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 !