Continuous Subcutaneous Insulin Infusion at 25 Years
Evidence base for the expanding use of insulin pump therapy in type 1 diabetes
Evidence base for the expanding use of insulin pump therapy in type 1 diabetes
Abstract
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 prebreakfast 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.
Footnotes
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Address correspondence and reprint requests to John Pickup, Metabolic Unit, GKT School of Medicine, Guy’s Hospital, London SE1 9RT, U.K. E-mail: john.pickup{at}kcl.ac.uk.
Received for publication 29 June 2001 and accepted in revised form 15 November 2001.
J.P. has received funds from MiniMed to support studies concerning insulin pump therapy.
A table elsewhere in this issue shows conventional and Système International (SI) units and conversion factors for many substances.
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