Continuous subcutaneous insulin infusion (CSII) 30 years later: still the best option for insulin therapy

Abstract

Thirty years after its introduction, the use of continuous subcutaneous insulin infusion (CSII) keeps increasing, especially among children and adolescents. The technique, when used properly, is safe and effective.Compared with traditional NPH-based multiple daily injections (MDI), CSII provides a small but clinically important reduction of HbA(1c) levels, diminishes blood glucose variability, decreases severe hypoglycaemic episodes and offers a better way to cope with the dawn phenomenon.Insulin analogues have improved the treatment of diabetes, eroding part of the place previously occupied by CSII, but CSII still remains the first option for patients experiencing severe hypoglycaemic episodes, high HbA(1c) values or marked glucose variability while being treated with optimized MDI. Furthermore CSII is better than MDI considering the effects on quality of life and the possibility to adjust insulin administration according to physical activity or food intake.CSII may be limited by cost. Present estimates suggest that CSII may be cost-effective just for patients experiencing a marked improvement in HbA(1c) or a decrease in severe hypoglycaemic episodes, but the effects on quality of life are difficult to measure.CSII does not merely imply wearing an external device; it requires a multidisciplinary team, intensive patient education and continuous follow up.

Nonmetabolic Complications of Continuous Subcutaneous Insulin Infusion: A Patient Survey

“…1 The comparative frequencies of ketoacidosis 2,3 and hypoglycemia 4 on CSII versus insulin injection therapy have been well researched in recent years. However, although the possible nonmetabolic, technical problems associated with modern CSII are given due note in recent reviews of this therapy 1,2,[5][6][7] and indeed widely recognized from clinical practice, there have been few if any surveys that formally record the types and frequencies of these risks using a standardized questionnaire, since the 1980s. 8 Complications of CSII may have changed in the last 25 years because of improvements and increasing sophistication in technology and clinical care; this should ideally reduce risks, but it may possibly exacerbate problems or introduce new ones.…”

Insulin Pump Therapy is Equally Effective and Safe in Elderly and Young Type 1 Diabetes Patients

“…Insulin therapy may be implemented either with continuous subcutaneous insulin infusion (CSII) via a personal pump or multiple daily injections (MDI) model. The currently available data suggest that in adults with T1D, CSII is more effective than MDI in optimizing glycemic control [1,[3][4][5]. However, there is insufficient evidence regarding adverse events, mortality, and morbidity [6].…”

Metabolic Control Targets for Patients with Type 1 Diabetes in Clinical Practice

“…Further, this improvement in glycaemia control is achieved with a lower quantity of insulin (Jeitler et al, 2008;Torres et al, 2009). Hence, CIIS has become established as the preferred modality of treatment, and an alternative to the multiple doses of insulin for those selected patients who do not achieve the target of glycaemia control with multiple injections of insulin (Bruttomesso et al, 2009). The patients with DM type 1 treated with multiple injections of insulin frequently present with the "dawn phenomenon" which consists of a sharp increase in glucose in the small hours of the morning; increase due to the increase in the counter-regulatory hormones that occur during this period and which are not sufficiently counteracted by long-acting insulin administered at bedtime.…”

“…The patients with DM type 1 treated with multiple injections of insulin frequently present with the "dawn phenomenon" which consists of a sharp increase in glucose in the small hours of the morning; increase due to the increase in the counter-regulatory hormones that occur during this period and which are not sufficiently counteracted by long-acting insulin administered at bedtime. The therapy with CIIS, enables basal infusion to be anticipated and programmed, which can be useful in controlling this phenomenon by increasing the basal rhythm to that suitable for the individual's needs (Bruttomesso et al, 2009;Cummins et al, 2010). When CIIS therapy was used initially, there were cases of severe hypoglycaemia reported which brought the safety of the system into question (Lock & Rigg, 1981).…”

“…CIIS therapy requires a specifically formed team of healthcare professionals with sufficient time dedication to their patients not only for the training but also for clinical follow-up. The circumstances for CIIS treatment apply to any age in achieving good metabolic outcomes (Bruttomesso et al, 2009;Cummins et al, 2010). The indications more widely accepted are collected in Table 4 HbA1c >7% despite good adherence to therapy with multi-injection systems Severe hypoglycaemias, recurrent, nocturnal or inadvertent Significant dawn phenomenon Brittle diabetes.…”