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Diabetes Care 26:967, 2003
© 2003 by the American Diabetes Association, Inc.

Letters: Comments and Responses
Letter

Response to Schade

To pump or not to pump?

Eugenio Cersosimo, MD, PHD

From Texas Diabetes Institute, University of Texas, San Antonio, Texas

In the editorial published in the November issue of Diabetes Care, entitled "To Pump or Not to Pump" (1), Dr. David Schade provides an excellent review of the recent history of the "intensive insulin therapy" approach for the management of type 1 diabetic patients and the gradual development of continuous subcutaneous insulin infusion utilizing an external insulin infusion pump (CSII). Surprisingly, despite the overwhelming evidence that CSII is superior to some multiple insulin injection (MDI) programs, including the report in the same issue by DeVries et al. (2), Dr. Schade concludes that CSII should be reserved for a "minority" or a subset of individuals with diabetes.

Most clinical trials (3,4), meta-analyses (5), and observational studies (6) have demonstrated greater reductions in HbA1c, lower rates of hypoglycemia (a major deterrent for the implementation of intensive insulin therapy in type 1 diabetes [7]), less daily glucose variability, improved clinical outcomes, and better quality of life in patients treated with CSII when compared with those in MDI programs. There are no data to support the notion that the advantages of CSII over MDI programs are offset by the higher cost of the CSII regimen, since most cost analyses do not take into account the savings associated with less frequent hospitalizations and emergency room visits, as well as the unequivocal benefits (7) of sustained prolonged lower HbA1c levels achieved over time in patients treated with CSII. In our recently published experience (8), we found less frequent hospitalizations and emergency room visits in type 1 diabetic patients who were treated on intensive insulin pump programs compared with those on multiple insulin injections.

Although we agree with Dr. Schade that "[...] placing individuals on CSII who are unable to master MDI first is a prescription for failure," extending CSII to the "majority" of patients with type 1 diabetes (and perhaps to selected insulin-requiring type 2 diabetic individuals) who are currently on intensive insulin therapy programs is recommended, consistent with good clinical practice, and based on scientific evidence. CSII programs can be easily and safely implemented in the outpatient setting and can result in substantial improvement in clinical outcomes (8).

Footnotes

Address correspondence to Eugenio Cersosimo, MD, PHD, Texas Diabetes Institute, 701 South Zarzamora MS 10-5, San Antonio, TX 78207-5209. E-mail: ecersosimo{at}university-health-sys.com.

References

  1. Schade DS: To pump or not to pump (Editorial)? Diabetes Care 25:2100–2102, 2002[Free Full Text]
  2. DeVries JH, Snoek FJ, Kostense PJ, Masurei N, Heine RJ, on behalf of the Dutch Insulin Pump Study Group: A randomized trial of continuous subcutaneous insulin infusion and intensive injection therapy in type 1 diabetes for patients with long-standing poor glycemic control. Diabetes Care 25:2074–2080, 2002[Abstract/Free Full Text]
  3. Chantelau E, Spraul M, Muhlhauser I, Gause R, Berger M: Long-term safety, efficacy and side-effects of continuous subcutaneous insulin infusion treatment for type 1 diabetes (insulin-dependent) diabetes mellitus: a one centre experience. Diabetologia 32:421–426, 1989[Medline]
  4. Hanaire-Broutin H, Melki V, Bessieres-Lacombe S, Tauber JP: Comparison of continuous subcutaneous insulin infusion and multiple daily injection regimens using insulin lispro in type 1 diabetic patients on intensified treatment: a randomized study: the Study Group for the Development of Pump Therapy in Diabetes. Diabetes Care 23:1232–1235, 2000[Abstract/Free Full Text]
  5. Pickup J, Mattock M, Kerry S: Glycemic control with continuous subcutaneous insulin infusion compared with intensive insulin injections in patients with type 1 diabetes: meta-analysis of randomized controlled trials. BMJ 324:705–710, 2002[Abstract/Free Full Text]
  6. Koivisto VA, Yki-Jarvinen H, Helve E, Karonen SL, Pelkonen R: Pathogenesis and preventon of the dawn phenomenon in diabetic patients treated with CSII. Diabetes 35:78–82, 1986[Abstract]
  7. The 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[Abstract/Free Full Text]
  8. Cersosimo E, Jornsay D, Arce C, Rieff M, Feldman E, DeFronzo RA: Improved clinical outcomes with intensive insulin pump therapy in type 1 diabetes (Abstract). Diabetes 51(Suppl. 2):A128, 2002

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D. S. Schade and V. Valentine
Response to Cersosimo
Diabetes Care, March 1, 2003; 26(3): 967 - 968.
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