1. To Pump OR To Inject … that is the Question … ?
Sanoe Harrison & Patrick Hanley

2. Autoimmune Diabetes Mellitus
Review of Problem

3. Glucose in Healthy Volunteers
Day Ave ± SD = 93.0 ± 7.0 mg/dl, Night Ave ± SD = 81.8 ± 6.3 mg/dl

6. DCCT (Diabetes Control and Complication Trial)

7. Goals for long term health …
A1c < 7.5
Absence of severe hypoglycemia
Minimize glucose variability …
Normal blood pressure
Normal cholesterol (LDL & HDL)
Normal weight (BMI <85th percentile for age & sex)

8. Insulin Discovery

9. First insulin syringe 1949
First glucometer 1968

10. 1963 - Dr. Arnold Kadish designed the first insulin pump to be worn as a backpack
First marketable pump available in 1976

11. Sanoe’s Story
Who are we: quick personal diabetes history (age of diagnosis, selection of MDI, etc)
Engage crowd – make it personal but to help in relation to crowd

12. Sanoe’s Timeline 13 diagnosed with T1D used NPH and Regular 16
began to use Humalog and Ultralente 21
began to use insulin pump 35
began to use glucose sensor

13. Pat’s Story
Talk about initial experience with glucometer and getting diagnosed – improvement in diagnosis
Then quick timeline on diabetes history
Who are we: quick personal diabetes history (age of diagnosis, selection of MDI, etc)
Engage crowd – make it personal but to help in relation to crowd

14. Pat’s Timeline

15. Discussion Questions …
What made you choose this breakout session?
Who uses a pump for insulin?
Who uses MDI for insulin?
Engage crowd
- Try to identify why they chose this session to address questions as we go through

16. Is there research to help us decide … ?
We all know the first key is … taking our insulin and checking our blood sugar!
But the question is … with more options today to deliver insulin and monitor glucose is one way better?
Evidence based medicine but also need to consider …
… what is best for you the individual patient/family?

17. Some Articles Comparing CSII to MDI
“Long-term health economic benefits of sensor- augmented pump therapy vs continuous subcutaneous insulin infusion alone in type 1 diabetes: a UK perspective” - Journal of Medical Economics 2016
“Continuous subcutaneous insulin infusion therapy and multiple daily insulin injections in type 1 diabetes mellitus: a comparative overview and future horizons” - Expert Opinion on Drug Delivery 2015
“Multiple Daily Injections OR Insulin Pump Therapy: Choosing the Best Option for Your Patient—An Evidence-based Approach” – Current Diabetes Reports 2015
“Does treatment with an insulin pump improve glycaemic control in children and adolescents with type 1 diabetes? A retrospective case–control study” - Pediatric Diabetes 2015

18. Articles Comparing CSII to MDI
“Insulin pump therapy, multiple daily injections, and cardiovascular mortality in 18,168 people with type 1 diabetes: observational study” – British Medical Journal 2015
“Insulin pump use in young children in the T1D Exchange clinic registry is associated with lower hemoglobin A1c levels than injection therapy” - Pediatric Diabetes 2014
“Long-term outcome of insulin pump therapy in children with type 1 diabetes assessed in a large population-based case–control study” –Diabetologia 2013
“A randomized, prospective trial comparing the efficacy of continuous subcutaneous insulin infusion with multiple daily injections using insulin glargine“– Diabetes Care 2004

25. NGSP HbA1c
 (%) IFCC HbA1c (mmol/mol)

26. Major findings of this paper
Showed that treatment with CSII resulted in an improvement in HbA1c levels up to 1 year (8.1% vs. 8.3%)
 # of severe hypoglycaemic events with CSII = incidence rates of severe hypoglycaemic episodes per 100 person-years were 3 in the CSII group & 6 in the MDI group
Frequency of ketoacidosis  in CSII group = There were 2.8 episodes of DKA/100 person-years in the CSII group & 0.5 in the MDI group
 insulin needed in CSII group & no change in weight
At 6 months 7.8% vs 8.4% with CSII
216 patients in CSII group and 215 in MDI group

27. Why do some people stop using pumps?
Main reasons found in one study:
Greater sense of disease (93%)
Difficulties in doing sports (70%)
Worse well-being during pump therapy (63%)
Having to attach the pump to the body (60%)
Embarrassment (56%)
Adhesions & pain in the place of needle insertion (50%)
Difficulties in controlling glycemia during physical exercise (43%)
Fear (43%)
High levels of HbA1c (36%)
Frequent blood glucose monitoring (26%)
“Reasons for the discontinuation of therapy of personal insulin pump in children with type 1 diabetes” Pediatr Endocrinol Diabetes Metab 2015;21,2:65-69
Not common … only about 4% of people that start CSII return to MDI
One study looked at 30 children who started using CSII & then stopped
No problems with technical operation of the pump or frequent episodes of severe hypoglycemia or ketoacidosis were reported

28. Pros & Cons of Pumps Pros Cons Flexible basal rates
Advanced bolus options
Convenience of giving multiple doses
Slightly decreased total insulin need
Cons
Risk of DKA with pump malfunction
Hardware attached to body
Cost

29. Pros & Cons of MDI Pros Cons Reliable absorption
Not connected to device
More affordable
Cons
Cannot alternate basal rates
Multiple injections
Harder to disguise

30. Special Considerations
Image from:

31. Case 1 18 y/o F, got a pump 2yrs ago, and is now going away to college
At school she is too busy to test sugar more than 2x per day
She noticed that her pump insulin reservoir lasts her 5 days
She usually gets home late, tests, changes her pump sites as needed right before going to bed

32. Case 2 14 year old boy on MDI since diagnosis 2 yrs ago
Normally hyperglycemic in the morning despite changing lantus dose
Hypoglycemia often with sports
Very active with sports & motivated to do better with his diabetes control …

33. How do you define success with Diabetes?
Tools to fit life
Image or link

34. Future Directions

35. Affreza – Inhaled Insulin

36. Absorption

37. Afrezza – Side Effects Respiratory
Decreased Lung function in some (6 vs. 3%)
Cough ~25 %
Cancer
4 cases of lung cancer (2 smokers)
2 years duration, a 15% or greater reduction in forced expiratory volume (FEV1) occurred in 6% of patients treated with inhaled insulin compared with a 3% decline in patients receiving comparator anti-diabetes treatment. Patients with chronic lung disease were not included in these studies. The FEV1 decline occurred during the first 3 months and persisted; it did not appear to worsen with increased duration of use. The changes in FEV1 were similar in patients with type 1 and type 2 diabetes mellitus.

38. Degludec

39. Degludec Pharmacokinetic properties:
Long half-life (25 h)
Long duration of action (42 h)
Lower variability (25% that glarginie) from other basal analogues
Need studies in pediatric patients …

40. Thank you very much for your attention & participation … any questions?
A few more questions …
Why did you choose your current therapy?
Do you want to change?
If so why?