The impact of insulin pump therapy compared to multiple daily injections on complications and mortality in type 1 diabetes: A real‐world retrospective cohort study

Aims

Clinical trials have demonstrated the benefits of insulin pump therapy compared with multiple daily injections (MDI) in type 1 diabetes. However, contemporaneous real-world data are limited. This study investigated the real-world impact of insulin pump therapy compared with MDI.

Materials and Methods

A retrospective cohort study of adults with type 1 diabetes was performed on the TriNetX platform, a global network providing access to anonymised medical records. Outcomes analysed include HbA1c, diabetic ketoacidosis, macro- and microvascular complications and all-cause mortality. The five-year follow-up period, between January 2018 and March 2025, was divided into time windows for analysis.

Results

95 122 individuals with type 1 diabetes were identified. After propensity score matching for confounders including age, ethnicity, gender, chronic kidney disease, retinopathy, HbA1c and microalbuminuria, 17 124 patients remained in both the pump and MDI cohorts. The absolute reduction in HbA1c was comparable at five years (−5.3 mmol/mol [−0.5%] in the pump group and −4.5 mmol/mol [−0.4%] in MDI). Overall mortality was lower (RR = 0.716 [95% CI 0.639–0.803], p < 0.001) in those on a pump compared to MDI. The occurrence of diabetic ketoacidosis was lower in the pump group compared to MDI (RR = 0.848 [95% CI 0.786–0.915], p < 0.001). The risk of diabetic retinopathy was increased in the pump group (RR = 1.331 [95% CI 1.247–1.420], p < 0.001).

Conclusions

Insulin pump therapy was associated with lower all-cause mortality and risk of diabetic ketoacidosis, but an increased risk of diabetic retinopathy compared with MDI. This result should be interpreted with caution due to potential differences in retinal screening frequency and subsequent bias.