Multiple Daily Injections vs Insulin Pump Therapy in Pregnant Women With T1D

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More research is needed to better understand how clinical teams can implement new technologies more effectively to optimize glycemic control during pregnancy involving T1D.
More research is needed to better understand how clinical teams can implement new technologies more effectively to optimize glycemic control during pregnancy involving T1D.

Multiple daily injection (MDI) therapy was better than insulin pump therapy at improving glycemic control and reducing hypertensive outcomes in pregnant women with type 1 diabetes (T1D), according to study results published in Diabetes Care.

The investigators of this multicenter observational study sought to compare pregnancy outcomes, glycemic control, and quality of life measures in pregnant women who used insulin pumps vs MDI therapy. In addition, the investigators evaluated the clinical effectiveness of continuous glucose monitoring compared to self-blood glucose monitoring alone.

The investigators performed a prespecified analysis of the Continuous Glucose Monitoring in Type 1 Diabetes Trial, which included 248 pregnant women from 31 centers in Canada, England, Scotland, Spain, Italy, Ireland, and the United States. The participants were assigned either insulin pump (n = 125) or MDI (n = 123) therapy. Glycemic control was the primary outcome measured using the change in hemoglobin (Hb) A1c levels from the time of randomization to 34 weeks of gestation. 

Secondary measures included time spent in target range (63 to 140 mg/dL) during continuous glucose monitoring, maternal-infant health outcomes, and patient-reported outcomes (including satisfaction with their glucose monitoring system, distress related to hypoglycemia and diabetes, and quality of life scores).

In the first trimester, insulin pump and MDI users had comparable HbA1c levels (51 ± 7.8 mmol/mol vs 52 ± 6.3 mmol/mol; P =.31), as well as comparable time spent in target range during continuous glucose monitoring (51% ± 14% vs 50% ± 13%; P =.40). At 34 weeks of gestation, MDI users reported a greater decrease in HbA1c levels compared with insulin pump users (-0.55% ± 0.59% vs -0.32% ± 0.65%; P =.001). The investigators found that MDI users were more likely to achieve target HbA1c levels <6.5% at both 24 weeks (P =.009) and 34 weeks (P =.001) of gestation. Compared with the MDI group, a greater proportion of insulin pump users reported increased gestational hypertension (14.4% vs 5.2%; P =.025), neonatal hypoglycemia (31.8% vs 19.1%; P =.05), and neonatal intensive care unit (NICU) admissions for >24 hours (44.5% vs 29.6%; P =.02). Although women who used the insulin pump had a larger overall reduction in hypoglycemia-related anxiety (P =.05), they also reported a greater decrease in general well-being measures (P =.02).

Investigators noted that because participants were not randomly assigned to MDI or insulin pumps, the participants' and caregivers' preferences may have confounded the study findings. Another limitation was lack of information regarding daily dose adjustments, including the frequency of capillary glucose tests, insulin pump downloads, or use of bolus calculators. In addition, data on the frequency of insulin pump use in pregnant women was not available.

The investigators concluded that pregnant women who received MDI therapy to control T1D had a larger decrease in HbA1c levels and were less likely to report gestational hypertension, neonatal hypoglycemia, and NICU admissions than women who used insulin pump therapy during pregnancy. “More research is needed to better understand which women benefit from insulin pumps and how clinical teams can implement new technologies more effectively to optimize glycemic control during pregnancy involving T1D,” concluded the researchers.

Multiple authors declare associations with the pharmaceutical industry. Please see original reference for a full list of authors' disclosures.

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Reference                    

Feig DS, Corcoy R, Donovan LE, et al. Pumps or multiple daily injections in pregnancy involving type 1 diabetes: a prespecified analysis of the CONCEPTT randomized trial [published online October 16, 2018]. Diabetes Care. doi:10.2337/dc18-1437

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