Leveraging advances in diabetes technologies in primary care: a narrative review

Primary care providers (PCPs) play an important role in providing medical care for patients with type 2 diabetes. Advancements in diabetes technologies can assist PCPs in providing personalised care that addresses each patient’s individual needs. Diabetes technologies fall into two major categories: devices for glycaemic self-monitoring and insulin delivery systems. Monitoring technologies encompass self-measured blood glucose (SMBG), where blood glucose is intermittently measured by a finger prick blood sample, and continuous glucose monitoring (CGM) devices, which use an interstitial sensor and are capable of giving real-time information. Studies show people using real-time CGM have better glucose control compared to SMBG. CGM allows for new parameters including time in range (the time spent within the desired target glucose range), which is an increasingly relevant real-time metric of glycaemic control. Insulin pens have increased the ease of administration of insulin and connected pens that can calculate and capture data on dosing are becoming available. There are a number of websites, software programs, and applications that can help PCPs and patients to integrate diabetes technology into their diabetes management schedules. In this article, we summarise these technologies and provide practical information to inform PCPs about utility in their clinical practice. The guiding principle is that use of technology should be individualised based on a patient’s needs, desires, and availability of devices. Diabetes technology can help patients improve their clinical outcomes and achieve the quality of life they desire by decreasing disease burden.

KEY MESSAGES

• It is important to understand the role that diabetes technologies can play in primary care to help deliver high-quality care, taking into account patient and community resources. Diabetes technologies fall into two major categories: devices for glycaemic self-monitoring and insulin delivery systems. Modern self-measured blood glucose devices are simple to use and can help guide decision making for self-management plans to improve clinical outcomes, but cannot provide “live” data and may under- or overestimate blood glucose; patients’ monitoring technique and compliance should be reviewed regularly. Importantly, before a patient is provided with monitoring technology, they must receive suitably structured education in its use and interpretation.
• Continuous glucose monitoring (CGM) is now standard of care for people with type 1 diabetes and people with type 2 diabetes on meal-time (prandial) insulin. Real-time CGM can tell both the patient and the healthcare provider when glucose is in the normal range, and when they are experiencing hyper- or hypoglycaemia. Using CGM data, changes in lifestyle, eating habits, and medications, including insulin, can help the patient to stay in a normal glycaemic range (70–180 mg/dL). Real-time CGM allows for creation of an ambulatory glucose profile and monitoring of time in range (the time spent within target blood glucose of 70–180 mg/dL), which ideally should be at least 70%; avoiding time above range (>180 mg/dL) is associated with reduced diabetes complications and avoiding time below range (<70 mg/dL) will prevent hypoglycaemia. Insulin pens are simpler to use than syringes, and connected pens capture information on insulin dose and injection timing.
• There are a number of websites, software programs and applications that can help primary care providers and patients to integrate diabetes technology into their diabetes management schedules. The guiding principle is that use of technology should be individualised based on a patient’s needs, desires, skill level, and availability of devices.

     

What's ahead in glucose monitoring? New techniques hold promise for improved ease and accuracy

Advances in blood glucose monitoring have made it easier, more comfortable, and more practical for patients to monitor frequently. The new meters for intermittent monitoring are smaller and less dependent on technical aptitude than older models. They require less blood, and many provide downloadable information for glucose analysis. Data systems used with new meters provide valuable information that can dramatically improve glycemic control. Continuous glucose sensing (figure 4) is another major breakthrough in management of diabetes. Current systems allow only retrospective analyses, but real-time readings should be available in the near future. Such technological advances hold promise for preventing both hypoglycemia and hyperglycemia and for reducing the risk of long-term complications associated with diabetes. An artificial, mechanical islet cell may be the big next step toward bringing this disease under control. By combining continuous glucose monitoring data with continuous insulin delivery via an external or an implantable insulin pump, the outlook promises to be much brighter for patients with type 1 diabetes.     

Continuous glucose monitoring in 2010

After the initial positive data several recent randomised controlled trials offer more firm evidence supporting the efficacy and safety of real-time continuous glucose monitoring (CGM) in type 1 diabetes (T1D). Integrating CGM with insulin pumps offers additional benefit. Improved metabolic control with significant lowering of glycated haemoglobin along with other parameters of glycaemia and without a concomitant increase in hypoglycaemia is demonstrated in all age groups, including children and adolescents. Reducing hypoglycaemia with CGM in well-controlled individuals with T1D remains to be demonstrated; however, evidence for reducing hypoglycaemia in critically ill patients seems convincing. Several important aspects of type 2 diabetes (T2D) were recently addressed by professional CGM. Adding predictive algorithms to CGM may considerably improve its efficacy and lead the way towards the closed loop.     

Continuous glucose monitoring: an overview of today's technologies and their clinical applications

The first glucose sensors that allow continuous glucose monitoring are now available. It is important that physicians understand the special clinical and technical aspects that are key to successful implementation of these sensors--and of other sensors being under clinical development--into the daily practice of patients with diabetes. One important question is whether under all circumstances changes in blood glucose are paralleled by glucose changes in the interstitial fluid, in terms of both absolute values and time. Only if this is the case can measuring glucose in the interstitial fluid be a reliable substitute for measuring blood glucose. Usually, glucose sensor readings of interstitial fluid are transformed by means of a calibration process, so that the readings show actual blood glucose levels and not the interstitial glucose levels. If the calibration factor is inaccurately estimated, this error would be perpetuated with potential clinical implications. Patients with diabetes have to learn the proper use of the individual glucose sensor system, including its calibration and quality control. They also have to be informed about the problems and limitations of each sensor. Continuous monitoring should supply the patients with all information required to optimise their insulin therapy. The relatively high costs of glucose sensor systems should be viewed in the context of the potential optimisation of metabolic control, which should ultimately reduce the costs for the treatment of late complications of diabetes. These reduced costs would clearly far outweigh the costs of self-monitoring and self-control. Clinical trials are necessary to clearly demonstrate the long-term benefits of continuous glucose monitoring. The development of glucose sensors has now reached a stage at which it is important to address such questions appropriately.     

Insulin glargine (Lantus)

Insulin glargine (Lantus) is a long-acting, human insulin analogue that has been specifically designed to overcome the deficiencies of traditionally available 'intermediate-acting' insulins that are currently used for basal insulin supplementation. In contrast to NPH insulin, subcutaneous insulin glargine injected once daily provides a relatively constant basal level of circulating insulin with no pronounced peak. In patients with type 1 and type 2 diabetes, once-daily insulin glargine achieves equivalent glycaemic control to NPH insulin given once or twice daily In patients with type 1 diabetes, it is associated with significantly lower fasting blood glucose (FBG) levels, especially in those patients previously on twice-daily NPH insulin. Insulin glargine is well tolerated and elicits less hypoglycaemia, especially nocturnal episodes, than NPH insulin, with similar levels of glycaemic control. This benefit is seen in patients with both type 1 and type 2 diabetes, in particular those previously on a once-daily NPH insulin regimen. Patients with type 1 and type 2 diabetes have also reported higher levels of treatment satisfaction when treated with insulin glargine. Insulin glargine provides the opportunity to achieve target blood glucose levels more effectively and safely compared with NPH insulin, due to the reduced risk of hypoglycaemia, especially nocturnal hypoglycaemia. Insulin treatment needs to be individualised, with the dose of insulin glargine adjusted according to the blood glucose level as part of an aggressive regimen in an attempt to achieve near normoglycaemia without incurring episodes of hypoglycaemia. Insulin glargine should be used in combination with short-acting insulin analogues in patients with type 1 diabetes. In patients where oral hypoglycaemic agents are failing, insulin glargine can be added. The early introduction of insulin in patients with type 2 diabetes is to be encouraged.     

Diabetes and exercise

The abnormal metabolic responses to exercise in insulin-dependent diabetes are in great part related to abnormal circulating plasma insulin concentrations. Exercising during relative insulin deprivation results in an increase in glycemia and ketosis. Exercise during insulin excess results in inhibition of hepatic glucose production and accelerated muscle glucose utilization and results in hypoglycemia. These responses can be significantly improved when insulin is administered more appropriately, as is the case with insulin infusion pumps. Self blood glucose monitoring before, during, and after exercise can provide important information that can be used to optimize the metabolic response to exercise in individual patients. A better understanding of the metabolic response to exercise in patients with diabetes will serve as the basis for developing specific recommendations to enable these individuals to have the freedom to take part in all forms of exercise with minimal restriction. However, the demonstration that exercise will have a long-term beneficial effect on the metabolic control of diabetes or prevent the development of the complications of diabetes remains to be established.     

Pharmacological management of diabetes: recent progress and future perspective in daily drug treatment

Glycaemic control in Type 1 diabetes has been proven efficient in preventing microvascular and neurological complications. The assumption that good control of hyperglycaemia may also have significant impact on alleviation of complications in Type 2 diabetes has gained growing support in recent years. Measures such as body weight reduction and exercise improve the metabolic defects, but pharmacological therapy is most frequently used. The sulphonylureas stimulate insulin secretion. Metformin and troglitazone increase glucose disposal and decrease hepatic glucose output without causing hypoglycaemia. Acarbose helps to spread the dietary carbohydrate challenge to endogenous insulin over time. These pharmacological treatments can improve blood glucose regulation in Type 2 diabetes patients. However, the key to strict glycaemic control with use of exogenous insulin lies in the creation of delivery methods that emulate physiologic insulin secretion. Insulin lispro, a recombinant insulin analogue, is identical to human insulin except for the transposition of proline and lysine at positions 28 and 29 in the C-terminus of the B chain. Evidence suggests that patients perceive their quality of life to be improved with insulin lispro when compared with regular human insulin, and that satisfaction with treatment is greater with the insulin analogue. Numerous new pharmacological approaches are under active investigation, with the aim of promoting insulin secretion, improving the action of insulin, or slowing carbohydrate absorption. With respect to continuous subcutaneous insulin infusion therapy and implantable pumps, despite that this approach is not widely utilised, it appears to bring us as close to achieving glycaemic control as is feasible with current treatment approaches. However, general application of such technology requires significant improvements in several areas, such as improvement of patency of catheter, pump failures due to early battery depletion incidents, and pump miniaturisation. Future perspective resides on insulin analogues with longer half-lives that would provide better basal insulin coverage in association with fast-acting analogues.     

A comparison of glycaemic variability in CSII vs. MDI treated type 1 diabetic patients using CGMS

Objective: To evaluate and compare glucose variability, hypoglycaemic events and daily glycaemic control in well‐controlled (HbA1c ≤ 7%), type 1 diabetic patients treated with either continuous subcutaneous insulin infusion (CSII) using lispro or multiple daily insulin injection (MDI) using glargine once daily and lispro with meals. Research design and methods: A total of 16 patients with type 1 diabetes receiving treatment with either CSII (eight patients) or MDI (eight patients), all with HbA1c levels < 7%, wore a continuous glucose monitoring system sensor for 3 days to compare the number, duration, timing and severity of hyperglycaemic and hypoglycaemic episodes. Results: There were several more episodes of hyperglycaemic [blood glucose (BG) ≥ 180 mg/dl] and hypoglycaemic (BG ≤ 60 mg/dl) excursions observed in patients treated with CSII than MDI. Glycaemic exposure over 150 mg/dl was similar between the two groups. Maintenance of near‐euglycaemia as determined by the average amount of time spent within the glucose range of 80–140 mg/dl was marginally significantly better for the MDI than for the CSII group. Although the CSII group had significantly more hypoglycaemic episodes below 60 mg/dl, the average duration of hypoglycaemia was not significantly different for the two groups. Similar percentages of nocturnal hypoglycaemia were seen. There were no reported major adverse events throughout the duration of the study. Conclusion: Well‐controlled type 1 diabetic patients treated with MDI had fewer hyperglycaemic and hypoglycaemic excursions than patients treated with CSII.     

iCare advanced blood glucose monitoring system

Health professionals working in the field of diabetes have a wide choice of blood glucose meters to offer patients, with different meters offering different options for monitoring and recording blood glucose results. Self-monitoring of blood glucose levels can be helpful to people with diabetes in helping to maintain day-to-day control, adjusting insulin doses, detecting hypoglycaemia, assessing control during intercurrent illness and helping to provide information that can be used in the prevention of long-term complications. The newly released iCare Advanced Blood Glucose monitoring System is an easy-to-teach and use blood glucose meter using the latest technology to provide people with diabetes with easy and comfortable testing, producing accurate blood glucose test results in just 6 seconds using a small blood sample of only 0.7ul. In the current NHS climate, the iCare Advanced blood Glucose meter offers patients and health professionals the latest technology alongside cost savings by providing a test strip that is low cost but does not compromise on quality.     

Control of insulin-dependent diabetes with portable miniaturized infusion systems

A method of insulin therapy that appears to achieve better control of diabetes than present conventional methods is the use of insulin infusion devices--either glucose-controlled feedback (closed-loop) systems or the preprogrammed (open-loop) infusion pump. In view of the problems with implantable glucose sensors, we have worked to develop a miniaturized, programmable infusion system. Its use in insulin-dependent diabetic patients to provide either intravenous doses or a continuous subcutaneous insulin infusion resulted in significant reductions in blood glucose levels, glycemic excursions and 24-h glucose excretion.     

Management of type 1 diabetes and perioperative fasting

Pre and postoperative fasting presents specific problems to patients with type 1 diabetes. Too much insulin can cause hypoglycaemia, whereas too little can lead to ketoacidosis. Simon Eaton explains how avoiding these complications requires use of appropriate treatment regimes and careful monitoring of glucose levels.     

Insulin therapy in type 2 diabetes: role of the long-acting insulin glargine analogue

Insulin glargine is a long‐acting insulin analogue, with a longer duration of action and a flatter time‐action profile compared with NPH insulin. These properties can be predicted to result in higher glucose levels during the night and lower glucose levels after dinner following bedtime injection of insulin glargine compared with an equal dose of NPH insulin injected at bedtime. In two large‐scale clinical trials involving either insulin‐naïve (426 patients treated for 1 year) or previously insulin‐treated (518 patients treated for 28 weeks) patients with type 2 diabetes, comparing addition of once‐daily insulin glargine or NPH insulin to oral agents, these predictions were proven to be correct. Nocturnal hypoglycaemia was reduced by 58% in insulin‐naive patients and by 22% in previously insulin‐treated patients, and dinner‐time glucose control was significantly better with insulin glargine than with NPH insulin once daily in the study in insulin‐naive patients. The ‘treat‐to‐target study’ (756 insulin‐naive patients treated for 24 weeks) showed that good glycaemic control can be achieved with aggressive titration of the insulin dose with either once‐daily insulin glargine or NPH insulin combined with oral agents (mean endpoint HbA_1c was 6·96% with insulin glargine and 6·97% with NPH insulin); however, this was achieved with less variability and nocturnal hypoglycaemia with insulin glargine. These data support use of insulin glargine instead of NPH insulin for basal insulin replacement in patients with type 2 diabetes.     

Bench-to-bedside review: Antidotal treatment of sulfonylurea-induced hypoglycaemia with octreotide

The major potential adverse effect of use of sulfonylurea agents (SUAs) is a hyperinsulinaemic state that causes hypoglycaemia. It may be observed during chronic therapeutic dosing, even with very low doses of a SUA, and especially in older patients. It may also result from accidental or intentional poisoning in both diabetic and nondiabetic patients. The traditional approach to SUA-induced hypoglycaemia includes administration of glucose, and glucagon or diazoxide in those who remain hypoglycaemic despite repeated or continuous glucose supplementation. However, these antidotal approaches are associated with several shortcomings, including further exacerbation of insulin release by glucose and glucagon, leading only to a temporary beneficial effect and later relapse into hypoglycaemia, as well as the adverse effects of both glucagon and diazoxide. Octreotide inhibits the secretion of several neuropeptides, including insulin, and has successfully been used to control life-threatening hypoglycaemia caused by insulinoma or persistent hyperinsulinaemic hypoglycaemia of infancy. Therefore, this agent should in theory also be useful to decrease glucose requirements and the number of hypoglycaemic episodes in patients with SUA-induced hypoglycaemia. This has apparently been confirmed by experimental data, one retrospective study based on chart review, and several anecdotal case reports. There is thus a need for further prospective studies, which should be adequately powered, randomized and controlled, to confirm the probable beneficial effect of octreotide in this setting.     

Driving mishaps and hypoglycaemia: risk and prevention

Driving is a complex, multi-task activity that can be affected by cognitive impairment resulting from episodes of severe hypoglycaemia. Intensive insulin therapy increases the likelihood of severe hypoglycaemia but there have been few studies examining effects on driving skills. A survey carried out recently indicated that patients with type 1 diabetes had twice the incidence of driving accidents than their non-diabetic spouses or patients with type 2 diabetes. The motor accidents were associated with more frequent low blood glucose while driving and less frequent self-monitoring. In driving simulation tests it was found that driving has an intrinsic metabolic demand that can contribute to hypoglycaemia. Driving performance began to deteriorate at around 3.6 mmol/l but drivers frequently did not recognise and failed to treat the hypoglycaemia. Those who did self-treat had more driving relevant symptoms and less neuroglycopenia quantified by EEG alpha-theta differences. Patients should be recommended not to begin driving if blood glucose is below 4.5 mmol/l and should not continue to drive if they suspect that blood glucose has fallen below 4 mmol/l while driving. If hypoglycaemia is suspected patients should immediately pull off the road, measure blood glucose if possible, treat themselves as necessary and not resume driving until glucose and cognitive-motor function return to normal. The problems of driving and hypoglycaemia should be discussed with patients with diabetes and behavioural interventions instigated. To this end, Blood Glucose Awareness Training (BGAT) and Hypoglycaemia Anticipation, Awareness and Treatment Training (HAATT) have been developed and shown to markedly reduce incidence of driving mishaps.     

Unsuspected hypoglycaemia, haemoglobin A1 and diabetic control

Control of diabetes in a group of 82 insulin-treated diabetics was assessed by in-patient 24-hour plasma glucose profiles and haemoglobin A1 (HbA1) estimation. Thirty-two of these patients (39 per cent) had hypoglycaemia (plasma glucose less than or equal to 2 mmol/l) which was rarely associated with symptoms. Twenty-seven (61 per cent) of 44 patients who took a series of out-patient pre-prandial capillary blood samples over a three-day period had hypoglycaemia. Conventional measurements of diabetic control including fasting plasma glucose and HbA1, were lower in patients with hypoglycaemia than in those without. Rebound hyperglycaemia following hypoglycaemia was not seen and its absence was not due to diabetic autonomic neuropathy. Cortisol/creatinine ratios in early morning urine samples were similar in patients with and without nocturnal hypoglycaemia, consistent with the absence or rebound hyperglycaemia. Diabetic retinopathy was less prevalent in patients with hypoglycaemia, possibly reflecting better long-term diabetic control in this group. HbA1 concentration reflects overall blood glucose control in diabetes but near-normal levels must be interpreted with caution since they may be associated with recurrent hypoglycaemia.     

Diabetes technology and treatments in the paediatric age group

Type 1 diabetes (T1D) is one of the most common chronic childhood diseases and its incidence has doubled during the last decade. The goals of intensive management of diabetes were established in 1993 by the Diabetes Control and Complications Trial (DCCT) (1). Children with T1D and their caregivers continue to face the challenge to maintain blood glucose levels in the near-normal range. It is important to prevent sustained hyperglycaemia which is associated with long-term microvascular and macrovascular complications and to avoid recurrent episodes of hypoglycaemia or hyperglycaemia, especially in young children, which may have adverse effects on cognitive function and impede efforts to achieve the recommended glycaemic targets. Advances in the use of technology that may help maintain the metabolic control goals for young people with T1D were centred on continuous subcutaneous insulin infusion (CSII) (2-4), continuous glucose monitoring (CGM) (5-7), and combining both technologies into a closed-loop system (8-10). The dilemma in paediatrics of patient selection for insulin pump therapy was found to be most successful in those with more frequent self-monitoring of blood glucose (SMBG) and younger age prior to pump initiation (2). Similarly, those who used a dual-wave bolus probably paid closer attention to their management and had lower HbA1c levels (3). The advantage of using a pre-meal bolus to improve postprandial glucose levels was shown to offer another potential method to improve glycaemic control (4). SMBG is an important component of therapy in patients with diabetes, especially in the paediatric age group. Standard use of glucose meters for SMBG provides only intermittent single blood glucose levels, without giving the 'whole picture' of glucose variability during the 24 h, and especially during the night, when blood glucose levels are seldom measured. Therefore, the use of a device such as real-time continuous glucose monitoring (RT-CGM) that provides continuous glucose measurements can help patients optimise glycaemic control. These devices may have the potential to increase the proportion of patients who are able to maintain target HbA1c values, to decrease glucose excursions and to decrease the risk of severe hypoglycaemia. Previous studies in paediatric T1D patients (11,12) have demonstrated that the frequency of CGM use was significantly associated with the effect of lowering HbA1c levels. The important STAR 3 study of 485 patients (156 children) with T1D showed the benefit of sensor-augmented pump therapy over remaining on multiple daily injections (MDI) (10). The Juvenile Diabetes Research Foundation Continuous Glucose Monitoring (JDRF-CGM) studies were initially described in the 2009 Yearbook (13). Further reports of youths and adults in this study found that those with initial low HbA1c levels (< 7%) show a significant benefit from the use of CGM (5). Prolonged nocturnal hypoglycaemia was shown to continue to be a common occurrence in the entire cohort using CGM (7). Thus, there is an obvious need for closing the loop. Many patients with diabetes and especially parents of diabetic children dream about the invention of an 'artificial pancreas'. CSII and RT-CGM can be combined to form closed-loop systems. Insulin is then delivered according to RT-CGM data, as directed by a control algorithm, rather than at pre-programmed rates. Few closed-loop prototypes have been developed with advanced control algorithms, such as those that are based on model predictive control (14). The group at Cambridge studied 19 young people in closed-loop systems and was able to demonstrate that exercise and diet variations could be aptly managed (9). It is expected that closed-loop studies in young people will continue to multiply in future years. T1D is characterised by immune-mediated pancreatic β-cell destruction. Thus, a major goal in the treatment of T1D in youth will be in the area of prevention. The identification of increased levels of inflammatory markers in the SEARCH study of young people with T1D may provide an important clue (15). Most of the studies countered the diabetes process by immunomodulation and/or enhancement of β-cell proliferation and regeneration (16). An initial pilot trial of a tumour necrosis factor α (TNF-α) binding agent, Entanercept, showed benefit in preserving C-peptide production in 18 young people with newly diagnosed T1D. HbA1c levels were also lower in the treatment group (5.9% ± 0.5% vs. 6.98% ± 1.2%; p < 0.05) (17). Similarly, β-cell function was shown to be preserved in children receiving the lower of two doses of ingested human recombinant interferon-α (hrINF-α) in comparison with subjects who received placebo (18). A future larger trial of both of these agents will be of interest. In this review of the literature we have tried to select recent publications that offer some insight into these issues in paediatric patients with T1D.     

Key considerations around the risks and consequences of hypoglycaemia in people with type 2 diabetes

Hypoglycaemia and its consequences represent a significant risk for many people who have type 2 diabetes, and hypoglycaemia is currently under‐recognised and commonly avoidable. Current clinical guidelines recommend the targeting of tight glycaemic control and this strategy may also be associated with an increased risk of hypoglycaemia. Hypoglycaemia impacts on morbidity, mortality and quality of life of people with type 2 diabetes, and improved recognition of the symptoms of hypoglycaemia will allow effective treatment and reduce the risk of progression to more severe episodes. A common cause of hypoglycaemia in people with type 2 diabetes is glucose‐lowering medication, in particular, those which raise insulin independently of ambient glucose concentration such as sulphonylureas and exogenous insulin. The recently published National Institute for Health and Clinical Excellence guideline recommends the use of Dipeptidyl peptidase‐4 inhibitors or thiazolidinediones (glitazones) as alternative second‐line therapy instead of a sulphonylurea in those patients who are at significant risk of hypoglycaemia and its consequences.     

Insulin pump therapy and rapid acting insulin: what have we learned?

Approximately 80 years after the discovery and first human use of insulin, we are still striving to replace insulin in a physiological manner. The development of insulin analogues with superior pharmacokinetics has made mimicking of meal and basal insulin requirements by subcutaneous injection more feasible. Administration by continuous subcutaneous insulin infusion (CSII) has provided additional flexibility in meal timing and modifying basal insulin replacement in response to circadian rhythms. Several studies have documented improved glycaemic control with CSII using a rapid-acting analogue such as insulin lispro, compared with regular human insulin. Lower postprandial glucose peaks and improved HbA1c levels were seen with insulin lispro by CSII. In addition, the frequency of hypoglycaemia was significantly reduced and the counter-regulatory hormone responses were maintained. The use of insulin lispro in CSII, compared with regular human insulin, resulted in improved hepatic glucose output in response to glucagon. The potential for problems of hyperglycaemia and ketoacidosis with interruption of insulin delivery by CSII has been studied. One study showed accelerated development of hyperglycaemia and ketosis with insulin lispro compared with regular human insulin while another showed no difference but return to normal glycaemia was faster when insulin lispro was administered. The use of CSII in the US has grown from 6,600 in 1990 to over 100,000 patients currently. With improved insulins, better methods of delivery and advances in glucose monitoring we will continue progress towards physiological insulin replacement and reduce the long-term complications of diabetes.     

Diabetes in pregnancy. No longer a barrier to successful outcome

There are three key goals in current management of the diabetic pregnancy. Normal diabetes control before conception and during the first trimester in an attempt to reduce the incidence of congenital abnormalities. This implies that all diabetic women of childbearing age should have counseling before pregnancy. Routine use of new techniques such as home blood glucose monitoring, intensified conventional insulin regimens, or an insulin infusion pump for maintenance of tight metabolic control both before and during pregnancy. Delay in delivery of the baby until the due date, assuming good diabetes control and normal antepartum monitoring of the fetus, to reduce the incidence of macrosomatia, decrease the rate of cesarean section, and decrease neonatal mortality. The current outlook for the pregnant woman with diabetes is an optimistic one. Until recently, most women with diabetes were told that they should avoid pregnancy. Sterilization was often suggested as a means of contraception. Unfortunately, some women are still getting that message from their physician. This is unacceptable, as it is obvious that diabetes is no longer a barrier to pregnancy. Most women with diabetes can now consider the possibility of pregnancy and know that they have a reasonable chance of having a healthy child. Furthermore, new developments in diabetes care continue and should lead to an even brighter future for this group of patients. New advances in treatment, such as implantable insulin pumps, glucose sensors, and islet cell transplants, are just over the horizon. With these developments, a woman with diabetes will be freed from the intensive regimen she must now practice to achieve a successful pregnancy.