utilizing insulin pump therapy in challenging populations bruce w. bode, md, face atlanta diabetes...
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Utilizing Insulin Pump Therapy in Challenging Populations
Bruce W. Bode, MD, FACE
Atlanta Diabetes Associates
Atlanta, Georgia
ACE / AACE Targets for Glycemic Control
A1C (HbA1c ) < 6.5 %
Fasting/preprandial glucose < 110 mg/dL
Postprandial glucose < 140 mg/dL
ACE / AACE Consensus Conference, Washington DC August 2001
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Retinop
Neph
Neurop
Microalb
RE
LA
TIV
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RIS
K
HbA1cSkyler, Endo Met Cl N Am 1996
Relative Risk of Progression of Diabetic Complications by Mean A1CBased on DCCT Data
HbA1c and Plasma Glucose
26,056 data points (A1c and 7-point glucose profiles) from the DCCT
Mean plasma glucose = (A1c x 35.6) – 77.3
Post-lunch, pre-dinner, post-dinner, and bedtime correlated better with A1c than fasting, post-breakfast, or pre-lunch
Rohlfing et al, Diabetes Care 25 (2) Feb 2002
Insulin
The most powerful agent we have
to control glucose
Patient J.L., December 15, 1922 February 15, 1923
The Miracle of Insulin
4:00 16:00 20:00 24:00 4:00
Breakfast Lunch Dinner
8:0012:008:00
Time
Pla
sma
insu
lin
Ideal Basal/Bolus Insulin Absorption Pattern
Glargine
Plasma Glucose
Time (hours)
220
200
180
160
140
120
12
11
10
9
8
7
0 4 8 12 16 20 24
mg
/dL
mm
ol/L
Lepore M, et al. Diabetes. 2000;49:2142–2148.
n = 20 T1DMMean ± SEM
SC insulin
NPH
Ultralente
CSII
Lauritzen. Diabetologia. 1983;24:326–329.
Fast (n = 12)
Semilente (n = 9)
Intermediate (n = 36)
Fra
ctio
n a
t in
j. si
te
1.00
0.75
0.50
0.25
06 12 18 24 36 42 4830
Hours after single SC injectionsFemoral region
Variability of Insulin Absorption
CSII <2.8%
SubcutaneousInjectable10% to 52%
Pump TherapyBasal & Bolus Short-Acting Insulin
Pump TherapyBasal & Bolus Short-Acting Insulin
Pump TherapyBasal & Bolus Short-Acting Insulin
Combined with SMBG, physiologic insulin requirements can be achieved more closely
Flexibility in lifestyle
History of Pumps
PARADIGM PUMP
Paradigm. Simple. Easy.
Paradigm Pump: Advantages
29% smaller, water resistant
Menu driven:
bolus, suspend, basal, prime, utilities
Reservoir based (easier to fill)
Silent motor
AAA batteries
Paradigm Pump: Advantages
Various bolus options
normal, square, dual, and “easy bolus”
Enhanced memory
Enhanced safety features
(low reservoir alarm, auto off, etc.)
Pump Infusion Sets
Softset QR Silhouette
Lauritzen. Diabetologia. 1983;24:326–329.
Pharmacokinetic Advantages CSII vs MDI
Uses only regular or very rapid insulin
– More predictable absorption than modified insulins (variation 3% vs 25 to 52%)
Uses 1 injection site
– Reduces variations in absorption due to site rotation
Eliminates most of the subcutaneous insulin depot
Programmable delivery simulates normal pancreatic function
Metabolic Advantages with CSII
Improved glycemic control
Better pharmacokinetic delivery of insulin
– Less hypoglycemia
– Less insulin required
Improved quality of life
Case 1: DM 1 not at goal A1C
35 year old female physician presents with Type 1 Diabetes since age 7
Control suboptimal (A1C 8.7%) on MDI with Regular AC and NPH HS.
SMBG 5/day with CHO counting
Complications: mild retinopathy and neuropathy, and hypoglycemia induced migraines
Case 1: DM 1 not at goal A1C
Recommend CSII but refuses; Does not want to be attached to something
Ask her to record, monitor 6 to 7 times per day, fax readings, and try lispro
She complies with minimal change in A1C falling to 8.4% at 3 months and 7.7% at 6 months
Still refuses CSII
Recommend a sensor (CGMS)
Case 1: DM 1 not at goal A1C
CGMS confirms a dawn rise
Try giving NPH later but no help; Try lente and ultralente but no help; Glargine only available in Germany
Patient gets married and desires children
Attempt to get Glargine from Germany but my contacts say no one uses glargine in pregnancy. Put her on a pump
Case 1: DM 1 Agrees to CSII
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4.5
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5.5
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7.5
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8.5
Nov-00 Feb-01 May-01 Aug-01 Nov-01 Feb-02
A1C
Case 1: DM 1 Agrees to CSII
Patient loves the pump
No more migraines from hypoglycemia
Patient now 13 weeks pregnant with A1C at 5.7%
CSII Reduces HbA1c
5.05.56.06.57.07.58.08.5.099.5
10.0
n = 58 n = 107 n = 116 n = 50 n = 25 n = 56Mean dur. = 36
Adolescents Adults
Mean dur. = 36 Mean dur. = 54 Mean dur. = 42 Mean dur. = 12 Mean dur. = 12
Chantelau E, et al. Diabetologia. 1989;32:421–426; Bode BW, et al. Diabetes Care. 1996;19:324–327;Boland EA, et al. Diabetes Care. 1999;22:1779–1784; Bell DSH, et al. Endocrine Practice. 2000;6:357–360;Chase HP, et al. Pediatrics. 2001;107:351–356.
Bell Rudolph Chanteleau Bode Boland Chase
Pre-pump Post-pump
Hb
A1
c
CSII Reduces Hypoglycemia
0
20
40
60
80
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120
140
160
n = 55Mean age 42
n = 107Mean age 36
n = 116Mean age 29
n = 25Mean age 14
n = 56Mean age 17
Eve
nts
per
hu
nd
red
p
atie
nt
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s
Chantelau E, et al. Diabetologia. 1989;32:421–426; Bode BW, et al. Diabetes Care. 1996;19:324–327;Boland EA, et al. Diabetes Care. 1999;22:1779–1784; Chase HP, et al. Pediatrics. 2001;107:351–356.
Bode Rudolph Chanteleau Boland Chase
Pre-pump Post-pump
Monitoring
–HbA1c = 8.3 - (0.21 x BG per day)
Recording 7.4 vs 7.8
Diet practiced–CHO: 7.2–Fixed: 7.5–Other: 8.0
CSIIFactors Affecting HbA1c
Bode et al, Diabetes 1997;46:143
Case 2: New Onset Diabetes
45 year old male lawyer presents with polys and weight loss
Sees internist who recommends metformin (blood glucose 500, urine ketones small, BMI 26)
The lawyer does some internet reading and seeks a second opinion from diabetes specialist who was a high school classmate he has not seen for 27 years
Case 2: New Onset Diabetes
Sees myself the following am (BG 514, urine ketones small)
I concur with him he has Type 1 Diabetes and metformin is not the treatment, insulin is.
He asks about insulin pump therapy instead of multiple injections.
I hospitalized him and told him I would get back to him the following am.
Case 2: New Onset Diabetes
I see him in the am and tell him that 8 out of 10 CSII patients polled yesterday would have started CSII at onset if offered the choice.
Dr. Pozzilli, an expert in DM 1 prevention, also recommended CSII at onset if it was him or a close relative
Patient opted for CSII
Case 2: New Onset Diabetes on CSII: A1C Results
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1011121314
Nov-99
Jan-
00
Mar
-00
May
-00
Jul-0
0
Sep-0
0
Nov-00
Jan-
01
Mar
-01
May
-01
Jul-0
1
Sep-0
1
Nov-01
A1C
Case 2: New Onset Diabetes on CSII
Patient extremely satisfied with his care
C-peptide 0.9 to 0.8 at 1 year
Does not understand why everyone is not on CSII with optimal control
Case 3: DM 2 Poorly Controlled
58 year old female presented with a 12 year history of poorly controlled, insulin treated diabetes
Ht 66’’, Wt 174#, BMI 28, C-peptide 2.1
A1C 10.4% on 165 units per day (70/30 BID)
Added troglitazone, metformin, glimepiride to MDI insulin
A1C range 7.7 to 12.6% over 3 years
Case 3: DM 2 Poorly Controlled
Admitted twice for IV insulin and fasting with short lived success (A1C to 7.6% but back up to 12.6%)
Tried weight watchers and appetite suppressants; no help
Decided to try CSII
Case 3: DM 2 on CSII, A1C Results
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Jan-
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Mar
-00
May
-00
Jul-0
0
Sep-0
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Nov-00
Jan-
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-01
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Jul-0
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A1C
Case 3: DM 2 Poorly Controlled
Patient loves the pump
On 110 units per day consuming 2 meals only per day (1.4 units per kg or 0.6 units per lbs)
Also on rosiglitazone 4 mg/day
7.197.57
9.2
5.00
6.00
7.00
8.00
9.00
10.00
Baseline 6 months 18 months
P = 0.026 P = 0.040
N = 11
CSII Usage in Type 2 PatientsAtlanta Diabetes Experience
Mean HbA1c (%)
Davidson et al, Diabetologia 1999; 42: 796
Glycemic Control in Type 2 DM: CSII vs MDI in 127 patients
A1C
7.0
7.2
7.4
7.6
7.8
8.0
8.2
8.4
CSII MDI
Baseline
End of Study (24 wks)
Raskin, Diabetes 2001; 50(S2):A106
DM 2 Study: CSII vs MDI
Overall treatment satisfaction improved in the CSII group: 59% pre to 79% at 24 weeks
93% in the CSII group preferred the pump to their prior regiment (insulin +/- OHA)
CSII group had less hyperglycemic episodes (3 subjects, 6 episodes vs. 11 subjects, 26 episodes in the MDI group) p<0.01
Normalization of Lifestyle
Liberalization of diet — timing & amount
Increased control with exercise
Able to work shifts & through lunch
Less hassle with travel — time zones
Weight control
Less anxiety in trying to keep on schedule
N = 165Average Duration = 3.6 yearsAverage Discontinuation <1%/yr
Continued 97%
Discontinued 3%
Current Continuation RateContinuous Subcutaneous Insulin Infusion (CSII)
Bode BW, et al. Diabetes. 1998;47(suppl 1):392.
6,600 8,700 11,40015,000
20,00026,500
35,00043,000
60,000
81,000
120,000
162,000
0
50,000
100,000
150,000
'90 '91 '92 '93 '94 '95 '96 '97 '98 '99 2000 2001
U.S. Pump UsageTotal Patients Using Insulin Pumps
Pump Therapy Indications
HbA1c >6.5%
Frequent hypoglycemia
Dawn phenomenon
Exercise
Pediatrics
Pregnancy
Gastroparesis
Hectic lifestyle
Shift work
Type 2
Marcus. Postgrad Med. 1995.
Current Candidate Selection
Patient Requirements
–Willing to monitor and record BG
–Motivated to take insulin
–Willing to quantify food intake
–Willing to follow-up
Meal bolus
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12 am 12 pm 12 am
Time of day
Basal rate
Pump Therapy
Units
Meal boluses Insulin needed pre-meal
– Pre-meal BG– Carbohydrates in meal– Activity level
Correction bolus for high BG
Basal rate Continuous flow of
insulin Takes the place of NPH
or glargine insulin
If A1C Not to Goal
SMBG frequency and recording
Diet practiced
– Do they know what they are eating?
– Do they bolus for all food and snacks?
Infusion site areas– Are they in areas of
lipohypertrophy?
Other factors:– Fear of low BG– Overtreatment of low BG
Must look at:
If A1C Not to Goal and No Reason Identified
Place on a continuous glucose monitoring system (CGMS) to determine the cause
Summary
Insulin pump therapy offers improvement in glycemic control with less major hypoglycemia and greater flexibility in lifestyle
Insulin pump therapy should be considered in all DM 1 patients and DM 2 patients failing conventional insulin therapy (basal insulin)
QUESTIONS
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