L'insulinothérapie par pompe externe à perfusion continue d'insuline

Type 1 diabetes mellitus requires an exogenous supply of insulin that ideally mimics physiological insulin secretion. The treatment goal is to achieve normoglycaemia in order to prevent or delay chronic complications, while limiting the risk of hypoglycaemia. Numerous advances have been performed in the last 10 years, as far as nature of insulin formulations, home blood glucose monitoring devices and modes of insulin delivery. Among the latter, continuous subcutaneous insulin infusion (CSII) using portable pumps represents the most sophisticated treatment capable of best mimicking normal insulin secretion. Such treatment provides better glucose control and glucose stability as compared to conventional multiple injection insulin therapy. However, it is essential to respect well defined indications and to organize a structured management by a multidisciplinary team in order to get the best metabolic results. The present paper describes recommendations, advantages and limits as well as cost of CSII with portable pumps in type 1 diabetic patients

Continuous glucose monitoring reduces both hypoglycaemia and HbA1c in hypoglycaemia-prone type 1 diabetic patients treated with a portable pump.

AIM: This study aimed to assess the effectiveness of continuous glucose monitoring (CGM) for glucose control in type 1 diabetic patients treated by continuous subcutaneous insulin infusion (CSII) and presenting with frequent hypoglycaemic episodes. METHODS: Thirteen patients with type 1 diabetes (diabetes duration: 25+/-15 years; CSII duration: 5.5+/-7.0 years), with more than six recorded capillary blood glucose (CBG) values <60 mg/dL, according to their metres for the past 14 days, were offered the permanent use of a CGM device (Guardian RT((R)), Medtronic) plus ongoing self-monitoring of blood glucose (SMBG) for 12 weeks, followed by a 12-week crossover period of SMBG only, or vice versa. Glucose control, determined by recorded 14-day CBG values <60 mg/dL and HbA(1c) levels, and quality of life according to the Diabetes Quality of Life (DQOL) questionnaire, were assessed at baseline, and after 12- and 24-week follow-ups. RESULTS: Four patients withdrew from the study during the first period (of whom three were using CGM). In the nine study completers, the number of low CBG values decreased significantly from 13.9+/-9.2 to 7.6+/-6.8 (P=0.011) when patients used CGM, in either the initial or final trial period, while a decrease in HbA(1c) from 8.3+/-0.7 to 7.7+/-0.6% (P=0.049) was also observed, in contrast to the absence of any significant differences during the SMBG-only period. DQOL scores were also essentially unaffected. CONCLUSION: This pilot observational study supports the hypothesis that CGM use can significantly improve overall glucose control while reducing hypoglycaemic episodes in hypoglycaemia-prone type 1 diabetic patients treated by CSII.L’apport d’une mesure continue du glucose réduit le taux d’HbA1c et la fréquence des hypoglycémies chez des patients diabétiques de type 1 traités par pompe portable à insuline et à risque hypoglycémique. Objectif. – Étudier l’efficacité d’un système de mesure continue du glucose sur le contrôle glycémique de patients diabétiques de type 1 traités par pompe portable à insuline et présentant des hypoglycémies fréquentes. Méthodes. – Treize patients diabétiques de type 1 (durée du diabète : 25±15 années ; durée du traitement par pompe : 5,5±7,0 années), présentant plus de six glycémies capillaires inférieures à 60 mg/dl enregistrées dans leur lecteur à mémoire durant les 14 derniers jours, ont participé à une étude observationnelle. Cette dernière comprenait deux périodes de 12 semaines en ordre croisé, avec soit le recours complémentaire à un système de monitoring du glucose (GuardianRT®, Medtronic), soit seulement la poursuite de l’autosurveillance glycémique habituelle. Le contrôle glycémique, évalué sur la base du nombre de glycémies capillaires inférieures à 60 mg/dl au cours des 14 derniers jours et du taux d’HbA1c, et la qualité de vie ont été analysés à l’inclusion, après 12 semaines et après 24 semaines. Résultats. – Quatre patients se sont retirés de l’essai durant la première période (dont trois alors qu’ils étaient sous Guardian RT®). Chez les neuf patients ayant achevé l’étude, le nombre de valeurs glycémiques basses a diminué de 13,9±9,2 à 7,6±6,8 (p = 0,011) lorsque les patients utilisaient le Guardian RT®, que ce soit en période 1 ou en période 2, tout en obtenant une réduction du taux d’HbA1c de 8,3±0,7 à 7,7±0,6% (p = 0,049), alors qu’il n’y avait pas de différences significatives durant la période sous simple autosurveillance glycémique habituelle. La qualité de vie n’a pas paru affectée

What Makes Tight Glycemic Control Tight? The Impact of Variability and Nutrition in Two Clinical Studies

Tight glycemic control (TGC) remains controversial, and successful, consistent and effective protocols elusive. This research analyses data from 2 TGC trials for root causes of the differences achieved in control and thus potentially in glycemic and other outcomes. The goal is to uncover aspects of successful TGC and delineate the impact of differences in cohorts. Protocols that dose insulin blind to carbohydrate administration can suffer greater outcome glycemic variability, even if average cohort glycemic targets are met. While the cohorts varied significantly in model-assessed insulin resistance, their variability was similar. Such significant intra- and inter- patient variability is a further significant cause and marker of glycemic variability in TGC. The results strongly recommended that TGC protocols be explicitly designed to account for significant intra- and inter- patient variability in insulin resistance, as well as specifying or having knowledge of carbohydrate administration to minimise variability in glycemic outcomes across diverse cohorts and/or centres

Management of blood glucose in patients with stroke.

Stroke is a leading cause of death worldwide and the most common cause of long-term disability amongst adults, more particularly in patients with diabetes mellitus and arterial hypertension. Increasing evidence suggests that disordered physiological variables following acute ischaemic stroke, especially hyperglycaemia, adversely affect outcomes. Post-stroke hyperglycaemia is common (up to 50% of patients) and may be rather prolonged, regardless of diabetes status. A substantial body of evidence has demonstrated that hyperglycaemia has a deleterious effect upon clinical and morphological stroke outcomes. Therefore, hyperglycaemia represents an attractive physiological target for acute stroke therapies. However, whether intensive glycaemic manipulation positively influences the fate of ischaemic tissue remains unknown. One major adverse event of management of hyperglycaemia with insulin (either glucose-potassium-insulin infusions or intensive insulin therapy) is the occurrence of hypoglycaemia, which can also induce cerebral damage. Novel insights into post-stroke hyperglycaemia management have been derived from continuous glucose monitoring systems (CGMS). This article aims: 1) to describe the adverse effects of hyperglycaemia following acute ischaemic stroke and the risk associated with iatrogenic hypoglycaemia; 2) to summarise the evidence from current glucose-lowering treatment trials; and 3) to show the usefulness of CGMS in both non-diabetic and diabetic patients with acute stroke