Insulin therapy in youths with T1D

Insulin Therapy in Youth with Type 1 Diabetes Mellitus: Multiple Daily Injections or Insulin Pump Therapy

Presented by:
Hood Thabit, MB BCh MD PhD
Manchester University NHS Foundation Trust
University of Manchester, UK

The 4 main goals for the management of type 1 diabetes are glycemic control, avoidance of hypoglycemia, reduction of morbidity & mortality, and maximization of treatment satisfaction (patient-reported outcome measures). In the child and adolescent population, according to type 1 diabetes registries, mean HbA1c levels are highest among those aged 13 to 25 years old (8.7%) and glycemic control worsens overtime in children 8 to 18 years old (both sexes).1,2 There has been a gradual decrease in the amount of severe hypoglycemia episodes over the past 10 years, and lowering HbA1c is no longer correlated with an increased risk of severe hypoglycemia. According to a large Nordic study evaluating the incidence of severe hypoglycemia between 4 countries with equal access to healthcare, no significant differences in hypoglycemia risk were observed between HbA1c groups in a multivariate analysis, after adjusting for gender, age and diabetes duration. Indeed, a trend towards lower risk ratio for severe hypoglycemia was observed in those with the lowest HbA1c.3,4 When comparing pump administration vs. multiple daily injections (MDI), observation studies have shown that pump users have consistently lower levels of HbA1c.2,5

Diabetic ketoacidosis (DKA) and severe hypoglycemia are short-term complications of type 1 diabetes and need to be considered in type 1 diabetes patients in both pump and MDI users. Previous randomized controlled trials suggested that DKA was less frequent among insulin pumps users than MDI users. However, these trials were not powered to detect these outcomes, and variability exists among registries.6 Similarly, there has been a general decline of severe hypoglycemia associated with insulin pump use when reviewing registry databases.3

Children and young adults with type 1 diabetes experience long-term complications over time, with 13% of children already experiencing signs of peripheral neuropathy, with that rate increasing every year.7 This may lead to other complications later in life such as lower limb amputations.7 In a study that compared rates of microvascular complications in adolescents with type 1 diabetes treated with pumps vs MDI, odd ratios were consistently in favor for pump use for lower rates of retinopathy, albuminuria, and peripheral/autonomic nerve abnormalities.8

According to the Swedish National Diabetes Register, when comparing 244 pump users to 15,727 MDI users, all-cause mortality was lower in patients using a pump, adjusted HR 0.73 (0.58 to 0.92), as was cardiac heart disease and cardiovascular disease:9

  • Fatal coronary heart disease: HR 0.55 (0.36 to 0.83)
  • Fatal cardiovascular disease: HR 0.58 (0.48 to 0.85).

Similar to other database reviews such as these, there were limitations as no data were available for pump duration of use, incomplete data on hypoglycemia (only ICD-10 diagnosis codes from hospital discharge were used), frequency of testing, and other factors that may have influenced the study.

There are a number of limitations with the studies that reviewed quality of life which make results difficult to determine. Many studies provided mixed results, had small sample sizes, poor methodology, and inconsistent assessment of quality of life.10,11 Taking these considerations into account, some findings that were consistent were greater treatment satisfaction and improved diabetes self-efficacy among pump users. In particular, adolescents using insulin pumps felt greater independence and responsibility for their diabetes regimen.10

Key Messages

  • Glycemic control appears to worsen in children from 8 to 25 years.
  • Pump therapy has been associated with modest HbA1c improvement, lower rates of severe hypoglycemia and DKA, reduced morbidity and mortality (independent of HbA1c), and better diabetes-specific quality of life.
  • The choice for insulin administration should be individualized and take into account individual/parent preference. The aim should be to maximize treatment satisfaction and quality of life.
  • Both MDI and pump users need support and education.


Present disclosure: The presenter reported that he provides research support for Dexcom, Inc.

Written by: Debbie Anderson, PhD

Reviewed by: Marco Gallo, MD


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