Well DAVE, I was just trying to be helpful.  You didn't have to jump all
over my comments by calling them "bullcrap".  Be a little more polite please
and less dogmatic.  What works for you and your wife may not work for/apply
to everyone.

Ok, I stand corrected on one thing.  Not all infusion sets use catheters,
but the one I use, the Silhouette, DOES.  Yes, it's called a CATHETER.  (If
you read the article below, they refer to it as a CATHETER site infection.)

For a discussion of insulin pumps versus multiple daily injections, read
this, and develop your own opinion.  (I agree that for SOME, the pump is
superior therapy, but not for ALL.)

The Role of Insulin Pumps
Posted 03/13/2003

from Medscape Diabetes & Endocrinology

Question
Ever since the introduction of insulin glargine (Lantus; Aventis
Pharmaceuticals Inc. Kansas City, Missouri), many of my patients have
noticed a significant improvement in their diabetes control. I'm wondering
if there is much of a need for insulin pumps any longer?

Response
from M. James Lenhard, MD, 03/13/2003

In 1993, the Diabetes Control and Complications Trial (DCCT) definitively
showed that achieving and maintaining glucose values as close to normal as
possible in people with type 1 diabetes will prevent the development and
slow the progression of microvascular complications. In the years following
the release of the DCCT, there was a rapid increase in the number of
prescriptions for insulin pumps. Continuous subcutaneous insulin infusion
(CSII) continued to become increasingly common throughout the 1990s. CSII
allows the user to program increases or decreases in insulin infusion based
on patterns or perceived needs. In addition to providing multiple
programmable basal rates, CSII allows the user to choose from several
"types" of mealtime boluses. The insulin can be delivered quickly or
stretched out over a protracted time in an attempt to mimic the normal
pancreatic secretion of insulin.

In 2000, insulin glargine was approved for use as a basal insulin. It has
become very popular for patients with type 1 diabetes. Studies have
suggested that the basal insulin profile obtained from glargine is superior
to NPH or Ultralente insulin, with a reduction in the incidence of
hypoglycemia.[1] Many patients have reported significant success with
glargine, and it has been dubbed the "poor man's pump." So which method is
optimal?

Unfortunately, there are no long-term studies comparing CSII with glargine.
It would appear that for many patients with type 1 diabetes, there is little
compelling reason to use anything other than glargine to supply basal
insulin. Cost, availability on formularies, the inability to mix it with
other kinds of insulin, and rare adverse reactions may lead some patients to
stick with NPH, but for the majority, glargine will be superior.

Over the last 2 decades numerous studies have shown that CSII helped to
achieve the goal of maintaining glucose levels as close to the normal range
as is safely possible. Many studies compared CSII to conventional therapy
(ie, 2 split and mixed injections per day). The best comparisons between
CSII and standard insulin injections are studies using multiple daily
injections (MDI). There are several advantages and disadvantages of CSII.[2]

Advantages of CSII
Glycemic control: Most studies have shown that CSII provides as good and
often better glycemic control than does intensive diabetes management with
MDI. Most studies suggest that the improvement is modest. For example, 1
study of 107 patients with type 1 diabetes treated with MDI that were
switched to CSII had a decline in the mean HbA1c from 7.6 to 7.1%.[3]

Hypoglycemia: The reduction in the variability of glucose levels and severe
hypoglycemia may be reduced as much as 4-fold with CSII in comparison with
MDI, with no discernible reduction in glycemic control. This decrease in
hypoglycemic events has been accompanied by an increase in self-reported
warning symptoms of hypoglycemia, as well as by an increase in
counterregulatory hormonal responses to hypoglycemia. Severe hypoglycemia
has now become an accepted indication for initiation of CSII therapy, and
may be the greatest advantage offered by CSII.
Other metabolic factors and diabetes complications: CSII has been shown to
cause improvement or slowing of diabetic nephropathy, peripheral and
autonomic neuropathy, retinopathy, hypertriglyceridemia and
hypoalphalipoproteinemia, and diabetic changes in transplanted kidneys.

Lifestyle flexibility: The improvement in lifestyle may be the most
important reason for the patient who chooses CSII. The ability to increase
flexibility in moment-to-moment living is the reason most frequently cited
by individuals who have chosen CSII. The increased flexibility that is
allowed may be fueling the upsurge in patient demand for CSII more than any
other factor.

Disadvantages of CSII
As recently as 1990, some authorities[4] asserted that "the use of CSII is
discouraged in routine clinical practice," suggesting instead that it be
limited to specific subsets of patients with type 1 diabetes. There are
several potential disadvantages of CSII.

Diabetic ketoacidosis: There is no subcutaneous depot of long-acting insulin
with CSII. If the flow of the regular, short-acting insulin is interrupted,
ketonemia and diabetic ketoacidosis can develop more rapidly and more
frequently with CSII.

Hypoglycemia: Although hypoglycemia is generally less common with CSII than
with MDI, proper use of the insulin pump requires the user to monitor
glucose frequently and to work with the diabetes team to program the
appropriate basal infusion rates. Without patient cooperation, hypoglycemia
may occur.

Catheter-site infection and contact dermatitis: The most common complication
associated with CSII is infection at the infusion site. This is one of the
most common causes listed for discontinuation of CSII, but most cases can be
prevented with close attention to hygiene.

Special Situations
In addition to the advantages and disadvantages listed, there are several
special situations where CSII may be preferred. Some children and
adolescents have improved acceptance of their diabetes and better glycemic
control when CSII is used. Pregnant women with type 1 diabetes may find less
variability in their blood glucose levels. People with type 1 diabetes who
engage in regular vigorous exercise often appreciate the ability to control
their insulin infusion very precisely.

The key to success with CSII involves the appropriate selection and training
of individuals. For the successful use of CSII, a skilled and motivated
health care delivery team is required, and a thorough evaluation and
training of the CSII candidate is necessary prior to implementation. There
is also a need for on-going close contact between the pump user and the
health care team. For many patients, the disadvantages and costs of CSII
outweigh the advantages. In this group, MDI using insulin glargine may prove
to be equally effective.

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References
 1.. Ratner RE, Hirsch IB, Neifing JL, Garg SK, Mecca TE, Wilson CA. Less
hypoglycemia with insulin glargine in intensive insulin therapy for type 1
diabetes: US Study Group of Insulin Glargine in Type 1 Diabetes. Diabetes
Care. 2000; 23:639-643. Abstract
 2.. Lenhard MJ, Reeves GD. Continuous subcutaneous insulin infusion: a
comprehensive review of insulin pump therapy. Arch Intern Med.
2001;161:2293-2300. Abstract
 3.. Rudolph JW, Hirsch IB. Assessment of therapy with continuos
subcutaneous insulin infusion in an academic diabetes clinic. Endocr Pract.
2002;8:401-405.
 4.. Selam J-L, Charles MA. Devices for insulin administration. Diabetes
Care. 1990;13:955-979. Abstract
About the Panel Members
M. James Lenhard, MD, Medical Director, Weight Management Program,
Preventative Medicine and Rehabilitation Institute and Chief, Section of
Endocrinology, Christiana Care Health Systems, Wilmington, Delaware.

--
Antonio
Age 37, Type 1 for 10 years
On Insulin Pump