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ORIGINAL ARTICLE Table of Contents  
Ahead of print publication
Predicting basal insulin rates on insulin pumps in Indian patients with type 1 diabetes: The rule of 5


 Kovai Medical Center and Hospital, Coimbatore, Tamil Nadu, India

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Date of Submission06-Apr-2021
Date of Decision15-Jun-2021
Date of Acceptance22-Jun-2021
Date of Web Publication19-Jul-2021
 

  Abstract 


Aims: To guide diabetes practitioners on setting up of basal rates in patients initiated on continuous subcutaneous insulin pump therapy (CSII) in India. Methods: Fifty patients on CSII for more than six months duration and stable glycemic control were analysed for mean basal rates. Results: Five basal rates per day with a thumb rule of 55% basal and 45 % bolus seems a good starting point for patients initiated on CSII therapy in the sub-continent. Conclusions: Our pilot study should guide medical professionals in setting up basal rates during CSII initiation to optimise glycemic control efficiently.

Keywords: Basal rates, Indian population, insulin pump, type 1 diabetes


How to cite this URL:
Swaminathan K. Predicting basal insulin rates on insulin pumps in Indian patients with type 1 diabetes: The rule of 5. Apollo Med [Epub ahead of print] [cited 2021 Nov 30]. Available from: https://www.apollomedicine.org/preprintarticle.asp?id=321829





  Introduction Top


The burden of type 1 diabetes is increasing exponentially in India with an (under) estimated 128,000 children and adolescents affected.[1] The numbers are increasing by 3%–5% per annum.[2] There is accumulating evidence for the benefit of continuous subcutaneous insulin infusion (CSII) for selected patients with type 1 diabetes in terms of reductions in glycosylated hemoglobin, recurrent hypoglycemias,[3] reductions in micro and macrovascular outcomes.[4],[5] However, such therapy is vastly underutilized in a country like India due to a multitude of factors including costs but more importantly, poor awareness of insulin pump therapy among medical professionals dealing with type 1 diabetes. In our experience, one of the major reasons for patient dropout during the trial period of insulin pump therapy is erratic glucose fluctuations due to improper basal and bolus rate settings. Our aim is to give guidance to medical professionals on the basal rate settings for patients from the Indian subcontinent based on our experience, so that patient dropouts can be minimized during the initial 2 weeks of pump trial.


  Methods Top


All the patients were selected from the type 1 diabetes database from Kovai Medical Center and Hospital, Coimbatore, India. Inclusion criteria were the following: patients on insulin pump therapy for >6-month duration with a last value of glycosylated hemoglobin <7.5%, regular follow-up with no default in clinic attendances, and no major hospital admissions for the past 6 months of therapy. Excluded were patients on <6 months of therapy, glycated hemoglobin >7.5%, pregnant women, and those with comorbidities like advanced renal failure. Results were tabulated in Microsoft Excel 2010. Mean (standard deviation) was calculated. Paired t-test was used to estimate the differences between means and a P < 0.05 was considered statistically significant.


  Results Top


A total of 50 patients were selected based on the inclusion and exclusion criteria [Table 1]. The mean age was 18.7 years (8.3) and the body mass index (BMI) was 19.0 (4.1). The mean duration of insulin pump therapy was 13.6 months (7.5). The last glycosylated hemoglobin was 7.1%. The mean total daily dose (TDD) was 47.3 units with a basal and bolus split of 25.8 and 21.5 units, respectively. The mean basal rates for 24 h were 0.8 units/h. The basal rates were largely split into 5 different time settings: 12–4 a.m., 4–8 a.m., 8–4 p.m., 4–8 p.m., and 8–12 midnight. The mean basal rates for these five settings were as follows: 0.77, 0.83, 1.0, 0.95, and 0.83, respectively. Data were analyzed for those <20 years of age versus patients >20 years of age on insulin pump therapy. There were no significant differences between different basal rates in both these groups: 0.76 versus 0.78 for 12–4 a.m. (p = 0.8), 0.85 versus 0.82 for 4–8 a.m. (P = 0.7), 0.97 versus 1.0 for 8-4 p.m. (p = 0.5), 0.93 versus 0.97 for 4–8 p.m. (P = 0.7), and 0.81 versus 0.84 for 8–12 midnight (P = 0.7). There were no severe hypoglycemias recorded in the preceding 6 months of therapy. The number of self-reported hypoglycemias (mild) reduced significantly from 4 episodes per month on Multiple daily insulin injections (MDI) to 1.2 episodes per month post-CSII therapy (P < 0.01) in the above cohort.
Table 1: Baseline characteristics of the insulin pump cohort (n=50)

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  Discussion Top


We present the first preliminary data from India on the mean basal rates at different time points on patients with type 1 diabetes on more than 6 months of CSII and stable glycemic control. We hope that these data can guide medical professionals in setting up the basal rates during the trial period to ensure smooth glycemic control and prevent dropouts due to erratic basal settings.

There are multiple challenges in India in initiating insulin pump therapy in indicated patients. Apart from the challenge of convincing a patient from the Indian subcontinent with type 1 diabetes from even trying out an insulin pump due to various taboos, the initial step of getting the basal and bolus settings right is an added challenge to prove the therapy during the trial period. Anecdotally, we find doctors struggling to get the basal rates correct, leading to huge fluctuations in glucose levels that demoralize an already skeptical child or their family. The balance is fine as ideally one would expect the settings to be less aggressive to prevent hypoglycemias and at the same time good enough to ensure rapid improvement in glycemic profile. There are considerable differences in calculating the basal rates (bodyweight vs. TDD) and initiating basal regimens (flat basal rates vs. different basal rates for different times of the day).

Our data show that five differential basal rates at different times of the day lead to smooth glycemic control over a period of time, as evidenced by a mean glycosylated hemoglobin of 7.1% with no severe hypoglycemias for at least 6 months of therapy. There was a small increase in basal rates at 4 a.m. consistent with the dawn's phenomenon. There were no significant differences in basal rates at ages <20 or >20 years. The mean bolus dose was 25.1 units spread across 5 boluses including three main meals and two snack boluses. A rough thumb rule of 55% basal and 45% bolus seems to be a good starting point, however, children going through puberty may have this percentage reversed.


  Conclusion Top


Overall, our pilot study should help medical professionals in India in initiating insulin pump therapy by giving an idea of the basal and bolus settings for a mean BMI of around 20, irrespective of age. While we totally agree that there may be huge individual variations based on multiple factors, some general pointers can be concluded based on our data. The rule of 5 is a simple thumb rule that providers can remember, five basal rates approximating to 0.8 units/h and five boluses for main meals and snacks. Further long-term follow-up of this cohort can be extremely helpful for creating algorithms for closed-loop pump settings in Indian population

Acknowledgments

The author wishes to acknowledge the Diabetes Team at Kovai Medical Center Hospital and Mr. Sabari Durai, Insulin Pump Therapist from Medtronic India for his expert help.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Virmani A. Type 1 diabetes in India: The numbers show the way ahead. Indian Pediatr 2019;56:189-90.  Back to cited text no. 1
    
2.
Aguiree F, Brown A, Cho NH, Dahlquist G, Dodd S, Dunning T, et al. 6th ed. IDF Diabetes Atlas. Brussels, Belgium: International Diabetes Federation; 2013.  Back to cited text no. 2
    
3.
Summers JC, Briganti EM, Fitzgerald ZA, Lambers LN, Cohen ND. Long-term effectiveness of continuous subcutaneous insulin infusion in the prevention of hypoglycemia in adults with Type 1 diabetes. Diabetes Technol Ther 2019;21:423-9.  Back to cited text no. 3
    
4.
Rosenlund S, Hansen TW, Andersen S, Rossing P. Effect of 4 years subcutaneous insulin infusion treatment on albuminuria, kidney function and HbA1c compared with multiple daily injections: A longitudinal follow-up study. Diabet Med 2015;32:1445-52.  Back to cited text no. 4
    
5.
Steineck I, Cederholm J, Eliasson B, Rawshani A, Eeg-Olofsson K, Svensson AM, et al. Insulin pump therapy, multiple daily injections, and cardiovascular mortality in 18,168 people with type 1 diabetes: Observational study. BMJ 2015;350:h3234.  Back to cited text no. 5
    

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Correspondence Address:
Krishnan Swaminathan,
Kovai Medical Center and Hospital, Coimbatore - 641 014, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_30_21




 
 
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