1. Insulin Pump Debrief

2. Now that you have worn a Pump… FAQ from people with diabetes Where do I wear this thing? What do I do with it when I play sports? What do I do when I shower or go swim? What do I do during times of intimacy? What if I roll over on the tubing in my sleep? FAQ from clinicians Who will put my patients on a pump? How do they get trained? Could I become a pump trainer?

4. Early Insulinization

5. Insulin resistance Impaired glucose tolerance Early diabetes Late diabetes High insulin levels Falling insulin production No insulin production Saltiel AR, Olefsky JM. Diabetes. 1996;45:1661-1669. Metabolic Staging of Type 2 Diabetes

6. Hepatic glucose output Glucose uptake Glucagon Insulin & Amylin Pancreas Liver Islet-cell dysfunction Adapted from Kahn CR, Saltiel AR. Joslin’s Diabetes Mellitus. 14th ed. Lippincott Williams & Wilkins; 2005:145–168. 1. Del Prato S, Marchetti P. Horm Metab Res. 2004;36:775–781. 2. Porte D Jr, Kahn SE. Clin Invest Med. 1995;18:247–254. Muscle Adipose tissue Hyperglycemia Major Pathophysiologic Defects in T2DM Insulin Resistance Excess glucose

7. Natural History of Type 2 Diabetes Obesity IFGDiabetesUncontrolled hyperglycemia Post-meal glucose Fasting glucose Insulin resistance Insulin level  -cell failure Glucose (mg/dL) Relative function (%) Yrs diabetes -10-5051015202530 Adapted from International Diabetes Center (Minneapolis, Minn).

8. Barriers to Using Insulin Patient resistance – Perceived significance of needing insulin – Fear of painful injections – Feelings of failure and guilt – Complexity of regimen – Cost

9. How Do You Get Patients on Board Early? Discuss – Disease progression – The real need for insulin – “This is not your grandmother’s insulin.” – New insulin delivery devices

10. Adam’s Injection Technique