Counterpoint: Are Insulin Pumps Underutilized in Type 1 Diabetes? No
- David S. Schade, MD and
- Virginia Valentine, CNS, BC-ADM, CDE
- Department of Internal Medicine/Endocrinology, Division of Endocrinology and Metabolism, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
- Address correspondence to David S. Schade, MD, Professor of Medicine, Chief, Division of Endocrinology and Metabolism, University of New Mexico Health Sciences Center, Department of Internal Medicine/Endocrinology–5ACC, MSC10 5550, 1 University of New Mexico, Albuquerque, NM 87131-0001. E-mail: dschade{at}salud.unm.edu
One of the major goals in the treatment of diabetes is to achieve an HbA1c (A1C) <6.5 or 7.0% (depending on which organization’s guidelines are used) without an unacceptable incidence of hypoglycemia. This goal has not been achieved in many patients with diabetes. The reasons are diverse and often complex. It is appropriate to ask whether placing more patients with type 1 diabetes on insulin pumps (continuous subcutaneous insulin infusion [CSII]) would achieve this goal and be the best use of limited medical resources. Alternatively, resources could be utilized to purchase insulin analogs, to train additional diabetes educators, to transport patients to diabetes centers, or to purchase improved insulin-delivery devices. Some clinicians believe that increasing the number of type 1 diabetic patients on pumps is the best solution (1,2). It has been estimated that at least 160,000 patients in the U.S. were already utilizing insulin pumps in 2001 and >200,000 worldwide (3). This article will address one specific question, i.e., whether a major effort should be made to increase the number of patients on insulin pumps in order to achieve the above-stated A1C goal.
Determinants of plasma glucose concentration
There are several factors that determine plasma glucose concentration. These include 1) the carbohydrate composition of food, 2) the rate of gastric emptying, 3) the rate of glucose absorption, 4) the concurrent magnitude of endogenous glucose production, 5) the concurrent rate of glucose disposal, 6) the diurnal change in insulin sensitivity, 7) the activity of counterregulatory hormones, 8) the change in the magnitude and type of exercise, and 9) the ambient insulin concentration. It is important to note that most of these factors are not directly under the patient’s control. Many of the factors are interrelated, so that altering one may affect the magnitude of the other. Thus, in attempting to normalize plasma …
