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[IP] 8. Who Are The Candidates for Continuous Insulin Infusion?
8. Who Are The Candidates for Continuous Insulin Infusion?
Who Are The Candidates for Continuous Insulin Infusion?
Almost 25 years ago the an account of a new technique for achieving long
strict blood glucose control in type 1 diabetes appeared in the BMJ.
subcutaneous insulin infusion,1 or insulin pump therapy, mimics
delivery by using a portable electromechanical pump to infuse insulin at a
basal rate throughout 24 hours, with patient activated boosts when food is
eaten. Developed as a research tool to investigate the impact of greatly
improved glycemic control on diabetic complications, continuous subcutaneous
insulin infusion is now used in everyday treatment by at least 130 000
worldwide, more than 80 000 in the United States alone.
Much of the skepticism about continuous subcutaneous insulin infusion
from misunderstandings about its effectiveness, safety, and clinical use.
example, it is often thought that continuous subcutaneous insulin infusion
not been rigorously compared with modern multiple insulin injection
At least 14 randomized controlled trials compare continuous infusion with
intensified injection regimens. An analysis of these studies showed that
glycemic control is slightly but significantly better during insulin pump
therapy, with a glycated hemoglobin percentage about 0.5% lower than on
optimized injection regimens.
As to safety, there were initial case reports of hypoglycemic coma, and the
Diabetes Control and Complications Trial reported a high rate of severe
hypoglycemia during continuous subcutaneous insulin infusion (0.54 episodes
patient year). However, other trials have recorded lower rates episodes per
patient year), and most evidence suggests that hypoglycemia is either no
frequent or less common during continuous infusion than on either optimized
non-optimized injection therapy. In two recent trials severe hypoglycemia
84% less and nearly 50% less than on multiple insulin injection therapy.
studies have found less hypoglycemia with the non-associating monomeric
analogue than with regular human insulin as the pump insulin.
The high rates of ketoacidosis on continuous subcutaneous insulin infusion
reported in early studies were probably due to lack of experience;
pump insulin, with aggregation causing cannula blockage; and the use of less
reliable pumps without alarms. Though the small subcutaneous depot of
would seem to put patients receiving a continuous infusion more at risk,
proper pump practice the frequency of ketoacidosis is the same as with
Continuous subcutaneous insulin infusion can also help improve control in
patients who suffer sharply raised blood glucose concentrations before
(the dawn phenomenon).Pumps can be programmed to increase basal infusion
during the night to counter this dawn rise. There may be other strategies to
cope with the dawn phenomenon, such as moving the evening injection of
action insulin from before supper to bedtime or using new long acting
(such as glargine) with essentially peakless action profiles, which need
comparison with continuous subcutaneous insulin infusion.
Even Medicare is now reimbursing for pump therapy for type 1 diabetes. But,
continuous subcutaneous insulin infusion is not indicated in most people
type 1 diabetes, who can achieve good control with intensified insulin
Establishing simple clinical guidelines for using continuous subcutaneous
insulin infusion has promoted its wider availability.
Who are the candidates for an insulin pump? It might be suggested that a
of continuous subcutaneous insulin infusion is indicated in patients with
diabetes with frequent, unpredictable hypoglycemia or a marked dawn blood
glucose rise, whose poor control persists in spite of optimized insulin
injection therapy (including educational support and attention to blood
self monitoring and injection technique). Some patients who lead
lives with delayed meals experience wide swings in blood glucose
and are particularly liable to hypoglycemia when they try to tighten control
with injection therapy. The few pregnant patients with diabetes who fail to
achieve impeccable control with injections should also be considered. All
candidates should be willing to learn about and undertake pump therapy and
associated procedures such as regular blood glucose monitoring; this
patients well controlled on insulin injections who simply prefer pump
and are willing to pay for their pumps and supplies. People with
problems and major psychiatric disorders tend not to do well in meeting the
demands of continuous insulin infusion.
For those patients where insulin infusion pump therapy is indicated, it can
substantially improve the quality of their lives and the course and outcome
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