Authors: Heiko Bratke, Hanna D. Margeirsdottir, Jörg Assmus, Pål R. Njølstad & Torild Skrivarhaug
Abstract
Objective
To examine the use of multiple daily injections (MDI), insulin pumps, self-measured blood glucose (SMBG), and continuous glucose monitoring (CGM) systems, and their association with glycated hemoglobin (HbA1c), diabetic ketoacidosis (DKA), and severe hypoglycemia.
Methods
In a pediatric population-based nationwide cross-sectional study, we analyzed data from 2623 participants up to 18 years of age with type 1 diabetes, using 2017 annual data from the Norwegian Childhood Diabetes Registry. HbA1c was adjusted for age, gender, and diabetes duration. Using a linear mixed-effects model, we assessed HbA1c and the incidence of DKA and severe hypoglycemia according to the use of MDI, insulin pumps, SMBG, and CGM.
Results
We observed that 74.7% of participants were using an insulin pump and 52.6% were using a CGM system. Mean HbA1c was 7.8% (62 mmol/mol). The HbA1c of pump users was 0.14 percentage points (pp) higher than that of MDI users. Fewer pump users than MDI users achieved an HbA1c of < 7.5% (38.3 vs. 41.6%). CGM users had a 0.18 pp lower HbA1c than SMBG users, with 40.5 and 38.0%, respectively, achieving an HbA1c of < 7.5%. The incidence of severe hypoglycemia or hospitalization due to DKA was not different in pump and CGM users compared with nonusers. Compared with other insulin pumps, patch pump use was associated with a significantly lower odds ratio for DKA.
Conclusions
Despite the broad use of diabetes technology, as many as 61% of our pediatric cohort did not reach the HbA1c target recommended by the International Society for Pediatric and Adolescent Diabetes (ISPAD). Lower HbA1c was associated with CGM use but not with insulin pump use. Acute complications were not less frequent in the groups using insulin pumps or CGM compared with those using MDI and SMBG. Further research is required to explore the lower incidence of DKA among patch pump users.
Key Summary Points |
| Knowledge on the use of continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) under real-world conditions is limited, and existing studies with different study designs have shown different results on the possible effect of these devices on glycated hemoglobin (HbA1c), diabetic ketoacidosis, and severe hypoglycemia in persons with type 1 diabetes. |
| The overall use of CSII was not associated with a higher proportion of children and adolescents with HbA1c < 7.5% (58 mmol/mol) or lower mean HbA1c. The use of continuous glucose monitoring, however, was associated with a 0.15 percentage point lower HbA1c. Acute complications were not less common when using CSII or CGM compared with nonuse. Patch pumps might reduce the risk of diabetic ketoacidosis. |
| Expectations for the use of technical devices, at least those prevalent in 2017, should be modest. Insulin pumps and CGM systems that are more user-friendly and more sophisticated, especially newer closed-loop systems, might lead to better metabolic control than the devices used in our 2017 cohort. |