Recommend CSII over MDI for T1DM not at A1C goal
STEP 1 — Gather Information
Confirm type 1 diabetes mellitus diagnosis, current insulin regimen (analog-based basal-bolus MDI), most recent A1C value, and assess patient and caregiver willingness and ability to operate a continuous subcutaneous insulin infusion pump (including site changes, troubleshooting, and follow-up).
STEP 2 — Rule In / Rule Out
Rule in if A1C is above individualized target despite MDI AND patient/caregiver are willing and able to use CSII; rule out if A1C at target or unwilling/unable to use device.
STEP 3 — Classify or Stratify
Classify as candidate for CSII over MDI when criteria met; no further stratification needed per guideline.
STEP 4 — Decide
Recommend initiating CSII (insulin pump therapy) in preference to continuing analog-based basal-bolus MDI.
Clinical Guardrails / Mimics / Pitfalls
Ensure comprehensive pump education; assess for contraindications such as inability to perform infusion set changes, active substance abuse, uncontrolled psychiatric illness, or lack of reliable follow‑up. Beware of increased risk of DKA with pump interruption; have a sick‑day plan and backup insulin. Do not initiate if patient cannot afford supplies or lacks insurance coverage.
Concrete Clinical Example
A 29‑year‑old woman with T1DM on basal‑bolus MDI (glargine U‑100 + aspart) has an A1C of 8.6% (target <7.0%). She completes pump training, demonstrates problem‑solving skills, and starts CSII with aspart. At 3‑month follow‑up her A1C is 7.3% with fewer hypoglycemic events.
Source: Insulin pump therapy without sensor augmentation (pages 4-5), Endocrine Society Clinical Practice Guideline, 2016, DOI: 10.1210/jc.2016-2534
TODO: consider adding scripts/calc.py for the endo-csii-over-mdi-t1dm-not-at-a1c-goal calculator