Optimizing type 1 diabetes after multiple daily injections and capillary blood monitoring: Pump or sensor first? A meta‐analysis using pooled differences in outcome measures

Abstract

Aims: Most people living with type 1 diabetes self-manage using multiple daily injection (MDI) insulin regimens and self-monitoring of blood glucose (SMBG). Continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) are adjuncts to education and support self-management optimization. The aim of this systematic review and meta-analysis was to assess which first-line technology is most effective. Methods: Electronic databases (MEDLINE, EMBASE and WEB OF SCIENCE) were systematically searched from 1999 to September 2020. Randomized controlled trials comparing either CSII with MDI or CGM with SMBG in adults with type 1 diabetes were included. Data were extracted in duplicate by two reviewers, and were analysed to assess individual and overall treatment effect measures (PROSPERO registration: CRD42020149915). Results: Glycated haemoglobin was significantly reduced for CGM when compared with SMBG [Cohen's d À 0.62 (95% CI À0.79 to À0.45)] and for CSII when compared with MDI [Cohen's d À 0.44 (95% CI À0.67 to À0.22)]. Rates of severe hypoglycaemia were significantly reduced with CGM compared with SMBG, but did not change for CSII when compared with MDI. Episodes of diabetic ketoacidosis were more likely to occur with CSII than MDI. Both CSII and CGM reduced glucose standard deviation, compared with MDI and SMBG respectively.Conclusions: Both CGM and CSII remain impactful interventions compared with SMBG and MDI but in adults with type 1 diabetes and in the contexts in which they have been studied, CGM might have a greater positive impact on glycaemic variability and severe hypoglycaemia than CSII, when added to MDI and SMBG. A head-tohead study, including patient reported outcomes, is required to explore these findings further. K E Y W O R D Scontinuous glucose monitoring (CGM), continuous subcutaneous insulin infusion (CSII), HbA1c, insulin pump, intensive insulin therapy, multiple daily injections (MDI), self-monitoring of blood glucose (SMBG), type 1 diabetes

Continuous Glucose Monitor, Insulin Pump, and Automated Insulin Delivery Therapies for Type 1 Diabetes: An Update on Potential for Cardiovascular Benefits

“…CSII is also beneficial for all ages of those with T1D, as it is associated with lower HbA1c [ 14 , 20 , 28 , 33 , 48 – 52 ]. One pediatric study showed that when compared to MDI users, pump users had lower HbA1cs for 6 years of treatment follow-up [ 53 ].…”

“…In older adults with T1D, people using CSII were less likely to exhibit cognitive dysfunction compared to those using MDI [ 33 ]. Recent data from diabetes registries and cohort studies also demonstrate associations between insulin pump use and reduced rates of DKA [ 13 , 14 , 48 , 58 ], although two meta-analyses analyzing results of clinical trials found higher incidence of DKA in people using CSII when compared to MDI use [ 28 , 52 ]. Like CGMs, insulin pump use is supported by US and international T1D clinical treatment guidelines for both pediatric and adult populations.…”

“…CGMs are beneficial for all ages of people with T1D, regardless of insulin delivery method. Studies performed around the world utilizing various CGMs have associated CGM use with reductions in hypoglycemia [18,[26][27][28][29][30][31] and HbA1c [12,14,19,30,[32][33][34], improvements in TIR [19], fewer episodes of diabetic ketoacidosis (DKA) [14,35], and improvements in psychosocial outcomes [36][37][38]. Furthermore, early initiation of CGM (i.e., within 1 year of T1D diagnosis) has shown association with lower HbA1c and fewer diabetes-related emergency visits [39,40].…”

Effects of initiating insulin pump therapy in the real world: A nationwide, register-based study of adults with type 1 diabetes

“…An estimated 63 % of adults with T1D in the US and 5-15 % of those in Europe use one [1,2]. The increasing uptake of insulin pump therapy (IPT) follows several meta-analyses of randomised controlled trials (RCTs) conducted in the past two decades of which most found a significant reduction in HbA 1c , compared with conventional treatment with multiple daily insulin injections (MDI) [3][4][5][6][7]. Although some RCTs have found reduced risk of diabetic ketoacidosis (DKA) and severe hypoglycaemia (SH), meta-analyses have found no or little effect on both outcomes or even an increased risk of DKA following IPT initiation [4,7,8].…”

Insulin Pump Use and Diabetic Retinopathy—Is Technology the Key to Preventing Retinopathy in Young People With Type 1 Diabetes?

“…3 There are data suggesting that the addition of CGM to CSII further improves time in range and glucose variability. 4 However, it is notable that Ferm and colleagues 1 did not find that CGM use was associated with a reduced risk of DR. This lack of association may reflect CGM use in routine practice rather than its use in focused studies.…”