2.2.0.0 In­sulin Pumps

Con­tin­u­ous sub­cu­ta­neous in­sulin in­jec­tion (CSII) or in­sulin pumps have been avail­able in the U.S. for 40 years. These de­vices de­liv­er rapid-‍act­ing in­sulin through­out the day to help man­age blood glu­cose lev­els. Most in­sulin pumps use tub­ing to de­liv­er in­sulin through a can­nu­la, while a few at­tach di­rect­ly to the skin, with­out tub­ing.

Most stud­ies com­par­ing mul­ti­ple daily in­jec­tions (MDI) with CSII have been rel­a­tive­ly small and of short du­ra­tion. How­ev­er, a re­cent sys­tematic re­view and meta-‍anal­y­sis con­clud­ed that pump ther­a­py has mod­est ad­van­tages for low­er­ing A1C (–0.30% 95% CI -0.58 to -0.02]) and for re­duc­ing se­vere hy­po­glycemia rates in chil­dren and adults (8). There is no con­sen­sus to guide choos­ing which form of in­sulin ad­min­is­tra­tion is best for a given pa­tient, and re­search to guide this de­ci­sion mak­ing is need­ed (9). Thus, the choice of MDI or an in­sulin pump is often based upon the in­di­vid­u­al char­ac­ter­is­tics of the pa­tient and which is most like­ly to benefit him or her. Newer sys­tems, such as sen­sor-‍aug­ment­ed pumps and au­to­mat­ic in­sulin de­liv­ery sys­tems, are dis­cussed else­where in this sec­tion.

Adop­tion of pump ther­a­py in the U.S. shows ge­o­graph­i­cal vari­a­tions, which may be re­lat­ed to pro­vider pref­er­ence or cen­ter char­ac­ter­is­tics (10,11) and so­cioe­co­nom­ic sta­tus, as pump ther­a­py is more com­mon in in­di­vid­u­als of high­er so­cioe­co­nom­ic sta­tus as reflected by race/‍ethnicity, pri­vate health in­sur­ance, fam­i­ly in­come, and ed­u­ca­tion (11,12). Given the ad­di­tion­al bar­ri­ers to op­ti­mal di­a­betes care ob­served in dis­ad­van­taged groups (13), ad­dress­ing the dif­fer­ences in ac­cess to in­sulin pumps and other di­a­betes tech­nol­o­gy may con­tribute to fewer health dis­par­i­ties.

Pump ther­a­py can be suc­cess­ful­ly start­ed at the time of di­ag­no­sis (14,15). Prac­ti­cal as­pects of pump ther­a­py ini­ti­a­tion in­clude: as­sess­ment of pa­tient and fam­i­ly readi­ness, (al­though there is no con­sen­sus on which fac­tors to con­sid­er in adults (16) or pe­di­atrics), se­lec­tion of pump type and ini­tial pump set­tings, pa­tient/ fam­i­ly ed­u­ca­tion of po­ten­tial pump com­pli­ca­tions (e.g., di­a­bet­ic ke­toaci­do­sis [DKA] with in­fu­sion set fail­ure), tran­si­tion from MDI, and in­tro­duc­tion of ad­vanced pump set­tings (e.g., tem­po­rary basal rates, extended/‍square/‍dual wave bolus).

Com­pli­ca­tions of the pump can be caused by is­sues with in­fu­sion sets (dis­lodge­ment, oc­clu­sion), which place pa­tients at risk for ke­to­sis and DKA and thus must be rec­og­nized and man­aged early (17); lipo­hy­per­tro­phy or, less fre­quent­ly, lipoa­t­ro­phy (18,19); and pump site in­fec­tion (20). Dis­con­tin­u­a­tion of pump ther­a­py is rel­a­tive­ly uncom­mon today; the fre­quen­cy has de­creased over the past decades and its caus­es have changed (20,21). Cur­rent rea­sons for at­tri­tion are prob­lems with cost, wear­a­bil­i­ty, dis­lik­ing the pump, subop­ti­mal glycemic con­trol, or mood dis­or­ders (e.g., anx­i­ety or de­pres­sion) (22).

Insulin Pumps in Pediatrics

The safe­ty of in­sulin pumps in youth has been es­tab­lished for over 15 years (23). Study­ing the ef­fec­tive­ness of CSII in low­er­ing A1C has been chal­leng­ing be­cause of the po­ten­tial se­lec­tion bias of ob­ser­va­tion­al stud­ies. Par­tic­i­pants on CSII may have a high­er so­cioe­co­nom­ic sta­tus that may fa­cil­i­tate bet­ter glycemic con­trol (24) ver­sus MDI. In ad­di­tion, the fast pace of de­vel­op­ment of new in­sulins and tech­nolo­gies quick­ly ren­ders com­par­isons ob­so­lete. How­ev­er, ran­dom­ized con­trolled tri­als (RCTs) com­par­ing CSII and MDI with in­sulin analogs demon­strate a mod­est im­provement in A1C in par­tic­i­pants on CSII (25,26). Ob­ser­va­tion­al stud­ies, reg­istry data, and meta-‍anal­y­sis have also sug­gest­ed an im­provement of glycemic con­trol in par­tic­i­pants on CSII (27–29). Al­though hy­po­glycemia was a major ad­verse ef­fect of in­ten­sified in­sulin reg­i­men in the Di­a­betes Con­trol and Com­pli­ca­tions Trial (DCCT) (30), data sug­gests that CSII may re­duce the rates of se­vere hy­po­glycemia com­pared with MDI (29,31–33). There is also ev­i­dence that CSII may re­duce DKA risk (29,34) and di­a­betes com­pli­ca­tions, in par­tic­u­lar, retinopa­thy and pe­riph­er­al neu­ropa­thy in youth, com­pared with MDI (35). Fi­nal­ly, treat­ment sat­is­fac­tion and qual­i­ty-‍of-‍life mea­sures im­proved on CSII com­pared with MDI (36,37). There­fore, CSII can be used safe­ly and ef­fec­tive­ly in youth with type 1 di­a­betes to as­sist with achiev­ing tar­get­ed glycemic con­trol while re­duc­ing the risk of hy­po­glycemia and DKA, im­prov­ing qual­i­ty of life and pre­vent­ing long-‍term com­pli­ca­tions. Based on pa­tient-pro­vider shared de­ci­sion mak­ing, in­sulin pumps may be con­sid­ered in all pe­di­atric pa­tients. In par­tic­u­lar, pump ther­a­py may be the pre­ferred mode of in­sulin de­liv­ery for chil­dren under 7 years of age (38). Be­cause of a pauci­ty of data in ado­les­cents and youths with Type 2 di­a­betes, there is insufficient ev­i­dence to make rec­om­men­da­tions.

Com­mon bar­ri­ers to pump ther­a­py adop­tion in chil­dren and ado­les­cents are con­cerns re­gard­ing the phys­i­cal in­ter­fer­ence of the de­vice, dis­com­fort with idea of hav­ing a de­vice on the body ther­a­peu­tic ef­fec­tive­ness, and finan­cial bur­den (27,39).