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 budgeting.
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 1416 U of regular insulin for breakfast, 5 U of NPH with usually 1214 U of regular for supper, and 16 U of NPH at bedtime.
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 6070 U/day. Her glucose levels are now typically in the range of 120180 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 significantly diminished, affecting her need for caloric intake.
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 initiated.
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 injection.3
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 control.6
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.
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