Glycaemic Control is Not Improving

Despite major and continuing changes in insulin and insulin regimes, glycaemic control has not improved over a decade in 21 international children’s centres.


 

Despite many changes over the past 10 years including increased use of insulin analogues, basal bolus regimes [4 injections + a day] and pumps:

  • those using twice daily free mix of soluble/regular plus NPH [intermediate-acting] and had lower HbA1cs than all other groups. “This suggests that the so-called conventional regimes may be superior to modern intensive regimes.”
  • HbA1cs on pump therapy were not significantly different from the total group even in centres where considerable numbers of patients were using them.

 So the researchers concluded that despite major and continuing changes in insulin and insulin regimes, glycaemic control has not improved over a decade in 21 international centres.

=============================== First study: Intensive therapy and pump therapy over 10 years has not improved HbA1cs but has increased insulin dosePrevailing therapeutic regimes and predictive factors for prandial insulin substitution in 26 687 children and adolescents with Type 1 diabetes in Germany and Austria. Diabetic Medicine, October 2007 The researchers classified the information about 26,687 children, treated from 1995 to 2005 in 152 paediatric clinics. Their average age was 13.6 years and average duration of diabetes 5.4 years. 73% were treated with 4 or more daily injections [intensive therapy], 14% with continuous subcutaneous insulin infusion [CSII] and 13% with 1-3 injections per day [conventional therapy].The researchers concluded that:
  • 87% of the children were treated with intensive or pump therapy but while this percentage increased over the period of the study, the average HbA1c [approx 8.0%] was almost constant – in other words, it did not improve.
  • Those using insulin analogues received up to 11% higher insulin doses per day compared with those treated with human insulin.
 Second study: Twice-daily free mix insulin regimes gave the best HbA1cs Continuing stability of centre differences in pediatric diabetes care: do advances in diabetes treatment improve outcome? Diabetes Care, Vol 30, number 9, September 2007 This international study in 21 paediatric diabetes centres investigated the influence of changes in insulin regimes, and other factors, on HbA1cs, hypoglycaemia and ketoacidosis. The 2,269 participants were aged between 11-18 and had diabetes at least a year. Fourteen of the centres had participated in previous studies so allowing a direct comparison of glycaemic control between 1998 and 2005.The average HbA1c result for the whole group was 8.2 with girls having higher results than boys [8.3 vs 8.1] and those who had a longer duration of diabetes had modestly higher HbA1cs. 85.3% of the children/adolescents were on one of 5 insulin regimes - the remaining 309 were on regimes that could not be classified. The HbA1c results for the different regimes were as follows: Regime                           HbA1c 8.2                    Insulin dose [by body weight] Miscellaneous                       8.2                                 0.66Twice daily premix                8.6                                 1.01Twice daily free mix              7.9                                 1.00Thrice daily                          8.2                                 1.24Basal bolus                          8.2                                  1.03Pumps                                 8.1                                  0.92 BMI [weight] was not significantly associated with HbA1cs. Insulin dosage was unrelated to hypoglycaemia but was significantly correlated with diabetic ketoacidosis [DKA], with higher insulin dose associated with poorer metabolic control and more frequent DKA.Comparison of the 1998 and 2005 studies
  • Participants in the 2005 study had a higher BMI and were on more intensive regimes than in the 1998 study.
  • There has been no significant improvement in HbA1cs and no difference in the frequency of hypoglycaemia.
  •  Only two centres significantly improved glycaemic control compared with 1998 but this was not explained by intensification of insulin regimes. 
 So what did the researchers conclude?Despite many changes over the past 10 years including increased use of insulin analogues, basal bolus regimes [4 injections + a day] and pumps:·                     those using twice daily free mix of soluble/regular plus NPH [intermediate-acting] and had lower HbA1cs than all other groups. “This suggests that the so-called conventional regimes may be superior to modern intensive regimes.”·                     HbA1cs on pump therapy were not significantly different from the total group even in centres where considerable numbers of patients were using them.

So the researchers concluded that despite major and continuing changes in insulin and insulin regimes, glycaemic control has not improved over a decade in 21 international centres.

Additional information