Do We Need Updated Guidelines on the Use of Insulin Pump Therapy in Type 2 Diabetes? A Review of National and International Practice Guidelines

Abstract

The management of type 2 diabetes mellitus remains a significant health care challenge. Despite evidence from landmark clinical trials and recommendations in published guidance, glycemic control is often poor for patients in clinical practice and insulin therapy can be delayed or is not optimized.1 Barriers to the initiation and intensification of insulin therapy include the known side effects, such as weight gain and increased risk of hypoglycemia, concerns over the complexity of the treatment regimen, and fear of injections.2-5 The implications of reluctance to initiate and intensify insulin therapy have been described in the primary care setting. 6,7 Analyses suggest that at least 40% of individuals initiating insulin failed to achieve target glycated hemoglobin (HbA1c) levels of ≤7.5% (58 mmol/mol), with average time-to-insulin initiation >11.5 years from diagnosis, suggesting that patients frequently fail to meet glycemic control targets with insulin therapy.Intensification of the insulin regimen to control hyperglycemia is traditionally achieved in type 2 diabetes with basalbolus insulin therapy (short-acting prandial insulin, together with long-acting insulin injections such as glargine or detemir), also known as multiple daily injections (MDI) of insulin. However, MDI regimens can be overwhelming and unpopular with a large number of patients, and despite combination with metformin, many patients still fail to achieve good glycemic control. Comorbidities such as obesity and hypertension are very common and weight gain associated Abstract Background: Continuous subcutaneous insulin infusion (CSII) is used less for type 2 than for type 1 diabetes because of inconsistencies in evidence of effectiveness. We reviewed published guidelines on intensive insulin therapy in type 2 diabetes to assess whether updating of guidance is needed with respect to evidence used and recommendations for CSII in diabetes management. Methods:A literature review was performed to identify published national and international guidelines on type 2 diabetes management. Searches were performed using PubMed, Cochrane Library, and Embase databases, and websites of national health care agencies, reimbursement agencies, and professional associations. Searches were limited to articles published in English between 2004 and 2014 and 1666 unique hits were identified, of which 22 were reviewed following screening.Results: Only 6 of the 22 guidelines identified from North and South America, Western Europe, Greece, and Israel provided specific recommendations on intensive insulin therapy and the role of CSII, and only 1 provided information on the grade of evidence supporting recommendations. Quality appraisal based on the AGREE II tool suggested that published guidelines may have limitations in terms of search methodology and evidence grading, and findings were of mixed rigor and clarity. Only 3 guidelines described the population for whom CSII may be appropriate. Conclusions:Guidelines need to improve the evidence base, rigor, clarity, and gra...

Use of insulin pumps and closed‐loop systems among people living with diabetes: A narrative review of clinical and cost‐effectiveness to enable access to technology and meet the needs of payers

“…There is a lack of updated guidelines for the use of insulin pumps in individuals living with T2D, 97 and there is still heterogenous dissemination of insulin pumps across countries for the treatment of T2D. Insulin Furthermore, given the complex nature of diabetes selfmanagement that impacts many aspects of the health-related QoL of individuals living with diabetes, 98 it is important to measure QoL outcomes.…”

“…There is a lack of updated guidelines for the use of insulin pumps in individuals living with T2D, 97 and there is still heterogenous dissemination of insulin pumps across countries for the treatment of T2D. Insulin pump efficacy has previously been demonstrated in T2D subpopulations such as obese insulin‐resistant people of White ethnicity, but data from Asian/African countries are controversial or still lacking.…”