What are the considerations for initiating insulin pump therapy in a type 1 diabetic patient currently on nasal bolus insulin (intranasal insulin), and what alternative interventions can be considered if pump therapy is not suitable?

Why This Patient Was Referred to You and What You Need to Consider

This patient was likely referred to you in error—insulin pump initiation should be managed by an endocrinologist or specialized diabetes team with expertise in continuous subcutaneous insulin infusion (CSII) therapy, not a general internist. 1 Additionally, "nasal bolus insulin" is not a standard therapy for type 1 diabetes, suggesting either a documentation error or an unconventional regimen that requires specialist clarification before proceeding.

Why This Referral Is Inappropriate

• Insulin pump therapy requires specialized training and ongoing support from diabetes teams experienced in CSII technology. 1 The British Journal of Anaesthesia explicitly states that pump therapy should be "prescribed, implemented and monitored by a skilled professional team familiar with it and capable of supporting the patient." 2

• Most guidelines emphasize that pump initiation involves complex technical education including pump mechanics, basal rate programming, bolus calculators, carbohydrate counting, and troubleshooting pump failures. 1, 3 This is beyond the scope of general internal medicine practice.

• The American Diabetes Association recommends that individuals with diabetes on CSII should have continued access to specialized pump teams across healthcare settings. 1

Critical Issues to Address Before Any Pump Consideration

Clarify the Current Insulin Regimen

• "Nasal bolus insulin" is not a recognized standard therapy for type 1 diabetes. 4 The FDA-approved insulin formulations for type 1 diabetes include subcutaneous injections (multiple daily injections or MDI) and continuous subcutaneous infusion via pump. 4

• You must determine what the patient is actually using: Is this intranasal glucagon for hypoglycemia rescue? Is there a documentation error meaning "basal-bolus insulin"? Is the patient using an experimental or off-label formulation? 4

• Without clarity on current therapy, you cannot safely transition to pump therapy. 1

Assess Patient Candidacy for Pump Therapy

If the patient is indeed appropriate for pump consideration, the following must be evaluated by a specialized team:

• Patient motivation and technical capability: The patient must demonstrate ability to perform carbohydrate counting, frequent self-monitoring of blood glucose (at least 4-6 times daily), understand pump mechanics, and troubleshoot problems like infusion set occlusions. 3, 5, 2

• Cognitive and visual function: Patients with visual impairment or cognitive deficits may not be suitable candidates, as they cannot safely manage pump programming and dose adjustments. 1

• Current glycemic control and hypoglycemia history: Pump therapy is indicated for patients with HbA1c >8.5% despite optimized MDI with analogue insulins, or those with recurrent disabling hypoglycemia. 1

• Psychological readiness: Some patients experience significant psychological burden from being "attached to a machine," which can lead to pump discontinuation. 1

Understand Pump-Specific Risks

• Diabetic ketoacidosis (DKA) risk is significantly elevated with pump failure: Because pumps use only rapid-acting insulin with no depot effect, pump disconnection or infusion set occlusion can lead to absolute insulin deficiency within 4 hours and ketosis. 1 Patients must be educated on recognizing and managing this emergency.

• Infusion site complications: Lipohypertrophy, lipoatrophy, and site infections occur and require proper site rotation every 2-3 days. 1, 2

• Technical failures: Catheter occlusions are more common with certain insulin types (insulin lispro) and when bleeding occurs at infusion sites. 2

What You Should Do Now

Immediate Actions

1. Contact the referring provider to clarify the referral rationale and the patient's actual current insulin regimen. 1

2. Refer the patient to an endocrinologist or specialized diabetes pump clinic immediately. 1 Do not attempt pump initiation yourself.

3. If the patient is currently on an unconventional or unsafe insulin regimen (e.g., truly using intranasal insulin as primary therapy), this is an urgent endocrine consultation for stabilization on standard subcutaneous basal-bolus therapy first. 4, 6

If You Must Provide Interim Management

• Ensure the patient is on a safe, evidence-based insulin regimen while awaiting specialist evaluation: This means basal insulin (insulin glargine, detemir, or degludec) plus rapid-acting prandial insulin (aspart, lispro, or glulisine) via subcutaneous injection. 6

• Target HbA1c <7% (53 mmol/mol) for most nonpregnant adults, with individualized targets based on hypoglycemia risk and comorbidities. 6

• Educate on self-monitoring of blood glucose at least 4 times daily (fasting, pre-meals, bedtime, and as needed for symptoms). 1

Key Pitfalls to Avoid

• Do not initiate pump therapy without specialized training and ongoing team support infrastructure. 1 This includes 24/7 access to pump troubleshooting expertise.

• Do not assume all type 1 diabetics are appropriate for pumps: Patient selection is critical, and pumps are not superior to well-managed MDI for all patients. 5, 6

• Do not overlook the need for continuous glucose monitoring (CGM) integration: Modern pump therapy increasingly involves sensor-augmented pumps or automated insulin delivery systems, which require additional expertise. 1