New Diabetes Guidelines: Insulin Pumps & CGM

Continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) have an important role in the treatment of diabetes, according to new clinical practice guidelines issued by the Endocrine Society.

A Task Force, including an eight-member writing panel led by Anne L. Peters, MD, professor of endocrinology at the University of Southern California, Los Angeles, CA, used the best available research evidence to develop the recommendations made for the new guidelines.

The Task Force commissioned a systematic review and individual patient data meta-analysis of randomized controlled trials (RCTs) that enrolled individuals with type 1 diabetes mellitus (T1DM) and compared real-time CGM to control groups. Pooled data from 11 RCTs suggested that the use of CGM was associated with a significant reduction in hemoglobin A1C, with improvements seen primarily in those aged 15 and older.

The success of these devices and technologies is directly linked “to the level to which people are educated, capable, and willing to use them,” the authors write, stressing the need for “patient and practitioner education and training in conjunction with clearly defined processes for patient follow-up, analysis of device data, and access to care should a problem arise.”

In addition, the Task Force notes that “data are lacking that demonstrate a clear superiority of CSII” over multiple daily injections (MDI). “However, diabetes specialists have confidence in pump therapy, despite its greater expense,” they write. Registry data of diabetes specialty clinics in the US shows that more than half of the adult T1DM patients use CSII and have lower A1C levels than those using MDI.

Five FDA-approved pumps are available in the US, providing numerous features “to improve accuracy, safety, dosing decisions, convenience, and overall usability,” they write. New guidelines only reviewed pumps that allow for multiple basal rates and use bolus dose calculators.

Current models of CGM measure the glucose concentration in the interstitial fluid, and “devices are evolving steadily in terms of accuracy and ease of use,” they write. The guidelines reviewed data regarding current CGM devices, giving specific consideration to more recent device technology.

Highlights of the guideline recommendations include:

• Insulin pump therapy without sensor augmentation.  CSII is recommended over analog-based basal-bolus MDI in patients with T1DM who have not achieved their A1C goal, as long as the patient and caregivers are willing and able to use the device.

• Insulin pump therapy in T2DM. CSII with good adherence is recommended for monitoring and dosing in patients with T2DM who have poor glycemic control despite intensive insulin therapy, oral agents, other injectable therapy, and lifestyle modifications.

• Insulin pump use in the hospital. Clinicians should continue CSII in all diabetes patients admitted to the hospital if there are clear protocols for evaluating patients as suitable candidates and appropriate monitoring and safety procedures.

• Selection of candidates for insulin pump therapy.  Before prescribing CSII, clinicians should assess a patient’s mental and psychological status, prior adherence with diabetes self-care measures, willingness and interest in trying the device, and availability for follow-up visits.

Reference: Peters AL, et al. Diabetes technology-continuous subcutaneous insulin infusion therapy and continuous glucose monitoring in adults: an Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016 Sep 2:jc20162534.