2. Quick Pump Facts o Constantly provides insulin o Pager-sized “mini-computer” worn outside the body o Pump itself is attached to your body by a small cannula inserted into the subcutaneous tissue (under the skin)

3. Goal o The goal of insulin pump therapy is to mimic the insulin action of a fully functioning pancreas. o In those without diabetes, the pancreas makes a constant stream of insulin o It makes extra insulin every time you eat

4. How Pumps Work o The pump automatically delivers a programmed basal (background) dose of insulin o The user (child or parent) delivers bolus dose insulin when they eat

5. Without Diabetes

6. Multiple Daily Injections Long-Acting Insulin Rapid-Acting Insulin Long-Acting Insulin = Lantus, Levemir Rapid-Acting Insulin = Humalog, Novolog, Apidra

7. Basal Rate Bolus Dose Insulin Pump Insulin Pumps use only Rapid-Acting Insulins: Humalog, Novolog, Apidra

8. Basal Rate o A constant delivery of insulin o Rate is pre-programmed by the pump o Replaces Long-Acting Insulin o Basal rate is measured in units per hour (units/hr)

9. Basal Rate o Determine your starting basal rate, when switching from injections to a a pump: o Take your total daily dose of Lantus/Levemir = _______ units o Divide this by 24 (there are 24 hours in a day) = _______ units/hour o When using an insulin pump, you may need less insulin than with injections. You may start with 90% (or less) of your total basal. o To find 90% of your total basal, multiply the answer above (units/hour) by 0.9 = _______ units/hour

10. Practice Calculating Basal Rates Marcy’s Current Injection Regimen: 15 units of Lantus every night Converting to basal rate: 15 ÷ 24= 0.625 units/hour 0.625 x 0.9= 0.563 units/hour (or 0.550, 0.560, 0.5)

11. Practice Calculating Basal Rates David’s Current Injection Regimen: 4 units of Levemir in the a.m. and 4 units of Levemir in the p.m. Converting to basal rate: 4 + 4= 8 units 8 ÷ 24= 0.333 units/hour 0.333 x 0.9= 0.299 units/hour (or 0.3, 0.25, 0.275)

12. Basal Rates o Rates can vary during the day, creating a stairstep effect rather than a flat line o Most patients start a pump with only one basal rate o Rates are programmed into the pump based on the child’s blood sugar trends o Rates remain the same from day to day, but may be altered when needed o The basal rate can also be temporarily changed for alterations in schedule, exercise or illness

13. Bolus Dose o A bolus dose of insulin is taken o For meals and snacks for carbohydrate coverage o Correct elevated blood sugar levels o Correction for elevated blood sugar should ALWAYS be delivered prior to eating o Some patients prefer to deliver part of the food bolus after the meal o Ideally the entire bolus is delivered before the meal o For best glycemic control: o Bolus insulin = 50-60% of total daily insulin o Most of bolus should be for carbohydrate coverage, not for elevated blood sugars

14. Smart Pumps o If turned on, the pump can calculate your bolus based on: o Blood sugar o Carbohydrate intake o Insulin-to-carbohydrate ratio (ICR) o Insulin sensitivity factor (Blood glucose correction) o Insulin on Board (IOB) – active insulin still in the body from the last bolus dose o Blood sugar target

15. Smart Pumps o Pump may be pre-programmed with your dosing regimen: o Simply enter the blood sugar and the amount of carbs they are about to eat o Pump calculates a precise dose, and recommends this o User can accept or override this calculated

16. Smart Pumps o The pump can be programmed to have different patterns throughout the day o Basal and/or bolus dosing patterns o People who may benefit from this are: o Athletes o Children who live in different households o Changes in routine (school day versus weekend)

18. Reservoir o Insulin is put in a reservoir or cartridge o Reservoir is then placed inside the pump o Omnipod – Reservoir is housed inside the pod o The reservoir can hold up to 200-300 units depending on the pump o All reservoirs and pods are one-time use only o Any insulin left inside them when they are changed gets thrown out

19. Infusion Set o Pump delivers insulin through an infusion set o Pump is attached to its user through a cannula (a tiny straw) that is inserted through the skin and taped into place o Omnipod – placed directly onto the skin o A needle is used to insert the cannula and then removed o There are multiple infusion sets available for each tubing pump o Some are inserted manually while others have an automatic inserter available.

20. Infusion Set o The infusion set is inserted into subcutaneous tissue o Stays in Place for 2-3 days o Must be changed at least every 3 days o Rotate between same sites used for insulin injections: o Abdomen o Buttocks o Outer Thighs o Back of Arms

21. Infusion Sets Inset 30 Comfort Short Inset Pod

22. Caution! o An insulin pump provides rapid-acting insulin ONLY. o If the pump stops infusing ketones and ketoacidosis can happen quickly. The pump may not alarm o For this reason, only patients who check blood glucose at least four times daily are safe to use pumps o Avoid changing pump site right before bedtime o If blood sugar is >300, then user needs to check urine ketones and blood sugar every 1-2 hours o You MUST change infusion set and give insulin boluses via injection if you have moderate or large ketones! o Sick Day A ction Plan for pump users

24. Extra Pump Supplies o Fast acting insulin (pen or vial) o Insulin syringes o Infusion sets / reservoirs o Pump batteries o Owner’s manual o Unopened Lantus/Levemir

25. Continuous Glucose Monitors (CGM) o Catheter inserted under the skin o Sites similar to those for insulin pumps o Some insulin pumps are paired with a glucose monitor o CGM may be used without a pump o Can be purchased/used independent of one another

26. Continuous Glucose Monitors o Require calibration by fingerstick checks at least twice daily o Does not replace fingersticks at meals and bedtime o Can recognize trends in blood sugars o Blood glucose level should be confirmed by fingerstick if CGM indicates a low blood sugar o May help identify highs and lows at times fingersticks not normally done (and while sleeping)

27. Common Pump Myths o Easy, no more injections EVER o Less time-consuming o Less blood sugar monitoring o Perfect blood sugars o No complications o Can eat whatever/whenever you want o Involves a surgical procedure

28. Challenges of Insulin Pumps o Increases risk of diabetic ketoacidosis o Requires more frequent blood sugar monitoring o Potential infusion site infection o Inconvenience of wearing o Troubleshooting problems during class, sports or activities o Cost

29. Psychological Roadblocks o Being connected to insulin pump continuously o Self image/modesty issues o Where to wear the pump for special events (i.e. sports, prom)

30. Psychological Benefits o Increased flexibility in lifestyle o Can more easily eat with friends at parties and events o Sleepovers o Late night snacking o Sleeping in o Can adjust rates for exercise or activities

31. Potential for Better Control o Provides more precise dosage delivery o Better absorption of insulin o Potential to improve blood sugar control o Less variability in blood sugars o Decreases hypoglycemia

32. Thanks for Listening! Division of Pediatric Endocrinology & Diabetes Washington University School of Medicine Phone: 314-454-6051 Fax: 314-454-6225