[The implantable insulin pump in the treatment of diabetes. Hopes and reality?].

Advantages and drawbacks of the treatment of insulin-dependent diabetes by intra-peritoneal administration of insulin through an implanted infusion system are presented. This review is based upon our personal studies and the french experience centralized by the EVADIAC group. Between 1989 and 1994, 312 insulin-dependent patients were implanted in France. The mean followed up was 36 +/- 1 months, allowing an experience of 660 patients years. The main benefit is an important reduction in the incidence of severe hypoglycemia falling down from 15 per cent patient years before implantation to 2.5 per cent after. Although the patients were previously treated by intensive insulin treatment and well controlled, mean glycated hemoglobin was slightly improved and the glycemic stability increased as evidenced by the reduction of standard deviation of glycemia. Life duration of the implanted system averaged 38 months excepted for incidents requiring an explantation. Although the frequency of incidents was non negligible, they were acceptable. Vigilance, as performed by EVADIAC group is still necessary. This point can be illustrated by a technical problem which appeared recently and was due to a poor compatibility between a new preparation of insulin and the ejection chamber of the pump. Intraperitoneal administration of insulin allows to obtain plasma insulin concentration through the day closer to the physiology than that obtained with subcutaneous insulin infusion. Blood levels of some proteins, mainly SHBG and IGF1, return to normal values. However, this mode of administration is associated in some cases with an important increase of the insulin antibody levels, increase which does not seem to have a deleterious metabolic effect, but has to be carefully evaluated on the long term.