Home / Conditions / Type 1 Diabetes / ADA/JDRF Type 1 Diabetes Sourcebook, Excerpt #18: Insulin, Part 3 of 3

ADA/JDRF Type 1 Diabetes Sourcebook, Excerpt #18: Insulin, Part 3 of 3

Dec 21, 2013

Anne Peters, MD, and Lori Laffel, MD, MPH, Editors
Jane Lee Chiang, MD, Managing Editor


Continuous Subcutaneous Insulin Infusion (CSII)

PEDIATRICS David Maahs, MD, PhD, and H. Peter Chase, MD

Standard of Care

A consensus statement on the use of insulin pump therapy, CSII, in youth with type 1 diabetes (T1D) is available, and will be referred to intermittently.

Who Should Use a Pump?

Pump therapy has been successfully used in pediatric patients of all ages, including preschoolers.2–5 The decision to initiate insulin pump therapy is made by parents, youth (referring to children or adolescents), and their diabetes care providers. In very young children, parents work with the medical team to make the decision. Important factors to consider are outlined in the Table 12.II.1.6 Fortunately, most health insurance companies require proof of a minimum of four blood glucose (BG) values per day in order to help fund CSII therapy. Subjects who do not routinely meet this criterion cannot safely use an insulin pump. In addition to the items in Table 12.II.1, many centers require knowledge of carbohydrate counting prior to initiating pump therapy. Only experienced pediatric diabetes care providers should treat youth initiating pump therapy….


Parameters Associated with Insulin Pump Use in Pediatrics

Youth (and parents of infants) usually state that the main reason for wanting to use a pump is to reduce the number of insulin injections per day.7 Clinical parameters to consider include:

  1. Reduction of A1C Levels: As with a meta-analysis of primarily adult studies, a reduction of 0.5% in A1C levels compared to prepump values is common, assuming proper patient selection for pump use and adequate follow-up.8–12 Other real-life data collected in the T1D Exchange Registry in the U.S. found a significant reduction (P <0.001) in A1C levels for all age-groups in 10,065 pump users, compared to 8,051 subjects using insulin injections.10 In a clinical trial of 485 people with T1D (STAR 3), youth and adults were randomized to remain on injections and BG checking or to use an insulin pump and a continuous glucose monitor (CGM).11 The latter group (for all ages) had statistically lower A1C levels by 0.5% (P <0.001) after one year. Youth who do more frequent BG checks and more frequent insulin boluses tend to have lower A1C levels.8–12
  2. Severe Hypoglycemia (SH): As with a meta-analysis of primarily adult studies, studies of youth using insulin pumps have shown a significant reduction in SH.9–13 In other real-life data, the T1D Exchange Registry has reported a lower incidence of SH in subjects using insulin pumps versus injections for people <50 years old.10 In contrast, the incidence of SH in the closely monitored STAR 3 trial was 13 episodes/100 person years in both the control and the pump/CGM groups.11
  3. Exercise is the number one factor associated with SH in children (particularly delayed hypoglycemia at night following heavy daytime exercise).14 A major advantage of CSII in youth is the ability to reduce or discontinue insulin during and following exercise to prevent hypoglycemia.15–16
  4. Diabetic Ketoacidosis (DKA): The incidence of DKA (6.2/100 person years) was similar to that of SH (6.6/100 person years) in 1,041 youth from 17 countries who used an insulin pump.13 In a study of 291 youth with T1D, the incidence of DKA was 1.4/100 person years in the year prior to initiation.9 After initiation of CSII therapy the incidence of DKA was 4.0/100 person years in the subsequent 1–9 years (mean 3.8 years; P = 0.08). The incidence in the same entire pediatric diabetes clinic (youth using and not using CSII) was 8/100 person years (with an incidence of 10/100 person years for youth not using CSII).17 Youth and families were screened and chosen to begin CSII therapy, resulting in the lesser likelihood of DKA. In the same pediatric diabetes clinic, 80% of cases of DKA occurred in 20% of the population.17 As DKA is the greatest cause of mortality in people under age 30 years, it is important to be selective in choosing youth for CSII therapy.18–19 For example, if rapid-acting insulin delivery is interrupted, hyperglycemia and ketonemia can develop within 3 h.20 In the absence of basal insulin, it is imperative that people using CSII routinely check their BG and, if elevated, blood or urine ketones. According preventative measures can then be taken. In other real-life data, the incidence of DKA in the first year of monitoring in the T1D Exchange Registry showed the highest rates in the 12–17 and the 18–25-year-old age groups using CSII therapy.10 The main cause of DKA in youth using insulin pumps is insertion-set occlusion with loss of available insulin.21 The use of a CGM to warn youth of high glucose levels essentially eliminated DKA in the STAR 3 trial.11 In summary, DKA may be slightly increased in youth after initiating CSII therapy; however, it is likely lower than in a general pediatric diabetes clinic population.9–17
  5. Psychosocial Parameters: Many youths who do not elect to use CSII report that they “do not want to be continually attached to something.”6 There have been many studies of patient satisfaction in youth before and after using CSII and the results are usually “improved” or “no changes.”4,22 A meta-analysis of the psychosocial impact of CSII (including five pediatric studies) found no consistent differences in anxiety, depression, quality of life, self-esteem, or family functioning.23 Further references to psychosocial issues can be found in the pediatric pump consensus statement.1

New Advances in Pump Therapy

Technologies will continue to advance for all people using insulin pumps. Patch pumps with no tubing between the pump and the infusion set have been popular with youth and will continue to improve. Incorporation of pump intelligence into a cell phone is already feasible but will require FDA approval for eventual use. The discontinuation of CSII with a low glucose level (Low Glucose Suspend) detected with CGM is already available in many countries and has been shown to result in less time spent in hypoglycemia.24–26

The use of CGM with a pump has been referred to above in the STAR 3 trial.11 The JDRF-CGM study demonstrated that use of a CGM in youth is only helpful when used 6 or more days/week.27 Unfortunately, 75% of youth do not succeed in this endeavor.10 The development of smaller, more comfortable, user-friendly, and more accurate sensors may help to encourage consistent CGM use. These technological advances will make CGM/insulin pump use, and life without SH and DKA, more likely for youth with T1D.

Howard Wolpert, MD

There are several published meta-analyses comparing insulin pumps and multiple daily injections (MDIs) as tools for intensifying glycemic control in adults with type 1 diabetes (T1D). These analyses of the randomized controlled trials in the literature indicate that adults using pump therapy have a 0.4–0.5% lower A1C than with MDI, without an increase in hypoglycemia and with lower insulin requirements. Several national and international clinical guide-lines recommend continuous subcutaneous insulin infusion (CSII) as a therapeutic option for adults with T1D with hypoglycemia unawareness and severe hypoglycemia or poor glycemic control. However, because of methodologic issues, the different meta-analyses regarding reduction of hypoglycemia with pump therapy have been conflicting. The meta-analysis conducted by Pickup, which was restricted to studies with a baseline rate of severe hypoglycemia of more than 10/100 episodes/patient years, showed that pump therapy was associated with a 2.9-fold reduction in severe hypoglycemia. Another meta-analysis, commissioned by the Endocrine Society, reached different conclusions that CSII is not associated with a significant reduction in either severe or nocturnal hypoglycemia. The validity of these conclusions is limited by the inclusion of short duration studies with low severe hypoglycemia incidence rates that would bias against detection of any treatment-related differences. In addition, the studies examined in this analysis predominantly involved use of older pumps that did not have bolus calculator software that can limit hypoglycemia from insulin stacking.

The potential complications of pump therapy such as device malfunction, infusion site problems, and ketoacidosis are often not reported in the clinical trials. Patient education about infusion site care and troubleshooting for unexplained hyperglycemia are crucial in decreasing the risk for ketoacidosis in pump users.


As in the pediatric population, the adults wishing to start on pump therapy need to be motivated and adherent with the requirements of intensive diabetes self-management and have an adequate diabetes knowledge base. In addition to the benefits of CSII as a tool to intensify glycemic control and minimize hypoglycemia, pump therapy can be advantageous in certain individual circumstances. These include preconception and pregnancy (see chapter 17), diurnal variation in basal insulin requirements (e.g., dawn phenomenon or steroid therapy) or low insulin requirements (better dosing accuracy and precision than injection therapy), and optimization of bolus coverage for gastroparesis and higher fat/complex carbohydrate meals that are more slowly absorbed. The published literature suggests that pump therapy is associated with improved quality of life; however, this has not been confirmed in all studies. This may relate to individual differences in perception about the trade-offs between potential benefits (such as increased lifestyle flexibility and reduced fear for hypoglycemia) relative to some of the negatives associated with wearing a pump (including body image concerns). In practice, ease of bolusing with the pump can be helpful to facilitate interprandial correction bolusing, coverage of snacks, and eating out at restaurants. Unrealistic notions, including the expectation that use of technology reduces need for attentiveness to self-care, need to be dispelled before patients start on pump therapy (see Table 12.II.2).

Relative contraindications to initiation of pump therapy include infrequent self-blood glucose monitoring (with related failure to detect and promptly treat unexplained hyperglycemia, and associated risk for ketoacidosis) and eating disorders with insulin omission and chronically elevated glucoses (with related failure to recognize hyperglycemia from insulin nondelivery). The development of cognitive impairment with compromised judgment, psychiatric problems with inattentiveness to self-care, and visual impairment (unless close family members can assist with pump/infusion set troubleshooting) can be grounds for discontinuing pump therapy in adults.


Considerations in calculating starting insulin doses for patients changing from MDI to pump therapy and optimizing both basal and bolus doses are covered in several publications, and therefore, will not be discussed here.


There are several pump-specific issues the clinician should consider in the pump patient presenting with erratic glucoses:

1. Routine history should include questions about frequency of catheter kinking or dislodgement and frequency of catheter and reservoir replacement. 


2. Routine examination should include evaluation of pump infusion sites for scarring and lipohypertrophy, which are not uncommon causes of erratic glucoses, especially in the long-term pump patient.

3. Review of blood glucose data should include evaluation to determine if erratic or elevated glucoses are more common in the period preceding set changes.

4. Review of pump downloads can be informative:

a. Priming history to determine frequency of reservoir change.

b. Bolus history to detect missed boluses.

c. Percent basal to bolus insulin. Basal > bolus in the patient with frequent hyperglycemia may indicate that bolus doses are being missed, whereas in the patient with frequent hypoglycemia this may indicate that high basal rates are contributing to hypoglycemia and would point to need to reevaluate basal settings.

d. Pump suspension or inappropriate basal rate reduction to determine if this is contributing to hyperglycemia.


To date only a few hospital facilities have introduced formal policies and procedures regarding the continued use of CSII pumps in patients with diabetes, however with more widespread use of pumps this is an issue that will need attention from hospital oversight bodies. Since most hospital staff do not have expertise with pump use, the patient needs to be alert and orientated and able to self-manage his or her pump (including administering boluses and changing reservoirs and infusion sets) in order to safely continue with pump therapy during hospitalization. Continued use of CSII pumps is contraindicated in patients who are critically ill or metabolically unstable. Because of the risk for overdelivery by insulin pumps that are in proximity to magnetic resonance imaging (MRI), it is critically important for hospitals and radiology facilities to have protocols to ensure that patients remove their pumps before entry into MRI suites.


There are always questions about whether information obtained from well-done randomized research studies vs. collection of real-life clinical data is more useful. The answer is, of course, that both are useful. It will be important to verify the lower A1C levels found in the STAR 3 Study in real-life situations.1 The T1D Exchange Registry, with large T1D patient numbers (~26,000 subjects), is now starting to fill this gap in the U.S.2 Funded by the Helmsley Charitable Trust, this registry plans to continue to provide longitudinal data to assist care providers and families of youth with T1D to select the best treatments available.

New Advances in Pump Technology

The next decade promises several technical improvements in pumps (including the introduction of smaller patch pumps with larger and prefilled insulin reservoirs) and infusion catheters that lead to more rapid insulin absorption, as well as advances of the insulin dosing software incorporated into insulin pumps. Current software incorporated into insulin pumps can be helpful in assisting patients with calculation of bolus doses to cover carbohydrates and correct hyperglycemia, and can be very important tools for reducing risk for hypoglycemia from stacking of insulin boluses. The insulin duration of action programmed into the pump software is a key factor in individualizing this function of the bolus calculator; if the duration of action is set too short (i.e., less than actual action time of the insulin bolus) the pump will indicate that there is less insulin on board than is the case, leading to dose stacking and hypoglycemia. In this regard it is important for the clinician setting the duration of action in the pump software to consider the pharmacodynamics, not the pharmacokinetics, of insulin boluses. The pumps currently in use apply different rules for this calculation; for example, the Insulet pump does not consider insulin from meal boluses when compensating for insulin on board. In addition to refinements of this function, future developments in pump software will include the incorporation of preprogrammable boluses to cover more complex meals and adaptive algorithms to refine basal insulin infusion rates.


The pharmacologic treatment tools and general approaches for T1D management have quickly and dramatically changed. In spite of this, the current treatment paradigm is still imperfect. The fundamental challenge, which separates T1D for all age groups from other chronic conditions, is the fact that for success, self-management will be required. Specific attention to diet and to the timing of insulin and vast attention to detail about all factors that impact blood glucose need to be appreciated by both patients and their families. The good news is many patients today can take advantage of these advances, especially in insulin and its delivery systems, and the burden of diabetes-related complications has dramatically lessened. The result is a new phenomenon, which we are just starting to appreciate: geriatric T1D. It is difficult to predict the public health magnitude this issue will be in 20 years, but it will likely be a major focus of public policy for organizations such as the American Diabetes Association. The already-developed tools described in this chapter are now allowing children and adults with T1D to be successful in all aspects of their life, an accomplishment never imagined just a few years ago.

  1. Diabetes Control and Complications Trial Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977–986, 1993
  2. Hirsch IB, Skyler JS: Management of type 1 diabetes. In Atlas of Diabetes. Skyler JS, Ed. New York, Springer Science + Business Media, LLC, 2012, p. 95–113
  3. Garber AJ, King AB, Del Prato S, Sreenan S, Balci MK, Muñoz-Torres M, Rosenstock J, Endahl LA, Francisco AM, Hollander P: NN1250-3582 (BEGIN BB T2D) Trial Investigators: Insulin degludec, an ultra-longacting basal insulin, versus insulin glargine in basal-bolus treatment with meal-time insulin aspart in type 2 diabetes (BEGIN Basal-Bolus Type 2): a phase 3, randomised, open-label, treat-to-target non-inferiority trial. Lancet 379:1498–1507, 2012
  4. Heller S, Buse J, Fisher M, Garg S, Marre M, Merker L, Renard E, Russell- Jones D, Philotheou A, Francisco AM, Pei H, Bode B: BEGIN Basal-Bolus Type 1 Trial Investigators: Insulin degludec, an ultra-longacting basal insulin, versus insulin glargine in basal-bolus treatment with mealtime insulin aspart in type 1 diabetes (BEGIN Basal-Bolus Type 1): a phase 3, randomised, open-label, treat-to-target non-inferiority trial. Lancet 379:1489–1497, 2012
  5. American Diabetes Association: Medical Management of Type 1 Diabetes. 5th ed. Kaufman, FR, Ed. Alexandria, VA, American Diabetes Association, 2008: 51–82; table on 58
  6. Hirsch, IB: Insulin Analogues. N Engl J Med 352:174–183; table on 177, 2005
  7. Hirsch LJ, Gibney MA, Albanese J, Qu S, Kassler-Taub K, Klaff LJ, Bai-ley TS: Comparative glycemic control, safety and patient ratings for a new 4mm×32G insulin pen needle in adults with diabetes. Curr Med Res Opin 26:1531–1541, 2010
  8. McKay M, Compion G, Lytzen L: A comparison of insulin injection needles on patients’ perceptions of pain, handling, and acceptability: a randomized, open-label, crossover study in subjects with diabetes. Diabetes Technol Ther 11:195–201, 2009
  9. Siegmund T, Blankenfield H, Schumm-Drager P: Comparison of usability and patient preference for insulin pen needles produced with different production techniques. Diabetes Technol Ther 11:523–528, 2009
  10. Marino MT, Costello D, Baughman R, et al. Pharmacokinetics and pharmacodynamics of inhaled GLP-1 (MKC253): proof of concept studies in healthy normal volunteers and in patients with type 2 diabetes. Clinical Pharmacology & Therapeutics 88:243–250, 2010
  11. Marino MT, Cassidy JR, Baughman RA, et al.: A new C-peptide correction model used to assess bioavailability of regular human insulin. Biopharmaceuticals & Drug Disposition 31:428–435, 2010
  12. www.clinicaltrials.gov. Accessed 4 October 2012
  13. Miles HL, Acerini CL: Insulin analog preparations and their use in children and adolescents with type 1 diabetes mellitus. Paediatr Drugs 10:163–176, 2008

American Diabetes Association: Clinical practice recommendations. Diabetes Care 35 (Suppl. 1), 2012 Maahs DM, Nadeau K, Snell-Bergeon JK, Schauer I, Bergman B, West NA, Rewers M, Daniels SR, Ogden LG, Hamman RF, Dabelea D: Association of insulin sensitivity to lipids across the lifespan in people with type 1 diabetes. Diabet Med 28:148–155, 2011. doi: 10.1111/j.1464-5491.2010.03143.x

Marino MT, Cassidy JR, Baughman RA, et al.: A new c-peptide correction model used to assess bioavailability of regular human insulin. Biopharmaceuticals & Drug Disposition 31:428–435, 2010.

Nadeau KJ, Regensteiner JG, Bauer TA, Brown MS, Dorosz JL, Hull A, Zeitler P, Draznin B, Reusch JE: Insulin resistance in adolescents with type 1 diabetes and its relationship to cardiovascular function. J Clin Endocrinol Metab 95:513–521, 2010. Epub 13 November 2009

O’Riordan SMP, Robinson PD, Donaghue KC, Moran A.: Management of cystic fibrosis-related diabetes. Pediatr Diabetes 10 (Suppl. 12):43–50, 2009

Paris CA, Imperatore G, Klingensmith G, et al.: Predictors of insulin regimens and impact on outcomes in youth with type 1 diabetes: the SEARCH for Diabetes in Youth Study. J Pediatr 155:161–162, 2009

Pickup JC, Renard E: Long-acting insulin analogs versus insulin pump therapy for the treatment of type 1 and type 2 diabetes. Diabetes Care 31 (Suppl. 2): S140–S145, 2008

Weinzimer SA, Ternand C, Howard C, Chang CT, Becker DJ, Laffel LM: Insulin Aspart Pediatric Pump Study Group: A randomized trial comparing con-tinuous subcutaneous insulin infusion of insulin aspart versus insulin lispro in children and adolescents with type 1 diabetes. Diabetes Care 31:210–215, 2008. Epub 5 November 2007


Continuous Subcutaneous Insulin Infusion (CSII): Pediatrics

  1. Phillip M, Danne T, Battelino T, Kaufman F, Rodriguez H: Use of insulin pump therapy in the pediatric age-group. Diabetes Care 30:1653–1662, 2007
  2. Weinzimer SA, Ahern JH, Doyle EA, Vincent MR, Dziura J, Steffen AT, Tamborlane WV: Persistence of benefits of continuous subcutaneous insulin infusion in very young children with type 1 diabetes: a follow-up report. Pediatrics 114:1601–1605, 2004
  3. Wilson DM, Buckingham BA, Kunselman EL, Sullivan MM, Paguntalan HU, Gitelman SE: A two-center randomized controlled feasibility trial of insulin pump therapy in young children with diabetes. Diabetes Care 28:15–19, 2005
  4. Fox LA, Buckloh LM, Smith SD, Wysocki T, Mauras N: A randomized controlled trial of insulin pump therapy in young children with type 1 diabetes. Diabetes Care 28:1277–1281, 2005
  5. Oprpari-Arrigan L, Fredericks EM, Burkart N, Dale L, Hodge M, Fos-ter C: Continuous subcutaneous insulin infusion benefits quality of life in preschool-age children with type 1 diabetes mellitus. Pediatr Diabetes 8:377– 383, 2007
  6. Chase HP, Messer L: Understanding Insulin Pumps and Continuous Glucose Monitors. 2nd ed. Denver, Children’s Diabetes Foundation at Denver, 2010
  7. Maahs DM, Horten LA, Chase HP: The use of insulin pumps in youth with type 1 diabetes. Diabetes Tech Ther 12:S59–S65, 2010
  8. Pickup J, Mattock M, Kerry S: Glycaemic control with continuous subcutaneous insulin infusion compared with intensive insulin injection in patients with type 1 diabetes: meta-analysis of randomized controlled trials. BMJ 324:1–6, 2002
  9. Scrimgeour L, Cobry E, McFann K, Burdick P, Weimer C, Slover R, Chase HP: Improved glycaemic control after long-term insulin pump use in pediatric patients with type 1 diabetes. Diabetes Technol and Ther 9:421–428, 2007
  10. T1D Exchange Registry Symposium: Advanced Technologies and Treatments for Diabetes, February 2012. Barcelona, Spain
  11. Bergenstal R, Tamborlane W, Ahmann A, Buse JB, Dailey G, Davis SN, Joyce C, Peoples T, Perkins BA, Welsh JB, Willi SM, Wood MA; STAR 3 Study Group: Effectiveness of sensor-augmented insulin-pump therapy in type 1 diabetes. N Engl J Med 363:311–320, 2010
  12. Danne T, Battelino T, Jarosz-Chobor P, Pankowska E, Ludvigsson J, et al: Establishing glycaemic control with continuous subcutaneous insulin infu-sion in children and adolescents with type 1 diabetes: experience of the PedPump study in 17 countries. Diabetologia 51:1594–1601, 2008
  13. Pickup JC, Sutton AJ: Severe hypoglycemia and glycaemic control in type 1 diabetes: meta-analysis of multiple daily injections compared with subcutaneous insulin infusion. Diabet Med 25:765–774, 2008
  14. Bhatia V, Wolfsdorf JI: Severe hypoglycemia in youth with insulin dependent diabetes mellitus: frequency and causative factors. Pediatrics 88:1187– 1189, 1991
  15. Tsalikian E, Mauras N, Beck RW, Tamborlane WV, Janz KF, Chase HP, et al: Diabetes Research In Children Network Direcnet Study Group: Impact of exercise on overnight glycemic control in children with type 1 diabetes mellitus. J Pediatr 147:528–523, 2005
  16. Taplin CE, Cobry E, Messer L, McFann K, Chase HP, Fiallo-Scharer R: Preventing post-exercise nocturnal hypoglycemia in children with type 1 diabetes. J Pediatr 157:784–788, 2010
  17. Rewers A, Chase HP, Mackenzie T, Walravens P, Roback M, Rewers M, Hamman RF, Klingensmith G: Predictors of acute complications in children with type 1 diabetes. JAMA 287:2511–2518, 2002
  18. Patterson CC, Dahlquist G, Harjutsalo V, Joner G, Feltbower RG, Svens-son J, Schober E, Gyürüs E, Castell C, Urbonaité B, Rosenbauer J, Iotova V, Thorsson AV, Soltész G: Early mortality in EURODIAB population-based cohorts of type 1 diabetes diagnosed in childhood since 1989. Diabetologia 50:2439–2442, 2007
  19. Dalhquist G, Kallen B: Mortality in childhood-onset type 1 diabetes. Diabe-tes Care 28:2384–2387, 2005
  20. Orsini-Federici M, Akwi JA, Canonico V, Celleno R, Ferolla P, Pippi R, Tassi C, Timi A, Benedetti MM: Early detection of insulin deprivation in con-tinuous subcutaneous insulin infusion-treated patients with type 1 diabetes. Diabetes Technol Ther 8:67–75, 2006
  21. Hannas R, Lindgren F, Lindblad B: A 2-year national population study of pediatric ketoacidosis in Sweden: predisposing conditions and insulin pump use. Pediatr Diabetes 10:33–37, 2009
  22. McMahon SK, Airey FL, Marangou DA, McElwee KJ, Carne CL, Clarey AJ, Davis EA, Jones TW: Insulin pump therapy in children and adolescents: improvements in key parameters of diabetes management including quality of life. Diabet Med 22:92–96, 2005
  23. Weissberg-Benchell J, Antisdel-Lomaglio J, Seshadri R: Insulin pump ther-apy: a meta-analysis. Diabetes Care 26:1079–1087, 2003
  24. Danne T, Kordonouri O, Holder M, Haberland H, Golembowski S, Remus K, Bläsig S, Wadien T, Zierow S, Hartmann R, Thomas A: Prevention of hypoglycemia by using low glucose suspend function in sensor-augmented pump therapy. Diabetes Technol Ther 13:1129–1134, 2011
  25. Choudhary P, Shin J, Evans ML, Hammond PJ, Kerr D, Shaw JA, Pickup JC, Amiel SA: Insulin pump therapy with automated insulin suspension in response to hypoglycemia. Diabetes Care 34:2023–2025, 2011
  26. Agrawal P, Welsh JB, Kannard B, Askari S, Yang Q, Kaufman FR.: Usage and effectiveness of the low glucose suspend feature of the Medtronic Paradigm Veo insulin pump. J Diabetes Sci Technol 5:1137–1141, 2011
  27. Chase HP, Beck RW, Xing D, Tamborlane WV, Coffey J, Fox LA, Ives B, Keady J, Kollman C, Laffel L, Ruedy KJ: Continuous glucose monitoring in youth with type 1 diabetes: 12-month follow-up of the Juvenile Diabetes Research Foundation continuous glucose monitoring randomized trial. Dia-betes Technol Ther 12:507–515, 2010

Continuous Subcutaneous Insulin Infusion (CSII): Adults

American Diabetes Association: Continuous subcutaneous insulin infusion. Dia-betes Care 27 (Suppl. 1):S110, 2004

Barnard KD, Lloyd CE, Skinner TC: Systematic literature review: quality of life associated with insulin pump use in type 1 diabetes. Diabet Med 24:607–617, 2007

Barnard KD, Skinner TC: Cross-sectional study into quality of life issues sur-rounding insulin pump use in type 1 diabetes. Practical Diabetes International 25, 2008

Fatourechi MM, Kudva YC, Murad MH, Elamin MB, Tabini CC, Montori VM: Hypoglycemia with intensive insulin therapy: a systematic review and meta-analyses of randomized trials of continuous subcutaneous insulin infusion versus multiple daily injections. J Clin Endocrinol Metab 94:729–740, 2009

Hammond P, Boardman S, Greenwood R: ABCD position paper on insulin pumps. Practical Diabetes International 23:395–400, 2006

Heinemann L: Insulin pump therapy: what is the evidence for using different types of boluses for coverage of prandial insulin requirements? J Diabetes Sci Technol 3:1490–1500, 2009

Jeitler K, Horvath K, Berghold A, Gratzer TW, Neeser K, Pieber TR, Sieben-hofer A: Continuous subcutaneous insulin infusion versus multiple daily insulin injections in patients with diabetes mellitus: systematic review and meta- analysis. Diabetologia 51:941–951, 2008

Kerr D, Morton J, Whately-Smith C, Everett J, Begley JP: Laboratory-based non-clinical comparison of occlusion rates using three rapid-acting insulin analogs in continuous subcutaneous insulin infusion catheters using low flow rates. J Diabetes Sci Technol 2:450–455, 2008

Linkeschova R, Raoul M, Bott U, Berger M, Spraul M: Less severe hypoglycae-mia, better metabolic control, and improved quality of life in type 1 diabetes mellitus with continuous subcutaneous insulin infusion (CSII) therapy; an observational study of 100 consecutive patients followed for a mean of 2 years. Diabet Med 19:746–751, 2002

Mecklenburg RS, Benson EA, Benson JW Jr, Fredlund PN, Guinn T, Metz RJ, Nielsen RL, Sanner CA: Acute complications associated with insulin infusion pump ther-apy. Report of experience with 161 patients. JAMA 252:3265–3269, 1984

Perriello G, De Feo P, Torlone E, Fanelli C, Santeusanio F, Brunetti P, Bolli GB: The dawn phenomenon in type 1 (insulin-dependent) diabetes mellitus: mag-nitude, frequency, variability, and dependency on glucose counterregulation and insulin sensitivity. Diabetologia 34:21–28, 1991

Pickup J, Mattock M, Kerry S: Glycaemic control with continuous subcutaneous insulin infusion compared with intensive insulin injections in patients with type 1 diabetes: meta-analysis of randomised controlled trials. BMJ 324:705, 2002

Pickup JC, Hammond P: NICE guidance on continuous subcutaneous insulin infusion 2008: review of the technology appraisal guidance. Diabet Med 26: 1–4, 2009 Pickup JC, Sutton AJ: Severe hypoglycaemia and glycaemic control in type 1 diabetes: meta-analysis of multiple daily insulin injections compared with continuous subcutaneous insulin infusion. Diabet Med 25:765–774, 2008

Retnakaran R, Hochman J, DeVries JH, Hanaire-Broutin H, Heine RJ, Melki V, Zinman B: Continuous subcutaneous insulin infusion versus multiple daily injections: the impact of baseline A1C. Diabetes Care 27:2590–2596, 2004

Ritholz MD, Smaldone A, Lee J, Castillo A, Wolpert H, Weinger K: Perceptions of psychosocial factors and the insulin pump. Diabetes Care 30:549–554, 2007

Swan KL, Dziura JD, Steil GM, Voskanyan GR, Sikes KA, Steffen AT, Martin ML, Tamborlane WV, Weinzimer SA: Effect of age of infusion site and type of rapid-acting analog on pharmacodynamic parameters of insulin boluses in youth with type 1 diabetes receiving insulin pump therapy. Diabetes Care 32:240–244, 2009

Weissberg-Benchell J, Antisdel-Lomaglio J, Seshadri R: Insulin pump therapy: a meta-analysis. Diabetes Care 26:1079–1087, 2003

Wolpert H: Smart Pumping: A Practical Approach to Mastering the Insulin Pump. Alexandria, VA, American Diabetes Association, 2002

Zisser H, Robinson L, Bevier W, Dassau E, Ellingsen C, Doyle FJ, Jovanovic L: Bolus calculator: a review of four “smart” insulin pumps. J Diabetes Technol Ther 10:441–444, 2008

Gaps in Current Knowledge
  1. Bergenstal R, Tamborlane W, Ahmann A, Buse JB, Dailey G, Davis SN, Joyce C, Peoples T, Perkins BA, Welsh JB, Willi SM, Wood MA; STAR 3 Study Group: Effectiveness of sensor-augmented insulin-pump therapy in type 1 diabetes. N Engl J Med 363:311–320, 2010
  2. T1D Exchange Registry Symposium: Advanced Technologies and Treat-ments for Diabetes, February 2012. Barcelona, Spain

Used with permission by the American Diabetes Association. Copyright © 2013 American Diabetes Association.

Please note: We are proud to have Dr. Anne Peters as a member of our Advisory Board member for Diabetes In Control, Inc.

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