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[IP] CSII and UK

Reviews/Commentaries/Position Statements

Continuous Subcutaneous Insulin Infusion at 25 Years

Evidence base for the expanding use of insulin pump therapy in type 1

John Pickup, DPHIL, FRCPATH and Harry Keen, CBE, MD, FRCP From the Department
of Chemical Pathology and Metabolic Unit, Guybs Kingbs and St Thomasb
Hospitals School of Medicine, Guybs Hospital, London, U.K. 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 insurancebfunded 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. Abbreviations: CSII, continuous subcutaneous
insulininfusion b" DCCT, Diabetes Control and Complications Trial
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