Factors associated with adherence to continuous subcutaneous insulin infusion in pediatric diabetes.

Background/aims: Continuous subcutaneous insulin infusion (CSII) is a safe and effective alternative to insulin injections in pediatric type 1 diabetes mellitus. CSII can be associated with an increased risk of hypoglycemia and diabetic ketoacidosis (DKA) in some patients. In our Center, patients/guardians are screened for proficiency in diabetes management skills as a prerequisite to initiation of CSII. We reviewed the clinical data from our patients to assess the predictors associated with nonadherence to CSII therapy.

Methods: We retrospectively collected clinical data on all our CSII initiations between July 1999 to June 2003, including: body mass index, hemoglobin A1c (HbA1c), total daily dose, bolus to basal insulin ratio, hypoglycemic episodes (blood glucose <60 mg/dL/week), mean fasting self-monitored blood glucose (SMBG), severity of lipohypertrophy, DKA, and pubertal status.

Results: Forty-six patients 9.90 +/- 3.4 years old (28 girls and 18 boys) started CSII in the 4-year period. While 39 patients (85%) 9.8 +/- 3.5 years old currently remain on CSII, seven patients (15%) 11.2 +/- 0.9 years old discontinued CSII. Fifteen patients (32.6%) were prepubertal at CSII initiation, and none discontinued CSII in this cohort, whereas seven of 31 (22.6%) pubertal patients discontinued CSII. The patients who continued CSII were similar to the CSII-discontinued cohort at baseline. At 12 months, rising HbA1c was the only predictor of future nonadherence to CSII. At 24 months, the discontinuation group had higher mean fasting SMBG levels and severe lipohypertrophy (P < 0.05). None of the prepubertal patients discontinued CSII, while all seven patients (100%) in the CSII-discontinued group were pubertal (P < 0.001).

Conclusions: Extensive screening by a multidisciplinary diabetes team prior to initiation of CSII regimen results in relatively lower discontinuation rates and a higher chance of maintaining optimal glycemic control (HbA1C < 8%) compared to previous studies.