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Re: [IPk] Bad pump propaganda

>There was a letter in this week's BMJ in response to Pickup's article a
>month or so ago

Thanks for spotting that, Abi. I'll put the whole text of the letter at the
foot of this email.

If you read the letter carefully, all he is doing is advertising some
research he himself did way back in the early 1980s. What he fails to
mention is that since then pump therapy has developed so much, particularly
in patient selection criteria and training, that quite frankly his research
is no longer relevant. You'll find dozens of more recent papers showing
that DKA does not increase when the patient is properly selected and

One death he mentions is most likely an alcoholic that Sheffield foolishly
put on a pump as a last ditch attempt to get his diabetes controlled. In a
drunken stupor he pulled out his infusion set before falling unconscious
from alcohol. His mum let him lie in the next morning, thinking he had a
bad hangover. In fact he was already in DKA coma. He died. A subsequent
enquiry reckoned he might well have lived had he been on injections. Many
think the doctors at Sheffield were professionally negligent for allowing
him on a pump in the first place.

Are you going to write the reply to the BMJ?


Extract from British Medical Journal 22 Sep 2001:

EDITOR - The editorial by Pickup and Keen about continuous subcutaneous
insulin infusion is worrying in advocating this treatment, albeit for a
comparatively small proportion of the diabetic population in Britain.1
Pickup and Keen do not highlight adequately the serious risks associated
with it for doctors considering introducing this treatment to their

Pickup and Keen acknowledge high rates of ketoacidosis with subcutaneous
insulin infusion but attribute it to lack of experience, unsuitable pump
insulin, and the less reliable devices previously available. They identify
that rates of ketoacidosis fell as physicians' experience with the
treatment increased,2 but they do not acknowledge that a new generation of
diabetes physicians considering using subcutaneous insulin infusion will be
unfamiliar with it, as will their support staff and patients.

In the early years of subcutaneous insulin infusion there seemed to be a
reluctance to identify ketoacidosis as a risk associated with it, and it
would be a mistake to allow this understatement of the problem to occur
again. In a large clinic based study of the treatment in Sheffield we
observed that subcutaneous insulin infusion occurred at a 17.5-fold greater
rate than in a group of patients treated by injection, although with
experience this was reduced to a twofold increase during the second year.3

Clearly, experience gained was important, but a doubled rate of
ketoacidosis in those infusing subcutaneous insulin was still observed.
Despite Pickup and Keen's attribution of the development of ketoacidosis to
insulin aggregation and unreliable pumps, of 18 observed episodes of
ketoacidosis, none was associated with pump failure or insulin aggregation,
although one occurred when a cannula became disconnected and another
happened when an empty insulin reservoir was not detected. Most episodes
(66%) were precipitated by intercurrent illness and were rapid in onset,
presumably because there was no subcutaneous insulin reserve in patients
with increased insulin requirements owing to physical stress. Two episodes
of cardiac arrest occurred as a result of severe hyperkalaemia, one leading
to death. Patients treated with subcutaneous insulin infusion with
ketoacidosis presented with seemingly more severe hyperkalaemia than those
having injection treatment.

Pickup and Keen emphasise the need to limit the availability of
subcutaneous insulin infusion for use from specialist centresalthough
financial costs may not be comparatively high, the treatment is expensive
in patient and professional time to ensure safety. Pickup and Keen do not
define specialist centresI suggest that physicians should avoid being
coerced into dabbling in pump therapy by patients or pressure groups.

G Knight, consultant physician. 
Rotherham General Hospitals NHS Trust, Rotherham General Hospital,
Rotherham S60 2UD

1. 	Pickup J, Keen H. Continuous subcutaneous insulin infusion in type
1 diabetes. BMJ 2001; 322: 1262-1263[Full Text]. (26 May.)
2. 	Bending JJ, Pickup JC, Keen H. Frequency of diabetic ketoacidosis
and hypoglycaemic coma during treatment with continuous subcutaneous
insulin infusion. Am J Med 1985; 79: 685-691[Medline].
3. 	Knight G, Jennings AM, Boulton AJM, Tomlinson S, Ward JD. Severe
hyperkalaemia and ketoacidosis during routine treatment with an insulin
pump. BMJ 1985; 291: 371-372[Medline].

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