[Previous Months][Date Index][Thread Index][Join - Register][Login]
[Message Prev][Message Next][Thread Prev][Thread Next]

[IP] Case Study: Use of an Insulin Pump in an Adolescent

VOL. 18 NO. 4 Fall 2000

Case Study: Use of an Insulin Pump in an Adolescent

Dace L. Trence, MD, FACE

J.B. is a 14-year-old girl with a 4-year history of type 1 diabetes. She was
referred for recommendations for improved glycemic control.

In the previous year, she had had six hospital admissions for treatment of
diabetic ketoacidosis (DKA). Despite increasing doses of insulin, she had
continued to have erratic glycemic control. Her HbA1c had decreased from 10.7
to 8.9% with multiple insulin dosing and instruction in varying her regular
insulin dose based on glucose levels, physical activity, and carbohydrate

Menses had started at age 11 and were regular, and the patient had grown 4
inches from the time of her initial diabetes diagnosis. However, she noted
chronic fatigue.

J.B.'s mother said that her school grades had fallen in the previous academic
year from A's to C's and that her interest in her classes and participation
in extracurricular activities were considerably lessened from previous years.

Physical examination was unremarkable. J.B.'s height was 172.5 cm, and her
weight was 70.4 kg. At presentation, her insulin dosing regimen consisted of
34 U NPH with usually 14b16 U of regular insulin for breakfast, 5 U of NPH

<FONT  COLOR="#000000" BACK="#ffffff" style="BACKGROUND-COLOR: #ffffff" SIZE=3

Over the ensuing 6 months, various changes were recommended and tried in an
effort to achieve glycemic control. These included a change from regular
insulin to lispro pre-meal insulin, with dosing based on carbohydrate grams
to be ingested. Ultralente insulin was added, with HbA1c decreasing minimally
to 8.3%.

J.B.'s morning hyperglycemia was particularly resistant to control despite
substantial increases in evening and bedtime insulin dosing. Her glucose
levels improved modestly throughout the day as she increased pre-meal insulin
boluses according to her flexible insulin management plan.

J.B. was started on an insulin pump delivery system after the subcutaneous
insulin regimens attempted did not result in optimal metabolic control. Her
total daily insulin dose then dropped from ~140 to 60b70 U/day. Her glucose
levels are now typically in the range of 120B-180 mg/dl, and her most recent
HbA1c was 7.6%. After an initial weight gain of 1.8 kg, she lost 3.0 kg. This
was primarily due to a decision to decrease the fat content of her meals
after she found that higher fat content had a negative effect on her
post-meal blood glucose control, although hypoglycemia frequency was also

<FONT  COLOR="#000000" BACK="#ffffff" style="BACKGROUND-COLOR: #ffffff" SIZE=3

She has noted a marked increase in her energy level. She is again
participating fully in school activities, and her grades are returning to her
previous A level. She has had no episodes of DKA since pump therapy was

Is insulin pump therapy a safe approach in adolescents who often have a
turbulent glucose profile?
Does continuous subcutaneous insulin infusion (CSII) therapy offer better
control of hyperglycemia than multiple subcutaneous injections in the
adolescent population?
Can a change in the insulin delivery system affect hyperglycemia-associated
comorbidities (i.e., frequent hospitalization for DKA, frequent hypoglycemic
events) for adolescents?
Can a pump have an effect on the psychosocial factors that are already a
challenge in this period of life?
Adolescence is a difficult age at which to try to achieve glycemic control.
However, poor glycemic control can affect school performance, socialization,
and the ability to participate in normal activities. Early reports1 suggested
that CSII systems were of questionable benefit in a young age group,
resulting in little improvement in glycemic control and having a high
discontinuance rate.2

But more recent reports suggest that CSII can be beneficial.3,4 It is
particularly likely to have a positive effect on the rate of DKA and
resultant hospitalizations.5 CSII can also reduce severe hypoglycemia3 as
well as severe hyperglycemia caused by the dawn phenomenon (early-morning
hyperglycemia caused by the physiological increase in counter-regulatory
hormone production).4 Most importantly for an age-group for which
psychosocial development is critical, coping with diabetes was reported to be
easier for adolescents using CSII than for those using multiple daily

Success with CSII depends on the adequacy of the education provided to
patients and their families. Education must be directed to the skills and
needs of individual patients and families. It must be reinforced by intensive
initial team support and reviewed as needed to maintain optimal metabolic

Clinical Pearls
CSII can be a very helpful and safe tool in achieving better glycemic control
in the adolescent population.
CSII can not only decrease hospitalizations for DKA, but also have a positive
impact on psychosocial issues for this age-group that is challenged by issues
of social acceptance and growth.

1Brink SJ, Stewart C: Insulin pump treatment in insulin-dependent diabetes
mellitus: children, adolescents, and young adults. JAMA 225:617-21, 1986.

2Knight G, Boulton AJ, Ward JD: Experience of continuous insulin infusion in
the outpatient management of diabetic teenagers. Diabetic Med 3:83-84, 1986.

3Boland EA, Grey M, Oesterle A, Frederickson L, Tamborlane WV: Continuous
subcutaneous insulin infusion: a new way to lower risk of severe
hypoglycemia, improve metabolic control, and enhance coping in adolescents
with type 1 diabetes. Diabetes Care 22:1779-84,1999.

4Kaufman FR, Halvorson M, Miller D, Mackenzie M, Fisher LK, Pitucheewanont P:
Insulin pump therapy in type 1 pediatric patients: now and into the year
2000. Diabetes Metab Res Rev 15:338-52, 1999.

5Steindel BS, Roe TR, Costin G, Carlson M, Kaufman FR: Continuous
subcutaneous insulin infusion (CSII) in children and adolescents with chronic
poorly controlled type 1 diabetes mellitus. Diabetes Res Clin Pract
27:199-204, 1995.

6Becker D: Individualized insulin therapy in children and adolescents with
type 1 diabetes. Acta Paediatr Suppl 425:20-24, 1998.

Dace L. Trence, MD, FACE, is chief of the Endocrinology Department at Group
Health Puget Sound in Seattle, Wash.

< <A
"><Case Study: Use of an Insulin Pump in an Adolescent</A>
for HELP or to subscribe/unsubscribe, contact: HELP@insulin-pumpers.org
send a DONATION http://www.Insulin-Pumpers.org/donate.shtml