Insulin pumps

This year there have been a number of articles evaluating and optimizing the utilization of insulin pumps. A new meta-analysis by Pala et al. attempts to break down decades of past studies comparing continuous subcutaneous insulin infusion (CSII) and injection. In this more detailed analysis, they stratify studies by dosing regimen and insulins utilized, which has evolved over time. They report a consistent hemoglobin A1c (HbA1c) benefit for pumps, but it was significantly greater in past trials using regular human insulin. There is a profound need to consider other outcome measures beyond HbA1c, such as continuous glucose monitor (CGM) metrics, ease of use, and quality of life. There are several unaccounted factors in the meta-analysis, including education, automated insulin delivery analyzed by Bosi et al., and bolus speed, which was investigated by Regittnig et al. Bosi et al. found that the suspendbefore-low feature on the Medtronic 640G reduced hypoglycemia in at-risk adults. Regittnig et al. observed that bolus delivery under one minute reduced postprandial hyperglycemia. These optimizations and features may affect primary outcomes in future systematic reviews. Additional explored outcomes for CSII included weight gain, which was evaluated in insulin pump and multiple daily injection users retrospectively by Alderisio et al. Despite improved glycemic control and lower prescribed insulin doses in the insulin pump cohort, weight gain was similar over 6–10 years of follow-up. This raises the question if the mechanism of weight gain differs between the therapies. Another study by Toresson Grip et al. evaluates the costs of insulin pump therapy compared to multiple daily injections within the Swedish National Diabetes Register. As anticipated, insulin pump therapy is more costly than multiple daily injections, but unmeasured benefits must also be considered. For those desiring pump therapy, many barriers to access still remain. Briganti et al. revealed that age need not be a limitation for pump use. In a retrospective review, they found that a population with type 1 diabetes age 50 years and over had similar outcomes to younger pump users with less weight gain and better glycemic outcomes than those 50 and over on multiple daily injections. In an effort to reduce educational barriers to access, Ehrmann et al. designed a structured insulin pump education program called INPUT (Insulin Pump Treatment). This education led to significant improvement in glycemic control while reducing severe hypoglycemia. Structured education leading to optimal utilization may increase the benefit of insulin pump therapy versus multiple daily injections. Ziegler et al. highlight the possible fatal consequences of insufficient education in a case series of six deaths from Teflon infusion sets that were found outside of the body at autopsy. Structured education and novel infusion-set design may reduce this feared risk of pump therapy. Multiple breakthroughs in diabetes technology have advanced pump care. Klonoff et al. investigated the use of Fiasp in insulin pumps, which was found to be non-inferior to insulin Aspart with some improved measures of postprandial hyperglycemia. Another trial by Heise et al. evaluated BioChaperone insulin lispro in CSII with euglycemic