Is a Pump for You?

Who should get an insulin pump?


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An insulin pump is one of the available means for giving insulin. The other, of course, is giving insulin by traditional injections, whether that is with a needle and syringe, or a “pen”. Pump therapy is one of the ways of “intensifying” therapy, the other being multiple daily injections. Thus pump therapy and multiple daily injections are often referred to as “intensive therapy”, as compared to older regimens, which are less “intensive”. In reality, however, “intensive therapy” is the standard modern therapy of diabetes for most patients who need insulin.

“Intensive therapy” actually refers simply to giving insulin in a way that mimics the way insulin is released in the body of a person who does not have diabetes. About half the insulin produced in a day is secreted as more-or-less stable background “basal” insulin that “keeps things in balance”. This is the amount of insulin that would be secreted in a person fasting at rest. And only about half is secreted in response to food - at the “right” time (when the person feels like eating) and in the amount appropriate for the size of the meal!

Thus “intensive therapy” always includes some basal insulin and mealtime “bolus” insulin. Multiple daily injection protocols usually use glargine (Lantus) given once or twice a day for the basal insulin, while a pump delivers a trickle of fast acting insulin all the time as the basal insulin. With both treatments fast acting insulin is used to “cover” meals, which can therefore be varied in time and size (insulin is given at a time and in an amount appropriate for the selected meal, making possible brunch and late romantic dinners)!

The pump does not measure blood sugar and does not “decide” how much insulin should be given. The latest pumps help with dose calculations, but the patient makes all decisions. Thus, whether on multiple daily injections or using a pump, at mealtimes a patient must check the blood sugar and decide the bolus based on the blood sugar, food to be eaten, anticipated exercise, etc.

So why bother with a pump? Some people prefer insulin delivered through the infusion set of a pump rather than giving “shots”. The pump infusion set – a plastic tube rather like a small “iv” – is inserted by the patient under the skin, and stays there 2 - 3 days before needing to be re-inserted at a new site. So while some like getting away from “shots”, others actually dislike being attached to something 24/7!

Other advantages? Without going into details, the pump is a much more refined tool than multiple daily injections. Thus, for instance, it is possible to set multiple basal rates during a day and different basal profiles for different days, it is possible to give boluses over several hours to cover high fat and high fiber meals, it is relatively easy to make adjustments for unanticipated exercise, and the newer pumps incorporate calculators to help calculate food boluses, correction boluses, avoid overlapping doses, etc. Because of these additional features most patients can lower their HbA1c ~ 0.5% compared with multiple daily injections and in addition the frequency of low and high blood sugars is decreased.

So, is a pump for you? In each case we will start with multiple daily injections, since many of the skills are identical. After that we will decide with you whether to move on to a pump. On the next page is the check list that we use to help decide whether to move on from multiple daily injections to a pump, and to guide the first few weeks of the changeover:

Insulin Pump Initiation Check list
Patients are deserving of a pump therapy trial when the answer to the question "Is it likely that this patient will be at least as well off and preferably better off using a pump than using injections?" is “yes”. The items under (1) below are not hurdles, but rather a roadmap. Patients who choose to not switch to a pump are making a reasonable choice and are NOT second-class citizens.

1. Pre– Pumping trial of multiple daily injections (MDI; almost always), demonstrating:

  • Frequent blood sugar checks
  • Carbohydrate counting (including an appointment with the dietician and endorsement)
  • Calculation(s) of correction dose
  • Record/log keeping
  • Correct hypoglycemia management (handout provided)
  • Prescriptions: Novolog (preferred, Humalog – acceptable), foil-wrapped ketone test strips, glucagon kit, adequate number of test strips
  • Give patient the Insulin Pumping book
  • Ascertain that there is still a need / patient still wants a pump after MDI

2. Expectations of initial pumping period:

  • Frequent visits to adjust basal rates and doses
  • Log/record keeping, including documentation of name, date of birth, basal rate, meal boluses, correction boluses, carbohydrate counts, activity and significant other issues (e.g., stress)
  • Methods of sending in blood sugars (email, fax; phone – acceptable but discouraged)
  • Read instructions that come with the pump PRIOR to training

After starting on the pump (points to cover; some level of knowledge and skill should be developed in all
these areas):

  • Infusion site selection and care / site infections / frequency of site change
  • Sick day management / DKA (handout) / use of ketone strips
  • Fine tuning basal rates (handout) / changing basal rates on the pump
  • Using pump / log sheets or Palm
  • Frequent blood glucose checks (including when blood glucose is >250 or <70)
  • Hypoglycemia protocol
  • Verifying the correction factor and carbohydrate ratio (handout)
  • Boluses – normal, square wave, dual wave
  • Exercise and pumping (handout)
  • Temporary basal rates 
  • Interruption of pump therapy (including frequency of blood glucose checks)
  • The Pumper’s Kit (handout) / emergency kit
  • Special considerations

i) Travel
ii) Airline travel (including prescriptions and travel letter)
iii) Hospital management
iv) Management of pump during procedures / surgery
v) Management of pump for X-Rays, CAT scans and MRI’s
vi) Other magnetic fields
vii) Free fall rides and roller coasters


 

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