Insulin Pump Therapy

Insulin Pump Therapy 2

What is insulin pump therapy?

How does an insulin pump work?

A small computerized, battery-operated pump
Allows the user to control exactly how much insulin is delivered
A pump reservoir
Similar to a regular syringe, holds 2-3 days worth of insulin
A thin plastic tube called an infusion set
Has a soft cannula or needle at the end inserted just under the skin, usually on the abdomen
How does it work?

Insulin passes from the pump reservoir through the tubing into the subcutaneous tissue.

What is insulin pump therapy?

How are pumps more effective?

Pumps can more closely mimic the insulin secretion of a healthy pancreas because they:

  • use rapid-acting insulin.
  • deliver insulin in two ways, basal and bolus.
  • use a Bolus Wizard® calculator.

The ultimate goal of every insulin regimen is to mimic the insulin delivery of a healthy pancreas.

 

What is insulin pump therapy?

Insulin pumps use only rapid-acting insulin

Rapid-acting insulin minimizes therapy errors due to pharmacodynamic variability in insulin action

This clinical study found there was a 46% variation in the effectiveness of intermediate-acting insulin, and 36% variability for long-acting insulin. The variability for rapid-acting insulin was only 16% – almost three times more consistently effective than intermediate-acting insulin.

*Percentages represent coefficients of variation (CV) for insulin action as measured by maximun glucose infusion rate in these euglycemic glucose clamp studies.
Heinemann L, et al. Variability of the metabolic effect of soluble insulin and the rapid-acting insulin analog insulin aspart. Diabetes Care. 1998;21:1910-1914.
Heise T, et al. Lower within-subject variability of insulin detemir in comparison to NPH insulin and insulin glargine in people with type 1 diabetes. Diabetes. 2004; 53:1614-1620.
 

What is insulin pump therapy?

Pumps use basal and bolus insulin delivery


Insulin delivery more closely mimics insulin secretion of a healthy pancreas.

 

What is insulin pump therapy?

Medtronic pumps use the Bolus Wizard® calculator

What is the Bolus Wizard feature?


The Bolus Wizard is a feature that calculates an estimated bolus to support food intake or to correct a high blood glucose.

The calculation is based on several items that are set up in the insulin pump:

  • Carb units (Grams or exchanges)
  • Insulin to Carbohydrate Ratio (ICR) – number of carbohydrate grams covered by one unit of insulin
  • BG units (mg/dL or mmol/L)
  • Insulin Sensitivity Factor (ISF) – the number of mg/dL one unit of insulin lowers glucose.
  • BG Target – BG values used in the correction formula when calculating a correction dose
  • Active Insulin – insulin remaining from previous boluses that continues to have a pharmacodynamic effect and the potential to lower glucose
AND
Items that the user enters into the insulin pump:

  • Current blood glucose (BG)
  • Carbohydrates to be eaten

 

What is insulin pump therapy?

Boluses are automatically calculated based on preset values

The Bolus Wizard Calculator

Click through the steps below to see a simulation of the Bolus Wizard in action.

The Bolus Wizard calculator:

  • Calculates the bolus amount the patient needs when they eat or need to correct a high glucose level.
  • Tracks the amount of active insulin still remaining from boluses that were given earlier.
  • Helps prevent the lows that occur from "insulin stacking" by subtracting any active insulin from a correction bolus amount before it provides the estimated amount or "Total Bolus" to the patient.

 

Insulin Pump Therapy

What is the scientific evidence?

Intensive insulin therapy reduces long-term complications

  • Intensive insulin therapy can reduce A1C
  • Lowering A1C reduces long-term complications
  • However, severe hypoglycemia increased as A1C decreased for intensive therapy group (a mix of pump and MDI patients)
  • The methodology flaw in this trial was that participants could choose MDI or pump, and could bounce back and forth between the two
  • Additionally, it should be pointed out that rapid-acting insulin was not yet available
  • This study made it very clear that intensive therapy reduced long-term complications, but it was not clear which method, MDI or pump was more effective

Adapted from DCCT Research Group: N England Journal of Medicine. 1993;329:977-986; "Endocrine Practice" 202, 8 (supp 1), pg 7.
 

What is the scientific evidence?

Pumps lower A1C better than MDI

Yeh HC, et al. Ann Intern Med. 2012;157:336-347
 

What is the scientific evidence?

Pumps reduce hypoglycemic events

Rate ratio 4.19 (95% CI 2.86-6.13)

Pickup JC, Sutton AJ. Diabet Med. 2008;25:765-774.
 

What is the scientific evidence?

Pumps do not increase the rate of DKA

 

·No change compared to MDI: 1 episode during study


These four studies published over an eight-year period all concluded that pumps do not increase the rate of DKA.

Plotnick LP, et al. Safety and effectiveness of insulin pump therapy in children and adolescents with type 1 diabetes. Diabetes Care 2003;26(4):1142-1146.
Bruttomesso D. Continuous subcutaneous insulin infusion (CSII) in the Veneto region: efficacy, acceptability and quality of life. Diabet Med. 2002;19(8):628-634.
Linkeschova, M, et al. Less severe hypoglycaemia, better metabolic control, and improved quality of life in type 1 diabetes mellitus with continuous subcutaneous insulin infusion (CSII) therapy; an observational study of 100 consecutive patients followed for a mean of 2 years. Diabetes 2002;19:746-751.
Steindel BS, et al. Continuous subcutaneous insulin infusion (CSII) in children and adolescents with chronic poorly controlled type 1 diabetes mellitus. Diabetes Res Clin Pract. 1995;27(3):199-204.
 

Insulin Pump Therapy 3

What is the process for initiating patients on the pump?

Five Steps:
  1. Identify candidates
  2. Initiate pump prescription
  3. Calculate starting doses
  4. Start patient on pump
  5. Follow-up

 

What is the process for initiating patients on the pump?

Candidate selection

Indications Include:

  • Elevated A1C
  • Glycemic variability
  • Recurrent hypoglycemia
  • Nocturnal
  • Activity induced
  • Hypoglycemia unawareness
  • Recurrent DKA
  • Dawn phenomenon
  • Pregnancy and/or pre-pregnancy
  • Gastroparesis
  • Patient quality of life
  • Meal flexibility
  • Busy lifestyle
  • Athletes
  • Tighter control
Assess for:

  • Willingness to monitor BGs
  • Quantify food intake
  • Comply with medical follow-up
  • Responsible / Psychologically stable
  • Adequate vision or hearing

 

What is the process for initiating patients on the pump?

Initiate pump prescription

Preparations for Initiating Pump Orders

  • Discuss therapy with interested patients
  • Have Medtronic review payer considerations
    - A1C - BG Journals - Other labs (as needed)
  • Draw labs needed for insurance approval
  • Write prescriptions:
  • Pump
  • Initial pump settings
  • Vial(s) of rapid-acting insulin
  • Test strips / lancets
  • Glucose Tablets
  • Glucagon Emergency Kit
  • Ketone Strips

 

What is the process for initiating patients on the pump?

Follow-up ensures patient success

Supporting and fine-tuning settings is especially important during the first few weeks after starting a patient on a pump.

 

Follow-up Ensures Patient Success

 

In summary, initiating patients on pump therapy is really about a team with the patient in the center. It is not just the healthcare provider and staff trying to take care of everything. By incorporating educators and the Medtronic team to enhance efficiency, you can create a seamless flow and, most importantly, ensure the safety of the patient transitioning to pump therapy.