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Indications: Benefits: 1) provides basal & meal bolus insulin requirements 2) provides tighter glucose control in selected patients with type 1 diabetes mellitus 3) reduces variability in absorption from injection sites 4) may benefit patients of all ages (including those < 4 years of age) [3] 5) minimizes nocturnal hypoglycemia [5] 6) reduces fatal cardiovascular events (RR=0.58) & all-cause mortality (RR=0.73) relative to daily insulin injections in patients with type 1 diabetes mellitus [8] Insulin: regular insulin or lisproinsulin Contraindications: 1) hypoglycemia-induced loss of consciousness 2) cardiovascular disease or cerebrovascular disease 3) seizures Complications: 1) catheter site infection 2) interruption of insulin delivery with pump malfunction - ketoacidosis Mechanism of action: - subcutaneously implanted insulin pumps provide continuous delivery of insulin (contrast with artificial pancreas) Clinical trials: 1) Clinical trial comparing insulin pump vs optimized injections [2] a) average glucose control better with pump (18 mg/dL) b) average HgbA1c less with pump (0.5%) c) average total insulin use less with pump (8 units/day) 2) sensor-augmented insulin pump that automatically suspends insulin delivery at a prespecified glucose threshold can reduce the incidence of hypoglycemia [6] 3) closed-loop insulin delivery system [13] Management: - insulin lispro by continuous subcutaneous insulin infusion pump is appropriate for noncritically ill patients with normal mental status & can appropriately adjust pump settings in hospitals with personnel who have expertise in insulin pump therapy [1] - decrease insulin dosage if episodes of hypoglycemia, even if glycemic control is poor* [1] * brittle diabetics may have episodes of hypoglycemia & hyperglycemia; hypoglycemic unawareness is especially problematic Notes: - lack of transparency from manufacturers regarding insulin pump safety [7] - training for patients recommended [7] - patients should report adverse events [7] - insulin pumps over-deliver > 1/2 unit on takeoff & under-deliver a somewhat less on landing [14]

Related

diabetes mellitus type 1 (insulin-dependent, juvenile)

Specific

automated closed-loop insulin delivery; automated insulin dosing controller; automated glycemic controller device; artificial pancreas

General

insulin device (device for administering insulin) infusion pump

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 11, 14, 17 American College of Physicians, Philadelphia 1998, 2006, 2015. - Medical Knowledge Self Assessment Program (MKSAP) 20 American College of Physicians, Philadelphia 2025
  2. Journal Watch 22(10):81, 2002 Pickup J et al Glycaemic control with continuous subcutaneous insulin infusion compared with intensive insulin injections in patients with type 1 diabetes: meta-analysis of randomised controlled trials. BMJ 324:705, 2002 PMID: 11909787
  3. Journal Watch 22(23):175, 2002 Litton J et al Insulin pump therapy in toddlers and preschool children with type 1 diabetes mellitus. J Pediatri 141:490, 2002 PMID: 12378187
  4. Prescriber's Letter 17(12): 2010 Insulin Pump Therapy Detail-Document#: 261203 (subscription needed) http://www.prescribersletter.com
  5. Bergenstal RM et al Threshold-Based Insulin-Pump Interruption for Reduction of Hypoglycemia. N Engl J Med. June 24, 2013 PMID: 23789889 http://www.nejm.org/doi/pdf/10.1056/NEJMoa1303576
  6. Ly TT, Nicholas JA, Retterath A et al Effect of Sensor-Augmented Insulin Pump Therapy and Automated Insulin Suspension vs Standard Insulin Pump Therapy on Hypoglycemia in Patients With Type 1 Diabetes. A Randomized Clinical Trial. JAMA. 2013;310(12):1240-1247 PMID: 24065010 http://jama.jamanetwork.com/article.aspx?articleid=1741822 - Choudhary P Insulin Pump Therapy With Automated Insulin Suspension. Toward Freedom From Nocturnal Hypoglycemia. JAMA. 2013;310(12):1235-1236 PMID: 24065008 ama.jamanetwork.com/article.aspx?articleid=1741800
  7. Heinemann L et al Insulin Pump Risks and Benefits:A Clinical Appraisal of Pump Safety Standards, Adverse Event Reporting, and Research Needs. A Joint Statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group. Diabetes Care. March 16, 2015 PMID: 25776138 http://care.diabetesjournals.org/content/early/2015/03/13/dc15-0168.full.pdf+html
  8. Steineck I et al Insulin pump therapy, multiple daily injections, and cardiovascular mortality in 18 168 people with type 1 diabetes: observational study. BMJ 2015;350:h3234 PMID: 26100640 http://www.bmj.com/content/350/bmj.h3234
  9. Bergenstal RM, Tamborlane WV, Ahmann A et al Effectiveness of sensor-augmented insulin-pump therapy in type 1 diabetes. N Engl J Med. 2010 Jul 22;363(4):311-20. PMID: 20587585
  10. American Diabetes Association. (6) Glycemic targets. Diabetes Care. 2015 Jan;38 Suppl:S33-40. PMID: 25537705
  11. FDA News Release. Feb 14, 2019 FDA authorizes first interoperable insulin pump intended to allow patients to customize treatment through their individual diabetes management devices. https://www.fda.gov/news-events/press-announcements/fda-authorizes-first-interoperable-insulin-pump-intended-allow-patients-customize-treatment-through
  12. FDA News Release. Jine 27, 2019 FDA warns patients and health care providers about potential cybersecurity concerns with certain Medtronic insulin pumps. https://www.fda.gov/news-events/press-announcements/fda-warns-patients-and-health-care-providers-about-potential-cybersecurity-concerns-certain - Certain Medtronic MiniMed Insulin Pumps Have Potential Cybersecurity Risks: FDA Safety Communication June 27, 2019 https://www.fda.gov/medical-devices/safety-communications/certain-medtronic-minimed-insulin-pumps-have-potential-cybersecurity-risks-fda-safety-communication
  13. Brown SA, Kovatchev BP, Raghinaru D et al. Six-month randomized, multicenter trial of closed-loop control in type 1 diabetes. N Engl J Med 2019 Oct 31; 381:1707-1717 PMID: 31618560 https://www.nejm.org/doi/10.1056/NEJMoa1907863
  14. Tucker ME Air Travel Alters Insulin Pump Delivery on Takeoff, Landing. Medscape.September 27, 2024 https://www.medscape.com/viewarticle/air-travel-alters-insulin-pump-delivery-takeoff-landing-2024a1000hna