Study Finds Declining Diabetic Ketoacidosis Risk with Insulin Pump Use in Type 1 Diabetes: A Four-Decade Trend

"The risk of diabetic ketoacidosis linked to continuous subcutaneous insulin infusion in type 1 diabetes has significantly decreased since the 1980s, with only a minimal risk observed in the past decade," the researchers wrote.

DKA is a serious complication of T1D, occurring when insulin deficiency leads to uncontrolled blood glucose levels, ketone buildup, and metabolic imbalance. While insulin pumps have been widely used to provide more precise glucose control, there have been concerns about their potential association with DKA, particularly in earlier years when technology was less advanced. To assess long-term trends, Bruce A. Perkins, Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, Ontario, Canada, and colleagues sought to assess long-term changes in risk following the implementation of CSII in the 1980s.

For this purpose, the researchers examined the relationship between time-varying CSII use and DKA events from 1983 to 2017, analyzing data by each decade for the 1441 participants in the Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications Study. They employed both crude and adjusted Cox proportional hazards models in their assessment.

The study led to the following findings:

• Time-varying CSII exposure was linked to a significantly higher risk of DKA in the 1980s (adjusted HR 5.81).
• In contrast, the risk of DKA was not significantly elevated in the 2010s (adjusted HR 1.24).

The researchers acknowledge several study limitations, including potential selection and volunteer bias. While these could influence the absolute risk, the secular trends remained consistent, with crude and adjusted risks showing similar patterns. The cohort, recruited in the 1980s, was not dynamic, excluding individuals diagnosed with type 1 diabetes after that period. Additionally, newer diabetes technologies, such as continuous glucose monitoring and automated insulin delivery systems, were not assessed, as they became available after the study’s follow-up period. Despite a five-fold higher DKA risk in the 1980s, this risk has significantly decreased and remains low since the early 2000s.

"While CSII use in the 1980s was associated with more than a five-fold higher DKA risk, this risk has significantly reduced and remains low since the early 2000s. As a result, clinicians can be confident that DKA risk should not hinder the initiation of CSII in appropriate patients with type 1 diabetes," the researchers concluded. 

Reference:

Budhram DR, Bapat P, Bakhsh A, Abuabat MI, Verhoeff NJ, Mumford D, Cheema W, Orszag A, Jain A, Cherney DZI, Fralick M, Alamri BN, Weisman A, Lovblom LE, Perkins BA. Insulin Pump Use and Diabetic Ketoacidosis Risk in Type 1 Diabetes: Secular Trends over Four Decades. Diabetes Technol Ther. 2025 Feb;27(2):139-143. doi: 10.1089/dia.2024.0272. Epub 2024 Oct 10. PMID: 39387222.