Continuous Subcutaneous Insulin Infusion Versus Multiple Daily Injections

Abstract

OBJECTIVE -Rapid-acting insulin analogs (insulin lispro and insulin aspart) have emerged as the meal insulin of choice in both multiple daily insulin injection (MDII) therapy and continuous subcutaneous insulin infusion (CSII) for type 1 diabetes. Thus, a comparison of efficacy between CSII and MDII should be undertaken only in studies that used rapid-acting analogs for both intensive regimens.RESEARCH DESIGN AND METHODS -We performed a pooled analysis of the randomized controlled trials that compared CSII and optimized MDII therapy using rapid-acting analogs in adults with type 1 diabetes.RESULTS -The three studies that met inclusion criteria provided data on 139 patients, representing 596 patient-months for CSII and 529 patient-months for MDII. Mean age was 38.5 years, with duration of diabetes of 18.0 years. The studies differed significantly in mean baseline A1c (7.95, 8.20, and 9.27%). The pooled estimate of treatment effect comparing the percentage reduction in A1c by CSII with that by MDII (CSII Ϫ MDII) was 0.35% (95% CI Ϫ0.10 to 0.80, P ϭ 0.08) using a random effect to account for heterogeneity between studies. Importantly, the interaction between baseline A1c and treatment modality emerged as an independent predictor of treatment effect (CSII Ϫ MDII) (P ϭ 0.002). The relative benefit of CSII over MDII was found to increase with higher baseline A1c. A model derived from these data predicts that in a patient with a baseline A1c of 10%, CSII would reduce the A1c by an additional 0.65% compared with MDII. Conversely, there would be no A1c benefit of CSII compared with MDII if baseline A1c were 6.5%. There was no significant difference between CSII and MDII in the rate of hypoglycemic events.CONCLUSIONS -When using rapid-acting insulin analogs in CSII and MDII regimens in adult patients with type 1 diabetes, insulin pump therapy is associated with better glycemic control, particularly in those individuals with higher baseline A1c. Thus, CSII emerges as an important modality for implementing intensive therapy and may be uniquely advantageous in patients with poor glycemic control.

Continuous subcutaneous insulin infusion versus multiple daily insulin injections in patients with diabetes mellitus: systematic review and meta-analysis

“…It should also be noted that the heterogeneity is not so much caused by qualitatively different results, but by quantitative differences. From these limitations it is clear that the results obtained from this meta-analysis have to be interpreted cautiously even though they are consistent with previously published meta-analyses [7,8,47,48].…”

“…Recently published meta-analyses of studies comparing CSII and MDI treatment [7,8] demonstrated an improvement in glycaemic control with the use of CSII therapy in patients with type 1 diabetes mellitus. Currently, only a few reviews are available on adults, adolescents or younger children with type 1 and patients with type 2 diabetes mellitus.…”

Continuous Subcutaneous Insulin Infusion Versus Multiple Daily Insulin Injections in Type 2 Diabetes: A Meta-analysis

“…Notably, the reduction of HbA1c with CSII was not associated with an increased risk of severe hypoglycemia. This result is consistent with those of a previous meta-analysis on a patient-level data from three small trials [19], and of two larger meta-analyses which included trials applying CSII with RHI [1,2].…”

“…Several randomized clinical trials, usually on small samples of patients, comparing CSII using short-acting analogs and multiple daily injections (MDI) have been performed, reporting either a similar efficacy of the two approaches [6][7][8][9][10][11][12][13][14][15][16] or a superiority of CSII [17,18]. A meta-analysis on patient-level data from three clinical trials suggests an improvement of HbA1c with CSII (with lispro) as compared with MDI [19].…”

Narrative Review: A Rational Approach to Starting Insulin Therapy

“…This approach provides increased flexibility in dosing and may improve quality of life in some patients. A meta-analysis of the studies evaluating the efficacy and safety of insulin pump therapy has found a modest advantage of this approach compared with multiple-dose insulin injection protocols (38,39). Currently, initiation of insulin pump therapy should be individualized, considering the patient's preferences, lifestyle, and self-care capabilities.…”