Advanced Pump Management Gary Scheiner MS, CDE Integrated Diabetes Services 333 E. Lancaster Ave., Suite 204 Wynnewood, PA 19096 (877) 735-3648 (610) 642-6055 www.integrateddiabetes.com gary@integrateddiabetes.com

Advanced Pump Management Basal Insulin Regulation Bolus Regulation Physical Activity Adjustment DKA Prevention Temporary Basal Rates Prolonged Boluses Alternate Basal Patterns

Basal Insulin Regulation Basal Insulin’s One And Only Job Is To Hold Blood Glucose Levels Steady In the Absence of Confounding Influences* * Food, Exercise, Bolus Insulin, Unusual Hormonal Conditions (illness, rebounds, menstruation)

Basal Insulin Regulation Conditions for Testing Basal Rates: No food or bolus for at least 4 hrs prior Last meal/snack low in fat No food or bolus during test phase (water/diet drinks OK) BG above 80, below 250 throughout No lows for previous 12 hrs Stay connected, no stopping/suspending Exercise OK up until test phase (if usually performed) No heavy activity during test phase Do not run test if sick or just prior to/start of period

Basal Insulin Regulation Sample Basal Testing Schedule Test Last Meal / Bolus By Check BG at May Eat / Bolus Again at Overnight 6pm (skip night snack) 10pm, 1am, 4am, 7am 7am Morning 3am (skip breakfast) 7am, 9am, 11am, 12noon 12 noon Afternoon 8am (skip lunch) 12 noon, 2pm, 4pm, 5pm 5pm Evening 1pm (have late dinner) 5pm, 7pm, 9pm, 10pm 10pm

Basal Insulin Regulation Average basal profiles* * Diabetes Research & Clinical Practice (2005) 14-21.

Basal Insulin Regulation Example 1: Sara Smiley Currently: .30 3am-9am, .25 9am-3am Skipped Breakfast BG results: 6am 109 8am 201 10am 230 12pm 224 Interpretation: Sharp rise 6am-8am Modest Rise 8am-10am Stable 10am-12 noon Adjustments: Basal by .1 5a-7a Basal by .05 7a-9a Repeat test from 6a-12p

Bolus Insulin Regulation I:C Ratios: The correct ratio should match pre-meal BG 3-4 hours (not 2!) after eating I:C Ratio often varies from meal to meal (bkfst dose > lunch & dinner)

Bolus Insulin Regulation Correction Boluses: 1500-Rule (aggressive) (Total Daily Ins.)/1500 1800-Rule (conservative) (Total Daily Ins.)/1800 May vary day vs. night (nighttime often 50% more than day)

Physical Activity Adjustments Activity Within 2 Hrs After Meal Activity Before or Between Meals Short Duration (<90 Minutes) Mealtime Bolus Snack Prior to Activity* Long Duration (>90 Minutes) Basal Rate Snack hourly

Physical Activity Adjustments Meal Bolus Adjustment* Low Intensity Cardio  25% Mod. Intensity Cardio  33% High Intensity Cardio  50% Competitive/Anaerobic ??? * If activity is after meal Basal Adjustment**  Basal rate 50% Start basal reduction 1 hr pre-activity ** For activities lasting > 90 Min.

Physical Activity Adjustments Snacking to prevent low (examples)   Carbohydrate Replacement Per 60 Minutes of Activity 50 lbs 100 lbs 150 lbs 200 lbs 250 lbs Skating 7-10g 14-20g 20-30g 28-40g 35-50g Gymnastics 8-12g 17-23g 25-35g 34-46g 42-57g Soccer 13-17g 27-33g 40-50g 54-66g 67-82g

Physical Activity Adjustments Watch Out for D’OH! (Delayed Onset Hypoglycemia) Following high-intensity exercise Following extended- duration activity May occur up to 24 hours afterwards Extra snacks or reduction in basal insulin may be necessary

Physical Activity Adjustments OK To Disconnect Up To 1 Hour w/ Activity

Physical Activity Adjustments Alternatives to Disconnection:  Wear It! (Sport Pack, Fanny Pack, Backpack Harness) Re-Connect hourly & bolus 50% of missed basal rate

DKA Prevention Normal Cellular Metabolism  

DKA Prevention Metabolism With Insulin Deficiency   

DKA Prevention Progression to DKA Higher B.G. + Dehydration    Higher B.G. + More Ketones + Dehydration  **KETOACIDOSIS**

DKA Prevention Causes of insulin deficiency in Pump Therapy    Malabsorption (site problems) Insulin Spoilage Tubing or infusion set clogs Leaks where the cartridge connects to the tubing Air pockets in the tubing Dislodgement of the canula from beneath the skin Improper or insufficient priming Extended pump suspension or disconnection

DKA Prevention

Temporary Basal Rates Basal Insulin Should Hold BG Steady Under Normal Conditions. How Often Is Life Under “Normal Conditions”?

Temporary Basal Rates High-Fat Food Duration Adjustment Notes 8:00 +60% Start After Meal

Temporary Basal Rates Illness Duration Adjustment Notes 24:00 +80% Repeat as Needed

Temporary Basal Rates Predictable Stress Duration Adjustment Notes 3:00 +80% Set 1-2 Hours Prior

Temporary Basal Rates Extended Inactivity Duration Adjustment Notes Varies (>3 hrs) +40% Great for long trips!

Temporary Basal Rates Menstrual Cycles Duration Adjustment Notes 12:00 +50% (pre) Start at night -30% (post)

Temporary Basal Rates Prolonged Activity Duration Adjustment Notes Minimum 2 hrs. -50% Start 1-2 hours prior

Temporary Basal Rates Alcohol Duration Adjustment Notes 2 hrs per drink -40% Begin after drinking

Prolonged Boluses Description Normal/Standard Boluses are delivered within a few minutes; peak is approx. 1 hr, duration approx. 4 hours Prolonged boluses are delivered over a period of a couple of hours; peak is delayed/blunted and duration is extended.

Prolonged Boluses Purpose To do a better job of matching the blood sugar rise caused by slow-digesting foods.

Prolonged Boluses Applications Very Large Portions Low-Glycemic-Index Foods Meals/Snacks that take a long time to consume

Prolonged Boluses Options for slow-digesting food: Normal Bolus

Prolonged Boluses Square/Extended Bolus Options for slow-digesting food: Square/Extended Bolus

Prolonged Boluses Dual/Combination Bolus Options for slow-digesting food: Dual/Combination Bolus

Alternate Basal Patterns Called Pattern A/B (Medtronic), Prog 2-4 (Animas), Pattern 1-4 (Deltec) Useful when basal changes are needed for several days (or more) in succession

Alternate Basal Patterns Potential Uses: Menstrual cycle phases Extended illness Recovery from surgery Periodic use of steroid medications Seasonal sports Off-day vs. work/school-day Extended travel Climate changes

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