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Healthcare Across Borders - September 2003 Introduction To Pumping Starting And Success John Walsh, P.A., C.D.E. North County Endocrine 700 West El Norte.

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Presentation on theme: "Healthcare Across Borders - September 2003 Introduction To Pumping Starting And Success John Walsh, P.A., C.D.E. North County Endocrine 700 West El Norte."— Presentation transcript:

1 Healthcare Across Borders - September 2003 Introduction To Pumping Starting And Success John Walsh, P.A., C.D.E. North County Endocrine 700 West El Norte Pkwy Escondido, CA (760) or The Diabetes Mall (619) Children With Diabetes Toronto, August 17, 2007

2 Healthcare Across Borders - September 2003 Highlights Why Pump? Whos A Candidate? Pump Basics Brands And Features Smart Pump Advantages Infusion Sets How To Start Settings That Affect Control Wrap Up

3 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 –>

4 Healthcare Across Borders - September 2003 Reasons To Use A Pump

5 Healthcare Across Borders - September 2003 Better Control –> Fewer Complications Retinopathy Progression 1 Laser Rx 1 Micro- albuminuria 2 Albuminuria 2 Clinical Neuropathy 3 Conventional Intensive 76% Risk Reduction 59% 39% 54% 64% Cumulative Incidence (%) 1.DCCT Research Group, Ophthalmology. 1995;102: DCCT Research Group, Kidney Int. 1995;47: DCCT Research Group. Ann Intern Med. 1995;122:

6 Healthcare Across Borders - September 2003 Poor Control Remains A Problem HbA 1c 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 Starch Wright A., Burden et al, Diabetes Care 2002; 25:330–336 Turner RC, Cull et al, JAMA 1999; 281:2005–2012 2/3 with diabetes (and most pumpers) remain out of control Avg. A1c in TYPE 1s Avg. A1c on Pumps Goal A1c 5%

7 Healthcare Across Borders - September 2003 Exposure Versus Variability One days tests every 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

8 Healthcare Across Borders - September 2003 The Challenge Of Diabetes Bringing the A1c down smoothly takes effort …for this you need ADVANCED therapy 100 (5.5) 200 (11.1) 300 (16.7) Normal A1C 4%–6% BG in mg/dL (mmol) Uncontrolled A1C ~9% A1C ~6% Controlled A1C <7% Time of Day

9 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

10 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.

11 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

12 Healthcare Across Borders - September 2003 Who Is A Pump Candidate?

13 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

14 Healthcare Across Borders - September 2003 Expectations UnrealisticRealistic The pump will cure my diabetesI will feel better I wont have to test as muchI must monitor very frequently I can eat anything I wantI will have more freedom with my food choices My blood sugar will be perfectI 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

15 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 – 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

16 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

17 Healthcare Across Borders - September 2003 Pump Basics

18 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)

19 Healthcare Across Borders - September 2003 Basals And Boluses A pump more easily matches the realities of daily life. bolus basal

20 Healthcare Across Borders - September 2003 Basal: MDI versus Pump Lantus or Levemir Pump 2:0016:0020:0024:00 7:00 12:007:00 Time Basal insulin delivery from a pump provides a better and faster match for lifes needs

21 Healthcare Across Borders - September 2003 HbA1c= / (BGpd+1.39) Atlanta Diabetes Associates study: 378 patients sorted from a database of 591 Pumps=MM 511 or earlier BG Target=100 C peptide <0.1 More Testing – > Lower A1c Data From 378 People On Pumps ADA: < 7% AACE: < 6.5% P. Davidson et al: Diabetes 53 (suppl 2): abstract 430-P, 2004

22 Healthcare Across Borders - September 2003 Brands And Features

23 Healthcare Across Borders - September 2003 Insulin Pumps – 2007 Pump info at Accu-Chek Spirit Animas 2020 Deltec CozMore 1800 Insulet Omnipod Medtronic Paradigm x22 Sooil Dana Diabecare IISG

24 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

25 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

26 Healthcare Across Borders - September 2003 Animas 2020 High contrast color screen for easy viewing Smallest mainstream pump Smallest basal rate increment – u Waterproof – 12 ft for 24 hrs ezCarb meal bolus calculator ezBG correction bolus calculator ezBolus shortcut to give bolus

27 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

28 Healthcare Across Borders - September 2003 Insulet Omnipod No tubing for easy wear Automatic cannula insertion and priming 200 units Limited to hrs use Watertight Controlled by PDM or smartphone 1000 food database

29 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

30 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

31 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

32 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

33 Healthcare Across Borders - September 2003 Pump Advantages

34 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

35 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!

36 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)

37 Healthcare Across Borders - September 2003 Infusion Sets

38 Healthcare Across Borders - September 2003 Infusion Sets Five 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.

39 Healthcare Across Borders - September 2003 Infusion Sets And Inserters Infusion set/site problems are a common cause for unexplained highs Smiths Medical Cleo Medtronic Sil-serter Disetronic Rapid-D Animas Inset Quik-serter

40 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

41 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

42 Healthcare Across Borders - September 2003 Pump Start

43 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 and troubleshooting

44 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

45 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

46 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

47 Healthcare Across Borders - September 2003 Stop Lows First Better 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!!!

48 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

49 Healthcare Across Borders - September u0.42 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 u1.25 u/h 8 grams 33 mg/dl Find Basals And Boluses From Starting TDD StartingCarb Factor Corr. Factor TDD 50% Basal 500 Rule 200 Rule An accurate TDD solves most control problems! 3.1 mmol

50 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

51 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!

52 Healthcare Across Borders - September 2003 Bolus Size (Relative To Wt) Affects The DIA Measured 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 u/kg = 3.75 u Becker et al. Diabetes. 2005; 54 (Suppl. 1): 1367P 4 hrs How long a bolus will lower the BG:

53 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.

54 Healthcare Across Borders - September 2003 When Major Control Problems Occur Adjust your TDD 1.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?

55 Healthcare Across Borders - September 2003 Adjust The TDD For A High Avg. BG or A1c Example: someone with a TDD of 35 units and few lows. A1c = 9%, so more insulin is needed: about 3.2 units. © Pumping Insulin, 2006

56 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

57 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 %

58 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 peopleDuration > 5 yrs Puberty Less active Insulin resistant Low carb diet

59 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 Pumping Insulin for details

60 Healthcare Across Borders - September 2003 Set & Test Basals First % Basal Pre-Pump TDD More Accurate TDD (55-95% of Pre-Pump Dose) % 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

61 Healthcare Across Borders - September 2003 How Many Basal Rates? 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

62 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

63 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

64 Healthcare Across Borders - September 2003 Glycemic Index: Different Carbs Have Different Speeds From 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

65 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

66 Healthcare Across Borders - September 2003 Carb Counting Accounts for half the days control Accuracy allows boluses to match carbs for post-meal control and a significantly lower A1c Made easier with automatic carb bolus calculations by pump

67 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

68 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!

69 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 #

70 Healthcare Across Borders - September 2003 An Accurate Carb Factor Returns the blood sugar: to within 30 mg/dl (1.7 mmol) of where it started by the time selected for your duration of insulion action (DIA) with no lows within 5 hours after carb bolus given

71 Healthcare Across Borders - September 2003 Carb Bolus Varieties Normal carb bolus Bolus taken immediately – most meals Extended or square wave bolus Bolus extended over time – gastroparesis Combo or dual wave bolus Some now, some later – bean burrito, some pastas and pizzas, Symlin

72 Healthcare Across Borders - September 2003 Most Carbs Much Faster Than Rapid Insulin % bolus activity remaining From Pumping 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 meals glucose rise has occurred, but 80% of rapid insulin activity remains

73 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

74 Healthcare Across Borders - September 2003 Bolus Timing Depends On Glucose Premeal BG Bolus Timing Low Use fast carbs, check BOB, and give carb bolus at start of meal NormalBolus 15 to 20 minutes before meal High Give carb bolus and correction boluses early but dont forget to eat! Check blood sugar 2 hours later to verify dose

75 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 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: , 2006

76 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?

77 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

78 Healthcare Across Borders - September 2003 Bottom Line If you dont have great control on a smart pump, your pump settings are likely off.

79 Healthcare Across Borders - September 2003 Where Next? Faster insulins – Biodel Viaject Can the loop be totally closed? Dual delivery pumps

80 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!

81 Healthcare Across Borders - September 2003 Questions And Discussion


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