Advances in pump technology: insulin patch pumps, combined pumps and glucose sensors, and implanted pumps.

This review discusses the most recent developments in insulin pump technology. The benefits of the insulin pump to patients with type 1 diabetes are recognized both for its metabolic effectiveness and its positive effects on quality of life. The current pumps are reliable, small and light, and are becoming more and more sophisticated. Nevertheless, there remain practical and psychological constraints for the patient. However, recent patch-pump advances should simplify the technical aspects of pump treatment and enhance patient comfort. Another advance combines the insulin pump with a glucose sensor. Such a combination is logical for optimizing pump use and, to that end, developing an automated or 'closed-loop'system that permits the delivery of subcutaneous insulin adjusted according to measured levels of subcutaneous glucose. Finally, implanted insulin pumps have proven their worth not only because of their simple use, but also for their contribution in the artificial pancreas project. Indeed, the prompt response with intraperitoneal administration of insulin makes it of interest for use in a closed-loop system.

[Management of gestational diabetes]. / Prise en charge thérapeutique du diabète gestationnel.

BACKGROUND: Maternal and perinatal complications linked to gestational diabetes could be decreased with an intensive treatment. AIM: To assess the effect of various treatments, glycaemia targets and procedures for blood glucose self-monitoring, on fetal and maternal prognosis. METHODS: Systematic review of literature studying the efficacy of the treatment of gestational diabetes to decrease fetal morbi-mortality thereof. Analysis based on bibliographic search in pubmed using the following keywords: "therapeutic", "treatment" and "gestational diabetes". RESULTS: Specific treatment of gestational diabetes (dietetics, physical exercise, blood glucose self-monitoring, insulin-therapy if appropriate) reduces severe perinatal complications (composite criterion), fetal macrosomia and pre-eclampsia compared to the absence of therapy, with however an increase in the number of triggered deliveries, and without any increase in the number of cesarean sections. Regarding oral antidiabetics, despite no difference was found in fetal or maternal prognosis upon treatment with glyburide, metformin, or insulin, they should not be prescribed. CONCLUSION: The treatment of "severe or moderate" gestational diabetes is recommended. Additional studies, in particular long-term studies in children, are warranted before oral antidiabetics can be used.

Therapeutic management of gestational diabetes.

BACKGROUND: Maternal and perinatal complications linked to gestational diabetes mellitus could be decreased with an intensive management approach. AIM: To assess the effect of various treatments, glycaemic targets and procedures for self-monitoring of blood glucose on the foetal and maternal prognosis. METHODS: Systematic review of literature studying the efficacy of the treatment of gestational diabetes in order to decrease maternal-foetal morbidity-mortality. Analysis based on bibliographic search in PubMed using the following keywords: "therapeutic", "treatment" and "gestational diabetes". RESULTS: Specific treatment of gestational diabetes (dietary, adapted physical activity, self-monitoring of blood glucose, insulin-therapy if appropriate) reduces severe perinatal complications (composite criterion), foetal macrosomia and preeclampsia compared to the absence of therapy, with however an increase in the number of labour inductions, and without any increase in the number of caesarean sections. Regarding oral antidiabetic agents (glibenclamide or metformin), despite the absence of difference found on foetal or maternal prognosis compared to insulin, they should not be prescribed during pregnancy at this time. CONCLUSION: The treatment of "severe or moderate" gestational diabetes is recommended. Additional studies, in particular long-term studies in children, are warranted before oral antidiabetic agents can be used.

Factors related to CSII compliance.

Many studies have demonstrated the metabolic efficacy of continuous subcutaneous insulin infusion (CSII) and particularly a reduction of glycaemic fluctuations in type 1 diabetic patients. Despite this benefit, many patients decide to discontinue the use of CSII. To determine the factors related to discontinuation of CSII we analyzed clinical data from a group of 70 patients who had been consecutively started on this treatment from April 2000 to April 2002. Patients were followed for up to 2 years. Eighteen (25.7%) patients decided to terminate CSII during the study after an average of 235 days (range 21-293). The reasons for stopping CSII were decision of the patients (10), end of pregnancy (4), needle site infections (3) and lack of compliance (1). No significant difference was found between patients who had continued and those who had discontinued CSII for age, duration of diabetes, reasons for starting CSII, marital status, prepump concentration of HbA1c and prepump frequency of hypoglycaemia. There tend to be more discontinuations for pregnant women, patients attending hospital visits versus liberal practitioner and patients with lower educational level (below or over baccalaureat) although none of these differences was statistically significant. In conclusion we could not identify any predictive factor of CSII discontinuation.

[Management of diabetes during corticosteroid therapy]. / Prise en charge du diabète lors d'une corticothérapie.

BACKGROUND: Corticosteroids are generally contraindicated in diabetic patients due to the risk of disrupting glucose control leading to acute decompensation. In some cases however, corticosteroid therapy can be beneficial if given early with a well-controlled regimen. Glucose disequilibrium after withdrawal can be anticipated with proper knowledge of the pharmacokinetics of the glucocorticoid used. FOR PATIENTS WITH TYPE I DIABETES: Ketose acidosis is a real risk in these patients. Insulin dose must be increased and the administration scheme optimized. FOR PATIENTS WITH TYPE II DIABETES: Whether oral drugs should be continued is a question of debate, excepting cases where the underlying disease might cause acute decompensation requiring insulin. Outside this situation, oral drugs can be continued at a higher dose if the fasting serum glucose is below 2 g/L. Finally, it is important to recognized steroid-induced diabetes in order to initiate proper antidiabetic measures. FOR ALL PATIENTS: The glucose curve is reproducible. Basically, the postprandial level rises, warranting repeated insulin injections. Rapid-release analogs and alpha-glucosidase inhibitors appear to be promising; biguanides affect insulin resistance.