Insulin Pump Outperforms Multiple Injections in Type 2 Diabetes
Sometimes, despite best efforts on the part of the clinician and the type 2 diabetes patient, A1c goals are not met. Although in some circumstances the underlying limitation to goal attainment is readily discernible (hypoglycemic episodes, non-compliance, medication misadministration, excessive weight gain, other adverse effects), it is no always so clear.
The combination of bolus insulin with basal insulin is designed to mimic endogenous insulin production in healthy individuals. Numerous titration schedules for both components have proven effective in clinical trials. Nonetheless, there remains a population for whom basal-bolus insulin is not sufficiently effective. Might the insulin pump provide better control in such patients?
Reznik et al performed an open-label trial comparing — among patients who had previously not been able to attain A1c goals using multiple daily doses of insulin — insulin pump treatment versus optimized basal-bolus dosing (n = 331). The mean baseline A1c at enrollment was 9.0%. At 6 months, the insulin pump treatment group enjoyed a substantially greater A1c reduction than the optimized basal-bolus dosing group (1.0% vs 0.4%).
It would be easy to walk away from this study with the simplistic conclusion that “the pump is just better,” a conclusion that may be premature. First, recall that the group enrolled in the trial had already demonstrated that they were not highly effective in utilization of multiple daily insulin doses (baseline A1c 9.0% despite utilization of basal-bolus insulin), so we should not be surprised that the treatment methodology that didn’t work before didn’t work again! Second, despite the insulin pump, the mean A1c reduction at the end of the 6-month trial was still insufficient to bring most patients to A1c goal (mean A1c in the pump group = 7.9%). Finally, insulin pump treatment is considerably more expensive than multiple injections.
Evidence-based updates in primary care medicine.
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