Insulin Pumps Produced Better Results and Better Quality of Life for Adults

In a comparative effectiveness analysis of approaches, researchers considered outcomes for treating and monitoring type 1 and type 2 diabetes, that might assist in decision-making.

Hsin-Chieh Yeh, PhD, and colleagues from Johns Hopkins University, Baltimore, Maryland, and Case Western Reserve University, Cleveland, Ohio, conducted a systematic review and meta-analysis of controlled clinical trials to evaluate comparative effectiveness and safety of intensive insulin therapy delivery method (continuous subcutaneous insulin infusion [CSII] vs multiple daily injections [MDI]; 19 trials) and glucose monitoring method (self-monitoring of blood glucose [SMBG] vs real time-continuous glucose monitoring [rt-CGM]; 10 trials), or sensor-augmented insulin pump with MDI and SMBG (4 trials).

Of the 33 studies analyzed, 24 had a parallel design and 9 were crossover studies.

A strength of the analysis of the CSII group compared with past studies is that the analysis did not include studies that used regular insulin instead of analogues, which are now standard clinical practice.

CSII and MDI had similar effects on hemoglobin A1c (HbA1c) and severe hypoglycemia for children or adults with type 1diabetes and adults with type 2 diabetes. One study found that CSII was more effective in reducing HbA1c in adults with type 1 diabetes. CSII and MDI also had similar effects on weight gain.

Rt-CGM was more effective than SMBG in lowering HbA1c (between-group change difference, -0.26% [95% confidence interval (CI), -0.33% to -0.19%]) without any difference in episodes of severe hypoglycemia. For type 1 diabetes, use of a sensor-augmented pump reduced HbA1c more than SMBG and MDI (combined mean between-group difference of change from baseline, -0.68% [95% CI, -0.81 to -0.54]).

The researchers concluded that intensive insulin therapy by MDI and CSII lower HbA1c to a similar degree for type 1 diabetes but that CSII produced better satisfaction with treatment in children and better quality of life for adults. "These data suggest that the approach to intensive insulin therapy can be individualized to patient preference that will maximize their treatment satisfaction and [quality of life], as both MDI and rapid-acting analog-based CSII have similar effectiveness for glycemic control," the researchers write.

"This is the first systematic review to examine the comparative effectiveness of both rt-CGM versus SMBG and sensor-augmented pump versus MDI/SMBG," they continue. "Our findings indicate that rt-CGM is superior to SMBG in lowering HbA1c levels, without increasing the risk of severe hypoglycemia, in type 1 diabetes, particularly those who are compliant with using the monitoring device."

A limitation of the meta-analysis is the number and size of studies considered. In addition, the chosen studies might not accurately reflect the diabetes population because participants tend to be highly compliant, and the techniques are costly, and therefore, might not represent what the average patient uses. Quality-of-life assessments might have been skewed because studies were not blinded. The investigators were unable to compare rt-CGM vs SMGB in patients using only CSII or MDI because the analyzed studies were not consistent.

Ann Intern Med. Published online July 10, 2012.