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Guideline: Pump therapy, CGM recommended for type 1, type 2 diabetes
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Insulin pump therapy and real-time, continuous glucose monitoring are recommended for people with both poorly controlled and well-controlled type 1 diabetes who are willing and able to use the devices, according to a new clinical practice guideline from the Endocrine Society.
The guideline task force also recommended insulin pump therapy for patients with poorly controlled type 2 diabetes as well as short-term, intermittent use of continuous glucose monitoring (CGM) when appropriate. The American Association for Clinical Chemistry, the American Association of Diabetes Educators and the European Society of Endocrinology co-sponsored the guideline.
“While [pump therapy and CGM] and other new technologies hold the potential for enhancing outcomes and improving [quality of life] for people with diabetes, reliable data on the efficacy of new advances is lacking,” Anne L. Peters, MD, professor at the Keck School of Medicine and director of the clinical diabetes programs at the University of Southern California, and colleagues wrote. “This guideline attempts to assess all available data on existing and emerging technologies and procedures for improving glycose control for patients with diabetes.”
In developing the guideline, the task force commissioned a systematic review and individual patient data meta-analysis of 11 randomized controlled trials enrolling patients with type 1 diabetes and comparing real-time CGM vs. control groups. Researchers used a two-step regression model to pool patient data from trial lists and device manufacturers.
Researchers found that the use of real-time CGM was associated with a mean –0.276% reduction in HbA1c (95% CI, –0.465 to –0.087) vs. controls. Researchers did not observe between-group differences for time spent in hypoglycemia or the number of hypoglycemic episodes, but acknowledged analyses were imprecise.
Researchers made six recommendations regarding use of the technology:
- Insulin pump therapy without sensor augmentation is recommended for patients with type 1 diabetes who either have not met their HbA1c goal or reached their HbA1c goal but continue to experience hypoglycemia or glucose variability, as well as for those who require increased insulin delivery flexibility.
- Insulin pump therapy is recommended for patients with type 2 diabetes with poor glycemic control despite intensive insulin therapy, oral agents, other injectable therapies and lifestyle modifications.
- Insulin pump therapy should be continued in the hospital setting for patients with type 1 or type 2 diabetes, if the institution has clear protocols in place for appropriate monitoring and safety procedures.
- Clinicians should perform a structured assessment of a patient’s mental and psychological status, prior adherence to self-care measures and willingness and interest in trying any device before recommending insulin pump therapy.
- Patients should be encouraged to use appropriately adjusted, embedded bolus calculators in insulin pump therapy and have appropriate education regarding their use.
- CGM is recommended for patients with type 1 diabetes who have not met their HbA1c target and those with well-controlled diabetes who are willing and able to use the devices on a near-daily basis; short-term, intermittent use is recommended for patients with type 2 diabetes not on prandial insulin with an HbA1c of at least 7%.
The researchers recommended that patients using pump therapy or CGM receive training and education to safely and effectively use the devices.
“It is imperative that as devices proliferate, we consider the human factor, both in terms of how easily, safely and effectively people with diabetes and their caregivers can use these devices and how easily and effectively caregivers can access data from these devices and provide feedback to patients in order to optimize care,” the researchers wrote. – by Regina Schaffer
Disclosure: Peters reports significant financial interest or leadership positions with Abbott Diabetes Care, AstraZeneca, BD, Biodel, Boehringer Ingelheim, Janssen, Lilly, Medtronic, Merck and Novo Nordisk,. Please see the full clinical practice guideline for the other authors’ relevant financial disclosures.
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