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endo-discontinue-csii-assess-smbg-frequency

This skill guides clinicians to reassess glucose monitoring frequency when discontinuing continuous subcutaneous insulin infusion (CSII) or transitioning to multiple daily injections (MDI). It is triggered by phrases such as 'Plan for glucose monitoring after pump stop' or 'Determine SMBG/CGM frequency post-pump' to ensure individualized glycemic goals are met.

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Assess glucose monitoring frequency when discontinuing CSII

STEP 1 — Gather Information

Collect current CSII settings, recent SMBG/CGM logs, hypoglycemia awareness, A1C, glycemic targets, and the planned MDI regimen (basal type, bolus insulin, dosing schedule).
Action: Proceed to evaluate need for monitoring frequency adjustment.

STEP 2 — Rule In / Rule Out

Determine if CSII discontinuation is permanent (e.g., pump failure, patient preference, surgery) or temporary (e.g., short‑term sensor issue). If permanent discontinuation or transition to MDI, rule in for reassessment; if temporary and CSII will resume shortly, rule out and maintain current monitoring plan.
Decision: Continue to classification if rule‑in; otherwise, end skill.

STEP 3 — Classify or Stratify

Classify glycemic stability: Stable (A1C at target, <4% hypoglycemia unawareness, low glucose variability) vs Unstable (recent severe hypoglycemia, A1C > target, high variability, pregnancy, or impaired hypoglycemia awareness).
Decision: Use stability level to guide monitoring intensity.

STEP 4 — Decide

For Stable patients: prescribe SMBG 2–4 times daily (fasting, pre‑meal, bedtime) and/or CGM as defined by HCP; for Unstable patients: prescribe SMBG 4–6 times daily (pre‑meal, post‑meal, bedtime, occasional overnight) and/or CGM with alerts enabled. Document the new MDI insulin plan and provide education on dose adjustments and monitoring technique.
Action: Implement monitoring plan and arrange follow‑up within 1–2 weeks.

Clinical Guardrails / Mimics / Pitfalls

Do not assume reduced monitoring is safe after pump stop; verify hypoglycemia awareness before lowering frequency. Avoid discontinuing CGM without confirming alternative detection methods. Do not rely on pre‑pump SMBG schedules without reassessment. Ensure patient understands MDI timing, carbohydrate counting, and sick‑day rules. Watch for pump‑withdrawal hyperglycemia during transition.

Concrete Clinical Example

A 48‑year‑old with T1D stops CSII due to pump malfunction and initiates basal‑glargine MDI with rapid‑acting bolus. Recent SMBG shows 4 checks/day, A1C 7.1%, no severe hypoglycemia in past 3 months. Clinician classifies as stable and advises SMBG before meals and at bedtime (4×/day) plus continued CGM use, documents the new insulin schedule, and schedules a telehealth visit in 5 days.

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

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