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Comparing MDI and pumping in advance of the REPOSE study

tim2000s

tim2000s

Expert
Retired Moderator
Messages
8,936
Location
London
Type of diabetes
Type 1
Treatment type
Other
In a recent tweet from Pratik Choudary, he mentioned that the REPOSE study showed that DAFNE+MDI was equal to DAFNE+pump in terms of clinical outcomes based on Hba1C.

I thought I'd compare my CGR data from my illicit, self funded pump with my MDI and to ensure it was almost like with like, one has easter in the data set and one has Christmas.

The results? I concur with the unpublished REPOSE outcomes. On both I have statistically insignificant difference in Hba1C and the standard deviation is exactly the same. But I also undertook tight management using Libre on MDI and carried that over to the pump.

So what, really, are the benefits of a pump? Lifestyle wise, I'd say the pump is massively easier to use in terms of Diabetes management and much more flexible. You have to think more to achieve the same on MDI. Especially if you are doing a lot of exercise.

I'm looking forward to reading the full study, but whilst it may seem controversial, this study of 1 seems to fit the conclusions!
 
Unfortunately I think having shown it can be done on MDI rather works against the case for moving to a pump, which was under consideration whilst I was on the naughty step. However, with the Libre I've now gone from 8.9 down to about 6 on the evidence of the last month's results. I can see many aspects I could more easily sort out with a pump but anticipate a struggle to argue the case now, expect I may make more progress with making the case for a Tresiba trial first.
 
I'd agree in terms of HbA1c, but that's not the only measure that should be applied. You rightly point out flexibility, whis really influences quality of life.

Trying to reduce a very complex issue to a single number is irresponsible. Some people will do better on a pump, others on MDI, the system should support that.
 
Unfortunately @ElyDave, these things tend to get measured on clinical outcomes. Hba1C reduction is always the clinical measure of T1D success, regardless of validity. I don't know whether repose looks at standard deviation, but it backs up the point that whatever the delivery system, the key is the person making the decisions and not the delivery system.
 
The other clinical outcome not mentioned so far is avoidance of hypos, one of the key reasons for me to start pumping, and successfully achieved vs MDI. Not so easy to quantify as a number, but still important.

As my HbA1c was already sub-50, no real improvement was possible there, rather maintaining which I have done.
 
My HbA1C has stayed basically the same on the pump, and, as I told my consultant at the time, I didn't expect it to do otherwise.

I got my pump because of nocturnal hypos that were impossible to control on MDI because having one or two 'lumps' of basal there independently doing it's thing wasn't appropriate for my body's needs. As an example of that, for part of the night I have minimal basal needs, but for the latter half my need increases a lot. There's no basal that can match that.

I do agree with the 'pump only being as good as its user' though.

I also think that pumps suit children better than MDI due to their lack of routine and small insulin needs.
 
I wonder why "quality of life" doesn't matter for Type 1s? Is it because we are often diagnosed as children, and children's opinions don't count? As far as I am aware "quality of life" is taken into account in most medical treatment, such as provision of wheelchairs and mobility devices, but also drug treatments. I think that it is time for Type 1s to organize independently of all diabetic organizations. Our concerns are consistently sidelined because we are fairly few in number, and because so many of us are young. We really do need to separate from Type 2 in terms of activism for treatment. Not because Type 2s are doing anything bad to us. Just because the public and the government do not seem to be able to see us clearly. We don't have a clear separate identity, and therefore they keep getting distracted from our needs.

In fact, we don't need separate T1 and T2 identities, we could benefit from going back to the old classifications: NIDDM and IDDM.

Non-insulin dependent diabetes mellitis, And Insulin Dependent Diabetes Mellitis. Because IDDM includes all T1s, LADA, MODY, and some T2s. The term "diabetes" is useless for any kind of activism.
 
My HBa1c has barely moved since going on to the pump last May, it is in the mid 40's. However the difference now is I no longer get nocturnal hypo's to the degree I was before. These were debilitating and dangerous for me as well as putting a stress on my marriage.

I am still fairly hypo unaware as I have been T1 for a long time while running low HBa1c's for the majority of that time however the actual severity of my hypo's has eased which means a great improvement in my quality of life. So as others here have said, it's more than just the numbers!
 
As an example of a quality of life question? Are amputees refused prosthetics because they don't die any earlier without them? If they buy their own spare for running, say, does the NHS then refuse to fit the regular, workaday prosthetic for the rest of the time? Ooh, you went private. You've lost ALL your rights now! WTH. I mean insulin dependent diabetics are clearly being treated worse than others.
 
RuthW said:
As an example of a quality of life question? Are amputees refused prosthetics because they don't die any earlier without them? If they buy their own spare for running, say, does the NHS then refuse to fit the regular, workaday prosthetic for the rest of the time? Ooh, you went private. You've lost ALL your rights now! WTH. I mean insulin dependent diabetics are clearly being treated worse than others.
Click to expand...
Great point Ruth. In reality though, the NHS generally provides fairly basic prosthetics and only offers the more advanced ones in fairly special cases. Much like MDI to Pump...
 
I agree with azure - I have only just started pumping, but don't expect a big hba1c reduction. I can get a good hba1c on MDI, but it's with micro management of injections (I was taking 7-9 injections a day to try and mimic what my body needs) and with excessive nocturnal hypos, as my basal needs could not be met by Lantus regardless of how it was split. But all the micro management I was doing on MDI means that the transition to a pump has maybe been easier on me than it would be on others, as I was already testing a lot every day and night to manage the many injections - I just now have a tool which is better suited to the job.

In some ways it's unfortunate that one of the criteria is to have hba1c above 8.5, because in my case I could get it lower by allowing diabetes management to dominate my life - the last week on the pump has shown me to what extent I was being ruled by it. Unfortunately, you can't get a statistic for how I feel now vs my life on MDI.
 
ArtemisBow said:
In some ways it's unfortunate that one of the criteria is to have hba1c above 8.5, because in my case I could get it lower by allowing diabetes management to dominate my life - the last week on the pump has shown me to what extent I was being ruled by it. Unfortunately, you can't get a statistic for how I feel now vs my life on MDI.
Click to expand...

that's not the only criteria (bold, underline) there are also the criteria related to quality of life, hypo management, severity, frequency etc.

All of which are the very things that this study seems to be ignoring, or am I being unfair?
 
ArtemisBow said:
I agree with azure - I have only just started pumping, but don't expect a big hba1c reduction. I can get a good hba1c on MDI, but it's with micro management of injections (I was taking 7-9 injections a day to try and mimic what my body needs) and with excessive nocturnal hypos, as my basal needs could not be met by Lantus regardless of how it was split. But all the micro management I was doing on MDI means that the transition to a pump has maybe been easier on me than it would be on others, as I was already testing a lot every day and night to manage the many injections - I just now have a tool which is better suited to the job.

In some ways it's unfortunate that one of the criteria is to have hba1c above 8.5, because in my case I could get it lower by allowing diabetes management to dominate my life - the last week on the pump has shown me to what extent I was being ruled by it. Unfortunately, you can't get a statistic for how I feel now vs my life on MDI.
Click to expand...
That is pretty much my story as well. I am a very active person and was sometimes having 10 injections a day trying to micro manage my levels with exercise and food and pretty much failing dismally. Now with a pump I have 8 different rates for different times of the day and feel my control is far better without the bad hypo's. Not saying it's perfect as I often still get hypo's (too often really) but the days of being woken in the middle of the night by paramedics is now a lot less frequent for me.
 
A better study, I feel, would be on CGM rather than pumping. For most diabetics better control is more about understanding how insulin, food and exercise interact than the actual injecting. I gained a huge amount of knowledge from using the Freestyle libre, before I started getting the rashes and so on from the system.

I'd be the first to admit that a pump would allow better control over exercise in that I could reduce bolus rather than having to nibble while exercising to avoid hypos.Other than that I'm maintaining a 5.1 HB1AC on MDI and carb control.

Now, if only I could be as strict whilst losing weight!
 
ElyDave said:
that's not the only criteria (bold, underline) there are also the criteria related to quality of life, hypo management, severity, frequency etc.

All of which are the very things that this study seems to be ignoring, or am I being unfair?
Click to expand...
There are in fact only two NICE criteria for a pump:

  • attempts to reach target haemoglobin A1c (HbA1c) levels with multiple daily injections result in the person having ‘disabling hypoglycaemia', For the purpose of this guidance, disabling hypoglycaemia is defined as the repeated and unpredictable occurrence of hypoglycaemia that results in persistent anxiety about recurrence and is associated with a significant adverse effect on quality of life; or
  • HbA1c levels have remained high (8.5% or above) with multiple daily injections (including using long-acting insulin analogues if appropriate) despite the person and/or their carer carefully trying to manage their diabetes.

The remainder are Association of British Clinical Diabetologists recommended criteria and do not fall into NICE guidance. http://www.diabetologists-abcd.org....on_papers/Position_Paper_on_Insulin_Pumps.pdf
 
My reasons for going on the pump where;

  • Dawn Phenomenon
  • HbA1c above 8% on MDI
Another good reason for others I suppose are those who are very sensitive and need tiny doses of insulin, without a pump, people just couldn't function.....

The way the insulin is delivered means that the dose that you give yourself as well as the basal insulin is used more effectively, not 100%, but close to it....injectable insulin, which goes in and sits there in one spot, is not absorbed the same and so you find you need more insulin for a meal than you would on the pump, so the pump means less insulin, which for some, means weight loss too......and well, less insulin is a good thing right? :)

The trick with the pump is the basal delivery, that's what its all about..........we all still need to struggle with food choices, jeez, that's always going to be the most difficult part of this condition.............so lifestyle benefits aside, I think the pump can bring a much more accurate and reliable basal dose to the table, which nothing can beat, nothing.....

I too believe its down to the user to make it more positive than injections..........I also believe that every pump user should have years of experience with dose adjustment and a vast knowledge of their own specific needs and behaviours, this way they can hit the ground running.............it doesn't seem like this is happening, at least not all the time....
 
novorapidboi26 said:
The way the insulin is delivered means that the dose that you give yourself as well as the basal insulin is used more effectively, not 100%, but close to it....injectable insulin, which goes in and sits there in one spot, is not absorbed the same and so you find you need more insulin for a meal than you would on the pump, so the pump means less insulin, which for some, means weight loss too......and well, less insulin is a good thing right?
Click to expand...

I wish this were true. For me my carb ratio is basically unchanged from MDI to pump. My basal insulin amount is quite a bit lower though (approx 75%).
 
tim2000s said:
I wish this were true. For me my carb ratio is basically unchanged from MDI to pump. My basal insulin amount is quite a bit lower though (approx 75%).
Click to expand...

whats not true then? weight loss....? or total daily dose?

my ratios are almost the same too, although my morning ratio, which was 3 units to ever 10g, has now came down to normal as my dawn phenomenon is now being dealt with....
 
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