Suggest CSII for T1DM needing flexibility or satisfaction

STEP 1 — Gather Information

Confirm adult (≥18 years) with type 1 diabetes mellitus, assess patient's expressed desire for increased insulin delivery flexibility or improved satisfaction, evaluate willingness and ability to use CSII device, review psychological status, adherence history, and availability for follow-up visits and education/training. If patient expresses desire for flexibility/satisfaction and is willing/able to use CSII, proceed to Step 2; otherwise, consider alternative insulin regimens.

STEP 2 — Rule In / Rule Out

Rule out contraindications: unwillingness to use pump, inability to perform required tasks (e.g., infusion site changes, bolusing), lack of access to follow-up/support, or active untreated psychological disorder that impedes self-care. If no contraindications and patient is willing/able, rule in for CSII consideration; if any contraindication present, rule out CSII and continue with MDI or other therapies.

STEP 3 — Classify or Stratify

Stratify patients based on primary motivation: those seeking lifestyle flexibility (e.g., variable schedules, exercise, travel) versus those seeking improved satisfaction with current regimen; both groups proceed to the same decision point as CSII addresses either need.

STEP 4 — Decide

Recommend initiating CSII with rapid-acting analog insulin, provide comprehensive education and training on pump operation, infusion site management, bolus calculator use, and hypoglycemia prevention, and arrange regular follow-up to assess outcomes and satisfaction.

Clinical Guardrails / Mimics / Pitfalls

Do not initiate CSII in patients unwilling or unable to perform pump tasks, those lacking access to ongoing support, or those with unrealistic expectations about glucose control; avoid using CSII solely for hypoglycemia reduction without evidence of benefit, and recognize that evidence supporting this recommendation is weak (low quality). Ensure patients understand pump limitations, including risk of diabetic ketoacidosis with infusion set failure, and have a backup plan for injected insulin.

Concrete Clinical Example

A 28-year-old adult with T1DM on MDI reports frustration with rigid meal timing and desires freedom to exercise spontaneously; willing to learn pump use, has no psychological contraindications, and can attend follow-up. After education, CSII is initiated with rapid-acting analog, resulting in improved satisfaction and ability to adjust basal rates for activity.

Source: Diabetes Technology—Continuous Subcutaneous Insulin Infusion Therapy and Continuous Glucose Monitoring in Adults: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, https://doi.org/10.1210/jc.2016-2534