Insulin pumps do not boost education effects on glycemic control
medwireNews: Research shows that switching to an insulin pump does not improve glycemic control in patients referred to an educational program after struggling to control their type 1 diabetes with multiple daily injections.
The randomized Relative Effectiveness of Pumps Over MDI and Structured Education (REPOSE) trial included type 1 diabetes patients who were referred to the UK’s DAFNE insulin management program owing to an average glycated hemoglobin (HbA1c) level of 9.1%.
These patients were randomly assigned to either receive an insulin pump or to continue with multiple daily injections. However, by the 24-month follow-up, the average HbA1c level had fallen by an absolute 0.85% among the 119 patients in the pump group, which, after accounting for center, course, and baseline HbA1c, did not significantly differ from the 0.42% improvement in 116 patients who continued to use injections.
Excluding any participants who had switched treatments (per protocol analysis) gave a slightly larger between-group difference of 0.36%, compared with 0.24% in the intention to treat analysis, but both of these were less than the prespecified minimal clinically important difference of 0.5%.
From a baseline of 10% and 9% in the pump and injections group, respectively, the proportion of patients achieving HbA1c of 7.5% or below increased to 25.0% and 23.3%, with no significant difference between the groups.
Writing in The BMJ, Simon Heller (University of Sheffield, UK) and study co-authors say that rather than being given insulin pumps, patients struggling with glycemic control “might be better served by ensuring far greater availability of high quality, structured self management training, which is currently only accessed by around 10% of adults in the UK.”
They add that patients “who find that despite their best efforts, injections fail to deliver the expected benefits could then be offered the additional technological advantages of an insulin pump.”
Patients assigned to receive pumps did report somewhat better diabetes-specific quality of life than those who continued with injections, with significantly better outcomes for measures including diet restrictions and daily hassle, and also reported significantly better treatment satisfaction at 12 and 24 months.
But, in the absence of other benefits, “those observations are probably insufficient to justify a major alteration in guidelines for the use of pumps,” say Heller and team.
Finally, the researchers highlight the very high baseline HbA1c level of the participants, and that only 3% achieved the current UK recommendation of 6.5%.
“There is an urgent need to explore the barriers to successful self management in adults with type 1 diabetes in the UK and to understand why referral for appropriate training is often left so long,” they conclude.
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