Is insulin pump therapy effective in Type 1 diabetes?

Abstract

There continues to be uncertainty about the effectiveness in Type 1 diabetes of insulin pump therapy (continuous subcutaneous insulin infusion, CSII) vs. multiple daily insulin injections (MDI). This narrative review discusses the reasons for this uncertainty, summarizes the current evidence base for CSII and suggests some future research needs. There are difficulties in interpreting trials of CSII because effectiveness varies widely due to factors such as differing baseline control, suboptimal use of best CSII practices, and psychological factors, for example, high external locus of control, non-adherence and lack of motivation. Many summary meta-analyses are also misleading because of poor trial selection (e.g. short duration, obsolete pumps, low baseline rate of hypoglycaemia) and reliance on mean effect size for decision-making. Both MDI and CSII can achieve strict glycaemic control without hypoglycaemia in some people with Type 1 diabetes, especially those who are motivated and have undergone structured diabetes education, and with high levels of ongoing input from healthcare professionals. CSII is particularly effective in those people with Type 1 diabetes who have not achieved target HbA levels without disabling hypoglycaemia using best attempts with MDI, and here there can be valuable and substantial improvement. Insulin pumps are safe, effective and accepted when used in newly diagnosed diabetes, particularly in children, where MDI may not be practicable. Future research needs include more studies on mortality associated with insulin pumps where registry data have suggested lower rates vs. MDI; and psychological strategies to improve non-adherence and suboptimal glycaemic outcomes on CSII.

Comparative characteristics of older people with type 1 diabetes treated with continuous subcutaneous insulin infusion or insulin injection therapy: data from the German/Austrian DPV registry

“…Very few specific recommendations on use of new diabetes technologies for older individuals exist and there are no ‘official’ criteria to decide about discontinuation of CSII . Discontinuation rates for insulin pumps are generally low, because CSII is an effective treatment option for achieving and maintaining good glycaemic control in people with type 1 diabetes, and treatment satisfaction can be better compared with insulin injection therapy . A recent longitudinal analysis of the T1D Exchange Registry on pump discontinuation rates reported that discontinuation rates among adults aged ≥ 26 years were < 1% .…”

“…Little is known, however, about the characteristics of adults aged ≥ 60 years using CSII. There are many studies examining the effectiveness and use of CSII in adults and children . However, research on the benefits of insulin pump use in older individuals with type 1 diabetes is scarce.…”

Lipid profile is associated with treatment regimen in a large cohort of children and adolescents with Type 1 diabetes mellitus: a study from the international SWEET database

“…The design of the present study did not allow us to investigate causes for the observed association between insulin regimen and lipid profiles; however, the finding of a favourable lipid profile with pump therapy in this cross‐sectional analysis of registry data requires further investigation for potential mechanisms. It is possible that characteristics of children with access to pump therapy are different from those who do not access pump therapy, such as lifestyle factors, including healthier diet, smoking avoidance, regular exercise, socio‐economic status, more intensive education and stronger motivation, and these may all affect lipid profiles . These factors were not examined in the present study as they are not currently collected in the SWEET database.…”

Standard mortality rates and years of life lost for serologically defined adult-onset type 1 and type 2 diabetes – A fifteen year follow-up

“…The importance of physical activity, when possible, and adequate diet, were acknowledged very early [28]. Most diabetes patients develop a need for drug treatment during the course of the disease, and there have been major developments in pharmacological, as well as technical, treatment the past two decades, with a number of new classes of glucose-lowering drugs becoming available, along with new types of insulins, and techniques for delivering insulin, that are beneficial at least to subgroups of patients [23,24,29]. The newest techniques for measuring glucose became more generally available after this study period, but it is reasonable to assume that all the factors mentioned have contributed to the improvements in prognosis and outcome now seen, where care is available, for the population with diabetes, despite that both incidence and prevalence of diabetes is still increasing in most regions, possibly with the exception of the northern western countries [9].…”