terapia con microinfusore nel paziente con diabete tipo 2 · terapia con microinfusore nel paziente...
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Terapia con microinfusore nel paziente con diabete tipo 2
Giorgio Grassi Endocrinologia Diabetologia e Metabolismo
Citta della Salute e della ScienzaTorino
6/10/2017
Conflitto di interessi
Confronto tra terapieMULTI-INETTIVA
MICROINFUSORE REPOSE, 2017
Funzioni avanzate
CALCOLATORE DI BOLO
BOLI COMBINATI
BASALE TEMPORANEA
Calola il bolo in base a:Quantit di CHORapporto I/CHOGlicemia correnteInsulina in circolo
Riduzione o aumento dei valori di basale per un breve tempo prestabilito
Caratteristiche del microinfusore
Continuous subcutaneous insulin infusion in diabetes: patient populations, safety, efficacy, and pharmacoeconomics
Diabetes/Metabolism Research and Reviews Volume 32, Issue 1, pages 21-39, 22 JUN 2015
http://onlinelibrary.wiley.com/doi/10.1002/dmrr.v32.1/issuetoc
Distribuzione Regionale Pazienti in CSIIIndagine 2013
Grafico1
Lombardia
Lazio
Sicilia
Piemonte
Campania
Emilia Romagna
Veneto
Puglia
Toscana
Marche
Sardegna
Friuli Venezia Giulia
Liguria
Abruzzo
Trentino Alto Adige
Calabria
Umbria
Basilicata
Molise
Valle d'Aosta
Regioni
Numero di pazienti
1923
1447
1364
668
615
557
535
537
465
340
282
271
259
247
129
105
91
62
61
4
Sheet1
LombardiaLazioSiciliaPiemonteCampaniaEmilia RomagnaVenetoPugliaToscanaMarcheSardegnaFriuli Venezia GiuliaLiguriaAbruzzoTrentino Alto AdigeCalabriaUmbriaBasilicataMoliseValle d'Aosta
1923144713646686155575355374653402822712592471291059162614
Commercially insured US adults (aged 18-64 years) with insulin-requiring diabetes who transitioned from MDII to CSII between July 1, 2009, and June 30, 2012 ("CSII initiators"; n = 2539), or who continued using MDI (n = 2539).
large spike in total medical expenditure after receiving the pump (Q3 for most clients)
Modest differences persisted after Q3, reflecting ongoing expenditures for pump supplies and follow-up encounteres.
A1C reduction 0,46% than MDI control in 2 year (P=.0003) and 0,32% lower in 3 year (P = .047). CSII initiators had higher rate of hypoglycemia 1 year after index date (P = .002)
Comparative effectiveness and costs of insulin pump therapy for diabetes.
OBJECTIVES: Continuous subcutaneous insulin infusion (CSII), or "insulin pump" therapy, is an alternative to multiple daily insulin injections (MDII) for management of diabetes. This study evaluates patterns of healthcare utilization, costs, and blood glucose control for patients with diabetes who initiate CSII.
STUDY DESIGN: Pre-post with propensity-matched comparison design involving commercially insured US adults (aged 18-64 years) with insulin-requiring diabetes who transitioned from MDII to CSII between July 1, 2009, and June 30, 2012 ("CSII initiators"; n = 2539), or who continued using MDI (n = 2539).
RESULTS: Over 3 years, mean per-person total healthcare expenditures were $1714 (95% confidence interval [CI], $1184-$2244) higher per quarter for CSII initiators compared with matched MDII patients (total mean 3-year difference of $20,565). Compared with matched controls, mean A1C concentrations became lower for CSII initiators by 0.46% in year 2 (P = .0003) and by 0.32% in year 3 (P = .047). CSII initiators also had a higher rate of hypoglycemia encounters in year 1 (P = .002).
CONCLUSIONS: For adults with insulin-requiring diabetes, transitioning from MDII to CSII was associated with modest improvements in A1C but more hypoglycemia encounters and increased healthcare expenditures, without significant improvement in other potentially offsetting areas of healthcare consumption.
Am J Manag Care. 2017 Jun;23(6):353-359.
Steineck I, et al , BMJ 2015, 350:h3234.
ECONOMIC OUTCOMES Due to the capital cost of an average insulin pump with, say, a
4-year lifetime, and the need to purchase regular pump supplies such as cannulae, reservoirs and batteries, CSII is on average about 40% more expensive than MDI in many healthcare settings.
However, pump therapy may be considered cost-effective for healthcare systems if cost savings are made in the long term, for example because CSII-induced lower HbA1c levels reduce the risk of diabetic complications developing.
Technology appraisal guidance Published: 23 July 2008
CSII and DMT2
0,0
50,0
100,0
% d
i paz
ienti
98,2%
1,8%
DM2DM1
Distribuzione dei Pazienti per Tipo di Diabete
Grafico1
CSIICSIICSII
% di pazienti
0.1584
0.0396
0.022
Grafico2
Ipoglicemie graviIpoglicemie gravi
KetoacidosiKetoacidosi
eventi/anno
*
*
MDI
CSII
eventi/anno
0.284
0.125
0.435
0.08
Foglio1
IpoglicemieMDICSIIRicoveriMDICSIIVantaggiFlessibilit pasti13.04
Media0.2840.125Media0.5160.23%Autonomia superiore26.81
DS0.6160.609DS0.690.69Maggior benessere40.58
ES0.540.053ES0.060.059Maggior libert40.58
p
1 out of 4 T2DM patients on MDI* is poorly controlled1
Poor glycaemic control increases complications rates 2 to 3 fold2
65,574,5
103,2
124,9
14,222,8
40,4
57,8
7% to
CHALLENGES OF MDI FOR TYPE 2 DIABETES
The limitations of MDI highlight the need for new treatment strategies in this subgroup of patients ?
51% of type 2 patients on MDI are in poor control (HbA1c>8%)1
Increased risk of hypoglycemia and weight gain as insulin regimens intensify2
Increased risk of diabetes related complications associated with hyperglycemia3
57% of patients admit to noncompliance by omitting insulin injections4
1 Annali AMD 2011. http://www.aemmedi.it/pages/annali_amd/2Reznik Y, Cohen O, Aronson R, et al. Insulin pump treatment compared with multiple daily injections for treatment of type 2 diabetes. Lancet 2014; 384:1265-72.3Stratton I, et al. Asssociation of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35). BMJ 2000;321;405-412.4 Peyrot M, Rubin RR, Kruger DF, Travis LB. Correlates of insulin injection omission. Diabetes Care. 2010 Feb; 33(2): 240-5
Exp Clin Endocrinol Diabetes. 2009 May;117(5):220-2Continuous subcutaneous insulin infusion versus multiple daily insulin injections in type 2 diabetes: a meta-analysis.Monami M1, Lamanna C, Marchionni N, Mannucci E.
RESULTS: A total of 4 RCTs was included in the analysis. CSII did notproduce any significant improvement of HbA1c in comparison with MDI (Standardized difference in mean: 0.09(-0.08;0.26)%; p=0.31). No significant difference was observed in the rate of hypoglycemicepisodes. CSII was associated with a nonsignificant trend toward the reduction of insulin doses used at the end of trial.
CONCLUSIONS: Available data do not justify the use of CSII for basal-bolus insulin therapy in type 2 diabetes
https://www.ncbi.nlm.nih.gov/pubmed/19301231https://www.ncbi.nlm.nih.gov/pubmed/?term=Monami%20M%5BAuthor%5D&cauthor=true&cauthor_uid=19301231https://www.ncbi.nlm.nih.gov/pubmed/?term=Lamanna%20C%5BAuthor%5D&cauthor=true&cauthor_uid=19301231https://www.ncbi.nlm.nih.gov/pubmed/?term=Marchionni%20N%5BAuthor%5D&cauthor=true&cauthor_uid=19301231https://www.ncbi.nlm.nih.gov/pubmed/?term=Mannucci%20E%5BAuthor%5D&cauthor=true&cauthor_uid=19301231
CSII THERAPY IN NEWLY DIAGNOSED T2D PATIENTS
The clinical study on short term CSII therapy at onset of the disease, published in 2008 by Weng et al., demonstrated thatearly use of CSII can sustain prolonged glycemic clinicalremission, protecting residual -cell function
CSII in type 2: Latest articles published
Glycemic control duringcontinuous subcutaneousinsulin infusion versus multiple injections in type 2 diabetes: individual patient data metaanalysis and meta-regression of randomized controlled trials. John C. Pickup, Diabetes Care, Vol 43, May 2017
Factors associated with improvedglycemic control followingsubcuttaneous insulin infusion therapy in patients with type 2 diabetes uncontrolled with bolus-basal insulin regimen: an analysisfrom the OpT2ise randomized trial. Muriel Metzger et al, Diabetes Metabolism and Obesity, in press.
Factors affecting the benefit of insulin dose intensification in people with Type2 diabetes: an analysis from the OpT2mise randomized trial.Schtz-Fuhrmann, J. et al.,Diabet Med. 2017 Feb;34(2)
Glycemic Control During Continuous Subcutaneous Insulin Infusion Versus Multiple Daily Insulin Injections in Type 2 Diabetes: Individual Patient Data Meta-analysis and Meta-regression of Randomized Controlled Trials
Diabetes Care Volume 40, May 2017
20Presentation Title (Edit on Slide Master) | June 1, 2015 | Confidential, for Internal Use Only
CHANGE IN A1C FROM BASELINE TO 6 MONTHS IN THE CSII AND MDI ARM ACCORDING TO BASELINE A1C
Glycemic Control During Continuous Subcutaneous Insulin Infusion Versus Multiple Daily Insulin Injections in Type 2 Diabetes: Individual Patient Data Meta-analysis and Meta-regression of Randomized Controlled Trials
Diabetes Care Volume 40, May 2017
Glycemic Control During Continuous Subcutaneous Insulin Infusion Versus Multiple Daily Insulin Injections in Type 2 Diabetes: Individual Patient Data Meta-analysis and Meta-regression of Randomized Controlled Trials
Diabetes Care Volume 40, May 2017
24Presentation Title (Edit on Slide Master) | June 1, 2015 | Confidential, for Internal Use Only
Raskin et al, 2003
Hermann et al, 2005 Wainstein et al, 2005 Berthe et al, 2007 Reznik et al, 2014
No. randomized 132 107 40 17 331
No. analyzed 115 98 29 17 331
Study design RCT, parallel RCT, parallel RCT, crossover RCT, crossover RCT, crossover
Dropout rate (%) 12.9 8.4 27.3 0 13.8
Age (years) 55.6 66.4 56.8 55.2 56.0
Diabetes duration (years)
15.4 16.2 Not given 16.8 15.1
Study duration (months)
24 12 4.5 3 6
Baseline A1C 8.1 8.6 9.6 9.0 9.0
Baselin insulin (u/kg) 0.72 0.77 1.16 1.04 1.10
MDI regimen Aspart before meals, isophane (novolin M) once or twice daily as basal
Lispro before meals, glargine once daily as basal
Actrapid or humalin R before meals, isophane (insulatard/ humalin N) as basal
Humalog mix 50 (lispro/Isophane) three times daily.
Asapart, Lispro or glulisine before meals, glargine or detemir as basal
Trial features No run-in period Older adults w type 2 diabetes.
Trial stopped early Baseline imbalances sex,
insulin dosage, weight)
Original data file lost, IPD analysis performed on original statistics files
Did not record BMI All participants obese Several discrepancies
between results in article and IPD
Discrepancies of labelling and citing of tables and figures in article
No missing data No washout period between
period 1 and 2 Baseline group imbalance for
age Baseline A1c for period 2 not
used in published analysis Some evidence of carryover
Participants had 2 months run-in in optimization of control on MDI; only those with A1C > 8% and insulin 0.7-1.8U/kg after run-in were randomized
Good agreement between article and IPD results
25Presentation Title (Edit on Slide Master) | June 1, 2015 | Confidential, for Internal Use Only
Conclusion from the meta analysis
A1C reduction is dependent on pre-randomization A1C levels with A1C: from -0.15% with baseline of 8.0% to -0.59% with baseline of 10%
Overall mean reduction in A1C is -0.4% for a mean A1C of 8.8% at baseline. Insulin dose reduction goes from -23.6 u/day for a baseline treatment of
100 u/day up to -35.5u/day for a baseline treatment of 150u/day. Insulin dose reduction at the end of study period is -25%, irrespective of
baseline insulin treatment. A1C reduction is greater in those patients that undergo pre-randomization
insulin dose optimization. CSII in type 2 diabetes may be targeted at thosewho have failed to achive target A1C levels after best attempts with MDI.
OpT2mise INTERNATIONAL STUDY
36 CENTERS AROUND THE GLOBE:
8 Canada, 23 Europe, 2 South Africa, 3 USA
OpT2mise STUDY DESIGN
DESIGN: Randomized controlled trial with single arm
cross over Subjects: 331 adult patients randomised (35-
75 years old)
OBJECTIVE: Compare the efficacy of pump therapy and multiple injection therapy in patients with type 2 diabetes who had failed to respond to a basal-bolus regimen after optimal insulin intensification.
METHODOLOGY: Primary endpoint: Between-group difference in mean
change in HbA1c from baseline to 6 months Pump HbA1c - MDI HbA1c
Secondary endpoints (CP): Within-group differences at 12 months in HbA1c Changes in glycemic variability, insulin dosage, lipid
parameters, weight, blood pressure Time spent in hypoglycemia/hyperglycemia Patient treatment satisfaction Safety: Number of severe hypoglycemic events and
diabetic ketoacidosis events
Subjects Characteristics
PATIENT POPULATION: Insulin-taking type 2 on MDI ( 3 injections/ day) 8.0% A1C 12% Insulin dose: 0.7 to 1.8 Units/kg/day (220 units/day) Mean number of blood glucose measurement
2.5 times/ day
There were no significant differences between the groups at baseline except for HDL cholesterol (higher HDL-cholesterol concentration in the multiple injections group)
590 patients screened to enter run-in
495 patients in 8 week run-in phase
331 randomized in 6-month study phase
291 completed CP
168 assigned to CSII/CSII
163 assigned to MDI/CSII
152 CSII/CSII finished SP*
156 MDI/CSII finished SP
Study phase (SP) 6 mo
Continuation phase (CP) 6 mo
146 CSII/CSII finished CP
145 MDI/CSII finished CP*
*
CSII provides significant, sustainable and reproducible improvements in glycemic control for type 2
SIGNIFICANT1.2% HbA1c drop vs baseline in both groups after 12 months
SUSTAINABLEReduction in HbA1c maintained over 12 months
REPRODUCIBLESimilar HbA1c reduction after 2 or 8 months of optimal insulin intensification
CHANGE IN HbA1c
Majority of Patients Achieved HbA1C < 8%
Over 50% of patients are able to achieve and maintain an HbA1c < 8%
% of subjects reaching HbA1c
~19% TDD (Total Daily Dose) reduction in both groups
Reduction in TDD maintained over 12 months
INSULIN UTILISATION
REDUCTION IN INSULIN NEEDS IS MAINTAINED WITH CSII
Treatment Effect on Glucose LevelsSTUDY PHASE: CSII: Greater reduction in time spent in hyperglycemia/day
(2.8 hrs, *p
Simple Approach to Pump Therapy is also Effective
Insulin pump therapy in type 2 can be successful irrespective of:
Use of a bolus calculator
Mean # of SMBG/day
58% of the patients used manual fixed boluses
Use of Bolus Wizard was NOT associated with greater A1C reduction
Simple bolus regimen use(fixed meal bolus, no bolus calculator)
Fingerstick testing (Mean # SMBG/ day)
HbA1c reduction was NOT related to mean number of SMBG performed per day
Additional Benefits of CSII Observed
SAFETY AND OTHER RESULTS No ketoacidosis events Severe hypoglycemia
One episode occurred in CSII/CSII groupTwo episodes occurred in MDI/CSII group (with same patient)
7 diabetes, device or study procedure related SAEs occurred in the CSII/CSII group, and 11 in the MDI/CSII group
LIPID PARAMETERS AND WEIGHT No significant differences were seen in any lipid parameters No significant differences were seen in body weight change
OpT2mise 12 Month Results Summary
MiniMed pump therapy treatment in sub-optimally controlled T2 MDI provides significant improvements in overall glucose control: Significant decreases in A1C levels (-1.2% vs baseline in both groups) over 1 year More than half of all patients achieved A1C < 8% Significant and sustained reduction of insulin dose when switched to CSII Increased and sustained patient satisfaction when switched to CSII No significant difference in body weight gain Simple approach to pump therapy is also effective
36Presentation Title (Edit on Slide Master) | June 1, 2015 | Confidential, for Internal Use Only
Mean Annual Expenditure: insulin and AntidiabeticsMedication
Am J Manag Care. 2014;20(11):e490-e497
Insulin Expenditure (by year) Relative to the year of Switch
Am J Manag Care. 2014;20(11):e490-e497
Switching from Multiple Daily Injections to CSII Pump Therapy: Insulin Expenditures in Type 2 Diabetes
Take-Away Points
The primary objective of this study was to identify the impact of switchingfrom multiple daily injections (MDIs) to continuous subcutaneous insulin infusion (CSII) pump therapy on insulin and other antidiabetic medicationexpenditures in individuals with type 2 diabetes mellitus.
This study demonstrated a significant reduction in insulin expendituresamong MDI patients who switched to CSII pump therapy throughout the study period.While insulin expenditures rose during the study period, switching to CSII pump therapy led to sizable reductions in insulin expenditures.
This reduction in insulin expenditures due to switching varied between$657 (SE $126; P
Cost-effectiveness CSII in DMT2: Cost-effectiveness of continuous subcutaneous insulin infusion in people with type 2 diabetes in the Netherlands
In the Netherlands, CSII represents a cost-effective option in patients with type 2 diabetes who continue to have poorly-controlled HbA1c despite optimization of MDI. Since the ICER falls below the willingness-to-pay threshold of EUR 80,000 per QALY gained, CSII is likely to represent good-value for money in the treatment of poorly-controlled T2D patients compared with MDI.
JOURNAL OF MEDICAL ECONOMICS, 2016 VOL. 19, NO. 8, 742749
reduction of complications and associatec costs for type 2 Diabetic Patients Using Continuoussubcutaneous insulin infusion in tHe Uk Methods: The incidence of diabetes-related complications was calculated
based on the Core Diabetes Model. The population characteristics, the reduction of HbA1c, and insulin dose were based on the Opt2mise
Results: The diabetes-related complications were reduced with CSII. At 5 years, the incidence reduction in complications associated with eyediseases, renal diseases, ulcer/amputation and cardiovascular diseaseswere -24%, -26%, -19% and -10%, respectively, in favour of CSII.
conclusions: Improvements in HbA1c with a decrease in overall insulinrequirements observed with CSII versus MDI, may offer importantreductions in diabetes-related complications and associated costs in a UK setting for uncontrolled T2DM patients.
VALUE IN HEALTH 18 (2015) A335A766
Only 6 of the 22 guidelines identified
Only 6 of the 22 guidelines identified
lombardia CSII
Maurizi AR, Suraci C, Pitocco D, Schia ni R, Tubili C, Morviducci L, et al.; C.S.I.I. Study Group of Lazio Region Italy. Position Statement on the management of continuous subcutaneous insulininfusion (CSII): e Italian Lazio experience. J Diabetes 2016;8:41-4
Indicazioni alla terapia con CSII
Grafico1
Scadente compenso glicemico
Ipoglicemia
Gravidanza
Qualit vita
Orari flessibili
Basso fabbisogno insulinico
Fenomeno alba
Percentuale centri
90
70
44
43
26
19
17
Sheet1
Scadente compenso glicemicoIpoglicemiaGravidanzaQualit vitaOrari flessibiliBasso fabbisogno insulinicoFenomeno alba
90704443261917
Numero nuovi pazienti avviati alla CSII suddivisi per anno di avvio
* primi 5 mesi dellanno
Grafico1
2000 e preced.
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
*
N.pz.avviati alla CSII
300
320
208
306
403
592
704
872
1078
1139
1201
1008
1268
615
Foglio1
N.pz.avviati alla CSII
2000 e preced.300
2001320
2002208
2003306
2004403
2005592
2006704
2007872
20081078
20091139
20101201
20111008
20121268
2013615
Per ridimensionare l'intervallo di dati del grafico, trascinare l'angolo inferiore destro dell'intervallo.
PaQ
Up to 3 days of continuoussubcutaneous insulindelivery
Worn on the abdomen 7 preset basal doses 2 bolus units delivered
with each button push Delivers up to 330 units
over 3 days
Possibile ruolo di patch pump easy ?
COMBINATION THERAPY BASED ON CSII THERAPY IN ADDICTION TO NOVEL ANTI-HYPERGLYCEMIC AGENTS
Recently CSII treatment has been tested in combination with new anti-hyperglycemic agents.
Ke et al. investigated the effects of liraglutide combined with short term CSII therapy on glycemic control and -cell function in newlydiagnosed T2D patients. e combined treatment was effective in furtherimproving -cell function, but the beneficial effects disappeared afterstopping liraglutide
When Intensive Insulin Therapy (MDI) Fails in Patients With Type 2 Diabetes: Switching to GLP-1 Receptor Agonist Versus Insulin PumpDiabetes Care 2016;39(Suppl. 2):S180S186
Patients who have not previously failed GLP-1 receptor agonisttherapy may show reduc- tion in weight and insulin dose, in additionto moderate improvement in HbA1c, when GLP-1 receptor agonisttherapy is added to MDI regimens.
In subjects with long-standing type 2 diabetes who do not respond to intensive insulin therapies, switching from MDI to CSII and/or the addition of GLP-1 receptor agonists to MDI have the potential to improve glycemic control without increasing the risk of adverseevents.
Diabetes Care Volume 39, Supplement 2, August 2016
Insulin pump therapy in type 2 diabetes is effective at lowering HbA1c levels, but, as with type 1 diabetes, it should be targeted at those persons with worst glycemic control and highest insulin dose after best attempts with MDI
%>18 anni
Distribuzione dei Pazienti per Et
Grazie !
Terapia con microinfusore nel paziente con diabete tipo 2 Conflitto di interessiConfronto tra terapieDiapositiva numero 4Continuous subcutaneous insulin infusion in diabetes: patient populations, safety, efficacy, and pharmacoeconomicsDiapositiva numero 6Commercially insured US adults (aged 18-64 years) with insulin-requiring diabetes who transitioned from MDII to CSII between July 1, 2009, and June 30, 2012 ("CSII initiators"; n = 2539), or who continued using MDI (n = 2539).A1C reduction 0,46% than MDI control in 2 year (P=.0003) and 0,32% lower in 3 year (P = .047). CSII initiators had higher rate of hypoglycemia 1 year after index date (P = .002)Comparative effectiveness and costs of insulin pump therapy for diabetes.Diapositiva numero 10ECONOMIC OUTCOMES CSII and DMT2Diapositiva numero 13Diapositiva numero 14CHALLENGES OF MDI FOR TYPE 2 DIABETESExp Clin Endocrinol Diabetes.2009 May;117(5):220-2Continuous subcutaneous insulin infusion versus multiple daily insulin injections in type 2 diabetes: a meta-analysis.Monami M1,Lamanna C,Marchionni N,Mannucci E.CSII THERAPY IN NEWLY DIAGNOSED T2D PATIENTS CSII in type 2: Latest articles publishedGlycemic Control During Continuous Subcutaneous Insulin Infusion Versus Multiple Daily Insulin Injections in Type 2 Diabetes: Individual Patient Data Meta-analysis and Meta-regression of Randomized Controlled Trials Diapositiva numero 20Diapositiva numero 21Glycemic Control During Continuous Subcutaneous Insulin Infusion Versus Multiple Daily Insulin Injections in Type 2 Diabetes: Individual Patient Data Meta-analysis and Meta-regression of Randomized Controlled Trials Glycemic Control During Continuous Subcutaneous Insulin Infusion Versus Multiple Daily Insulin Injections in Type 2 Diabetes: Individual Patient Data Meta-analysis and Meta-regression of Randomized Controlled Trials Diapositiva numero 24Conclusion from the meta analysisOpT2mise INTERNATIONAL STUDYOpT2mise STUDY DESIGNSubjects CharacteristicsCSII provides significant, sustainable and reproducible improvements in glycemic control for type 2Majority of Patients Achieved HbA1C < 8% Diapositiva numero 31Treatment Effect on Glucose LevelsSimple Approach to Pump Therapy is also Effective Additional Benefits of CSII ObservedOpT2mise 12 Month Results SummaryDiapositiva numero 36Mean Annual Expenditure: insulin and Antidiabetics Medication Insulin Expenditure (by year) Relative to the year of SwitchSwitching from Multiple Daily Injections to CSII Pump Therapy: Insulin Expenditures in Type 2 Diabetes Cost-effectiveness CSII in DMT2: Cost-effectiveness of continuous subcutaneous insulin infusion in people with type 2 diabetes in the Netherlands reduction of complications and associatec costs for type 2 Diabetic Patients Using Continuous subcutaneous insulin infusion in tHe UkDiapositiva numero 42Diapositiva numero 43lombardiaDiapositiva numero 45Diapositiva numero 46Numero nuovi pazienti avviati alla CSII suddivisi per anno di avvioPaQCOMBINATION THERAPY BASED ON CSII THERAPY IN ADDICTION TO NOVEL ANTI-HYPERGLYCEMIC AGENTSWhen Intensive Insulin Therapy (MDI) Fails in Patients With Type 2 Diabetes: Switching to GLP-1 Receptor Agonist Versus Insulin Pump Diabetes Care 2016;39(Suppl. 2):S180S186 Diapositiva numero 52Grazie !