|ISSN No. 1606-7754 Vol.16 No.2 August 2008|
Insulin Pump Therapy in Type 1 Diabetic Patients: Experience at the American University of Beirut Medical Center
M Merheb, J Chaiban, I Salti, R Sammak, M Choucair, M Nasrallah
Division of Endocrinology, Department of Medicine, American University of Beirut Medical Center, Beirut, Lebanon
Objective: To study glycemic control after initiation of pump therapy in a group of patients with type 1 diabetes..Materials and Methods: We reviewed all consecutive charts of adolescent and adult Lebanese patients with type 1 diabetes treated at the American University of Beirut Medical Center who were started on continuous subcutaneous insulin infusion (CSII) between 2003 and 2005. Their previous insulin regimen included premixed insulin preparation, glargine/lispro or NPH with short-acting insulin, as 2 or 3 injections per day. Results: The charts of 12 patients (7 men and 5 women) were reviewed. Their median age was 24.5 years (range 16-45) and the median disease duration was 10 years (range 2-21). At the time of study, the median duration of pump use was 18 months (range 2-28). Hemoglobin A1C significantly improved [median 8.4 (6.5-10) to 6.9 (5-8.5) % , p=0.003] and the rate of hypoglycemia was reduced (from a total of 32 to 4 episodes per week), with no significant effects on body weight or insulin dose. While on CSII, all patients reported satisfaction in their quality of life in terms of physical, emotional and social well-being. Conclusion: This case series is the first to report the use and outcome of CSII in Lebanon with improved glycemic profile and quality of life in adult patients with type 1 diabetes
Key Words: Type 1 Diabetes; insulin pump; continuous subcutaneous insulin infusion; Lebanon; Middle East.
In 1993, The Diabetes Control and Complications Trial (DCCT) demonstrated that tight glycemic control in young adults with type 1 diabetes reduced the incidence of microvascular complications.1,2 The benefits of this intense control was maintained even when HbA1c did not remain in the tight range after the DCCT was over, as was demonstrated in the EPIC study which is a follow-up on the DCCT population.3 The EPIC study also demonstrated more recently that the benefits of tight glycemic control extend to prevention of macrovascular complications.
Since its first use in the 1970s by Pickup et al. in UK, 4,5 overwhelming evidence supports the effectiveness of Continuous Subcutaneous Insulin Infusion (CSII) also known as “insulin pump therapy” to achieve better metabolic control in patients with type 16-9 and type 210-12 diabetes who have failed to achieve their targets on multiple daily insulin injections (MDI). The overall decrease in HbA1c which is attributed to CSII is 0.35%, among various study groups, with less hypoglycemic episodes.
Since its publication, the DCCT has inspired the initiation of several clinical trials to assess this intensive therapy, through non-randomized studies including children and adolescents using at that time regular insulin for the pump.13-15 In fact in the ‘intense glucose control’ arm of the DCCT, 42% of patients were using insulin pump therapy at the end of the study and were able to maintain a mean HbA1c of 6.8 % vs. 7.0% in MDI-treated subjects (p<0.05).16
The implementation of the insulin pump therapy mandates a lot of input and motivation on behalf of the patient in coordination with a highly skilled multidisciplinary team. Cultural diversity and social support systems may play a role in the success rate of this technology. Socioeconomic status, more so than race/ethnicity, plays an important role in metabolic control.17 There are no reports of pump use among Middle East adult patients with type1 diabetes. Given that the culture and social background of these patients may be different from those in previously published insulin pump studies, we have asked whether the benefits of this new technology are seen across our population as well. We have conducted this study to assess the outcome in Lebanese type 1 diabetic patients who were placed on Continuous Subcutaneous Insulin Infusion at the American University of Beirut.