Anyone who has treated patients with Type 1 diabetes knows the challenges of optimizing glycemic control while trying to minimize the risk of severe hypoglycemia. Some studies have suggested that in adults, insulin pumps may be more effective than multiple daily insulin injections at achieving this goal. Other studies have pointed to continuous glucose monitoring (CGM), recently made feasible by technologies that measure glucose levels in real time, as a good way to reduce glycated hemoglobin levels in adults.
A sensor-augmented pump combines these two components –the insulin pump and CGM – in a single system. The Sensor-Augmented Pump Therapy for Glycated Hemoglobin Reduction (STAR) 3 study, a randomized, controlled trial, compared the effectiveness of sensor-augmented pumps (“pump therapy”) with that of multiple daily insulin injections (“injection therapy”) in achieving glycemic control.
As Bergenstal et al. report this week, the STAR 3 study found that a significantly greater proportion of patients on pump therapy reached the targeted glycated hemoglobin level (<7%) than those on injection therapy. This was true for both adults and children. The study also found that the greater the sensor use, the greater the reduction in glycated hemoglobin level. Rates of adverse events – namely, severe hypoglycemia and diabetic ketoacidosis – were similar across the two study groups and age groups.
In an accompanying editorial, Continuous Glucose Monitoring – Coming of Age, Dr. Howard Wolpert of the Joslin Diabetes Center in Boston stated, “The benefits of CGM are also balanced by increased demands this technology places on the patient. For patients with frequent hypoglycemic episodes or fear of hypoglycemia the immediate quality-of-life benefits provided by CGM may readily offset these extra demands. For other patients, these demands – including the complex task of inserting and calibrating the sensor, trouble-shooting device malfunctions, and responding to alarms – can become a burden that detracts from the benefits of the technology.”
What has been your clinical experience with the use of pump therapy versus injection therapy in the management of type 1 diabetes?
Given the challenges of patient adherence, as well as the training required to operate a sensor-augmented pump system, how will the STAR 3 study findings influence your approach to treating Type 1 diabetes?