www.diabeticretinopathy.org.uk

General

Insulin pumps

David Kinshuck

 

Insulin pumps are also called CSII...continuous subcutaneous insulin infusion.

There is increasing evidence that these will produce even better diabetic control than the most modern multiple dose injection regime. Recent pumps indicate pumps are becoming ever more effective, and can now be combined with a glucose sensor (NEJM 2010). Many doctors urge patients to consider pumps, although to achieve good glucose control insulin doses have to be adjusted regularly and glucose levels have to be tested frequently.

These 2013 NICE guidelines.

Continuous subcutaneous insulin infusion or ‘insulin pump' therapy is recommended as a possible treatment for adults and children 12¬†years and over with type 1 diabetes mellitus if:

  • attempts to reach target haemoglobin A1c (HbA1c) levels with multiple daily injections result in the person having ‘disabling hypoglycaemia', or
  • HbA1c levels have remained high (8.5% or above) with multiple daily injections (including using long-acting insulin analogues if appropriate) despite the person and/or their carer carefully trying to manage their diabetes.

My comments: whilst these guidlines seem to limit the use of pumps, many patients do risk severe hypos if aiming for tight diabetic control. Certainly, at a recent pump meeting, pumps seem ideal for may type 1 patients. (Also for may type 2, but these are not supported by NICE.)

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Pumps are well tolerated  by young people and reduce HbA1c levels from about 8% to 7.2%. They also provide good control without extra hypos in adults. Patients prefer pumps. They work with poorly controlled patients. However, in children, this paper  and this one indicated little difference, although pump patients had fewer severe hypos. This paper, also in children, indicated better control after meals. Some patients return to insulin, here. Improving diabetic control too quickly can aggravate retinopathy, but helps in the long-term. The article suggests they "Glycaemic control is better during continuous subcutaneous insulin infusion compared with optimised injection therapy, and less insulin is needed to achieve this level of strict control. The difference in control between the two methods is small but should reduce the risk of microvascular complications".

Whatever you decide, read up and visit http://www.insulin-pumpers.org/about.shtml. See how your control can improve . For more medical details see the BMJ, Diabetic Medicine, Diabetic Medicine. For children and exercise on a pump and an excellent lecture but in US units.  & a Leeds page.

For further details about pumps and your local INPUT branch, contact John Davis by email at input@care4free.net or tel 01590 677911 (from outside UK: +44 1590 677911).

With continuous glucose monitoring and intensive treatment of Type 1 Diabetes NEJM 2008. The Lancet 2010 reports improved control with a closed loop delivery (continuous glucose monitoring controlling insulin dose from an insulin pump).

Pumps help Greece 2009. The BMJ 2011 and editorial reviews 'closed loop' pumps...these measure glucose levels and inject the appropriate insulin dose, even during the night. They give better glucose control,  but they are still in their early stages of development and cannot be bought.