Continuous subcutaneous insulin infusion at 25 years - Evidence base for the expanding use of insulin pump therapy in type 1 diabetes

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 increasing. We review the evidence base that 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 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 Men 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 alter attempts to improve control with intensive insulin injection regimens. In any circumstances, candidates for CSII 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.