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