1. Bradford Insulin Pump Service Gill Atherton Sandra Dudding Diabetes Specialist Nurses

2. CSII service started in Aug 2002 60 patients on CSII ( to Jan 07) 1 pt started by Harrogate team 2001 3 pts 2002 5 pts 2003 10 pts 2004 14 pts 2005 21 pts 2006 6 pts – Jan 07 2 pts – died 2 pts discont

3. Criteria for CSII NICE guidelines Type1 DM Preconceptual / ante-natal ‘failed’ MDI therapy ie unable to maintain HbA1c no greater than 7.5% (6.5% if microalbuminuria present) without causing disabling hypo’s Be committed and competent to use CSII

4. Local Guidelines Life disrupting hypo’s (unawareness) / hyperglycaemia (DKA) Already on pump Dawn phenomenon Small insulin requirements

5. NICE also state ‘ CSII therapy should only be initiated by trained specialist team’ All individuals on CSII should have ongoing support and agree a common core of advice appropriate for CSII users.

6. 26 pts – hypo unaware 5 pts (dialysis) : 2 died, 1 renal transplant now preconceptual, 1 on PD, 1 haemodialysis – both on pancreas / kidney waiting list 11 pts with raised MCR 2 pt DKA 2 pts gastroparesis preconceptual Age range 18 - 70

7. CSII Medtronic 508 / 511 / 512 / 712 / 515 / 715 Realtime 522 / 722 Quickset / silhouette / softset catheters Novorapid / Humalog Pumps cost £2,680 Consumable approx £1000 p.a

8. Pro’s Different basal rates –adjusts to 0.05 u /hr Wizard bolus (calculates insulin bolus to 0.1 unit and calculates active insulin) Adjustments - CGMS Hypo awareness Flexibilty and stability Accuracy (small insulin doses) Needle phobia / freedom from injections

9. Con’s ‘attached’ to a machine (body image) Risk of DKA Frequent blood glucose monitoring On-call for healthcare professionals Resite catheters every 3 days Carrying back-up supplies Intensive education / time commitment

10. Outcomes 1 patient severe hypo’s requiring paramedics 1 DKA (infrequent HBGM) required admission –taken off pump 1 pt requested swap back to MDI Most patients happier with CSII, improvement in hypo awareness Lower Hba1c – weight gain Continuous support

11. Future Developments 1 st patient pump update day held Oct 06 2 nd update day to be arranged Qualitative research Protocols Education

12. Pre – Conceptual pump service

13. Why ? Maintaining near normal blood glucose levels before and during pregnancy has been shown to reduce the risk of complications for both mother and baby. During pregnancy blood glucose levels can rapidly change, due to hormonal changes. A CSII offers the advantage of being able to administer the correct amount of insulin at the correct time. It also helps with dietary changes, nausea and vomiting

14. Who ? Type 1 Diabetes Unable to maintain HbA1c below 7% prior ro conception Erratic blood glucose control Hypoglycaemia unawareness Be prepared to test blood glucose 6 – 8 times daily Carbohydrate counting Be prepared to attend frequent appointments in pre conceptual clinic Be aware that the CSII is only funded for pregnancy

15. When ? 3 to 6 month prior to conception Aiming for HbA1c of 5-6% during pregnancy To take folic acid 5mg OD Referred to Mr Tuffnell for pre conceptual advice Patient is taught to adjust both basal and bolus insulin patterns The CSII is worn throughout delivery for both normal labour and LSCS Basal rates reduced post natal and breast feeding encouraged

16. BRI data 20 patients on CSII 6 Boys and 2 girls 2 ladies pregnant