- Both syringes and pens (combining syringe, vial and button) can be used to deliver insulin, depending on patient's preference, insulin type and dosing, and costs. Inhaled insulin is also available.
- For people unable to properly self-inject insulin because of dexterity or visual issues, pens with aids can be helpful.
- Needle gauges from 22 (broader) to 33 (thinner) are available, being thinner less painful.
- Needle lengths from 4 to 12 mm are available, shorter lengths reduce risk of IM deposit.
- Injection or infusion sites must be checked at least annually.
- Smart pens and dose calculator help the patient in some cases.
- In-patients must be allowed, when possible, to self-administrate their insulin.
INSULIN PUMPS
- Pumps should be offered to any adult, child or adolescent with type 1 diabetes who is able to safely manage the divice.
Pumps (CSII) have been around for more than 40 years. Studies comparing them to MDII are short and small. Meta-analysis show small advantages of CSII in terms of A1c (0,3%) and severe hypoglycemia.
Problems with pumps are related to infusion set (risk of DKA) or skin (infection, lipohypertrophy or atrophy.
Little data compare CSII and MDI in children, RCT are difficult because of financial issues, rapid change of technology that renders old devices obsolete, and lack of blinding. It is possible that it slightly lowers A1c and DKA risk. There are no data in teenagers.
Some patient with other types of diabetes, like long-term type 2 diabetes, pancreatectomized, or cystic fibrosis-related, as well as older patients with T1DM, may benefit from CSII in selected cases.
PUMP AND SENSOR COMBINATION
- Sensor-augmented pumps with low glucose suspend can help adults and children with T1DM reduce hypoglycemia. These devices can be considered in case of frequent nocturnal hypoglycemia.
- Automated insulin delivery systems may be considered in children (B) and adults (A) to improve glycemic control. Currently these devices are hybrid closed-loop systems, where basal insulin infusion rate is controlled by an algorithm that receives continuous imputs from the sensor, but bolus must be manually added. They can reduce exercise-induced hypoglucemia and have psychological benefits. Here the result of a 6-month-trial that caused an update in ADA Standard in june, where closed-loop systems outperformed sensor-augmented pumps in TIR and rest of ranges.
- DIY devices cannot be prescribed by health providers, but they can provide safety information and backup stategies.
DIABETES AND INTERNET
- Patients seek more and more medical advice in the internet. This activity is not regulated and many apps and websites have been manufactured by people with low expertise in diabetes.
- Data collection and storage poses security and privacy problems.
- Despite lack of scientific evidence, many apps help people with diabetes and prediabetes lose weight and control their glycemia, therefore they can be a reasonable choice on an individual basis.
