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endo-csii-suggest-t2dm-poor-control-despite-intensive

Suggests CSII with good adherence to monitoring and dosing for adults with type 2 diabetes mellitus who have poor glycemic control despite intensive insulin therapy, oral agents, other injectable therapy, and lifestyle modifications. Trigger phrases include 'T2DM on multiple injectables still uncontrolled' and 'Consider pump for insulin-requiring T2DM failing other therapies'.

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Suggest CSII for T2DM with poor control despite intensive therapy

STEP 1 — Gather Information

Collect current regimen: insulin type/dose (basal-bolus MDI), oral agents (e.g., metformin), other injectables (GLP-1 RA, basal insulin), lifestyle changes, adherence, A1C, hypoglycemia episodes, glucose variability, patient willingness/ability to perform site changes and carb counting, education/support availability, comorbidities.

STEP 2 — Rule In / Rule Out

Is the patient on intensive insulin therapy (basal-bolus MDI) plus oral agents and/or other injectables with lifestyle modifications yet still has poor glycemic control (e.g., A1C >7.5‑8.0%)? If YES, proceed; if NO, optimize current therapy before considering CSII.

STEP 3 — Classify or Stratify

Assess suitability for CSII: adequate dexterity/vision, cognitive ability, willingness to perform frequent glucose monitoring, carbohydrate counting, and infusion site care; absence of uncontrolled psychiatric illness or substance abuse; reliable follow‑up access. Classify as suitable if criteria met.

STEP 4 — Decide

If suitable, initiate CSII with comprehensive education/training on pump operation, bolus calculator use, site rotation, and hypoglycemia/DKA prevention; schedule frequent follow‑up to review data and adjust settings.

Clinical Guardrails / Mimics / Pitfalls

Do not offer CSII to patients unable to perform self‑care tasks, lacking education/support, or with unrealistic expectations; avoid as first‑line before maximizing oral/GLP‑1/basal insulin; monitor for infusion site infections, lipohypertrophy, and DKA risk from pump failure; consider cost/access barriers.

Concrete Clinical Example

A 58‑year‑old on basal glargine 40 U qd, prandial lispro sliding scale, metformin 1000 mg BID, liraglutide 1.8 mg daily, with A1C 9.2% despite adherence, is motivated, passes carb‑counting and site‑care assessment, and has regular follow‑up; CSII is suggested with training.

Source: Diabetes Technology—Continuous Subcutaneous Insulin Infusion Therapy and Continuous Glucose Monitoring in Adults, Endocrine Society, 2016, DOI:10.1210/jc.2016-2534

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