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Advancing the Treatment of Diabetes With Insulin and TechnologyIntroductionThis is an exciting time in diabetes management. There have been several advancements in the treatment of diabetes with insulin including the ability to overcome barriers to insulin use, the establishment of standardized protocols for initiating insulin, advancements in insulin pumps and continuous glucose sensor monitoring, breakthroughs in insulin technology, and increasing patient autonomy. The Diabetes Control and Complications Trial and the UK Prospective Diabetes Study were benchmark studies that have shown that good glycemic control can reduce the risk of diabetic complications and poor outcomes. Still, in the years since the publication of the initial results, most patients have not been able to achieve target blood glucose control. In fact, the average A1C level has risen in the United States. Clinicians should not, however, be discouraged. There are better tools in the way of new insulin analogs, with more physiologic time-action profiles, greater predictability, and reproducibility. The use of insulin-delivery devices, from pens to pumps, is increasing and providing more accurate delivery of insulin in a more patient-friendly manner. Along with this is the ability to monitor the results of insulin therapy and to make appropriate insulin adjustments. In addition, progress is being made toward achieving an "artificial pancreas." Couple this with the team approach: the involvement of physicians, pharmacists, nurses, dietitians, physician assistants, diabetes educators, and the patients themselves. It is easy to see where this is headed: better glycemic control for patients, young and old, with type 1 and type 2 diabetes. This supplement provides valuable information on how challenges can be overcome and how to work together to improve the care of patients. In the first article, Jerry Meece reviews the many myths that exist about insulin therapy, which have contributed to the reluctance to initiate or advance its use, particularly in patients with type 2 diabetes. He reviews these challenges and provides the science to share with patients on the benefits of insulin therapy. Jan Pearson and Margaret A. Powers share the successful use of standardized diabetes management in their institution and the options for insulin initiation, which factor in patient characteristics, and provide a roadmap to initiate and titrate to achieve and maintain glycemic targets. Susan Owen takes us through the challenges of caring for children with type 1 diabetes. She shows the benefits of insulin pump therapy and confirms that there is no lower age limit for introducing this technology to patients. Steven D. Wittlin then discusses the entire spectrum of diabetes and looks more closely at how fasting and prandial glucose excursions contribute to A1C levels and how to target them for glycemic control. In addition, he discusses patient types in more detail (ie, obese patients with insulin resistance, patients with atypical diabetes, patients with latent autoimmune diabetes in adults, and patients with lean type 2 diabetes and insulinopenia) and the changing nature of adult patients with diabetes, including the elderly and the role of insulin pumps in these patients. Finally, Lynda K. Fisher addresses the future by discussing the role of continuous glucose sensor monitoring used in association with continuous subcutaneous insulin infusion to adjust to changing glycemic needs.
The Diabetes Educator, Vol. 32, No. 1,
7S-8S (2006)
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