Real-world data support early insulin pump initiation in children
medwireNews: Starting children on an insulin pump within 6 months of type 1 diabetes diagnosis is associated with improved outcomes relative to delaying for 2 or 3 years, shows an analysis of data from the DPV registry.
The study included 8332 children, diagnosed between 6 months and 15 years of age (median=6.1 years), in 311 diabetes centers in Germany, Austria, Switzerland, and Luxembourg.
The 48.1% of participants given a pump within 6 months of diagnosis were markedly younger than the 51.9% in whom pump therapy was not started until the second or third year after diagnosis, at a median of 3.6 versus 9.0 years.
Clemens Kamrath (Justus Liebig University, Giessen, Germany) and study co-authors say this is in line with guideline recommendations to use insulin pumps in very young children “and consistent with other reports that have shown highest use of technical devices in preschool children.”
Of note, these children were significantly less likely to discontinue pump use than those who started using it later, at 8.1% versus 14.1%.
During follow-up, children in the early pump therapy group had slightly but significantly lower glycated hemoglobin (HbA1c) levels than those in the delayed group, at 7.9% (62.6 mmol/mol) versus 8.0% (64.1 mmol/mol), after adjustment for factors including age at diabetes onset, sex, socioeconomic factors, diabetes duration, and continuous glucose monitoring use.
Early pump therapy was also associated with slightly but significantly lower systolic blood pressure, at 117.6 versus 118.5 mmHg.
Kamrath et al stress that, although the HbA1c and blood pressure differences are small, “it is important to note that each 0.09% (1 mmol/mol) increase in HbA1c is associated with [a] 2% higher relative risk for death and that each 1 mm Hg increase in systolic blood pressure is associated with a 1.5% higher relative risk for stroke in patients with type 1 diabetes.”
Children given early pump therapy also had a slightly improved lipid profile, compared with the later adopters, resulting from higher levels of high-density lipoprotein cholesterol.
And early pump therapy was also associated with a reduced risk for acute diabetes complications, the researchers report in The Lancet Child & Adolescent Health.
Rates of severe hypoglycemia did not differ significantly between the two groups, although the incidence rate ratio (IRR) of 0.86 tended to favor early pump use, especially for children aged 11–15 years. But there was a significant reduction in hypoglycemic coma risk in the early versus late pump group, at an IRR of 0.44 with the effect again most striking in the 11–15-year age group.
“The reduction of hypoglycaemic coma in this study is of particular clinical relevance, because severe hypoglycaemia with coma is associated with a real risk of morbidity and mortality in children, and children with type 1 diabetes have an increased risk of long-term neurocognitive deficits due to severe hypoglycaemia in the developing brain,” write the researchers.
They highlight that the use of continuous glucose monitoring was similar between the groups after accounting for age, and therefore did not account for the differences in hypoglycemic coma.
The IRR of diabetic ketoacidosis did not differ according to timing of pump initiation, but early initiation was associated with significantly fewer days in hospital for diabetes, especially for children younger than 6 years and those aged 11–15 years.
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