Technologies in diabetes have progressed rapidly in the last few years, especially for people with type 1 diabetes. Continuous subcutaneous insulin infusion (CSII), or insulin pump therapy, is now the standard of care for people with type 1 after many trials showed the superiority of pump therapy to multiple daily injections (MDI) in this group. There is, however, less robust evidence and fewer guidelines for insulin pump use in type 2 diabetes.
A few months back, Steve and I had the opportunity to evaluate the current literature available for the use of insulin pumps in people with type 2 diabetes. We investigated who would be a good candidate for insulin pump therapy, barriers to pump use, and future studies required to make pump use more mainstream for type 2 diabetes. We recently had this extensive review of literature published in the journal Diabetes, Obesity and Metabolism and we wanted to share the summary of our discoveries here.
Why Consider Insulin Pump Use in People with Type 2 Diabetes?
Although we now have many insulin-sparing regimens for people with type 2 diabetes, the natural trajectory of this disease in some people includes the progressive need for insulin due to pancreatic beta cell exhaustion. Real-world data shows that most people with type 2 on multiple daily injections of insulin have a difficult time adhering to therapy due to a number of issues, like difficulty understanding complicated regimens, injection burden, fear of injections, fear of hypoglycemia, social stigma, and concerns of weight gain. For these reasons, we think an insulin pump could be considered for those with type 2 who have poor glycemic control despite multiple daily insulin injections.
What Types of Insulin Pumps Have Been Studied with Type 2 Diabetes?
Both conventional and simple patch pumps were studied in different trials. The conventional pumps are those with fancier algorithms like the Animas, Medtronic, Tandem, and Omnipod pumps. Simple pumps are those like V-GO (now owned by MannKind) and Simplicity (bolus-only pump owned by Cequr.), which do not have an advanced algorithm but can set a basal rate and administer mealtime bolus doses with “clicks” – each click providing two units of insulin. Typically, simple patch pumps are easier to train on and can be replaced every 1-3 days, depending on the user’s daily insulin requirements.
What Are Some Advantages of Insulin Pump Use, and Who Might Benefit from These Devices?
In our literature review, we found that most studies showed a reduction in A1c of at least -1% or more in T2 pump users compared to MDI users. Moreover, user satisfaction and adherence to treatment were higher with pump users compared to those on MDI. The total daily dose of insulin, as well as weight changes showed mixed results, with most studies showing less insulin use and either neutral or less weight gain in pump users. Repeatedly, all studies showed that those who benefitted the most from insulin pump use were those who were previously poorly controlled on MDI. Economical analysis also favored pumps, mostly due to the lower quantity of insulin, which is quite expensive these days, being used by the pump users.
What Are Some Barriers to Insulin Pump Use?
One of the biggest barriers, especially with conventional pump use, is cost. Although the long-term cost analysis is favorable because less insulin is being used by pump users, the initial costs associated with an insulin pump are very high. This, along with only sparse randomized controlled trials, which is the most accepted way to evaluate therapies, available to support pump therapy in type 2, has prevented insurers from paying for these devices.
Another barrier includes the technological complexity of conventional pumps. Many people, especially those who are older or with cognitive impairment, would not be able to use conventional pumps. However, we did find that the use of simple patch pumps like the V-GO to be clinically and cost-effective, while requiring less rigorous training and troubleshooting from the user and the healthcare provider. Moreover, the simple patch pump training can easily be done in a primary care setting, without the need for a highly specialized diabetes center.
Here Are Some Insulin Pump Options to Explore:
Conventional Pumps/AID Systems with Algorithms that communicate with a CGM:
- Tandem CIQ
- Tandem Mobi
- Insulet Omnipod 5
- Medtronic 780G
- iLet Bionic Pancreas (no carb counting or basal adjustments – just enter “small, medium or large” for your meal)
Simplified Pumps and Patch Pumps:
- Valeritas V-Go
- CeQur Simplicity (this is a bolus-only pump that gives 2 units of insulin at a time)
- Omnipod Go (basal insulin only)
Conclusions and Future Directions for Research
After a thorough review of the literature, we concluded that a conventional pump or a simple patch pump would benefit those with uncontrolled type 2 on MDI, with or without other oral/non-insulin diabetes medications. Simple patch pumps are also cost effective without the need for rigorous training. However, both simple and conventional insulin pumps are limited in how much insulin they can carry, with a maximum of about 300 units in conventional pumps. For those with type 2 who have high insulin resistance, future directions for research should include utility of a simple patch pump that can carry at least 300 units of insulin. Additionally, larger randomized-controlled trials with longer follow-ups comparing MDI use to simple or conventional patch pumps are needed to move the needle on making the use of these devices mainstream (and covered by insurance!) for people with type 2. Some pumps and some patch pumps are covered, but not by all companies.
Here is a link to the full article in Diabetes, Obesity and Metabolism