Association of Insulin Pump Therapy vs Insulin Injection Therapy With Severe Hypoglycemia, Ketoacidosis, and Glycemic Control Among Children, Adolescents, and Young Adults With Type 1 Diabetes

IMPORTANCE Insulin pump therapymay improve metabolic control in young patients with type 1 diabetes, but the association with short-term diabetes complications is unclear. OBJECTIVE To determine whether rates of severe hypoglycemia and diabetic ketoacidosis are lower with insulin pump therapy compared with insulin injection therapy in children, adolescents, and young adults with type 1 diabetes. DESIGN, SETTING, AND PARTICIPANTS Population-based cohort study conducted between January 2011 and December 2015 in 446 diabetes centers participating in the Diabetes Prospective Follow-up Initiative in Germany, Austria, and Luxembourg. Patients with type 1 diabetes younger than 20 years and diabetes duration of more than 1 year were identified. Propensity score matching and inverse probability of treatment weighting analyses with age, sex, diabetes duration, migration background (defined as place of birth outside of Germany or Austria), body mass index, and glycated hemoglobin as covariates were used to account for relevant confounders. EXPOSURES Type 1 diabetes treated with insulin pump therapy or with multiple (similar to 4) daily insulin injections. MAIN OUTCOMES AND MEASURES Primary outcomeswere rates of severe hypoglycemia and diabetic ketoacidosis during the most recent treatment year. Secondary outcomes included glycated hemoglobin levels, insulin dose, and body mass index. RESULTS Of 30 579 patients (mean age, 14.1 years [SD, 4.0]; 53% male), 14 119 usedpump therapy (median duration, 3.7 years) and 16 460used insulin injections (median duration, 3.6 years). Patients usingpumptherapy (n = 9814) were matched with 9814 patients using injection therapy. Pumptherapy, compared with injection therapy, was associated with lower rates of severe hypoglycemia (9.55 vs 13.97 per 100 patient-years; difference, -4.42 [95% CI, -6.15 to -2.69]; P <.001) and diabetic ketoacidosis (3.64 vs 4.26 per 100 patient-years; difference, -0.63 [95% CI, -1.24 to -0.02]; P =.04). Glycated hemoglobin levelswere lower withpumptherapy than with injection therapy (8.04% vs 8.22%; difference, -0.18 [95% CI, -0.22 to -0.13], P <.001). Total daily insulin doseswere lower forpumptherapy compared with injection therapy (0.84U/kg vs0.98U/kg; difference, -0.14 [-0.15 to -0.13], P <.001). Therewas no significant difference in body mass index between both treatment regimens. Similar resultswere obtained after propensity score inverse probability of treatmentweighting analyses in the entire cohort. CONCLUSIONS AND RELEVANCE Among young patients with type 1 diabetes, insulin pump therapy, compared with insulin injection therapy, was associated with lower risks of severe hypoglycemia and diabetic ketoacidosis and with better glycemic control during the most recent year of therapy. These findings provide evidence for improved clinical outcomes associated with insulin pump therapy compared with injection therapy in children, adolescents, and young adults with type 1 diabetes. (C) 2017 American Medical Association. All rights reserved.