1. Advanced Pumping Della Matheson, RN, CDE University of Miami Research Coordinator

2. Thinking Like a Pancreas: utilizing advanced pump features

3. Adjustment Guidelines Make changes based on patterns Fix lows before making ANY increases When increasing, start with the first high of the day Make one change at a time and give it a few days to see effect

4. How do we determine TDD and Basal Rate? Total Insulin Replacement Average adult: 0.5 – 0.7 u/kg BW Average adolescent: 0.7- 1.4 u/kg BW Example: female, age 23, 120 lbs (54 kg), 32u/day 32 units = 0.6 units/kg 54 kg @ 50% of the TDD should be BASAL!!! 32÷2 = 16 ÷ 24hours = 0.66 u/hour

5. Basal Rate Basal Rates are designed to keep blood sugars in range while in the fasting state!!! Start with a single basal rate Move to multiple basal rates to individualize An Optimal Basal Rate keeps glucose from rising or falling more than 30mg/dl when you are sleeping or skip a meal.

6. Basal Rate: checking overnight rates Check on a night when your last bolus was taken before dinner and bedtime starts 5 hours after that bolus (Ex 6:00 p.m. dinner; 11:00 p.m. bedtime) and is within your target range Wear CGM to bed OR wake up and test at 3:00 a.m. (or more if you can) Test at rising Want blood glucose at rising to be within 30mg/dl of target!

7. Basal Rate: testing daytime rates Harder – fasting involved! Split day into 3 segments Be sure last bolus was 5 hours earlier Only do this when BG in target, no unusual activity or circumstances, and you can frequently test or wear CGM Breakfast Lunch 8:00 a.m. 1:00 p.m. 6:00 p.m. Dinner

8. Basal Rate: when and how much to change Don’t change WHEN the rise or fall in BG occurs – BEGIN THE CHANGE AT LEAST 2 HOURS EARLIER!!! 90% of pumpers use more than a single basal rate but beware of over manipulation and too many basal rates! 12 mn 2 a.m. 12 noon 2:00 p.m.

9. Bolus Calculation or Insulin:CHO Ratio @ 50% of Total Daily Dose = Bolus A Quick calculation guide (the “2.6 rule”) Weight in pounds x 2.6 ÷ TDD = INS:CHO Ratio Example: 120 x 2.6 = 312÷ 32u/day = 9.75 This is a starting point, then, it needs to be evaluated!!

10. Bolus Adjustments Things To Do Before changing Ins:Cho ratios Know how insulin works! Know how food works! Be sure you are CHO counting correctly! Most foods digest and start to raise your glucose quicker than today’s rapid acting insulins can lower it! Glucose Time: minutes 10 40 80 120 150 180 240 300 Take insulin 15 to 20 minutes BEFORE the start of the meal!!

11. Bolus Adjustments: Be Realistic! Expect some elevation 2 hours after a normal meal; ADA = 180mg/dl or less European Policy Group = 165mg/dl International Diabetes Federation = 140 mg/dl as long as hypoglycemia can be avoided Pregnancy = 120mg/dl Bolus should be adjusted if BG stays more than 30mg/dl above the pre-meal level 4 – 5 hours after the meal: avoid “stacking” insulin!!

12. Insulin on Board/Active Insulin IOB feature helps you to calculate how much glucose lowering activity still remains from your last bolus If set properly it should prevent “stacking of insulin” Average duration of action of today’s rapid acting insulin = 5 to 6 hours* *variability exists!!! Pumps offer IOB to be set on average between 2 and 8 hours; default usually set at 4 hours

13. Insulin on Board: variability Volume If taking more than 12 to 15 units, you may want to set your IOB at 6 -6.5 hours vs. 4 2 units 20 units Placement Calculation of IOB depends on your pump

14. Insulin on Board: pump variation Linear: Accu-Chek and OmniPod use set amount, 20% to 25%, per hour Works best if set from 4.25 to 6 hours Bolus 0 1 2 3 4 5 6 Curvi-linear (more accurate because they better match delayed tailing action of Insulin): Animas, Medtronic, and Tandem Works best if set from 4.5 to 6.25 hours Bolus 0 1 2 3 4 5 6

15. Know Your Pump: How is “Insulin on Board” counted on your pump ? Is Bolus INCLUDED in IOBIs Bolus SUBTRACTED from IOB CarbCorrectionCarbCorrection Best PracticeYes AnimasYes No (only if < target) Yes MedtronicYes NoYes OmniPodNo (new Model will) YesNoYes TandemYes No (only if < 70) Yes (only if < 70) Accu-Chek Spirit Yes Adapted from “Pumping Insulin” Walsh, J, Roberts, R Torrey Pines Press, 5 th Edition 2012

16. Bolus: Combo Bolus Used for foods that are slowly digested Low glycemic CHO’s + lots of fiber High fat/protein + dense CHO Gastroparesis Symlin, Acarbose, GLP-1 agonist = all these slow digestion Ask yourself this question: With a standard bolus, do I go low immediately after this meal and then go high 2 – 4 hours later? START: 50% immediate, and 50% delayed for 2 – 3 hours

17. Foods That Cause Excessive Rapid Highs: The Super Bolus 40 grams of CHO or more and are high glycemic foods Example: 60 grams CHO Meal INS:CHO ratio = 1:10 Basal Rate = 1 unit/hour SUPER BOLUS: Increasing pre-meal bolus while decreasing basal using temporary basal rate 6 units per usual calculation Temporary basal rate: decrease by 70% x 3 hours (- 0.7u x 3 hours = 2.1) ADD 2.1 units to 6 units for a total pre-meal of 8.1 Better bolus coverage with less risk of low later

18. Bolus: Combo Bolus & Super Boluses WRITE YOUR RESULTS DOWN AND “TWEAK” TO MATCH YOUR PERSONAL “DIGESTIVE PATTERNS”

19. Correction Factors: how are they derived? The number of mg/dl that 1 unit of insulin takes to reduce you blood sugar. That amount depends on how sensitive to Insulin you are = Insulin Sensitivity Factor Rule of 1800 Divide 1800 by Total Daily Dose Example: 120 woman, TDD 32u/day 1800 ÷ 32 = 56

20. When is it OK to Over-ride the pump calculation?? When you know more than it does!! Foods you know have a greater affect on your BG than the actual stated CHO amount Stress factors that you know historically alter BG Adjustments for exercise

21. Our Biggest Challenge: Exercise Benefits Improved cardiovascular outcomes Reduces fatigue and improves musculoskeletal system Combats depression, increases sense of well-being, and lowers stress DOWN-SIDE: “sometimes it feels like more trouble than it’s worth”……

22. Our Biggest Challenge: Exercise Control During Exercise Depends On: 1.Your current insulin on board, glucose, glucose trend 2.Timing of exercise relative to recent meals and boluses 3.Duration and intensity of exercise 4.Your training level 5.Whether the exercise is aerobic or anaerobic 6.Stress hormone release in competitive sports

23. How energy is created during exercise Sources of Fuel: Circulating Glucose from recently consumed CHO Stored glucose in Muscle Stored glucose in Liver Fat = body’s largest fuel reserve; 2,000 times as large as stored glucose Balancing the Fuel: Insulin Glucagon FFA provide fuel FFA, @ 25% available glucose; 50% glucose; 50% FFA

24. Anaerobic Exercise Very Intense, short duration Competitive exercise Raises glucose immediately after the exercise due to release of stress hormones

25. Glucose and Insulin Levels Impact Performance Blood GlucoseInsulin levelEffect on metabolismImpact on performance < 70HighNot enough glucose available to cells Fatigue, poor performance 70-180IdealGlucose & fat released as fuel normally Maximum performance > 180Ideal to ?If insulin level OK, fuel use normal Performance might be reduced – OK to exercise > 250Low to ?If insulin is OK (ketone level not moderate or high) exercise should lower ; if insulin levels low, fuel use inadequate and high BG might occur Reduced performance – if insulin levels OK, moderate exercise OK, No strenuous exercise. DO NOT EXERCISE if moderate to high ketones

26. Carbohydrate Intake & Exercise < 120mg/dl = 30 grams CHO before exercise 120 – 200 mg/dl = 15 grams CHO before exercise > 200mg/dl = no additional CHO needed RE-TEST every 30 minutes of exercise and re-evaluate need for additional CHO

27. Ex Carbs = How many Carbs an exercise is likely to consume From “Pumping Insulin” Walsh, J, Roberts, R Torrey Pines Press, 5 th Edition 2012

28. Your Training Status Training builds glycogen stores in the muscles large glycogen stores tend to reduce glucose fluctuations Once basal rates and boluses are appropriately adjusted, the fit person tends to have more stable blood glucoses. If Untrained or lapsed = 25% more glucose After unusual or prolonged activity larger fall in glucose occurs several hours (in some cases up to 24 hours) after as glycogen stores are replenished { “Carb loading” before and after prolonged, intense exercise enhances muscle glycogen stores: important in preventing exhaustion}

29. From “Pumping Insulin” Walsh, J, Roberts, R Torrey Pines Press, 5 th Edition 2012 ©2012 Diabetes Services, Inc

30. When & how do I lower insulin? For very short, unplanned for exercise: increase CHO intake no insulin adjustment necessary For moderate duration (60-90 minutes): increase CHO OR decrease bolus before activity For prolonged duration (90 minutes or longer): increase CHO Make adjustments to bolus and basal rates

31. Decreasing Insulin for Exercise Stopping Insulin: never should stop or disconnect for more than 60 to 90 minutes Insulin is needed to utilize circulating glucose for energy and to suppress uncontrolled release of glucose from liver and muscle = this uncontrolled release can lead to hyperglycemia; potential DKA Reducing Insulin: Moderate exercise of > 60 minutes = Lower by 20% Strenuous exercise of > 60 minutes = Lower by 50%

32. Decreasing Insulin for Exercise

33. Life Lessons You Can Learn from Albert Einstein: Follow your curiosity Make Mistakes “a person who never made a mistake never tried anything new” Try something new…. “Insanity: doing the same thing over and over again and expecting different results.” “Everything should be made as Simple as possible, but not Simpler” Perseverance is priceless Knowledge comes from experience Learn the “Rules” and then play better