Integrated Diabetes Services Insulin Pump Therapy Gary Scheiner MS, CDE Integrated Diabetes Services 333 E. Lancaster Ave., Suite 204 Wynnewood, PA 19096 (877) 735-3648 Gary@integrateddiabetes.com www.integrateddiabetes.com

Insulin Pump Therapy 101 How Pumps Work Pros & Cons Strategies for Success Q & A

What A Pump IS Beeper-sized, battery-operated. A way of giving insulin. Worn externally. Programmable for individual needs.

Pump Evolution 1970s

Pump Evolution  1970s

Pump Evolution    1970s 1980s

Pump Evolution Modern Day Insulin Pumps

Insulin Used In Pumps Rapid-Acting Analogs are Preferred Aspart (Novolog) Lispro (Humalog Glulisine (Apidra) Modes of Delivery Basal Bolus

Basal Insulin Steady “Drip” of Insulin Matches Glucose Released by Liver Meets Body’s Basic Energy Needs May Need Different Settings at Different Times of Day

Bolus Insulin Given to “cover” carbs in meals and snacks. Used to “correct” high blood glucose levels

Insulin 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.

Infusion Set Types Infusion sets vary by: Angle of insertion Canula length Plastic vs. steel Tubing length

Infusion Set Insertion Soft plastic canula inserted by way of an introducer needle. Mechanical “inserters” are available for some types of insusion sets.

Clinical Advantages of Pump Therapy Reduction in HbA1c1 Less BG Variability2 Reduction in duration, frequency and severity of hypoglycemia3 Better psychosocial outcomes & quality of life4

Clinical Advantages of Pump Therapy 1 Bode et al; Diabetes Care 1996; 19:324-7 Weinzimmer et al; Pediatrics 2004; 114: 1601-5 5 Nations Trial; Diabetologia 2004; 47 (1): #82 DeVries et al; Diabetes Care 2002; 25:2074-80 2 DeVries et al. Diabetes Care. 2002 Nov; 25(11):2074–80 Diabetes Nutr Metab. 2004 Apr;17(2):84-9 N. Weintraub et al: Arch Pediatr Adolesc Med. 158: 677-684, 2004 3 Hissa et al; Endocrine Practice 2002: 8; 411-416 DeVries et al. Diabetes Care. 2002 Nov; 25(11):2074–80. Rudolph and Hirsh; Endocrine Practice 2002: 8; 401-405 Siegel et al; Diabetes Care 2004; 27: 3022-3. 4 Peyrot and Rubin; Diabetes Care 2005; 28: 53-58 McMahon et al; DiabeticMedicine 2005; 22:92-96 Bruttomesso et al 2002; 19:628-634 Shapiro, 1984; Skyler, 1982 References

Practical Benefits: Pump Basal Aspects

Practical Benefits: Pump Basal Aspects Potential Problems: Too much in middle of the night? Too little late in the day? General Inconsistency

Practical Benefits: Pump Basal Aspects Potential Problems: Too much in middle of the night? Midday peak requires consistent mealtimes Poor coverage of post-lunch peak General Inconsistency

Practical Benefits: Pump Basal Aspects Potential Problems: Failure to offset dawn phenomenon Too much in middle of the day? 1 shot May not last full 24 hrs

Practical Benefits: Pump Basal Aspects Basal insulin can be matched to the body’s daily needs.

Practical Benefits of Pump Basal Delivery: Stable BG between meals & overnight Can skip/delay meals without dropping Can vary sleep & work schedules Fewer issues with travel/time zone changes Can correct for dawn effect No long-acting insulins (more consistent insulin action) Immediate, temporary basal adjustments possible

Practical 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 boluses Rate of delivery can be extended Insulin delivery history stored in pump One needle stick every 3 days (approx) Built-in bolus calculator

Bolus Calculator: Example Estimate Details Est total: Food intake: BG: Food: Correction: Active ins: ACT to proceed ESC to back up Automatically calculates insulin bolus requirement for the patient 7.0 U 60 gr ICR 1:10 gram Here’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 U 200 (11.1) – 100 5.5 = 2.0 units 50 (2.8) 2.0 U 1.0 U Active insulin is subtracted from the correction 23

What A Pump Is NOT A cure for diabetes. A substitute for blood glucose monitoring & carb counting. As effective as a healthy pancreas.

Potential Drawbacks to Pump Therapy Cost Learning Curve Extra Testing Risk of Ketosis & DKA Weight Gain Potential Skin Irritation Inconvenience Time/Discomfort of Set Changes Teaching & Follow-Up Required

What Makes A Good Pump Candidate? Responsible Pre-Pregnancy Irregular Schedule Endurance Athletes Existing Complications Difficulty w/BG Control Frequent or Severe Lows Insulin-Dependent (1 or 2) Hypoglycemic Unawareness Sensitivity to Small Insulin Doses Possess Proper Self-Management Skills Adequate Insurance or Financial Resources

Strategies for Success: Pre-Pump Education BG monitoring 4+ times/day Detailed Record Keeping Carbohydrate Gram Counting Self-Adjustment of Insulin Principles of Basal/Bolus Therapy

Strategies for Success: Post-Pump Management Frequent communication w/health care team Basal Testing Bolus/Correction dose fine-tuning Activity adjustments Application of advanced pump features Persistent self-care (don’t miss boluses!) Effective troubleshooting, prevention of DKA

Strategies for Success: DKA Prevention

Strategies for Success: Pump Selection Criteria Insulin Reservoir Volume Screen Readability Bolus Maximums & Increments Bolus Calculator Flexibilty Alarm Distinction Water-Tightness

Strategies for Success: Pump Selection Criteria Link w/Meter or CGM Convenience Factors (tubing, clip) Infusion Set Options Aesthetics Out-Of-Pocket Costs

Strategies for Success: Infusion Set Selection/Use Appropriate depth for body type Correct priming amount Site preparation technique Frequency of change-outs  3 days Proper site rotation

Think Like A Pancreas!