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Item
#10
Expanding Use of Insulin Pump
Therapy in Type 1 Diabetes
After 25
years, results show better control.
Continuous subcutaneous insulin infusion (CSII) is used in
selected type 1 diabetic subjects to achieve strict blood glucose
control. A quarter of a century after its introduction, world-wide
use of CSII is increasing. We review the evidence base that
justifies this increase, including effectiveness compared with
modern intensified insulin injection regimens and concern about
possible complications. Review of controlled trials shows that, in
most patients, mean blood glucose concentrations and glycated
hemoglobin percentages are either slightly lower or similar on
CSII versus multiple insulin injections.
However, hypoglycemia is markedly less frequent than during
intensive injection therapy. Ketoacidosis occurs at the same rate.
Nocturnal glycemic control is improved with insulin pumps, and
automatic basal rate changes help to minimize a pre-breakfast
blood glucose increase (the "dawn phenomenon") often seen with
injection therapy. Patients with "brittle" diabetes characterized
by recurrent ketoacidosis are often not improved by CSII, although
there may be exceptions. We argue that explicit clinical
indications for CSII are helpful; we suggest the principal
indications for health service or health insurance–funded CSII
should include frequent, unpredictable hypoglycemia or a marked
dawn phenomenon, which persist after attempts to improve control
with intensive insulin injection regimens. In any circumstances,
candidates for CSII must be motivated, willing and able to
undertake pump therapy, and adequately psychologically stable.
Some diabetic patients with well-defined clinical problems are
likely to benefit substantially from CSII and should not be denied
a trial of the treatment. Their number is relatively small, as
would therefore be the demand on funds set aside for this purpose.
The evidence base suggests that the expanding use of CSII is
justified. The unwillingness to fund pump therapy in some
countries arises in part from the erroneous belief that it is
indicated for a large proportion of type 1 diabetic patients,
which would open a floodgate of cost implications. If we can reach
agreement about some simple clinical guidelines for CSII, those
who stand to benefit could be greatly helped at an affordable
cost. Finally, we recommend a continued audit of the clinical
reasons for starting pump therapy, its metabolic effectiveness,
possible side effects, impact on long-term tissue complications,
quality of life, and patient choice of treatment methods in type 1
diabetes.
Diabetes Care 25(3):593-598, 2002
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Did
you know?
Who are the candidates for you to recommend for insulin pump
therapy. Medtronic Minimed wants you to learn more about pump
therapy see
http://www.diabetesincontrol.com/pumpprotocol.htm
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