To pump or not to pump

Abstract

Sir, Continuous subcutaneous insulin infusion (CSII) has been shown to improve glycaemic control and reduce hypoglycaemia.1 However, some people with type 1 diabetes mellitus (T1DM) struggle to perform adequate self-monitoring of blood glucose (SMBG) and remain safe on pump therapy. In the UK, the National Institute for Health and Care Excellence recommends insulin pump therapy in patients who have struggled to achieve optimal glucose control (HbA1c >8.5% [69mmol/mol]) or those with ongoing problematic hypoglycaemia despite optimised multiple injection therapy. Observational data also confirm that the benefits seen in studies are realised in clinical practice.2–4 However, these data hide a proportion of patients who do not seem to receive benefit, or who fail to sustain it. Nixon et al. found that up to 50% of patients have an initial improvement followed by a gradual regression to baseline, with 12% showing no benefit from baseline.5 To achieve benefit from insulin pumps and maintain safety, patients are required to perform a number of tasks, such as timely set changes, adequate capillary blood glucose monitoring and adequate boluses. In addition to this, regular review of data and engagement with the health care team can often be markers of sustained benefit. The UK Diabetes Technology Network guidelines recommend that clinicians consider CSII discontinuation where there are safety concerns, inability to self-manage the pump or no clinical benefit seen.6 We present three cases where we discontinued insulin pump therapy for a variety of reasons, and the outcomes from that.