Full Guideline: Diabetes Technology—Continuous Subcutaneous Insulin Infusion Therapy and Continuous Glucose Monitoring in Adults
JCEM | September 2016
Anne L. Peters (Chair), Andrew J. Ahmann, Tadej Battelino, Alison Evert, Irl B. Hirsch, M. Hassan Murad, William E. Winter, and Howard Wolpert
The 2016 guideline on Diabetes Technology addresses:
- Matching individuals to the best-suited technological solutions for type 1 and type 2 diabetes management
- Deciding when individuals would benefit from continuous subcutaneous insulin infusion (CSII) and real-time continuous glucose monitoring (RT-CGM)
- Assessing and re-assessing individual psychological status, self-care behavior, and education and training before and during use to ensure adherence and maximize successful adoption of technology
Essential Points
The guideline task force gave its strongest recommendation in support of using CGM technology in individuals with type 1 diabetes who are able and willing to use the monitors. The task force also suggested that CGMs can be used on a short-term, intermittent basis for individuals with type 2 diabetes whose blood glucose is above targeted levels.
The guideline task force also recommended the use of insulin pumps over multiple daily insulin injections in individuals with type 1 diabetes who have not met their A1C goals and are willing and able to use the device. In addition, pumps are recommended for people with frequent hypoglycemia or glucose variability, and those who require increased insulin delivery flexibility or improved satisfaction with their diabetes care. Insulin pump use was suggested for people with type 2 diabetes who were not meeting their glycemic goals.
Summary of Recommendations
+ 1.0 Insulin pump therapy without sensor augmentation
- 1.1 We recommend continuous subcutaneous insulin infusion (CSII) over analog-based basal-bolus multiple daily injections (MDI) in patients with type 1 diabetes mellitus (T1DM) who have not achieved their A1C goal, as long as the patient and caregivers are willing and able to use the device. (1|⊕⊕⊕⚪)
- 1.2 We recommend CSII over analog-based basal-bolus MDI in patients with T1DM who have achieved their A1C goal but continue to experience severe hypoglycemia or high glucose variability, as long as the patient and caregivers are willing and able to use the device. (1|⊕⊕⚪⚪)
- 1.3 We suggest CSII in patients with T1DM who require increased insulin delivery flexibility or improved satisfaction and are capable of using the device. (2|⊕⊕⚪⚪)
+ 2.0 Insulin pump therapy in type 2 diabetes mellitus
- 2.1 We suggest CSII with good adherence to monitoring and dosing in patients with type 2 diabetes mellitus (T2DM) who have poor glycemic control despite intensive insulin therapy, oral agents, other injectable therapy, and lifestyle modifications. (2|⊕⊕⚪⚪)
+ 3.0 Insulin pump use in the hospital
- 3.1 We suggest that clinicians continue CSII in patients admitted to the hospital with either type of diabetes if the institution has clear protocols for evaluating patients as suitable candidates and appropriate monitoring and safety procedures. (2|⊕⊕⚪⚪)
+ 4.0 Selection of candidates for insulin pump therapy
- 4.1 We recommend that before prescribing CSII, clinicians perform a structured assessment of a patient’s mental and psychological status, prior adherence with diabetes self-care measures, willingness and interest in trying the device, and availability for the required follow-up visits. (1|⊕⊕⚪⚪)
+ 5.0 Use of bolus calculators in insulin pump therapy
- 5.1 We suggest encouraging patients to use appropriately adjusted embedded bolus calculators in CSII and have appropriate education regarding their use and limitations. (2|⊕⊕⚪⚪)
+ 6.0 Real-time continuous glucose monitors in adult outpatients
- 6.1 We recommend real-time continuous glucose monitoring (RT-CGM) devices for adult patients with T1DM who have A1C levels above target and who are willing and able to use these devices on a nearly daily basis. (1|⊕⊕⊕⊕)
- 6.2 We recommend RT-CGM devices for adult patients with well-controlled T1DM who are willing and able to use these devices on a nearly daily basis. (1|⊕⊕⊕⊕)
Use of continuous glucose monitoring in adults with type 2 diabetes mellitus
- 6.3 We suggest short-term, intermittent RT-CGM use in adult patients with T2DM (not on prandial insulin) who have A1C levels ≥7% and are willing and able to use the device. (2|⊕⊕⚪⚪)
Education and training on the use of continuous subcutaneous insulin infusion and continuous glucose monitoring
- 6.4 We suggest that adults with T1DM and T2DM who use CSII and continuous glucose monitoring (CGM) receive education, training, and ongoing support to help achieve and maintain individualized glycemic goals. (Ungraded Good Practice Statement)
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