How effective and safe are ultra-rapid insulin analogues in insulin pumps for patients with type 1 diabetes?

This review assessed the effectiveness and safety of ultra-rapid insulin analogs (URIAs) with continuous subcutaneous insulin systems (CSII) in adults with type 1 diabetes (T1D). The authors concluded that URIAs were compatible with CSII systems and had a better glucose-lowering effect after meals compared to rapid-acting insulin analogs (RAIAs) but may need more infusion set changes.

Patients with T1D need daily insulin either through CSII (insulin pumps) or multiple injections. Monitoring blood glucose levels is necessary to ensure that a blood sugar target is met during a 24-hour timeframe (TIR; 70 mg/dL to 180 mg/dL (3.9 mmol/L –10.0 mmol/L)). Insulin pumps provide a small, continuous quantity of basal insulin during the day and night, with the release of a larger dose or bolus at mealtimes. These devices are attached under the skin using an infusion set consisting of a thin plastic tube with a needle or cannula.

Insulin types can be rapid or short-acting which reduce blood glucose at mealtimes. RAIAs include aspart (IAsp; Novolog^®), lispro (Humalog^®), and glulisine (Apidra^®). URIAs like ultra-rapid lispro (URLi) provide improved and faster absorption. FIAsp^® is a fast-acting insulin that works more rapidly than aspart. Studies indicate that the use of CSII with URIAs may provide better glucose-lowering effects compared to RAIAs. However, it is necessary to review whether URIAs can be effectively and safely used with CSII in patients with T1D.

This review analyzed the results of 9 randomized, controlled trials with 1,156 adults with T1D. Patients had been using CSII for at least 2 weeks with either URIAs or RAIAs. Data were analyzed for TIR, time spent in hypoglycemia (very low blood glucose levels; less than 70 mg/dL), and high blood glucose levels (more than 180 mg/dL,) 1 and 2-hour post-prandial glucose (PPG; blood glucose after meals), HbA1c (average blood glucose control over 2-3 months), average insulin dose, unplanned infusion set changes, and severe low blood glucose.

Based on TIR, time spent in hypoglycemia, and 1 and 2-hour PPG, URIAs were better than RAIAs. HbA1c levels and average insulin doses were similar between groups. However, unplanned infusion set changes were higher for URIAs.

The study showed that URIAs combined with CSII provided better PPG control with greater TIR compared to RAIAs but may require more infusion set changes for patients with T1D.

The studies that were included had a small number of patients and were short in duration. The reasons for unplanned set changes were not explored.