Pump Therapy Candidate Assessment

Continuous Subcutaneous Insulin Infusion (CSII) Without and With Sensor Integration (PDF Download)

Assessing the Readiness of Pump Therapy Candidates

Assessment of the person with diabetes (PWD) is important in ensuring success with pump therapy. The diabetes care and education specialist must evaluate the physical and psychological readiness of each pump candidate to assume the responsibilities and challenges of pump therapy.

There are a number of clinical and lifestyle indicators and desired attributes that should be considered when performing a thorough assessment of whether a person is an appropriate candidate for insulin pump therapy. Some private insurance providers and all government-based insurers require additional documentation, such as a specific fasting blood glucose and C-peptide levels or antibody results.⁵

Clinical Indications for Insulin Pump Use

• Persons with Type 1 diabetes or Type 2 diabetes requiring frequent multiple daily injections
• Inadequate glycemic management despite optimized multiple daily injection therapy
• High glucose variability
• Elevated A1C
• Recurrent, severe or unpredictable hypoglycemia
• Nocturnal hypoglycemia
• Hypoglycemia unawareness
• Recurrent hyperglycemia
• Dawn phenomenon
• Preconception planning
• Pregnancy
• Extreme insulin sensitivity
• Gastroparesis
• Early neuropathy or nephropathy
• Renal transplantation
• Potentially persons with needle phobia
• Lifestyle Indications
• Erratic schedule
• Varied work shifts
• Frequent travel
• Desire for flexibility
• Inconvenience of multiple daily injections

Desired Attributes of a Pump Candidate (and/or parent(s) of pump candidate)

• Motivation to succeed, as pump therapy requires readiness, preparedness and time investment before and during initiation
• Realistic expectations of the capabilities of pump therapy
• Demonstration of independent diabetes management and knowledge of the basics of diabetes education, including all topics listed in the National Standards for Diabetes Self-Management

Education and Support⁶

• Ability to problem solve potential challenges with pump or infusion set malfunctions and how to maintain continuous insulin care in those circumstances
• Ability to accept and deal with challenges that arise and check blood glucose levels consistently throughout the day or utilize CGM^{7, 11}
• Capacity to learn, practice and understand insulin pump therapy parameters such as insulin-to-carbohydrate ratios (ICR), correction or sensitivity factors (CF), and the application of the parameters to determine appropriate insulin dosing adjustments in response to hypoglycemia, hyperglycemia, stress, exercise and other personal parameters
• Physical ability to view the pump screen and hear the alarms; dexterity to insert or charge the pump battery, fill and replace the insulin cartridge/reservoir in the pump; insert an infusion set; wear the pump; and perform the technical functions⁵
• Emotional stability and adequate emotional support from family or significant others
• Parents and caretakers must have a thorough understanding of pump therapy and willingness to spend the time needed to work with their child and health care professionals, when applicable
• Patience and willingness to work with their health care provider during the time of pre-pump training and initiation; when appropriate basal rates, insulin-to-carbohydrate ratios and correction (sensitivity) factors are being determined
• Adequate insurance benefits or personal resources to afford the cost of the pump and necessary supplies

Although these attributes are desired, they are not “requirements” for pump use. Diabetes care and education specialists are uniquely qualified to assist individuals in overcoming limitations or deficits to achieve optimal outcomes.

Regular assessments should be done to evaluate changes in a PWD’s clinical condition, motivation, abilities and life circumstances that may necessitate the need to reconsider appropriateness of pump therapy.

Considerations for Discontinuing an Insulin Pump

• Lack of insurance or means to pay for an insulin pump and pump supplies
• Change in physical or mental capacity to manage an insulin pump
• Any suicidal ideation

References:

^{American Diabetes Association. Standards of Medical Care in Diabetes—2024. Diabetes Care. ADCES Insulin Pump Therapy Guidelines, ISPAD Clinical Practice Consensus Guidelines 2022: Insulin Pump Therapy. Endocrine Society. Management of Continuous Subcutaneous Insulin Infusion (CSII) and Continuous Glucose Monitoring (CGM). Clinical Research on Insulin Pumps & Automated Insulin Delivery (AID) Systems: Beck RW, Riddlesworth T, et al. Effect of Continuous Glucose Monitoring on Glycemic Control in Adults With Type 1 Diabetes Using Insulin Injections: The DIAMOND Randomized Clinical Trial. JAMA, 2017.}