. Therefore, patients were recruited from our diabetes clinics, and by random assignment, experimental and control groups were created (n = 26 and 27, respectively) that were not different at 0 mo regarding 20 demographic, physiological, and treatment variables. Experimental patients practiced an algorithm for adjustment of insulin dosage based on daily prebreakfast capillary blood glucose (CBG) measurements and any symptomatic hypoglycemia. At 2-, 4-, and 6-mo visits, records of CBG measurements were available to the physicians (n = 7), who changed insulin dosages of both groups ad libitum. Feasibility of the experimental treatment is evidenced by study completion by 87% of enrollers, monitoring on 88% of days, accuracy of CBG recording (recorded as percentage of memory meter value, 100.8), weight gain not exceeding that of control subjects, practice of treatment algorithm to effect changes in insulin dosage, modest increase in frequency of mild insulin reactions, and a decrease of glycosylated hemoglobin into the normal range.

The effect of the control of diabetes with diet and insulin upon plasma levels of human pancreatic polypeptide and glucagon was determined in eight patients with Type 2 (insulin independent) diabetes mellitus. The mean +/- SEM fasting plasma glucose was 15.9 +/- 1.3 mmol/l for 5 days of diet treatment and 5.9 +/- 0.4 mmol/l for the last 5 days of treatment with diet plus insulin (p less than 0.0001); corresponding fasting plasma pancreatic polypeptide levels were 328 +/- 97 and 247 +/- 71 pg/ml (p less than 0.05) and immunoreactive glucagon levels were 95 +/- 11 and 62 +/- 6 pg/ml (p less than 0.005). Cooked ground beef was administered on the first day of diet treatment and on the last day of treatment with diet plus insulin; mean maximal rise of pancreatic polypeptide, and total and incremental plasma pancreatic polypeptide response areas were significantly lower following treatment (p less than 0.01), as was total area for immunoreactive glucagon (p less than 0.05). Normalisation of fasting plasma glucose by short-term treatment with diet plus insulin is associated with decreases in basal and stimulated secretory activity of the pancreatic polypeptide cells in insulin independent diabetes mellitus.