Insulin-Pump Therapy for Type 1 Diabetes Mellitus

A 39-year-old man with type 1 diabetes of 27 years' duration visits his endocrinologist for review of his blood glucose control. He is overweight (body-mass index [the weight in kilograms divided by the square of the height in meters], 28.4). The overall glycemic control has been suboptimal, with glycated hemoglobin values of 7.5 to 8.0% in recent years. He reports unpredictable swings in self-monitored blood glucose concentrations and frequent episodes of severe hypoglycemia, which markedly disrupt his work and home life. He also reports that he now has fewer warning symptoms of hypoglycemia than he had previously. These findings are present despite the patient's best efforts to achieve glycemic control with intensified insulin-injection therapy, regular visits to a diabetes clinic, and input from diabetes nurse educators. He attended a structured diabetes education course 1 year previously, which he found to be useful and which led to slight improvements in glycated hemoglobin levels; however, the frequency of hypoglycemic episodes was unchanged. His endocrinologist has ruled out coexisting illnesses, including celiac disease and Addison's disease, as causes of poor glycemic control and wonders whether a trial of insulin-pump therapy is appropriate. Since the endocrinologist has little experience with this type of therapy himself, he refers the patient to a center with a specialized insulin-pump clinic.