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prevention in primary health care of hypertensive solutions of these problems in the family doctor's patients are highlighted. Authors outline possible practice.
Материал поступил в редакцию 20.11.2012 г.
U.D.C. 616.43;616-008.9;616.39
N. Toktarova1, A. Muratalina2, A. Tulegalieva2, G. Kulkaeva2, A. Sagyndykova, S. Lee2, J. Welsh2, G.
orozslan2, L. Yedigarova2, f. Kaufman2
1National scientific medical recarch center, Astana, Kazakhstan
2Ministry of health of Republic of Kazakhstan
INSULIN PUMP IMPLEMENTATION IN KAZAKHSTAN
Objective. To introduce insulin pump therapy to children age 5-15 years with type 1 diabetes in Kazakhstan in order to improve glycemic control and HbAlc levels. An efficient collaborative program was developed involving, industry, and local healthcare providers in all regions of the country.The first child was started on pump therapy in February, 2012, and there were 589 children using this technology as of October, 2012. Pediatric endocrinologists from all regions attended systematized training and are currently implementing a surveillance program to ensure optimal long-term clinical outcomes. The program provides an example for successful deployment and adoption of advanced technologies for the treatment of children with type 1 diabetes in countries such as the Republic of Kazakhstan.
Key words: Kazakhstan, type 1 diabetes, children, insulin pump therapy, HbA1c, treatment efficacy.
Introduction. Type 1 diabetes is an autoimmune disease usually diagnosed in children and young adults. Its incidence is dramatically increasing; the annual rise in Europe was about 3.9% in the past several years [1]. Despite the advances in diabetes care, type 1 diabetes remains a serious cause of morbidity and mortality among young patients [2-4, and as a result, the lifespan of patients with type 1 diabetes is shorter by approximately 19 years in comparison with healthy children [5].
Insulin therapy through one or more daily injections was previously the only treatment option for children with type 1 diabetes in Kazakhstan. Achieving and maintaining optimal glycemia was difficult for the majority of children and adolescents, due to the complex interplay of insulin, food and activity in the face of growth and rapidly-changing energy needs [6,7]. Numerous studies in recent years have demonstrated that optimal glycemic control prevents type 1 complications and reduces the risk of macro- and microvascular problems in the kidneys, lower limbs and retina [8]. Sustained euglycemia also reduces the rates of the most severe acute complications of type 1 diabetes, such as hypoglycemic coma and ketoacidosis [9].
Currently, optimal glucose control in patients with type 1 diabetes is achieved with intensive diabetes management employing multiple doses of insulin, including the usage of insulin pumps [10], frequent monitoring of glucose levels, and matching
insulin doses with carbohydrate intake. At the present time, insulin pump therapy is the most physiological way to deliver basal bolus insulin therapy, to match insulin delivery with carbohydrate intake, and to prevent the late complications of diabetes. Insulin pump therapy has been shown to lower HbA1c, reduce severe hypoglycemia, and improve quality of life when compared to conventional therapy[11]. Although insulin pump therapy is widely used for the management of diabetes in the developed world, fewer than 1% of patients are using this therapy in former Soviet Union countries.
Methods. An effective model for the implementation of insulin pump therapy program for children age 5-15 years with type 1 diabetes in the Republic of Kazakhstan was developed with the goal of optimizing their glycemic control. The Kazakhstan government provided funding for purchasing and installation of 790 insulin pumps. Insulin pumps (Medtronic Minimed 554 (Paradigm® Veo, Figure 1) and appropriate consumables such as reservoirs and infusion sets were purchased under the terms of the tender. Rapid-acting insulin analogs were used in the pumps. Medtronic, Inc. conducted multiple trainings for the physicians and nurses on the basics of insulin pump therapy in type 1 diabetes; educational brochures for physicians' and patients' education were developed as well.
Figure 1. Insulin pump
Currently Veo is the only insulin pump that has continuous glucose monitoring function with low glucose suspend (LGS). LGS prevents patients from potentially experiencing dangerous hypoglycemic episodes and is considered the first step in artificial pancreas development.
Results. A pediatric endocrinologist and a nurse were identified in each of 16 regions. In a short period of time (January - May 2012), 17 pediatric endocrinologistsweretrainedoninsulinpumptherapy in specialized centers in the United States, Russia, Israel, and Slovenia. Two educational seminars on the basics of pump therapy, led by leading pediatric endocrinologists from the US and Europe, were conducted in Kazakhstan in January and May of 2012. Several Kazakh physicians traveled to Israel and Slovenia to attend advanced training classes on pump therapy. Multiple training sessions and round table discussions with experts to address the questions arising during implementation of insulin pump therapy in Kazakhstan were organized in the framework of different international congresses and conferences (ADA, Philadelphia, USA, June, 2012; Almaty, Kazakhstan, June, 2012; Moscow, Russia, September, 2012; ISPAD, Istanbul, Turkey, October, 2012).Thus, pediatric endocrinologists in all regions of the country received necessary comprehensive training for the optimal management of the patients with type 1 diabetes on insulin pump therapy.
Leading specialists from the US and Europe provided not only lectures and training sessions for the physicians, but also met with the patients
and their parents during this project. Physicians, patients, and their parents received instructions and guidelines on type 1 diabetes management, detailed recommendations on insulin pump therapy, including step-by-step user's guide for the pumps, as well as tables for the initial calculations related to bolus insulin delivery.
Some parameters were revised based on local needs. It is well known that proper carbohydrate calculation in each meal is extremely important to achieve adequate glycemic control and is the key to successful treatment. Unfortunately, most of the foods in Kazakhstan do not have information on carbohydrate quantity. It was recommended to patients and their parents that they should convert carbohydrate grams to exchange units based on the estimate that 1 exchange unit is equal to 15 g of glucose. In addition, it was recommended that each meal not exceed 4-5 exchange units.
The first insulin pump was installed in February 2012, and there were 589 patients participating in the program as of October 2012. The number of patients by region varied from 11 to 105 (Figure 2), and the mean age in each region varied slightly (Figure 3). Pump data is regularly downloaded with CareLink Pro. Data analysis allows for the provision of therapy adjustments as well as advising patients on dietary compliance and lifestyle modifications. Treatment adjustments are made depending on a child's level of activity, such as school time activities, other physical activities and vacations.
Number of Patients by Region
120 100 SO 60 40 20
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Figure 2. Number of patients by region
Figure 3. Mean age of children starting on insulin pump therapy
by region
There were no significant problems noted with the placement and care of the infusion sites, nor were serious adverse effects or severe complications reported during program implementation. None of the patients refused pump therapy during the program.
Conclusion. The above-described model of implementation of insulin pump therapy provides a foundation for dissemination of these advanced treatment technologies for patients with type 1 diabetes around the globe. Baseline data on this cohort of Kazakh children with type 1 diabetes suggest that they have less-than-optimal glycemic control and that insulin pump therapy may be an
effective treatment regardless of age and duration of the disease by allowing for flexible insulin delivery based on their diet, physical activity, and glucose levels. Target A1C values and treatment guidelines have been provided by the International Society for Pediatric and Adolescent Diabetes (ISPAD) as well as local healthcare provider organizations. The goal of meeting these targets is to improve growth, well-being and to prevent the long-term complications of this disease. Long-term data are necessary to confirm the expected improvements in glycemic control and quality of life in the participants of this collaborative project in the Republic of Kazakhstan.
References
1.
2.
Patterson CC, Dahlquist GG, Gyurus E, et al. Incidence trends for childhood type 1 diabetes in Europe during 1989-2003 and predicted new cases 2005-20: a multicentre prospective registration study. Lancet, 2009 Jun 13;373(9680):2027-33.
Vehik K, Dabelea D. The changing epidemiology of type 1 diabetes: why is it going through the roof? Diabetes Metab Res Rev. 2011 Jan;27(1):3-13
3. Nathan DM, Cleary PA, Backlund JY, Genuth SM, Lachin JM, Orchard TJ, Raskin P, Zinman B: Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group: Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med 2005, 22: 2643-2653
4. Vehik K, Hamman RF, Lezotte D, et al. Childhood growth and age at diagnosis with Type 1 diabetes in Colorado young people. Diabet Med. 2009 Oct;26(10):961-7
5. Narayan KM, Boyle JP, Thompson TJ, Sorensen SW Williamson DF. Lifetime risk for diabetes mellitus in the United States. JAMA. 2003;290(14):1884-1890
6. Favalli V, Bonfanti R, Meschi F, et al. Long term efficacy of insulin pump therapy in preschool children with diabetes. Pediatr Med Chir. 2012 May-Jun;34(3):129-32.
7. Petryaykina E.E., Duhareva O.V., Rybkina I.G. et al. Insulin pump therapy in children and adolescents with type 1 diabetes in the Moscow region. " "Diabetes mellitus"", 2009, № 3, 60-63
8. Hofer S., Meraner D., Koehle J. Insulin pump treatment in children and adolescents with type 1 diabetes. Minerva Pediatrica 2012 August;64(4):433-8
9. National Institutes of Health-National Institute of Diabetes and Digestive and Kidney Diseases. 1997. Diabetes mellitus: challenges and opportunities. Final report and recommendations. Report of an NIH-NIDDK Conf. Bethesda, MD, Sept. 4-5, pp. 37-38
10. Fox L.A., Buckloh L.M., Smith S.D., Wysocki T., Mauras N. A randomized controlled trial of insulin pump therapy in young children with type 1 diabetes Diabetes Care. 2005; 28: 1277- 1281.
11. Hirose M, Beverly EA, Weinger K. Quality of life and technology: impact on children and families with diabetes. Curr Diab Rep. 2012 Dec;12(6):711-20.
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Зерттеудщ манаты Казахстан
Республикасында 5 пен 15 -ке дешнп жас тобы бойынша 1 типт кант диабет бар наукастарда (СД1) кeмiрсу алмасуын бакылауды жетiлдiру мен гликирленген гемоглобиннщ (HbAlc) де^гешн темендету Yшiн помпалы инсулинмен емдi енпзу. Аталмыш ем тYрiн енпзудщ 8серi жогары моделi ^азакстан Республикасыньщ барлык
аймактарында баедарламаны жузеге асыру Yшiн жасалган болатын. Алгашкы инсулиндi помпа 2012 жылдыщ акпанында орныктырылды. Осы жылдыщ караша айындагы м8лiметтер бойынша 589 бала помпалы емде. Барлык аумактардагы балалар эндокринологтары осы багытта б^мш толыктырып, осы емдi ке^нен колдануда.
Казахстанская модель внедрения помповой инсулинотерапии
Цель: Внедрение помповой инсулинотерапии у больных сахарным диабетом 1 типа (СД1) в возрастной группе от 5 до 15 лет в Республике Казахстан для достижения оптимального контроля углеводного обмена и снижения уровня гликированного гемоглобина (НЬА1с). эффективная модель внедрения помповой инсулинотерапии была разработана для
осуществления программы на всей территории Республики Казахстан. Первая инсулиновая помпа была установлена в феврале 2012. По состоянию на октябрь 2012 количество детей на помповой терапии - 589. Детские эндокринологи во всех регионах страны получили необходимое многоуровневое обучение и успешно применяют инновационный метод лечения СД1.
The material of post-saws in a release 02.10.2012
