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Is insulin pump therapy superior to multiple daily injections in type 1 diabetes?
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An insulin pump offers more precise, physiologic insulin delivery, as well as a greater ability to handle conditions that can alter insulin requirements.
All pumps on the market offer several useful features for people with type 1 diabetes. These include multiple basal rate options, square- and dual-wave bolus features, the ability to calculate a suggested bolus dose based on insulin to carb ratio, insulin-on-board features to avoid insulin “stacking,” occlusion and reservoir alarms, and data downloading capabilities. If a user downloads pump data, the pump coordinates insulin doses with continuous glucose monitor data. This is important information for the user or a caregiver. Insulin pens offer none of these features.
Bolus dosing with a pump is quick, discrete, easier to administer and more accurate vs. an injection. A person used to multiple daily injections can reduce the number of needle sticks from three or seven or more per day to once every 3 days.
Perhaps the biggest benefit of a pump is the ability to respond to CGM trend data. If users know their correction factor, they can easily respond to a trend arrow with a 1-U dose of insulin.
The decision of insulin pump vs. injections comes down to personal choice. Whether a person with diabetes is using a pump or multiple daily injections, it is important to use a CGM and respond to the trend arrows. The insulin regimen should mimic what happens in a person without diabetes.
A pump offers a greater ability to respond quickly to changes that affect insulin requirements, including the “dawn phenomenon” (early morning rise in glucose), stress or illness. Unlike insulin pens, with pumps, basal rates can be suspended or reduced to avoid hypoglycemia. With a pump, a user can program different sets of basal rates for different patterns or situations, such as workdays vs. weekends. This makes a pump flexible and individualized.
Multiple companies are at work on an artificial pancreas, in addition to the Medtronic 670G already available. People with diabetes need to become comfortable with insulin pump technology because closed-loop systems will be more widely available soon. If you want to achieve optimal glucose control without having to think about it, you need to be on a pump.
For more on this topic, watch Steven Edelman, MD, and Irl Hirsch, MD, debate this issue for Taking Control of Your Diabetes at https://www.youtube.com/watch?v=T-JdpbqMKLM.
Steven Edelman, MD, is an Endocrine Today Editorial Board Member and professor of medicine at the University of California, San Diego, and the Veterans Affairs Medical Center, and founder and director of the nonprofit Taking Control of Your Diabetes. Disclosure: Edelman reports no relevant financial disclosures.
Many patients can do well on multiple daily injection therapy, and it remains a viable and useful option.
Both an insulin pump and multiple daily injections, or MDI, are ways of giving insulin. Both depend on the user making appropriate choices. Historically, when using a pump that is not part of an integrated system, the injection approach and the pump approach are equivalent in glycemic outcomes, when compared in recent, randomized studies using analog insulin.
Injections do not require a person to wear a device on his or her body. A lot of people do not want to wear a pump — either with or without tubing — that they have to fuss with. They don’t want to worry about infusion issues and technology. Instead, giving yourself a shot of long-acting insulin every day is a comforting, simple task and mealtime injections are easy to control. Patients know the insulin is in their body with shots. The new, longer-acting insulins can provide a steady, predictable overnight basal that just works, without the complexity of alarms, occlusion problems, need to change the infusion set at inopportune times and every other issue that can come with a pump.
Regardless of the delivery method, insulin still needs to be given 15 to 30 minutes before eating, and that is a barrier whether using a pump or injection therapy. Insulin with a pump is not always steady. Pumps are only as good as the infusion site, and infusion sites have issues. Tubing has clogging. This is subcutaneous insulin delivered by a system. None of that is physiologic, and all of it has barriers.
To me, it is not a debate so much as a choice. For people who want to be on MDI, of course they should be, and of course they can get to target. A continuous glucose monitor with either method would help patients manage the best. It is not about how you use insulin. It is about how you monitor it.
For non-high-tech-adopting humans with diabetes, MDI is the default. People can even use nonanalogue insulin if necessary. I don’t want to make people feel less than because they cannot afford or be on some fancy system. This is a tough disease, and these are tools, not cures. No one should be forced to use a technology they don’t want to use, because patients are the ones using these things every day. What people are comfortable with is what will work best.
Anne Peters, MD, is an Endocrine Today Editorial Board Member and professor of clinical medicine at Keck School of Medicine at the University of Southern California, Los Angeles. Disclosure: Peters reports she has various financial ties with Abbott, Becton Dickinson, Bigfoot, Boehringer Ingelheim, Dexcom, Eli Lilly, Janssen, Lexicon, Livongo, Medscape, Merck, Novo Nordisk, Omada Health, Sanofi and Science 37.