COMMENTARY

EASD's Highlights on Insulin Pumps

News on Insulin Pumps From EASD 2014: Reduced Mortality, Benefits of the Closed Loop, and Monitoring Consensus

Eric Renard, MD, PhD

Disclosures

September 24, 2014

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Good morning. I am Eric Renard from Montpellier University Hospital in France. I am here at the European Association for the Study of Diabetes (EASD) meeting in Vienna, Austria. Yesterday (September 18, 2014), I chaired a session dedicated to medical devices for diabetes. The session was quite interesting in showing how devices are now naturally among the treatment for diabetes.

Reduction in Mortality and Microalbuminuria

Very important results were reported from a Swedish registry[1] showing a reduction in mortality in patients treated with insulin pumps vs patients treated by multiple daily injections. The reason for this reduced mortality is still not clearly known; however, it was very significant in terms of both mortality and nonfatal cardiovascular events. This has to be further explored to better understand how insulin pumps can be beneficial to the patients on insulin therapy.

Of interest, two other communications reported that in patients using insulin pumps, microalbuminuria was improved.[2,3] This is potentially connected to reduced mortality, because it is well known that people with high microalbuminuria have a higher risk for mortality.

The reason for this reduced microalbuminuria in patients who had high levels before switching to pumps is also not clearly understood. Because insulin doses were reduced during insulin pump therapy, it was suggested that some form of insulin resistance could be induced when insulin is administered by multiple daily injections. It could be related to the long-acting analogs, because usually patients attempt to increase the dose to obtain good basal control; whereas with the insulin pumps, because of the possibility of modulating the basal rate, those doses are lower. This must be further explored, but it is a positive signal in favor of insulin pumps.

New Data on the Artificial Pancreas

We cannot speak of insulin pumps today without suggesting that they could be connected to continuous glucose monitoring. This is what we call the "closed-loop system," or "artificial pancreas." There was a brilliant presentation from the Cambridge research team[4] on this topic yesterday. They cumulated their results in adolescents and adults showing that overnight use of a closed-loop, at-home system brought many benefits for the patients, including reduced hypoglycemia, increased time in normoglycemia, and improved mean blood glucose levels; in addition, technical incidents were quite infrequent. The only reported events were related to the connection of devices to the closed-loop platform, which was a tablet, and so they agreed that this should be improved.

These studies from Cambridge, along with those conducted in France (Montpellier), Italy (Padova), and the United States,[5] demonstrate that closed-loop overnight control is safe and efficacious. This is now a good reference for the treatment of patients with type 1 diabetes.

Closed-loop studies are quite positive for overnight control. Some studies are in progress trying to use closed-loop, at-home control for several weeks or several months, all day long. It is clear that it won't be closed-loop at all times, because meal announcement is necessary for obtaining good control after meals, but all of these are very positive signs in favor of artificial pancreas development in forthcoming years.

A US/Europe Consensus on Device Monitoring

The final point that should be underscored is the consensus between American Diabetes Association (ADA) and the EASD on the way that medical devices—or, more specifically, insulin pumps—should be monitored after coming on the market. Both scientific associations found that there were very poor reports about events that occurred in patients with insulin pumps.

Following approval to go to market, reports from the manufacturers are infrequent, and they depend on the manufacturer, so these associations agreed on a series of good manufacturing practices. These include reporting events occurring with pumps and infusion systems, because the catheter was clearly identified as the weakest part of the pump, so they ask for more exhaustive reports about the failures or the incidents occurring with pump and catheters, with the view of increasing safety of these devices. In real practice, pumps are now very reliable, and this report will be very important to improve catheters, which are the weakest parts of infusion systems.

EASD is now very much involved in diabetes technology. During the past year, a discrepancy between the ADA and EASD meetings was limited presentation on devices at the EASD, so now EASD is also a diabetes technology meeting.

This was a summary of what occurred on medical devices at EASD meetings this year. Thank you for your attention.

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