Healthcare Across Borders - September 2003
Introduction To PumpingIntroduction To PumpingStarting And SuccessStarting And Success
John Walsh, P.A., C.D.E.John Walsh, P.A., C.D.E.North County Endocrine North County Endocrine 700 West El Norte Pkwy 700 West El Norte Pkwy
Escondido, CA 92126Escondido, CA 92126 (760) 743-1431 (760) 743-1431
or The Diabetes Mall or The Diabetes Mall (619) 497-0900 (619) 497-0900
[email protected]@diabetesnet.com
Children With Diabetes Children With Diabetes Toronto, August 17, 2007Toronto, August 17, 2007
Healthcare Across Borders - September 2003
Highlights
Why Pump?
Who’s A Candidate?
Pump Basics
Brands And Features
Smart Pump Advantages
Infusion Sets
How To Start
Settings That Affect Control
Wrap Up
Healthcare Across Borders - September 2003
Origins
The first insulin pumps appeared in 1978 when large portable chemotherapy pumps were converted to deliver insulin
Autosyringe AS2C and Harvard Apparatus Mill Hill Infuser were early models
Used large 50 ml syringe that required users to dilute insulin to U-36 or U-18
Had only one basal rate and no memory
1976 Biostator (top) and 1978 Autosyringe AS2C –>
Healthcare Across Borders - September 2003
Reasons To Use A Pump
Healthcare Across Borders - September 2003
Better Control –> Fewer Complications
•55.0
29.8
•23.9
•5.1
•13.413.0
7.9
16.4
5.02.50
10
20
30
40
50
60
RetinopathyProgression1
Laser Rx1 Micro-albuminuria2
Albuminuria2 ClinicalNeuropathy3
Conventional
Intensive
76%76%Risk ReductionRisk Reduction
59%59%Risk ReductionRisk Reduction
39%39%Risk ReductionRisk Reduction
54%54%Risk ReductionRisk Reduction
64%64%Risk ReductionRisk Reduction
Cu
mu
lati
ve In
cid
ence
(%
)
1. DCCT Research Group, Ophthalmology. 1995;102:647-661
2. DCCT Research Group, Kidney Int. 1995;47:1703-1720
3. DCCT Research Group. Ann Intern Med. 1995;122:561-568.
Healthcare Across Borders - September 2003
Poor Control Remains A Problem HbA1c
10%
9%
8%
7%
6%
ADA
EASD/AACE
ADA = American Diabetes Assoc., IDF = Inter. Diabetes Federation, EASD is European Assoc. for the Study of Diabetes, AACE = American Association of Clinical Endocrinologists
Novo Nordisk Type 2 diabetes market research, Roper StarchWright A., Burden et al, Diabetes Care 2002; 25:330–336Turner RC, Cull et al, JAMA 1999; 281:2005–2012
2/3 with diabetes (and most pumpers) remain out of control
Avg. A1c in TYPE 1sAvg. A1c on Pumps
Goal A1c
5%
Healthcare Across Borders - September 2003
Exposure Versus Variability
40
60
80
100
120
140
160
180
200
220
240
260
280
300
320
340
360
380
400
2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00
PM
11:00 PM 12:00
AM
1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00
AM
11:00
AM
12:00
PM
1:00 PM 2:00 PM
glucose (mg/dl)
One day’s tests every 30-60 min with usual meals and insulin. The DCCT proved that exposure to high blood glucose was
damaging. New emphasis is on glucose variability.
Exposure or Average =
Variability or Swing =
A1c or avg. BG from meter
Standard deviation or GlycoMark test
Healthcare Across Borders - September 2003
The Challenge Of DiabetesBringing the A1c down smoothly takes effort
……for this you need ADVANCED therapyfor this you need ADVANCED therapy
100 (5.5)
200 (11.1)
300 (16.7)
Normal A1C 4%–6%
BG
in
mg
/dL (
mm
ol)
0800 1200 1800 0800
Uncontrolled A1C ~9%
A1C ~6%
“Controlled” A1C <7%
Time of Day
Healthcare Across Borders - September 2003
Advantages Of Pumps Over MDI
• More reliable insulin action
• Fewer missed/skipped doses
• Precision – 0.05 u versus 0.5 u
• Automatic dose calculations
• Less insulin stacking
A More Normal Lifestyle
Flexible mealtimes
Less hypoglycemia
Flexible insulin delivery for exercise, skipping meals, erratic schedules, shiftwork
Less hassle with travel and time zones
Increased sense of well being
Less anxiety while staying on schedule
Plus reminders, history, accurate dose calculations, etc.
Healthcare Across Borders - September 2003
Poor control, high A1c, wide BG excursions
Nocturnal or frequent lows, hypo unawareness
Frequent hospitalization/DKA
Insulin sensitivity
Varied or intense exercise/activity
Dawn phenomenon, gastroparesis, pregnancy
Varied work or school schedule, travel
Insulin resistance, Type 2 diabetes
Why Physicians Recommend Pumps
Healthcare Across Borders - September 2003
Who Is A Pump Candidate?
Healthcare Across Borders - September 2003
Candidate Requirements
• Realistic expectations
• Willing to monitor at least 4 times a day and keep records
• Counts carbs or otherwise able to quantify food intake for meals
• Willing to solve problems using diabetes management skills
• Comes to clinic for follow up
Healthcare Across Borders - September 2003
Expectations
Unrealistic Realistic
The pump will cure my diabetes I will feel better
I won’t have to test as much I must monitor very frequently
I can eat anything I want I will have more freedom with my food choices
My blood sugar will be perfect I will have better control with fewer lows
It will be as easy to learn as a meter
It will take time to learn and adjust to the pump
Healthcare Across Borders - September 2003
Benefits For Infants & Toddlers
Little ones are ideal pump candidates if parents are
Delay or split boluses for fussy eaters
Faster insulin adjustment for erratic activity
Precise dosing – 0.025 basal and 0.05 bolus – assists infants who cannot convey hypoglycemia Sxs and have frequent illnesses
Secure between shoulder blades and use lock out to avoid self dosing
Back Buddy
Healthcare Across Borders - September 2003
Benefits For Kids & Teens
Better for growth spurts, hormone changes in puberty, Dawn Phenomenon
Easy to cover snacks
TDD and bolus history available to ensure consistent dosing
Fast adjustments of basals and boluses for changes in activity/exercise
Lessens impact of BG swings on top of peer pressure, struggle for independence, mood swings, college, and issues with alcohol, sex, drugs
Healthcare Across Borders - September 2003
Pump Basics
Healthcare Across Borders - September 2003
Terms
Basal –background insulin released slowly through the day
Bolus – a quick release of insulin
Carb bolus – covers carbs
Correction bolus – lowers high readings
Bolus On Board (BOB) – bolus insulin still active from recent boluses
TDD – total daily dose of insulin (all basals and boluses)
Healthcare Across Borders - September 2003
Basals And Boluses
A pump more easily matches the realities of daily life.
bolus
basal
Healthcare Across Borders - September 2003
Basal: MDI versus Pump
Lantus or Levemir
PumpPump
2:00 16:00 20:00 24:00 7:0012:007:00
Time
Basal insulin delivery from a pump provides a better and faster match for life’s needs
Healthcare Across Borders - September 2003
4
5
6
7
8
9
10
11
12
0 2 4 6 8 10 12 14SMBG Frequency (BG per day)
HbA1c
HbA1c=5.99+5.32 / (BGpd+1.39)
Atlanta Diabetes Associates study:378 patients sorted from a database of 591 Pumps=MM 511 or earlierBG Target=100C peptide <0.1
More Testing –> Lower A1cData From 378 People On Pumps
ADA:< 7%% AACE:
< 6.5%
P. Davidson et al: Diabetes 53 (suppl 2): abstract 430-P, 2004
Healthcare Across Borders - September 2003
Brands And Features
Healthcare Across Borders - September 2003
Insulin Pumps – 2007
Pump info at www.diabetesnet.com/diabetes_technology/
Accu-Chek Spirit
Animas 2020
Deltec CozMore 1800
Insulet Omnipod
Medtronic Paradigm x22
Sooil Dana Diabecare IISG
Healthcare Across Borders - September 2003
Things To Consider In Choosing A Pump
• Look, feel, color
• Features: reminders, child block, waterproofing
• Basal and bolus increments
• Infusion set choices
• Customer support
• Access to history and ease of data downloads and analyses
• Accessories: meter, covers, cases, PDA, smart phone
Healthcare Across Borders - September 2003
Accu-Chek Spirit
• Boluses based on BG not on BOB
• 300 units
• 0.1 u basal & bolus increments
• Reversible display
• Side-mounted tactile buttons
• Accu-Chek Pump Configuration Software
• IR (direct line) control from optional Palm PDA or smartphone
• Database of 1,000 Calorie King foods in PDA
Healthcare Across Borders - September 2003
Animas 2020
• High contrast color screen for easy viewing
• Smallest mainstream pump
• Smallest basal rate increment – 0.025 u
• Waterproof – 12 ft for 24 hrs
• ezCarb meal bolus calculator
• ezBG correction bolus calculator
• ezBolus shortcut to give bolus
Healthcare Across Borders - September 2003
Deltec Cozmo
• Most features:
HypoManager, Weekly Schedule, Missed Meal Bolus, Disconnect Bolus, Basal Test, Meal Maker with CozFoods, Therapy Effectiveness
• Most flexible setup
• Direct BG entry from attachable Freestyle meter
• 300 units
• 0.05 unit basal and bolus increments
• Accurate bolus calculations
• IR download
• Best for blind or visually impaired
Healthcare Across Borders - September 2003
Insulet Omnipod
• No tubing for easy wear
• Automatic cannula insertion and priming
• 200 units
• Limited to 72-80 hrs use
• Watertight
• Controlled by PDM or smartphone
• 1000 food database
Healthcare Across Borders - September 2003
Medtronic Paradigm
• CGM displays BG, 3 hr trend, trend arrow, and advance warning of lows and highs
• Considered least accurate CGM for detection of lows
• Simple interface, less scrolling
• BD meter transmits BG directly
• Proprietary infusion sets
• History of carbs, TDD, %basal, %carb, %correction
• CareLink online software
Healthcare Across Borders - September 2003
Pump + Meter Or Continuous Monitor
Current Feature
With direct BG entry• Deltec Cozmo + Freestyle CoZmonitor• Omnipod + Freestyle• Paradigm + BD Logic• Dana Diabecare IISG
With continuous monitor display•Medtronic 5/722 + Paradigm RT
Planned continuous monitor displays• Abbott Navigator with Deltec Cozmo and Insulet Omnipod• Animas and Lifescan• AccuChek pump and monitor
Healthcare Across Borders - September 2003
CGM Benefits
• Increased sense of security
• Immediate feedback – look and learn
• Improves control when used
• Worth out of pocket cost for many
• One unit available for about “a Starbucks a day”
• Reimbursement gradually catching on
Healthcare Across Borders - September 2003
Look And Learn
Excess night basal or bedtime bolus
Breakfast bolus too small or too late
Lunch bolus too small or afternoon basal too low
Healthcare Across Borders - September 2003
Pump Advantages
Healthcare Across Borders - September 2003
Advantages Of A Smart Pump
Automatic carb and correction calculations based on:• Preprogrammed carb and correction factors
• Glucose targets
• Duration of insulin action to avoid insulin stacking
Easy to check history, basal/bolus balance, and correction bolus %
Direct glucose entry from meter or continuous monitor
Helpful reminders and alerts, weekly schedule, alternate basal profiles
Healthcare Across Borders - September 2003
Helps Prevent Lows
Better bolus accuracy with carb and correction factors
Less insulin stacking due to tracking BOB after boluses are given
A glucose test can reveal the current deficit – carb or insulin
Faster reduction in insulin level for exercise
Smaller pool of insulin under skin lessens risk of a large release in hot tub or weather
More predictable insulin action
Proper dosing is required!
Healthcare Across Borders - September 2003
Helpful Reminders
Reminders (alarms) to
• test BG after a bolus
• test BG after a low reading
• test BG after a high reading
• give a bolus at certain time or certain period of the day
• warn when bolus delivery was not completed, etc.
• change infusion site
• warn of low reservoir (20, 10, 5 and 0 units with an extra 10 “hidden” units for use in basal delivery)
Healthcare Across Borders - September 2003
Infusion Sets
Healthcare Across Borders - September 2003
Infusion SetsFive varieties:
• Self-contained (Omnipod)
• Slanted Teflon
• Straight-in Teflon
• Slanted metal
• Straight-in metal
Three connections:
• Luer lock pumps: ~ 25 varieties
• Paradigm: ~ 4 varieties
• Omnipod: 1, auto-inserted
A reliable and comfortable infusion set is critical to success on a pump.
Healthcare Across Borders - September 2003
Infusion Sets And InsertersInfusion set/site problems are a common cause
for unexplained highs
Smith’s Medical CleoSmith’s Medical Cleo
Medtronic Sil-serterMedtronic Sil-serter
Disetronic Rapid-DDisetronic Rapid-D
Animas InsetAnimas Inset Quik-serterQuik-serter
Healthcare Across Borders - September 2003
Use Sterile Technique For Site Prep
30% of people are constant staph carriers and 25% are intermittent. MRSA is now common. Prevent infections:
• Wash hands
• Sterilize skin with IV Prep
• Place bio-occlusive IV3000 over site
• Insert infusion set through IV 3000
Steps for staph carriers:
• Use antiseptic soap all over body once every 1-2 weeks
• Occasionally, apply bacitracin ointment to inside of nose
Healthcare Across Borders - September 2003
Tape The Tubing!!!
One inch tape over the infusion line stops tugging
• Tape stops tunnelling – movement of teflon nder skin allows insulin to tunnel to the surface, causing unexplained highs
• Less skin irritation from movement
• Prevents pull outs
At tug time, lose tape not insulin!
Photo courtesy of [email protected]
Healthcare Across Borders - September 2003
Pump Start
Healthcare Across Borders - September 2003
Prepare For Pump Start
• Use basal/bolus approach first with injections
• Use accurate carb counts
• Read Pumping Insulin and pump manual
• Practice with your pump as soon as it arrives
• View CD/DVD as you practice with your pump
• Get training in pump operation andtroubleshooting
Healthcare Across Borders - September 2003
Preparation
Ask how to discontinue your long-acting insulin
Determine start-up settings for TDD, basal/bolus balance, carb and correction factors, and DIA
Get prescriptions for insulin, test strips, IV Prep, IV 3000 dressings, etc.
Have contacts for MD, CDE, pump company, pump rep, other pumpers
Healthcare Across Borders - September 2003
Steps To Success
• Test often
• Keep great records (Smart Charts, download, etc)
• Take a bolus for every bite
• except when carbs are used to raise a low BG
• or when eating to compensate for exercise
• Take boluses early
• Write down a reason for every high and low
• Change infusion site on schedule and whenever unexpected highs occur
Healthcare Across Borders - September 2003
Steps To Control
Stop lows first
Set a realistic DIA
Determine an optimum TDD
Set and test basals
Determine starting carb factor with 450 Rule (450/TDD) and correction factor with 2000 Rule (2000/TDD)
Periodically check basal/bolus balance
Look for and correct unwanted patterns
Healthcare Across Borders - September 2003
Stop Lows FirstBetter control and more stability
Mild lows cause followup lows Small epinephrine release makes
muscles sensitive to insulin
Can lead to another low as much as 36 hours after the first
More carbs than usual are needed
Severe lows cause highs
Higher stress hormone release makes glucose rise for 6-10 hrs
Excess carb intake leads to highs
Boluses may be reduced/skipped
More insulin than usual needed
To stop lows, lower the TDD!!!
Healthcare Across Borders - September 2003
Find Your Optimum Doses!
Start with an accurate TDD –
1. How much total insulin do you average a day?
2. Adjust the TDD – are highs or lows primary problem?
Stay in basal/bolus balance – 50/50 or 45-65% as basal
Use the 500 and 2000 Rules to estimate starting carb and correction factors
Then adjust your basal and bolus doses
TEST your blood glucose
LOOK for blood sugar patterns
ADJUST basals and boluses from your patterns
Healthcare Across Borders - September 2003
20 u 0.42 u/h 25 grams 100 mg/dl
25 u 0.52 u/h 20 grams 80 mg/dl
30 u 0.63 u/h 17 grams 67 mg/dl
35 u 0.73 u/h 14 grams 57 mg/dl
40 u 0.83 u/h 13 grams 50 mg/dl
50 u 1.04 u/h 10 grams 40 mg/dl
60 u 1.25 u/h 8 grams 33 mg/dl
Find Basals And Boluses From Starting TDD
Starting Carb Factor Corr. Factor TDD 50% Basal 500 Rule 200 Rule
An accurate TDD solves most control problems!
3.1 mmol
Healthcare Across Borders - September 2003
Duration Of Insulin Action (DIA) Time
An accurate DIA time is critical to success on a smart pump
Current research suggests that DIA times are NOT different between children and adults
• Shorter for those more sensitive to insulin, but NOT children in general
But immediate factors can affect insulin action time:
• Shorter with activity and exercise
• Shorter in hot weather
• Longer with fat in diet
Healthcare Across Borders - September 2003
DIA Tips
• If your pump often suggests boluses that you know are not enough, do not shorten your DIA– it is usually NOT the problem
• Instead, ask what is causing the highs and where more insulin is needed – in basal rates, in carb boluses, or both
• Exercise or activity can mobilize insulin faster but DO NOT shorten the DIA for occasional activity. Instead:
• lower boluses or basals ahead of time for planned activities
• or eat more carbs or lower basals for unplanned activities
A low basal rate makes the DIA appear SHORT!
Healthcare Across Borders - September 2003
Bolus Size (Relative To Wt) Affects The DIAMeasured as units per kg(2.2 lb)
Larger boluses have a longer duration of action.
For 50 kg (110 lb) person:
0.3 u/kg = 15 u
15 u/kg = 7.5 u
0.075 u/kg = 3.75 u
Becker et al. Diabetes. 2005; 54 (Suppl. 1): 1367P
4 hrs
How long a bolus will lower the BG:
Healthcare Across Borders - September 2003
Recommendations For DIA Times
Mudaliar et al: Diabetes Care, 22: 1501, 1999
DIAs on current pumps can be set from 2 to 8 hours.
An inaccurate DIA can significantly impact control.
Healthcare Across Borders - September 2003
When Major Control Problems Occur
Adjust your TDD1. Determine the current TDD
2. Lower it:
• For frequent lows
• If both highs AND lows occur – which comes first?
3. Raise it:
• For a high A1c or a high average BG on your meter
4. While keeping basal rates and the daily carb bolus total balanced
TDD too low or too high?
Healthcare Across Borders - September 2003
Adjust The TDD For A High Avg. BG or A1cExample: someone with a TDD of 35 units and few lows.
A1c = 9%, so more insulin is needed: about 3.2 units.
© Pumping Insulin, 2006© Pumping Insulin, 2006
Healthcare Across Borders - September 2003
Change Your TDD For
A change in diet
A loss or gain in weight
Seasonal changes
An overall change in activity
Starting/stopping a sport
Vacation
Growth or start of puberty
Menses
Healthcare Across Borders - September 2003
Look For Patterns
• Frequent highs
• Frequent lows
• High at B/L/D/Bed
• Low at B/L/D/Bed
• Low to high
• High to low
Check Insulin Use
• Similar TDDs day to day
• Basal/Bolus balance
• Correction bolus %
Healthcare Across Borders - September 2003
Basal/Bolus Balance
< 50% Basal ~ 50% Basal > 50% Basal
Duration < 5 yrs
Thin
Physically active
High carb/low fat diet
Most people Duration > 5 yrs
Puberty
Less active
Insulin resistant
Low carb diet
Healthcare Across Borders - September 2003
Basal Rates
Should keep the blood sugar flat overnight or when a meal is skipped
Relatively easy to test
See See Pumping InsulinPumping Insulin for detailsfor details
Healthcare Across Borders - September 2003
Set & Test Basals First
40 - 65%
Basal
Pre-Pump TDD
More Accurate TDD
(55-95% of Pre-Pump Dose)
30 - 55%
Bolus
In reducing TDD, take into account A1c, history of highs or lows
50% basal is a good place to start for adults and many children
Test Basal Rates First
© Pumping Insulin, 2006© Pumping Insulin, 2006
Healthcare Across Borders - September 2003
How Many Basal Rates?
0
5
10
15
20
25
Number of Basals
1 2 3 4 5 6 7 8 9 10
Percentage of pumpers who use 1 to 10 basals per day from self reports of several hundred pumpers at insulin-pumpers.org
%
One basal rate may work in children, while the complex metabolism of puberty often requires multiple rates
Healthcare Across Borders - September 2003
Basal Tips
• 50% Rule: basals usually make up 40 to 65% of an accurate TDD
• Basal rates will be similar through the day, such as between 0.45 and 0.7, or between 1.0 and 1.4
• Adjust basal rate in small steps – 0.05 to 0.1 u/hr
• Change basals 3 to 8 hours before need arises
Healthcare Across Borders - September 2003
Test Carb And Correction Factors After Basals
Test Basal Rates First
2000 / TDD =Correction Factor
Then Test Carb & Correction Factors
450 / TDD =Carb Factor
© Pumping Insulin, 2006© Pumping Insulin, 2006
Healthcare Across Borders - September 2003
Glycemic Index: Different Carbs Have Different Speeds
From Gary Scheiner, MS, CDEFrom Gary Scheiner, MS, CDE
Fast
Breads/Crackers
Salty Snacks
Potatoes
Rice
Cereals
Sugary Candies
Slow
Pasta
Legumes
Salad Veggies
Dairy
Chocolate
Average
Fruit
Juice
Pizza
Soup
Cake
Healthcare Across Borders - September 2003
Duration Of Carb Action
Most carbs have most of their affect within 1 to 2.5 hours
But delay can occur with complex carbs, more fat content, etc
0 hrs 1 hr 2 hrs 3 hrs 4 hrs
High GI
Med GI
Low GI
Healthcare Across Borders - September 2003
Pump As Carb Counter
Pump or external controller contains user-selected food list for accurate carb counting
• Easy carb calculation• More accurate boluses
Available in Animas 2020, Deltec Cozmo, PDM for Omnipod, and PDA for Spirit
Healthcare Across Borders - September 2003
Carb Factor
Carb factor – how many grams of carb are covered by 1 unit
Carb bolus is based on:
• Your carb factor
• How many grams of carbs you plan to eat
• Your BG allows a correction bolus determination
• Amount of BOB still active (ALSO determined from BG!)
A pump can determine the bolus needed for a meal when the carb count and the carb factor are accurate
Visit your dietician to learn!
Healthcare Across Borders - September 2003
Check Your Carb Boluses
Does your carb factor work for LARGE meals? – half your weight (lbs) as grams of carb
Are carb counts accurate?
Are boluses given 20 min before meals when the glucose is normal?
For frequent lows after meals –> raise carb factor #
For frequent highs after meals –> lower carb factor #
Healthcare Across Borders - September 2003
Carb Bolus Varieties
Normal carb bolusBolus taken immediately – most meals
Extended or square wave bolusBolus extended over time – gastroparesis
Combo or dual wave bolusSome now, some later – bean burrito,
some pastas and pizzas, Symlin
Healthcare Across Borders - September 2003
Most Carbs Much Faster Than “Rapid” Insulin
% bolus activity remaining
From From Pumping InsulinPumping Insulin
Take Home: Bolus 15 to 30 minutes before meals Use extended and boluses sparingly.
Time over which most meals affect the BG
One hour after a meal, half of a meal’s glucose rise has occurred, but 80% of rapid insulin activity remains
Healthcare Across Borders - September 2003
Importance Of Bolus Timing
Figure shows rapid insulin injected 0 min, 30 min, and 60 minutes before a meal
Normal glucose and insulin profiles are shown in the shaded areas
Healthcare Across Borders - September 2003
Bolus Timing Depends On Glucose
Premeal BG
Bolus Timing
LowUse fast carbs, check BOB, and give carb bolus at start of meal
Normal Bolus 15 to 20 minutes before meal
HighGive carb bolus and correction boluses early but don’t forget to eat!
Check blood sugar 2 hours later to verify dose
Healthcare Across Borders - September 2003
Missed Boluses Cause High A1cs
• Start well– give a bolus for every bite!
• Use pump reminders or other reminder
• Review pump history once a week and work toward increasing the number of boluses
• Work toward solutions without blame
8.38.48.58.68.7
8.88.9
99.19.29.39.4
Before 6 mos
Control+Rmindr
48 youth in poor control (A1c > 8%). All put on a Deltec Cozmo pump, with half using reminders. Significant reduction for reminder at 3 mos but no difference after 6 mos.
H. Peter Chase et al: Diabetes Care 29:1012-1015, 2006
Healthcare Across Borders - September 2003
Correction Factor
Correction Factor – how many mg/dl (or mmol) the BG falls per unit of insulin
Lets a smart pump determine the bolus needed to bring a high blood sugar to target
Test to ensure accuracy – Does a correction bolus lower a high glucose safely to your target in 4-5 hrs?
Healthcare Across Borders - September 2003
When BG Goes High, Keep All Culprits In Mind
Bad infusion set or site
Bad insulin
Inaccurate carb counts
Rebound from stress hormones
Empty refrigerator syndrome
Hypobolusemia
Stress
Pain
BG
Healthcare Across Borders - September 2003
Bottom Line
If you don’t have great control on a smart pump, your pump settings are likely off.
Healthcare Across Borders - September 2003
Where Next?
Faster insulins – Biodel Viaject
Can the loop be totally closed?
Dual delivery pumps
Healthcare Across Borders - September 2003
Wrap Up
Pumps offer the latest technology for precise insulin delivery
Benefits include more flexibility, less hypoglycemia, less glucose exposure and variability, and a healthier life
Requires commitment & responsibility
Training and follow-up is required to ensure safe and effective treatment
Make the commitment to health. Start pumping!
Healthcare Across Borders - September 2003
Questions And Discussion