1. Insulin Pump What to tell your patient!! Prakash Abraham Isla Fairley

4. Present generation pumps Paradigm (Medtronic £2750) Animas (Johnson & Johnson, £2600) Spirit (Roche, £2375) Deltec Cozmo (Smiths Medical, £2750)

5. Insulin Pump Usage: Grampian ~2% vs UK 4%

6. What does the pump do?

7. 2008 NICE recommendations Disabling hypoglycaemia (repeated and unpredictable occurrence of hypos that result in persistent anxiety about recurrence and adverse quality of life) HBA1c > 8.5% despite high level of care Children <12 (where MDI impractical) and should have a trial of MDI between 12- 18years.

8. Who can consider the pump 1 Patient characteristics Type 1 DM Basal bolus regime Well motivated Cope with CHO counting (DAFNE) Monitoring at least 4 times No evidence of Psychological illness

9. Who can consider the pump 2 Disease characteristics Frequent hypoglycaemia Hypoglycaemia unawareness Gastroparesis Poor control Marked dawn phenomenon

10. New Aspects to consider for pump Carbohydrate Ratios –DAFNE (Dose adjustment for normal eating) Insulin Sensitivity / Correction doses –DAFNE Basal Rates (Additional to DAFNE) –1 basal injection to potentially 48 choices –Fasting at different times to titrate

11. Carbohydrate/ Insulin Ratio number of grams CHO covered by 1 unit insulin The 500 Rule: 500 divided by total daily dose equals CHO ratio. Usually 10-15 May vary at different times of the day.

13. 4 8 12 16

14. Insulin sensitivity how much 1 unit of insulin lowers bg over 2-4 hours Correction dose The 100 rule: 100 / total daily insulin dose May vary at different times of the day

16. 8 4 12 16

17. An overnight drop of upto 2mmol/l is OK 5 10 15

19. What does the pump involve? Insulin set changes every 2-3 days Correction doses –Insulin sensitivity to be checked at different times Carbohydrate ratios –Monitor Meal Bolus rates for each of the meals

20. What does the pump involve? Basal rates to be checked –Skip breakfast for overnight rate –Skip lunch for daytime rate –Skip dinner for evening rate Takes 3-6 months of work to get the various rates and ratios sorted. Then work out weekends, more active days etc

21. Assessment Interview with DSN/Doctor/Dietitian Confirm eligibility and motivation CHO counting (DAFNE course) Pump demonstration Dummy pump (CGMS) to carry for 2 days Pump panel for funding decision

22. Pump Start First week: Intensive (Days off Work) Patient Contract QOL (PAID) / Hypo questionnaires First 3 months: 3 to 6 visits to Diabetes Resource Room, then at 6 & 12 months Pump clinic: 4.5 /9 /15 months then ~4 monthly (CGMS)

23. Patient contract

24. Initial Pump Support Variations Two of the new starts in 2007 MT –4 months: Phone calls 2 weekly –emails 2 weekly –9 appointments (3 with Doctor) GN –6 month: 3 phone calls –3 emails –3 appointments (2 with doctor)

25. Disadvantages Wearing a device Essential to check BMs minimum 4 times a day. Risk of DKA as only short acting insulin Work involved in assessing rates and ratios.

26. Advantages Minimise Hypoglycaemia Less variability in blood sugars More precise insulin dosing Flexibility to change basal rates depending on activity Quality of Life

27. Summary of profiles over 3 days

28. CSII NOT for everyone

29. Effort vs Reward