Head To Head Study:
Pumps Versus Glargine and Fast Acting Insulin
The study authors concluded that CSII was
more effective at controlling type 1 diabetes
in children than was MDI.[1]
Several studies were presented at the 63rd
Scientific Sessions of the American Diabetes
Association that examined CSII compared with
glargine.
Glargine is a long-acting basal insulin,
with little or no peak over its 24-hour
profile. When used with rapid-acting insulin
analogs such as aspart or lispro, it has been
called the "poor man's pump" because
the basal and bolus regimen is similar to that
obtained with an insulin pump. A randomized,
prospective comparison between CSII and
glargine in children was conducted at Yale
University. Twenty-six children (39% male, 79%
white) with a mean age of 12.7 ± 2.7 years
completed the 16-week study. The study is
ongoing, and after 16 weeks the subjects are
allowed to choose the therapy they desire. The
children who were randomized to multiple daily
injections (MDI) with glargine and aspart had
no significant change in their hemoglobin A1C
(HbA1c), with values declining minimally from
8.4% to 8.1%. The children on CSII with aspart
had a significant decline, from 8.1% to 7.2%.
There were 4 severe hypoglycemic events in the
group treated with MDI, and 2 severe events in
the group treated with CSII. In addition,
subjects randomized to the group with CSII
were able to decrease their total daily dose
of insulin, while the subjects in the MDI
group had no change. The study authors
concluded that CSII was more effective at
controlling type 1 diabetes in children than
was MDI.[1]
A retrospective chart review of 103
patients with type 1 diabetes compared CSII
(58 patients) with MDI (45 patients)
consisting of glargine plus a rapid-acting
insulin analog. This study used a longer
duration of treatment than the Yale study
described above, with 16 months of treatment
for the CSII group and 11.6 months for the MDI
group. The authors found no difference in
HbA1c levels between the 2 groups (6.79% vs
6.84%), nor was there a difference in severe
hypoglycemic events.[2]
A third study looked at patients who wanted
to take a break from CSII and go on a pump
holiday. Thirty patients with CSII-treated
type 1 diabetes were randomized to either 4
months of continuing CSII or MDI with glargine
and an analog. There was no significant change
in the HbA1c levels in either group, nor was
there a change in the incidence of
hypoglycemia.[3]
Also presented was a multicenter,
open-label, randomized crossover study of
adults with type 1 diabetes. This study
involved 100 subjects with CSII-treated
diabetes. Subjects were randomized to either
continuing CSII or MDI with glargine and
aspart. After 5 weeks the patients were
switched to the alternative therapy for 5
additional weeks. During the last week of each
treatment period, subjects wore a continuous
glucose monitoring system (CGMS; Medtronic
MiniMed) for 2-3 days. Glycemic control was
superior with CSII as measured by fructosamine
(343 vs 355 micromol/L for CSII and MDI,
respectively) or by area under the curve
glucose from the CGMS. There was no change in
hypoglycemia.[4]
These 4 studies are interesting but
probably are not the final chapter in the
comparison between CSII and MDI. They confirm
some of the things that we already know about
CSII. CSII is usually at least as effective as
MDI in both achieving glycemic control and
preventing hypoglycemia, and may be superior.
The skill, training, and patience of the
healthcare team providing the treatment
directly affect success with CSII as well as
MDI. The proper selection of the patients who
use CSII plays a significant role in the
successful outcome. It is possible that
studies that fail to show an improvement in
outcome from using CSII suffer from
excessively talented healthcare providers that
are capable of achieving excellent outcomes
with MDI.
References
- Boland E, Weinzimer
S, Ahern JA, Steffen A, Tamborlane W.
Randomized, prospective trial of CSII
vs MDI with glargine in children: a
preliminary report. Program and
abstracts of the 63rd Scientific
Sessions of the American Diabetes
Association, June 13-17, 2003; New
Orleans, Louisiana. Abstract 192-0R.
- Mathur R, Harmel ALP.
A comparison of continuous
subcutaneous insulin infusion (CSII)
therapy versus multiple daily
injection (MDI) therapy with premeal
rapid acting insulin and glargine
insulin in patients with type 1
diabetes. Program and abstracts of the
63rd Scientific Sessions of the
American Diabetes Association, June
13-17, 2003; New Orleans, Louisiana.
Abstract 1900-PO.
- Torlone E, Pampanelli
S, Porcellati F. Short-term comparison
between glargine as basal insulin and
CSII in CSII-treated type 1 diabetic
patients switching to MDI: the pump
holiday study. Program and abstracts
of the 63rd Scientific Sessions of the
American Diabetes Association, June
13-17, 2003; New Orleans, Louisiana.
Abstract LB-13.
- Bode B, Hirsch I, Hu
P, Santiago O. Type 1 diabetes
patients can temporarily switch from
continuous subcutaneous insulin
infusion with insulin aspart to basal
bolus therapy with insulin aspart and
insulin glargine. Program and
abstracts of the 63rd Scientific
Sessions of the American Diabetes
Association, June 13-17, 2003; New
Orleans, Louisiana. Abstract 438-P.
