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endo-csii-over-mdi-t1dm-at-a1c-goal-severe-hypo-or-variability

Recommends continuous subcutaneous insulin infusion (CSII) over multiple daily injections (MDI) for adults with type 1 diabetes who have achieved their A1C goal but experience severe hypoglycemia or high glucose variability, provided the patient and caregivers are willing and able to use the device. Consider CSII when clinicians hear 'A1C is at goal but patient has severe lows or glucose swings' or think 'pump for hypoglycemia-prone controlled T1DM'.

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dromlakhani/MD2SKILL

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Recommend CSII over MDI for T1DM at A1C goal with severe hypoglycemia or high variability

STEP 1 — Gather Information

Confirm T1DM diagnosis, current A1C (at target), documented severe hypoglycemia (requiring assistance) or high glucose variability (e.g., CV >36%), and patient/caregiver willingness and ability to perform CSII tasks (infusion site changes, bolusing, troubleshooting).

STEP 2 — Rule In / Rule Out

Is A1C at goal AND patient experiences severe hypoglycemia or high glucose variability? If yes, proceed to assess willingness/ability; if no, CSII not indicated for this scenario (consider other indications).

STEP 3 — Classify or Stratify

Assess patient and caregiver willingness and ability to use CSII (including education, training, follow-up access). If willing and able, proceed; if not, CSII is contraindicated—optimize MDI and address barriers.

STEP 4 — Decide

Recommend initiating CSII over continuing MDI, arranging education/training and follow-up per local protocol.

Clinical Guardrails / Mimics / Pitfalls

Do not start CSII if patient unwilling/unable, if hypoglycemia/variability absent, or if unable to perform infusion site care; avoid using CSII as sole therapy without education; do not ignore need for SMBG/CGM if not using sensor-augmented pump.

Concrete Clinical Example

A 28-year-old with T1DM has A1C 7.0% (goal), reports two severe hypoglycemic events/month requiring assistance and high glucose variability (CV 38%). Willing to try pump. Recommend CSII.

Source: Insulin pump therapy without sensor augmentation, 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-at-a1c-goal-severe-hypo-or-variability calculator

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