RESUMEN
BACKGROUND: It is generally held that basal insulin substitution with continuous subcutaneous insulin infusion (CSII) provides less variable glucose levels than with long-acting insulin analogs, e.g., glargine, in patients with type 1 diabetes, although this has not been convincingly demonstrated by continuous glucose monitoring. METHODS: To compare glucose control assessed by a continuous glucose monitoring system (CGMS) during basal insulin substitution with glargine versus CSII, we conducted a non-blinded, randomized, crossover trial in 15 type 1 diabetes patients experienced with CSII. All subjects were randomly assigned to receive either a morning dose of insulin glargine, comprising their average 24-h basal insulin requirement, minus 2.4 U, which was delivered by the pump, or to continue as before for 4 weeks followed by a 1-week washout period and a crossover. All mealtime doses of insulin were given by the pump as before. CGMS data were blinded until the end of the study. RESULTS: The mean blood glucose was lower in the non-glargine arm according to self-monitoring of plasma glucose (9.2 vs. 10.6 mmol/L; P = 0.010) and CGMS (9.1 vs. 10.3 mmol/L; P = 0.002), and hemoglobin A1c was 6.5% without glargine versus 6.8% with (P = 0.018). There were no significant differences in glucose variability measured as SD of plasma glucose (SDPG) or mean amplitude of glycemic excursions (MAGE), although significantly longer periods of glucose values spent within the target of 4.5-10.0 mmol/L were demonstrated in the non-glargine arm using CGMS (P = 0.034). More episodes below 3.5 mmol/L were seen during the CSII period (P = 0.053). CONCLUSIONS: CSII provided improved glucose control compared to glargine with a lower mean plasma glucose and longer periods of glucose values within target on a somewhat lower insulin dose. There was a tendency with more episodes below 3.5 mmol/L during CSII. No difference with respect to glucose variability was found when calculated as SDPG or MAGE.
Asunto(s)
Diabetes Mellitus Tipo 1/tratamiento farmacológico , Hipoglucemiantes/administración & dosificación , Sistemas de Infusión de Insulina/normas , Insulina/análogos & derivados , Adulto , Anciano , Glucemia/análisis , Glucemia/metabolismo , Estudios Cruzados , Diabetes Mellitus Tipo 1/sangre , Hemoglobina Glucada/análisis , Hemoglobina Glucada/metabolismo , Humanos , Bombas de Infusión Implantables/normas , Insulina/administración & dosificación , Insulina Glargina , Insulina de Acción Prolongada , Persona de Mediana EdadAsunto(s)
Antihipertensivos/uso terapéutico , Diabetes Mellitus Tipo 2/complicaciones , Angiopatías Diabéticas/tratamiento farmacológico , Antagonistas de los Receptores de la Endotelina A , Péptidos Cíclicos/uso terapéutico , Anciano , Anciano de 80 o más Años , Humanos , Isquemia/tratamiento farmacológico , Pierna/irrigación sanguínea , Microcirculación , Enfermedades Vasculares Periféricas , Sístole/efectos de los fármacosRESUMEN
A cross-sectional survey of severe hypoglycaemia was performed in type 1 diabetes mellitus patients in 1984 and repeated in 1998 at the diabetes out-patient clinic of a Swedish university hospital. The study revealed that the prevalence of severe hypoglycaemia had increased by more than 50 per cent over 14 years, in spite of more frequent use of multiple insulin injection therapy and daily self monitoring of blood glucose. A multiple logistic regression analysis of risk factors for severe hypoglycaemia explained less than 10% of the variance, implicating only unawareness of hypoglycaemia and HbA1c. It is concluded that long duration type 1 diabetes mellitus patients are increasingly vulnerable with respect to severe hypoglycaemia and that this should be taken into account when individual treatment goals are being proposed to patients. Novel short-acting and long-acting analogs of insulin as well as insulin pumps may prove useful to minimize the risk of severe hypoglycaemic episodes. It is argued that the ability of currently marketed glucose monitoring systems to sensitively and specifically detect hypoglycaemia is limited.