Issue 99 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