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Management of diabetes mellitus: is the pump mightier than the pen?

Nature Reviews Endocrinology volume 8, pages 425–433 (2012)Cite this article

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Abstract

Continuous subcutaneous insulin infusion (CSII, or insulin pump therapy) reduces HbA1c levels and hypoglycaemia in patients with type 1 diabetes mellitus (T1DM) compared with multiple daily insulin injections (MDI). The greatest reduction in HbA1c levels with CSII occurs in patients with the worst glycaemic control; therefore, the most appropriate and cost-effective use of CSII in adults with T1DM is in those who have continued, elevated HbA1c levels or disabling hypoglycaemic episodes with MDI (including the use of long-acting insulin analogues and structured patient education). The disadvantages of CSII include higher costs than MDI and the risk of ketosis in the event of pump failure. In children with T1DM, CSII may be used when MDI is considered impractical or inappropriate. Pumps are not generally recommended for patients with type 2 diabetes mellitus but may improve control in some subgroups. A new generation of smaller insulin infusion pumps with an integrated cannula, called patch pumps, could improve uptake of CSII in general. The important clinical question is not whether CSII is more efficacious than MDI in general adult T1DM, but whether CSII further improves glycaemic control when this control continues to be poor with MDI, and evidence exists that in most cases it does.

Key Points

  • Continuous subcutaneous insulin infusion (CSII) can reduce HbA1c levels and hypoglycaemia in many patients with type 1 diabetes mellitus (T1DM), compared with multiple daily insulin injections (MDI)

  • However, an MDI regimen that includes frequent self-monitoring of blood glucose levels and structured diabetes education can achieve good glycaemic control in many individuals with T1DM

  • A trial of CSII is indicated in patients who do not achieve acceptable glycaemic control with MDI because of continued, elevated HbA1c levels or disabling hypoglycaemic episodes

  • The greatest reduction in HbA1c levels with CSII occurs in patients with T1DM who have the worst glycaemic control with MDI

  • Blood glucose variability, quality of life and treatment satisfaction are also usually improved with CSII versus MDI

  • Sensor-augmented insulin pump therapy further improves glycaemic control, with the best effect in patients with the highest HbA1c levels and in those who use the sensor most often

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Figure 1: A proposed treatment pathway for adults with type 1 diabetes mellitus.
Figure 2: Meta-regression of severe hypoglycaemia rate ratio (MDI:CSII) with hypoglycaemia rate with MDI as a covariate.
Figure 3: Meta-regression of the mean difference in HbA1c level (CSII versus MDI) with HbA1c on MDI as a covariate.

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The author declares associations with the following companies: Animas (consultant), Cellnovo (consultant, grant/research support), Medtronic (consultant, speakers bureau), Roche (speakers bureau).

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Pickup, J. Management of diabetes mellitus: is the pump mightier than the pen?. Nat Rev Endocrinol 8, 425–433 (2012). https://doi.org/10.1038/nrendo.2012.28

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