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