1. Should this patient be on insulin pump Tuan Quach Staff Specialist John Hunter Hospital

2. Case 1 19 year man shift worker; labourer Epilepsy: hypos induced Type one diabetes for 10 years Lantus 25 mane Novorapid 2-2.5 unit per exchange Monitors 4-8/day HbA1c about 8.5-8.9% for years No complications

3. Case 1 Fear of hypos and seizure Erratic hours Good hypos awareness Try to keep BGL 8-12 mmol/L Frustrated with swing of BGLs

4. Case 1 Attended intensive insulin education course ( empowerment course) –Update about basic insulin therapy –Hypos/ sick day management –Review carb counting; correction Still not improved 3 months later : –Still run BGL 8-12 mmol/L –More stability

5. Case1 Pre-pump education –Expectations of pump –Benefits and harm with pump –Types of pump Pump started successfully Follow up with educator and physician weekly then monthly for on going adjustment/ advance pump skills Achieved HbA1c 8.0% for the first time with no hypos

6. Advantages Of Pumps Over MDI More reliable insulin action Fewer missed/skipped doses Precision – 0.05 u versus 0.5 u Automatic dose calculations Less insulin stacking

7. A More Normal Lifestyle Flexible mealtimes Less hypoglycemia Flexible insulin delivery for exercise, skipping meals, erratic schedules, shift work Less hassle with travel and time zones Increased sense of well being Less anxiety while staying on schedule Plus reminders, history, accurate dose calculations, etc.

8. The Challenge Of Diabetes Bringing the A1c down smoothly takes effort …for this you need ADVANCED therapy (5.5) (11.1) (16.7) Normal A1C 4%–6% BGL (mmol) 0800120018000800 Uncontrolled A1C ~9% A1C ~6% “Controlled” A1C <7% Time of Day

9. Poor Control Remains A Problem HbA 1c 10% 9% 8% 7% 6% ADA EASD/AACE ADA = American Diabetes Assoc., IDF = Inter. Diabetes Federation, EASD is European Assoc. for the Study of Diabetes, AACE = American Association of Clinical Endocrinologists Novo Nordisk Type 2 diabetes market research, Roper Starch Wright A., Burden et al, Diabetes Care 2002; 25:330–336 Turner RC, Cull et al, JAMA 1999; 281:2005–2012 2/3 with diabetes (and most pumpers) remain out of control Avg. A1c in TYPE 1s Avg. A1c on Pumps Goal A1c 5%

10. Benefits of insulin pump Reduction in HbA1c 0.2-0.6% Reduction of blood glucose by 1 mmol/L Reduction of daily insulin dose by 14% Reduction of server hypos Improvement in quality of life

12. Case 2 Miss JL 18 years old transition form paediatrician DM 1 for 7 years Has been on pump for 3 years Good diabetes control when she was younger Left school moved in with much older boyfriend

13. Case 2 Binge alcohol and smokes Experimented with drugs Eating and sleeping pattern erratics No monitor; not bolusing; not changing line DKA 3-5 times per year Poor attendance to clinic HbA1c >10%

14. Case 2 Persuaded to take off pump Re-educated on Lantus and Novorapid Re-enforced that Lantus is important to prevent DKA Perhaps only take Novorapid when remembered No further admission for DKA for the past 2 years

15. Transition patient Often very good control when still living at home; parents cook; supervise insulin Often have very poor basic diabetes skills Often have very poor insulin/pump skills Adolescent issues Chronic illness behaviour : psychological dependency on the pump

16. Risk of DKA and pump Theoretical risk as pump only have short acting insulin and no long acting With interruption of insulin pump within 4- 6 hours DKA can be precipitated Often in patient who does not monitor BGL No different rates of DKA in trials compare MDI vs CSII

17. Benefits For Kids & Teens Better for growth spurts, hormone changes in puberty, Dawn Phenomenon Easy to cover snacks TDD and bolus history available to ensure consistent dosing Fast adjustments of basals and boluses for changes in activity/exercise Lessens impact of BG swings on top of peer pressure, struggle for independence, mood swings, college, and issues with alcohol, sex, drugs

19. Case 3 35 years old executive; DM I 15 years No complications Travels lots Lantus insulin 30 mane (0700) Novorapid 3 units per exchange HbA1c 8.2% Problem: high BGL on waking ( 12-16 mmol/L)

20. Causes of high BGL in early AM Lantus running out Eating too much late at night Dawn phenomena Somogyi’s effect

21. Dawn phenomena BGL raise in the early hour of the morning Normal diurnal rhythm : BP ;PR; Temp… Part of other hormones: cortisol; adrenaline Can be difficult problem in diabetes Can be managed by split dose basal insulin May need insulin pump: basal dose can be programmed

22. Case 3 Patient was confirmed to have Dawn phenomena by repeated overnight testing Splitting of Lantus dose was partially helping Patient travels makes control harder Insulin pump was initiated after extensive education process: problem corrected.

23. Novorapid Time 0600 120018002400 1.5unit/hr 1.2unit/hr 0.6unit/hr Basal rate can be programmed to over come the Dawn’ phenomena

24. Somogyi’s effects Hyperglycaemia follow a hypos Responding to stress hormones of a hypos : cortisol; sympathetic hormones; growth hoemones Nocturnal or early am hypoglycaemia may manifest as early am high BGL Always ask patient to set alarm and check BGLs early am before change insulin

25. Groups of patient that may benefit from pump therapy Dawn phenomena Frequent hypos Hypo-unawareness Small TDD; ‘brittle’ diabetes Injection site problems Variable meal time; work; exercise Pregnancy Young adolescent Gastroparesis

26. Type 1 pregnancy and Pump Preconception tightening up of HbA1c 6- 7% lower risk of foetal malformation Improvement of glycaemia through pregnancy can lower marternal and foetal complications Minimize risk of hypos as patient tend to run BGL a lot lower

27. Lipodystrophy and insulin absorption 20% to 50% of MDI patient Increased variability in insulin absorption Induced variability in glycaemia 20% variability of insulin absorption for each administration Pump can over come this problem

29. Keys to have successful insulin pump patients Patient selection Education process: before and after Supports/ Follow up

30. Patient selection Patient has be willing and able to be on pump Motivated to have self management Commitment to have a partnership with the pump team Other clinical criteria as above

31. RCT indication for pump efficacy HbA1c persistently elevated despite intensify MDI (A) Recurrent hypoglycaemia(A) Marked glycaemic variability(B) No evidence for type 2 diabetes

34. Expectations UnrealisticRealistic The pump will cure my diabetesI will feel better Poorly controlled diabetes make me depressed; pump will fix my depression I need to get treatment for depression I won’t have to test as muchI must monitor very frequently I can eat anything I wantI will have more freedom with my food choices My blood sugar will be perfectI will have better control with fewer lows It will be as easy to learn as a meter It will take time to learn and adjust to the pump

35. Contraindication Absolute: –Severe psychiatric illness –Severe progressive proliferative retinopathy Relative contraindication –Not monitoring –Poor basic diabetes education

36. Three stages of insulin pump initiation Diabetes education –Basal-bolus concept –Carb counting competency –Hypos; sick day management Education of technical aspect of pump: –Infusion set; line changes –Pump function; programming Follow up: –Ongoing education/ adjustment –Advance pump skills –Emergency plan; supports

38. Pump team Educator Dietitian Endocrinologist

39. Follow up plan: more education Regular contacts with educator: review line changes; pump rates Monthly visit with physician until stable Care link; internet; phone Texting; Email; Facebook All need emergency plan: –Check BGL 1-2 hours after line changes –High BGL management –Low BGL management

40. Emergency plan Severe hypos: ( <2.5 mmol/L+need help) –stop/suspend pump –Treat hypos and review cause –Restart pump only when BGL>4.0mmol/L Hyperglycaemia: persistent BGL>12-15 –Correction boluses via pen –Line change Pre-DKA/DKA –Sick day plan –Present to ED prepared to suspend pump –Patient need to be aware of own total basal in pump

41. Insulin pump and resources Insulin pump treatment is costly Insulin pump takes up significant resources Shortage of educator with pump expertise

44. Thank you