Insulin pumps have been shown to improve glycemic control in adults with type 1 diabetes based on evidence from randomized controlled trials and meta-analyses. The evidence is mixed for glycemic control benefits in children, though some studies and meta-analyses favor insulin pumps. Insulin pumps reduce the risk of microvascular complications and glycemic variability even when average blood sugar levels are similar to multiple daily injections. The risk of hypoglycemia is similar for pumps and injections, while the risk of ketoacidosis depends on experience with pump use. Importantly, insulin pumps consistently improve quality of life for people with type 1 diabetes.

1. INSULIN PUMP- EVIDENCE
FROM CURRENT ERA
F.A.Q. FROM PATIENTS AND REFERRING
DOCTORS ANSWERED WITH EVIDENCE
DR. OM J LAKHANI
MD, DNB (ENDO)
CONSULTANT ENDOCRINOLOGIST
ZYDUS HOSPITALS
AHMEDABAD

3. LEVELS OF EVIDENCE

4. Level A - A well conducted RCT
and meta-analysis of this RCT

5. Level B - A well conducted Cohort
study

6. Level C - Evidence from poorly
controlled or uncontrolled studies

7. Level E - Expert recommendation

8. THE PUMP VS CAR
‘THE I CAN’T AFFORD A
PUMP NONSENSE’

10. A car typically costs around 3-5
lakhs while the pump typically
costs 2-6 lakhs

11. A car has a running cost of
around Rs. 3000-4000 per month
including fuel and maintenance.
A pump running cost is around
5000 per month

12. If you can buy afford a car for
yourself and can’t buy a pump for
your T1D child - SHAME ON YOU !

13. Level of evidence ?

14. QUESTION 1

15. Q. I am 26 years old type 1
diabetic. Will use of an insulin
pump improve my glycemic
control ?

16. 2000 study

17. Open-label randomized crossover
study

18. Included only Adult patients

19. Duration of Study was 4 months
in each arm of cross-over

20. The mean HbA1c with CSII was
7.89 % , while the mean HbA1c
with MDI was 8.24% the difference
was statistically significant

21. Level of evidence ?

23. Included 23 RCT on CSII vs MDI

24. There was a statistically
significant
difference in HbA1c favouring
CSII - weighted mean difference -
0.3% (95% confidence interval -
0.1 to -0.4).

26. Level of evidence ?

27. Answer- Yes. Pumps improve
glycemic control in Adult patients
with Type 1 Diabetes.

28. QUESTION 2

29. Q. My child is 7 year old with type
1 diabetes. Will use of Insulin
pump improve glycemic control in
my child ?

30. Q. My child is 7 year old with type
1 diabetes. Will use of Insulin
pump improve glycemic control in
my child ?

31. Randomized Cross-over trial

32. Patients were on CSII or MDI for
3.5 months each

33. Glycemic control was similar in
both CSII and MDI

34. Level of evidence ?

36. In studies that included
participants less than 18 years of
age the mean difference of
HbA1c was estimated to be -
0.2%(95%CI -0.4 to -0.03) in favour
of CSII compared with MI.

37. Level of evidence ?

38. Answer: In Children with T1D, the
use of CSII has mixed evidence
over MDI in terms of HbA1c
Reduction though Meta-analysis
does favour CSII

39. QUESTION 3

40. Q. Does the use of the newer
Sensor Augmented Insulin pump
have further benefit for HbA1c
reduction ?

42. RCT, compared MDI vs Sensor-
augmented CSII in more than 400
participants

43. Both Adults and Children
included

44. Follow-up was for 1 year

45. At 1 year, the baseline mean
glycated hemoglobin level (8.3%
in the two study groups) had
decreased to 7.5% in the pump-
therapy group, as compared with
8.1% in the injection-therapy
group (P<0.001).

47. An Extension cross-over study (6
months extension) showed
continued benefit for those
already on pump and those
switched from MDI to Pump

49. Answer- The newer sensor
augmented insulin pumps
produce significant HbA1c
reduction.

50. Level of evidence ?

51. QUESTION 4

52. Q. Will the use of Insulin pump
reduce the risk of Diabetic
Microvascular complications in in
patients having type 1 diabetes ?

54. This was a prospective cohort
study involving >900 participants
with T1D

55. Patients treated with CSII or MDI
for atleast 12 months

56. The Mean HbA1c in both the
groups was similar.
Around 8.6%

57. Though pumps lead to lower risk
of Microvascular complications -
the difference was not statistically
significant

59. However, in a multivariate
analysis when confounding
factors were (Higher HbA1c at
beginning of treatment, older age,
longer duration of disease) were
factored in the analysis- the risk
of microvascular complications
was lower in the CSII group.

60. Level of evidence ?

61. Answer- Insulin pumps reduce the
risk of microvascular
complications over and above
MDI- despite similar HbA1c !

62. Q. Why is it that despite similar
reduction in HbA1c, pumps
reduce the risk of Microvascular
complications ?

64. A specific subgroup analysis of
STAR3 trial

65. Independent CGM was performed
in the beginning of the trial and at
the end of 1 year of the trial

66. The study found that SD and CV
calculated from the CGM values
was lower in the pump group vs
the MDI group when the HbA1c
was <8%

68. Level of evidence ?

69. QUESTION 5

70. Q. Will use of a pump reduce the
risk of hypoglycaemia ?

71. Non-severe hypoglycemia- the
Cochrane study found similar risk
of Non-severe hypoglycaemia in
MDI vs CSII

72. Severe hypoglycaemia - the data
was not enough for meta-analysis

73. Level of evidence ?

75. This is an Cross-over RCT which
compared the use of bio
hormonal bionic pancreas with
conventional insulin pump for 5
days

76. The mean frequency of
interventions for hypoglycemia
among the adolescents was lower
during the bionic-pancreas period
than during the control period

77. Among the adults, the bionic
pancreas, as compared with their
usual care, reduced the time that
glucose levels were below 60
mg/dl by 67% (by 94% during the
overnight period).

78. Level of evidence ?

79. Answer- Insulin pumps do not
reduce the risk of Hypoglycaemia
- this holds true for both mild as
well as severe hypoglycaemia.
Biohormonal bionic pancreas may
have advantage in this area.

80. QUESTION 6

81. Q. Does the use of Insulin pump
reduce the risk of admission due
to Diabetic ketoacidosis ?

83. Large retrospective observational
study from a Danish T1D registry

84. Risk of DKA was similar in CSII vs
MDI users

85. However in those clinics having
more than 250 CSII users- the risk
of DKA was significantly lower

86. Level of evidence ?

87. Answer- the risk of DKA is lower
with CSII amongst experienced
users. In general the risk is
similar to MDI

88. QUESTION 7

89. A question which NOBODY asks
in India

90. Q. Will the use of Insulin pump
improve the quality of life ?

92. Multi-centre RCT conducted
across 5 nations

93. The overall score of the diabetes
quality of life questionnaire was
higher for CSII (P < 0.001)

94. There was an improvement in
pump users' perception of mental
health was detected when using
the SF-12 questionnaire (P < 0.05).

95. Level of evidence ?

96. Answer- Insulin pumps
undoubtedly improve the quality
of life amongst patients with T1D

97. Q. What specific advantage will
my child have when he uses
Insulin pump ?

98. TAKE HOME MESSAGES

99. Insulin pumps improve Glycemic
control in Adults with T1D
They may have benefit in children
as well for glycemic control

100. Insulin pumps reduce the risk of
Microvascular complications

101. Pumps reduce glycemic
variability

102. The risk of hypoglycaemia is
similar in both MDI vs CSII

103. The risk of Diabetic ketoacidosis
is similar in MDI vs CSII

104. Insulin pumps improve the quality
of life

105. Buy a pump for your child today -
it would improve his/her life.

106. THANK YOU !