What are the recommendations for a type 1 diabetic patient on basal-bolus (basal-bolus insulin therapy) insulin therapy considering insulin pump therapy?

Insulin Pump Therapy Consideration for Type 1 Diabetes Patients on Basal-Bolus Insulin

Most people with type 1 diabetes on basal-bolus insulin therapy should be offered continuous subcutaneous insulin infusion (insulin pump therapy) if they are not meeting glycemic targets (A1C <7%), experiencing frequent or severe hypoglycemia, have pronounced dawn phenomenon, or prefer this modality and have access to reimbursement. 1, 2

Primary Indications for Transitioning to Pump Therapy

Consider insulin pump therapy when:

• Inadequate glycemic control: A1C remains ≥7% despite optimized multiple daily injections (MDI) with appropriate basal-bolus dosing 1, 2
• Hypoglycemia burden: Frequent hypoglycemic episodes (especially nocturnal) or severe hypoglycemia requiring assistance 2
• Dawn phenomenon: Pronounced early morning hyperglycemia that cannot be adequately controlled with basal insulin adjustments 2
• Patient preference: Highly motivated patients who desire greater flexibility and are willing to engage in intensive diabetes self-management 1
• Lifestyle factors: Need for precise insulin adjustments around variable meal timing, carbohydrate intake, or exercise patterns 3

Clinical Advantages of Pump Therapy Over MDI

Insulin pumps offer several measurable benefits:

• Modest A1C improvement: Meta-analysis shows mean A1C reduction of 0.30% (95% CI -0.58 to -0.02) compared to MDI 1
• Precise basal delivery: Quantitative administration with capacity for instantaneous change and cessation, allowing hourly rate adjustments for circadian insulin needs 1, 3
• Enhanced bolus accuracy: Integrated calculators for matching insulin to carbohydrate intake, premeal glucose, and anticipated activity 1, 3
• Reduced hypoglycemia risk: Modern pumps can suspend insulin when glucose is low or predicted to drop within 30 minutes 3
• Greater flexibility: Ability to adapt to exercise, stress, illness, and menstrual cycle variations without changing injection regimens 3

Patient Selection Criteria

Appropriate candidates must demonstrate:

• High motivation and education level: Pump users must be capable of managing "sick day rules" and unforeseen circumstances regarding glucose control 1
• Carbohydrate counting proficiency: Mastery of matching prandial insulin to carbohydrate intake is essential before pump initiation 1
• Frequent glucose monitoring commitment: Willingness to perform regular blood glucose checks (at least 4-6 times daily) in addition to continuous glucose monitoring if available 3, 4
• Technical aptitude: Ability to learn pump mechanics, troubleshoot basic problems, and recognize pump malfunction 1

Contraindications and Barriers

Pump therapy may not be appropriate when:

• Patient cannot self-manage: Situations involving delirium, severe pain, loss of consciousness, or inability to make diabetes management decisions require reversion to MDI or IV insulin protocols 1
• Psychological barriers: Some patients find being attached to a device psychologically burdensome, which outweighs clinical benefits 1
• Limited support system: Lack of access to diabetes specialist team for pump training and ongoing troubleshooting 1
• Cost and reimbursement issues: Pump therapy requires ongoing supplies (infusion sets every 2-3 days) and may not be covered by all insurance plans 3

Critical Safety Considerations

Patients and providers must understand:

• Rapid insulin deficiency risk: Disconnection, occlusion, or pump malfunction causes insulin deficiency within 1 hour and absolute deficiency within 4 hours, risking hyperglycemia and diabetic ketoacidosis 3
• Only rapid-acting insulin used: Pumps use only rapid-acting analogues (Novorapid, Humalog, Apidra), not long-acting basal insulin 1, 3
• Hospital protocol requirements: Facilities must have clear protocols for inpatient pump management with education for healthcare professionals and close diabetes team liaison 1
• Procedure limitations: Pumps must be removed during CT/MRI, body X-rays, and cardiac catheterization procedures 1, 3

Referral Pathway for Remote Communities

For your specific context (general medicine internist with diabetes training in remote community):

• Initiate pump therapy locally if you have completed specialized pump training and have access to pump company support for technical issues 1
• Establish telemedicine connection with endocrinology center for complex cases and ongoing consultation 1
• Ensure patient has written management plan with signed consent for pump use, including protocols for pump failure and sick days 5
• Coordinate with hospital administration to develop institutional policies supporting inpatient pump use before initiating therapy 1

Common Pitfalls to Avoid

• Inadequate patient education: Never start pump therapy without ensuring patient mastery of carbohydrate counting and correction dose calculations 1
• Insufficient follow-up: Pump initiation requires frequent contact (often daily) for the first 1-2 weeks to optimize basal rates and bolus settings 6
• Ignoring pump alarms: Patients must respond immediately to occlusion or low insulin alarms to prevent diabetic ketoacidosis 3
• Assuming hospital staff competence: Patient or diabetes team must maintain pump control during hospitalization; do not assume general hospital staff can manage pumps 5