Continuous subcutaneous insulin infusion versus multiple daily injection regimens in children and young people at diagnosis of type 1 diabetes: pragmatic randomised controlled trial and economic evaluation

Blair, J.C., Thronborough, K., Peak, M., Annan, F., Hughes, D.A. | 2019 | Continuous subcutaneous insulin infusion versus multiple daily injection regimens in children and young people at diagnosis of type 1 diabetes: pragmatic randomised controlled trial and economic evaluation | BMJ | 365 | l1226 | doi: https://doi.org/10.1136/bmj.l1226

A study that followed 293children and young people aged between 7 months and 15 years, with a new diagnosis of type 1 diabetes participated between May 2011 and January 2017 patients were randomly assigned to either continuous subcutaneous insulin infusion (CSII) or multiple daily injection (MDI) has been published in the BMJ.  The research team report that within the first year of the study the child participants no clinical benefit of CSII over MDI was identified in the participants in the UK setting, and treatment with either regimen was suboptimal in achieving HbA1c thresholds. CSII was not cost effective. 

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The full article is available to read from the BMJ 

Abstract

Objective To compare the efficacy, safety, and cost utility of continuous subcutaneous insulin infusion (CSII) with multiple daily injection (MDI) regimens during the first year following diagnosis of type 1 diabetes in children and young people.

Design Pragmatic, multicentre, open label, parallel group, randomised controlled trial and economic evaluation.

Setting 15 paediatric National Health Service (NHS) diabetes services in England and Wales. The study opened to recruitment in May 2011 and closed in January 2017.

Participants Patients aged between 7 months and 15 years, with a new diagnosis of type 1 diabetes were eligible to participate. Patients who had a sibling with the disease, and those who took drug treatments or had additional diagnoses that could have affected glycaemic control were ineligible.

Interventions Participants were randomised, stratified by age and treating centre, to start treatment with CSII or MDI within 14 days of diagnosis. Starting doses of aspart (CSII and MDI) and glargine or detemir (MDI) were calculated according to weight and age, and titrated according to blood glucose measurements and according to local clinical practice.

Main outcome measures Primary outcome was glycaemic control (as measured by glycated haemoglobin; HbA1c) at 12 months. Secondary outcomes were percentage of patients in each treatment arm with HbA1c within the national target range, incidence of severe hypoglycaemia and diabetic ketoacidosis, change in height and body mass index (as measured by standard deviation scores), insulin requirements (units/kg/day), partial remission rate (insulin dose adjusted HbA1c less than 9), paediatric quality of life inventory score, and cost utility based on the incremental cost per quality adjusted life year (QALY) gained from an NHS costing perspective.

Results 294 participants were randomised and 293 included in intention to treat analyses (CSI, n=144; MDI, n=149). At 12 months, mean HbA1c was comparable with clinically unimportant differences between CSII and MDI participants (60.9 mmol/mol v 58.5 mmol/mol, mean difference 2.4 mmol/mol. Achievement of HbA1c lower than 58 mmol/mol was low among the two groups (66/143 (46%) CSII participants v 78/142 (55%) MDI participants; relative risk 0.84 (95% confidence interval 0.67 to 1.06)). Incidence of severe hypoglycaemia and diabetic ketoacidosis were low in both groups. Fifty four non-serious and 14 serious adverse events were reported during CSII treatment, and 17 non-serious and eight serious adverse events during MDI treatment. Parents (but not children) reported superior PedsQL scores for those patients treated with CSII compared to those treated with MDI. CSII was more expensive than MDI by £1863 (€2179; $2474; 95% confidence interval £1620 to £2137) per patient, with no additional QALY gains (difference −0.006 (95% confidence interval −0.031 to 0.018)).

Conclusion During the first year following type 1 diabetes diagnosis, no clinical benefit of CSII over MDI was identified in children and young people in the UK setting, and treatment with either regimen was suboptimal in achieving HbA1c thresholds. CSII was not cost effective.

Trial registration Current Controlled Trials ISRCTN29255275; European Clinical Trials Database 2010-023792-25.

 

See also:

BMJ Patient Perspective Emma Cartwright: The importance of choice between an insulin pump or multiple daily injections

BMJ Author Perspective Joanne Blair: What is the most effective way to deliver subcutaneous insulin—pumps or injections?

Number of people with diabetes reaches 4.7 million

Diabetes UK | February 2019 | Number of people with diabetes reaches 4.7 million

Data analysed by Diabetes UK shows that 1 in 10 over 40s now has type 2 diabetes, with the total number of people living with diabetes reaching 4.7 million. This is expected to increase to 5.5 million by 2030.

Diabetes UK’s latest figures indicate that 3.8 million are living with the condition, 90 per cent of these people have diabetes 2, but estimates suggest the ‘real figure’ could be much higher as there are almost 1 million people who do not realise they have diabetes.

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Chris Askew,  Chief Executive of the charity said:

“Millions of Type 2 diabetes cases could be prevented if we help people understand their risk and how to reduce it. Even though the older people get the more likely they are to have Type 2 diabetes, it is never too early to know your risk so that you can make changes to prevent or delay it.

“The signs of Type 2 diabetes are often not obvious, that’s why spotting them early can be life-changing. Early diagnosis means that fewer people will experience diabetes-related complications such as sight loss, amputation, kidney failure, stroke and heart disease, because they could seek support to manage their condition effectively as soon as possible.

“We urge people over 40 to get an NHS Health Check and we advise everyone to find out their risk of developing Type 2 diabetes with the Know your Risk tool.”

Read the full story at Diabetes UK 

In the news:

The Express Type 2 diabetes: Three exercises to do every day to help prevent a high blood sugar level

 

 

NHS Diabetes Programme Language Matters

NHS Diabetes Programme | February 2019| Language Matters

The NHS Diabetes Programme is calling on health care practitioners caring for people with diabetes – to help them evaluate the impact of the : Language and Diabetes guidance. Their aim is to find out whether the guidance has informed current practice or is likely to do so in the future (Source: NHS Diabetes Programme @NHSDiabetesProg)

Complete the survey on Survey Monkey

Improving diabetes care at Mid Cheshire Hospitals NHS Foundation

NHS England | February 2019 | Improving diabetes care at Mid Cheshire Hospitals NHS Foundation

Nurses at Mid Cheshire Hospitals NHS Foundation Trust (MCHFT) have developed and implemented a specialist inpatient diabetes service to address unwarranted variation in practice. 

Senior nurses reviewed current practice and engaged with the Diabetes Specialist Nurses to identify key areas to focus on in the improvement programme. These areas included:

  • Standardising diabetes management across wards;
  • Educating and supporting medical and nursing staff to make evidence based decisions when dealing with hyper/hypoglycaemic events;
  • Reducing length of stay (LOS) where appropriate for patients with diabetes by improving pathways;
  • Ensuring safe transition of care into the community.

To address these changes, the Diabetes Inpatient Team recruited Diabetes Inpatient Specialist Nurses to:

  • Develop and implement individualised management plans for all diabetic inpatients;
  • Liaise with the community health and social care teams to ensure continuity of care;
  • Develop and manage diabetes guidance and support service provision across the Trust;
  • Offer consistent specialist staff support via an advisory service with referral on to the Diabetes Consultant for assessment and advice in complex cases.

This new service has led to improved outcomes and experience for diabetes inpatients as well as improved use of resources at the Trust (Senior: NHS England).

Read the case study at NHS England 

Diabetes Prevention Week 2019: toolkits now available

diabetes prevention week

Diabetes Prevention Week 2019 will run from 1-7 April 2019.

The campaign aims to:

  • Raise awareness of the Healthier You: NHS Diabetes Prevention Programme – with the public and healthcare professionals (specifically GPs, Practice Nurses and Pharmacists)
  • Raise awareness of the causes of Type 2 diabetes
  • Raise awareness of the complications associated with Type 2 diabetes
  • Raise awareness of at risk groups – particularly BME populations

Local NHS organisations can order a toolkit from Public Health England which includes everything you need to run your own event, including posters, leaflets and more.

Full detail at Public Health England

#TalkAboutComplications

Scibilia, R. & Aldred, C. | 2019|#TalkAboutComplications| BMJ|364 |k5258

In the latest edition of the  BMJ, Renza Scibilia and Chris Aldred write about how to take the blame out of complications for patients and their determination to reframe the way complications are discussed by changing the language used in these conversations.  They write about their #TalkAboutComplications hashtag on Twitter and how people with diabetes and chronic conditions engaged with and responded to it. 

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“Often the focus and language around complications are on prevention rather than on risk reduction. The understanding is that no matter how well a condition is managed, there is always some risk that a complication could develop. Even if the self management of diabetes is not ideal, there is no value in apportioning blame.” (Renza Scibilia and Chris Aldred)

Read the full piece in the BMJ 

Type 2 diabetes and the risk of incident hearing loss

Gupta, S., Eavey, R. D., Wang, M., Curhan, S. G., & Curhan, G. C. |2019|Type 2 diabetes and the risk of incident hearing loss| Diabetologia|62|2|P. 281-285.

New research published in the journal Diabetologica examined whether type 2 diabetes (including diabetes duration) is associated with incident hearing loss in two prospective cohorts. 

Abstract

AIMS/HYPOTHESIS:

Type 2 diabetes mellitus has been implicated as a risk factor for hearing loss, with possible mechanisms including microvascular disease, acoustic neuropathy or oxidative stress. A few small studies have examined the longitudinal association between type 2 diabetes and hearing loss, but larger studies are needed. Our objective was to examine whether type 2 diabetes (including diabetes duration) is associated with incident hearing loss in two prospective cohorts: Nurses’ Health Studies (NHS) I and II.

METHODS:

We conducted a longitudinal study of 139,909 women to examine the relationship between type 2 diabetes and the risk of self-reported incident hearing loss. A physician-diagnosis of diabetes was ascertained from biennial questionnaires. The primary outcome was hearing loss reported as moderate or worse in severity (categorised as a ‘moderate or severe’ hearing problem, or ‘moderate hearing trouble or deaf’) on questionnaires administered in 2012 in NHS I and 2009 or 2013 in NHS II. Cox proportional hazards regression was used to adjust for potential confounders.

RESULTS:

During >2.4 million person-years of follow-up, 664 cases of moderate or worse hearing loss were reported among those with type 2 diabetes and 10,022 cases among those without type 2 diabetes. Compared with women who did not have type 2 diabetes, those with type 2 diabetes were at higher risk for incident moderate or worse hearing loss (pooled multivariable-adjusted HR 1.16 [95% CI 1.07, 1.27]). Participants who had type 2 diabetes for ≥8 years had a higher risk of moderate or worse hearing loss compared with those without type 2 diabetes (pooled multivariable-adjusted HR 1.24 [95% CI 1.10, 1.40]).

CONCLUSIONS/INTERPRETATION:

In this large longitudinal study, type 2 diabetes was associated with a modestly higher risk of moderate or worse hearing loss. Furthermore, longer duration diabetes was associated with a higher risk of moderate or worse hearing loss.

Rotherham NHS staff can request this article from the Library

Diabetic eye screening: cohort management

Public Health England | February 2019 | Diabetic eye screening: cohort management

This guidance explains the management of the cohort (people on the programme register) for the NHS diabetic eye screening (DES) programme.

pexels-photo.jpgThis document explains the management of the cohort for diabetic eye screening (DES).

It includes:

  • exclusions
  • suspensions
  • people who are ineligible or off-register
  • situations that require special consideration
  • rarer forms of diabetes
    (Source: Public Health England)

Diabetic eye screening: cohort management