Insulin delivery method and mortality

Here are findings from an observational study of pumping vs. MDIs and mortality:

http://www.bmj.com/content/350/bmj.h3234

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Great… think insurance company will read this and let me get a pump now?
:frowning:

We’re all going to die eventually. I’d rather live 75 years than 75.5 strapped to a machine 24 hours a day, granted I might feel different if I wasn’t able to accomplish good control with mdi. Now that I use afrezza I wouldn’t even consider a pump… I think they’ll soon be relics of history.

I wonder why I haven’t seen ads on TV for afrezza?

strapped to a machine 24 hours a day

Just curious, have you ever actually used a pump? I just find a description such as “strapped to a machine” overly dramatic to the extreme…

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I haven’t… And I don’t mean to discount the benefits they’ve provided other people, but they certainly aren’t for me… Sorry for being overly dramatic…

LOL! I love being “strapped to a machine”, as you put it. Pumping has given me a semblance of a normal life–something I didn’t have during the years 1978 to 1996 when on shots. “Don’t knock it if you haven’t tried it” is an apt comment for your obvious disdain for insulin pumps. A pump is great for those with DP, those who need the accuracy of small boluses, and those with varied schedules or active lifestyles. DP control is my favorite feature of using a pump.

Interesting study. It seems odd that you’d do a study and not keep track of other problems-- hypos, strokes, car accidents or whatever-- while you were at it.

That’s what I’m wondering…whether insurance companies will ease up on their restrictions because of findings like this.

By all means, sounds like pumping is a great arrangement for you then.

I have no disdain for insulin pumps… For the people who need them, I think they’re nothing short of miraculous. I just don’t happen to need one. I think that some people benefit from them greatly and those people should use them— I don’t however think that they should necessarily be considered any sort of standard-of-care for anyone, unless that individuals specific case warrants one. Studies like these have little practical value because they aren’t comparing people who achieve equal levels of control with and without a pump. The pump itself isn’t some magical device that makes people live longer, it’s just a “machine” that makes dosing insulin easier for some people.

Also, historically, pump use became widespread around the same time as modern analogs such as lantus, humalog, etc replaced the vastly inferior regular and nph insulin— how much of the improved outcomes we’ve observed are due to widespread pump use and how much to better insulin? We may never really know but I’d tend to think the latter plays a larger role.

When folks who have never used a pump speculate about the realities of pump use, it feels to me a bit like a (actually) celibate priest expounding on sex. It’s not that you can’t know a lot about the subject merely from observation & education so much as … well, something. There is a subjective, not easily explained reason I have added “! Please save my pump !” to my medic alert wrist band.

The other aspect this reminds me of is how hard it is for even PWDs to realize the extent to which our individual experiences of diabetes differ. Knowing intellectually that we’re not all the same does not stop me from assuming that others are “still pretty much” the same as me. One of the biggest benefits I find to hanging out on discussion boards such as Tu is it repeatedly reminds me how wrong I am about that.

Sure, from the “neck up” I always know this. But the rest of me tends to forget surprisingly quickly. :flushed:

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I can say without a shadow of a doubt that pumping enabled me to live more independently, have children without any complications, feel “normal”, sleep feeling safe and confident at night, have much better control and A1c’s than I ever had on MDI.

Now, with all that being said, that is MY story and testimonial. Everyone is different and results may vary. Luckily it IS one of the standards of care that endocrinologists recommend.

Sarah :four_leaf_clover:

Studies like these have little practical value because they aren’t
comparing people who achieve equal levels of control with and without a
pump.

The two groups in the study DID have comparable levels of control. Pump users had an average A1c of 7.9% while MDI users had an average A1c of 8.0%. So they weren’t achieving tight control, but you can’t say their control wasn’t within the same range (and a range that is about average for people with Type 1).

I don’t however think that they should necessarily be
considered any sort of standard-of-care for anyone, unless that
individuals specific case warrants one.

People with Type 1 are hardly being forced to use pumps if they don’t want to use them. If anything, pumps are still difficult for many who would benefit from them to access. Statistics I’ve seen say something like 10-15% of Type 1s use pumps. That’s nowhere near a majority.

If you are able to achieve tight control without a pump then that’s great, but I don’t understand why that would make you so vehemently against them that you would advocate for decreased access to pumps (my understanding is “standard of care” just means that pumps would be accessible as a treatment option to the average person with Type 1, which they should be!).

how much of the improved outcomes we’ve observed are due to widespread pump use and how much to better insulin?

I’m sure insulin analogues have had a hugely positive impact. There are large studies that show a great decrease in complications and death for people with Type 1 diabetes in recent years, and those studies included both pump and MDI users. But the purpose of this study was to look at pumps compared to MDI (which implies that all participants were using analogues, since not many people do MDI with regular or NPH), and it showed a benefit specific to the group using pumps.

Wow, getting a little carried away here now… From my comments above

“For the people who need them, I think they’re nothing short of miraculous”

" I think that some people benefit from them greatly and those people should use them-"-

— I don’t know how anyone could read my comments and reach the conclusion you did.

As to “standard of care”— if an insulin pump is a “standard of care” for a t1 diabetic it also would mean that any doctor not prescribing it to every single T1 patient regardless of circumstance isn’t practicing standard of care and is therefore committing malpractice, or any patient not using one was non compliant… Thus I don’t think it would ever be appropriate to call it a standard of care. It is a very effective and entirely appropriate and justified treatment plan for certain people who have T1 diabetes. You apparently are one of them, I apparently am not.

Clearly I’ve hit nerve here and it doesn’t seem my perspective is real appreciated since I’ve never used a pump. Guess I’ll stay out of this discussion-- didn’t mean to upset any pumpers— I’m very happy that you’ve found what works best for you.

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As to “standard of care”— if an insulin pump is a "standard of care"
for a t1 diabetic it also would mean that any doctor not prescribing it
isn’t practicing standard of care and is therefore committing
malpractice, or any patient not using one was non compliant.

This is not my understanding of “standard of care” at all. I’m no health care professional (so maybe I am wrong), but I’ve never heard of a disease where there is one and only one treatment available. Standard of care, from my understanding, just means that a treatment (among several) is commonly available and prescribed because it has been shown through research to be beneficial, rather than being a treatment that is only available under exceptional circumstances.

I don’t know how anyone could read my comments and reach the conclusion you did.

My comment was because pumps (and MDI) are already standard of care since they are recommended in clinical guidelines. Saying that they shouldn’t be is, essentially, taking a step backwards.

“Standard of care” means that anything less would not be appropriate, prudent, reasonable, or legally defensible.

It does not mean something is available.

If that’s the case, then I apologize for misinterpreting your statement. So, who sets the standard of care? If it’s clinical practice guidelines, then pump and MDI are both recommended (in Canada, at least, I don’t know what’s recommended in the U.S.). Who has advocated for pumps to become the one and only acceptable treatment for Type 1?

I don’t know… I don’t believe it’s so much a written code of specific things as it is a legal concept…

So effectively, saying an insulin pump is the “standard of care” would mean that it is the accepted MINIMUM level of care… Not just that it is justifiable or that insurances had to cover it, etc

The standard of care are the standards postulated by the medical associations, the governing bodies of medical practitioners. They are written down, by the ADA and the JDRF and the AADE. These, in turn, are used by insurers to regulate coverage. I suspect there’s collusion and conspiracy involved which, if it could be proven, would likely substantiate that PWD have had our civil rights violated. I suspect the AMA has a sort of deferential relationship with the “specialist” organizations here but that there’s some communication between them and, perhaps, some rounds of golf from lobbyists?

If you are implying that there is one and only one “standard of care” then I think you are mistaken.

Medicine is complicated so it does not seem plausible to me that there would be one and only one method of treatment in most cases.

Considering just diabetes we know that there are now many different standard treatments such as various oral drugs and/or insulin. And the insulin can can be administered by MDI, pump, or (most recently) inhalation. A doctor is expected to select from these options. Is one method of treatment any more or less “standard” than the others?

Coming at it from another direction, if there can be one and only one “standard of care” then it appears to me that a standard of care does not currently exist for treating diabetes. No? :confused: :wink: