1. 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.comgary@integrateddiabetes.com

2. Advanced Pump Management Basal Insulin RegulationBasal Insulin Regulation Bolus RegulationBolus Regulation Physical Activity AdjustmentPhysical Activity Adjustment DKA PreventionDKA Prevention Temporary Basal RatesTemporary Basal Rates Prolonged BolusesProlonged Boluses Alternate Basal PatternsAlternate Basal Patterns

3. Basal Insulin Regulation Basal Insulins One And Only Job Is To Hold Blood Glucose Levels Steady In the Absence of Confounding Influences*Basal Insulins 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)

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

5. Basal Insulin Regulation 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 Sample Basal Testing Schedule

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

7. Basal Insulin Regulation Example 1: Sara Smiley Currently:Currently:.30 3am-9am,.30 3am-9am,.25 9am-3am.25 9am-3am Skipped BreakfastSkipped Breakfast BG results: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

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

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

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

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

12. Physical Activity Adjustments Snacking to prevent low (examples)Snacking to prevent low (examples) Carbohydrate Replacement Per 60 Minutes of Activity 50 lbs100 lbs150 lbs200 lbs250 lbs Skating 7-10g14-20g20-30g28-40g35-50g Gymnastics 8-12g17-23g25-35g34-46g42-57g Soccer 13-17g27-33g40-50g54-66g67-82g

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

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

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

16. DKA Prevention Normal Cellular Metabolism Normal Cellular Metabolism

17. DKA Prevention MetabolismWithInsulinDeficiency

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

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

20. DKA Prevention

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

22. Temporary Basal Rates High-Fat FoodHigh-Fat FoodDurationAdjustmentNotes8:00+60% Start After Meal

23. Temporary Basal Rates IllnessIllnessDurationAdjustmentNotes24:00+80% Repeat as Needed

24. Temporary Basal Rates Predictable StressPredictable StressDurationAdjustmentNotes3:00+80% Set 1-2 Hours Prior

25. Temporary Basal Rates Extended InactivityExtended InactivityDurationAdjustmentNotes Varies (>3 hrs) +40% Great for long trips!

26. Temporary Basal Rates Menstrual CyclesMenstrual CyclesDurationAdjustmentNotes12:00 +50% (pre) Start at night 12:00 -30% (post) Start at night

27. Temporary Basal Rates Prolonged ActivityProlonged ActivityDurationAdjustmentNotes Minimum 2 hrs. -50% Start 1-2 hours prior

28. Temporary Basal Rates Prevention of DOH! (Delayed-Onset Hypoglycemia) DurationAdjustmentNotes 6-10 hours -25% Base timing on experience

29. Temporary Basal Rates AlcoholAlcoholDurationAdjustmentNotes 2 hrs per drink -40% Begin after drinking

30. Temporary Basal Rates OffsettingBedtimeInsulin-On-BoardDurationAdjustmentNotes 4 hours Enough to offset IOB Will not work if very large IOB

31. Temporary Basal Rates BG Dropping (w/nausea)BG Dropping (w/nausea)DurationAdjustmentNotes 4 hrs -75% Monitor BG hourly

32. Prolonged Boluses DescriptionDescription 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.

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

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

35. Prolonged Boluses Options for slow-digesting food: Normal Bolus

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

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

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

39. Alternate Basal Patterns 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 Potential Uses:

40. The Ultimate Pump Challenge