Background
Although continuous subcutaneous insulin infusion therapy (ie, insulin pump therapy)
is associated with improved metabolic control compared with multiple daily insulin
injections in children with type 1 diabetes, it is unclear when it is best to start
it after diagnosis. In this study, we aimed to compare the outcomes between early
and delayed start of insulin pump therapy in young patients with type 1 diabetes.
Methods
We based the current study on data from the multicentre, prospective diabetes follow-up
registry (ie, Diabetes-Patienten-Verlaufsdokumentation [DPV]). The DPV registry comprises
501 diabetes centres from Germany, Austria, Switzerland, and Luxembourg. We included
patients diagnosed with type 1 diabetes between 2004 and 2014, who were aged between
6 months and 15 years at the time of diagnosis, who had started insulin pump therapy
either within the first 6 months (ie, the early treatment group) or in the second
to third year (ie, the delayed treatment group) after diabetes diagnosis, and who
were treated with insulin pump therapy for at least 1 year. The outcome parameters
included the glycated haemoglobin (HbA
1c) values, the cardiovascular risk profile, and rates of acute complications and diabetes-associated
hospital admissions (ie, hospitalisation) during the most recent documented treatment
year with insulin pump therapy. Statistical models were adjusted for age at diabetes
diagnosis, year of diagnosis, sex, immigrant background, use of continuous glucose
monitoring, centre size, and the German Index of Socioeconomic Deprivation 2012 terciles.
Findings
Our study sample comprised 8332 patients from 311 diabetes centres in Germany, Austria,
Switzerland, and Luxembourg. The early treatment group consisted of 4004 (48·1%) of
8332 patients, and the delayed treatment group consisted of 4328 (51·9%). The median
diabetes duration during follow-up was 6·7 years (IQR 5·1–8·7 in the early group;
5·0–8·7 in the delayed group) in both groups. Patients with early initiation of insulin
pump therapy compared with those with delayed initiation of insulin pump therapy had
significantly lower estimated mean HbA
1c values (7·9% [95% CI 7·8–7·9] and 62·6 mmol/mol [95% CI 62·1–63·2]
vs 8·0% [8·0–8·1] and 64·1 mmol/mol [63·6–64·6]; p=0·0006), and lower rates of hypoglycaemic
coma (incidence risk ratio 0·44 [95% CI 0·24–0·79]; p=0·0064) and hospitalisation
(0·86 [95% CI 0·78–0·94]; p=0·0016). A better cardiovascular risk profile was observed
in patients with early initiation of insulin pump therapy than in those with delayed
initiation: an estimated mean systolic blood pressure of 117·6 mm Hg (95% CI 117·2–117·9)
versus 118·5 mm Hg (118·2–118·9), p=0·0007; and HDL cholesterol of 62·8 mg/dL (95%
CI 62·2–63·5) versus 60·6 mg/dL (60·0–61·2), p<0·0001; however, diastolic blood pressure;
concentrations of LDL cholesterol, non-HDL cholesterol, and triglycerides; and estimated
body-mass index standard deviation scores during follow-up did not differ significantly
between both groups.
Interpretation
Our findings provide evidence for improved clinical outcomes associated with the early
initiation of insulin pump therapy in children with type 1 diabetes.
Funding
The German Center for Diabetes Research (Deutsches Zentrum für Diabetesforschung),
German Robert Koch Institute, German Diabetes Association, and Diabetes Agenda 2010.
