8Insulin Used In Pumps Rapid-Acting Analogs are Preferred Aspart (Novolog)Lispro (HumalogGlulisine (Apidra)Modes of DeliveryBasalBolus
9Basal Insulin Steady “Drip” of Insulin Matches Glucose Released by LiverMeets Body’s Basic Energy NeedsMay Need Different Settings at Different Times of Day
10Bolus Insulin Given to “cover” carbs in meals and snacks. Used to “correct” high blood glucose levels
11Insulin Infusion (aka “getting under your skin”) Durable, clog-resistant tubing carries insulin from the pump to the infusion set*.The infusion set delivers insulin into the fatty layer below the skin.Set uses either a flexible plastic catheter (canula) or a steel needle.Almost always disconnectable near the infusion site.* OmniPod does not have tubing; it attaches directly to the skin.
12Infusion Set Types Infusion sets vary by: Angle of insertion Canula lengthPlastic vs. steelTubing length
13Infusion Set Insertion Soft plastic canula inserted by way of an introducer needle.Mechanical “inserters” are available for some types of insusion sets.
14Clinical Advantages of Pump Therapy Reduction in HbA1c1Less BG Variability2Reduction in duration, frequency and severity of hypoglycemia3Better psychosocial outcomes & quality of life4
15Clinical Advantages of Pump Therapy 1 Bode et al; Diabetes Care 1996; 19:324-7Weinzimmer et al; Pediatrics 2004; 114:5 Nations Trial; Diabetologia 2004; 47 (1): #82DeVries et al; Diabetes Care 2002; 25:2 DeVries et al. Diabetes Care Nov; 25(11):2074–80Diabetes Nutr Metab Apr;17(2):84-9N. Weintraub et al: Arch Pediatr Adolesc Med. 158: ,20043 Hissa et al; Endocrine Practice 2002: 8;DeVries et al. Diabetes Care Nov; 25(11):2074–80.Rudolph and Hirsh; Endocrine Practice 2002: 8;Siegel et al; Diabetes Care 2004; 27:4 Peyrot and Rubin; Diabetes Care 2005; 28: 53-58McMahon et al; DiabeticMedicine 2005; 22:92-96Bruttomesso et al 2002; 19:Shapiro, 1984; Skyler, 1982References
17Practical Benefits: Pump Basal Aspects Potential Problems:Too much in middle ofthe night?Too little late in theday?General Inconsistency
18Practical Benefits: Pump Basal Aspects Potential Problems:Too much in middle ofthe night?Midday peak requiresconsistent mealtimesPoor coverage ofpost-lunch peakGeneral Inconsistency
19Practical Benefits: Pump Basal Aspects Potential Problems:Failure to offset dawnphenomenonToo much in middle ofthe day?1 shot May not last full24 hrs
20Practical Benefits: Pump Basal Aspects Basal insulin can be matched to the body’s daily needs.
21Practical Benefits of Pump Basal Delivery: Stable BG between meals & overnightCan skip/delay meals without droppingCan vary sleep & work schedulesFewer issues with travel/time zone changesCan correct for dawn effectNo long-acting insulins (more consistent insulin action)Immediate, temporary basal adjustments possible
22Practical 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 bolusesRate of delivery can be extendedInsulin delivery history stored in pumpOne needle stick every 3 days (approx)Built-in bolus calculator
23Bolus Calculator: Example Estimate DetailsEst total:Food intake:BG:Food:Correction:Active ins:ACT to proceedESC to back upAutomatically calculates insulin bolus requirement for the patient7.0 U60 grICR 1:10 gramHere’s what the Bolus Wizard calculator looks like on the insulin pump. The patient would enter his/her current blood glucose value (200 in this example), and if he/she is about to consume a meal, the carbohydrate content of that meal. In this example, the patient first needs a correction bolus. Because the insulin sensitivity factor is set at 50, he/she would require two units for the correction (target = 100). In addition, he/she is consuming 60 grams of food, for which he/she would take a 6 unit bolus based on a 1:10 insulin-to-carbohydrate ratio.The calculation also takes active insulin remaining “on board” into account, so that over-bolusing and resulting hypoglycemia is less of a possibility.There is still 1 unit of active insulin remaining from the prior injection, which means that if the patient took 8 units then he/she would take 1 unit too many.The Bolus Wizard calculator therefore recommends 7 units for this bolus.200 (11.1)6.0 U200 (11.1) – = 2.0 units50 (2.8)2.0 U1.0 UActive insulin is subtracted from the correction23
24What A Pump Is NOT A cure for diabetes. A substitute for blood glucose monitoring & carb counting.As effective as a healthy pancreas.
25Potential Drawbacks to Pump Therapy CostLearning CurveExtra TestingRisk of Ketosis & DKAWeight Gain PotentialSkin IrritationInconvenienceTime/Discomfort of Set ChangesTeaching & Follow-Up Required
26What Makes A Good Pump Candidate? ResponsiblePre-PregnancyIrregular ScheduleEndurance AthletesExisting ComplicationsDifficulty w/BG ControlFrequent or Severe LowsInsulin-Dependent (1 or 2)Hypoglycemic UnawarenessSensitivity to Small Insulin DosesPossess Proper Self-Management SkillsAdequate Insurance or Financial Resources
27Strategies for Success: Pre-Pump Education BG monitoring 4+ times/dayDetailed Record KeepingCarbohydrate Gram CountingSelf-Adjustment of InsulinPrinciples of Basal/Bolus Therapy
28Strategies for Success: Post-Pump Management Frequent communication w/health care teamBasal TestingBolus/Correction dose fine-tuningActivity adjustmentsApplication of advanced pump featuresPersistent self-care (don’t miss boluses!)Effective troubleshooting, prevention of DKA