Point: Are Insulin Pumps Underutilized in Type 1 Diabetes? Yes

The use of insulin pump therapy has been increasing over the past number of years in many countries. The Diabetes Control and Complications Trial (DCCT) have proven that better glycaemic control with fewer hypoglycemic events is achievable with insulin pump therapy. The delivery of subcutaneous insulin through an insulin pump mimics physiological insulin delivery better than Multiple Daily Injection of insulin (MDI). Insulin pump therapy is an attractive therapeutic option for many patients with T1DM with the potential to improve glycaemic control and quality of life. Technological developments over the past few years have enhanced the functional capabilities and appearance of modern insulin pumps. Careful patient selection for insulin pump therapy by health care professionals is still important, to optimize its benefit and to lessen the associated risk. In this review article, the clinical evidence for insulin pumps, its advantages and disadvantages, as well as patient selection criteria for insulin pumps are outlined. Examples of insulin pump devices that are currently available, including the advent of newer devices and technology in this field are also reviewed.

This article reviews the performance of our hospital's inpatient insulin pump policy. Twenty-five hospital admissions of 21 unique patients receiving outpatient insulin pump therapy were reviewed. Between November 1, 2005, and November 30, 2006, there were 25 hospital admissions involving 21 patients receiving outpatient insulin pump therapy. The average age and duration of diabetes among these 21 patients was 50 and 29 years, respectively; 67% were women, 90% had type 1 diabetes, and all were white. The mean length of hospital stay was 4 days, and the average reported length of insulin pump therapy was 4 years. Patients in 16 of the admissions were identified as candidates for continued use of the insulin pump during the hospital stay. Over 90% of patients remaining on the insulin pump had documentation by nursing of the presence of the pump at the time of admission; 100% of the patients had an admission glucose recorded; 88% had a record of signed patient consent; 81% had evidence of completed preprinted insulin pump orders; 75% received a required endocrine consultation; and 75% of cases had documentation of completed bedside flow sheet. A high frequency of both hypoglycemic and hyperglycemic events occurred in the patients; however, no adverse events were related directly to the insulin pump. Insulin pump therapy can be safely continued in the hospital setting. While staff compliance with required procedures was high, there was still room for improvement. More data are needed, however, on whether this method of insulin delivery is effective for controlling hyperglycemia in hospitalized patients.

In the early 1960s, Dr. Arnold Kadish developed the first insulin pump, which was the size of a Marine backpack.1 Over the years, insulin pumps have become much more refined and have decreased in bulk to the size and weight of a small pager. Insulin pump therapy, also known as continuous subcutaneous insulin infusion, is no longer seen as experimental and controversial, but rather is viewed as an acceptable alternative to multiple daily injection (MDI) therapy in the management of insulin-dependent diabetes2 (Table 1).3 The insulin pump is an electromechanical device that mimics the body's natural insulin secretion from pancreatic β-cells by subcutaneously delivering rapid-acting insulin both at preset continuous basal rates and in extra bolus doses at mealtimes on demand.4 Insulin pumps allow for up to 24 different hourly basal rates in a 24-hour period. For bolus doses, pump users input their current blood glucose level and the number of carbohydrates they will consume, and the pump customizes their dose based on insulin currently on board (i.e., the remaining active insulin from the previous dose), their individualized insulin-to-carbohydrate ratio, and their individualized insulin sensitivity factor (i.e., their expected drop in blood glucose from 1 unit of insulin).1,5 Thus, insulin pumps are able to deliver insulin in a more physiological manner than other injection-based insulin regimens.5 In the late 1970s, results of the first human trials of insulin pump therapy were published. This was followed by numerous additional studies comparing insulin pump therapy to traditional MDI regimens with regard to long-term glycemic control and minimization of hypoglycemia.6–11 Then, in 1993, the Diabetes Control and Complications Trial12 confirmed the importance of intensive glycemic control using either insulin pump therapy or an MDI regimen along with frequent self-monitoring of …

The National Institute for Health and Clinical Excellence (NICE) was reviewing its previous guidance on continuous subcutaneous insulin infusion (CSII). The review provided an assessment of evidence which had been published since the previous NICE appraisal (TA 151) in 2007. To examine the clinical effectiveness and cost-effectiveness of using CSII to treat diabetes. To update the previous assessment report by reviewing evidence that has emerged since the last appraisal, and to take account of developments in alternative therapies, in particular the long-acting analogue insulins, which cause fewer problems with hypoglycaemia. A systematic review of the literature and an economic evaluation were carried out. The bibliographic databases used were MEDLINE and EMBASE, 2002 to June 2007. The Cochrane Library (all sections), the Science Citation Index (for meeting abstracts only) and the website of the 2007 American Diabetes Association were also searched. The primary focus for type 1 diabetes mellitus (T1DM) was the comparison of CSII with multiple daily injection (MDI), based on the newer insulin analogues, but trials of neutral protamine Hagedorn (NPH)-based MDI that had been published since the last assessment were identified and described in brief. For type 2 diabetes mellitus (T2DM), all trials of MDI versus CSII were included, whether the long-acting insulin was analogue or not, because there was no evidence that analogue-based MDI was better than NPH-based MDI. Trials that were shorter than 12 weeks were excluded. Information on the patients' perspectives was obtained from four sources: the submission from the pump users group--Insulin Pump Therapy (INPUT); interviews with parents of young children who were members of INPUT; some recent studies; and from a summary of findings from the previous assessment report. Economic modelling used the Center for Outcomes Research (CORE) model, through an arrangement with the NICE and the pump manufacturers, whose submission also used the CORE model. The 74 studies used for analysis included eight randomised controlled trials (RCTs) of CSII versus analogue-based MDI in either T1DM or T2DM, eight new (since the last NICE appraisal) RCTs of CSII versus NPH-based MDI in T1DM, 48 observational studies of CSII, six studies of CSII in pregnancy, and four systematic reviews. The following benefits of CSII were highlighted: better control of blood glucose levels, as reflected by glycated haemoglobin (HbA1c) levels, with the size of improvement depending on the level before starting CSII; reduction in swings in blood glucose levels, and in problems due to the dawn phenomenon; fewer problems with hypoglycaemic episodes; reduction in insulin dose per day, thereby partly off-setting the cost of CSII; improved quality of life, including a reduction in the chronic fear of severe hypoglycaemia; more flexibility of lifestyle--no need to eat at fixed intervals, more freedom of lifestyle and easier participation in social and physical activity; and benefits for the patients' family. The submission from INPUT emphasised the quality of life gains from CSII, as well as improved control and fewer hypoglycaemic episodes. Also, there was a marked discrepancy between the improvement in social quality of life reported by successful pump users, and the lack of convincing health-related quality of life gains reported in the trials. With regard to economic evaluation, the main cost of CSII is for consumables, such as tubing and cannulas, and is about 1800-2000 pounds per year. The cost of the pump, assuming 4-year life, adds another 430-720 pounds per annum. The extra cost compared with analogue-based MDI averages 1700 pounds. Most studies, assuming a reduction in HbA1c level of 1.2%, found CSII to be cost-effective. The most important weakness of the evidence was the very small number of randomised trials of CSII against the most modern forms of MDI, using analogue insulins. Based on the totality of evidence, using observational studies to supplement the limited data from randomised trials against best MDI, CSII provides some advantages over MDI in T1DM for both children and adults. However, there was no evidence that CSII is better than analogue-based MDI in T2DM or in pregnancy. Further trials with larger numbers and longer durations comparing CSII and optimised MDI in adults, adolescents and children are needed. In addition, there should be a trial of CSII versus MDI with similar provision of structured education in both arms. A trial is also needed for pregnant women with pre-existing diabetes, to investigate using CSII to the best effect.

RETRACTED: The impact of anxiety and depression on patients within a large type 1 diabetes insulin pump population. An observational study

Diabet. Med. 29, 971 (2012) Insulin therapy using an insulin injection was introduced in 1922. Progress towards a more physiological approach to insulin replacement has been painfully slow. One advance has been the use of continuous subcutaneous insulin infusion (CSII or insulin pumps) with or without glucose sensor augmentation. However, this therapeutic option is expensive and requires a trained multidisciplinary team to deliver an insulin pump service. It is therefore important to consider who would most benefit from such therapy and its cost-effectiveness. The availability of insulin pumps as a therapeutic option for the treatment of diabetes varies both between and within countries depending on the health system and its affordability for that country. In this month’s issue, Carlsson and colleagues (page 1055) examine the availability of insulin pump therapy in people with Type 1 diabetes attending 10 hospital outpatient clinics in Sweden. The use of insulin pumps varied between clinics and women were 1.5-fold more likely to use such therapy. Other features associated with pump use were a higher HbA1c at baseline, lower creatinine, high and low insulin doses, and younger age. People with Type 1 diabetes aged 20–30 years were two times more likely to begin to use insulin pumps than those aged 40–50 years. In the UK there are national guidelines (the National Institute for Health and Clinical Excellence; NICE) that recommend consideration of pump therapy in people with Type 1 diabetes on multiple daily injections with HbA1c > 69 mmol/mol (8.5%) despite the person trying to improve their diabetes control or in those in whom target HbA1c cannot be reached because of hypoglycaemia. The recommendations are even more relaxed in children. NICE also states that insulin pump therapy should only be started by a trained team that includes a doctor who specializes in insulin pump therapy, a diabetes nurse and a dietician. It is then recommended that the therapy should only be continued if there is a sustained improvement in HbA1c and/or less hypoglycaemia; quality of life should also be added to this list. An audit of pump services is currently being undertaken in the UK but it is likely to find that access is variable between sites, with some regions still not having access to a pump service as the commissioners of health care will not fund the service that requires not only the cost of the pump and its consumables but all members of the pump team, including the funding of educational packages. The availability of an insulin pump for a person with Type 1 diabetes then becomes a post-code lottery. This is an unacceptable state of affairs. Some patients with Type 1 diabetes do not want to use an insulin pump, but would consider the use of a continuous glucose monitoring system (CGMS). Unfortunately, there is no formal guidance on this issue in many countries, which makes it even more difficult for this to be considered an option, despite the wishes of those living with diabetes and health professionals advising on best practice.

Advances in medical technology and research documenting clinical effectiveness have led to the increased use of insulin pumps worldwide. However, their use by children in the UK is relatively limited and there is little evidence regarding their impact on patients' lives. This study aimed to examine the impact of switching from multiple daily injections to insulin pumps on the glycaemic control and daily lives of children/young people and their families. University College London Hospital, London. Face-to-face semi-structured interviews were conducted with children/young people with type 1 diabetes mellitus (5-17 years; N = 34) and their parents (N = 38), receiving insulin pump therapy and attending paediatric diabetes outpatients clinics at a major university teaching hospital in London. Glycated haemoglobin A1c values from 6 months prior to, and after pump therapy were obtained. Qualitative and quantitative approaches were undertaken for data analysis. Glycated haemoglobin A1c and the impact of the use of insulin pumps on the children and their families. The majority of parents (N = 32) and the children/young people (N = 30) reported that glycaemic control was easier to maintain within the target range with pumps compared to injections. This was supported by glycated haemoglobin A1c measures. Participants generally found the devices easy to use and more acceptable than injections. However, parents and children/young people reported many challenges in the early stages of pump therapy (e.g. 7 children/young had worse control at 6 months after starting CSII). Parents and children/young people reported an overall increase in lifestyle flexibility and an improved ability to participate in home, school and social activities whilst maintaining glycaemic control. Administration of insulin via pumps rather than injections was generally preferred. Participants reported most difficulty at the commencement of use. Pump therapy conferred benefits in terms of glycaemic control, general well-being, enabling young people to be more in control of their condition and live more normal lives, as reported by most participants. These are important goals of health policy for children/young people with long-term conditions in the UK.

Insulin pump therapy in toddlers and preschool children with type 1 diabetes mellitus

To investigate the effect of DAFNE and continuous subcutaneous insulin infusion in clinical practice. Within NHS Lothian, continuous subcutaneous insulin infusion started in 2004 and DAFNE education began in 2006. We extracted anonymized data from the national database for all those aged > 18 years with type 1 diabetes having a Dose Adjustment For Normal Eating course or continuous subcutaneous insulin infusion start date (n = 4617). In total, 956 persons received DAFNE education, and 505 had received an insulin pump, 208 of whom had DAFNE education followed by insulin pump. Mean (SD) HbA1c before DAFNE education was 68 (15) mmol/mol (8.4% [1.4%]) and 66 (13) mmol/mol (8.2% [1.2%]) before continuous subcutaneous insulin infusion. In the year following DAFNE education, the mean fall in within-person HbA1c was 3.8 mmol/mol (95% CI 4.0 to 3.4; 0.3% [0.4% to 0.3%]). Those with the poorest control (HbA1c ≥ 85 mmol/mol [9.9%]) experienced the largest decline (15.7 mmol/mol [1.4%]). Those in the lowest HbA1c band at initiation (< 53 mmol/mmol [7.0%]) experienced a rise. In the year following continuous subcutaneous insulin infusion initiation there was a mean fall in within-person HbA1c of 6.6 mmol/mol (6.8 to 6.4; 0.6% [0.6% to 0.6%]). In those with the poorest control (HbA1c ≥ 85 mmol/mol [9.9%]), the mean fall in HbA1c was 22.2 mmol/mol (23 to 21; 2.0% [2.1% to 1.9%]). Continuous subcutaneous insulin infusion effectiveness was not different with or without DAFNE education. The effects of both interventions were sustained over 5 years. Both DAFNE education and insulin pump therapy had the greatest effect on HbA1c in those with higher baseline values. There was little difference to attained HbA1c when Dose Adjustment For Normal Eating education was introduced before insulin pump therapy.

To explore health professionals' views about insulin pump therapy [continuous subcutaneous insulin infusion (CSII)] and the types of individuals they thought would gain greatest clinical benefit from using this treatment. In-depth interviews with staff (n = 18) who delivered the Relative Effectiveness of Pumps Over MDI and Structured Education (REPOSE) trial. Data were analysed thematically. Staff perceived insulin pumps as offering a better self-management tool to some individuals due to the drip feed of insulin, the ability to alter basal rates and other advanced features. However, staff also noted that, because of the diversity of features on offer, CSII is a more technically complex therapy to execute than multiple daily injections. For this reason, staff described how, alongside clinical criteria, they had tended to select individuals for CSII in routine clinical practice based on their perceptions about whether they possessed the personal and psychological attributes needed to make optimal use of pump technology. Staff also described how their assumptions about personal and psychological suitability had been challenged by working on the REPOSE trial and observing individuals make effective use of CSII who they would not have recommended for this type of therapy in routine clinical practice. Our findings add to those studies that highlight the difficulties of using patient characteristics and variables to predict clinical success using CSII. To promote equitable access to CSII, attitudinal barriers and prejudicial assumptions amongst staff about who is able to make effective use of CSII may need to be addressed.

The integration of continuous subcutaneous insulin infusion (CSII) (insulin pump therapy) and continuous interstitial glucose monitoring (CGM) appears to be an excellent solution for obtaining the desirable metabolic control for most insulin-treated subjects (1–4). Several studies have suggested that CGM with readings in real-time (CGM-RT) further improves blood glucose control (5–9). The introduction of CGM and CSII into clinical practice has generated an inevitable increase in the amount of data to be managed and interpreted. Telemedicine facilitates data management and preprocessing to optimize therapy. Among other potential benefits, telemedicine improves communication among patients and health care providers, improves quantity and quality of data collection, and eases decision-making and therapy adjustment (10–12). DIABTel, a web-based telemedicine system, is a good example for a solution designed to supply these needs (13). PARIS (Pancreas Artificial Telemedico Inteligente) is a coordinated research project to develop and validate a telemedical artificial pancreas (TAP), a multi-access telemedicine system that integrates CGM-RT, insulin pump, a smart assistant (SA), and close-loop control algorithms. SA is a personal intelligent assistant based on a handheld digital device to provide both personal and remote loop strategies, using CGM, CSII, and mobile general packet radio service (GPRS) communication with a telemedicine central server (TMCS). This review summarizes acquired experiences with TAP, integrating these new technologies with the objective to improve glycemic control of type 1 diabetic patients. ### Description of the DIABTel telemedicine system The telemedicine architecture consists of two components: the medical unit (a telemedical central server) and the patient unit (a smart assistant). The TMCS at the diabetes center of the hospital continuously runs, receiving and processing patients' monitoring data, messages, and requests for professional advice. A previous publication already reported the benefits of DIABTel, allowing the implementation of an easy-to-use, user-tailored telemedicine system with a technological platform allowing tight …

There are currently few data available on the long-term use of continuous subcutaneous insulin infusion (CSII) (insulin pump) therapy in children. Charts from 291 youth with type 1 diabetes (T1D) who were treated with CSII therapy for at least 1 year were reviewed. Data analysis included hemoglobin A(1c)(HbA(1c)) values, body mass index (BMI) values, and the occurrence of severe hypoglycemia (SH) or diabetic ketoacidosis (DKA) events. For the 291 patients, the mean age (+/-SD) for beginning CSII therapy was 13.3 +/- 3.7 years. The mean duration of CSII was 3.7 +/- 1.9 years (range 1-9 years). The baseline HbA(1c) value was 8.7 +/- 1.0%, compared to 8.2 +/- 0.9% after 1 year (P < 0.0001). The most recent value for all patients was 8.3 +/- 1.3% (P < 0.0001 compared to the baseline values for the same subjects). There was no advantage in glycemic control in the teen years as a result of initiating CSII in the pre-teen years compared to the teen years. SH events decreased from 9.06 events per 100 patient-years before CSII therapy to 7.96 events per 100 patient-years while on CSII therapy. The incidence of DKA increased from 1.39 events pre-CSII to 3.98 events per 100 patient-years while on CSII therapy. BMI z-scores showed a nonsignificant increase. The long-term use of CSII in pediatric patients is beneficial in lowering mean HbA(1c) levels and the number of SH events. However, there was an increase in the number of DKA episodes.

Introduction: According to White et al., health literacy is defined as ‘the degree to which individuals can obtain, process, understand, and communicate about health-related information needed to make informed health decisions. Nearly 36 percent of adults in the United State have low health literacy. Low health literacy not only affects the individual and the communities but also puts a lot of burden on healthcare resulting in high healthcare costs. It has adversely influenced diabetes care due to lack of use of preventive services, poor physician-patient communication, poor comprehension of medical instructions, and errors in medication dosing, and timing. Continuous subcutaneous insulin infusion (CSII), also known as insulin pump therapy, and continuous glucose monitors (CGM) are commonly indicated in patients with inadequate glycemic control, high glucose variability, unpredictable hypoglycemia, patients with an erratic schedule or varied work shifts. We present a case of uncontrolled diabetes mellitus in a patient with low health literacy, with significant improvement in glycemic control after starting CSII with CGM.Case: A 59-year-old female with a 13-year history of Latent Autoimmune Diabetes in Adults, on Insulin and Semaglutide, presented for evaluation in the clinic. She was struggling with insulin dosing and blood glucose control with multiple hospital admissions for hypo- and hyperglycemia. Her home blood glucose levels ranged from 92 to 536 mg/dl. Her HbA1C was between 12 and 18% in the past years. She had developed microvascular complications like diabetic nephropathy, neuropathy, and had a cerebrovascular accident in the past. Her current insulin dose was Glargine 50 units daily at nighttime and Lispro 25 units with each meal. Her most recent HbA1c was 14.5. She was not compliant with diet and has difficulty exercising due to residual weakness from CVA. The patient was struggling with insulin injection with errors in the dosing and timing of insulin due to difficulty in understanding medical instructions. Considering all the struggles and uncontrolled diabetes, CSII with CGM was initiated, with a simple protocol for her, one-click, or two clicks depending on the meal size. Within two months there was a significant improvement in her glycemic control. Her recent HbA1C was 9.5%.Conclusion: CSII can be considered as a viable treatment option in patients with low health literacy with uncontrolled diabetes mellitus like in our patient.

Background and objectivesThe adoption of insulin pumps in diabetes management has seen a significant rise globally, offering promising advancements in glycemic control. Despite this progress, notable disparities remain in the utilization of this technology across different populations. We hypothesized that insulin pump therapy improves glycemic control and reduces acute complications compared to multiple daily injection (MDI) therapy. This study aimed to assess the impact of insulin pump therapy on glycemic control and acute diabetes complications among patients with type 1 diabetes mellitus at King Fahad Armed Forces Hospital (KFAFH), Jeddah. We sought to compare patient outcomes before initiating insulin pump therapy (while on MDI insulin therapy), using Abbott FreeStyle Libre 2 continuous glucose monitoring (CGM), to their results after transitioning to insulin pump therapy for six months. The findings will contribute to understanding the effectiveness of this technology in a clinical setting and addressing gaps in its adoption.MethodsA cross-sectional study was conducted among patients with type 1 diabetes mellitus aged seven years and older who attended the Diabetes and Endocrine Department at KFAFH, Jeddah. Data were collected using a structured survey.ResultsThe study included 24 patients with type 1 diabetes mellitus, with a mean age of 22.79 ± 8.86 years and a mean BMI of 24.35 ± 4.96. The mean age at diagnosis was 12.25 ± 5.29 years. Most patients (n = 22, 91.7%) used the MiniMed™️ 780G system, which employs an advanced hybrid closed-loop (AHCL) algorithm. All participants underwent carbohydrate-counting sessions prior to the initiation of insulin pump therapy. After six months of insulin pump therapy, significant improvements (p<0.05) were observed in hemoglobin A1C (HbA1c) or glucose management indicator (GMI) levels, Percentage of time spent in target blood glucose range (TIR) per day, Percentage of time below target glucose range (TBR) per day, percentage of time very low below target glucose range per day, Frequency of hypoglycemia per week, diabetic ketoacidosis (DKA) admissions, and meal time flexibility. The findings will contribute to understanding the effectiveness of this technology in a clinical setting and addressing gaps in its adoptionConclusionsInsulin pump therapy is associated with improved and sustained glycemic control in patients with type 1 diabetes mellitus. Achieving optimal blood glucose levels is critical for reducing the risk of diabetes-related complications and lowering mortality rates. These improvements significantly enhance the quality of life and reduce the economic burden associated with diabetes management.

Background: The use of continuous subcutaneous insulin infusion (CSII), or insulin pump therapy, has been shown to improve glycemic control in patients with type 1 diabetes (T1D), however, there is limited real-world evidence on the rates of insulin pump use and impact on glycemic control across age groups in the U.S. This study aims to examine A1c trends among insulin pump users in one of the largest U.S. based population-based cohorts of people with type 1 diabetes.Methods: The analysis included 15,113 patients in the T1D Exchange Quality Improvement (T1DX-QI) database for whom electronic medical record data was available from eight endocrinology clinics participating in the T1DX-QI collaborative. Patients with at least one completed clinic encounter from 2017-2020 were included in this analysis.Results: In this population, 73% (N=11,046) of T1D patients were insulin pump users, whereas 27% (N=4,067) were non-users. Insulin pump use during the years of 2017 through 2020 remained constant in the range of 74%-76%. Mean Hba1c among insulin pump users was lower than for non-users (Mean [SD]: 8.0 [1.7] vs. 8.6 [1.8] (p<0.001). This difference persisted when compared across all age groups.Conclusions: This study highlights the benefit of uptake of insulin pump therapy to achieve better glycemic control across all groups using one the largest real-world databases for people with T1D.View largeDownload slideView largeDownload slide DisclosureN. Noor: Research Support; Self; Dexcom, Inc. O. Ebekozien: None. S. Corathers: None. R. Mcdonough: None. E. Carlson: None. A. B. Mekhoubad: None. S. Hsieh: None. C. Demeterco-berggren: None. S. Majidi: Advisory Panel; Self; Companion Medical. M. Desimone: None. K. Obrynba: None.