To Pump OR To Inject … that is the
Question … ?
Sanoe Harrison & Patrick Hanley
Autoimmune Diabetes
Mellitus
Review of Problem
Glucose in Healthy Volunteers
Day Ave ± SD = 93.0 ± 7.0 mg/dl, Night Ave ± SD = 81.8 ± 6.3 mg/dl
Insulitis Grading
0
progression of insulitis
1
2
3
4
DCCT (Diabetes Control and Complication Trial)
Goals for long term health …
O A1c < 7.5
O Absence of severe hypoglycemia
O Minimize glucose variability …
O Normal blood pressure
O Normal cholesterol (LDL & HDL)
O Normal weight (BMI <85th percentile for age &
sex)
Insulin Discovery
First insulin syringe 1949
First glucometer 1968
1963 - Dr. Arnold Kadish
designed the first insulin pump
to be worn as a backpack
Sanoe’s Story
Sanoe’s Timeline
13
16
21
35
•diagnosed
with T1D
•used NPH
and Regular
•began to use
Humalog
and
Ultralente
•began to use
insulin pump
•began to use
glucose
sensor
Pat’s Story
Pat’s Timeline
Discussion Questions …
O What made you choose this breakout
session?
O Who uses a pump for insulin?
O Who uses MDI for insulin?
Is there research to help us decide … ?
O We all know the first key is … taking our insulin and
checking our blood sugar!
O But the question is … with more options today to
deliver insulin and monitor glucose is one way
better?
O Evidence based medicine but also need to consider
…
O … what is best for you the individual patient/family?
Some Articles Comparing CSII to MDI
O “Long-term health economic benefits of sensor- augmented
pump therapy vs continuous subcutaneous insulin infusion
alone in type 1 diabetes: a UK perspective” - Journal of
Medical Economics 2016
O “Continuous subcutaneous insulin infusion therapy and
multiple daily insulin injections in type 1 diabetes mellitus: a
comparative overview and future horizons” - Expert Opinion
on Drug Delivery 2015
O “Multiple Daily Injections OR Insulin Pump Therapy:
Choosing the Best Option for Your Patient—An Evidencebased Approach” – Current Diabetes Reports 2015
O “Does treatment with an insulin pump improve glycaemic
control in children and adolescents with type 1 diabetes? A
retrospective case–control study” - Pediatric Diabetes 2015
Articles Comparing CSII to MDI
O “Insulin pump therapy, multiple daily injections, and
cardiovascular mortality in 18,168 people with type 1
diabetes: observational study” – British Medical Journal
2015
O “Insulin pump use in young children in the T1D Exchange
clinic registry is associated with lower hemoglobin A1c levels
than injection therapy” - Pediatric Diabetes 2014
O “Long-term outcome of insulin pump therapy in children with
type 1 diabetes assessed in a large population-based case–
control study” –Diabetologia 2013
O “A randomized, prospective trial comparing the efficacy of
continuous subcutaneous insulin infusion with multiple daily
injections using insulin glargine“– Diabetes Care 2004
Major findings of this paper
• Showed that treatment with CSII resulted in an
improvement in HbA1c levels up to 1 year (8.1% vs. 8.3%)
# of severe hypoglycaemic events with CSII =
incidence rates of severe hypoglycaemic episodes per
100 person-years were 3 in the CSII group & 6 in the MDI
group
• 
• Frequency of ketoacidosis  in CSII group = There were
2.8 episodes of DKA/100 person-years in the CSII group
& 0.5 in the MDI group
• 
insulin needed in CSII group & no change in weight
Why do some people stop using pumps?
Main reasons found in one study:
“Reasons for the discontinuation of therapy of
personal insulin pump in children with type 1
diabetes” Pediatr Endocrinol Diabetes Metab
2015;21,2:65-69
Greater sense of disease (93%)
Difficulties in doing sports (70%)
Worse well-being during pump therapy (63%)
Having to attach the pump to the body (60%)
Embarrassment (56%)
Adhesions & pain in the place of needle insertion (50%)
Difficulties in controlling glycemia during physical exercise
(43%)
O Fear (43%)
O High levels of HbA1c (36%)
O Frequent blood glucose monitoring (26%)
O
O
O
O
O
O
O
Pros & Cons of Pumps
O Pros
O Flexible basal rates
O Advanced bolus options
O Convenience of giving multiple doses
O Slightly decreased total insulin need
O Cons
O Risk of DKA with pump malfunction
O Hardware attached to body
O Cost
Pros & Cons of MDI
O Pros
O Reliable absorption
O Not connected to device
O More affordable
O Cons
O Cannot alternate basal rates
O Multiple injections
O Harder to disguise
Special Considerations
Image from: http://keralaeditor.com/kerala-toprovide-free-insulin-pumps-for-diabetic-kids/
Case 1
O 18 y/o F, got a pump 2yrs ago, and is now
going away to college
O At school she is too busy to test sugar more
than 2x per day
O She noticed that her pump insulin reservoir
lasts her 5 days
O She usually gets home late, tests, changes
her pump sites as needed right before going
to bed
Case 2
O 14 year old boy on MDI since diagnosis 2 yrs ago
O Normally hyperglycemic in the morning despite
changing lantus dose
O Hypoglycemia often with sports
O Very active with sports & motivated to do better
with his diabetes control …
How do you define success
with Diabetes?
Future Directions
Affreza – Inhaled Insulin
Absorption
Afrezza – Side Effects
Respiratory
O Decreased Lung function in some (6 vs. 3%)
O Cough ~25 %
Cancer
O 4 cases of lung cancer (2 smokers)
Degludec
Degludec
O Pharmacokinetic properties:
O Long half-life (25 h)
O Long duration of action (42 h)
O Lower variability (25% that glarginie)
from other basal analogues
O Need studies in pediatric patients …
Thank
veryquestions
much for your
A
fewyou
more
…
O
attention & participation … any
Why did you choose
your current therapy?
questions?
O Do you want to change?
O If so why?