Finding the right route for insulin delivery – an overview of implantable pump therapy

ABSTRACT

Introduction: Implantable pump therapy adopting the intraperitoneal route of insulin delivery has been available for the past three decades. The key rationale for implantable pump therapy is the restoration of the portal-peripheral insulin gradient of the normal physiology. Uptake in clinical practice is limited to specialized centers and selected patient populations.

Areas covered: Implantable pump therapy is discussed, including technical aspects, rationale for its use, and glycemic and non-glycemic effects. Target populations, summaries of clinical studies and issues related to implantable pump therapy are highlighted. Limitations of implantable pump therapy and its future outlook in clinical practice are presented.

Expert opinion: Although intraperitoneal insulin delivery appears closer to the normal physiology, technical, pharmacological, and costs barriers prevent a wider adoption. Evidence from clinical studies remains scarce and inconclusive. As a consequence, the use of implantable pump therapy will be confined to a small population unless considerable technological progress is made and well-conducted studies can demonstrate glycemic and/or non-glycemic benefits justifying wider application.

KEYWORDS:

• Type 1 diabetes
• implantable pump
• intraperitoneal insulin delivery
• diabetes technology

Contributions

L Bally and H Thabit were responsible for drafting the article. All authors revised the article for important intellectual content. All authors approved the version published.

Article highlights

• Key rationale of implantable pump therapy is the restoration of the portal-peripheral insulin gradient of the normal physiology

• Although implantable pump therapy has been available for over three decades, data from randomised controlled trials remain limited

• The use of implantable pump systems remains restricted due to technical, pharmacological and cost barriers and the need for specialist input

• Advances in implantable pump therapy technology has made it more reliable with fewer technical failures and clinical adverse events

• Well-conducted studies demonstrating beneficial effects of implantable pump therapy on glycaemic and/or non-glycaemic outcomes are still needed to justify wider adoption in clinical practice

This box summarizes key points contained in the article.

Declaration of interest

R Hovorka reports having received speaker honoraria from Eli Lilly and Novo Nordisk, serving on advisory panels for Eli Lilly and Novo Nordisk, receiving license fees from BBraun and Medtronic; having served as a consultant to B. Braun, and patents and patent applications related to closed-loop. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Additional information

Funding

Supported by National Institute of Health Research Cambridge Biomedical Research Centre, NIHR Efficacy and Mechanism Evaluation programme (#14/23/09), The Leona M. and Harry B. Helmsley Charitable Trust (#2016PG-T1D045), JDRF (#2-SRA-2014-256-M-R), National Institute of Diabetes and Digestive and Kidney Diseases (1UC4DK108520-01), and Diabetes UK (#14/0004878). L Bally receives support from the Swiss National Science Foundation (P1BEP3_165297).