Tue said:Bill,
Textbooks, by the nature of the editorial process, tend to lag months to years behind journals.
Pump patients no longer have higher DKA rates than other patients. This was true 15 years ago, but
not now.
DKA has become less and less common with insulin pumps, and is now to the point where the DKA
rates in MDI patients (using basal / bolus insulin) are indistinguishable from CSII patients (pump
insulin).
there's a reason for that
it's called *peaky* background insulin
15 years ago, the large majority of insulin using diabetics in the USA were still using non-peaky
beef insulin. 🙂
(namely: Lilly's Iletin-I (a nominal 85/15 beef/pork mix))
(also, the USA is the main (only significant one?)
country in the world that has insulin pump usage)
Quoted message said:There have been several improvements over the last decade, including better training standard,
better infusion sets, and automatic insertion devices like the Softserter.
I haven't had any of my pump patients experience a DKA in well over a year....in fact I can't
remember when the last DKA occured.
i wonder if those that have close calls report it to you?
i know that i didn't report my own close call to my own doc in summer of '93. 🙁 and yes, i now know
that i should have
it took me 7 hours of no insulin (due to my own user error with my pump) to get violently sick
in a discussion that i had with you on m.h.d., roughly 4 years ago, you stated that the fastest DKA
case you knew of (i.e. in your own experience?) took 5 hours. but you didn't give details
fwiw, based on your comments, i'm pretty sure that i didn't get into DKA in 7 hours, that'd taken
another 2-to-4 hours in my specific case. "just" violently sick. what was most interesting is how
quickly it all fell apart from hour 6 (where i still felt ok) to hour 7
Quoted message said:
Most of the current studies cite pumps having the same DKA rate, and lower hypoglycemia rates when
compared to MDI .
my 8 years of pump usage kept me free of unconscious hypos. 🙂 whereas my 10 years of pork-NPH usage
gave me 4 or 5 unconscious hypos. 🙁((((
if there's any one thing i'd dread trying, it'd be to use peaky "human"-NPH for background
Quoted message said:
Diabetes Care. 2003 Apr;26(4):1142-6. Safety and effectiveness of insulin pump therapy in children
and adolescents with type 1 diabetes. After adjusting for duration and age, mean HbA(1c) after
pump start was significantly lower than before pump start (7.7 vs. 8.1%; P < 0.001). The number of
medical complications (diabetic ketoacidosis, emergency department visits) was similar before and
after pump start. There were fewer hypoglycemic events after pump start (12 vs. 17, rate ratio
0.46, 95% CI .21-1.01). CONCLUSIONS: This study suggests that pump therapy is safe and effective
in selected children and adolescents with type 1 diabetes.
interesting set of articles (above and below)
the problem i have with it is you
you, coz you are implying that it is *pump* error that causes insulin pumping T1s to run into DKA
afaik, that's not been true in the last 15 years of insulin pump usage. in fact, it may never
have been true
anyhow, i'll take it all with a very BIG grain of salt coz my own hunch is that it is USER ERROR
with insulin pump usage that causes the large majority of no insulin delivery problems, even with
the latest/greatest insulin pump
and i couldn't call going from an A1c of 8.1% to 7.7% "significantly better. especially given the
extra b/g testing that pumpers do and the HUGE yearly increase in dollars spent for the insulin pump
and the expensive on-going supplies (infusion sets, etc. etc.)
Quoted message said:
Diabetes Care. 2003 Apr;26(4):1079-87. Insulin pump therapy: a meta-analysis A descriptive review
of potential complications of CSII use (e.g., hypoglycemia, diabetic ketoacidosis [DKA], pump
malfunction, and site infections) suggests a decreased frequency of hypoglycemic episodes but an
increased frequency of DKA in studies published before 1993. CONCLUSIONS: CSII therapy is
associated with improved glycemic control compared with traditional insulin therapies
(conventional therapy and multiple daily injections) and does not appear to be associated with
significant adverse outcomes. Additional studies are needed to further
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
Quoted message said:examine the relative risks of CSII therapy, including the potential psychosocial impact of this
technologically advanced therapy.
anytime i see "additional studies are needed...", i start to think what a bunch of [censored]
was this article really a full 8 pages???
and what is "a descriptive review"???
do you really read these things? or do you simply pull up these crappy conclusions on the bloody
computer for us?
Quoted message said:
Diabetes Metab Res Rev. 2002 Jan-Feb;18 Suppl 1:S14-20 Diabetes management in the new millennium
using insulin pump therapy. Most important, in adults and adolescents with type 1 diabetes, CSII
has been shown to lower HbA(1c) levels, reduce the frequency of severe hypoglycemia and limit
excessive weight gain versus MDI without increasing the risk of diabetic ketoacidosis. Similarly
positive results are being seen with CSII in adults with type 2 diabetes. The effectiveness of
CSII and improvements in pump technology have fueled a dramatic increase in the use of this
therapy.
interesting comment on type 2 pumpers. the pump companies will be overjoyed. 🙂
Quoted message said:
Diabetes Care. 2002 Mar;25(3):593-8. Continuous subcutaneous insulin infusion at 25 years:
evidence base for the expanding use of insulin pump therapy in type 1 diabetes. Pickup J, Keen H.
Continuous subcutaneous insulin infusion (CSII) is used in selected type 1 diabetic subjects to
achieve strict blood glucose control. A quarter of a century after its introduction, world-wide
use of CSII is increasing. We review the evidence base that justifies this increase, including
effectiveness compared with modern intensified insulin injection regimens and concern about
possible complications. Review of controlled trials shows that, in most patients, mean blood
glucose concentrations and glycated hemoglobin percentages are either slightly lower or similar on
CSII versus multiple insulin injections.
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
doesn't say much for insulin pumping
Quoted message said:However, hypoglycemia is markedly less frequent
exactly right, but only in comparison to *peaky* background insulin
Quoted message said:than during intensive injection therapy. Ketoacidosis occurs at the same rate.
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
again, only in comparison to *peaky* background insulin
Quoted message said:Nocturnal glycemic control is improved with insulin pumps, and automatic basal rate changes help
to minimize a prebreakfast blood glucose increase (the "dawn phenomenon"😉 often seen with
injection therapy.
Pumps might be worth another look for you, since you were a pumper
^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^^
Quoted message said:back in the old days. You might be pleasantly surprised
^^^^^^^^^^^^^^^^^^^
'91-thru-'98 was "the old days"???
LOL!
Quoted message said:on how well the infusion sets and pumps work now.
get real doc
for one thing my pump experience isn't that old
for another, i cannot believe that the 180,000 USA T1s who pump really need to be using an
insulin pump
maybe 10,000 of them do, but certainly nowhere near 180,000. and yes, you're the one with real
clinical experience and not me
but you're also the one who leaps to ever newer insulins
john walsh too, 🙁 (walsh and his wife are both T1 and both pump) so i sometimes consider that
before i blast you
even when these new insulins haven't yet been on the market anywhere close to long enough. iow, imo
increased pump usage is likely due to our switch this past 20 years to *peaky* background insulin
(mainly peaky "human" insulin and now peaky glargine/Lantus). 🙁((((
for myself, my last 5 years with beef-Lente has been a real eye opener (in a positive way)
this last 9 months, i've tried mixing Iletin-I-L and Iletin-II-L 50/50 but it's nowhere near as good
as using pure Iletin-I-L (i.e. flat in the 12-to-26 hour period with 1x dosing)
i'm down to my last 2 vials of Iletin-I-L and back to using it 1x by itself. what an
improvement. 🙂))))
if i can't scrape up the money for CP's pure beef-L, i'll be switching to a simple MDI routine using
2x of Iletin-II-L for background
i'm NOT going to waste what money i do have on an insulin pump and the bloody expensive supplies!
best advice i can give to any T1 who's interested in a pump (and is going to pay out of pocket), is
to take the $6,000+ and spend $1,000 for a used lab fridge and start buying CP's beef-L at $40/1000u
another alternative is to spend $2,000 for a two week vacation in Bombay and buy USV's u40 beef-L at
less than $10/1000u
put the remainder of yer $6,000+ in a mutual fund. 🙂
anyhow, Iletin-II-L (pure pork) can still be gotten from www.canadapharmacy.com for $18/vial. 🙂
btw, i sure don't like what is going on in the USA with skyrocketing pharma and doc costs. i suspect
that mike gray's take on the current political [censored] is dead on. which means that the costs will
continue to skyrocket for the forseeable future)
Quoted message said:Cheers, > William C Biggs, MD
indeed. 🙂
thank YOU for taking the time to bother to post to me. and yes, this is a real thank you. 🙂
btw, i suspected all along that you saw my posts. 🙂
bill t1 since '57, ex 8-yr pumper, beef-L 1x, simple MDI/DAFNE
Quoted message said:"willbill" wrote
Quoted message said:Quoted message said:a local Borders Book Store has the 3rd edition (c 2000?) of "Pumping Insulin" by John
Walsh et al
to my pleasant surprise, it is the first book i've even seen with useful info on DKA, especially
that it gives a page (or two?) on the subject of treatment (drink water first!)
another interesting thing is that the book gives some stats
86]
Quoted message said:Quoted message said:on the higher incidence of DKA due to pumping and how that has come down (but it still higher
than using UL/L/N/Lantus) with the newer improved pumps
i'd appreciate anyone who has both the 3rd edition and the 1st edition if they'd provide an
assement of any major differences in the DKA info in those two editions
