Insulin Pump Therapy

Ovid: Diabetes Management in the Primary Care Setting

Aut hor s: Title :

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Unger , Je ff

Diab ete s M anag e me nt in the Pr imar y Care Se tting , 1s t Ed it io n

C opy right  ©2007 Lippincott Williams & W ilk ins > T abl e of C ontents > 6 - Insuli n Pum p Therap y

6 Insulin Pump Therapy Take Home Points 

Insulin pump the rapy allows patient s to man ag e t h eir d iab et es in te n sive ly by u sing a met hod th at is p harmacologically sup erior to multiple daily inje ction s (MDI s)

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Pumpe d insulin is de live re d via basal, bolus , an d su pp leme nt al in su lin

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Patient s who use insulin p ump s must be tr ain ed in u sin g MDIs be fore be gin nin g p ump th e rapy. If t he pump malfunctions, the p at ient w ill n ee d t o re ve rt to u sin g MDIs on a te mpor ar y b as is

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Alt hough pr oviding s up er ior phys iologic in su lin r ep lace men t th er ap y w he n compare d w ith MDIs an d c onsist ently be ing favore d in qualit y-of- life asse ssme nt st ud ies ov er oth er forms of ins ulin r ep lace ment ther ap y, pumping insulin is mu ch more cost ly t han “t radit ion al th er ap ie s. â€

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Any patie nt who us es insulin is a p ote nt ial can didate for an in su lin pu mp

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The ne we st te chnology combines insu lin pu mping with c on t in u ous gluc ose sen sin g. Th is allows p at ients to re ce ive an alar m that is t ran smitte d f rom th e se ns or site t o th e in su lin p ump , w ar nin g t he m if the ir int er st it ial g lucose lev els ar e t oo high or too low. An im mediate th e rape ut ic adjust ment c an be made . Patie nt s wh o u se th e pu mp -au gme nt ed sen sor are ab le t o efficie nt ly mod ify the ir continuous s ub cutane ous ins ulin in fu sion (C SII) –p re scr ibed parame te rs

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Pre sc ribe rs and p at ients de siring C SII s hou ld c ar efu lly con side r t h e adv an t ag es an d d isadvan tage s of insulin p ump ther apy ov er sy ring es , v ials, and pe n- in jec tor dev ices .

P. 266

Case 1 Le onar do, ag e 15, w as diagnosed as hav ing ty pe 1 diab et es (T1DM) 6 mon th s ago afte r a 3 -d ay vir al uppe r res pirator y infec tion. Se ve n days aft er th e up pe r r esp ir atory infe ct ion r esolve d, h e b eg an e xpe rie nc ing weak ne ss, fre que nt urinat ion , m ild ab dominal pain , an d we igh t loss, de sp it e havin g a vor ac ious ap pet ite . H is family physician, notin g t hat Leon ardo ap pear ed de hy drat ed, pe rf or med a rand om finge rst ic k b lood glucose le ve l measure me nt , w hich was 338 mg p er dL . Af te r t he patie nt was r eh yd rate d in the off ic e, insulin ther ap y w as initiate d b y u sin g a BID 70/30 mixe d analogu e in su lin -p en in ject or.

W it hin 4 days , L eonar do imme diat ely be gan to gain weig ht and fee l more en e rge tic, alth ou g h h is b lood glucose re ading s r emaine d f ar ab ove targ et . Fou r mon th s late r, Le onard o's A1C w as 7.8%. Howe ve r, he was e xp er iencing wide g ly ce mic swings, wit h g lucos e le ve ls ran ging from 50 t o 275 on a ne ar -daily b as is .

The family d octor sugg est ed that L eonar do be st arte d w ith basal -bolu s ins ulin th er ap y c ons is ting of be dt ime g larg ine and pr eme al g lulisine wit h p en in ject ors. Wit h t h e h elp of a re gist ere d diet ic ian , Le onar do was able to le ar n carbohyd rate (car b) c ou n tin g. He be gan c he ck in g his b lood glu cose lev els s ix to e ight t imes daily , and his A1C leve ls d ecr ease d 1. 5% with in 3 mon th s of in te n sifyin g h is in su lin re gime n.

Ov er a 30 -d ay r ecor ding pe riod, 10% of th e patien t 's pre su pp er re ad in g s we re less th an 60 mg pe r dL on basal-bolus insulin. His fasting g luc os e le ve ls we re aver aging 145 mg pe r d L. Le on ard o was a cr os scountry runne r, and his low blood g lucos e le ve ls corr elate d wit h t h e d ay s on wh ich he in ten siv ely traine d for mor e than 60 minute s. Desp ite re ducing th e dose of h is me altime bolu s by 80% 4 hou rs be fore be ginning his t raining s ess ion and targ et ing a pre -e xe rcise blood gluc ose le ve l of 180 t o 240 mg pe r dL , Le onar do would st ill b ec ome hyp og lyce mic e it he r du rin g th e ru n or wit hin 4 hou rs of comp le tin g t he tr aining se ssion. A lt hough he had no e vide nc e of sev er e h yp oglyc emia, t he pat ie n t and h is moth er we re bot h c onc er ne d about how e lse they should modify his in su lin r egime n to min imiz e h is sig nifican t gly cemic ex cursions, e sp ecially wit h his act iv e life sty le.

Le onar do's family phys ic ian sugg est ed that u sin g an in su lin p ump migh t h e lp main tain a mor e pre dict ab le lev el of g lyce mic contr ol. The p hysician ex plain ed th at some of t he n ew est -ge n er at ion pu mp s comb in e d

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glucose -se ns ing tec hnology with ins ulin pu mpin g. Re al- time in te rst itial g luc os e r eadin gs ar e d isplaye d on the pump sc re en, and an alarm would warn Le onar do wh en t he glu cose lev els ap pear ed to be de cr easin g too quick ly or b ec oming e lev at ed above the 240 -mg pe r d L tar get . On he aring th e alarm, Le onar do sh ould chec k his blood g lucos e le ve l with his standard home blood g luc os e me te r an d t ak e th e app ropr iat e act ion to cor re ct the hyp er glyc emia or hyp oglyce mic e ve nt . A lt hou gh t he pu mps ar e mor e ex pen siv e t han ins ulin pe ns , L eonar do's long -te rm diab et es manage men t w ould cer tainly be simplified . Pu mpin g in su lin sh ould re duce not only his risk of short- te rm comp lic at ion s [ diabet ic ke toacidos is (DKA ) and h ypog ly ce mia] b u t also long-t er m comp lications s uch as macr ovascu lar and microv as cu lar dise as e.

Introduction T he use of continuous subc ut ane ous insulin in fu sion (CS II), als o kn own as ins ulin pu mp t he rapy , allows p atients with diabe te s t o ac hie ve im prov ed glyc emic c on t rol (lowe r A1C s) w hile us in g le ss daily in su lin, r ed uc ing the like lihood of we ig ht gain, and limit ing diu rn al g ly ce mic variability compare d P. 267 w ith syr ing es , v ials, and pe n-injec te d insulin . 1 Be cause of t he lifes tyle flex ibilit y t hat in su lin p ump er s e njoy , quality -of-life score s c onsis tent ly favor CSI I ove r M DI s. 2 Swit ch in g f rom MDIs to C SII will limit t he numbe r of s hor t-t er m complications such as h yp oglyce mia an d DK A, as we ll as lon g -t er m microv as cu lar d isease . 1 , 3 , 4 Although C SII is cer tainly the mos t sop hist icate d and pr ec is e in su lin -d elive ry met hod c ur re nt ly availab le , patient s who init iate p ump th er ap y mu st be come solid ly committ ed to d iab et es s elf manageme nt. Blood glucose lev els must be ch e cke d 6 t o 8 times daily . Patie nt s mu st un de rs tand ins ulin p har mac ok ine tics , c ar bohydr ate count ing, and some ex er cise ph ysiology . Be cau se a p ump is a me ch an ical d ev ice that may, on occ as ion, malfunction, p at ien ts mus t b e ade pt at tr oub le sh ootin g an d cor re ctin g unex plaine d hyp er glyce mia by using t he su r vival sk ills t he y le ar n ed from u sin g MDIs .

Pumpe rs ar e t he most knowle dge able, de dicate d, and de te rmin ed in div id uals t hat primary care ph ys ic ian s ( PC Ps) will c ome t o know wit hin the ir diabe te s patie nt pop ulation . Man y of t he se patie nt s are se lfs uf fic ient, confident , and tot ally committe d t o improv ing th eir own out comes . PC Ps wh o fe el comfor table managing patie nt s w it h diab et es should also commit th ems elve s t o learn ing th e dyn amics an d be n efit s of insulin p ump ther apy.

I ns ulin pump t he rapy is d esigne d t o simulate n ormal panc re at ic be ta -ce ll fun ct ion b y p hy siolog ic ally d elive ring b oth basal and bolus insulin to patie nt s w it h typ e 1 an d t ype 2 diabe te s. The b asal in sulin limits the he patic g lucos e p roduct ion t hat oc cu rs in th e fastin g st ate . Pran dial ( bolus ins ulin ) is n ormally s ec re ted fr om the p ancr eatic bet a ce lls in a firs t- an d se con d-p hase r esp ons e t o meals. The firs t-p hase insulin r esp ons e oc curs as one pre pare s t o eat, wh e re as th e s ec on d - ph as e in su lin r esp ons e c ont in u es as long as ne ces sary to pr ev ent post prandial h y per glyc emia occu rr ing as n ut rien t s are ab sorb ed from t he g ut. The tig ht ly contr olle d g ly ce mic range (70 to 140 mg pe r d L) is re flect ive of th e nor mal r elation b et we en basal ins ulin and gluc ose, as we ll as th e re spon se of th e be ta ce lls to a mealtime carboh yd rate c hallenge , as show n in Figure 6 -1.

I de ally, ex oge nous insulin r ep lace ment shou ld mimic t he n ormal glu cose an d in su lin r es pon se t o th e f as ting and pr andial stat es. Howe ve r, pr and ial inje ct ion th e rapy , wh e th er give n by a syr in g e or a p en d ev ice, cannot pr ov ide both a firs t- and s econ d- ph as e p hy siolog ic ins ulin dosage . E x og en ou s in sulin is p rov id ed in hope s t hat the r at e of the d rug's abs or pt ion will coin cide with th e inc rease in pr an dial g luc os e. Basal ins ulin, pr ovide d as e ither glarg in e or d et emir, onc e g ive n, assu mes th at on e's b asal insulin r eq uire me nt s do not change during a 24 -h our pe riod. Howe ve r, if one e xe rcise s, basal insu lin r eq uir eme nt s are re duce d. Be fore ge tt ing up in t he morn in g, basal in su lin r eq uire me nt s in cre as e in r es ponse to phys iologic insulin r es is tance c au se d b y in cr ease d pr odu ction of cor tisol and gr owth h ormon e.

I n the aft ernoon hours , insulin r equire ments are ty pically low er th an d ur ing th e morn in g an d e ve n in g hours. U nf or tunat ely, once the injec tion of basal in su lin is give n, th e dru g 's in flu en ce on b asal in su lin le ve ls cannot be alt er ed . That is, one cannot â €œ tu rn u p or down â € th e le ve l of glarg in e or d ete mir injec te d t he ev ening be fore in re sponse to e xe rcise or varyin g d eg re es of ins ulin re sistan ce.

P. 268

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Fig ure 6-1 Normal Phy siology of Ins ulin and Glucos e R es pon se to Me als. In a n on diabe tic in div id ual, basal glucose le ve ls r ange be tw ee n 70 an d 100 mg pe r d L w hile fas tin g. Bas al g lucos e s up plies th e he art and centr al ne rv ous s yst em with an imme diate an d cons tant sou rce of e n erg y. Basal ins ulin lev els p re ve nt the liv er from acce ler at ing its r ele as e of g luc os e in to t he plasma via gly coge nolys is and glucone oge ne sis. If t he p at ie nt is in th e fed st at e, glu cose lev els w ill in cre as e, tr igge rin g t he pancre at ic be ta ce lls to r ele as e e noug h in su lin t o main tain p ostp ran dial g lu cos e le ve ls less th an 140 mg p er dL. Not e t hat the b as al and p rand ial glu cose lev els vary ac cord in g t o th e time of day as w ell as the quantit y and qualit y of cons ume d n u tr ie n ts at an y give n me al. In t he ear ly morn ing h ou r s, lev els of c ir culat ing count er re gulator y hormon es (gr owt h h ormon e an d c ortisol) ar e in cre ased , re sult ing in a s tate of ins ulin re sistance . A nor mally fu n ct ion ing pan cre as ove rcome s t his state of ins ulin re sistance by sec re ting more ins ulin in r es pon se t o th e se c oun te rr eg ulator y h ormon es.

Ther efor e, insulin re quir eme nts are normally ele vate d in th e morn ing . In t he afte rn oon h ou rs, ins ulin re sistance is minimize d, and ins ulin re qu ir eme n ts d ec re as e. Su ppe rs te nd to b e t he large st meal of the day, during which time one consumes th e most c alorie s, carboh yd rate s, an d fat s. Th e h igh er fat conte nt in f ood will de lay gastr ic emp ty in g as we ll as t he absor pt ion of car boh ydr at es from t he gu t .

Pat ie nts w ho must use ex og enous insulin sh ould at te mpt to re plicate th is c omp lex int er ac tive sch e me to maint ain blood gluc ose le ve ls as near to n ormal as possib le . Diffe re n t b as al and bolu s-d elive ry patt er ns mus t b e use d t o mat ch this p hy siolog ic en dog en ous ins ulin milie u. On e can s ee wh y e ve n se as one d insulin pump patients hav e d if ficult y ach iev in g nor malcy by us ing ex oge nou s in su lin .

By having t he ability t o pr ogram changes in b asal an d b olu s in su lin -d elive ry rate s, pu mp u se rs can simulate normal be ta -ce ll insulin s ecr et ion. On e c an p rogr am h igh e r basal rat es in ant icipation of pe riods of heighte ned insulin r es is tance ( ie , dawn ph en ome non ) an d lowe r b asal rat es in t he afte rn oon h ou rs when insulin re sist ance is minimal. Diffe re n t me alt ime bolu s p at te rn s may b e u se d t o con trol p ostp rand ial glucose ex cursions be tt er .

As of 2006, an est imat ed 280, 000 insulin pu mp u se rs we re re giste re d in th e U nite d S tate s. 5 As pu mps be come mor e use r friendly and te chnologically P. 269 ad vanced , t he number of p at ie nts inquiring abou t in su lin pu mp s will un dou bt ed ly in cre as e. PCPs wh o ar e familiar wit h inte nsive insulin re plac eme nt th e rapy can s uc ces sfu lly manage pu mp patien ts .

Det er minations of the basal rate s, mealtime bolus es, and su pp le men t al in su lin re qu ire men ts ar e similar to t he formulas used to c alculate the d iffer en t compon en ts of MDIs. C ert ified pu mp t raine rs, pr ovide d b y the pump-manufact ur ing companies, can be inv alu able ass is tant s w he n pu mp t he rapy is init iat ed. Ne arly all p ump tr ainer s are ce rtifie d d iabe tic edu cat or s (C DE s) an d are qu alifie d t o te ac h p at ien ts ev er y aspe ct of ins ulin pump use , including safe ty is sues, pr ope r pu mp -ins ert ion t ec hn iqu es , in fu sion -s it e mon itor in g,

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basal and bolus de liv er y pat te rns, sick- day man ag eme nt , as well as t rou bles hoot acu t e h yp er glyc emia and pump malfunct ions (Table 6- 1) . Sales pe rson n el can h elp d ire ct in te re ste d p er son ne l toward ins ulin pump e ducation pr og rams w hile ser ving as liais ons be twe en t he ins ur an ce comp an ies , p ump manufacture r, phys ician office st aff , and th e patie nt . O nc e t he ph y sician an d th e patie nt agre e to conside r pump ther ap y, a le tt er of me dical ne ce ssity (similar to t h e t emp late let te r s how n in Ap pen d ix 1 ) should be writ ten t o the t hir d-p ar ty payor . Th e ph ys ic ian mu st t he n calcu late and pr es cribe th e pu mp paramet er s (b asal r ates , anticipate d mealtime b olu se s, ins ulin -se ns it ivity factor , in su lin -to- carboh yd rate ratio, per sonal lag t ime, and typ e of insulin t o be pu mpe d), wh ich can be wr it te n on a form lik e t hat in App endix 2. The patient and t he p ump tr ain er can mee t in th e ph ysician 's of fice t o init iate t he pu mp ther ap y b y using t he pr es cribe d w ritt en p ar ame te rs .

Pat ie nts w ho ar e init ially informe d ab out in su lin p ump s may be afr aid of “ we ar in g a h igh ly t ech n ical de vice on their b elt s 24 hours a day. †Howe ve r, patien ts wh o are ne w t o pu mp t he rapy n ee d on ly unde rs tand how to s elf-inse rt the p ump 's infu sion se t p rope rly an d h ow t o dose a pr ope r and ph ys iologic mealtime bolus . The other â €œ be lls and w hist lesâ € c an b e w orke d ou t ov er time as th e patien t s be come more confid ent with the ir abilit y t o “han dleâ € t he pu mp.

Pat ie nts must und er stand t hat t he p ump doe s n ot “cu re †diabe te s, b ut offe rs th em an oppor tu n it y t o manage their diabe te s phys iologically. By imp rov in g on e 's over all c on t rol, t he risk of d iabe te s-r elate d complicationsâ €” both short and long te rmâ €”will be minimize d. Pump er s will ne e d to bec ome e xp er ts in diabe tes se lf -manage ment. For many p at ien ts committe d to ins ulin pu mp t he rapy , man aging diabe te s be comes both c halle nging and ex citing!

Evolution of Modern Pump Technology In the 1960s, a p ed iatr ician named Arnold K ad es h d ev elope d t he firs t â €œins ulin pu mp. †Wor n on a back pack ( Fig . 6-2A) , t he pump d elive re d in su lin an d glu cagon int rave n ou sly . Alt hou gh in it ially in te nd ed as a re sear ch inst rument in t he 1970s, pumps we re foun d to be e ffec tive in imp rovin g g lyce mic con tr ol in patie nt s wit h â €œbr ittle ty pe 1 diabet es †6 (Fig. 6-2B). Aft er th e M in iMed 502 p ump was in tr od uc ed and mar ke te d in 1983, pump use be gan to gr ow in popu lar ity . By 1990, th e U n ite d St at es was h ome t o 6,600 re gist ere d pump use rs 7 (Fig. 6- 2C ).

P. 270 P. 271 P. 272 P. 273

TABLE 6-1 Responsibilities of the Physician, Sales Personnel, Pump Trainer, and Patients Who Are Involved in Pump Therapy

Phys ician Pr es cr ibe r

Pump Sale s

C er tifie d P um p

Per so n

Tr aine r

Pum p Patie nt

I dent ify and qualify the p at ient as a p ot ent ial

E xplain t he be ne fits of C SII

T he pu mp t raine r will t each pu mp patien t s

View th e ed u cational

p ump cand idate

to p hy sicians an d patie nt s

all as pe cts of C SII b as ed on t h e

mate rial t hat is de liv er ed with t he

p ar amete rs pr ovide d

pu mp bef or e th e

b y t he ph y sician .

date of t he pu mp

A lt hou gh t he pu mp

init iation

t raine r may su gge st app ropr iat e p u mp p ar amete rs , t he u ltimate pr esc ribin g of t he par ame te rs is th e r es pon sibilit y of t h e p hy sician.

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As sist in p re paring a le tte r of med ic al

Promote pu mp ed uc at ion an d

A spe cts of C SII t h at t he pu mp tr ain er s

R ead t he ins tr uct ion man ual

ne ces sity for insulin

aware ne ss f or

t each :

be fore init iat in g t h e

p ump ther apy

phys ic ians an d

Pr op er infu sion -sit e

ins ulin pu mp

patie nt s

in se rtion How to p rovid e a bolu s S ic k-d ay parame te rs T rou blesh ootin g me ch anical malfu nc tions an d acu te h yp er glyce mia B olu s W izard me ch anics Pu mp-alarm in te rp re tation H ow to c han ge pu mp b at te rie s C arb oh y drate (c ar b) c oun tin g E xe rc is e w ith th e p ump T empor ar y s us pe ns ion of th e p ump S howe rin g w ith th e p ump Me ch anics an d in te rp re tation of th e s en sorau gme nt ed p ump Man ag eme n t of h yp oglyc emia I nitiation of a t emp orary basal rate U sin g d if fer en t b as al p rofiles (ie, one pr ofile w hile men st ru at ing an d an oth er wh ile n ot ) H ow to ob tain p ump s up plies

De te rmine p ump

Ass is t p hy sicians

Per form h ome

p ar ame te rs : Basal rate (s)

in c omplet ing th e nece ssar y

blood g lucos e mon it oring be fore

Mealtime bolus es

pape rw or k f or

and afte r me als, at

Typ e of b olus patient

third party payor s

be dt ime , an d in th e

s hould use at me als

ear ly AM h ou rs

( nor mal, ex te nd ed or

U nd er stan d h ow t o

c omb ination)

tr oub le sh oot

Pe rsonal lag t ime

mec han ical

I nsulin sensit iv it y

malf un ct ion s an d

fact or

h ype rg lyce mia

I nsulin/ carbohyd rate r at io

Tar get blood g luc os e

Kn ow h ow t o

le ve ls (fast ing,

manage diabe tic

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p re prandial, p ostp rand ial, be dtime ,

ke toacidos is an d sick days

noct ur nal)

U nd er stan d t he

Ty pe of insulin to b e

pr incip le s of

use d in the pump

ex er cisin g wh ile on

( lisp ro, as part ,

th e pu mp

g lulisine , U- 500) W hic h, if any , p ump

U nd er stan d h ow t o manage

alar ms s hould be p rogr amme d

h ypog ly ce mia ef ficien tly wh ile on

For patient s using the

a pu mp

Med tronic 722

U nd er stan d h ow t o

p ump s, alarms mus t be

pe rfor m basic p ump

p rogr amme d for

fu nc tions inc lu din g

hyp er glyc emia and

ins er tion of th e

hyp oglyc emia

inf usion se t,

r ec og nit ion

pr ovidin g a mealtime and su pp le me nt al (cor re ction ) bolu s C ar ry eme rg en cy su pp lie s at all time s in case of a pu mp malfu nc tion

Locate ce rt ifie d pump t raine rs for

U nd er stan d int en siv e in su lin

phys ic ians w ho

th e rapy be fore

re quire initiation of C SII in t he

be gin nin g C SII C ar b cou n tin g

office se ttin g

Prope r d osing of mealtime ins ulin C ommit tin g t o pr ope r me alt ime blood g lucos e mon it oring and ins ulin adminis tration Ke e ping follow -u p appoin tme nt s w it h th e med ic al s taff

Se rve as a liaison be tw ee n t h e

Notify ph ys ic ian if blood g lucos e

pump

lev els r emain

manufactu r er, phys ic ian, off ic e

con sist en tly high or low, des pite

st aff, insu ranc e

follow ing all of t he

company, and

pr es cribe d

patie nt

tr eatme n t parame te rs

De te rmine w hich

Fac ilit at e d elive ry

T rain t he patie nt in

Le arn to u se th e

p at ient w ould b ene fit

and tr aining of

t he pr ope r t ech n iqu e

se ns or t o op timize

fr om using a

the sensor de vice

of sen sor in se rt ion ,

th e ir pu mp

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p ump augme nte d se nsor Se t sensor parame ter s

to t he pat ie n t

c alibr at ion , t rou bles hoot in g, and

for hype rg ly ce mia and

on -line dat a

hyp oglyc emia alarms

man ag eme n t

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parame te rs

E st ab lis h an on- site p ump download st at ion t o ad jus t t he pump p ar ame te rs

C SII , c ont inuous subcutaneous insulin inf us ion .

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Fig ure 6-2 Insulin Pumps: Past , Pr ese nt, an d Fu t ur e. A: In 1963, A rn old Kade sh , MD, de ve lope d th e first ins ulin pump p rotot ype d esigne d t o prov ide his d aug ht er , w ho h ad t ype 1 diabe te s, with improv ed glyc emic c ont rol. This b ac kpack pu mp delive re d b oth int rave n ou s in su lin an d g lu cagon s. B: From 1978 t o 1987, p ump s b ecame miniatu rize d. C: Sin ce th e mid -1980s, pu mps hav e b ecome more te chnologically adv ance d and are de sign e d t o delive r in su lin in a man n er th at simu lat es nor mal b et ace ll function. *Not comme rcially available

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P. 274 The Diabe tes C ont rol and Comp licat ions Tr ial (DC C T) w as pu blish ed in 1993. 8 At th e con clus ion of t he DCC T, 42% of the inte nsive ly manage d p at ien ts we re us in g in su lin p ump th e rapy, and 56% we re on MDIs. Pat ie nts in the DCC T w ho w er e on ins ulin pu mp t he rap y h ad a 0.3% lowe r A1C compar ed with th e int ensive ly manag ed ind iv iduals w ho use d M DI s. As C SII gaine d g lob al p opu larit y, th e s ize, qu alit y, re liability , me chanics, comfor t, efficie ncy, and softw ar e of th e p ump s c on tin u ed to impr ove . In su lin pumping now p rovide s p at ients with diabe te s t he ir be st hop e of ac hie ving ph ys iologic glyce mic con tr ol while re ducing t he ir incide nc e of s hor t- an d lon g-t er m complication s.

From a pr imar y car e p rosp ect ive, more pat ie n ts ar e b ecomin g p roactiv e an d in qu ir ing ab out th e be ne fits of using CS II t o tr eat t he ir own d iab ete s. Th es e c on ce rn s s hou ld b e add re sse d in an in te llig en t an d suppor tive manne r, re memb er ing that any patie nt wh o re qu ire s ins ulin may be con side re d a can didate for an insulin pump. Patients ar e also app earin g in e mer gen cy de part men ts or ope rat in g r oom su ite s we ar ing their insulin pumps. Not infre que nt ly , pumpe rs h ave be en aske d t o â €œ re move th eir cell ph on es wh ile in the eme rge ncy d ep ar tme nt ,â € or â €œ you won 't be ne e ding th at mach ine in th e h osp it al. †In re ality , patie nt s who use insulin p umps are e xtr eme ly mot iv ated , k n ow led geab le , an d w ell ve rs ed in d iabe te s se lf- manage ment s kills. Phys ic ians w ho choose to c ar e f or pu mp patien ts will ne ed to adv an ce t he ir own insig ht s into and knowle dge re gard ing diabe tes manage men t . In so d oing , t he se ph ys ic ian s will be able to pr ov ide a highe r lev el of c ar e to all of t heir d iab et es patien ts wh et he r or n ot t he y are u sing pu mp ther ap y. PCPs should s ympat hize wit h p at ien ts wh o mig h t be n efit from p ump th er apy, ye t may ne e d to wait months b efore se e ing a d iab ete s s pe cialist an d ev en long er be fore ac tu ally re ceiv in g th eir in su lin pumps. By be coming pump pre scr ibe rs, PCPs w ill allow patie nt s t o be ne fit mor e r ap id ly fr om int ensification of their diabe te s re gime n.

The “ant ique p ump †infusion se ts w er e an ch ore d in to th e ab domin al sk in b y a me tal ne ed le. Th ese infusion se ts t ende d t o be unc omf or table , b ec ame easily dislodge d f rom th e skin , an d h ad t o be man u ally and painfully inser te d b y t he patie nt ev er y 2 d ay s. Th e n ew er pu mps us e a sp rin g -loade d se lf-ins er te r de vice (Fig. 6 -3), w hich implants t he Silastic in fu sion cat h et er pain les sly in to t he sk in. In fu sion s et s hav e an e as y p oint of disconnect fr om the s it e of in se rt ion , allowin g p at ie n ts t o be apart from t he ir p ump at any time for showe ring, swimming, ex erc ising , or en gagin g in int imat e act ivitie s. B ec au se th e in fu sion se ts are e it her 23 or 43 inches in le ng th, t h e p ump can easily b e p lace d u n de r a pillow du r in g slee p or hid de n in clothing .

Some pumps allow â €œ discr et e b olusingâ € b y u sin g a re mote con tr ol. A w oman wh o we ars t he pu mp unde r a d re ss c ould use t he re mote contr ol d ev ic e t o sign al a me alt ime b olu s r at h er th an s tru gg le w it h tr ying to r emov e t he pump from her clothin g du rin g a b oar d-r oom mee tin g. An in su lin r es er voir w it hin the insulin p ump pr ovide s a pr ep rogr amme d in divid ualize d basal rat e t o each patie nt . B efor e me alt imes, the patient simply d et er mine s the blood g lu cose lev el an d p rovid es a p hy siolog ic bolu s ove r a s pec ifie d time through the infusion set .

P. 275

Fig ure 6-3 One of Se ver al Available Sp ring -load ed In su lin Pu mp In fu sion Set In se rtion Dev ic es .

Aft er the s kin is cleaned with an alcohol -base d adh e sive pad, th e Silast ic inf usion -se t t ip is p lace d in the cocke d inse rt er . As the inse rt er is posit ion e d in paralle l with t he sk in su r fac e, lig ht pr es su re is ap plied to t he dist al e nd of t he de vic e, wh ic h qu ic kly an d p ain less ly pr oject s t he cath e te r t ip th rou gh the skin. R emov ing the whit e adhe sive st rips f rom arou nd th e cath et er tips will pre ve n t th e cath et er

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from d islod ging fr om the infusion site for u p t o 72 h ou rs.

The ultimate challeng e in tr eating insulin -r equ irin g d iab et es is to de sign a re liab le “close d-loopâ € ar tificial panc re as sys te m. Such a futurist ic mode l wou ld inc lu d e a se lf-con taine d in su lin -d elive ry de vice , such as an insulin p ump , and a continuous g lu cos e s en sor. Th e s en sor wou ld tr an smit th e p at ien t's amb ient g lucos e r eadings to the pump, which wou ld , in tu rn , re spon d b y in fu sing th e ex ac t amoun t of basal and bolus insulin r eq uir ed to r each th e patien t 's targe te d b lood glu cose lev el. Suc h tec hn ology would ce rt ainly lead to a re duct ion in diur n al g ly ce mic variation s, a p roce ss t hat is be lie ve d t o be th e corne rst one of micr ov ascular and mac rovasc ular d iabe te s- relate d c omplicat ions . Th e two an ch orin g components of the close d-loop art ific ial p an cr eas (p um ps an d se n sors) are alr eady commer cially av ailable . In 2006, the first U. S. Food and Dru g A dminist ration (FDA)â €“app rove d p ump -se n sor d ev ic e was mark et ed : the Med tronic R eal-Time Par ad ig m 722 p ump and se ns or (Fig. 6-4).

Us er s of t he Par adigm 722 self- inse rt both t he in fus ion se t an d a se n sor-t ran smitt in g d ev ice in to t wo se parate ar eas in t he abdome n (Fig. 6- 4) . Th e sen sor re ads in te rst itial g luc os e le ve ls ev er y 5 min ut es and transmits the d ata to t he ins ulin pump s ur fac e p an e l for v ie win g an d in te rpr et at ion . Alth oug h th e tr ansmitt ing se ns or data d o not dr iv e p ump ins ulin de liv er y, th e pu mp can be pr ogramme d t o alarm for both high and low glucose value s. On hearin g t he alar m, t he pat ie n t acqu ire s a con firmator y fin ge rst ick glucose le ve l and corr ec ts t he abnormalit y. R eal -time tre n d g raph s may b e d own loade d t o a PC or disp laye d on t he pump scre e n, which can be us efu l in id en tify in g g lyce mic tr en ds in r es pon se to ph y sical ac tivit y, meals, insulin, menst ruation, illnes s, an d so on. Pump se ns ors w ould be us efu l for p atien ts ag e 18 and olde r w ho



Have hyp og lyce mic unawar enes s



Have wid e g ly ce mic variations wit h or with ou t C SII th er ap y



Ar e p re gnant or conte mplating pr eg nan cy



Have rig id or inte ns e athle tic-t raining sc he du les



Ar e me mbe rs of ce rtain profe ss ions ( shift wor ke rs, ph ys ic ian s/s ur ge ons, fire figh te rs , p olice office rs)



Have aut onomic ne ur opathy ( cardiac, gast ropare sis)



Have had a re ce nt myocard ial infar ct ion , an gioplast y, or cor on ary arte ry by pass g raftin g



Have chronic k id ne y dise ase (t o improv e g lyce mic con tr ol an d d elay d is ease pr ogre ssion )

P. 276

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Fig ure 6-4 Med tr onic 722 Se ns or -aug men t ed Pu mp Syst em.

To Pump or Not to Pump: That Is the Question!

Anyone c onsid er ing pump the rapy should cons id er th e ad van tage s and disadv an t ag es ass ociat ed with CS II, as disc uss ed lat er and summar ized in Tab le 6 -2.

P. 277 P. 278

TABLE 6-2 Advantages and Disadvantages of Insulin Pump Therapy Advantages

D is adv ant ag e s

L ower A1C

R eq u ir es hig he r le ve l of train in g th an oth e r me th ods

R ed uc ed long - and short- te rm d iabe te s-

of in su lin d elive ry (sy rin ges , v ials, and pe n

r elate d comp lic at ions

in jec tors ). Patie nt s will n ee d t o be followe d u p by

I mprov ed quality of life. Pat ients fee l in

p hy sicians wh o ar e traine d to mon it or or coun se l

mor e in contr ol of t heir ow n g lyce mic d est iny .

p at ien ts on p ump s.

Me ch anical de vice may malfu nc tion, re qu irin g th e

I mprov ed life st yle f le xib ility . Me als can b e e ate n â €œad libâ € or skip ped

p at ien t t o be kn owled ge ab le abou t M DI te ch niq ue s.

c omp let ely r ather than on a sche dule d

O th er s may r ec ogn iz e t h at patie nt has diab et es .

b as is .

Mor e acc ur at e insulin d elive ry (can

R eq u ir es ad dition al p ap er work and prior au th orization from in su ran ce compan y for cove rage

d elive r insulin in te nt hs of unit s)

Patie nt s may b e le ss able to p er ceiv e h yp oglyc emia

Prov ides pr ogrammable and p hysiologic

w hile on t he pu mp th an w hile on MDIs .

C ost s more th an MDI s (s ee be low )

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insulin de live ry C an manage the â €œdawn

I nfe ct ion s may de ve lop at inf usion site .

Patie nt s mu st carry tr ad itional diabe te s su pp lie s

p he nome nonâ €

w it h th em at all time s, es pec ially w he n tr av eling , in

C an e asily sk ip or d elay me als

c as e of a p ump malfu n ction .

R ed uc ed inc id ence of hypog lyce mia

A lt hou gh p at ie n ts m ay ge t a re place men t p ump

C an s low or r ev er se complications such

w it h in 24 h in most case s wh ile in th e Un ite d

as r et inopat hy , ne phropathy, g as trop ar es is , hyp oglyc emic

S tate s, ab ility to locate and acqu ire pu mps in for eign c ou n tr ie s may be limite d.

unaw ar ene ss, er ect ile d ysfunction R ed uc es incid ence of noc turnal

De vice mu st b e w orn 24 h/d , alth ou gh th e qu ic kr ele as e in fu sion s et s allow for simp le se paration

hyp oglyc emia

fr om th e pu mp for bath ing , e tc .

Minimiz e d ay-t o-day g lyce mic variation s

R apid d ev elopme nt of DKA if ins ulin de liv er y is

Simp lifie s e xe rcise routines

in te rr up te d.

Safe and easy for long-d istance

Mor e f req u en t h ome blood glu cose mon it oring is

t rave ling

s ug ge ste d t o he lp impr ove glyc emic c ont rol.

Minimiz es total daily d ose of insulin

S en sor c ompon en ts for t he pu mps may n ot b e

L ess we ight gain U se s only a single t yp e of rapid-act ing

c over ed by th ird -part y p ay ors.

insulin analogue for basal/b olus t he rapy Simulat es nor mal p hy siologic insulin d elive ry R ed uc es incid ence of DKA and hospit alizations in hig h- risk patient s I nd iv idual insulin inje ct ions are e liminate d.

Te mpor ar y b as al r at es can be us ed to p hy siolog ically manage hy pog ly ce mia and r educe e xe rcise -induced gly cemic e xc ur sions .

Pumps can s afe ly impr ove hyp er glyc emia be fore at te mpt ing p re gnancy .

Pumpe rs c an s le ep in w ithout worr ying about mis sing an inject ion and d ev eloping DK A. The se ns or -aug ment ed pump sy st em d is plays t re nd gr ap hs and pr ov ide s alar ms for hig h and low b lood glucose le ve ls .

The se ns or -aug ment ed pump also p rovid es r eal-t ime glucose re ading s t o t he pat ie nt.

C os ts fo r the r ap ie s are es timate d as follows :

Th er ap y Ty pe

An nual Ins ulin C os t ($US)

Ann ual C ost s of Sup p lies ($US )

To tal C os ts ($US)

Ne e dles and s yringe s

1, 700

350

2,050

Pe n injec tors

4, 000

350

4,350

C SII

1, 700

2, 000

3,700

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MDI, multiple daily inje ction; DKA , d iab etic ke toacidosis.

Not es : (1) Pump s tart- up cost s are appr oximate ly $5, 500. In fu sion s et s, r es er voirs, and b at te ries for t he p ump will cost ap prox imat ely $2,000 ann u ally. If an ins ur an ce comp an y pays 80% of t he cost of t he pump and s up plies, a patie nt wh o be gin s C SII will h ave a $1, 240 ou t-ofp ocke t e xp ense during t he firs t y ear of pu mping . T he re af te r, th e an nu al patien t finan cial r es pons ibilit y w ill be re duce d t o $740. ( 2) Ass umin g t hat home blood g lu cos e mon itorin g c os ts 50 ce nt s p er str ip, MDI patie nt s would s pe nd $730 ann u ally on t est ing . Pu mp p at ie n ts of ten c he ck 7 t o 8 time s pe r d ay . The ir annu al te st s trip ex pe ns e w ou ld b e $1,370 pe r y ear.

Fr om Amer ican Diabe te s Ass ociat ion. In su lin pu mp th er ap y. ht tp ://w ww. diabe te s.or g/t ype -1d iab ete s/ insulin-p um ps. jsp. Acc ess ed 11/13/05; Bod e B W, Tamborlane W V, an d Davids on PC .

I nsulin pump t he rapy in t he 21st c entu ry : s trate gie s for su cce ssfu l u se in adu lts, adoles cen ts , and childre n with d iabe te s. Pos tgr ad Me d. 2002;111. Availab le at: htt p:/ /ww w.p ostg radme d. com/issue s/2002/05_02/b ode 3. h tm. Acce sse d 11/13/05; Le nh ard MJ, R ee ve s GD. Continuous subcutaneous in su lin inf us ion : a comp re he ns ive re view of ins ulin pu mp t he rapy . A rch Inte rn Me d. 2001;161: 2293– 2300; R ud olp h J W, Hirs ch IB. Ass ess men t of t he rapy with c ont inuous subcutaneous in su lin inf us ion in an acade mic diabe te s clin ic . E n docr Pract . 2002;8:401â €“ 405; Shade DS, Valen tin e V . To p ump or n ot t o pu mp. D iab ete s C are .

2002; 25:2100â €“2102. U ng er J, Mar cu s A. In su lin p ump th er apy: wh at you n ee d t o kn ow. Eme rg Me d. 2002;34:24â €“33.

Improved Overall Glycemic Control and Glycemic Variability The impr ove d A1C values ass ociat ed with C SII re flect th e be ne ficial p har mac ok ine tics as sociate d wit h pump t he rapy . I ns ulin pumps us e only a sin gle s hor t-act ing insu lin an alog ue for both basal and bolu s insulin delive ry . M ultip le basal ins ulin rate s can be pr ogramme d in to t he pu mp t o match t he met abolic re quirem ents of ind iv idual p at ie nts. Ne it her CS II or MDIs r esu lt in comp le te n ormaliz at ion of g lu cos e concentr ations throughout the day. Howe ve r, if th e A1C is re du ce d safe ly to as ne ar n ormal as possib le , long- and short- te rm diabe tic c omplication r ate s will be re du ce d. The DC CT has d emon st rate d su pe rior it y of C SII v er sus MDIs to r educe A1C lev els. CS II is s up er ior to MDI s u sing NPH in re du cin g A1C lev els 9 an d has bee n found to be supe rior to MDIs when fast- ac tin g bolu s in su lin is u se d for meals. 1 0 A1C lev els ar e low er in p ump patie nt s t han in t hos e using MDIs with g larg ine ins ulin . 1 1 In ad dition to imp rove ment in A1C lev els, glyc emic variabilit y can be re du ce d in patie nt s u sin g p ump s. As discuss ed in C hap te r 7 , a s tr ong corr elation e xis ts b et we en glyc emic v ariab ilit y an d th e lik elih ood of de ve lop ing long- te rm comp lic at ions. Glyce mic v ar iab ility is minimize d in pu mp patien t s. B ec au se a sing le rapid- ac ting analogue is ab sorb ed from a sin gle in su lin d ep ot, day -t o-day P. 279 glyc emic v ar iab ility ave rage s 3% v er sus 52% with NPH. 1 2 I mpr ov ed glyc emic v ariab ilit y is acc om panie d by a 15% t o 20% red uction in t otal daily ins ulin re qu ir eme n ts w he n compare d w ith th at in patien t s u sing MDI. 1 2 Insulin pumps pr ovide patie nt s wit h b as al, bolu s, an d s up pleme n tal in su lin in a ph ys iologic, pr og rammable f or mat, prov iding patie nt s wit h mor e p re dict ab le an d re pr odu cible glyce mic con tr ol ( Fig. 65). T his p hy siologic insulin de liv er y e nsur es con scie nt iou s p ump patie nt s of ach iev ing ne ar-n ormal basal and post prandial g luc os e c ont rol while min imiz in g glyce mic v ar iab ility . Mos t p at ie n ts r eq uir e on e or tw o diffe re nt basal rate s, inc luding one that re du ce s h yp er glyce mia in t he ear ly morn ing h ou r s be fore a patie nt aw ak ens. W he n P. 280 this â €œ dawn phe nome nonâ € is b ett er con tr olle d, patien t s will aw ak en w it h ne ar -n ormal blood g lu cose leve ls. Howe ve r, if fasting b lood glucose le ve ls are con sist en tly e lev at ed , p atien ts will be work in g to corr ec t hyp er glyce mia throughout the day.

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Fig ure 6-5 Progr ammab le Insulin De liv er y wit h Pu mp T he rapy . Patie nt s wit h d iab et es can r ec eive ind iv idualize d, pr ogrammable insulin d elive ry via pu mp t h erap y. By u sin g on ly a sin gle typ e of rapidac ting insulin analogue ( lisp ro, as part , or glu lisin e) , t he day -to-d ay absor ption of ins ulin varie s by less than 3%, meaning that t he patie nt 's glyc emic c ont rol will be more pre dict able an d r eliab le t han by us ing other forms of basal/bolus ins ulin th er ap y. Basal rate s can be pr ogramme d t o mat ch th e patie nt 's ind iv idual b as al glucose re quire men ts . For ex amp le, a high e r b asal rat e c an be pr ogr amme d for t he e ar ly morning hour s t o limit t he h yp er glyc emia caus ed by “t he dawn p he n ome n on. †As ins ulin re sistance be gins to d ecr ease in th e e arly aft ern oon hou rs , t he basal rat es c an b e r ed uc ed . If a patient ex er cises consiste ntly d ur ing a cer tain time of day, th e b asal r ate can b e p rogr ammed at a low er rate , beg inning at t he ant icipate d on set of act iv ity, and inc re as ed 1 t o 2 hou rs afte r t he ex er cise se ssion ends. Patients can set a “t emp orary basal rate †in an ticipation of activ it ies th at may induce hy poglyc emia (such as inte ns e e xe rc is e) or in res pon se to mild h yp oglyce mia, so t hat the blood glucose lev el will inc re as e b y h ep atic glu cose pr odu ction rath e r t han by th e patien ts hav ing to â €œ eat t heir w ay â € out of hyp oglyce mia. Bolu s in su lin may b e p rovide d for me als in se ve ral forms. An immed iat e b olus may be give n all at on e t ime t o corr ec t h yp er glyce mia or to pr ev ent an inc re ase in blood g lucose lev els, wh ich will occu r in re sp onse t o a b et we en -me al sn ack .

The s quar e- wave (ex te nd ed -wave ) b olus p rov id es th e p atien t w ith mealtime insu lin delive ry ove r se ve ral hours and mimics the physiologic s econ d- ph as e in su lin re sp on se of e ug lyce mic in dividu als . A dual- wave bolus combines an imme diat e an d e xt en de d- wave bolus , s o th at a pe rce n tage of th e total mealtime dose of insulin is pr ovide d at th e on se t of t h e me al, and th e r emain de r is g iv en ove r a 2 to 5-hour pe riod.

The p ump 's basal insulin d elive ry maintain s ambien t plas ma gluc ose read in gs in t he fast in g state by limit ing he patic g lucos e p roduct ion. The p rogr ammable basal rate s are calcu lat ed base d on th e patien t's size , age , ge nd er , act iv ity le ve l, d eg ree of in su lin re sist an ce , an d ot he r ou t lie rs, as sh own in Tab le 6-3.

Pat ie nts may choos e t o by pass t he pr es crib ed basal delive ry rate b y placin g t he mse lv es on a t emp orary basal rate to e ither slow or incr ease the rate of in sulin de liv er y. For e xample, mild h yp oglyce mia may be tr eate d b y se tt ing a te mporary basal rate and slowin g in su lin de liv er y. By allowin g t he plasma glu cose leve l to incr ease spontaneously, patie nt s w ill n ot g ain we ig h t by â €œ eatin g t he ir w ay out of hy pogly ce mia. †Bolus ins ulin de liv ere d by t he p ump simulate s p hy siolog ic firs t - an d s econ d- ph as e in su lin re sp onse (Fig. 6-5). T he amount of insulin t o be de liv er ed as a bolus as we ll as th e t ime ove r wh ic h t h e b olu s is ad minist er ed is base d on pr ep randial g lucos e le ve ls , t he amoun t of carboh yd rate s an d fats th at will be consumed during a meal, and t he anticipate d act iv ity le ve l afte r a me al. The t hr ee ty pe s of p ump ed bolus es include the follow ing:



Im me d iate (now) bolus : I f one miscalcu lat es th e mealtime b olu s an d r ec ords an e lev at ed glu cose lev el 2 to 4 hours aft er eating, a supple men tal (cor re ction bolu s) may be ad min ist er ed th rou gh th e pump to cor re ct t he hyp er glyce mia. An immed iat e b olu s may also be give n f or small sn ac ks,

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P. 281 be fore e xe rcise in patients who are hy pe rgly cemic , an d afte r t he in ser tion of a ne w in fu sion s et .

TABLE 6-3 Initial Total Daily Dose Requirements for a Patient with Type 1 Diabetes Mellitus D os e (U/ kg/ day)

P atie nt' s Co ndit io n

0. 5

C onditione d or tr ain ed ath lete

0. 6

Mot iv ate d e xe rcise r, woman in firs t p hase (follicu lar) of me nst ru al cyc le

0. 7

W oman in las t we ek (lu te al p hase ) of me n str ual cy cle or in f ir st trime ste r of p re gnancy , ad ult mild ly ill w it h a viru s, ch ild star ting pu be rt y

0. 8

W oman in se cond tr imest er of pr eg nan cy, ch ild in midpu be rt y, ad ult with a se ve re or localize d vir al in fec tion

0. 9

W oman in third trime ste r of pre gn anc y, ch ild at th e pe ak of pu be rt y, adult ill with b ac ter ial in fec tion

1. 0

W oman at t er m of pr eg nan cy , p ub esc en t c hild w ho is ill, ad ult with a s ev ere b act er ial in fec tion or illn e ss

1. 5–2. 0



S eve re ly ill man or woman, ch ild at p eak p ub es cen ce wh o is ill

Exte nded (square -wave ) bo lus : Insu lin is in fus ed ove r t ime , typ ically 30 min ut es to 4 h our s. Th e e xte nde d bolus is use ful for manag ing patien ts with g ast rop ar esis an d may als o be ad min ist er ed for snacks with high fat conte nt, such as ic e c re am.



Co mb ination (dual-w av e) bolus: By combin ing th e imm ediate and th e ex te nd ed -wave bolu s, t h is be come s the most p hysiologic me ans b y w hich p rand ial in su lin can be de liv er ed . Af te r de te rmin ing the pr eme al g lucos e, the p atient c alcu late s h ow mu ch ad dition al in su lin sh ou ld be adde d or subt ract ed to the pr esc ribe d d os e of in su lin in th e immediate por tion of th e bolus th at will allow t he patie nt to at tain t he tar get ed glucose lev el. Carb ohy drat e c ou n tin g or a p re de te rmine d dose of ins ulin may the n b e ad minist ere d by u sin g t he comb in ation bolus . T he ex te n ded bolu s con tin ue s t o de liv er ins ulin for 2 t o 4 hours, de pe n ding on th e q uan tity and fat c on te n t of t he me al. Fat te n ds t o de lay carb ohy drat e abs or pt ion, re quir ing lon g er ex te nd ed -bolu s time s.

Reduction in Frequency and Severity of Hypoglycemia The incide nc e of s ev er e hyp oglyc emia is les s fre qu e nt with C SII th an w it h MDI s, ye t t he abilit y t o pe rce ive low blood g lucos e le ve ls is les s appar en t t o pu mp p at ien ts. Te ac hin g p at ien ts to admin is te r a pr eme al b olus p rope rly and av oid â €œ insu lin s tackin gâ € w ill sig nifican tly r ed uc e t he fr eq ue nc y an d se ve rity of hypog ly ce mia (s ee C hapt er 5 ). Pu mp p atien ts ofte n mon itor th eir glu cose le ve ls b efore me als, 2 hours af ter e at ing, at b ed time, be fore and afte r e xe rcise , be fore driv in g, and any time th ey su sp ect hy pogly ce mia.

The most se rious adve rs e e ffe ct of int ensive ins ulin th er ap y is sev er e h y poglyc emia, w hich r eq uire s t he as sistance of anot he r p er son for r ev er sal. In th e DCC T, th e in cide n ce of se ver e hy pogly cemia was t hr ee times gr eate r in the gr oup re ceiv ing MDI s t han in c on v en tion al t he rapy (tw ice- daily inje ction ) p at ie n ts. In a study by Bode e t al, 1 3 patie nt s sw it ched from MDI s to C SI I h ad a re du ction in s ev er e h yp oglyce mia

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ev ents from 138 ep is ode s pe r 100 patie nt -ye ars, with MDIs , t o 22 p er 100 p at ie n t-y ears in t he firs t y ear of C SII use . Hyp og lyce mic e ve nt s re maine d lowe r in pu mp patien ts th rou gh ye ars 2 t o 4, w it h no in cre ase in A 1C lev els. Multiple studie s hav e conf ir med a re du ction in f req u en cy of hy pogly ce mia assoc iate d w ith CS II. 1 4 Hyp oglyc emia may occur whenev er any form of in su lin t he rapy be come s in ten sifie d. If t he pu mp basal insulin rate is pr ogramme d inap prop riate ly h ig h, h yp og lyce mia w ill follow. Pat ie n ts mu st ch ec k b lood glucose le ve ls fr eq ue ntly and b e p re pare d to t re at h yp og lyce mia in a rapid , e fficien t, and safe man n er .

Pat ie nts w ho ar e e xt re mely s ensitiv e t o small c han ge s in circu lating ex oge nou s in su lin lev els ar e le ss lik ely to be come hy pog ly ce mic by us ing pu mp t he rapy . 1 5 Th e b asal an d b olu s d elive ry rate s of in su lin pumps can b e adjust ed P. 282 by te nt hs of units , allowing pr ecision dos in g of th e in su lin d ur in g both t he fastin g an d p rand ial st ates .

In patie nt s who hav e had T 1DM f or more th an 5 y ear s, au ton omic dy sfu nc tion de velop s, w hich p re clud es them from re cog nizing t he sy mpt oms of hyp og lyce mia (fatigu e, sw eatin g, blu rre d v ision, dizz ine ss, palpitations, and imp aire d cognition) . Patien ts with h yp oglyce mic u nawar en es s als o los e t he ir ability to pr od uc e e noug h c ounte rr eg ulatory hormon es (cort isol, g rowt h h ormon e, e pine ph rin e , an d glu cagon ) t o pr ot ec t t he m from and r ev er se the hy poglyc emia. A ctivit ie s s uc h as d rivin g, ex er cisin g, an d caring for child re n may be challeng ing and d ange rous f or patie nt s w it h hy pogly cemic un aware ne ss. In su lin p ump ther ap y c an r est ore one 's abilit y t o pe rce ive hy pogly ce mia. Simply r ed uc in g th e p ump 's basal rate s an d mealtime bolus es will allow patie nts t o main tain a h igh er tar get blood g luc os e le ve l wh ile minimizin g t he fre quency and se ve rity of hypog ly ce mia. For e xample, a targ et of 150 t o 220 mg pe r d L in a patien t with fre quent hy pogly cemia might b e p re fer able t o th e stan dard glyce mic t ar ge t of 80 to 120 mg p er dL . Aft er 6 to 8 we ek s of hyp oglyc emic avoidance , t he basal rate of t he in sulin pu mp c an b e in cre ased , allowing the physician to re duce the targ et glucose rang e s af ely t oward nor mal. 1 2 A s glu cose lev els imp rove , hy pogly ce mic aw ar ene ss r et ur ns .

P. 283

Case 2 This 36-ye ar -old c omp uter de sign e ng ine er was d iag nose d w ith T1DM at age 6. At th e time h e was st ar te d on C SII, he had nonp rolifer at ive re tin op ath y; c hr onic kidn ey dise ase, st ag e I II; diab et ic pe rip he ral ne uropathic p ain; and ort hos tatic h yp ote ns ion . His A1C was 5. 9%. Base d on h is bod y we igh t and pr ior ins ulin dose re quire ments , he was place d on a basal rate of 1.0 u nit pe r h our and u sed carb ohy dr at e c ounting (1 unit cov er s 10 g of c ar boh ydr at es ) to det er mine h is combin ation w av e pran dial ins ulin dose . His home b lood glucose met er down load (Fig. 6-6A) sh ows th at th e patie nt has sign if ic an t fr eque nt hypog ly ce mia. Another ind ic at ion of f req u en t h yp oglyc emia can b e d et er mine d b y e valuatin g t h e mathematic al r elation b et we en the standard de viation (SD) an d th e mean blood g lu cos e ( MBG) ave rage .

Doub ling the S D value of 75 rais es the le ve l to gr eat er th an t he MBG av er ag e of 122, imply in g a te nde nc y tow ar d hyp oglyc emia. O f this pat ie n t's 85 total blood g luc os e v alu es (N) du rin g th is 28 -day pe riod, 35.3% are less than 70 mg pe r dL , an d h e re cord ed 21 e ve nt s le ss t han 60 mg pe r d L. At no t ime did the p at ient r ep ort any symp toms of hy poglyc emia. A fte r r ev ie win g t he dow nload dat a, th e pu mp's basal rate was re duced to 0. 8 units p er hou r , an d h e w as pr ov ide d wit h a n ew ins ulin -to-c ar boh ydr ate rat io ( 1 unit cov er s 15 g of c ar bohydr ate s). Th e p at ie n t w as ad vise d t o give 25% of h is mealtime bolus to c oincid e wit h the s tart of the m eal and 75% ov er a 3- hou r p er iod to le sse n t h e like lih ood of imme diate pos tpr andial hypog ly ce mia.

Aft er adjus ting t he pump p aramet er s, t he p at ie n t w as ab le t o av oid h ypog ly ce mia ( Fig . 6-6B) . Th e SD of 65 when double d now is le ss t han the MBG le ve l of 184, s ug ge stin g t hat th e p atien t is ex pe rien cin g le ss gly cemic variation with no tre nd tow ar d hyp oglyc emia. O nly on ce du r in g th is 28- day p er iod did t he patie nt hav e a b lood glucose value les s than 60 mg pe r d L, wh ic h h e was able to de te ct an d corr ect wit hout ass is tanc e. The b as al r at es can be ad just ed in th e fu t ur e if h is b lood gluc ose le ve ls re main e le vate d and his A1C inc re as es to gr eate r th an 6.5%.

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Fig ure 6-6 Home Blood Glucose Met er Down load. A: Re ading s sh ow t h at patie nt has sign if ic an t fre quent hy pogly cemia. B: Downloads afte r adju st men ts to h is re gime n, wh ich imp rov ed his hy pog ly ce mia. Hyp os, ev ents of hy pogly cemia; MB G, me an b lood glu cose ; N, nu mb er of re ad ing s; SD, s tandard dev iat ion.

P. 284

Pump Therapy Reduces Total Daily Insulin Requirements and Limits Weight Gain R e duced ins ulin re quire ments and g re at er flex ibilit y in food in take may r esu lt in min imal we igh t g ain for p ump use rs w he n compare d w ith MDI patie nt s. 8 , 1 3 Patie nt s in te ns iv ely man age d in th e DC C T gain ed on av er ag e 10 pounds mor e ov er a 6- year pe riod t han did t h os e u sin g c on v en tion al t he rapy . B ecau se pu mps infuse insulin e fficie nt ly, us ing only a s ingle su bcu t an eou s d ep ot and on e r ap id -actin g in su lin an alogu e , one 's total daily dos e of insulin c an be re du ce d in many case s by 10% to 15% wh e n c ompare d wit h MDI s.

L es s insulin use limits we ig ht gain.

E q ually import ant is how pumpe rs can physiologically manage e pisode s of mild h y poglyc emia. I ns te ad of “e at ing their way out of hy pogly cemia,⠀ p ump patie nt s may e ith er su sp en d t he pu mp or place th e p ump on a te mporary basal rate unt il t he b lood gluc ose le ve ls in cre as e in re sp onse t o in cr ease d h ep atic g luc os e p roduct ion. Whe n one eats to cor re ct h y poglyc emia, e xt ra calories ar e c ons ume d, and th e c orre ct ed blood g lucose lev els te nd to sur pass t he int en d ed targe t of 70 t o 100 mg pe r dL . Face d w it h a p ostc orre ct ion glucose of 280 aft er the con sump tion of a bowl of ice cr eam t o corr ect a glu cose le ve l of

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54 mg pe r d L, the p atient m ay de cide to g iv e a s up pleme n tal bolus to cor re ct t h e h yp er glyc emia. Th is may re sult in insulin st ac kin g and a re tur n t o hy pogly ce mia, followe d b y e ve n gr eate r food consumption. B ecause pump p at ients te nd to h ave le ss fre qu en t epis od es of h ypog ly ce mia t hat th ey can manage with g lucose t ab le ts rather than with can dy bars an d ice cr eam, weig ht gain is min imize d.

Pumps Reduce and Reverse Diabetic Retinopathy Insulin pumps hav e b ee n show n to re duce and ev en r eve rs e d iab et ic re tin op ath y. An Italian st ud y 1 6 of 20 patie nt s wit h T 1DM w it h an ave rage age of 37 year s and ave rage du ration of diabe te s of 18 ye ar s w ho we re followe d up for 2 y ears show ed an ov er all pu mp - driv en re du ct ion in A1C from 9.1% t o 7.5%. Of 10 patie nt s wit h nonprolife rative diabe tic r et in opath y (4 mild , 5 mod er at e, and 1 sev er e) , 6 sh owe d re gre ss ion to a lowe r g rade of diabe tic r et inop at hy . T wo of 4 patie nt s w it h prolifer ative re tin opath y showed a re duction in ret inal les ions. The e n han ceme n t in glyc emic c ont rol ach ie ve d v ia in su lin p ump ther ap y r es ult ed in sig nificant impr ove men t in diabe tic r et in opat hy .

Lifestyle Flexibility CS II allow s pat ie nts t o hav e a more fle xible life st yle. Pump ing simplifies ir re gu lar meal sc he du les, ex er cise , t rave ling, and other unp lanne d act ivitie s. T he se advan tage s may e xp lain wh y 50% of h ealth care pr of ess ionals with T1DM who are me mber s of t h e Ame rican Diab et es Association (ADA) an d Amer ican Ass oc iat ion of Diabet es Ed ucat ors us e insu lin pu mps . Patie nt ac ce ptan ce of pu mp t he rapy is e xt re mely hig h. Of patients us ing pumps, 97% show lon g-t er m cont inu ation rate s. 1 7 P. 285

Continuous Subcutaneous Insulin Infusion is more Expensive than Multiple daily Injections Insulin pump ther ap y is mor e e xp ensive t han tr ad it ion al insu lin delive ry de vice s s uc h as v ials, sy rin ge s, and pe n injec tors (Table 6- 2) . Initial start -u p c os ts for pu mp th er ap y ave rage $5,500. In fu sion set s, re se rvoirs , and cat he te rs cost $1, 500 to $1,800 pe r y ear. Pump patie nt s are u su ally mor e w illin g t o pe rfor m home blood g lucos e monitoring, addin g t o th e e xp en se of t his n e ces sary proc edu r e. Preg n an t patie nt s wit h T 1DM w ho are inte ns iv ely man age d on pu mp t he rapy will spe n d on ave rage $140 pe r mon th more on all diabe te s-re lat ed supp lie s t han will patien ts u sing MDIs. 1 8 Kanak is et al. 1 9 re view ed the relativ e c os ts of in su lin p um ping in 2002. E xclu din g t he in it ial st ar t- up cost s of p ump ther ap y, C SII c osts ap prox imat ely $2, 000 more pe r y ear th an sy rin ge s and vials, an d $1, 500 more t han pe n injec tors .

Med icar e and Me dicaid in most stat es and in su ran ce c ompanie s n ow cov er ins ulin pu mps an d s up plies with pr ope r d oc ume ntation and prior ap prov al ( App en dix 3 ). Patien ts with Me dicare and th ird- part y payor s must p ay 10% to 20% of t he init ial cost (d ur ab le e qu ipme nt cove rage ) an d a pr oport ion of continuing supp lie s.

Skin Infections and Irritations Subcutaneous s kin infe ctions at t he infus ion sit e are like ly to oc cur if th e patie nt doe s n ot ch ang e th e infusion site at least e ver y 72 hour s. Pat ie n ts mu st be tr ain ed to r ec og n iz ed sign s of e arly abs ce sse s, which include pe rsis tent it ching , p ain, or re dn es s arou nd th e infu sion site , or a grad ual inc rease in blood glucose le ve ls as insulin absor ption is r edu ce d f rom an in fe cte d s it e. Most su bcu t an eou s abs ce sse s can be tr eate d e mpirically w it h antib iot ic s dir ect ed at St ap h ylococcu s au re us infe ct ion s. Larg er ab sce sse s w ill re quire surgical dr ainage . Prop er inse rt ion t ec hn iqu e an d in fu sion-s ite mon itor in g will r ed uc e t he r is k of an abs ces s de ve loping .

On rare occ as ions, the author has note d r ecu r ring localiz ed skin irrit at ion occ ur rin g at t he in su lin inf us ion site within 24 t o 48 hours aft er initiating t he n ew infu sion se t. In it ially p at ien ts ex pe rien ce mild itch in g ar ound the s it e, which pr ompts them to ch ang e t he ir in fu sion s et s and re inse rt th e m in a d iff er en t are a.

Howe ve r, the ir ritation re curs within 48 hour s in as sociation with an in cr ease in b lood glu cose le ve ls.

Some patien ts may att emp t to use supp leme nt al in su lin b olu se s t o nor malize th e ir glu cose lev els, wh ich only wors ens t he localiz ed skin re action. Be in g forc ed to ch an ge th e in fu sion s et s e ver y 2 d ay s in cre ases the cost of pump t he rapy . Patie nt s be come fru st rate d b y t he fact th at th e y are forc ed to make fre qu e nt site chang es, while t he ir g lucos e le vels fail t o nor malize . S ome may d ec id e to st op pu mpin g altog et he r and re turn to MDIs . H owev er , b y s witching to a d if fer en t in su lin for mulation (i.e ., from lisp ro t o glulisin e or asp ar t), the patient will notic e sig nifican t an d rap id improv eme n t in th e s us pe cte d localiz ed ins ulin

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alle rgy . 2 0 , 2 1 P. 286

Some Physical Activities May Damage the Pump Pump s cannot be worn d ur ing cer tain typ es of sp or tin g act iv ities , su ch as p lay in g foot ball or ru g by, or SC UB A div ing. Although some pumps may be de taile d as bein g â €œw at er proof, †patie nt s sh ou ld be aw ar e that pumps ex pose d t o wate r p res su re s be low 10 fee t may not main tain th eir prot ec tive st at us .

Pat ie nts ar e t he re fore st rongly e ncour ag ed to d is con ne ct th eir pu mps w hile part ic ip at ing in w at er sp or ts .

Diabetic Ketoacidosis May Occur Rapidly and Without Warning in Pump Patients DKA may occur r ap idly in pump p atients un d er th e followin g sit uation s: ( a) an u n der lyin g in fect ion de ve lop s, such as a viral illnes s or app endic it is; (b ) t he infu sion se t b ecome s d is con ne ct ed or is improp er ly ins er te d; ( c) t he inf usion se t b ecome s ob str uc te d, clogge d, or filled with a lar ge air bu bb le (in which case, the patie nt 's insulin d ose is su bst itu te d w it h air) ; (d ) th e patie nt simply mis calc ulate s t he pr op er dose of insulin to ad ministe r to cov er th e amou nt of carb ohy dr at es cons ume d d u ring a meal; (e ) the patient omit s a mealtime dose of insulin ; (f ) th e patien t ru ns out of in su lin in t h e p ump re se rvoir ; or (g) the p ump has a major malfunction and fails t o de liv er ins ulin . DK A may occ ur in e ve n th e mos t compliant of patie nt s, which emp hasize s t he impor tanc e of c ar efu l pu mp ed ucat ion and follow -u p.

Fre quent b lood glucose se lf -monit or ing should ale rt patien t s to in cre asing blood g luc os e le ve ls , w hich would pr ompt them t o inst itute their “ eme rge n cy p rot oc ol. â € Pat ien ts mus t be in forme d t hat w he n faced with incre asing blood g lucos e le ve ls , t he y mu st alw ay s â €œfix t he d iabe te s fir stâ € b efor e tr oub le shooting the insulin pump to det er mine th e caus e of t h e in te rru pt ion in ins ulin de liv er y.

Subcutaneous insulin inje ct ions may be ad minist er ed un t il t he pu mp malfu n ction s are de te rmine d an d corr ec ted .

Indications for Insulin Pump Therapy Althoug h anyone with diabe te s may b e a p ot en t ial pu mp c an did at e, some patie nt s de se rv e s pec ial conside ration for pump initiation.

Failure to Achieve Targeted A1C with Multiple Daily Injections Failure to achiev e t re at ment t arge ts with e le vate d p las ma g lucos e le ve ls and A1C le ve ls is an in dic at ion for a more agg res sive ye t p hy siologic t reat men t app roach . O ne of t he most common re as on s c er tain patie nt s do not achie ve gluc ose tre atme nt targ et s is t he fe ar of h yp og lyce mia. Many patie nt s con sc iou sly ove re at to p re ve nt hy pogly ce mia. By s ele ctin g in su lin pu mp th er ap y, th e patien t can b et te r matc h med ic al nutr it ional ther ap y and e xe rcise wit h in su lin admin istr at ion . Pre cise an d p re dict ab le in sulin dosing is p rov id ed through the insulin pump. For ex ample, 0.9 u nit s migh t b e e xc es sive , b ut P. 287 0.4 units would be app ropr iate . A dos e of 0. 5 un its w ould be difficu lt t o ad min ist er via a syr in ge or ev en a pen inject or. The b as al insulin infus ion v ia C SII is more pr ed ic table an d r eliable, ye t adju st ab le.

Be cause t he basal ins ulin infusion is “ pe ak le ss ,⠀ th e risk for h yp oglyc emia is de cr ease d.

Hypoglycemia and Hypoglycemic Unawareness The fe ar of b ec oming hyp oglyc emic is the â €œrat e-limitin gâ € factor in s uc ce ssfu lly ach ie vin g g lucos etr eatme nt targ et s. With ot he r for ms of insu lin de live ry, th e patie nt with diabe te s may s tr iv e f or pr esc ribe d t re at ment t arge ts , have hy pogly cemia, an d t h en ove re at to c ompen sat e wit h r es ult an t hy pe rg ly ce mia. The p at ie nt is t hen on a â €œr olle r-coast er †glyc emic c ur ve . W ith CS II, a closer carbohyd rate -t o- insulin ratio is maint ained by ad minist er in g min u te amou n ts of ins ulin wh en n ece ss ar y.

If t he plasma glucose should de cre ase b elow th e t re at men t targe t rang e, th e patien t may su spe n d or ce as e insulin inf us ion for a t ime. We ight g ain is avoide d t hr oug h imme diate ins ulin su spe ns ion r at he r than s up pleme ntal carbohyd rate s. In this fash ion , th e rolle r - coas te r e ffe ct is min imize d, hy pogly cemia is less common, and the glucose leve l appr oximate s tr eatme n t t ar ge ts. In addit ion , ex ces sive we ig h t gain is av oided in those p atients who “ eat t he ir w ay out of h yp og lyce mia. ⠀

Athletes and Patients Who Incorporate Exercise into Their Daily Routines Ex er cise pose s a sp ec ial pr oblem f or patie n ts r ec eivin g in su lin . Ide ally, pat ie n ts h ave be en in str uc te d to

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ex er cise at those time s whe n injec ted subc ut an e ou s in su lin is not pe ak in g . E ac h su bcu tan eou s in ject ion of ins ulin es tablishes a d if fer ent s ub cutane ou s de pot from w hich in su lin may b e abs or be d ov er time. As one e xer cise s, insulin ab sorb ed from multiple de pots is more lik ely to r esu lt in h ypog ly ce mia t han is insulin ab sorb ed from a single infusion site . W ith CS II, th e p atien t can s afe ly e ith er su spe n d in sulin infusion for a short time (<1 hour) or modify t h e b as al in fus ion t o a v er y low rate . If su spe n ding infusion, t he pat ie nt can de te rmine w he ther to c ease infu sion abru pt ly or to admin is te r a bolu s (u su ally no mor e t han 50% of the planned inf us ion du rin g t h e e xe rcise p eriod ) be fore ce as in g in fu sion .

Althoug h the p ump should not be wor n b y p at ie n ts wh o particip at e in con tact or w at er spor ts, gly cemic control is much more p red ictable while e xe rcisin g w it h pu mps t h an wh e n u sin g MDI s of in sulin .

Persistent Fasting Hyperglycemia on Rising (Dawn Phenomenon) In some patient s, a d aw n p he nomenon corr esp ond s to an inc re as e in plasma glu cose lev els d ur ing th e early morning hours (4 to 9 AM) . 2 2 Insulin r esist anc e in te ns ifie s in dire ct pr op ortion to t he p hy siolog ic incr ease in cort is ol and g rowt h hor mone lev els. A p at ie n t w ho d oe s n ot have diabe te s simp ly P. 288 pr od uc es more endog enous insulin in r esp ons e t o th es e c ou n te rr egu latory h or mone s. Pat ien ts with diabe tes who inje ct insulin at be dtime cann ot au tomatically in cre ase th e c ir cu lat in g dose of th at in su lin in re sponse to an inc rease in glucose le ve ls. Howe ve r, prog ramming a 100% t o 150% in cre ase in b asal insulin delive ry on an insulin pump for 4 to 5 h ou rs, be gin nin g 1 h our be fore th e an t ic ip at ed ons et of th e dawn phe nome non, allows t he p at ie nt t o wake n w ith ne ar-n ormal gly cemic le ve ls.

Pregnancy CS II is an ex ce lle nt me thod to achiev e and main tain t he me ticu lou s gluc ose c ont rol re qu ire d d ur in g pr egnanc y for the pre ve ntion of fet al malformation s an d obs tet ric complications . Fr equ e nt basal rate s c an be se t d ur ing the 24 -hour pe riod, and one can ad minist er a bolus immed iate ly w it h food in take to con tr ol post prandial plas ma gluc ose. Progr ammed basal- rate ch ang es ar e n e ede d, as in sulin re qu ire men ts ar e diffe re nt during e ach of the pre gnanc y t rimes ter s ( see C hapt er 8 ). Patie nt s c on t emplatin g p re gn an cy will also find that using C SII s imp lifie s t he ir man ag eme nt of h yp er glyce mia. 2 3

Shift Workers Shif t wor ke rs t end to hav e a v er y d if fic ult time with gly cemic cont rol. 7 Th e p hy siolog ic st re ss c au se d b y chronic slee p dep rivat ion and alt er ed work sch e du les res ult s in in cr easin g s eru m c or tisol lev els. In su lin re sistance is ex acer bate d in re sp onse to t h e h igh er cort isol le ve ls. 2 4 Patien t s wh o wor k alte re d sh ifts can ad jus t t he ir b asal r at e p rofiles to cor re spon d t o th eir sch ed ule s. For e xample, a re gist er ed nu rs e w ho work s t he â €œ grav ey ar d shiftâ € M onday th rou gh Friday can u se a de sign ate d pu mp patt ern on th ose days that would p rovide les s basal ins ulin from mid nigh t th rou gh 7 AM. On h er days off , t he pu mp patt er n may be alt er ed automatically b y t he patie nt so t hat ad dition al in su lin is p rovide d as she sle ep s from midnight through 7 AM. Many women also fin d th is p at te rn tool u se ful, as th eir ins ulin re qu ir eme n ts may jump 10% to 15% dur ing the 3 t o 5 days p rior t o th e on se t of men st ru at ion . 2 5 W h en th e patien t re cognize s an incr ease in he r insulin re quire men ts , s he simply swit che s h e r p ump se ttin g fr om patt er n A to p at te rn B. Pat te rn A can be re sumed onc e again af te r 5 to 7 d ay s as p roge st eron e leve ls fall an d insulin res istance wane s.

Pediatric Patients, Highly Insulin-sensitive Individuals, and Poorly Compliant Adolescents Pediatr ic patie nt s may r eq uir e minute amou n ts of in su lin , wh ich can b e d elive re d v ia C SI I in variations of 0.1 units of ins ulin for b olus and 0. 05 unit s for basal alt er at ion s. C SII allows min ut e variations in t he amounts of insulin infuse d to acc ommodate th es e s pec if ic re qu ire men ts. Th is accu racy su rp as se s th e dilut ion of U -100 insulin then inje ct ed subcu tan eou sly.

P. 289 In a re view of 80 ad ole sce nt p at ie nts t ransfe rre d f rom MDIs to e it he r CSI I or MDI s u sing glarg in e an d fast-act ing ins ulin, t hose sw it ched to p ump s h ad a sign ificant A1C dec re as e fr om 8.4% t o 7. 8%, w he re as MDI pat ie nts d id not hav e a s ig nificant d ec re ase in A1C (8.5% to 8. 2%). The ris k of b ot h mode rate an d se ve re hy pogly cemia de cline d in bot h grou ps . 2 6 In 65 v er y y oung childr en w it h a me an age of 4. 5 y ear s at p ump in itiation (ran ge , 1. 4 t o 6.9 ye ars) , mean A1C dec re as ed significant ly from 7. 4% to 6.9% at 12 mon th s, wit h fu r th er re du ction s b y 2 ye ars. 4 Se ver e hy pogly cemia was r ed uc ed by 53%. In a ran domize d tr ial of C SI I ve rs us MDIs 2 7 in a g rou p of

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young child re n with a mean ag e of 3. 6 ye ar s, no d iffer en ce in A1C or hy pog ly ce mia w as de fin e d, alt hou gh pump t he rapy was f ound t o be safe and e ffe ctiv e in you n g ch ildre n .

Tee nag er s who r equire fr eque nt hos pitalization for DKA or fin d litt le p le asu re in followin g an in su lin re gimen b y using tr aditional pe n -inje ct or de vice s h ave be en sh own to r ed uc e t h eir in cide nc e of hos pitaliz ations and DK A b y using C SII. 2 2 Tec hnical ex pe rtis e is ne ed ed for pat ie nts u sin g in su lin p ump s. T o be su cce ssfu l pu mpe rs , p at ien ts sh ou ld be come proficie nt at t he sk ills list ed in Table 6-1. C h ild re n an d adole sce nt s wh o u se ins ulin pu mps mu st hav e t he assist ance and encourage me nt of th e ir pare n t(s) to man ag e p ump th e rapy effe ct iv ely an d safely . Pare nt s must super vise adoles cent s to make ce rt ain th at t he y ar e n ot t aking dan ge rou s â €œ sh ort cuts. â € For e xample , s ome adoles cent s may â €œforg et †to g iv e a me alt ime b olu s w he n th ey are amon g frie nd s be cause they do not w ant t o attr act att en tion to t he ir d isease st at e. Ot he rs may simply ad minist er a bolus of ins ulin without firs t ch e ckin g a b lood gluc ose le ve l, p re fer rin g to â €œg o by how they fe elâ € rathe r t han by what the y k now is be st for th e m. O ccasion ally, te en age rs m ay de lay ch an gin g their infusion se t on sche dule , bec ause the y h ave more pre ss in g is su es to wh ich th ey mu st at te nd , or they may inad ve rt ently allow the ir re se rv oir s t o ru n ou t of insu lin.

Dis turb ed eating b ehav ior is v er y c ommon in you ng wome n w ith T1DM. B et wee n 45% an d 80% of t ee nag e girls ar e b inge e at er s, and up to 40% will eat wh ile omit tin g in su lin in an att emp t t o cont rol th e ir we ig ht . 2 8 E at ing disor der s are associate d w it h man y ne gativ e me dical out come s, in clu ding poor met ab olic control, incr ease d f req uency of diabe tes -re lat ed h os pitalizations , an d h igh er rate s of d iab et es - re late d complications, p articularly r et inopat hy and pe rh ap s n eu rop at hy . 2 8 Patien ts with clin ic ally sign if ic an t eating d isorde rs should not be placed on in su lin p u mp th e rapy .

Special Situations That May Affect Glycemic Control: Menstruation and Traveling Shortly be fore and during me ns truation, some wome n fac e h igh er ins ulin re qu ireme n ts. In cr easin g th e basal infusion rate in anticipat ion of and du r in g men se s ofte n re su lt s in improv ed glu cose con trol. A se parate basal-rate pr ofile may b e initiated as gly cemic con trol b egin s t o wors en be fore th e ons et of P. 290 menst ruat ion. Re sumpt ion of t he orig inal basal rate s can be gin on d ay 5 to 7 of t he me ns tru al cyc le .

Trave ling be twe en t ime z one s is s imp lifie d w it h th e u se of an in su lin p ump . I f on e n ormally inje ct s th e pr esc ribe d b as al insulin at 10 PM while at h ome in Los An ge le s, and th en flies to Ne w Y or k, th e basal insulin should b e injec te d at 1 AM. This may r eq uir e t he patie nt to w ak e up from s le ep to admin iste r t h e inje ction. A n insulin p ump prov ide s basal ins ulin 24 h ou rs a d ay , s o on e doe s n ot h ave to be con ce rn ed ab out consist ency. The fle xib ility pr ovide d b y t he ins ulin pu mp allow s p at ie n ts t o tr av el s afe ly an d confid ent ly (se e Chapte r 9 for more de tails).

Discussing Pump Therapy with Prospective Patients P. 291

Case 3 Je rr y, 37 y ears old , is see n for his initial offic e v is it . A fte r b ein g d iagn ose d w it h T1DM at age 24, Je rry fe els as thoug h he is re ady f or the “ ne xt ste p⠀ in managin g h is d iabe te s. Wit h NPH an d re gu lar ins ulin tw ic e d aily, Je rr y's A1C is 5.2%. He has bee n ch ec king h is blood g lu cos e le vels “ int er mit te nt ly⠀ ove r t he p as t month. H is ele ctr onic log s in dicate th at 94% of h is glu cose lev els lie be tw ee n 70 and 170 m g pe r d L, and on ave rag e, he is mon itorin g b lood glu cose le ve ls 1.6 t imes a d ay .

He has ex pe rience d no hyp og lyce mic e ve nt s in th e p as t mon th . Jer ry 's labor at ory stu die s an d ph y sical e xamination ar e nor mal, and he has no d iab ete s - re late d s ymp toms or complication s. A s a bu ye r f or a lar ge clothing chain, Jer ry 's job re quire s h im to b oar d a plane and tr av el on 10 of 30 days e ach mont h.

He flies inte rnationally 6 t im es a y ear. Makin g n o se cre t as t o h is ag en da, Je rry ann ou nc es t h at he wan ts to p ur chase an ins ulin pump. He is a â €œ ve ry b u sy man †an d cann ot affor d t o take time off wor k t o st ar t t he pump . He wants to pay cash for t he pu mp an d s up plies , say in g “Don 't worr y abou t my ins ur ance cov er ag e. I'll d eal wit h t he m late r.â € The following q ue st ions r eg ar ding Je rr y s hou ld be add re sse d: 1. Is Je rr y an insulin p ump candidate ?

Any one who re quire s ins ulin ther apy is cer tainly an in su lin pu mp cand id ate. As su min g th at h e is w illing to le ar n inte nsive diabe te s manage me nt , car boh ydr at e coun tin g, sick -day man age men t,

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diabe te s t rave ling s trat egie s, eme rg en cy pu mp p rotocols, ins ulin ph armacokin et ic s, ag re e t o part icipate in f ollow-up ap point ment s, an d p er form fr eq ue n t h ome b lood glu cose monit or ing , J er ry would b e an ex celle nt pump c andid at e.

2. How should one ad dr ess the ap prop riaten e ss of p u mp th e rapy with th is p at ien t?

Insulin p ump ing does not cur e diabet es . R ath er , t he pu mp simply p rovid es a mor e p hy siolog ic me ans of d elive ring insulin t han do su bc ut an e ous in je ction s. To ac hie ve th e mos t b en ef it from C SI I, patie nt s must be come ded icate d diabe te s se lf-man ag er s. S imp ly r eplacin g t he inf us ion se t e ve ry 3 days and ad minist er ing bolus ins ulin be fore meals will n ot allow patien ts to b ec ome su cc ess ful pumpe rs . Pumping re quire s d ed ic at ion , ed uc at ion , an d a lon g -t er m commitme nt to imp rovin g on e's diabe te s short - and long -te rm outc omes.

3. W hat s te ps c an t he phys ic ian take on th is visit th at migh t e n cou rage Jer ry to â €œraise th e b arâ € on his commitme nt to d iab et es self- managem en t in pr ep ar at ion for initiatin g p ump th er apy?

Je rr y should be place d on a physiologic b as al-b olu s th er ap y b y u sin g a rapid -ac tin g in su lin analogu e and a onc e-d aily b asal insulin analogu e . Pre fe rably, h e s hou ld be in str uc te d on how to u se an ins ulin -pe n inje ctor , as t he se de vice s may b e u se fu l as a backu p shou ld a me ch an ical dy sfu nc tion occur during tr ave l w ith the pump. Jer ry mus t agr ee to p er form h ome mon itor in g be fore each me al to d et er mine the prop er amount of insu lin h e will n e ed to in je ct be fore eatin g. Be dtime glu cose lev els w ill also be r ecor de d to le sse n th e like lihood of noc tu rn al h yp oglyc emia de ve lop in g.

R ecog niz ing and t re at ing hy pog ly ce mia p rope rly by u sin g g lucos e t ab s or ge ls is en cou rage d.

Be caus e J er ry does part ic ipate in c ar diovascu lar con dition ing 4 times we ek ly , t h e man ag eme nt of e xer cise for p atients with T1DM should als o be ad dr ess ed . Je rr y s hou ld join th e A DA an d partic ip at e in the monthly g roup d iabe te s e ducation pr og rams at th e local h os pital, w hich are tau gh t b y t he C DE. Finally , Jer ry may choose to att en d a local “p ump clu b me et in g †so th at h e can in te ract with ot he r p ump er s and pr ospe ct iv e p u mp pat ie n ts.

W hen e valuating a patie nt as a pot ential cand id ate for an in su lin p u mp, th e p ros an d con s of pu mp t her ap y must be discuss ed . Blood gluc ose le ve ls will hav e t o be ch eck ed more fre qu e nt ly th an for p at ie n ts using MDI s, and p ump er s must be complian t with tr eatme n t s ug ge stion s and follow -u p office visit s.

A lt houg h most pat ie nts p lace d on insulin pu mps are av id part icipant s in diabe te s se lf -manage me nt , s ome indiv id uals w ho p oor ly manag e d iab ete s w ith MDIs migh t be come s uc ces sfu l pu mpe rs. Many inad equ ate ly c ont rolled patient s hav e b ec om e fr us trat ed an d discou rage d b ecau se MDIs h ave n ot h elpe d t he m ach iev e t heir t arge te d g ly ce mic goals. As p at ie nts b eg in t o us e in su lin p ump s, th eir en th us ias m for d ev elopin g a p artne rship w it h the he althcare t eam gr ows. Pat ie n ts of te n fe e l mor e e n er ge tic and â €œ in c on t rol†of t heir d iab et es with the us e of t he p ump .

Phys ic ians s hould be familiar with the diffe re nt ty pes of ins ulin pu mps th at are commer cially av ailable ( Table 6 -4). On occ as ion, patients will re qu es t a pr esc ript ion for a cer tain typ e of in su lin p ump . A s pe cialist in d iab et es car e is lik ely to hav e an cillar y me dical pe rson n el in th e off ic e w ho c an assist p atients on t he w or king me chanics of ind iv idu al in su lin pu mps . PC Ps, in con tr as t, may wish t o be come as f amiliar as pos sible w ith a sing le t ype of in su lin pu mp to impr ov e th eir c omfort le ve l with man ag in g pu mp p atients . L earning ev er yt hing about one pu mp is e asier th an le ar n in g small t id bits ab out mu lt iple p um ps.

I nq uir ie s r eg ar ding e ducational pr ogr ams for PC Ps int er est ed in man aging pu mp p atien ts sh ould be d ire cte d t o the p ump manufact ur er s' We b sit es .

M any p atients with diabe te s are not conside re d c an did at es for p ump s be cau se of un de rly in g c omorbidit ie s. A p oste r p re sent at ion 2 9 ex amin ed P. 292 P. 293 P. 294 P. 295 13 “pump- challenge d⠀ p at ients, whose comorb idities inc lu de d s ev er e h yp oglyc emic u n aw ar en e ss, mov eme nt dis or de rs, att ention de ficit d is or de r, men tal re tar dation, sc hizop hr en ia, dr u g or alcoh ol ab us e, p er sonality disor de r, dep re ssion or s ev ere p an ic att ac ks, a hist ory of fals if yin g glu cose re cord s, hy poglyc emic e ncep halopathy, and e xtr eme ins ulin re sist an ce th at r equ ire d U -500 insu lin. Pre -C SII e ducation took 5 mont hs on ave rage , and A1C le ve ls de cre ased from 9. 4% to 8.4% ov er a 6 - to 12-mon th p er iod . S ev er e hyp oglyc emia was r educe d b y 76%. Th e au th ors c onclu de d t hat “s uc ces s is r elative ,⠀ and p ointe d out that when d ealing with this g rou p of p at ien ts, th e sk ill and patie nc e of t h e p re scr ib in g p hysician and he alt hc ar e t eam are cr ucial.

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TABLE 6-4 Insulin Pump Comparison

Fe atur e

Nipr o Am igo

D e lt ec C os mo

Insule t

Me d ro nic

Anim us I R-

Om niPo d

P ar adig m

1250

Phone c ont act

888-6517867

800-8269703

781-4575000

800-9333322

877-9377867

W eight

3. 1 oz

2. 7 oz

4.0 oz

3.8 oz

3. 1 oz

Av ailable c olor s

Mid night , f laming o,

B lue , b lac k, p urple

—

Cle ar , smoke , blu e, pu rp le

B lu e , silve r, b lack

300 U

200 U

176 U (515) 300 U (715,

200 U

p ac ific , g rape , s now , solar

I nsulin r es erv oir siz e

300 U

722)

B as al incre me nt

0. 05 U

0. 05 U

0.05 U

0.05 U

0. 025 U

Tot al numbe r of b as al

48

48

7

3 patt er ns each wit h 48

48

r at es which

rate

c an be p rogr amme d

capability

B as al

15 min

30 min

30 m in

30 min

30 min

B as al

3- or 15-

E v er y 3 min

—

3 min V ar ie s,

E ve ry 3 min

d elive ry

min inte rv als

inte rv als

0.6 U /h ev er y 10 min . Basal rate de liv er y, 0.5â €“ 3. 5 U/ h

Te mpor ar y b as al

R ate in U /h ( 15 min to

I n 0. 05- U incr eme nt s or

% of U /h (1– 12 h

±0. 1- U inc rem en t as

- 90% t o + 200% in

24 h in 15 -

100% to

in 30-min

sin gle b as al

in cre me nt s

min incr eme nt s)

+ 140% in incr eme nt s of

inc re men ts)

rate for 0.5â €“ 24 h or

of 10% for 0. 5 t o 24 h

or % of

5% for 0.5 t o

as % of

( 30-min

act ive p rofile

72 h (30-min incr eme nt s)

cu rr en t b as al rate

in cre me nt s)

( 10% –200% in 10% st ep s)

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B olus incre me nt s

0. 1â €“5. 0 U in 0.1-U

0. 05, 0.1 v isual; 0. 05,

s te ps

0.05, 0. 1, 0.5, 1. 0 U

Page 24 of 43

0.1 U . B olu s de liv er y

0. 05 v is ual or au dio,

0. 1, 0.5, 1.0

ran ge 0â €“25

0. 1, 1.0, 5

v isual or

U. R emot e

au dio

audio

de liv er y av ailable

C arbohyd rate and

—

M anu al e nt ry

—

c or re ction fe ature s

Manu al or bolu s wizar d

Man ual e n try +

en tr y

ass is t fr om E ZMan ag er Plu s Palm s of tware

B olus

N or mal,

S tand ard,

Normal, d ual-

St and ar d,

d elive ry

e xt ende d,

e xt en de d,

—

wave ,

e xt en de d,

laye re d

c ombinat ion

squ are -wave .

Adju st ab le

c omb ination

ac tive in sulin cu rv es de cre ase ch an ce of ins ulin stack ing

B at te ry typ e

C R 2 camera

and b at te ry

b at te ry 30

1 A AA 3 wk

life

d

Me mory

90 d on

90 d (2,000

s cre en and

e ve n ts) of

s tore s 1 -y r hist or y

2 AAA 4 w k

1AAA 3â €“4

1 AA lit hiu m

wk

6– 8 we ek s

90 d .

600 bolus ,

Down load t o

270 basals,

b asals , car b b oluse s,

PC for fu ll an alysis or

120 daily t otals , 30

c orre ct ion b oluse s,

vie w u p t o 31 d of h ist or y

alar ms

alarms

on p u mp

—

scr ee n

Sof tware for

Pump PA L,

e zMan ag er

me te r and p ump

—

C O Zman age r: I R p ort , p rog ram

—

radiowave via BD me te r t o

Plu s and IR k it , cradle ,

d ownloading

p ump and

re vie w,

an d

d own load last

modify

s of tware

4, 000 e ve nt s

an d /or back up pu mp se ttin gs . 90 Med tr on ic Car eLin k Manage men t Sys te m lin ks pu mp, met er , an d log book down load s for u se by

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med ical pr ov ide rs

E xt ra

—

fe ature s

I nt eg rate d

Back ligh t ,

(1) R emot e

C lip-on

Fr ee st yle

re mind er s

ac ce ss g ood

c ov er s,

me te r,

and ale rt s,

for

p er sonalize d

p er son alize d

ch ild lock,

pe diatrics ,

c ar b an d

c ar b an d c orre ct ion

int eg rate d Fre es tyle

vibr at ion feat ur e for

c or re ction fact ors,

f ac tors , t rack s

met er , st or es

patie nt s wit h he arin g loss;

t racks r es id ual

r es id u al

1,000

(2)

b olu s in su lin

b olus in su lin, many

common foods in

Backligh t ; (3)

r emin de rs

PDA for

Squ are wave

inclu din g

carb

bolu s

mis sed bolu s,

cou nt ing

feat ur e; (4)

d aily c orre ct ion

Au to off f or hig h- risk

b olus total,

hy pog ly ce mia

d et aile d hist ory in

patie nt s; ( 5) Bolus wizard

p ump

feat ur e for carb cou nt in g an d corr ec tion bolu ses ; (6) 8 Cu st omizable daily re mind er s; (7) W ir ele ss con ne ct ion lin ks to B D glu cose met er and bolu s wizar d; (8) C h ild block an d re mote bolus capability

Pump g uarante e

—

4y

4y

4y

4y

p rogr am

C arb, carb ohy dr at e; h, hour (s); min, minu te s; PDA, pe rs onal digit al assist ant (h an d- he ld d ev ic e); U , unit s.

Placing individuals on a pump if t he y are u nab le to mast er MDIs f ir st is a pre scr iption for f ailu re an d dang er . Patie nt s must be fam iliar wit h usin g MDI s of in sulin be fore be gin nin g p ump th er apy. All med ical de vice s, including insulin pumps , may malfu n ction . Patien ts mu st b e able to t rou bles hoot th e p ossible mec hanis ms for the p ump malf unct ion and kn ow h ow t o manage any re su ltant h ype rg lyce mia. Th e r u le for manag ing any insulin p um p malf unct ion is t o “always tr eat t he d iabe te s fir st. †Th is may r equ ire re ve rting b ack t o us ing MDIs t emp or arily u nt il a n e w pu mp be comes av ailable. Alt hou gh ins ulin dosin g is

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similar with MDIs and C SII , t he ir p rimary diffe ren ce is in th e ph ysiologic me ans of ins ulin de live ry and the fle xib ility they afford . A dult patie nt s w ho h ave no k now le dg e of MDIs can not safe ly be place d on pump t he rapy .

Initiating Pump Therapy in the Primary Care Setting Pump s may b e initiat ed in t he p ractit ioner 's office by a cer tified pu mp t raine r in abou t 1 h our . A patie nt who is new to pump ther ap y b as ic ally m ust u nd er stan d h ow t o in se rt th e in fu sion se t and pr ovide a mealtime bolus . Pump s tude nt s should not be init ially ov er challen ge d t o learn e ve ry featu re th at is incor porat ed into their p ump. The basic skills any firs t -t ime pu mp er mus t maste r prior to leavin g t h e office include (a) how and whe n t o chang e t he ins ulin re se rvoir an d in se rt th e in fu sion s et , ( b) h ow and when t o prop er ly administ er a pr andial bolus of ins ulin , ( c) h ow oft en to c he ck blood g lu cose lev els, and (d) how to r esp ond appr opriate ly t o hy pe rgly cemia and h ypog ly ce mia. Pat ie n ts s hou ld b e p rovid ed with ope n acc ess to t he pump trainer and t o the ph ysician sh ould an y is su es or qu e stion s arise re gard in g th eir insulin pump. Follow-up visits should be sch ed ule d for 2 we eks afte r p ump initiation , at wh ic h t ime paramet er s may b e fine tuned and ad ditional sk ills may be addr es sed . O ve r t ime , patien ts can be inst ruct ed on c ar bohyd rate count ing, e mer ge ncy manag eme nt of pu mp malfu n ction , b olu s w iz ard feat ur es, pump data manage ment , sic k-d ay re gimen s, tr ave l p roce du re s, pu mp- au gme n ted se ns or sys te ms, us e of s up pleme ntal insulin, and initiation of te mpor ar y b as al r at es . Patien ts do n ot n e ed to be give n saline to “ pr act ice their button p ush in gâ € be fore be ing giv en ins ulin . To t hos e p ump tr ain er s who ad vocat e using saline init ially, I ask , â €œWou ld y ou live in a c av e f or a we ek be fore you move int o your b rand -new mansion?†As P. 296 a PC P managing mor e t han 280 p ump patie nt s, not onc e h ave I r ecomme nd ed th at an yon e b e p lace d on saline prior to using ins ulin

TABLE 6-5 Online Pump Training Com pan y

Online P um p- training S it e

Me dt ronic MiniMe d

ht tp ://w ww. pumpsc hoolon lin e. com

Animus

ht tp ://w ww. animascorp .c om/ vp ir 1200/vp m.h tm

De lt ec

ht tp ://w ww. cozmor e. com/de fault .cf m/PID = 1. 2. 10

Various tr aining oppor tunit ie s ar e availab le to patien ts , in clu ding pu mp v ide os , on lin e virt u al p ump pr og rams ( Tab le 6-5), and pump manuals. Acc ept ance of C SII is qu ite h ig h on ce th e pu mp is in itiate d.

Phy sicians who pre scr ibe pump t he rapy mu st b e able to d et er min e th e safe an d e ffe ctive in it ial p ump paramet er s t hat will allow patie nt s t o ac hie ve ad eq uat e g ly ce mic con trol w it hou t bec omin g hy pogly cemic.

Dur ing the s ub se quent f ollow-up ap point men ts , p hy sicians may ch oose to add ad dition al b as al r at es , change t he nat ur e of the me alt ime b olus, and monit or th e patie nt for acu te and ch ron ic comp licat ion s re lat ed to C SII.

Setting the Pump Parameters (Don't Worry—This Is the Easy Part!)

The following case will illustr ate the s te ps r eq uir ed to de te rmin e th e in itial p ump parame te rs f or a patie nt who is be ginning C SII .

P. 297 P. 298 P. 299 P. 300

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P. 301 P. 302 P. 303 P. 304 P. 305

Case 4 Je n, age 20, is p re paring to s tart insulin pu mp th e rapy today . Sh e we ig hs 70 k g, and sh e h as a h ab it of sk ip ping b re ak fas t b ut eat ing a mod est lun ch an d large din ne r. Sh e has c ons is te nt hy pe rg ly ce mia on rising e ach morning (6 AM), wit h he r fast in g blood glu cose valu es av er ag in g 40 mg pe r d L gr eate r th an her pr elunc h v alues . J en e xer cise s for 60 min u tes , 5 d ay s a we ek , b et we en 4 and 8 PM, and e at s din n er around 9 PM. H er blood glucose lev els at be dtime be fore init iatin g p ump th e rapy have be e n ave rag in g 200 mg pe r d L. The following s te ps w ill guide the phys ic ian in t h e in it ial s tep s r eq uire d for pu mp prog ramming : 1. W hat is Je n's anticipate d t otal daily dose of in su lin re qu ire men t? (Fig. 6- 7, ite m 1) ď Ź

De te rm ine t he p atient 's total d aily d ose (TD D) of in sulin.

The firs t ord er of busines s to cons id er wh en p re scr ib in g pu mp p ar ame te rs is to d et er min e how much insulin a patie nt re quire s ove r a 24 -h our pe riod. By takin g t he patie nt 's cu rr en t w eigh t in kilog rams and multiplying t hat we ig ht by 0.7 u nit s, on e can d et er mine th e TDD of ins ulin req uir ed for a 24 -hour pe riod as follows:

Figur e 6-7 For mulas f or Progr ammin g Pu mp Parame te rs. Th es e in clud e t otal daily dos e (TDD) of insulin, insulin-s ensitiv it y fact or ( ISF), insu lin/ carboh yd rate ratio ( I/C ), per son al lag time, and rule for managin g h yp oglyc emia. *Alth ou gh many pe ople h ave a 50/50 rat io

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of b as al/b olus insulin, other s may have a ratio of 40/60 ratio, m eanin g t hat more in su lin is r eq uir ed to maint ain PPG th an FPG lev els.

TD D = W e ight in kg × 0. 7 units In J en's case , 70 kg × 0.7 = 49 u n it s (O K t o rou nd th is off to 50 U p er day) The TDD of ins ulin also varies de pe nd in g on t he pat ie n t's lev el of p hy sical con dition in g, age , g ende r, de gre e of the patient 's ph ysical st re ss, an d body we ig ht . A we ll- cond itione d ath let e, for ex amp le, would hav e a TDD of w eigh t in k g à — 0. 5 un its. Table 6- 3 su gge sts dosin g s trate gie s for calc ulating t he TDD base d on th e se mult ip le fact ors. Ke ep in min d th at th is allow s t he phys ic ian to e st ab lis h t he in it ial dos e of in su lin . 

As sign how m uch of the T DD is app lied to b asal and how m uch t o b olus insu lin p e r d ay .

O nc e t he TDD of insulin is calculat ed ,  ½ o f that to tal d aily do se is as sig ne d to bas al ins ulin de liv er y, and ½, t o bo lus insulin d elive ry :



50% of t he TDD = b as al insulin



50% of t he TDD = b olus insulin In J en's case , 25 units is applie d to t h e b as al in su lin and 25 u n its t o th e bolus insu lin.



D e ter m in e the pat ie nt' s ho urly b asal ins ulin re q uir e me nts .

The initial hourly basal ins ulin re qu ir eme n ts are d ete rmin ed by divid in g th e t otal basal in su lin b y 24 hours .

For Jen, 25 U p er 24 hour s = 1.0 U pe r h our . T hu s t he in it ial b as al r at e of in su lin is 1. 0 U p er hour .

Ad ditional b as al r at es may be pr ogr amme d at fut ur e v isits based on th e p re se nc e of t he dawn p he nome non; timing , fr eq ue ncy, and se ve rity of re cord ed ep isode s of h yp oglyce mia; and th e p at ie nt's g ly ce mic re sponse to e xe rcis e. Most p atien ts re qu ire 1 to 2 basal rate s. Gen e rally , t he mor e b as al r at es prog rammed , t he more comp licat ed in su lin p um ping be comes for b oth th e p at ie nt and t he phys ic ian. Patie nt s w ho h ave mult ip le b as al r at es (more th an 4) prog rammed into t he ir pump s, y et are unable to maint ain adeq u at e A 1C lev els (6.5% t o 7. 5%) wh ile s howing s ig ns of wid e g ly ce mic variation , may imp rove by simply limitin g t h em t o 1 to 2 basal r at es .

2. W hat is Jen's insulin -se ns itivity factor ? (Fig. 6- 7, ite m 2) The ins ulin se nsitivit y facto r (ISF) allow s p at ie n ts t o calcu late t he ant ic ipate d re du ct ion in glucose lev el afte r a 1 -unit ins ulin bolus .

Pat ients can use the ISF t o corr ec t hyp er glyce mia res ult in g from u n der dosin g of pran dial in su lin , th e ins ulin re sistance that occ ur s on sick days, or p re -e xe rcise gly cemic elev ations . Glyc emic t arge ts may v ar y t hr oug hout the d ay . Patie nt s may b e adv ise d to main tain a d ay time t arge t of 80 t o 140 mg pe r d L, but a night-t ime t ar ge t of 150 to 180 mg pe r dL t o pr ev en t n oct ur nal h ypog lyce mia. Th e “ de fault s af e t ar ge t⠀ for corr ect ing hy pe rg ly ce mia is 150 mg p er dL . Th is allow s pat ie n ts t o ove rs hoot their m ar k slightly without be comin g h yp oglyce mic. If t he targ et is se t t oo low (100 m g pe r d L), pat ie nts w ill commonly ov er corre ct int o a state of h yp oglyce mia.

The ISF is calculat ed by dividing 1, 700/t otal daily dose of in su lin . J en 's ISF w ould be 1, 700/50 = 34. Thus, if the g lyce mic targ et is 150 mg pe r d L, and Je n's cu r re nt blood g lu cose lev el is 250 mg pe r d L, Je n w ould do the follow ing calc ulation to re ach th e t arge t: St ep 1: 250 - 150 = 100 mg p er dL St ep 2: 100/34 = 2. 9 units St ep 3: Targe t goal = 150 dur ing the d ay Giving a 2.9 -U dos e at noon will allow Je n to ach iev e a n ormal glu cose le ve l with in 1 to 2 h ou r s afte r administe ring t he bolus. (Note th at t he pu mp s allow patien ts to admin iste r in su lin b y te n th s of unit s. T his c annot b e d one with sy ringe s and vials or in su lin p en s. ) Whe n corre ct ing hy pe rgly ce mia, patien t s sh ould be en cou rage d t o re ch ec k t he ir blood g luc ose le ve ls within 1 to 2 hour s of t he cor rec tion dose to make ce rt ain th at t he y ar e app roach in g , y et have n ot e xce ed ed , t he tar get .

Pat ients who mus t fr eq ue ntly c or re ct post pran dial hy pe rgly cemia sh ould be pr ovide d wit h a r ev is ed ins ulin -to-c ar bohyd rate ratio. Ex te nd in g th e s qu ar e- wave port ion of t h e b olu s for a lon ge r time may

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obv iat e t he nece ss it y for fre que nt corr ec tions . H ype rg ly ce mia t hat fre qu en tly occu rs in t he pr ep rand ial or fas ting st ate re quir es ad jus tme nt s in basal -rate ins ulin de liv er y.

3. W hat is Jen's insulin/carb ohy drat e r at io (I/C )? ( Fig . 6-7, it em 3) The I/C r atio pr ovide s p at ients with an e st imat ion of h ow mu ch 1 u nit of in su lin w ill c ov er th e gly cemic ex cursion antic ip at ed with car bohy dr at e in ge st ion .

Divide 450/T DD insulin t o ge t t he I/C .

In Je n's cas e, 450/50 = 9. Thus , if J en con su mes 100 g of carb oh y drate s, sh e will n e ed to adminis te r a bolus of 100/ 9 = 11.1 U of ins ulin .

I/C s may vary throughout t he day, ofte n be in g low er in t he morn in g and h ig he r in t he ev en in g. Jen may act ually hav e an I/ C of 1:8 f or br eakf ast and 1:11 for din n er . Patien ts wh o are ed uc at ed on the ir I/C v alues will re alize that consu ming carb ohy drat es will n e ces sitate a dose of in sulin . For e xample, if Je n goes to a movie and eats popc orn , s he will ne e d to p rov id e in su lin for th at carb ohy dr at e s nack . O ther wise , her blood g luc os e le ve l will b e v er y h igh by th e time sh e r et ur ns home afte r the s how.

4. W hat is Jen's pe rs onal â €œ lag t imeâ € ?

Ab sorp tion r ates diffe r for each p at ien t. By calc ulatin g a p er so nal lag t im e , p ostp rand ial gly ce mic e xcurs ions mig ht be minimize d. 3 0 T he met h od s r eq uire d t o calcu late t he pe rs on al lag time appr opr iate ly are de tailed in Figure 6 -7, it em 4.

A p at ient w it h blood glucose lev els gre ate r th an 180 mg per dL sh ould in cr ease th e lag time , allowing t he insulin to imp rove gly cemic cont rol be fore e at ing . Patien ts wh o are hy pogly cemic be fore me als s hould d elay t he mealtime bolu s u nt il aft er th e meal is comple te d t o pre ve n t a wor sen in g of the hy pogly ce mic state .

5. How sh ould J en's boluses be monit ored and adju ste d?

A p er cent ag e of t he t otal amount of in su lin assign e d for mealtime bolus es du ring a 24- hou r p er iod should be assigned to b re ak fast, lunch , an d dinn e r. As s hown in Figu re 6- 1, gly cemic re qu ir eme n ts are hig he st during the early morning hou rs and in t he e ve nin g h our s. Th er efor e, pr an dial in su lin re quire ments ar e highe st f or br eakf as t and su pp er an d low est for lu n ch .

In Je n's cas e a t otal of 25 unit s is ass ign ed to pr ev en t postp ran dial h y per glyc emia. J en can ap ply the se 25 unit s t o meals base d on t he amou n t of car boh yd rate s sh e will be cons umin g at each meal.

Howe ve r, if Je n has had t rouble with carb ohy drat e cou n tin g, a p re scr ib ed (su gg es te d) “ base line⠀ d osage of ins ulin may be de liv er ed at e ac h me al. From t his base lin e d osage , t he patie nt can inc rease or dec re as e t he dos e of p ran dial in su lin b ase d on s eve ral fact or s:



Incr ease 1 to 2 unit s for larg e me als



Dec re as e 1 t o 2 units f or smaller meals



C alculate the I SF to d et er mine how muc h in su lin w ould be re qu ir ed to adju st th e p re pr an dial glu cose lev el t o 150 mg per dL and then add th is tot al t o th e pre scr ibe d dos e. For e xample, if th e init ial blood g luc os e le ve l is 250 mg pe r d L, pre pr an dial glu cose targ et is 150 mg pe r d L, ISF is 1:50 mg pe r d L, and the s ug ge ste d lunch- time dose of ins ulin is 4 u nits , t he pat ie n t wou ld t ak e a t otal of 6 unit s for lunch (250 mg pe r d L - 150 mg p er dL = 100/50 = 2 un its . Th e se 2 u n its p lus th e sugg est ed lunch d os e of 4 units = 6 un its ).

Ther efor e J en is adv ised to make the follow in g de cisions: a. If the p re pr andial glucose le ve l is be tw ee n 70 t o 170 mg pe r dL , s he may e ith er cou nt c ar bohydr at es or p lan to administe r a b olu s of ap prox imat ely 10 u nit s of in su lin for bre akfast , 4 unit s for lunch, and 11 units for d inn er . b . W he nev er possib le , us e a â €œdu al- wave bolus †to con tr ol th e an ticipate d hy pe rgly cemia assoc iat ed with mealtime . The du al- wave bolus con sists of a rapid imme diate bolu s simu lat in g normal first -phase ins ulin re spon se an d a s qu ar e- wave bolus similar to a n ormal sec ond -ph ase insulin re lease , w hic h is ad minist ere d ov er a 2 - to 3-h ou r pe riod (Fig. 6- 5) .

The dual- wave bolus can be ad min ist er ed in man y d iff er en t w ay s. Pr ovidin g 50% of t he tot al b olus imme diate ly and 50% ov er a 2 - to 3-h ou r pe riod will w ork well for man y patien t s. I f th e p re meal glucose le ve ls are gr eate r t h an 150 mg pe r d L, su pple men tal in sulin can be calc ulate d into t he init ial bolus to targe t a 150 mg p er dL gluc ose le ve l. For examp le , if th e p re lu n ch g lucos e le vel is 250 mg per dL and th e I SF is 1:25, J en sh ould give 4 + 2 or 6 u n its as an imme diat e bolus and 2 units as s qu ar e- wave de liv er y ov er a 2 -h ou r p er iod . If th e p re lun ch g lucos e le vel is le ss than 70 mg p er dL , Je n can eith er re du ce th e immediate bolu s t o 1 u n it

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and giv e t he usual s quar e- wave bolus , or be gin th e d ual-wav e b olu s aft er eatin g t o av oid hyp oglyce mia. U tilization of the b olus wizard av ailable on Me dt ron ic pu mps may als o be b enef ic ial for det er mining t he amoun t an d t imin g of an in dividu al meal bolu s. W ith pr ac tice , p at ie nts will le ar n how to de liver th e most ph ysiologic d ual -wave bolu s for each me al c onsume d. Patie nt s w ho use pr amlin tide with t he ir in su lin pu mps may e xpe rie nc e le ss hyp oglyce mia if 25% of their mealtime b olus plus th eir corr ec tion bolus is give n with t he meal and 75% of the calculate d b olus is pr ov ide d ove r a 3 -h ou r pe riod. Pramlint id e p atien ts wh o ar e p rone t o post prandial hy pogly cemia may e ve n beg in t h eir me alt ime b olu se s afte r th ey comple te t he ir me al r at her than just be fore th e on se t of t h e car boh ydr at e in tak e. 

How can J en's bolus wizar d fe at ure be us ed to h er advan tage ?

The bolus wizard feat ur e allow s p at ie n ts t o re ce iv e as sistan ce from t he actu al in su lin p ump soft ware to d ose an insulin bolus pr ope rly. The b olu s wizard , wh ich is u n iq ue t o Medt ron ic in sulin pu mps , re duce s math e rror s, de cre ases the nu mbe r of c orre ct ion b olu se s r equ ire d, and he lps pre ve n t in sulin st ac king. This ad vanc ed feat ur e c an be link ed dire ct ly to a BD L ogic b lood glu cose met er or upload ed manually from a diff ere nt b lood glu cose met er .

A mos t use ful t ool in the bolus wizard sy ste m is t he abilit y t o re cogn ize active in su lin lev els g iven in a pr ev ious b olus. Act ive insulin dep ots remain to b e abs or be d fr om a prior bolus . Th is w ill r ed uce the chance of st acking insulin be fore a pr ior bolu s is comp le te ly abs orbe d. For e xample , if J en atte mpt s t o us e a cor re ction dose of 6 u nit s 2 h ou r s afte r e at ing a meal, t he pu mp will ad vise he r that t he safe st way to infuse insulin mig ht be to r ed uc e t he cor re ction bolu s by 60% , as t hat quant ity of insulin remains to b e ab sorb ed aft er th e in itial bolus . W h en Je n at te mpts to g iv e t his supp le me nt al insulin, the p ump will as k h er if sh e wou ld pr efe r r ed uc in g th e d ose by 40% t o pr eve n t ins ulin stack ing . The se calc ulations are pr epr ogr amme d in to t he pu mp. Th e bolus wizard als o may be helpf ul whe n p rov id ing supple mental ins ulin for h igh blood g luc os e le ve ls .



W hat t yp e of insulin should Je n us e w hile p um ping ?

The majorit y of p at ients us e a fast -ac tin g in su lin analogu e ( lisp ro, as part , or glu lisin e) as th eir pumpe d insulin.

All fast- ac ting analogues ar e FDA ap prov ed for u se in in su lin p ump s. Pat ie n ts w ith se ve re in su lin re sist ance who re quire hig h- volume basal and bolu s flow r at es , r es ultin g in more th an 150 u nits of daily insulin, mig ht be candidate s for con cen tr ated U -500 r eg ular in su lin . 3 1 Pu mp r ese rv oir s are de signe d to c ar ry be twe e n 200 and 300 u nit s of in su lin . I f a patie nt us es 200 u nit s of in su lin pe r day, t he re se rvoir and infusion set s w ou ld h ave to b e c han ge d e ve ry 24 t o 36 h ou rs r at h er th an e ver y 3 d ay s, ad ding t o the ov er all e xpe n se for pu mp su pplies . U -500 in su lin c an b e b en ef ic ial for ins ulin -re sist ant patients . B ecause U- 500 h as a muc h s low er ons et of action th an a r ap id -actin g ins ulin analogue, patie nt s using conce nt rate d in su lin sh ou ld de lay eatin g f or be tw ee n 45 an d 60 minut es aft er star ting the ir dual- wave bolu s. B ec au se U -500 in su lin is 5 time s as p ote nt as st an dard U -100 insulin, patient s can re duce their basal an d b olu s rate s by 80% . For ex amp le , a b as al r at e of 3.0 U pe r hour can be re duce d t o 0.6 U pe r h our on U- 500. Meal bolus es totaling 50 u n its c an b e chang ed to a dual -wave bolus of 5 unit s immed iat ely an d 5 u n it s ov er a 3-h ou r p er iod . Familie s of patie nt s using U -500 insulin s hould b e t rain e d in th e ad min ist ration of eme rg en cy glu cag on for r ar e case s of insulin -induce d hyp og lyce mia.



W hat inst ructions should be give n re gard in g â €œp ump eme rg en cy prot ocolsâ € ?

Pat ients us ing insulin p ump s must be ab le t o an t ic ip at e, sc re en for, and man age sh ort -te rm comp lications s uch as hyp er glyc emia, DK A, an d h y poglyc emia. A lt hou gh t he se task s are ofte n t aug ht by ce rt ifie d p ump ed uc at ors and C DE s, ph ysicians sh ould pe riodically asse ss p at ien ts ' u n de rst an din g of â €œeme rg ency pump p rotoc ols .â € If J en awake ns with a fasting b lood glu cose lev el of 280 mg pe r dL, sh e may ad minist er a corr ec tion bolus t o targe t the g lucos e le ve l t o 150 mg pe r d L. In Jen 's case , he r t ar ge t b lood glu cose of 150 is 130 mg pe r d L b elow her curr ent le ve l. K now in g th at h er ISF is 1:30, Jen d ete rmin es th at sh e mus t pr ovide an imme diate bolus of 4.3 unit s for th e c orre ct ion . On e h ou r afte r adm in iste rin g t he bolu s, anot he r b lood glucose lev el should be de te rmin ed . If th e b lood glu cose lev el is d ecr easin g, sh e c an assume that the infusion se t line is p at en t an d t he pu mp mech anic s are in or de r. Howe ve r, if th e 1 hour post corr ec tion b lood glucose lev el is g oin g h igh er de sp it e t h e u se of th e su pple men tal bolu s, she mus t pr oce ed to tr oub leshoot t he p ump , in fu sion s et , an d th e infu sion site .

Hy pe rgly cemia may r es ult from a mismatch b et wee n th e d ose of ins ulin prov ided and th e qu an tit y of food c ons ume d, a los s of insulin pot en cy (inc or re ct sh ip pin g and pack ag ing of mail -or de re d in su lin may r esult in re duce d p ote nc y), an un de rlyin g in fec tion res ult in g in an ac ut e in su lin -r es is tant st at e, an insulin -f low obst ruction through t he infu sion se t, or a pu mp mech anic al malfun ct ion . If a pu mp is

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subje ct to a stat ic discharg e, similar to a fin ger -t ip sh ock on e ex pe rien ce s in win te r wh ile w alk in g on carpe t, the pump p ar amete rs may be e rase d fr om th e p ump 's int er nal me mor y. Most pu mps will de liv er an auditor y or vibr at ing alarm if in su lin d elive ry is int er ru pt ed . In su lin c an n ot b e d elive re d if the infusion cathet er is kinke d w ithin t he ins er tion site . Th e pu mp w ill se n se wh en abn ormal pr es sure is re quire d to p ump insulin again st an ob str uc tion an d s ub se qu en tly emit an alar m.

Whe n patients ex pe rience une xp ec te d h yp erg lyce mia, th e y sh ou ld alw ay s fix th e d iab et es fir st by giv ing a s ub cutane ous cor rec tion dose of ins ulin via a syr ing e or pe n d ev ice, targ et ing a 150 mg per dL blood g lucos e le ve l. The infusion set and re ser voir sh ou ld b e c han ge d an d an alte rn ative inf us ion site chose n. Once the new infusion set h as be en ins er te d, th e p at ien t s hou ld car efu lly mon it or b lood glucose lev els ov er the ne xt 2 - to 3-h ou r pe riod, makin g ce rt ain t hat t h e h yp er glyc emia is n ot wor sening (w hich could b e indicativ e of a sy st emic in fec tion ) or t hat hy pogly cemia h as de ve lop ed fr om us ing an e xce ssiv e cor re ction bolu s.

TABLE 6-6 Managing Diabetic Ketoacidosis If nause a or v omit ing is pr ese nt, imme diate ly ch e ck y our blood g luc os e an d k et one s. If your blood gluc ose is ab ove 250 mg/ dL an d/ or ke ton es are pre se nt :  

Call your he althcar e p rovide r.

Take an inject ion of a r ap id-act in g in su lin an alogu e with a sy ring e or pe n de vice (n ot through the pump). The amou n t sh ou ld be th e same as if y ou wer e takin g a corr ec tion



bolus .

Chang e entire infus ion se t s yst em ( ne w r es er voir, infu sion se t, an d c an n ula).

Trouble shoot the pump. If h elp is n ee de d, call t he 24 -h Pr odu ct Help Line (t he p hon e



numb er is on t he b ac k of y our pu mp).

Drink liquid s w it h no c alorie s e ve ry 30 min (for ex amp le , 8 oz . d iet ging er ale , brot h,



wate r).

Che ck y our blood g luc os e an d u rin e ket one s in 1 h . Blood ke ton es c an b e d et ect ed via the Pr ec is ion QI D home blood g lucos e me te r ( Abb ot t) (h ttp ://w ww.



diabe tes he alt hconne ction.com/ prod uc ts/ mon itor s/pr ec is ion /p re cisionx tr a. aspx ).

Continue t o take ins ulin as discu ss ed with h ealth care pr ofes sion al.



Call your he althcar e p rofe ssional immed iat ely if you r b lood gluc ose an d k et one s are not de cre asing or y ou ar e un ab le t o drin k f lu ids.



If y our blood g lucos e is le ss t han 200 mg /dL and ke ton es ar e p re se nt , d rin k liqu id s containing calorie s (for ex amp le, juice or c af fein e-f re e, non -d ie t s oda). Also, ad ditional insulin is usually re qu ire d. Con tact you r h ealth care pr ofes sional for s pe cific guide lines for insulin dos es wh en ke ton es ar e pre se nt .

Pat ients should always be pr ovide d wit h a c op y of th eir p re scr ibed parame te rs in case th e pu mp nee ds eme rge ncy r ep rogr amming. A d elay in re pr ogrammin g th e pu mp may re su lt in h y per glyc emia and DKA. Patients can get assist ance on re prog ramming th eir pu mps dire ctly from t he pu mp manufact ur er s' te le phone help lines (Table 6-4). 

C an Je n safely manage DKA w hile wear in g an ins ulin pu mp?

Be caus e insulin p ump s use rapid- ac ting ins ulin an alog ue s, an in te rr up tion in d ru g d elive ry will quick ly re sult in hy pe rgly ce mia. Any pat ie n t in wh om hy pe rg ly ce mia d ev elops (blood g lu cose >240 mg p er dL ) in as sociation w ith nause a, vomitin g, abdomin al p ain , an d an alt er ed lev el of consciousnes s should be ev aluate d for ke tosis. U rine ke ton e te st k its ar e r eadily availab le, an d some home b lood glucose monitor s (Pr ecision Xt ra, A bbot t) c an be u se d t o scr ee n f or th e pr ese n ce of ke tone bodie s. T ab le 6-6 lists the man ageme n t s trate gie s for DKA in pu mp patien ts .

Ow ing to the hig h r ate of fet al m or talit y ass ociat ed with DKA in p re gn an cy , p u mp u se rs s hou ld conside r injec ting 0.2 U pe r k g of N PH at be dt ime t o pre ve n t DKA if th e in fu sion set be come s dislodg ed for any r eason. 2 2 This small amou n t of in su lin w ill n ot affe ct n oct ur nal gly cemia. Pr eg nan t patie nt s may choos e t o us e alte rnat ive infu sion site s su ch as arms or le gs, as th e ir abdome n s e xpand in the thir d t rime ste r.



How ofte n s hould Je n change t he infu sion se t an d pu mp re ser voir?

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To p re vent ir ritat ion and inf ect ion at t h e in fu sion -s et inse rt ion s it e w hile main tainin g ade qu ate ins ulin flow into the subcutaneous insu lin de pot site , t h e in fus ion se ts and re ser voirs sh ould be chang ed ev er y 2 to 3 d ay s. Site s may n e ed to be ch ang ed soon er if discomfor t or irrit ab ility de ve lops at the inse rtion site . A st eady incr ease in gluc ose le ve ls may b e in dicativ e of imp aire d ins ulin ab sorp tion from t he inf us ion -sit e s ub cu tane ous de pot. Aft er ins er tin g a n ew in fu sion set int o the skin, the p at ient s hould p rovide a immed iate 1 - t o 2- un it b olu s of in su lin t o â €œ prime th e site â € and es tablish a de pot fr om which th e in su lin may be con tinu ou sly abs or be d. Th e p riming bolus will not re duce the patie nt 's blood glu cose lev el. In fus ion s ets sh ould be ch an ge d on ly d ur ing the waking hour s, be caus e an improp er ly ins er te d se t c an r esu lt in sign ificant h ype rg lyce mia, wh ich may g o unde te ct ed while the patient slee ps. Tw o hou rs aft er th e ne w in fu sion s et is ins er te d, a blood g luc os e le ve l should b e d et er mine d t o mak e c er tain t hat th e p atien t's g lyce mic con tr ol is within the pre scr ibe d tar get range . O th er wise , a cor re ction bolu s may b e admin iste re d.

Pump batt er ies should b e r ep lace d e ve ry 30 days. Pump s w ill also emit a warn in g alarm adv ising th e patie nt to c hange the batte rie s. Once th e alarm sou n ds, th e patien t sh ould chan ge th e batt erie s within 24 hours. 

W hat p re caut ions should J en take whe n s he tr avels with th e pu mp?

Pat ients on insulin p ump s who tr ave l s hou ld always have th e follow in g eme rge n cy s up plies in t he ir pos ses sion, not in th eir c hec ked bag g ag e : 

B ack up blood gluc ose me te r, lance ts , lanc et de vice , an d s trip s



Glucose table ts t o manage hypog lyce mia



A list of t he pump p ar amet er s



E xt ra pump and b lood glucose – mete r batte rie s



E xt ra inf us ion se ts and r es er voirs (if n ece ssar y, th e in fu sion s et s can be place d th r ou gh t he s kin manually, without t he use of a self - in se rt ion de vic e)



E xt ra vial of ins ulin



Pe n injec tor of rapid-act ing insu lin an alog ue plu s e xt ra n ee dles



Food and w at er , in case ac ce ss is limite d



If going to a for eign country , be su re to carr y in formation on wh o to con tact in c as e of a p ump malfunct ion. The U . S. p um p manu fact ur er s can as sist patien t s with t his in format ion .

R eme mbe r t hat insulin p re parations available out side of th e U nite d S tate s are n ot ide nt ical t o wh at is mark et ed in t his count ry. Plan accor ding ly wh e n p re parin g t o trav el wit h an y in su lin -d elive ry de vice s.

TABLE 6-7 Sick-day Protocol for Pump Users 

Monit or your blood glucose ev er y 2 h wh ile y ou ar e awake and at least on ce ov er nig ht .



Dep ending on the re sult s of b lood glu cose an d k et one t est ing , y ou may ne ed to make pe riodic insulin adjustme nts wh ile you are sick.



You will s till re quir e insulin, ev en wh e n y ou ar e u n ab le t o eat.



If y our blood g lucos e is abov e 250 mg/d L, follow th e hy pe rgly cemia pr otocol to av oid the pote nt ial of d iab et ic ke toacidosis f rom illn e ss or infe ct ion .



Re memb er to c all your he alt hc ar e p rovid er if you r b lood glu cose is above 250 mg /dL and ke tones ar e p re sent .



How sh ould J en manage â €œsick daysâ € w hile on t he pu mp?

Sick days ar e e asily manag ed with pu mp t h er ap y (T ab le 6 -7).

Te mporary basal rate s may ne ed to b e s et for mild p er sist en t h yp er glyc emia th at may occ ur in re sp onse t o a v iral infe ction or t he te mpor ar y u se of cor ticost er oid s (s ee Fig. 7- 12, sh owing a patie nt wit h B ell palsy who is taking p re dn is one ). Pat ie n ts s hou ld b e in str uc te d t hat m ealtime boluse s are not mand at ory and s hould b e p rogr amme d w he n a meal is con su med . I f a patien t is

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unable to e at, the b as al insulin flow c an be su fficie nt to c ont rol glyc emia. S up pleme n tal in su lin may be use d e ve ry 4 t o 6 hours to contr ol ac ut e h yp er glyc emia. 

W hat is the p rope r prot oc ol for t reat in g h y poglyc emia?

Mild sy mpt om at ic hy pog ly ce mia is man ag ed by patie nt s u sin g th e “r u le of 15†(Fig. 6- 8) . Pu mp patie nt s and t he ir familie s s hould always b e t raine d in u sing a glu cagon eme rg en cy kit for re ve rsin g se ve re hypog ly ce mia.

Fine-tuning Pump Therapy Patie nt s should be re -e valuate d w ithin 1 t o 2 w ee ks of pu mp in itiation t o be gin th eir paramet er ad just ments . B as al and bolus d os es ar e ad ju st ed accord ing to t he patie nt 's blood g lu cos e me as ur eme nts t ake n b efor e me als , 2 hour s afte r meals, at be dtime , at mid nig ht , an d at 3 A M ( Table 6- 8) .

T he basal rate should be inc re as ed or de cr ease d b y 0.1 u n it s p er hou r to ke ep th e pr epr and ial and ov er nig ht blood g lucos e le vels within a 30 -mg gluc ose exc ur sion from b as eline . I f th e glu cose le ve l incr ease s more than 30 mg pe r d L fr om the 3 A M measu re men t to t he pr eb re ak fas t me asur eme n t, a s ec ond basal rate (appr oximate ly 1.5 t ime s t hat of th e in itial basal r ate ) is add ed for 4 to 6 h ou rs, b eg inning 2 to 3 hour s b efore t he usual b reak fas t t ime . Day time b asal r ates are ad jus te d on ly if s ignific ant g luc os e e xc ur sions occur mor e t h an 4 h ou r s afte r t he me altime bolu s. To gu ide dayt ime basalr ate ad jus tme nt s, the P. 306 p atient s hould b e instr ucte d t o de lay or sk ip a meal wh ile mon itorin g b lood glu cose lev els e ve ry 2 hou rs in the fasting s tate . This s hould be d one pe riodically to asc er tain t hat basal rate s are not se t t oo high or t oo low .

Figur e 6-8 Managing Hy pogly cemia. “Th e Ru le of 15⠀ an d e mer ging safe ly from hy poglyc emia.

B olus dose s are ad jus te d accor ding to b lood glu cose measu re me nt s tak en 2 hou rs afte r me als. Patien ts ar e p rovid ed spe cific guide line s for ad jus ting ins ulin bolus es or t he I/C t o main tain r eason able g luc os e e xc ur sions . I f the blood glucose lev el 2 hour s afte r e atin g is 40 mg or less h ig he r t h an th e pr eme al g luc os e le ve l, t he I/C was corr ect ly d ete rmin ed . H owev er , if th e 2 -h ou r pos tpr and ial lev el is g re at er th an 40 mg pe r dL , a higher I/C for a give n me al sh ou ld b e u se d t h e n ex t t ime t he pat ie n t e at s t hat s ame me al. O ne common source of fr us trat ion among patie nt s wh o att emp t, ye t fail to cou n t carb ohy dr at es

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corr ec tly, is that t his met hod of pr eme al in su lin de te rmin ation is be st u se d w he n blood glu cose lev els ar e within the t ar ge te d r ange of 70 to 170 mg p er dL. C ar boh ydr ate cou nt in g wh en a patie nt 's blood glu cose value s P. 307 ar e cons is te nt ly more than 300 mg per dL , f or ex ample, will only re su lt in p er sist en t h yp er glyc emia.

Pat ie nts c an use bot h c ar bohydr ate count in g an d t he ir I SFs t o det er mine th e ir pr eme al in su lin d os e; a calc ulation that is p er forme d automatically by th e B olu s Wizard feat ur e on Me dtr onic pu mps.

TABLE 6-8 Adjusting Pump Parameters B asal and bolus d os es should be ad jus te d for an d based on bloo d g luco se le ve ls at: 

Pr ep rand ial



1- to 2-h post pr andial

 

At b ed time At 3 am (monitor f or nocturnal hy pogly cemia occu r ring be tw ee n 2 am an d 4 am)



Dawn p he nome non ( hy pe rgly cemia occu r ring on wakin g)

O ver nig ht blo od gluco se 

Goal of 100 mg/d L (Â ±30 m g/dL )



If blood g luc os e g re at er than 100 mg/ dL at 3 AM, p rogr am a sec ond bolus at 1.5 × t he basal d ose . This se cond b olus dose sh ould beg in b et we en 3 am an d 4 am for 4 to 6 h (pr ebr eak fas t).

 

Adjust basal r ate during day to comp en sate for s kipp ed or d elaye d me als.

Teach patie nt to c he ck blood g lucos e in a daytime fastin g s tate ev er y 2 h .

B olus dos e should b e based on the c ar b ohyd r at e-t o-insulin r at io and ad jus te d for :  

1- to 2-h post pr andial blood g lucose Chang es in car bohy dr at e t o ins ulin ratios adju st ed ev er y 2 day s to main tain 1- t o 2-h postp randial b lood glucose , 180 mg/d L



Carb ohy drat e-t o-ins ulin ratio for each meal can be es timate d (afte r th e b olu s d ose is we ll mat ched to a st ab le me al p lan).



Opt imal rat io r ang es from 1 U /5 g C HO to 1 U /25 g C HO. (Mos t pat ie n ts r eq uir e 1 U /10 g CHO .)

C HO , c holes te rol.

Us ing ele ctr onic home blood glucose dow nload d at a is ve ry he lpfu l in d et er min in g th e eff ic ac y of t he patie nt 's bolus re gimen. If at le as t 50% of t he patie nt 's post meal glu cose lev els ( take n 2 h ou rs aft er eating) for e ac h me al ar e w ithin t he 70 to 170 mg pe r d L r an ge , th e p at ien t b olu se s are ade qu at e. If more than 3% of the p at ient's p os tpr and ial lev els ar e le ss t han 70 mg pe r d L, th e patien t sh ou ld b e ad vise d t o re duce the t otal bolus for t hat part ic ular me al by 10% t o 20% to avoid h yp oglyc emia. Patien ts who show pe rs is te nt ele vations in post pran dial gluc ose le ve ls sh ould incr ease th e ir pr eme al in su lin b olu s or conside r work ing hard er on c orre ct ly cou n ting carb ohy drat es.

Pat ie nts w ith an A1C lev el g re at er than 8. 5% sh ou ld f oc us th eir pu mp adju st men ts on imp rovin g t he ir fasting b lood gluc ose le ve ls. As A1C lev els P. 308 be come norm alize d (A 1C le ss t han 8.5%), adju stme nt s in bolu ses will fur th er impr ov e th e A 1C lev els:



C hange I/C for cer tain meals



C hange ISF



Det er mine and us e one 's per sonal lag t ime

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

C ar ry ex te nd ed bolus ove r a 2 - t o 3- hou r p er iod



Provid e 25% of t otal bolus im mediate ly w it h th e on se t of t he me al an d 75% ove r t he following 2 - to 3-hour pe riod



C onsid er us ing pramlint ide to impr ove glyc emic v ar iat ion

Case 5 This pat ie nt re ce ive d her ins ulin pump on Ju ly 20 (Fig. 6 -9). B ec au se sh e t rave led a lon g d istan ce to th e office , t he p at ie nt was ad vise d t o call in her blood glu cose lev els on Ju ly 24. The b asal rat es wer e subs eq ue nt ly adjust ed ov er the phone . On Au gu st 9, th e patien t's h ome blood g lu cose me te r w as dow nloade d at t he office . T he adjustme nts made on th e pu mp par ame te rs re su lt ed in s ig nifican t impr ov eme n t in glyc emic c ont rol, w ith 80% of he r b lood glu cose re ad ing s in th e r ang e of 70 to 170 mg pe r d L. He r A1C de cr ease d fr om 9% to 6.8% w ith th e us e of t he in su lin pu mp.

Figure 6-9 Blood Glucose Le ve ls fr om a New Pump Pat ie n t. The lev els in dic at e a de cr ease in A IC .

Pat ie nts w ho e xhibit fre quent e pisod es of hy pog ly ce mia (> 3% of th e met er down load s are <60 mg p er dL or d oubling t he me te r SD for any mealtime re ad in g s is gr eat er th an t he ir ave rage blood g luc os e le ve ls at that time ) r ed uce t he ir insulin dose s. Many of th e se patien ts may be st ackin g in su lin by adminis ter ing bolus es of additional d rug b efor e t he abs or pt ion of t he pr ior dos e h as be en c omp let ed. Ot h ers may simp ly be ove rcalculat ing the amount P. 309 of ins ulin they actually ne e d for any g ive n me al. Some patie nt s are ju st as f earfu l of be ing “hy per glyc emic⠀ as ot he rs are of be ing hy pogly cemic. No matt er wh at t he cau se of th e hy pogly ce mia, the incide nce of low blood g lu cose lev els mus t be r edu ce d. Pat ien ts sh ould b e tre ate d to the low est ye t s afe st lev el of A1C that t he y c an ach iev e.

Long-term Follow-up of Insulin Pump Patients Once the p atient is stabilize d on the pump p ar ame te rs , p at ien ts may be re -e valuate d e ve ry 3 to 5 mont hs , w it h at te nt ion p aid to the follow in g is su es:

1. Home blood g lucos e monitoring e lect ron ic logs s hou ld b e c ar efu lly in spe ct ed to de te rmin e if f in e tuning of the basal and b oluse s is ne ce ssary .

2. R ev ie w t he pr otocol for managing hyp og lyce mia ( Fig . 6-8), h yp erg lyce mia (us in g su pple men tal ins ulin), pre ve ntion, and initial tr eatme n t of DK A ( Fig. 6-5), s ick-d ay manag eme nt (Table 6-7), an d the eme rg ency prot ocol for p ump malfu n ct ion ( Table 6-8).

3. R ev ie w t he pump paramet er s (T ab le 6 -8) t o mak e c er tain t hat th e p hy sician- dire cte d b asal r ates hav e not bee n chang ed by t he p at ient. Pat ie n ts s hou ld u n de rst an d th at th ey are in c harg e of th eir me altime and supple mental boluse s. Howe ve r, th e me dical te am sh ould dire ct an y alte ration s in basal rate s.

4. E valuate the ar eas sur rounding the in fu sion site s to mak e c er tain t hat ab sce sse s an d sc ar tiss ue are

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not for ming. Ar eas of inflamm at ion may b e in dicativ e of a localiz ed ins ulin alle rgy , w hich may re quire swit ching to a diffe re nt short -actin g in su lin analogu e.

5. Insulin s tacking s hould be d is cusse d, esp ec ially for patie nt s e xpe rie nc in g more th an 5% hypog lyce mia on the ir e le ct ronic log s.

6. A1C lev els s hould be monit ore d 3 t o 4 t imes a y ear.

7. R eme mbe r t hat ap prox imat ely 50% of t he pat ie n t's tot al d aily in su lin d ose shou ld b e p rovid ed as bolus insulin, and 50%, as basal insu lin. If t h e p at ie n t is p rovid in g mult ip le cor re ction and supp le me nt al b oluse s, the r atio of basal to b olu s in su lin w ill be far le ss t h an 1:1. T he basal rate s will hav e t o be analyze d and r eadjust ed .

Table 6 -9 d is cusse s q ue stions t hat should b e e xp lor ed for p um p patie nt s h avin g diffic ulty ach ie vin g a targ et ed A1C le ss t han 7%.

Exercising with an Insulin Pump Ex er cise is be neficial for p at ients with diabe te s. T he u se of an in su lin pu mp can f ac ilitate th e ad minist ration of ins ulin to maint ain normoglyc emia and av oid dan ge rou s h yp og lyce mia aft er ex er cise .

Ex er cise can re sult in initial hy per glyc emia, f ollowe d b y p os te xe rcise h yp og lyce mia. As ex erc ise b eg ins , fre e f at ty ac id s are re lease d fr om the ad ip ose tissu e as an in itial s our ce of P. 310 ene rgy . W ithin 10 minut es of be ginning e xe rcise , t h e live r acc eler ates th e prod uc tion an d r ele as e of glucose , w hich pr ovide s s ke le tal muscles with a su st ain ab le s ou r ce of en er gy . If glu cose le ve ls in cre ase in an ins ulinop enic p at ie nt w ho is alre ady h y per glyc emic ( blood g lu cose lev el > 240 mg pe r dL ), ex er ciseind uc ed ke tosis may oc cur. Some indiv id uals may ne ed to g iv e a s mall ins ulin bolu s at t he ons et of ex er cise if their blood glucose lev el is mor e t h an 240 mg pe r d L.

TABLE 6-9 Questions to Ask Pump Patients When Their Follow-up A1C Levels Are >7% 1. Is t he patie nt monit oring his or h e r blood g luc ose le ve ls 4 to 6 t ime s p er day?

2. Is t he basal ins ulin rate se t p rope rly? Can th e p atien t skip a me al w ith out ex pe rien cin g hy poglyc emia or hyp er glyc emia?

3. Doe s t he patie nt count carb ohy dr at es ac cu rate ly and give pr ope r b olu se s? Is th e patien t using t he d ual-wave (or ex te nd ed ) bolu se s or are on ly immed iat e ( nor mal b olu se s) b ein g use d to dose t he ins ulin?

4. Doe s t he patie nt use the p rope r corr ect ion b olu s fact or t o tr eat e lev at ed blood g lu cose le ve ls?

5. Doe s t he patie nt tr eat low blood g lu cose lev els with th e ap pr op riate amou n t of car bohyd rate s?

6. Has the pe rsonal lag t ime for ins ulin be en de te rmin ed ?

7. Is t he patie nt forg et ting to ad min ist er bolus insu lin for some meals?

8. Is t he patie nt â €œ gues sing †on w hat his/ he r p re pran dial gluc ose le ve l is rath e r t han act ually p er forming a te st be fore “g u ess in gâ € h ow m uch in su lin to ad min ist er for t he meal?

9. Has the patient ex pe rience d any s ig nifican t w eigh t g ain ? If so, h is or he r in su lin req uir eme nts w ill incre ase.

10. Is t he patie nt taking any me dication s t hat may caus e in su lin r esist anc e, ab nor mal b lood gluc ose v alue s, or A1C le ve ls t hat do n ot appe ar t o be re flect ive of th e patien t's ov er all glyce mic contr ol (se e C hap te r 7 )?

11. Is t he patie nt pr eg nant?

12. Doe s t he patie nt hav e insulin r eq uire me nt s th at app ear to inc re as e d ur ing men st ru ation?

An ins ulin pump can be wor n d ur ing most exe rc ise an d s port s activ it ies. Pre caut ions mus t b e add re sse d in p at ients inv olv ed in c ont act sp orts . Patien t s n ee d t o be taug h t to mak e s afe basal -r at e alte ration s in pr epar at ion for ex er cise and how to pr ev en t in adve rt en t disru pt ion/d islocation of cath et er or pu mp du rin g

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int ense ex er cise or sp ort s activit ie s.

Adjust ments in b as al insulin de liv er y w hile ex er cising sh ould be ind iv idu alize d. Th e b as ic ru le of th umb is that a we ll- cond itione d athlet e who is part ic ipating in th e s ame activ it y for wh ich he h as be en t rain in g rare ly nee ds to alte r the rate of insulin de liv er y or su spe n d t he pu mp w hile ex er cising . H owev er , a p oor ly conditioned indiv id ual who is e mbark ing on a mode rat e or P. 311 more int ensive e xer cise re gime n w ill nee d t o re du ce or s us pen d th e in su lin d elive ry wh ile active . Patie nt s should always chec k t he blood g luc os e le ve ls be fore be gin nin g e xe rcis e an d e ve ry 30 min ut es du rin g ex er cise to de te rmine how a g iven act iv ity mig ht affe ct t he ir g ly ce mic con tr ol. Th e b lood glu cose sh ould also be monitor ed imme diate ly afte r e xe rc is ing as we ll as 4 h ou rs aft er comple ting th e ac tivit y in case a de lay ed hy pogly cemic re sponse to t he ex er cise de ve lop s. Blood glu cose lev els s hou ld b e maint ain e d in the targe t r ang e of 120 to 180 mg p er dL du ring th e ex er cise prog ram.

When e xe rcis ing in the basal stat e (b ef or e bre akfast or more th an 4 h ou rs aft er th e pre viou s me al), th e basal infusion rate is init ially r ed uc ed by 50%. Su bse qu e nt ly , th e adju st ed te mporary basal infu sion rate is adjuste d acc or ding t o self- monitor ing blood glu cose (SM BG). For e xample, if a patie nt with a u su al basal rate of 1.6 unit s pe r hour jog s or c ycle s for 1 h ou r in th e early morn in g be fore bre akfast , t his r ate is re duce d t o 0. 8 units pe r hour . Afte r individ ual SMBG measu re men ts , t his tem porary basal infu sion rate can be fur ther adjuste d. Some at hle te s choose to d ecr ease th e infu sion rate for 30 t o 60 min ut es du rin g the poste xe rc is e p er iod be caus e of incr ease d in su lin se n sitivity . I n ad dition , t he su bse qu e nt mealtime bolus is ofte n re duce d b y 30% to 50%. Wh en t he ins ulin pu mp is c ont inu ed du rin g an y e xe rcis e, th e patie nt should monitor for hyp er glyc emia du e to malf un ct ion or dislodgin g of t h e in fu sion c at he te r. To limit we ig ht gain, many e xe rcising p at ie nts choos e in su lin adju stme n t r at he r t han su pp le me nt al food int ak e.

With p rolong ed endurance ex er cise (eg , hikin g, walking , r u nn ing , c yclin g), a “s te ad y s tate †de ve lop s, and p atients maintain plas ma gluc ose le ve ls wit hin a pre dict ab le r an ge wh ile b alan cing carbohyd rate intake and ex er cise. They may b alanc e a low -d ose te mporary basal infu sion rate wit h int er mit te nt food t o offse t c aloric exp endit ur e. In th is s it uation , t h e t emp or ary basal r ate is se t at 0. 1 to 0.2 units pe r hour. With e xpe rie nc e, many patie nt s maint ain glu cose lev els b et we en 100 mg pe r d L an d 140 mg pe r dL during s ev er al hour s of act ivity .

A ge ner al g uide line for c ar bohyd rate consu mption with e xe rcise is 15 to 30 g eve ry 30 to 60 minu te s.

Le ss insulin and fe we r calories are re quir ed with impr ove d fitn e ss le ve l an d f av orable en viron men t al conditions. W hen the ind iv idual is e xe rc is in g du rin g we ath er ex tr eme s, ad just men t s in both basal ins ulin and calor ic int ak e ar e oft en nec ess ar y. Ex er cisin g at a lowe r fit ne ss le ve l in c old we at he r m ay re qu ire more calor ies, whe re as ex er cising in a hot e n viron men t may lead t o hy pogly ce mia d ue to p oor appe tit e and re duced caloric intake , s ug ge sting a lowe r in su lin re qu ire men t.

Suggestions for Exercising While on an Insulin Pump 

C he ck blood g lucose at t he time of e xe rcise . The tar get blood g luc os e le ve l for b egin n in g ex er cise is 120 t o 180 mg pe r d L. If the blood g lu cos e is g re at er th an 240 mg p er dL , ch e ck for u rin e k et one s.

If p ositive (+ ), delay or post pone e xe rc is e u n til ke ton es clear an d b lood glu cose lev els r et ur n to P. 312 the targ et rang e. If ket one s ar e neg at ive (-), con side r g ivin g a small bolus of ins ulin be fore be ginning e xe rc is e.



If b lood glucose lev els are les s t han 120 mg pe r dL be fore e xer cise , c ons ume 15 g of car bohy dr at es and be gin a te mporary basal rate (TB R), as d esc ribe d late r.



C he ck blood g lucose 30 to 45 minute s in to e xe rcise t o ev alu at e f or h yp erg lyce mia.



C he ck blood g lucose 2 to 4 hours aft er comple tion of ex er cise to mon it or for hy pogly cem ia.



In ge ner al, physical condit ioning ove r t ime r edu ce s g lyce mic variability as sociated with e xe rc is e.

U nt raine d athlet es may e xpe rie nc e mor e g lu cos e flu ct uation s and be come hy pogly ce mic af ter concluding ex er cise .



If e xe rc is e t imes ar e c onsis tent , b as al r at es may be lower ed be gin nin g at th e on se t of an ticipate d e xer cise and continue d for 2 to 4 hour s afte r e xe rc is e is c omplet ed .



Pat ients may choose to se t a TB R w hile ex er cising . R ed u ce t h e p re scr ib ed basal rate by 50% to 75%

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while e xe rcising, and continue this TB R for 1 to 2 h our s afte r f in ish ing th e train in g.

Use of Insulin Pump Therapy for Patients with Type 2 Diabetes Pat ie nts w ith T2DM can suc ce ssfully be tr ain e d in an ou tp at ie n t se tt ing to man ag e t he ir d iab ete s b y u sin g insulin pump t he rapy . A study by Rask in e t al. 3 2 d emon str at ed th at p ump in g in su lin w as as safe an d eff ect ive at improv ing glyc emic c ont rol in in su lin -n aiv e patien ts as was MDI s. T his 24 -w ee k ope n -lab el study assign e d 136 patients to initiat e insu lin t he rapy by u sing eit he r C SII with in su lin aspart or b as al bolus MDIs b y using NPH plus aspart with p en inje ct or s. Hyp oglyc emic e ve nt s w er e mild, and th e re cord ed ev ents eq ually dis trib ut ed be twe en t he tw o grou ps . T he tr eatme n t-sat is fac tion su rve ys favore d pumping ove r MDI s at t he e nd of the study . Nin e ty -th re e p er ce nt of th e CS II-t re at ed patie nt s b eliev ed that the pump w as conve nie nt , s imp le t o us e, an d offer ed lif est yle flex ib ility . T he sign ificant ly g re at er satisfact ion sc ore s re por te d by C SII - tre ate d su bje ct s su gg est th at C SII may be th e pr efe rr ed met hod of int ensive ins ulin ther apy f or capable patie nt s wit h T 2DM w ho d es ir e op timal glyce mic c on tr ol.

Summary Inte ns iv e d iab et es manage ment c an be ach iev ed with th e us e of in su lin p ump th er apy. C ompare d wit h MDIs, CS II has be tt er ins ulin phar macokinet ic s, le ss variabilit y in ins ulin ab sorp tion, and de cre ase d ris k of hypog ly ce mia. Pat ie nts using insulin p ump s e njoy gre ate r lifes tyle flex ibilit y an d oft en be come more pr oact ive in t he ir app roach to d iabe te s s elf-man ag eme nt . Alth oug h mor e P. 313 ex pe ns iv e t han MDIs, pump ther ap y offe rs patie nt s a mu ch more ph ysiologic app roach to c on t rollin g t h eir diabe tes . C are ful e valuat ion of p ump cand idate s, patien t edu cat ion , an d t imely f ollow- up visits ar e vital to t he succe ss of pump t he rapy .

As w e e nte r the dawn of a new ag e of diab et es man age men t w ith mec han ic al s en sors an d pu mps w ork in g in unis on, impr ov eme nt in glyc emic c ont rol for p at ien ts with diabe te s se em s to b e h e ad in g in a pos it ive dire ct ion. Until a close d-loop fe ed back sys te m be twe e n t he pu mp an d sen sor is de ve loped and marke te d, basal bolus ins ulin ther ap y using an insulin p u mp re mains state of t he art. PC Ps sh ould take a proact iv e role in pr omoting and managing p at ients us in g in su lin p ump th e rapy.

P. 314

Appendix 6-1 Samp le Le tte r of Medical Ne ces sit y, W hich Can B e Se nt to a Thir d-p art y Payo r fo r a Patie nt in Ne ed of Ins ulin Pum p T her apy Dear S ir or Madam: __________is a ___ -ye ar-old p at ient w ho w as diagn osed as h av ing diabe te s at age __. Th e p at ien t h as the following d iab ete s- relate d c omplicat ions : (h yp oglyce mic u nawar en es s; w id e g lyce mic var iation s; noc turnal hyp oglyc emia; cor onary ar te ry dise as e; pe riph er al v ascu lar dise as e; ch ron ic kidn e y dis ease , stage ___; autonomic neurop at hy ; p er ip he ral n eu rop at hy ; p re gn an cy ). T he patie n t h as be en u sing physiologic insulin -r ep lace me nt ther ap y s in ce _____. De spit e p ractic in g c ar boh yd rate cou nt ing , me dical nut ritional the rapy , p ar ticipating in a health y -life sty le pr ogr am, and pe rfor min g fre qu en t b lood glu cose monit or ing , his or he r g lyce mic contr ol c ould be op timize d w it h th e u se of con tin u ou s sub cu tan eou s insulin infusion (pump) ther ap y. I b eliev e t hat th e p at ien t's s hor t - an d lon g-t erm glyce mic c on tr ol, as we ll as his or he r q uality of lif e w ill be e nh anc ed with th e us e of an in sulin pu mp. I am t he re fore re commending t hat a (sp e cific pump name he re ) p ump be appr ove d for his or h er imme diate u se.

It has b ecome appar ent in re ce nt ye ars t hat th e p re se nt con ve nt ion al tr eatme nt of t he ty pe I diabe te s patie nt who re quire s ins ulin is ofte n unable to con tr ol t h e b lood glu cose le ve ls ade qu at ely . Now ge ne ral ag re eme nt e xist s among diabet es spe cialis ts t h at th e life span of patie n ts w it h diab et es mellitu s can be incr ease d and t he incide nce and se ve rity of diabe tic c omplications , s uch as b lin dn e ss an d k id ne y d isease , can be re duced and /or p re ve nt ed by at te nt ion t o main tainin g t h e b lood gluc ose le ve l at as n early nor mal leve ls as p ossible throughout the patie nt 's life time .

Fur ther , r ec ent s tudies ind ic at e that the onse t of diabet ic comp licat ion s, su ch as n ep hr opath y an d re tinop athy, may be de lay ed by us ing int en sive ins ulin th er ap eu tic re gimen s t o main tain ne ar -n ormal blood sug ar leve ls.

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Be ginning in the late 1970s, mult iple inve st ig at ors have re por te d th at n e ar -n ormal blood glu cose con tr ol could be achie ve d w it h an e xt er nal ins ulin pu mp.

Por table insulin- pump t he rapy is cos t e ffec tive be cau se it can re du ce th e n u mbe r of h ospit alization s ne ce ssary for uncontr olle d br ittle diabe te s me llitu s an d/or h ypog ly ce mia.

Theore tically, it can als o de cre as e t he number of h ospit alization s n ec ess ar y for th e tre atme nt of th e complications of d iabe te s me llit us . Diabet es mellitu s is t he lead in g cau se of b lin dn es s in th e U n ite d State s, account s for 75% of all nont raumat ic ampu tations , an d w ill accou n t for 50% of all patie nt s w ho re ac h e nd-s tage re nal dise ase and w ill r eq uire e it h er re nal dialysis or re nal tr ans plan tat ion or both in th e 1990s.

The insulin pump is an op en -loop de vic e t hat in st ills s ub cu tane ou sly a pr ed et er min e d amoun t of ins ulin (the basal rate ). The b asal rat e c an be pr ogr amme d in to t he pu mp to re flec t ch ang es in b as al in su lin re quirem ents as they are aff ect ed by daily activ it y, str es s, in fe ction , an d ot he r p ar ame te rs th at ch ang e the blood su gar le ve l.

Add it ionally, the p ump has a b olus feature t hat allows t he pat ie n t t o in st ill v ar yin g amoun ts of ins ulin to stimulat e t he p hy siolog ic re sponse of t he pan cre as to me als or ot he r h yp er glyc emic e ve n ts.

Pump ther ap y t hus differ s fr om conve nt ion al th er ap y in th at it is a muc h mor e p hy siologic for m of tr eatme nt for patients with d iabe te s me llit us . It h as fu rth e r adv an tage s in th at b ec au se only re gu lar - or short- ac ting ins ulin is inf us ed, the patie nt h as P. 315 muc h mor e libe rt y t o go about his or he r d aily ac tivitie s wit hou t f ear of ab sorpt ion p eaks of ins ulin caus ing hy pogly cemia.

The d ev ic e in (t his p at ient's) case is a ne ce ssity an d not mer ely a c onv en ien ce . H e or sh e h as b ee n unable to br ing the diab et es unde r good me tabolic con tr ol des pite st rict ad he re n ce to a comple x r eg ime n of die t, ex er cise, se lf-monit oring of b lood glu cose, and mu lt iple d aily in je ction s of t hr ee diffe re nt ty pe s of insulin.

Us e of this ins ulin pump will allow me t o as sist th is patie nt in ach iev ing th e low est and safes t p os sible A1C le ve ls that have be en re comme nd ed by nu me rou s pr ofes sional con se ns us gu id elin es, in clud in g th e Ame rican Diabe te s As sociation ( ADA) and t he Ame rican Assoc iat ion of C lin ical En doc rinologist s ( AAC E) .

If y ou r eq uir e any furt he r informat ion, please do n ot h e sitate to c on t act me .

Sinc er ely, P. 316 P. 317

Appendix 6-2

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P. 318

Appendix 6-3

Commonly s ee n B et a C e ll T est s:



IC A (I slet Ce ll Autoant ib ody)



GAD (Glutamic acid d ecar boxy lase )



IAA (Insulin Auto A nt ibody )



IA- 2 (RI A)



All te st re sult s should be docume nt ed by obtain in g c opies of actu al lab rep ort s.



Pat ient must als o mee t all other Med ic ar e crite ria .



Thes e c rite ria ar e also r eq uire d for on going pu mp s up plies.

P. 319

References 1. W eiss be rt- Be nche ll J , A nt is de l- Lomaglio J, S esh adr i R. In su lin pu mp th er ap y: a me ta -an alys is .

Diab ete s C are . 2003; 26:1079â €“1087.

2. Gr af f MR, R ub in R R, W alk er EA. How diabe tes sp ecialis ts t re at th e ir own diabe te s: f in din gs from a st ud y of A ADE and A DA memb er ship . Diabe tes E du c. 2000;26: 460â €“ 467.

3. B oland E A, Gre g M, Oe ste rle A, et al. C on t in u ous su bcu tan eou s in su lin in fus ion : a n ew way t o lowe r ris k of se ve re hyp og lyce mia, impr ov e met ab olic c ont rol, an d e n han ce copin g in ad ole sce n ts with t ype 1 diabe te s. Diabe te s C ar e. 1999;22:1779â €“1784.

4. W einzime r S, Aher n J, Boland E , Ste ffe n A , Tamb or lan e W. Con tin u ou s su bcu tan eou s in su lin inf us ion is safe and eff ect ive in v er y y oun g c hildr en wit h t yp e 1 d iabe te s: prog ram and ab str acts of

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the 63r d Sc ie ntific Se ssions of t he Ame rican Diab et es A ssociation ; Ju n e 13â €“ 17, 2003. New Orle an s, Louisiana: Ab str act 1744- P.

5. Millennium R es earc h Gr oup . U S Mar ket s for Dr u g D elive ry 2005 . T or ont o: Millen ium R es earc h Group, 2004.

6. Pick up JC , K ee n H, Par sons JA, Albe rt i KGMM. Th e u se of con tin uou s s ub cu tane ou s ins ulin infu sion to achiev e normog lycaemia in diabet ic patie n ts [ ab str ac t]. D iab etologia . 1977; 13:425A.

7. B ode BW, Tambor lane W V, Dav id son PC. In su lin p ump th er ap y in th e 21s t ce n tu ry: st rate gies for succe ss ful use in ad ults , adole sce nt s, an d ch ildr en w it h diab et es . Post grad M ed. 2002;111. O nlin e: U RL : http :// www .pos tgr ad med .c om/ is sues/ 2002/05_02/bod e3.h t m. Ac ce sse d 11/13/ 05.

8. T he Diab et es C ontr ol and C omplications Trial Re se ar ch Grou p. Th e effe ct of int en sive tr eat men t of diabe te s on the dev elopme nt and p rogr ess ion of lon g -t er m complication s in in su lin- dep en de n t diabe te s me llitus. N E ngl J Me d. 1993;329: 977â €“ 986.

9. Pick up J, Mat tock M, Ke rry S. Glycae mic con trol w it h cont inu ou s su bc ut an e ou s in su lin in fu sion comp ar ed with int ensiv e insulin inje ct ion s in patie nt s w it h typ e 1 d iab et es: met a- an aly sis of randomize d c ont rolle d t rials. B r Me d J . 2002; 324:705â €“710.

10. R et nakar an R , H oc hman J, DeVr ies JH, et al. C on t in u ous su bcu tan eou s in su lin in fus ion v ers us mult iple d aily inje ctions: t he impact of base lin e A1C. D iabe te s C are . 1994; 27:2590â €“2596.

11. Doyle EA , W einzime r SA, St eff en AT, et al. A r and om iz ed , p rosp ect ive trial compar in g th e e fficacy of continuous s ub cutaneous insulin infusion with mu ltiple daily inje ct ion s u sin g in su lin glarg in e .

Diab ete s C are . 2004; 27:1554â €“1558.

12. U ng er J. A p rimar y c ar e ap proach to c ont in u ous su bcu tan eou s in su lin in fus ion . Clin Diabe te s.

1999;7:113–120.

13. Bod e B W, Ste ed R D, Davidson PC . R ed uc tion in se ve re h ypog lyce mia w ith lon g- te rm con tin u ou s subc ut ane ous insulin infusion in ty pe 1 diabet es . D iabet es Car e. 1996;19:324â €“327.

14. C hante lau E , S praul M, Muhlhauser I, et al. Lon g- ter m safe ty , e fficacy an d s id e e ffe ct s of continuous s ub cutane ous ins ulin infusion tr eatme nt for typ e 1 ( in su lin-d ep en de n t) d iab et es me llit us : a one ce ntre e xpe rie nc e. Diabe tologia . 1989; 32:421–426.

15. Shade DS, V ale nt ine V. To pump or n ot to p u mp. Diabe te s C ar e. 2002;25:2100â €“2102.

16. Ar ag ona M, Giannar elli R, C oppe lli A . Im prov eme nt in ret inop at hy in typ e 1 d iab etic patien t s tr eate d w ith continuous subc ut ane ous insu lin in fu sion: pr og ram and abst ract s of th e 63r d Sc ien tific Se ssions of t he Ame rican Diabe te s A ssociation; Ju ne 13–17, 2003, Ne w O rle an s, Lou isian a, A bst ract 435-P.

17. Bod e B W, Gross T, Ste ed D, e t al. A re ce nt as se ssme nt of con tin uation rate s f or con tin uou s subc ut ane ous insulin infusion ( CS II) [ ab str ac t 393]. D iabet es . 1998; 21(s up pl 1):393.

18. Gabb e SG, Holing E , Te mple P, B rown ZA. Be n efits , r isks , cos ts, and patie nt satisfact ion associate d w it h insulin p ump the rapy for t he pr eg nan cy complicate d by ty pe 1 diabe tes mellitu s. Am J Ob ste t Gy necol . 2000;182:1283–1291.

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19. K anakis SJ , W atts C, Le ichte r SB . T he bu sin ess of ins ulin pu mps in d iabe te s c ar e: clinical and e conomic c ons id er at ions. C lin Diab et es. 2002;20:214â €“216.

20. Ab raham MR , al-S harafi BA , Saave dr a GA , K hard ori R . L is po in th e t re at men t of ins ulin aller gy .

Diab ete s C are . 1999; 22:1916â €“1917.

P. 320 21. Ot te nsen JL , N ilss on P, Jami J, et al. Th e p oten t ial immun oge n ic it y of hu man in su lin an d in su lin analogues ev aluated in transge nic mous e mod el. Diabe tologia. 1994;37:1178â €“1185.

22. U ng er J, Marcus A . Insulin p ump the rapy : wh at y ou n ee d to kn ow. E mer g Me d. 2002;34: P24-P33.

23. U ng er J. Pre conc ep tion manageme nt of w omen with t ype 1 diabe te s. Th e Fe male Pat ie n t (O B/GY N e dition) . 2001; 26:45â €“ 51.

24. Lac G, C hamoux A . E lev at ed saliv ar y c ortisol le ve ls as a re su lt of sle ep de priv at ion in a sh ift wor ke r. Occ up Med . 2003; 53:143–145.

25. U ng er J. Inte ns iv e manage ment of t yp e 1 d iabe te s. Em erg Me d. 2001;33: 30â €“42.

26. Ale mzade h R , Ellis JN , Holz um MK , Part on EA. C omparison of con tin uou s ( su bcu tan eou s in su lin inf us ion (C SII ) with fle xible mult ip le d aily in su lin ( FMDI ) re gime n u sin g in su lin g larg ine in ped iat ric ty pe 1 diabet es mellitus: p rog ram and ab str acts of th e 63rd Scie nt ific Se ssion s of t he Ame rican Diab et es Assoc iation, J une 13â €“17, 2003. Ne w Or lean s, L ouisian a. Abs tr ac t 434- P.

27. W ilson D, Buckingham B, Kuns elman E, et al. A t wo ce n te r r an domize d c ont rolled trial of ins ulin pump ther ap y in young child re n with diabe te s: p rogr am an d ab str ac ts of th e 63rd Scie nt if ic Se ssions of t he Ame rican Diabe te s As sociation, Ju n e 13â €“ 17, 2003. N ew Orle an s, Lou isiana: Ab st ract 1745- P.

28. Br yd en KS , Ne il A, May ou R A, et al. E at ing hab it s, body we ig h t, an d in su lin misu se : a long itu dinal st ud y of t ee nag er s and young adults w it h ty pe 1 d iab et es. D iab et es Care . 1999;22: 1956– 1960.

29. Le nhard M, Mas er R. Succe ss is re lat iv e: CS II in ch alle ng ed patie nt s: p rogr am an d abs tr ac ts of the 63r d Sc ie ntific Se ssions of t he Ame rican Diab et es A ssociation ; Ju n e 13â €“ 17, 2003. New Orle an s, Louisiana: Ab str act 2129- PO .

30. Hir sch IB. Inte nsive tr eatme nt of t ype 1 diabe te s. Med Clin Nort h A m . 1998; 82:689–719.

31. K ne e TS, Seide nstick er DF, W alt on J L, Solber g L M, L as se ter DH. A n ove l us e of U -500 in su lin for continuous s ub cutane ous ins ulin infusion in p at ien ts with ins ulin re sistan ce : a case se ries . E n docr Pract . 2003;9:181– 186.

32. R as kin P, Bod e B W, Mar ks JB, et al. C ont in u ous ins ulin in fu sion an d multip le daily in ject ion the rapy ar e e qually eff ect ive in t yp e 2 diabe te s. Diabe te s C are. 2003;26:2598â €“2603.

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