{ Practicalities of intesive insulin therapy to optimase diabetes control Ewa Pańkowska MD, PhD Warsaw, Poland Warsaw, Poland

 At least four injections per day  At least four glucose measurements per day. Outcomes:  Less microvascular complications  More severe hypoglycemia events Intensive Insulin Therapy DCCT, NEJM, years ago…

{ as a first choice regime for persons with type 1 diabetes Flexible, Intensive Insulin Therapy FIIT ISPAD recommendation, ADA recommendation, PDA recommendation 10 years ago…

British Medical Journal; 2002; Conclusion: Skills training promoting dietary freedom improved quality of life and glycaemic control in people with type 1 diabetes without worsening hypoglycemia

What FIIT means? Tsukuda, K. DT&T, 2009

{ The tools and the algorythm in FIIT Multiple daily injection vs continuous subcutaneous insulin infusion

1. There are a lot of evidences that CSII improves metabolic control (HbA1c) comparing to MDI method. Is that True or False? 2. Insulin pump therapy significantly decreases risk of severe hypoglycemia events. True or False? questions:

The comparison between MDI and CSII. Are there relevant differences for metabolic control

Pańkowska, E, ADA 2011 P<0,05 Basal insulin IU/kg/d Total daily dose IU/kg/d MDI CSII Parallel day – to – day study

 Mealtime insulin Regular insulin Regular insulin Rapid acting analogue Rapid acting analogue  Basal insulin: NPH NPH Long acting analogue Long acting analogue  Delivering insulin: subcutaneous and shots administartion subcutaneous and shots administartion  Mealtime insulin Rapid acting analogue Rapid acting analogue  Basal insulin: Rapid acting analogue Rapid acting analogue  Delivering insulin: Subcutaneus and continuous administartion Subcutaneus and continuous administartion * NPH – Isophane insulin (intermediate-acting)

 Number of injection/month average: average:  Insulin depot in subcutaneous tissue basal insulin dose - 20 IU basal insulin dose - 20 IU  Logbook as a form of injected insulin dose registration  Number of injection/month average: 8-10 average: 8-10  Insulin depot in subcutaneous tissue Basal: 20 IU/day - 0,8 IU/h Basal: 20 IU/day - 0,8 IU/h  Electronic memory as a form of delivered insulin dose registration

 Basal insulin  Once or twice a day  Insulin dose adaptation once or twice per day  If injected, cannot be revoked  Basal function:  Insulin dose adaptation every hour or every half an hour  Possibility of suspension of basal insulin administration  Possibility of keeping different basal insulin profile in electronic memory – Basal Profiles  Possibility of adaptation of basal insulin for current needs - Temporary basal rate

 Bolus function: One shot of insulin (RI or analogue) before the meal One shot of insulin (RI or analogue) before the meal One meal – one shot of insulin One meal – one shot of insulin One kind of insulin shooting One kind of insulin shooting  Correction insulin: combine with meal insulin in one injection  Bolus function:  Three kinds of boluses:  Normal (for Carbohydrates)  Extended (for Fat-protein)  Multiwave (for Mixed)  Possibility of programming one meal bolus as a multi-bolus (before, during and after a meal)  Correction insulin: programmed separately

The schema of insulin dosing in FIIT Total daily dose 50% Meal insulin 15% lunch 20% dinner 50% Basal insulin 15% Breakfast

 Patient’s age  Diabetes duration ( years)  C-petid residual secretion  BMI  Concomitant disease and hormonal therapy The factors influence basal insulin dose

Patient’s age and duration of diabetes patients with T1DM on insulin pumps

The Percentage of basal insulin AgeAverageSD Preschooler Prepubertal Pubertal Danne T., Diabetologia, 2008 AgeAverageSD Preschooler Prepubertal Pubertal Pańkowska E.. Pediatric Diabetes, 2008

Duration of diabetes and C-peptide residual secretion C-peptide and percentage of basal insulin in TDD

The basal to bolus proportion related to C-peptide Pańkowska E., Pediatric Diabetes, 2008 * p<0,05 *

Basal insulin patterns

Basal insulin dose in children and adolescents preschooler 1-6 ys, 0, 2-0, 3j/g Prepubertal 7-12 ys, 0,4-0,5j/g pubertal, ys; 0,9-1,0 j/g

5years old girl with diabetes from 2 years. Basal insulin 6-10% of TDD 15 years old girl with diabetes from 10 ys Basal insulin 30-45%of TDD

Anna, 7 years old Diabetes for second year of life 5 years duration, c-peptide naive c-peptide naive Asthma bronchiale Hb1c- 6,5% ( average) Case report

Blood glucose and insulin applaying pl-insmadz.pdfpl-insmadz.pdf

Case report  14 years old boy,  Diabetes duration 4 years,  HbA1c 7,0%

The blood glucose profile and insulin applying Paweł.pdfPaweł.pdf Temporal basal rate and sick days

The optional boluses in insulin pump Normal bolusExtanded bolus Dual-wave bolus BASAL RATE IR x nCUIR x nFPU IR x nCU + IR x nFPU

 the proportion of basal to bolus insulin can be ranged from 10% to 60%  Meal daily plan are flexible in term of meal’s size, timing for breakfast, lunch and dinner and meal nutrients contains.  Dual wave boluses/multiwave are applied by patients in their daily care.  Basal rate is lower during a day than night hours, Summary

Tailoring insulin programming in pump therapy is one of the way in getting recommended metabolic control. Conclusion