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Are We Helping Or Harming Our Insulin-Treated Diabetic Patients

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Are We Helping Or Harming Our Insulin-Treated Diabetic Patients Annals of Agricultural and Environmental Medicine 2013, Vol 20, No 2, 346–350 www.aaem.pl ORIGINAL ARTICLE Are we helping or harming our insulin-treated diabetic patients during ambulatory treatment? Grzegorz Szcześniak1, Piotr Dziemidok1,2, Piotr Paprzycki3 1 Diabetology Ward, Institute of Rural Health, Lublin, Poland 2 Institute of Public Health, Pope John Paul II State School of Higher Education, Biala Podlaska, Poland 3 Department of Functional Research, Institute of Rural Health, Lublin, Poland Szcześniak G, Dziemidok P, Paprzycki P. Are we helping or harming our insulin-treated diabetic patients during ambulatory treatment? Ann Agric Environ Med. 2013; 20(2): 346–350. Abstract Introduction. Correctness of insulin treatment depends on both the experience and skills of the doctor and knowledge and behaviour of the patient. Objective. Evaluation the adequacy of insulin doses administered to diabetes patients in ambulatory conditions. Material and methods. The treatment of 59 patients hospitalized in the Diabetology Ward was evaluated at admission, discharge and 3 months after hospitalization. Results. The mean daily doses of insulin significantly differed at times of evaluation and were: 53.90, 39.31 and 43.34 units, respectively (p≈0.000001). A significant reduction of body weight, 90.86 vs. 88.25 kg (p≈0.000001), was obtained only during hospitalization, and was maintained 3 months after discharge (87.86 kg). Significant differences were also noted in the body mass index (33.44 vs. 32.48 vs. 32.37 kg/m2, p≈0.000001). The change in waist circumference was not statistically significant (107.87 vs. 104.89 cm; p≈0.06). A decrease in the number of hypoglycaemia episodes was observed, but were statistically insignificant (25 vs. 23; p≈0.7). Three months after hospitalization an insignificant decrease of HbA1c level was noted (8.41% vs. 8.03%; p≈0.07). Conclusions. During treatment in the Diabetology Ward the procedure of choice was more frequently a reduction than an increase in insulin doses. This management led to the reduction of the patients’ body weight, improvement of glycaemia, without any significant effect on the diabetes control determined by the HbA1c level. Key words diabetes mellitus, insulin therapy, body weight, glycated haemoglobin INTRODUCTioN treatment becoming recognized as a mandatory method, both for specialists and family doctors, and a significant The discovery of insulin and method of its extraction by reduction of chronic complications found in those studies Frederick Banting and Charles Best in 1921, and the start gave them the sense that they possessed magic wand. of mass production of insulin a year later, was undoubtedly The results of the ACCORD [6] and VADT [7] studies, which a turning point in the treatment of diabetes and one of the suggested that there may possibly exist groups of patients who most important discoveries in medicine of the first half of do not benefit from the intensification of treatment, were not the 20th century. The diagnosis of diabetes was no longer received enthusiastically. A controversial report by Hemkens a death sentence. The life span of patients with diabetes was widely criticized – especially due to the methodology considerably increased. Among the consequences of which of research, whereas the reports by other groups, which did was the necessity to struggle with the consequences of chronic not confirm the reports concerning glargine, did not refer complications associated with diabetes mellitus – micro- to the section of the study pertaining to an increased cancer and macroangiopathies. To improve insulin treatment, new risk according to insulin doses [8]. ‘Yellow lights’ has been methods of insulin delivery (jet injectors and pumps) and downplayed by many practitioners. new types of insulin were developed. However, despite many The aim of the study was evaluation of the doses, years of experience and excellent equipment mistakes in number of injections, and the adequacy of insulin doses insulin treatment cannot be avoided. administered in ambulatory conditions in patients admitted Insulin therapy is the only method of type 1 diabetes to the Diabetology Ward due to hyperglycaemia. Of special treatment. It becomes indispensable when in type 2 diabetes interest were the effect of the dose dependent effect of a deficit of insulin secretion by the pancreatic beta cells insulin (metabolic control of diabetes, changes in patients’ joins with insulin resistance, and in special situations such body weight, number of hypoglycaemic episodes), and the a pregnancy, surgery, myocardial infarction (in some cases influence of insulin dose change on diabetes control 3 months temporarily) soon after diabetes diagnosis [1, 2]. Publication after discharge from hospital. of the results of the DCCT study [3], and subsequent UKPDS [4] and Kumamoto Study [5] resulted in intensive insulin MATERIAL AND METHODS Address for correspondence: Piotr Dziemidok, Diabetology Ward, Institute of Rural Health, Jaczewskiego 2, 20-090 Lublin, Poland The prospective study covered patients who received e-mail: [email protected] treatment in the Diabetology Ward during the period from Received: 19 December 2012; accepted: 4 March 2013 1 June 2010 – 31 December 2010. The inclusion criteria were Annals of Agricultural and Environmental Medicine 2013, Vol 20, No 2 347 Grzegorz Szcześniak, Piotr Dziemidok, Piotr Paprzycki. Are we helping or harming our insulin-treated diabetic patients during ambulatory treatment? age 18–80, and diabetes treated with insulin for at least one Table 1. Dynamics of changes in insulin doses during the study. year, while the exclusion criteria were as follows: admission/ discharge/ admission/ – treatment with any oral medications, apart from Daily insulin dose discharge follow up follow up metformin, during the period of the study and 3 months N % n % n % before the study; Increase 9 15 34 58 14 24 – pregnancy; – infectious disease; Without change 4 7 16 27 5 8 – cancerous disease; Reduction 46 78 9 15 40 68 – heart failure > NYHA Class II; – thyroid function disorders. At admission, discharge and 3 months after hospitalization, Table 2. Changes of daily insulin doses per kilogram of body weight in anthropometric parameters were evaluated (body weight, different types of diabetes. height, waist circumference, body mass index – BMI), as Type of admission discharge follow up n p well as glycated haemoglobin (HbA1c) level, number and diabetes Mean SD Mean SD Mean SD size of doses, and types of insulin, presence of hyper- and hypoglycaemia registered in the patient’s diabetes self-control type 1 12 0.63 0.28 0.57 0.18 0.58 0.20 0.98 diary. type 2 45 0.60 0.22 0.43 0.19 0.49 021 0.00000 Measurements of the percentage of HbA1c in capillary secondary 2 0.46 0.01 0.35 0.08 0.45 0.01 0.14 blood samples collected by finger stick were performed using all 59 0.60 0.22 0.45 0.19 0.51 0.21 0.00000 immunological tests and a chemical technique with the use of Bayer A1cNow+ analyzer. Statistical analysis was conducted by means of Statistica 8.1 Due to changes introduced in the management of diabetes, PL package. In order to compare co-variance of the dynamics an improved glycaemic control was obtained, understood as of the selected quantitative characteristics (body weight, the HbA1c level, and also a decrease in glycaemic variability. HbA1c level, insulin doses), apart from comparing changes The mean HbA1c level at admission was determined in absolute value, these characteristics were standardized to be 8.41±1.68%, and during follow-up examinations – by recalculation to the fraction of the initial value. In 8.03±1.57%; p ≈ 0.07. Hyperglycaemia of over 200 mg% 3-month observation the decreases in parameters were at admission was found in 52 (88%) respondents, while noted negatively, while increases – positively. Due to the 3 months after hospitalization – in 36 (61%); p ≈ 0.008, deviations from normal distribution, the significance of the whereas hypoglycaemia defined as the level of glycaemia relationships were investigated by means of Spearman rank below 60 mg% was diagnosed in 25 (42%) and 23 (39%) correlation test. In the case of ordinal scale, Kruskal-Wallis respondents, respectively; p ≈ 0.8. ANOVA test by ranks was applied. In order to compare the Table 3 presents changes of anthropometric parameters changes of distribution in 3 paired variables, Q Cochran test during the study. Waist and hips circumferences were not for dychotomic variables and ANOVA Friedman test were measured at discharge from hospital. used for the remainder. Table 3. Changes in anthropometric parameters during observations. admission discharge follow up RESULTS p Mean SD Mean SD Mean SD The study covered 59 patients: 12 (20.3%) with type 1 body weight (kg) 90.86 20.53 88.25 18.75 87.86 18.77 0.00000 body mass index diabetes, 45 (76.3%) with type 2 diabetes and 2 (3.4%) with 33.44 7.38 32.48 6.74 32.37 6.90 0.00000 secondary diabetes – 27 females (46%) and 32 males (54%). (kg/m2) waist circumference The mean age of the respondents was 59.4 years (20–79). The 107.87 14.63 --- --- 104.89 14.97 0.07 mean duration of diabetes was 14.8±7.87 years (1–40), and (cm) hips circumference duration of treatment with insulin – 8.4±5.8 years (1–24). 110.63 13.64 --- --- 108.39 12.98 0.04 In 32 respondents (54%) macrovascular complications (cm) were diagnosed, whereas in 49 (83%) – microvascular waist/hips ratio 0.98 0.07 --- --- 0.97 0.08 0.80 complications. The mean daily insulin dose at admission was 53.9±23.71 IU, at discharge – 39.31±15.59 IU, while 3 months after Table 4 presents the relationship between the dynamics hospitalization (follow-up) – 43.34±17.01 IU.
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