Insulin Pump Therapy Insulin Pump Therapy

Gary Scheiner MS, CDEGary Scheiner MS, CDEIntegrated Diabetes ServicesIntegrated Diabetes Services

333 E. Lancaster Ave., Suite 204333 E. Lancaster Ave., Suite 204Wynnewood, PA 19096Wynnewood, PA 19096

(877) 735-3648(877) 735-3648Gary@integrateddiabetes.comGary@integrateddiabetes.comwww.integrateddiabetes.comwww.integrateddiabetes.com

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Insulin Pump Therapy 101Insulin Pump Therapy 101

How Pumps WorkHow Pumps Work Pros & ConsPros & Cons Strategies for SuccessStrategies for Success Q & AQ & A

What A Pump ISWhat A Pump IS

Beeper-sized, Beeper-sized, battery-operated.battery-operated.

A way of giving A way of giving insulin.insulin.

Worn externally.Worn externally.

Programmable for Programmable for individual needs.individual needs.

Pump EvolutionPump Evolution

1970s1970s

Pump EvolutionPump Evolution

1970s1970s

Pump EvolutionPump Evolution

1970s1970s 1980s1980s

Pump EvolutionPump Evolution

Modern Day Insulin PumpsModern Day Insulin Pumps

Insulin Used In PumpsInsulin Used In Pumps

Rapid-Acting Analogs are PreferredRapid-Acting Analogs are Preferred Aspart (Novolog)Aspart (Novolog) Lispro (HumalogLispro (Humalog Glulisine (Apidra)Glulisine (Apidra)

Modes of DeliveryModes of Delivery BasalBasal BolusBolus

Basal InsulinBasal Insulin

Steady “Drip” of InsulinSteady “Drip” of Insulin Matches Glucose Released by LiverMatches Glucose Released by Liver Meets Body’s Basic Energy NeedsMeets Body’s Basic Energy Needs May Need Different Settings at Different Times of DayMay Need Different Settings at Different Times of Day

00.20.40.60.8

11.21.41.61.8

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Bolus InsulinBolus Insulin

Given to “cover” carbs in meals and snacks.Given to “cover” carbs in meals and snacks.

Used to “correct” high blood glucose levels Used to “correct” high blood glucose levels

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Insulin Infusion(aka “getting under your skin”)Insulin Infusion(aka “getting under your skin”)

Durable, clog-resistant tubing carries insulin from the pump to Durable, clog-resistant tubing carries insulin from the pump to the infusion set the infusion set**..

The infusion set delivers insulin into the fatty layer below the The infusion set delivers insulin into the fatty layer below the skin.skin.

Set uses either a flexible plastic catheter (canula) or a steel Set uses either a flexible plastic catheter (canula) or a steel needle.needle.

Almost always disconnectable near the infusion site.Almost always disconnectable near the infusion site.

* OmniPod does not have tubing; * OmniPod does not have tubing; it attaches directly to the skin. it attaches directly to the skin.

Infusion Set TypesInfusion Set Types

Infusion sets vary by:Infusion sets vary by: Angle of insertionAngle of insertion Canula lengthCanula length Plastic vs. steelPlastic vs. steel Tubing lengthTubing length

Infusion Set InsertionInfusion Set Insertion

Soft plastic canula inserted by way of an Soft plastic canula inserted by way of an introducer needle.introducer needle.

Mechanical “inserters” are available for some Mechanical “inserters” are available for some types of insusion sets.types of insusion sets.

Clinical Advantages of Pump TherapyClinical Advantages of Pump Therapy

Reduction in HbA1cReduction in HbA1c11

Less BG VariabilityLess BG Variability22

Reduction in duration, Reduction in duration, frequency and severity of frequency and severity of hypoglycemiahypoglycemia33

Better psychosocial Better psychosocial outcomes & quality of lifeoutcomes & quality of life44

Clinical Advantages of Pump TherapyClinical Advantages of Pump Therapy

11 Bode et al; Diabetes Care 1996; 19:324-7Bode et al; Diabetes Care 1996; 19:324-7Weinzimmer et al; Pediatrics 2004; 114: 1601-5Weinzimmer et al; Pediatrics 2004; 114: 1601-55 Nations Trial; Diabetologia 2004; 47 (1): #825 Nations Trial; Diabetologia 2004; 47 (1): #82DeVries et al; Diabetes Care 2002; 25:2074-80DeVries et al; Diabetes Care 2002; 25:2074-80

22 DeVries et al. Diabetes Care. 2002 Nov; 25(11):2074–80Diabetes Nutr Metab. 2004 Apr;17(2):84-9N. Weintraub et al: Arch Pediatr Adolesc Med. 158: 677-684,

2004

33 Hissa et al; Endocrine Practice 2002: 8; 411-416Hissa et al; Endocrine Practice 2002: 8; 411-416DeVries et al. Diabetes Care. 2002 Nov; 25(11):2074–80.Rudolph and Hirsh; Endocrine Practice 2002: 8; 401-405Rudolph and Hirsh; Endocrine Practice 2002: 8; 401-405Siegel et al; Diabetes Care 2004; 27: 3022-3.Siegel et al; Diabetes Care 2004; 27: 3022-3.5 Nations Trial; Diabetologia 2004; 47 (1): #825 Nations Trial; Diabetologia 2004; 47 (1): #82

4 4 Peyrot and Rubin; Diabetes Care 2005; 28: 53-58Peyrot and Rubin; Diabetes Care 2005; 28: 53-58McMahon et al; DiabeticMedicine 2005; 22:92-96McMahon et al; DiabeticMedicine 2005; 22:92-96Bruttomesso et al 2002; 19:628-634Bruttomesso et al 2002; 19:628-634Shapiro, 1984; Skyler, 1982Shapiro, 1984; Skyler, 1982

ReferencesReferences

Practical Benefits: Pump Basal Aspects Practical Benefits: Pump Basal Aspects

Avg. Basal Needs

12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am

Pump Basal Delivery

12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am

NPH (nighttime only)

12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am

NPH (morning and night)

12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am

Lantus or Levemir

12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am

Practical Benefits: Pump Basal Aspects Practical Benefits: Pump Basal Aspects

Avg. Basal Needs

12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am

NPH (nighttime only)

12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am

Potential Problems:Potential Problems:

Too much in middle of Too much in middle of the night?the night?

Too little late in the Too little late in the day?day?

General InconsistencyGeneral Inconsistency

Practical Benefits: Pump Basal Aspects Practical Benefits: Pump Basal Aspects

Avg. Basal Needs

12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am

NPH (morning and night)

12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am

Potential Problems:Potential Problems:

Too much in middle of Too much in middle of the night?the night?

Midday peak requires Midday peak requires consistent mealtimesconsistent mealtimes

Poor coverage of Poor coverage of post-lunch peakpost-lunch peak

General InconsistencyGeneral Inconsistency

Practical Benefits: Pump Basal Aspects Practical Benefits: Pump Basal Aspects

Avg. Basal Needs

12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am

Lantus or Levemir

12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am

Potential Problems:Potential Problems:

Failure to offset dawn Failure to offset dawn phenomenonphenomenon

Too much in middle of Too much in middle of the day?the day?

1 shot May not last full 1 shot May not last full 24 hrs24 hrs

Practical Benefits: Pump Basal Aspects Practical Benefits: Pump Basal Aspects

Avg. Basal Needs

12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am

Pump Basal Delivery

12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am

Basal insulin can be Basal insulin can be matched to the body’s matched to the body’s daily needs.daily needs.

Practical Benefits of Pump Basal Delivery:Practical Benefits of Pump Basal Delivery:

Stable BG between meals & overnight

Can skip/delay meals without dropping

Can vary sleep & work schedules

Fewer issues with travel/time zone changes

Can correct for dawn effect

No long-acting insulins (more consistent insulin action)

Immediate, temporary basal adjustments possible

Practical Benefits of Bolusing with a PumpPractical Benefits of Bolusing with a Pump

Can dose very precisely (.1 or .05 units)

Convenient to give insulin anytime, anywhere

“Unused Insulin” adjustment prevents stacking of boluses

Rate of delivery can be extended

Insulin delivery history stored in pump

One needle stick every 3 days (approx)

Built-in bolus calculator

Estimate DetailsEst total:

Food intake:

BG:

Food:

Correction:

Active ins:

ACT to proceed

ESC to back up

Automatically calculates insulin bolus requirement

for the patient7.0 U

200 (11.1)

60 gr

2.0 U

ICR 1:10 gram

200 (11.1) – 100 5.5 = 2.0 units 50 (2.8)

6.0 U

1.0 U

Bolus Calculator: ExampleBolus Calculator: Example

Active insulin is subtracted from the correction

What A Pump Is NOTWhat A Pump Is NOT

A cure for A cure for diabetes.diabetes.

A substitute for A substitute for blood glucose blood glucose monitoring & carb monitoring & carb counting.counting.

As effective as a As effective as a healthy pancreas.healthy pancreas.

Potential Drawbacks to Pump TherapyPotential Drawbacks to Pump Therapy

Cost

Learning Curve

Extra Testing

Risk of Ketosis & DKA

Weight Gain Potential

Skin Irritation

Inconvenience

Time/Discomfort of Set Changes

Teaching & Follow-Up Required

What Makes A Good Pump Candidate?What Makes A Good Pump Candidate?

ResponsibleResponsible Pre-Pregnancy Pre-Pregnancy Irregular ScheduleIrregular Schedule Endurance Athletes Endurance Athletes Existing ComplicationsExisting Complications Difficulty w/BG ControlDifficulty w/BG Control Frequent or Severe LowsFrequent or Severe Lows Insulin-Dependent (1 or 2)Insulin-Dependent (1 or 2) Hypoglycemic Unawareness Hypoglycemic Unawareness Sensitivity to Small Insulin Doses Sensitivity to Small Insulin Doses Possess Proper Self-Management SkillsPossess Proper Self-Management Skills Adequate Insurance or Financial ResourcesAdequate Insurance or Financial Resources

Strategies for Success: Strategies for Success: Pre-Pump EducationPre-Pump EducationStrategies for Success: Strategies for Success: Pre-Pump EducationPre-Pump Education

BG monitoring 4+ times/dayBG monitoring 4+ times/day

Detailed Record KeepingDetailed Record Keeping

Carbohydrate Gram CountingCarbohydrate Gram Counting

Self-Adjustment of InsulinSelf-Adjustment of Insulin

Principles of Basal/Bolus TherapyPrinciples of Basal/Bolus Therapy

Strategies for Success: Strategies for Success: Post-Pump ManagementPost-Pump ManagementStrategies for Success: Strategies for Success: Post-Pump ManagementPost-Pump Management

Frequent communication w/health care teamFrequent communication w/health care team

Basal TestingBasal Testing

Bolus/Correction dose fine-tuningBolus/Correction dose fine-tuning

Activity adjustmentsActivity adjustments

Application of advanced pump featuresApplication of advanced pump features

Persistent self-care (don’t miss boluses!)Persistent self-care (don’t miss boluses!)

Effective troubleshooting, prevention of DKAEffective troubleshooting, prevention of DKA

Strategies for Success: Strategies for Success: DKA PreventionDKA PreventionStrategies for Success: Strategies for Success: DKA PreventionDKA Prevention

Unexplained High Blood Sugar

Check for Ketones

Ketones Ketones Negative Positive

Bolus w/Pump BS Doesn’t Drop 1. Shot w/Syringe

BS Drops 2. Drink Water 3. Change Out Pump

O.K.

Strategies for Success: Strategies for Success: Pump Selection CriteriaPump Selection CriteriaStrategies for Success: Strategies for Success: Pump Selection CriteriaPump Selection Criteria

Insulin Reservoir VolumeInsulin Reservoir Volume

Screen ReadabilityScreen Readability

Bolus Maximums & IncrementsBolus Maximums & Increments

Bolus Calculator FlexibiltyBolus Calculator Flexibilty

Alarm DistinctionAlarm Distinction

Water-TightnessWater-Tightness

Strategies for Success: Strategies for Success: Pump Selection CriteriaPump Selection CriteriaStrategies for Success: Strategies for Success: Pump Selection CriteriaPump Selection Criteria

Link w/Meter or CGMLink w/Meter or CGM

Convenience Factors Convenience Factors (tubing, clip)(tubing, clip)

Infusion Set OptionsInfusion Set Options

AestheticsAesthetics

Out-Of-Pocket CostsOut-Of-Pocket Costs

Strategies for Success: Strategies for Success: Infusion Set Selection/UseInfusion Set Selection/UseStrategies for Success: Strategies for Success: Infusion Set Selection/UseInfusion Set Selection/Use

Appropriate depth for body typeAppropriate depth for body type

Correct priming amountCorrect priming amount

Site preparation techniqueSite preparation technique

Frequency of change-outs Frequency of change-outs 3 days 3 days

Proper site rotationProper site rotation

Think Like A Pancreas!Think Like A Pancreas!