Therapeutics of Diabetes Mellitus: Focus on Insulin Analogues and Insulin Pumps
Table 2
Indications, limitations and contraindications of CSII in diabetic patients
Long-term indications When clear proven benefit over MDI is proven and when other intensified insulin regimens fail to achieve adequate glycaemic control.
Short-term indications
Contradictions
(1) Elevated HbA1c with MDI therapy (2) Marked same-day or between-day glucose levels fluctuations (3) Variability of insulin requirements (i) Endogenous causes: dawn phenomenon (ii) Exogenous causes: work type particuliarities (e.g., shift workers or business travellers) (4) Recurrent hypoglycaemia (severe or non-severe) (i) Failure to maintain HbA1c targets (7.0%) without the occurrence of disabling or frequent symptomatic or asymptomatic hypoglycaemic events (4/week) (ii) Incidence of 1 episode(s)/year of unexplained severe hypoglycaemia (5) Other reasons: (i) Allergy to insulin (ii) Lipoatrophic diabetes (iii) Very low insulin requirements
(1) Acute situations (e.g., in diabetology units): (i) For the treatment of mild ketoacidosis or acute hyperglycaemia (ii) For acute infections (iii) Undergoing enteral alimentation (2) Transient situations (i) Severe painful neuropathy (ii) Chronic infections, foot ulcers and all wound-healing cicatrization situations (iii) Pregnancy or the intention to become pregnant
(1) Absolute Contradictions (i) Severe psychiatric disorders (ii) Progressive ischaemic or proliferative retinopathy (iii) Due to the patient’s environment or pump: (a) A non-educated medical environment (b) Living with extreme circumstances of either heat or cold for professional or personal reasons (c) Underwater diving (d) Exposure to high electromagnetic fields (NMR) (2) Relative Contradictions (i) Poor compliance or patient reluctance to live with the current management of treatment, (e.g., frequent visits to diabetology centre, glycaemia monitoring, ketosis testing) (ii) Poor local hygiene and/or Staphylococcus presence (iii) In some cases of end-stage renal failure because of acidosis risk attributed to patient incompliance (iv) Sensory or gestural impairment (difficulty with the technical aspects of pump management)
