Slide 1

Why We Pump Henry Anhalt, DO, CDE Director, Pediatric Endocrinology and Diabetes Saint Barnabas Medical Center Livingston, NJ Slide 2 Pump Gasoline? Slide 3 Pump Iron? Slide 4 Pump Breast Milk? Slide 5 THE PANCREAS THROUGHOUT HISTORY 1550 BCE-Papyrus describes polyuria and its treatment 4 th century BCE-Ayur Veda of Susruta (India) described sugarcream urine which attracted ants. 7 th century CE-Chinese physician Chen Chuan recorded sweet urine in diabetes 1869-Langerhans describes islets 1909-the name insuline is suggested by Jean de Meyer (Brussels) 1921-Banting and Best-report discovering Insulin used in 1922 Slide 6 BANTING-1891-1941 & BEST-1899-1978 Orthopod who became a physiologist and died in air crash in Newfoundland while on wartime mission Together they isolated insulin and Banting won the Nobel Prize in 1923 knighted in 1934 Slide 7 First commercial insulin Slide 8 Diagnosed Type 1 Diabetes 1.5 Million(1:400- 600 children) Diagnosed Type 2 Diabetes 14 million Undiagnosed Diabetes 6 Million Prevalence of Diabetes in the US 1.5 million new cases of diabetes were diagnosed in people aged 20 years or older in 2005 Slide 9 DCCT Research Group. N Engl J Med. 1993;329:977-986. Ohkubo Y et al. Diabetes Res Clin Pract. 1995;28:103-117. UKPDS 33: Lancet. 1998;352:837-853. HbA 1c Retinopathy Nephropathy Neuropathy Macrovascular disease DCCT 9 7% 63% 54% 60% 41%* Kumamoto 9 7% 69% 70% UKPDS 8 7% 17-21% 24-33% 16%* * not statistically significant Good Glycemic Control (Lower HbA 1c ) Reduces Incidence of Complications Slide 10 HbA 1c and Microvascular Complications Relative Risk 15131197531 HbA 1c, % 789101112 Neuropathy Nephropathy Retinopathy 10 Slide 11 Every 1% HbA 1c Increase Above Goal Elevates the Risk of Diabetic Complications Increase in Any Diabetes-Related Endpoint Increase in Risk of Myocardial Infarction (MI) Increase in Risk of Stroke Increase in Risk of Microvascular Complications Incidence of Diabetes- Related Complications (%) +21% +37% +12% +14% Adapted from Stratton et al. BMJ. 2000;321:405-412. Slide 12 Physiology of Insulin and blood glucose Breakfast Lunch Dinner Basal Insulin Insulinsecretion Basal blood glucose Bloodglucose Slide 13 Onset ofDuration of Action Peak Action Humalog/Novalog5 to 15 min1 to 2 hr4 to 6 hr Human Regular30 to 60 min2 to 4 hr6 to 10 hr Human NPH1 to 2 hr4 to 6 hr10 to 16 hr Human Lente1 to 2 hr4 to 6 hr10 to 16 hr Human Ultralente2 to 4 hrUnpredictable Candidates for pump therapy Typical Criteria Only motivated patients only patients who showed good compliance on previous regimen Adults and children > 6y old My Criteria Any patient who is willing to start and has abilities to learn May improve compliance Any age adults and children of any age (independent users 7-80 y old) Particularly non- compliant patients Slide 50 ADVERSE EVENTS Slide 51 PSYCHOSOCIAL OUTCOMES Slide 52 The Yale Experience > 200 children started on pumps over last 5 yrs No difference in severe hypoglycemia Parents report less mild hypoglycemia Ahern et al., Journal of Pediatric Endocrinology and Metabolism 2000, 13(suppl 4):1220. HbA 1c Age (yr) pre3 mos post < 77.66.7 7-127.87.3 13-187.97.5 Slide 53 Additional Evidence From Yale Ahern, JAH, et.al. Pediatric Diabetes 2002;3:10-15. Decreased hypoglycemia No change in BMI or TDD 98% remained on CSII Slide 54 CSII vs. MDI With Glargine in Children Boland et al., Diabetes 2003, 52:S1, A45, 192-OR CSII (aspart) n=12 MDI (aspart/glargine) n=14 Injection therapy Randomized, Parallel-group, 16 week study Subjects at baseline Age: 8-19 yr (mean 12.7 2.7) Type 1 DM > 1 yr duration Standard insulin therapy (2-3 injections/day) Slide 55 Pump Group Achieved Better Control Overall Changes in HbA1c Levels 6.5 7 7.5 8 8.5 Baseline4 wks8 wks12 wks16 wks Pump MDI p =.03 p=.30 (NS) p=.15 (NS) p=.001 Boland, E. Diabetes 52,(Suppl 1), 2003 Abstract 192. Slide 56 More Pump Wearers Achieved HbA1c 6.9% % Patients Achieving HbA1c < 6.9% 0 10 20 30 40 50 Pump Glargine Boland, E. Diabetes 52,(Suppl 1), 2003 Abstract 192. < _ Slide 57 Swedens Experience 89 children 3-21 y.o Diabetes duration 6.1 years 30% using CSII HbA 1c decreased from 9.2% to 8.4% after CSII start Severe hypos Pump: 11.1/100 pt years MDI: 40.3/100 pt years. Hanas, Diabetes, 2000, 49 (Suppl 1):A133. Slide 58 Patient Characteristics of Successful Pediatric Pumpers Able to maintain follow up appointments with health care provider Willing to record blood glucose values Able to count carbohydrates Good family/social support system Slide 59 Pump therapy benefits Improved control - more physiological basal rates (dawn phenomenon match), different boluses for food, less absorption variability Less hypoglycemia More flexible lifestyle and possibility to exercise Precise dosing - 0.1u - 0.025u increments for basal rate and boluses Less injections - improved quality of life Less possibility of overdose Adapted from Plotnick L et al; Diabetes Care 2003; 26(4):1142-1146. Slide 60 Pump Use in Children Is Increasing 200,000 users (adults and kids in the US). 10,000 are adults with type 2 diabetes ~ 20,000 children using pump therapy 10% of all children with diabetes Penetration as high as 90% in some pediatric clinics (ours) Increasing use in younger children (as young as 10 months) Current outcomes indicate CSII is safe and effective in children Increasing acceptance likely due to DCCT findings as well as the introduction of smaller, safer insulin pumps There are approximately 400,000 insulin pump users worldwide Slide 61 Avoiding DKA Give a pen with the pump Instruct that any time the patient feels nauseated or has abdominal pain -- change the site Blood sugar is greater than 250 mg/dl Take correction dose Check for ketones Recheck in 60 minutes If coming down, leave alone If not, take a shot and change the site Slide 62 Summary Pump therapy is an intensive process for pediatric patients and their families and the diabetes education team. Successful pumpers are motivated and willing to maintain follow-up, carbohydrate count, and check blood glucose frequently. Benefits of pump therapy for pediatric patients include: improved lifestyle, decrease in hypoglycemia, accurate dosing, ability to review history to see if doses were actually given. Slide 63 Summary Children with diabetes should be intensively treated to avoid short and long term complications Insulin pumps can provide better control and less hypoglycemia than MDI With good support and a standardized process, insulin pump therapy can help to improve diabetes management in children Insulin pump therapy should be the only form of therapy offered to children with diabetes Slide 64 When meditating over a disease, I never think of finding a remedy for it, but rather, a means of preventing it. Louis Pasteur, 1884 Slide 65