Pumping ProtocolA Guide to Insulin Pump Therapy Initiation
Includes an introduction to continuous glucose monitoring (CGM) and therapy management software
Innovating for life.
Medical EducationAcademia
1Table of Contents
Table of Contents
Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Insulin Pump Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
Guidelines for Initial Pump Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Calculate Starting Doses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
The Bolus Wizard® Calculator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Adjusting Pump Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Basal Rate Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
Bolus Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Infusion Site Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
DKA Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
Unexplained High Glucose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
Prevention of Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20
Treatment of Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
Special Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22
Therapy Management Software . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
Continuous Glucose Monitoring (CGM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34
References and Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36
2
Bruce W. Bode, MD, FACEAn internationally known speaker and author on insulin pump therapy and continuous glucose monitoring, Dr. Bode, a graduate of Emory University School of Medicine, is in private practice with Atlanta Diabetes Associates. He is active in both the Georgia affiliate of the American Diabetes Association and the Juvenile Diabetes Research Foundation. Dr. Bode is also the editor of the American Diabetes Association’s Medical Management of Type 1 Diabetes.
Contributors
Jennifer Kyllo, MDJennifer Kyllo, MD is the Medical Director of the McNeely Pediatric Diabetes Center and Endocrine Clinic at Children’s Hospitals and Clinics of Minnesota. She attended medical school at the University of Minnesota and completed her residency and fellowship at the University of Iowa. Her principal areas of interest include caring for children with diabetes and improving access to new diabetes technology for children.
Francine R. Kaufman, MDFrancine Ratner Kaufman, MD is Chief Medical Officer and VP of Global Clinical, Medical and Health affairs at Medtronic Diabetes and a Distinguished Professor Emerita of Pediatrics and Communications at the Keck School of Medicine and the Annenberg School of Communications of the University of Southern California. Dr. Kaufman was president of the American Diabetes Association (2002-03), and serves on the Advisory Council of the Diabetes Branch of the NIH.
While every reasonable precaution has been taken in the preparation of this guide, the author, sponsor and publisher assume no responsibility for errors or omissions, nor for the uses made of the materials contained herein and the decisions based on such use. This document does not contain all of the information necessary for the proper care and treatment of patients with diabetes. As such, no individual may rely on the information presented herein in forming a comprehensive treatment program or in treating any patient with diabetes. No warranties are made, expressed or implied, with regard to the contents of this work or to its applicability to specific patients or circumstances. Neither the author, sponsor, nor the publisher shall be liable for direct, indirect, special, incidental or consequential damages arising out of the use or inability to use the contents of this guide.
3Purpose
PurposeThis booklet is designed for clinicians who are just beginning to prescribe pump therapy, as well as those who already have experience and want to review the latest strategies for optimizing glycemic control with insulin pump therapy. It provides information on proper candidate selection and the indications and protocols for initiating insulin pump therapy. Guidelines for fine-tuning insulin doses and strategies for preventing insulin pump problems are also presented.
Fundamental ConceptsOver the past three decades, insulin pump therapy has proven to be the most effective insulin regimen available for achieving tight glycemic control while minimizing the risk for hypoglycemia.1 It is readily used for the intensive management of adults, adolescents and children with type 1 diabetes and those with insulin-requiring type 2 diabetes.
Effectiveness of insulin pump therapy is attributed to three fundamental principles:
1. Pumps use only rapid-acting insulin for basal and bolus insulin requirements.
Eliminating longer acting insulin helps improve glycemic control during fasting states because:
•Theaction/peaktimeofrapid-actinginsulinismorepredictableandreproduciblethan long-acting insulin.2
•Thetinybasaldosesthatarecontinuouslydeliveredovereachhouraremoreconsistentlyabsorbed by the body.
2. Pumps deliver insulin in two ways, basal and bolus.
•Basal Insulin is a continuous infusion of insulin that is delivered automatically 24 hours a day. The purpose of basal insulin is to cover hepatic glucose production and to maintain glucose stability during fasting states (between meals and during sleep).
•Bolus Insulinisdelivered“on-demand,”bythepatient,forfoodintakeand/ortocorrectglucose levels that are above the patient’s target range, delivered separately or together.
− Food Bolus: Insulin given to cover food or drink that contains carbohydrates.
− Correction Bolus: Insulin given to correct blood glucose (BG) levels that are abnormal.
3. Medtronic pumps use a Bolus Wizard® calculator.
The Bolus Wizard calculator helps make diabetes management and bolus dosing easier and more accurate because it:
•Calculatesthebolusamountforthepatient,accordingtotheirpersonalizedsettings.
•Trackstheamountofactiveinsulinremainingfrompreviousboluses.
•Subtractsactiveinsulinfromcorrectiondosesbeforesuggestingthetotalbolusamount, which helps to prevent lows that result from the stacking of insulin.
•RecordsBGreadings,carbohydratesconsumed,unitsofinsulindeliveredandthetimeeachwas entered. Data can be downloaded into reports for easier, more accurate evaluation.
4 Insulin Pump Therapy
Insulin Pump Therapy
Indications3-5
Type 1 and insulin-requiring type 2 patients who are unable to achieve acceptable glycemic control, including those with:
•ElevatedA1C.
•Glycemicvariability.
•Recurrenthypoglycemia,nocturnalhypoglycemia,activity-inducedhypoglycemia and hypoglycemia unawareness.
•Pregnancy/Pre-pregnancy.
•Recurrentdiabeticketoacidosis(DKA)/recurrenthospitalizations.
•Dawnphenomenon.
•Gastroparesis.
•Patientpreference,meal-timingflexibilityandnormalizationoflifestyle.
•Lowinsulinrequirements(noteasilymeasuredviasyringe).
•Inabilitytoself-administerinsulin(pre-school/gradeschool).
•Inabilitytopredictfoodormealintake(infant/toddler).
Patient Requirements5-10
•Responsibleandpsychologicallystable
•Willingnesstomonitorbloodglucose(BG)aminimumoffourtimesaday
•Willingnesstoquantifyfoodintake
•Willingnesstocomplywithmedicalfollow-up
Benefits3,4,7,11
•Improvedglycemiccontrolanddecreasedglycemicvariability
•Improvedcontrolofdawnphenomenon
•Decreasedseverityandfrequencyofhypoglycemia
•Increasedflexibility,normalizationoflifestyleandsenseofwell-being
Precautionary Areas7
•Hyperglycemiaand/orDKAifinsulininfusionisinterrupted
•Lipohypertrophy(wheninfusionsitesarenotrotatedproperly)
•Infusionsitereactions(rashandskinirritation)orinfections
5Guidelines for Initial Pump Settings
Guidelines for Initial Pump SettingsInsulin pump therapy uses rapid-acting insulin for both basal and bolus insulin requirements.
* Hypoglycemic unawareness or other concerns, use the lower dose .† The percentage split for total daily basal and total daily bolus varies, especially in pediatric populations .
Basal Rate (BR)
Daily Basal Dose ÷ 24 = Hourly BR
Reduced Dose
Based on Daily Injection Dose
Injection Dose x 0.75 = Reduced Dose
Total Daily Basal Dose†
Pump TDD x 40% to 50% = Daily Basal Dose
Pump Total Daily Dose (TDD)
Average of Reduced Dose and Weight Dose*
(Reduced Dose + Weight Dose) ÷ 2 = Pump TDD
Weight Dose
Based on Weight
kg x 0.50 or lb x 0.23 = Wt. Dose
Insulin-to-Carb Ratio (ICR)
Daily Carbs ÷ Daily Bolus Dose = ICR
Total Daily Bolus Dose
Pump TDD - Daily Basal Dose = Daily Bolus Dose
Insulin Sensitivity Factor (ISF)
1700 ÷ Pump TDD = ISF
Guidelines for Transitioning to Pump Therapy
Goal: Eliminate as much intermediate/long-acting insulin as possible before starting pump . •Stopintermediate-actinginsulin12hoursbeforeandlong-actinginsulin24hoursbeforeinitiatingpumptherapy. •Havepatientgiveinjectionsusingsmallamountsofrapid-actinginsulinasneeded(every3to4hours)tokeepBGs
acceptable until pump therapy is initiated . •Insituationswhereintermediateorlong-actinginsulinisnotdiscontinued,programatemporarybasalrateto
deliverareducedbasalamount(50%to90%lessthancalculatedstartingrate)forthefirst12to24hoursoftherapy.
6
Pump Total Daily Dose (Pump TDD)Reduce the current total daily injection dose by 25 percent, calculate the weight dose and then average the two together.
TOTAL DAILY DOSEThe total amount of insulin(basalandbolus)delivered by the pump each day .
BASAL INSULINA continuous infusion of insulin given to cover hepatic glucose production .•Intendedtomimic
pancreatic basal secretion and maintain glucose stability in fasting states (betweenmealsand duringsleep).
•Replaceslong- acting insulin .
•Programmedtomatchpatient’s individual diurnal variation .
BOLUS INSULINGiven on demand by patient, as needed, for carbohydrateintakeandcorrecting abnormal glucose levels .
I N ITIAL PUM P TD DTake average of Reduced and Weight Dose
(Reduced Dose + Weight Dose) ÷ 2 = Pump TDD
E X A M P L E PAT I E N TType 1 Male Weight: 70 kg (154 lb)
Current Daily Insulin Regimen Rapid-acting: 11 units pre-meal x 3 33 u/day Long-acting:20units(Bedtime) + 20u/day
Total Daily Injection Dose = 53 u/day
R E D U CE D D OS EBased on daily injection dose
Injection Dose x 0.75 = Reduced Dose
W E I G HT D OS EBased on weight
kg x 0.5 u = Weight Doseor
lb x 0.23 u = Weight Dose
Reduced Dose
53 u/day x 0 .75 = 40 u/day
Weight Dose
70kgx0.5u=35 u/day or
154 lb x 0 .23 u = 35 u/day
Calculate Starting Doses
Initial Pump TDD
(40u/day+35u/day)÷2=37.5 u/day(Reduced Dose) (Weight Dose) (Pump TDD)
Calculate Starting Doses
Clinical Considerations for Pump TDD
•Uselessthana25%reductionifdailyinjectiondoseismorethan70%rapid-actinginsulin.•Pediatricpatientswhohavegoodcontroloninjectionsmayrequireaslittleasa5%reduction.•Forchildren&teens,TDDisvariable.Mayrequireasmuchas1.0u/kgtocalculateweightdose.•Hypoglycemiaorhypoglycemiaunawareness,usethelowerofthetwovalues.•Persistenthyperglycemia,elevatedA1Corpregnancy,usethehighervalue.•Erraticglucosecontrol,startingtherapyatdiagnosisorfromoralmedications,useweightmethod.
7
Total Daily Basal and Total Daily BolusFirst, determine the percent of TDD to be delivered as basal insulin and then multiply TDD by that percent. This will give you the Total Daily Basal amount. To calculate Total Daily Bolus subtract the Total Daily Basal amount from the TDD.
Basal RatePump therapy is typically initiated with a single basal rate that is delivered evenly over each hour, 24 hours a day. To calculate the initial basal rate, divide 24 hours into the Total Daily Basal amount.
TOTAL DAILY BASALTotal amount of basal insulin delivered over 24 hours .
TOTAL DAILY BOLUS: Total amount of bolus insulin(foodandcorrection)delivered over 24 hours .
BASAL RATEThe amount of basal insulin programmed to deliver evenly over each hour .
BASAL RATES <1 UNIT/HOURProgram in 0 .025 unit increments .
BASAL RATES >1 UNIT/HOURProgram in 0 .050 unit increments .
BA SALPump TDD x % Basal = Total Daily Basal
BO LUSPump TDD - Total Daily Basal = Total Daily Bolus
I N IT IAL BA SAL R ATETotal Daily Basal ÷ 24 hours = Hourly Basal Rate
Calculate Starting Doses
E X A M P L E PAT I E N TTotal Daily Basal: 18.75 u/day
E X A M P L E PAT I E N T50% of TDD as Total Daily Basal
Total Daily Basal
37.5 u/day x 0.5 = 18.75 u/day (PumpTDD) (TotalDailyBasal)
Initial Basal Rate
18.75 u/day ÷ 24 hours = 0.78 u/hour (TotalDailyBasal) (HourlyBasalRate)
Start initial basal rate at 0.775 or 0.800 units per hour
Total Daily Bolus
37.5 u/day – 18.75 u/day = 18.75 u/day (PumpTDD) (DailyBasalAmount) (TotalDailyBolus)
Calculate Starting Doses
Clinical Guidelines for Total Daily Basal and Bolus Percentages
Total Daily Basal Total Daily Bolus
Adults: 40%to50% 50%to60%
Puberty to Adult: 30%to40% 60%to70%
Pre-Puberty to Puberty: 20%to40% 60%to80%
8
Insulin-to-Carbohydrate Ratio (ICR)If a patient on multiple daily injections has established an ICR that provides reasonable post-prandial control, start pump therapy using that ICR. Or, use one of the methods below to calculate the initial ICR. If a patient is not yet carb counting or does not have an accurate food log, use the 450 Rule.
Fixed Gram or Exchanges per Meal MethodFor patients who are not yet carbohydrate counting or who have low cognitive ability, use the Fixed Gram or Exchange per Meal method explained below:
1) Calculate patient’s ICR using the 450 Rule.
2) Instruct patient on number of carbs or exchanges to enter for: a snack, a small meal, a medium size meal, a large meal.
3) Have patient use the Bolus Wizard® calculator to enter current BG and the number of grams or exchanges you told them to use for the size meal they are planning to eat.
This allows non-carb counting patients to use the Bolus Wizard and receive similar benefits to a carb counting patient, making diabetes management and record keeping easier.
INSULIN-TO- CARBOHYDRATE RATIONumber of carbohydrate grams covered by one unit of insulin .
ICR is used to calculate food bolus amounts .
ESTIMATING DAILY CARBOHYDRATE INTAKEHave patients who are not yetcarbcountingkeepa24 hour food log for 4 to 7 days .
Have diabetes educator review food log and estimate average daily carbohydrateintake.
METHOD 1Estimated Daily Carb Intake
Carb Grams ÷ Total Daily Bolus = ICR
M E TH O D 2450 Rule
450 ÷ Pump TDD = ICR
OR
Calculate Starting Doses
E X A M P L E PAT I E N TEstimated Daily Carbs: 225 grams Total Daily Bolus: 18.75 u/day Pump TDD: 37.5 u/day
Method 1
225 grams ÷ 18.75 u/day = 12 grams/unit
1 unit covers ~ 12 grams of carbohydrate
ICR = 12 grams
Method 2
450 ÷ 37.5 u/day = 12 grams/unit
1 unit covers ~ 12 grams of carbohydrate
ICR = 12 grams
OR
Calculate Starting Doses
Key Concepts for ICR
•PatientsoftenrequiremorethanoneICRtoobtainoptimalpost-prandialcontrol.
•DifferentICRscanbeprogrammedintotheBolusWizardfordifferenttimesduringtheday. Example:breakfast,lunch,dinner,snacktimes.
9
Insulin Sensitivity Factor (ISF)If a patient on multiple daily injections has an established ISF that currently provides reasonable correction doses, you can start pump therapy using that ISF. Or, use one of the methods below to calculate the initial ISF. For patients who have frequent hypoglycemia or hypoglycemia unawareness, use the 2000 Rule.
INSULIN SENSITIVITY FACTORThe number of mg/dL one unit of insulin lowers glucose .
Usedtocalculate correction bolus amounts .
BG TARGETBG value used in the correction formula when calculating a correction dose .
CORRECTION DOSEAmount of insulin calculated to correct a BG that is above target . Or, the amount of insulin subtracted from a food bolus when the BG is below target .
E X A M P L E PAT I E N TBG Target = 100 mg/dL ISF = 45 mg/dL
I F B G I S A B OV E TA R G E T (160 mg/dL): A positive correction dose is calculated .
(160–100)÷45=1.3units
I F B G I S AT TA R G E T: No correction amount is calculated .
I F B G I S B E LOW TA R G E T (60 mg/dL): A negative correction dose is calculated and subtracted from the food bolus .
(60–100)÷45=–0 .9 units
Calculate Starting Doses
I S F CO R R E C TI O N FO R M U L A(Current BG – BG Target) ÷ ISF = Correction Dose
E X A M P L E PAT I E N TPump TDD: 37.5 u/day
Method 1
1700 ÷ 37.5 = 45.3 mg/dL
One unit decreases BG ~ 45 mg/dL
ISF = 45 mg/dL
Method 2
2000 ÷ 37.5 = 53.3 mg/dL
One unit decreases BG ~ 53 mg/dL
ISF = 53 mg/dL
OR
METHOD 11700 Rule
1700 ÷ Pump TDD = ISF
M E TH O D 22000 Rule
2000 ÷ Pump TDD = ISF
OR
Calculate Starting Doses
10
Once the Bolus Wizard is programmed with the patient’s settings, the patient simply enters their current BG and the grams of carbohydrate they plan to eat. The Bolus Wizard uses this information to calculate the total bolus (called the “Estimate Total”) for the patient.
BOLUS WIZARD CALCULATORA feature in the pump that calculates meal and correction boluses and tracksactiveinsulinfor the patient .
ACTIVE INSULINInsulin remaining from previous boluses that continues to have a pharmacodynamic effect and the potential to lower glucose .
BG TARGET RANGEThe range of glucose valuestheBolusWizard uses to determine if a correction dose needs to be calculated .
To determine theBG Target Range:•EstablishthehighBGvaluefortheBolusWizardto use when correcting elevated BGs .
•EstablishthelowBGvalue for it to use when correcting low BGs .
E X A M P L E S O F B O LU S W I Z A R D CO R R E C T I O N C A LC U L AT I O N STarget Range Setting = 90 – 110 mg/dL ISF = 45 mg/dL
A B OV E R A N G E: (175 mg/dL)(175-110)÷45=1.4units(correctionbolus)
B E LOW R A N G E: (72 mg/dL)(72-90)÷45=–0.40units(subtractedfromfoodbolus)
Negative correction amounts are subtracted from food boluses before the Estimate Total is given .
•Moreaccuratebolusdosing
•Tracksactiveinsulin
•Helpspreventstackingofinsulindoses
•Reducesriskoflowsrelatedtostacking
•Keepscomprehensiverecordof: - BG readings - Carbohydrate grams - Insulin doses - Times of each entry
Benefits of using Bolus Wizard calculator12
TheBolusWizardCalculator
Correction Bolus and Bolus Wizard Target RangesWhen a BG reading is above the programmed Target Range, the Bolus Wizard uses the higher value in the range to calculate the correction dose. When a BG is below the Target Range, the Bolus Wizard uses the lower value to calculate the negative or reverse correction dose.
The Bolus Wizard® Calculator
•Insulin-to-CarbohydrateRatio(ICR)
•InsulinSensitivityFactor(ISF)
•BGTargetRange
•ActiveInsulinTime
Bolus Wizard Settings
Multiple target ranges are used to accommodate daytime, nighttime, pre- and post-meal glucose goals. When determining Bolus Wizard target ranges, keep in mind, these are not the same as ADA or AACE BG guidelines; instead they are the values the pump “targets” when correcting high or low BGs.
Clinical Considerations for Setting Initial Bolus Wizard Target Ranges*
Daytime Nighttime
•AdultsandAdolescents(13+yrs) 90–100mg/dL 100–110mg/dL•SchoolAge(6–12yrs) 90–110mg/dL 100–120mg/dL•ToddlertoPre-school(0 –6yrs) 100–120mg/dL 110–130mg/dL•HypoglycemiaUnawareness 100–120mg/dL 110–130mg/dL•Pregnancy 80–90mg/dL 90–90mg/dL
*Modifications to Bolus Wizard Target Ranges should be based on each patient’s clinical history.
11
ACTIVE INSULIN TIMEThe length of time the BolusWizardtracks active insulin after a bolus is given .
IMPORTANT POINTS•Activeinsulinisnever
subtracted from a meal bolus amount .
•Activeinsulinisonlysubtracted from correction bolus amounts .
TheBolusWizardCalculator
Active Insulin TimeThe length of time rapid-acting insulin lowers glucose varies in each individual. Therefore, Active Insulin Time can be adjusted to track for 2, 3, 4, 5, 6, 7 or 8 hours. The 7 and 8 hour Active Insulin times are only needed if regular insulin is used in place of rapid-acting insulin.
The Bolus Wizard tracks and calculates the amount of active insulin based on the patient’s individually programmed Active Insulin Time. When a patient’s BG is above target, the Bolus Wizard subtracts the active insulin from the correction insulin before calculating the Estimate Total.
How the Bolus Wizard Calculates the Estimate TotalWhen a patient enters their BG and carbohydrate grams, the Bolus Wizard does the math, using the patient’s pre-programmed settings (ICR, ISF, Target Range and Active Insulin Time) to calculate the Estimate Total for the patient.
TOTAL BO LUSFood bolus + (Correction bolus - Active Insulin) = Estimate Total
The Bolus Wizard® Calculator
Clinical Considerations for Setting the Active Insulin Time
Adults: 4 to 5 hours • Children: 3 to 4 hours • Pregnancy: 3 to 4 hours
E X A M P L E PAT I E N T
ICR: 12 grams ISF: 42 mg/dL BG Target: 100 – 110 mg/dL Active Insulin Time: 5 hours Food to be Eaten: 24 grams Current BG: 220 mg/dL
1.Calculatesfoodbolus: 24grams ÷ 12 grams/unit = 2 .0 units (foodintake) (carbratio) (foodbolus)
2.Calculatescorrectionbolus: (220 mg/dL – 110mg/dL) ÷ 42 mg/dL/unit = 2 .6 units (BG) (targetBG) (sensitivityfactor) (Correction)
3 . Subtracts active insulin: 2 .6 units – 1 .6 units = 1 .0 unit (correction) (activeinsulin) (adjustedcorrection)
4.Addsfood+adjustedcorrectionforestimatetotal: 2 .0 units + 1 .0 unit = 3 .0 units (foodbolus) (adjustedcorrection) (totalbolus)
Bolus Wizard® Settings
Wizard: OnCarbUnits: GramsCarb Ratios: 12Sensitivity: 42BGTarget: 100–110Active Ins Time: 5 hours
Estimate Details
Estimate total: 3 .0 unitsFoodIntake: 24gramsBG: 220 mg/dLFood: 2 .0 unitsCorrection: 2 .6 unitsActive Insulin: 1 .6 units
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Evaluating glucose control and adjusting pump settings is a logical, systematic process. It is based on the concept that rapid-acting insulin has a predictable glucose lowering effect, basal insulin covers hepatic glucose production, and bolus insulin covers food intake and the correction of high BGs.
Evaluating and adjusting insulin pump settings is accomplished by reviewing pertinent BG data, insulin delivery and carb intake. This data is typically obtained either by having patients manually writetheinformationonaBGlogsheet,orbyuploadingthepumpintoCareLinkPersonalorProfessionalSoftwareandreviewingtheCareLinkreports.
Likeallinsulinregimens,adjustinginsulinisanongoingprocess.Duringthefirstfewweeks of pump therapy, and any time pump settings need to be re-evaluated, have the patient follow these guidelines.
Patient Guidelines •DuringadjustmentphasescheckBGasfollows:
- Upon waking - Bedtime
- Pre-meal - Mid-sleep (or every 3 to 4 hours during sleep)
- Post-meal (2 hours)
•Avoidsnackingbetweenmeals(unlesstreatingalow).
•Eatlow-fatmealsinwhichcarbgramscanbeaccuratelycounted.
•UsetheBolusWizard®calculatortogiveallboluses.
•UploadpumptoCareLinkPersonalevery3to7days.
•IfnotusingCareLink,recordBGs,carbs,bolusesonlogsheetforreviewevery3to7days.
•Callyourofficeifanylowsoccur(lowsmustbeeliminatedtosuccessfullyfine-tune).
Evaluation Guidelines Evaluate glycemic control by time segments:
•Bedtimetomid-sleep(orevery3to4hoursduringsleep)
•Mid-sleeptowake-up
•Pre-mealtopost-meal(2hour)
•Post-mealtonextpre-meal
•Post-mealtobedtime
CARELINK® PERSONAL SOFTWAREAn online tool that allows patients to upload data from their pump and meter into reports .
CARELINK PROA diabetes therapy management software for personal computers that allows healthcare professionals to upload data from pumps and meters into reports .
CARELINK REPORTSOrganizedgraphsandstatistical tables that provide a historical review of glucose and pump data.CareLinkreportscanhelpmaketheevaluationand adjustment process more efficient .
Adjusting Pump Settings
Adjusting Pump Settings
13Adjusting Pump Settings
Adjustment Guidelines Basal rates, carbohydrate ratios and insulin sensitivity factors are the primary settings that need to be adjusted. While all three are reviewed simultaneously, it is usually best to first focus on getting basal rates (especially overnight) set correctly. The secondary settings, Active Insulin Time and Target Ranges, rarely need to be adjusted, and should not be changed until after primary settings have been verified as correct.
To make adjustments:
•Identifyglycemicrise/fallpatternsandanyotherissuesineachtimesegment.
•Adjustsettingsbasedontheglycemicrise/fallpatternandidentifiedissues.
•Makeone(nomorethantwo)changesatatime.
- Hyperglycemia Adjustments: Make adjustments after observing pattern for 3 to 7 days.
- Hypoglycemia Adjustments: Consider adjusting if any lows occur. Avoiding lows during adjustment phases is key, because lows and the treatment of lows disrupts BG patterns.
•Re-evaluateBGs3to7dayspostadjustmenttoconfirmnootherchangesareneeded.
Adjusting Pump Settings
BEHAVIOR AL CHECKS
❏ Are there 3 or more boluses/day?❏ Are there 4 or more BGs/day?❏ IstheBolusWizard®calculatorbeingused?❏ Is infusion set changed every 2 to 3 days?❏ Is pump suspended less than 1 hour/day?❏ Troubleshootdecisionmaking
❏ Do they use a temp basal for exercise?❏ Are they bolusing before meals?❏ Are they disconnecting appropriately?
THER APY CHECKS
❏ Verify pump settings❏ Verifybasalpercentis<50%ofTDD❏ Evaluateovernightcontrol(basal)❏ Evaluatepre-mealcontrol(basal)❏ Evaluatepost-mealcontrol(carbratio)❏ Are they having significant excursions?
Key Concept
Basalinsulindeliversintinyamountseachhouranditsaffectonglucosetakesplaceoveraperiod of time . Therefore, changes made to basal rates should be programmed to begin 2 to 3 hours prior to the observed BG rise or fall . Goal: Prevent the glycemic excursion from occurring .
Typical diabetes management behaviors and therapy checks that should be assessed prior to adjusting insulin settings are listed below.
14 Basal Rate Adjustments
BEDTIME BG PATIENT GUIDELINESInstruct patient that bedtime BGs should always be at least 100 mg/dL before going to sleep .
FASTING METHOD PATIENT GUIDELINESInstructpatienttoskipamealandcheckBGeveryhour.Neverskipmorethanone meal per day .
NON-FASTING METHOD PATIENT GUIDELINESInstruct patient: •Nottoeatbetweenmeals.•Nottocorrectpost-mealhighs(unless>250mg/dL).
Usedforpatientswhocannotskipmeals(i.e.,children,pregnancy).
Basal Rate AdjustmentsWhen basal rates are set correctly, patients should be able to sleep late, eat late, or even skip a meal without experiencing glycemic excursions.
Overnight Basal Rates Evaluation Guidelines
Assessovernightcontrolbyobservingrise/fallpatternsacrosstimesegments(bedtimeto mid-sleep; mid-sleep to wakeup). Adjust basal insulin to match diurnal variations.
Adjustment Guidelines
Goal: BGremainswithintarget(doesnotriseorfall>30mg/dL)throughthenight.
•IfBGrisesorfalls>30mg/dL:Adjustrateby10–20%,2to3hoursbeforeobservedriseorfall.
•IfBGdropsbelow70mg/dL:Instructpatienttotreatthelowanddecreaserate10–20%.
Obtaining optimal overnight glycemic control minimizes the risk of nocturnal hypoglycemia, allows patients to sleep through the night and wake within target, making evaluation of daytime basal easier since patients are not treating lows or correcting highs.
Daytime Basal Rates: Fasting Method Evaluation Guidelines
Evaluate BGs across skipped-meal time segment (pre-breakfast to pre-lunch, pre-lunch to pre-dinner,orpre-dinnertobedtime).Adjust/addbasalrate(s)basedonrise/fallpatternacross skipped-meal time.
Adjustment Guidelines
Goal: BGremainsstable(doesnotriseorfall>30mg/dL)duringskipped-mealtime.
•IfBGrisesorfalls>30mg/dL:Adjustrate10–20%,2to3hoursbeforeobservedriseorfall.
•IfBGdropsbelow70mg/dL:Instructpatienttotreatthelowanddecreaserate10–20%.
Daytime Basal Rates: Non-Fasting Method Evaluation Guidelines
Evaluate basal rates by comparing the two-hour post-meal BG to the next pre-meal BG. If a high is corrected, do not include that post- to pre-meal segment in your evaluation.
The following principles apply when evaluating basal rates in a non-fasting state:
•Two-hourpost-mealBGsshouldbe30to60mg/dLhigherthanpre-mealBGs;
•Two-hourpost-mealBGsshouldsteadilydeclineandbewithinpre-mealrangesbynextmeal.
Adjustment Guidelines
Goal: Post-meal BGs steadily decline and are back within pre-meal target range by next meal.
•IfBGfalls>60mg/dL,ordropsbelowtarget:Lowerrate10–20%.
•IfBGrises,staysthesameordecreases<30mg/dL:increaserate10–20%.
15
WHEN EVALUATING INSULIN-TO-CARB RATIO Instruct patient:•Toeatlow-fatmealswithknowncarbcontent.
•Nottoeatbetweenmeals.
2-HOUR POST- MEAL TARGET•ADA:≤180mg/dL•AACE:≤140mg/dL•Pregnancy:≤120mg/dL
WHEN EVALUATING INSULIN SENSITIVITY FACTORInstruct patient to:•Watchforatimewhen
BG is above target and no insulin has been given or food eaten for ~ 3 hours .
•UseBolusWizard to calculate and give recommended correction dose .
•CheckBGeveryhourforthe next 4 hours .
•Avoideatingordrinkinguntil the 4 hour BG has beenchecked.
Bolus Adjustments
Insulin-to-Carbohydrate Ratios (ICR)Evaluation Guidelines
Evaluate ICRs by comparing each pre-meal BG to its corresponding 2-hour post-meal BG.
Adjustment Guidelines
Goal: Two-hourpost-mealBGisbetween30mg/dLto60mg/dLhigherthanpre-mealBG.
•If2-hourpost-mealBGhasincreasedmorethan60mg/dLfromthepre-mealBG: DecreaseICR10–20%or1to2grams/unit.
•If2-hourpost-mealBGhasincreasedlessthan30mg/dLfromthepre-mealBG: IncreaseICR10–20%or1to2grams/unit.
Questions to Ask Prior to Adjusting ICR
•Werebolusesmissedoradministeredlate?Bolusesshouldbegivenbeforeeating.
•Didthepatientcountcarbohydratescorrectly?
•DidpatientadheretoBolusWizard®calculatorrecommendations?
Insulin Sensitivity Factor (ISF)Evaluation Guidelines
Evaluate ISF by comparing pre-correction BG to the 2- and 4-hour post-correction BGs.
Adjustment Guidelines
Goal: Post-correction, 2-hour BG is about halfway to target and at target by 4 hours.
•If2-hourpost-correctionBGisnothalfwaytotargetand4-hourpost-correctionisnot attarget:AdjustISF10–20%asneeded.
Bolus Wizard Target Ranges and Active Insulin TimeBG target ranges and active insulin settings are based on patient history, glycemic awareness and clinical judgment. These settings rarely need to be changed and should only be adjusted after primary settings (basal rates, ICRs and ISF) are correctly set.
Bolus Adjustments
Adjusting ICR and ISF Ratios
WhenworkingwithICRandISFratios:•Todecreasebolusamounts,increasetheratio.•Toincreasebolusamounts,decreasetheratio.Example:For60gramsofcarbohydrateifICRis:1:15=4units;1:12=5units;1:10=6units.
16 Infusion Site Care
PREGNANCYConsider inserting infusion sets in areas of subcutaneous tissue that are not tense from increasing abdominal girth, especially during the third trimester .
Infusion SetsMedtronic offers many types of infusion sets with varying lengths of cannulas and angles of insertion. Generally, when a patient has minimal subcutaneous fat, a shorter cannula or a set that goes in at an angle is used.
Auto-insertion devices designed to ensure proper insertion technique and reduce pain upon insertion are available for most infusion sets. The clinical manager in your area can help you and your patients decide which set is most appropriate.
•Sitesshouldbechangedandrotatedevery2to3days.
•Propersiterotationhelpsto:
- Prevent lipohypertrophy and scar tissue.
- Ensure tissue heals before inserting in that area again.
- Maintain healthy, viable tissue, which enhances consistent insulin absorption.
Patient Guidelines for Insertion and Rotation
Instruct patients to:
•Insertinfusionsetsintoeasy-to-accesssubcutaneoustissue.
•Insertsetsintositesthatareatleast2to3inchesawayfromprevioussite.
•Use“clock”,“M”or“W”methodtohelpensureproperrotation.
•Avoidinsertingintoscartissueorareaswithlipohypertrophy.
•Avoidareassubjecttoexcessivemovementorconstrictedbyclothing.
Commonly Used Infusion Sites Site Rotation Methods
Infusion Site Care
17Infusion Site Care
Infection PreventionInfection is rare when proper insertion guidelines are followed. To minimize the risk of infection encourage the use of good clean technique:
•Washhands
•Cleansitethoroughlywithaskinprepwipe
•Keepallinfusionsetssterile
•Changesetandrotatesiteevery2to3days
If an infection occurs:
•Itisusuallystaphylococcalinnatureandtypicallyrequiresoralantibiotictreatment.
•Ifinfectionsarerecurrent,recommendroutine: - Use of Hibiclens®, followed by alcohol to cleanse the site before inserting the set. - Application of an antibiotic ointment immediately after removing the infusion set.
•Ifanabscessoccurs,performanincision,draintheareaandculturethefluid. - Rule out methicillin-resistant staphylococcus. - Consider using Bactroban® in the nares weekly to minimize recurrent infections.
Skin Irritation
If skin irritation occurs, different treatment approaches are recommended depending on the source of irritant:
•Tape: Change type of tape (i.e., Polyskin®, IV 3000® or silk tape).
•Tubing: Place tape under and over tubing (sandwich technique).
•Soap or Alcohol: Change to antibacterial soap or use Skin Prep™ wipes.
If a patient experiences problems with their infusion set tape, he or she can download a copy of Tape Tips and Site Managementatwww.medtronicdiabetes.com/downloads.Thepatientmayalsocallthe24-HourHelpLineat1.800.646.4633.
Key Point: Instruct patients to wait to insert infusion sets until their skin is completely dry. This helps reduce the risk of skin reactions that can occur when adhesive dressing is placed on a wet site that has been cleansed with a skin prep, cleaner or wipe.
Infusion Site Care
18
ILLNESS INCREASES THE RISK FOR DKASystemic illnesses and localizedinfectionsareoften forerunners to DKA . It is important for patients to clearly understand that basalinsulinisrequiredeven when they are not able to eat or when they are nauseated or vomiting .
DKASince signs and symptoms of DKA are similar to flu orstomachvirus(nausea,vomiting,stomachpain)patientsoftenmistakenausea and vomiting associated with DKA for the flu .
Patients should fully understand that nausea and vomiting can be caused by DKA and they shouldchecktheirBG and monitor their urine orbloodforketonesanytime they experience these symptoms .
DKA Prevention
DKA Prevention Because insulin pump therapy uses only rapid-acting insulin, the onset of diabetes ketoacidosis (DKA) can occur quickly if insulin delivery is interrupted for a period of time. Therefore, all type 1 patients must be educated on DKA prevention strategies. The most important of which are: 1) adhering to a routine BG monitoring schedule (four to six times per day) and 2) never ignoring an unexplained high blood glucose.
Protocol for Treating Hyperglycemia
Have patients follow the “Troubleshooting Guidelines” (found on next page) any time they have unexplained high BGs that do not respond to a correction bolus.
Best Practice: Provide type 1 patients with a prescription for ketone strips prior to pump initiation. TeachandreinforcetheimportanceoftestingforketonesanytimeBGsareabove250mg/dL.
Patients should fully understand the following concepts:
•UnexplainedhighBGsshouldNEVERbeignored.
•TwounexplainedhighBGsinaroworahighBGthatisnotrespondingto a correction bolus may indicate an infusion set or insulin pump problem.
•NauseaandvomitingcanbecausedbyDKA.
•IllnessincreasestheriskfordevelopingDKA.
•Whenill,patientsshouldcheckBGeveryonetotwohours,checkforurineketones every time they urinate, and drink fluids. Staying hydrated helps prevent DKA.
•Neverexercisewhenketonesarepositive.
When DKA does occur, keep in mind that even after DKA has been properly treated and glucose returns to normal ranges, ketones may continue to be present for up to 24 hours.
When BG is ≥250 mg/dL:
If Ketones are Positive Or nausea and/or vomiting is present
•Giveacorrectiondoseviainjection
•Changeinfusionset,reservoirandinsulin
•MonitorBGevery1to2hoursand give insulin via injection until BGs are within target
•If BG is not decreasing, and you have moderate to high ketones, nausea, vomiting or difficulty breathing, call healthcare provider or go to emergency room
The point and time healthcare providers want to be notified varies. Establish a clear protocol for patients to follow.
If Ketones are Negative
•Giveacorrectiondoseviainsulinpump
•RecheckBGinonehour
•IfBGhasnotdecreased - Give a manual injection - Change infusion set, reservoir
and insulin
•ContinuetomonitorBGuntilglucoselevelsare within desired range
The most common causes of unexplained hyperglycemia that does not respond to a correction bolus include: a kinked or displaced cannula, an infusion set or reservoir issue or a “bad” (denatured) vial of insulin.
Check for KETONES and follow these guidelines:
19UnexplainedHighGlucose
TRO U B LE S H O OTI N G G U I D E LI N E S
WhattoCheck QuestionstoAsk If Yes…
Infusion site •Isitred,irritatedorpainful?
•Isitwet,ordoesitsmelllikeinsulin?
Change infusion set, reservoir and insulin
Infusion set tubing •Aretherebubbles(largerthan champagnebubbles)inthetubing?
•Istherebloodinthetubing?
Change infusion set, reservoir and insulin
Connection between reservoir and infusion set
•Arethereleaks/breaks?
•Isconnectionloose/easilymoved?
Change infusion set, reservoir and insulin if unable to correct the problem by tightening
Reservoir •Isitloadedincorrectly?
•Isthereservoirempty?
•Arethereexcessivebubbles?
Change infusion set, reservoir and insulin if unable to correct the issue
Insulin •Hasinsulinvialexpired?
•Hasinsulinbeenexposedtohightemperatures or direct sunlight?
Change infusion set and reservoir using a newvialofinsulin.(Whenindoubt,change itout!)
Checkinsulinpumpsettings
- Bolus Delivery
- Basal Rates
- Time
•Waslastmealbolusmissed?
•Arebasalratessetincorrectly?
•Istime(AM/PM)setcorrectly?
Give correction dose
Reset basal rates
Set time correctly
Insulin pump •Isinsulinpumpnotworkingor inoperable?
•Notsureifinsulinpumphas a problem?
CalltheMedtronicDiabetes24-HourHelpLine at 1 .800 .646 .4633
(The phone number is located on the back of the insulin pump)
Unexplained High Glucose
20 Prevention of Hypoglycemia
Prevention of HypoglycemiaInsulin pump therapy is associated with a marked reduction in the incidence of severe hypoglycemia. This is due to the predictable glucose lowering effects of rapid-acting insulin and the precise and flexible delivery system of an insulin pump. Patients should be taught the following concepts to help further reduce the risk of hypoglycemia.
Check BG a Minimum of 4 to 6 Times a DayRoutine monitoring of pre-meal, bedtime, nocturnal and exercise-related blood glucose levels is essential for safe and effective pump use. Therefore consider: •Periodicmonitoringofpost-mealand3:00AMBGsregardlessofsymptoms. •Conservativecorrectiondosesatbedtimeandpost-exercise. •PeriodicCGMusetoobtaincontinuoustracingsandconfirmtrends,patterns
and missed hypoglycemia.
Use the Bolus Wizard® Calculator for all Bolus DosesUsing this feature can help prevent hypoglycemia that results from the stacking of insulin and the over-correction of highs when there is active insulin remaining from previous boluses. The Bolus Wizard: •Trackstheamountofactiveinsulinremainingfrompreviousboluses. •Subtractsactiveinsulinfromcorrectiondosesbeforecalculatingatotalbolusamount.
BG Target Range Settings can be adjusted to prevent hypoglycemia. •Bedtimetargetrangescanbesethigherthandaytimetargetranges. •Patientswithahistoryofhypoglycemiamayneedahighertargetrangeallday.
Exercise Precautions •MonitorBG -Pre-exercise(BGmustbe>100mg/dL) - Every 30 minutes during exercise - Post-exercise (periodically, until BG lowering effect of exercise has subsided)
•UseTemporaryBasalRate -Startbydecreasingthebasalrate50%onehourbeforeexercisebegins,throughout
the exercise time, and for at least one hour post-exercise. - Adjust temporary basal rate percentage and duration as needed
(varies depending on the intensity and duration of exercise). •Useconservativecorrectiondosesduringthepost-exerciseperiod. •Forintenseenduranceexercise,patientsmayneedtoconsume15gramsofcarbohydrate
for each 15 to 30 minutes of activity. Titrate according to individual glycemic response.
Accurate Carbohydrate Counting Hypoglycemia can result from overestimating carbohydrate intake. Post-meal hypoglycemia is an indication that additional training on carb counting is needed or that the ICR needs to be adjusted.
HYPOGLYCEMIAAny glucose level <70 mg/dL .
MILD HYPOGLYCEMIACharacterizedby symptoms such as sweating, trembling, difficulty concentrating and lightheadedness .
TEMPORARY BASAL RATEAllows basal rate to be immediately increased or decreased for the temporary length of time the patient sets . Can be programmed from 30 minutes up to 24 hours .
SEVERE HYPOGLYCEMIACharacterizedbyaninability to self-treat due to mental confusion resulting in a loss of judgment, lethargy or unconsciousness .
Because the onset and magnitude of symptoms differ greatly in patients from episode to episode, an absolute glucose value cannot be used to measure the severity of a hypoglycemic event.
21
GLUCAGON EMERGENCY KIT PATIENT GUIDELINESInstruct patient to be sure family members, co-workers,friendsareproperly trained on how to administer glucagon .
Manyfindithelpfultowritethe instructions in their own words on a note card andattachittothekit.
HYPOGLYCEMIA PATIENT GUIDELINESInstruct patients to notify the healthcare team if a hypoglycemic event requiringassistanceoccurs.
Treatment of Hypoglycemia
Treatment of HypoglycemiaA common problem in diabetes is over-treating hypoglycemia, which causes hyperglycemia. To help patients prevent highs that result from over-treating, have patients follow a specific strategy, such as the 15-15 Rule, for treating low blood sugars. Encourage the use of glucose tablets for treating lows.
15–15Rule When glucose levels fall below 70 mg/dL:
1) Consume 15 grams of a fast-acting carbohydrate.
2) Recheck BG in 15 minutes.
3)IfBG<70mg/dL,repeatstepsoneandtwountilBGreturnstonormalrange (IfBGis<50mg/dL,patientcanstarttreatmentwith30grams).
Below70mg/dLatMealtimeWhen BG is below 70 mg/dL at mealtime:
•Instructpatientstoeatandmakesureglucoselevelsarewithintargetbeforebolusing.
•Havethemgivethebolusamountthatwascalculatedusingtheirpre-meallow.
Glucagon •Aswithallinsulin-requiringpatients,provideaprescriptionforaGlucagonEmergencyKit
before starting insulin pump therapy.
•Refillonceayearandimmediatelyuponusage.
Reporting Hypoglycemic Events Because some hypoglycemic incidents go unreported, ask about hypoglycemia at every visit
•Sinceyourlastvisit,haveyouhadanyhypoglycemiathatrequiredassistancefromafamilymember?…acoworker?…others?
•Isyourglucagonkitavailable?Wheredoyoukeepit?Whoknowshowtouseit?
Use of Continuous Glucose Monitoring (CGM)ConsidertheuseofCGMinpatientswhohaveahistoryofhypoglycemiaand/orthosewhoareunable to alert others when hypoglycemic symptoms occur.
22 Special Populations
Type 2 PatientsInsulin-requiring, type 2 patients respond favorably to insulin pump therapy. Below are some clinical considerations to assess when placing type 2 patients on pump therapy.
Initiation
Initiation is the same as in type 1 diabetes.
•ThestartingTDDcanbebasedonweight(0.5xkg=TDDUnits).Thismethodhasbeenshownto be effective.
–Startwith50%asbasaland50%asbolus.
–Type2patientstypicallyrequireonlyoneortwobasalrates.
Since many type 2s do not carb-count at initiation, consider using the “Fixed Gram or Exchange per Meal” method (as explained in the ICR section of this book). Set up the Bolus Wizard® using the ICR calculated with the 450 Rule. Evaluate 2-hour, post-prandial control and adjust ICR as needed.
Oral Medications
1) Stop sulfonylureas and meglitinides.
2) Continue metformin, incretin mimetics, and insulin sensitizers, if you choose.
–Onceatgoal,considerdiscontinuinganyoftheabovemedications,oneatatime,toseeif they are actually needed.
–Ifglucoselevelsdecompensatewhendiscontinued,resumethemedication.
Insulin Resistance
1) Some type 2s have marked insulin resistance, aggravated by both lipo and glucose toxicity.
–Onceglucoselevelsnormalize,insulinrequirementsmaydecrease.
–Whenthisoccurs,adjustpumpsettings(basalrate,ICR,ISF)topreventhypoglycemia.
2) In other cases, insulin resistance persists and large insulin requirements continue to be needed.
–Trytoreduceinsulinresistancewithexerciseandbydecreasingconsumption of calories (specifically high carbohydrate-containing foods).
–Considerusinginsulinsensitizersand/orGLP-1agonists.
Special Populations
EASY BOLUS FEATUREAn alternate way to program bolus amounts when the patient does notusetheBolusWizardfeature, does not count carbsorcheckBG before meals .
Modified Pump Start
ForpatientswhoareunabletocountcarbohydratesandcheckBGsbeforemeals,considerthefixed unit per meal bolus method using the Easy Bolus feature .
23Special Populations
Pregnancy Patients Maintaining tight glycemic control during pregnancy is key to preventing complications for both mother and neonate. Consider using Continuous Glucose Monitoring (CGM) throughout the perinatal period to help achieve optimal glucose control. •BGsshouldbemonitoredfrequentlyinpregnancy(pre-andpostmeal,bedtimeandmid-sleep). •Adjustmentstopumpsettingsneedtobemadefrequentlyforcontinuedoptimalcontrol. •Expectinsulinrequirementstosteadilyriseasthepregnancyadvances.Increasedinsulin
requirements are primarily due to the progressive rise in placental hormones which results in increased insulin resistance and decreased sensitivity to insulin action.13
Pre-Conception and 1st TrimesterMaintaining glucose control during organogenesis greatly reduces the risk of fetal anomalies and spontaneous abortion. •Theriskofhypoglycemia,especiallyovernight,increasesduringthefirstfewweeksof
pregnancy and insulin requirements are often less than pre-conception requirements. •Monitorfastingglucoseandcheckurineforketoneseverymorning. –PositiveketoneswithhighBGindicateneedforadditionalbasalinsulin. –PositiveketoneswithnormalorlowBGisindicativeof“starvationketones.”Consider
increasing bedtime snack or adding a midnight snack. •Insituationsofhyperemesis,considerusingasquarewavebolusover30minutessobolus
can be stopped if vomiting occurs.
2nd TrimesterThe placenta is fully developed and growth as well as hormones will begin to steadily rise causing insulin requirement to steadily increase as the pregnancy progresses. •Usuallyrequiresincreaseinbasal,meal,andcorrectioninsulin. •Pumpsettingsmayneedtobeadjustedevery2to3weeks.
3rd Trimester Maintaining tight glucose control throughout the last trimester helps to enhance fetal lung development, prevent fetal macrosomia and reduce the risk of neonatal hypoglycemia (post-delivery). •Insulinrequirementstypicallyincreaseeveryweek(duringthelastfewweeksofgestation).
Labor and DeliveryPatients can remain on pump throughout labor and delivery. •BGsshouldbemonitoredeveryhourandsmallbolusesgiven(ifneeded)tokeepglucose
in desired range.
Post-PartumImmediately after delivery and up to 24 hours post-delivery, insulin requirements decrease significantly. Therefore, basal rates, ICR, ISF and Target Ranges should be reduced to pre-conception settings or to at least half the current settings.
BreastfeedingBG levels can drop dramatically during breastfeeding. •Instructmotherto: –MonitorBGscloselyduringandforatleastanhourafternursing. –Alwaysdrinkandeatwhilebreastfeeding. –Consideruseoftemporarybasalrate(reductionupto50%)foranhourpost-nursing. –ConsideruseofCGM.
Special Populations
SQUARE WAVE BOLUSA feature that allows the patient to deliver a bolus over an extended period of time . Can be programmed to deliver in 30 minute increments from 30 minutes up to 8 hours .
24 Special Populations
Pediatric PatientsDiabetes brings unique challenges in the pediatric, adolescent and young adult age ranges. Depending on cognitive maturity and development skills, the need for increasing independence and the eventual transition to adult care, there is variability in parental/caregiverinvolvementnecessaryforinsulinpumpmanagement.
Special Populations
PE D IATR I C G U I D E LI N E S
Age Knowledge/Skills/Attitudes DiabetesandPumpManagement
Birth to 3 years of age, infants and toddlers
•Inherenttrustinparents/caregivers
•Rapidchangesincognitiveandmotorskills,nutritionrequirements,sleep/wakepatterns,andacquisitionofdevelopmentalmilestones
•Unawareandunabletocommunicateanyissues with health and diabetes/glucose levels
•Tempertantrumsmaybefrequentandassociatedwithdiabetestasks
•Pumpsabletodeliversmalldosesofinsulin with accuracy
•Issueswithpumpplacement,infusionsites,tubing,skinandchildacceptance
•Childcannotunderstandrequirementsofdiabetes management
•Erraticfoodintake,activity,mood,behavior
•Parents/caregiversmustdoalldiabetesmanagementtasks
•Riskandfearofhypoglycemia
3–6 years of age, preschool
•Beginstoshowsomeminimalunderstandingof diabetes procedures and management issues, such as nutrition
•Mightbegintorecognizehypoglycemiaandtell others
•Canhavenegativeattitudes
•Overallstilllacksmotorskillsandcognitiveability to contribute to diabetes management
•Beginstorealizehavingdiabetesisdifferent
•Childincreasinglyawareofpresenceofdevices, early understanding as to need to protect devices
•Moreinteractionwithpeerswhoareinterestedin devices as well
•Interactswithdecisionsastowhichfingertocheckglucose,wherepumpiswornandinfusion set placed
•Startstoaskaboutfooditemsandiftheycanbe eaten, and if bolus must be given
7–11 years of age, school-aged
•Increasingawarenessoftasksandgoalsofdiabetes management and ability to do them
•Stillreliantonparents/caregiversfordiabetesdecisions
•Mightstrugglewithbeingdifferentandbeginto be self-conscious about diabetes
•Mightbeangryordepressedaboutdiabetes
•Emergingabilitytocarbcount,takeboluses
•Increasingabilitytomanageinfusionset,hooks/unhooks
•Moretimeawayfromparents/primarycaregivers
•Abletoprotectdevices
•Abletodobloodglucosetesting,andknowsnumbers/goals
•Someawarenessastoroleofexerciseinglucose control
25
PE D IATR I C G U I D E LI N E S
Special Populations
Special Populations
Byage12,suggestthatyourpatients/parentsholdaweeklydiabetesmeeting.Ratherthanparentsquizzingthechildonwhat they are doing all day long, they should upload pump and meter data to review reports together. Determine number of BGs, boluses/day,useofBolusWizard,infusionsitechange,carbentries.Usethereportstoassessbehavior,rewardimprovement, and identify adherence problems.
Age Knowledge/Skills/Attitudes DiabetesandPumpManagement
12–15 years of age, young adolescents
•Understandsgoalsofdiabetesmanagement
•Diabetesaffectedbypubertybothphysiologically and psychologically
•Rebellionandrisktakingbehavior
•Peergroupidentificationpreeminent
•Issueswithbodyimage/weight/ disordered eating
•Moreindependence,parentalconflict
•Insulinrequirementsincreasesignificantly
•Erraticeatingandsleepingbehaviors
•Forgetsboluses
•Beginningoftransitionofmajorityofdiabetescare to child, although strong parent/care giver presencestillrequired
•Self-consciousaboutpump/diabetes,mighthide diabetes and devices
•Candomostdiabetes/pumptasks,exceptmight have trouble with changing basal rates and bolus doses
16–21 years of age, older adolescents
•Emergingindependence
•Decideseducation,livinglocation,longtermgoals/jobs/relationships
•Risktakingbehavior,psychologicalissues
•Needtofollowsafedrivingprinciples
•Beginstofullycontrolandmanagediabetes,with parental involvement still present but minimal
•Beginstoberesponsibleforpumpsupplies,health care appointments
•Preparestotransitiontoadultcare
Resources
TheNationalDiabetesEducationProgramwebsite(http://ndep.nih.gov/)hascomprehensiveinformationregardingrightsof children with diabetes in school . There are guides for school nurses, teachers, coaches, administrators, parents and students . All diabetes management and safety information is covered, including pump therapy .
26 Special Populations
Hospitalized PatientsIn general, patients who self-manage on insulin pump therapy prior to hospitalization prefer to stay on the pump when hospitalized. Having patients self-manage their own therapy is practical and easier for staff, as long as the patient remains mentally alert, psychologically sound and physically able.
If a hospital does not have a protocol for managing patients on insulin pump therapy, provide orders upon patient admission.
Orders should include:
•Rxforavialofrapid-actinginsulin(suppliedbyhospitalpharmacy).
•Currentsettings(BasalRates,ICR,ISF,TargetRangeandActiveInsulinTime).
•BGmonitoringrequirements:
- Frequency and if monitoring is to be performed by patient or staff.
- Documentation of BG readings.
- Glucose levels (upper and lower) at which treatment is required.
- Hypoglycemia protocol
- Hyperglycemia protocol
-Events/glucoselevelsforwhichyouoryourofficeshouldbenotified.
•Alternateinsulinregimenforprocedures:
-Lastinglongerthan2hoursandrequirepumpremoval/discontinuation.
- Requiring fasting (basal insulin continues to be needed).
- Requiring sedation (intravenous insulin should be started just before discontinuing the pump).
•Instructionstoremoveinfusionset,sensor,pumpandtransmitterandleaveoutsideofimagingroom for procedures involving MRI, CT scans, X-Ray (reconnect pump upon completion).
•Proceduretofollowifpatientstatuschangesandisunabletoself-manage.
•Frequencyforinfusionsiteandreservoirchangetobecompletedbypatient.
•Troubleshootingresourcessuchas:
-MedtronicHelpLinenumber1.800.646.4633(locatedonbackofpump).
- Family member who is well versed in pump therapy.
- Your office staff contact.
Hospitals do not typically stock insulin pump supplies. Instruct patients to bring enough infusion sets and reservoirs to change their infusion site every 2 to 3 days during hospitalization.
Special Populations
27TherapyManagementSoftware
Meter BG Reading Carbohydrate Gram Entries
Patient checks BG, enters carbohydrates and boluses simultaneously
Basal Rate Change Bolus Delivery
Therapy Management SoftwareAdvances in technology have now made it possible to electronically capture glucose data necessary for effective evaluation. CareLink®TherapyManagementSoftwareorganizescaptureddata(BGvalues,bolusamounts,basalrates,carbintake)intomeaningful reports for a historical, comprehensive review of the “cause-and-effect” relationship between these parameters.
Ask patients to upload their meter and insulin pump regularly. Review reports at each visit.
ThereportsthatfollowareavailablethroughCareLinkProSoftware.
Example of Daily Detail ReportDisplays each day’s pump and BG meter information and lists the details (time, amount, type) of each bolus that was given.
28 Adherence Report
SuspendDuration(h:mm)
TubingAmount (U)
TubingFills
CannulaAmount (U)
CannulaFillsRewindOverridden
WithCorrection
WithFood
BolusWizardEvents
ManualBoluses
SensorDuration(h:mm)
BGReadings
Fill EventsBolus EventsGlucose Measurements
Adherence (1 of 1)6/2/2010 - 6/15/2010 Data Sources: Paradigm Revel - 523
23583Wednesday6/2/2010
3793Thursday6/3/2010
3474Friday6/4/2010
7.610.62156106Saturday6/5/2010
3695Sunday6/6/2010
2573Monday6/7/2010
56105Tuesday6/8/2010
9.110.511228106Wednesday6/9/2010
3596Thursday6/10/2010
13475Friday6/11/2010
166137Saturday6/12/2010
8.410.31156114Sunday6/13/2010
12575Monday6/14/2010
2563Tuesday6/15/2010
0m8.4U/fill30.4U/fill
439.8%34.1%63.4%8.8/day0.0/day4.8/daySummary
Partial day Note: Partial days will not be included in summary averages. Days on which a time change occurred are considered to be partial days.
Glucose Measurements This section displays frequency of BG meter tests and duration of glucose sensor tracing information.
Bolus Events This section captures the patient’s use of the Bolus Wizard® calculator including the frequency of manual boluses and overrides.
•ManualBolus:Ahighincidenceofmanual boluses indicates under-utilization of the Bolus Wizard calculator.
•BolusWizardOverrides:Maybeappropriate,butshould always be investigated as they may indicate the need for additional patient education, or the need to assess insulin pump settings.
Fill (Priming) Events This section is used to determine if the patient is rewinding and priming the insulin pump appropriately.
•Rewindinglessthanonceeverythreedays indicates extended use of infusion sets or insulin
Suspend Duration Use this section to evaluate if suspend time is reasonable. Investigate frequent suspends and suspend times greater than one hour.
2
2
3
3
4
4
1
1
Example of Adherence ReportProvides new insights into a patient’s self-management behavior and helps confirm optimal device use.
29
Example of Sensor and Meter Overview Report
Meter Overlay Displays BG meter readings to assist in identifying excursionsand/orpatterns.
Statistics Table Displays BG meter, sensor glucose, carbohydrate, and insulin statistics over the reporting period.
Bedtime to Wake-up Meter Overlay Displays BG meter readings from bedtime to wake-up to help identify overnight patterns.
Meal Meter Overlay Realigns BG meter readings around meals (at the time carbohydrates are entered into the Bolus Wizard) to assess pre- and post-meal control.
2
3
4
1
SensorandMeterOverviewReport
6/2/2010 - 6/15/2010Sensor & Meter Overview (2 of 3)
Data Sources: Paradigm Revel - 523
Avg Carbs/Insulin: 12.2g/U Avg Insulin: 1.7U Avg Carbs: 20g
Meals Analyzed: 19 Dinner: 4:00 PM - 10:00 PM
Avg Carbs/Insulin: 11.8g/U Avg Insulin: 2.5U Avg Carbs: 30g
Meals Analyzed: 11 Lunch: 11:00 AM - 3:00 PM
Avg Carbs/Insulin: 11.6g/U Avg Insulin: 2.4U Avg Carbs: 28g
Meals Analyzed: 9 Breakfast: 6:00 AM - 10:00 AM
Wake-up: 5:00 AM - 9:00 AMBedtime: 8:00 PM - 12:00 AM
Bedtime to Wake-up
24-Hour Meter Glucose Overlay - Readings & Averages (mg/dL)
52%12.0Avg Daily Bolus (U)
48%11.0Avg Daily Basal (U)
± 1.723.0Avg Total Daily Insulin (U)
11.0Carbs/Bolus Insulin (g/U)
± 23134Avg Daily Carbs (g)
Avg AUC < 70 (mg/dL)
Avg AUC > 140 (mg/dL)
Sensor Avg (mg/dL)
5%3Readings Below Target
51%33Readings Above Target
4.8/day65BG Readings
± 56 147Avg BG (mg/dL)
- 6/156/2Statistics
Meter Glucose Overlay Bedtime to Wake-Up and Meal Periods – Readings & Averages (mg/dL)
Off chart Average within target range Average outside target rangeBG readingBG reading
Breakfast Example
One hour pre-meal
Target BG Range* (70–140 mg/dL)
6/2/2010 - 6/15/2010Sensor & Meter Overview (2 of 3)
Data Sources: Paradigm Revel - 523
Avg Carbs/Insulin: 12.2g/U Avg Insulin: 1.7U Avg Carbs: 20g
Meals Analyzed: 19 Dinner: 4:00 PM - 10:00 PM
Avg Carbs/Insulin: 11.8g/U Avg Insulin: 2.5U Avg Carbs: 30g
Meals Analyzed: 11 Lunch: 11:00 AM - 3:00 PM
Avg Carbs/Insulin: 11.6g/U Avg Insulin: 2.4U Avg Carbs: 28g
Meals Analyzed: 9 Breakfast: 6:00 AM - 10:00 AM
Wake-up: 5:00 AM - 9:00 AMBedtime: 8:00 PM - 12:00 AM
Bedtime to Wake-up
24-Hour Meter Glucose Overlay - Readings & Averages (mg/dL)
52%12.0Avg Daily Bolus (U)
48%11.0Avg Daily Basal (U)
± 1.723.0Avg Total Daily Insulin (U)
11.0Carbs/Bolus Insulin (g/U)
± 23134Avg Daily Carbs (g)
Avg AUC < 70 (mg/dL)
Avg AUC > 140 (mg/dL)
Sensor Avg (mg/dL)
5%3Readings Below Target
51%33Readings Above Target
4.8/day65BG Readings
± 56 147Avg BG (mg/dL)
- 6/156/2Statistics
Meter Glucose Overlay Bedtime to Wake-Up and Meal Periods – Readings & Averages (mg/dL)
Off chart Average within target range Average outside target rangeBG readingBG reading 5 hours post-meal
9 meals over 14 days
Average daily carb intake for breakfast
Average daily insulin given for breakfast
Average carb to insulin ratio for breakfast
Meal bolus given
Average pre-meal glucose in target
Average post-meal glucose in target at 2 and 4 hours
Statistics6/2/2010 - 6/15/2010Sensor & Meter Overview (2 of 3)
Data Sources: Paradigm Revel - 523
Avg Carbs/Insulin: 12.2g/U Avg Insulin: 1.7U Avg Carbs: 20g
Meals Analyzed: 19 Dinner: 4:00 PM - 10:00 PM
Avg Carbs/Insulin: 11.8g/U Avg Insulin: 2.5U Avg Carbs: 30g
Meals Analyzed: 11 Lunch: 11:00 AM - 3:00 PM
Avg Carbs/Insulin: 11.6g/U Avg Insulin: 2.4U Avg Carbs: 28g
Meals Analyzed: 9 Breakfast: 6:00 AM - 10:00 AM
Wake-up: 5:00 AM - 9:00 AMBedtime: 8:00 PM - 12:00 AM
Bedtime to Wake-up
24-Hour Meter Glucose Overlay - Readings & Averages (mg/dL)
52%12.0Avg Daily Bolus (U)
48%11.0Avg Daily Basal (U)
± 1.723.0Avg Total Daily Insulin (U)
11.0Carbs/Bolus Insulin (g/U)
± 23134Avg Daily Carbs (g)
Avg AUC < 70 (mg/dL)
Avg AUC > 140 (mg/dL)
Sensor Avg (mg/dL)
5%3Readings Below Target
51%33Readings Above Target
4.8/day65BG Readings
± 56 147Avg BG (mg/dL)
- 6/156/2Statistics
Meter Glucose Overlay Bedtime to Wake-Up and Meal Periods – Readings & Averages (mg/dL)
Off chart Average within target range Average outside target rangeBG readingBG reading
Average BG with standard deviation
Number of BGs for the reporting period and average number of BGs/day
Number of BGs above and below target* as well as percent of total BGs above and below target
Average carbs per day when using the Bolus Wizard® calculator
Average units of insulin per gram of carbohydrate when using the Bolus Wizard calculator
Average total number of units of insulin per day
Average number of units of basal insulin per day with percent of total
Average number of units of bolus insulin per day with percent of total
12
43
*Targets determined by provider during report setup
Displays blood glucose meter readings and statistics to allow for identification of glycemic excursions and patterns.
30 LogbookReport
ExampleofLogbookReport
Logbook Cell Section Each cell contains up to three numbers:
•TopNumber:BGmeterreading
•MiddleNumber:Carbohydrates
•BottomNumber:BolusInsulinDelivered
Meals can be quickly identified by looking for the carbohydrate amounts (highlighted in black).
Daily Totals Summarizes the following values from each day of the reporting period:
•Average:DisplaysthetotalnumberofBGmeterreadings taken and the BG meter average.
•Carbs:Displaysthetotalamountofcarbohydratesentered into the Bolus Wizard.
•Insulin:Displaysthetotalamountofinsulindelivered and the percentage delivered as a bolus.
1 2
Logbook Cell Section
Daily Totals
Carbs: Displays the total amount of carbohydrates entered into the Bolus Wizard® calculator.
Insulin: Displays the total amount of insulin delivered and the percentage delivered as a bolus.
Average: Displays the total number of BG meter readings taken and the BG meter average.
Top Number: BG Meter Reading highlighted if above or below target.*
Middle Number: Carbohydratesin black background
Bottom Number: Bolus insulin delivered
DinnerLunchBreakfast
6/2/2010 - 6/15/2010
Logbook (1 of 1)Data Sources: Paradigm Revel - 523
Daily Totals11 PM10 PM9 PM8 PM7 PM6 PM5 PM4 PM3 PM2 PM1 PM12 PM11 AM10 AM9 AM8 AM7 AM6 AM5 AM4 AM3 AM2 AM1 AM12 AM
Average (3):
Carbs: 118gBolus: 51%Insulin: 22.9U
160mg/dL
0.23
153
0.701.5018
2.0525
2.9530
147
0.10
180
1.3515
2.7030
Wednesday6/2/2010
Average (3):
Carbs: 161gBolus: 58%Insulin: 25.6U
190mg/dL
3.1525
214
2.0525
2.0024
3.0530
202
1.0512
0.385
153Thursday6/3/2010
Average (4):
Carbs: 108gBolus: 48%Insulin: 20.8U
133mg/dL
0.18
131
2.5030
0.85
192
3.3040
0.738
0.03
104
2.3030
105Friday6/4/2010
Average (6):
Carbs: 160gBolus: 58%Insulin: 28.1U
214mg/dL
2.0525
3.1538
174
1.20
286
1.25
266
0.8310
3.7545
0.637
Saturday6/5/2010
Average (5):
Carbs: 139gBolus: 54%Insulin: 23.7U
137mg/dL 110
1.2515
1.6520
1.3316
0.23
128 170
5.0060
0.75
168
2.5028
0.05
108Sunday6/6/2010
Average (3):
Carbs: 141gBolus: 56%Insulin: 24.6U
140mg/dL
1.1514
3.7545
1.60
247
3.1538
1.4516
63Monday6/7/2010
Average (5):
Carbs: 131gBolus: 56%Insulin: 23.9U
169mg/dL
0.23
156
0.8310
1.2515
3.1835
126
1.2515
2.5030
0.75
212
2.3526
1.00
223Tuesday6/8/2010
Average (6):
Carbs: 146gBolus: 50%Insulin: 21.8U
110mg/dL
0.5814
113
1.0012
3.8046
1.3032
75 99
1.0012
100
2.7030
114
0.50
161Wednesday6/9/2010
Average (6):
Carbs: 109gBolus: 49%Insulin: 21.2U
123mg/dL
1.3016
0.658
96
2.0525
0.75
205
2.5030
84
2.8530
132
0.20
124Thursday6/10/2010
Average (5):
Carbs: 108gBolus: 51%Insulin: 22.1U
147mg/dL
2.0525
1.75
261
0.658
3.7545
101
2.7030
0.30
136Friday6/11/2010
Average (7):
Carbs: 150gBolus: 56%Insulin: 26.5U
186mg/dL
3.7545
0.8310
1.6310
205
0.90
252
3.7545
0.38
147 167
3.0540
0.68
174Saturday6/12/2010
Average (4):
Carbs: 146gBolus: 51%Insulin: 23.3U
103mg/dL
1.0012
170
2.0030
2.5030
0.10
71
0.8310
3.3040
101
2.1524
71Sunday6/13/2010
Average (5):
Carbs: 185gBolus: 56%Insulin: 24.7U
114mg/dL 101
1.6520
4.4845
166
5.0060
78
2.7060
58Monday6/14/2010
Average (3):
Carbs: 134gBolus: 51%Insulin: 22.3U
97mg/dL
0.587
85
2.0525
2.6034
64
3.1538
2.7030
0.28
141Tuesday6/15/2010
Time change
< 70mg/dL
> 140mg/dL Multiple readings (most extreme shown)
Pump rewind
Suspend
Manual bolus or bolus with correction Skipped meal
Partial day
Other
Exercise
DinnerLunchBreakfast
6/2/2010 - 6/15/2010
Logbook (1 of 1)Data Sources: Paradigm Revel - 523
Daily Totals11 PM10 PM9 PM8 PM7 PM6 PM5 PM4 PM3 PM2 PM1 PM12 PM11 AM10 AM9 AM8 AM7 AM6 AM5 AM4 AM3 AM2 AM1 AM12 AM
Average (3):
Carbs: 118gBolus: 51%Insulin: 22.9U
160mg/dL
0.23
153
0.701.5018
2.0525
2.9530
147
0.10
180
1.3515
2.7030
Wednesday6/2/2010
Average (3):
Carbs: 161gBolus: 58%Insulin: 25.6U
190mg/dL
3.1525
214
2.0525
2.0024
3.0530
202
1.0512
0.385
153Thursday6/3/2010
Average (4):
Carbs: 108gBolus: 48%Insulin: 20.8U
133mg/dL
0.18
131
2.5030
0.85
192
3.3040
0.738
0.03
104
2.3030
105Friday6/4/2010
Average (6):
Carbs: 160gBolus: 58%Insulin: 28.1U
214mg/dL
2.0525
3.1538
174
1.20
286
1.25
266
0.8310
3.7545
0.637
Saturday6/5/2010
Average (5):
Carbs: 139gBolus: 54%Insulin: 23.7U
137mg/dL 110
1.2515
1.6520
1.3316
0.23
128 170
5.0060
0.75
168
2.5028
0.05
108Sunday6/6/2010
Average (3):
Carbs: 141gBolus: 56%Insulin: 24.6U
140mg/dL
1.1514
3.7545
1.60
247
3.1538
1.4516
63Monday6/7/2010
Average (5):
Carbs: 131gBolus: 56%Insulin: 23.9U
169mg/dL
0.23
156
0.8310
1.2515
3.1835
126
1.2515
2.5030
0.75
212
2.3526
1.00
223Tuesday6/8/2010
Average (6):
Carbs: 146gBolus: 50%Insulin: 21.8U
110mg/dL
0.5814
113
1.0012
3.8046
1.3032
75 99
1.0012
100
2.7030
114
0.50
161Wednesday6/9/2010
Average (6):
Carbs: 109gBolus: 49%Insulin: 21.2U
123mg/dL
1.3016
0.658
96
2.0525
0.75
205
2.5030
84
2.8530
132
0.20
124Thursday6/10/2010
Average (5):
Carbs: 108gBolus: 51%Insulin: 22.1U
147mg/dL
2.0525
1.75
261
0.658
3.7545
101
2.7030
0.30
136Friday6/11/2010
Average (7):
Carbs: 150gBolus: 56%Insulin: 26.5U
186mg/dL
3.7545
0.8310
1.6310
205
0.90
252
3.7545
0.38
147 167
3.0540
0.68
174Saturday6/12/2010
Average (4):
Carbs: 146gBolus: 51%Insulin: 23.3U
103mg/dL
1.0012
170
2.0030
2.5030
0.10
71
0.8310
3.3040
101
2.1524
71Sunday6/13/2010
Average (5):
Carbs: 185gBolus: 56%Insulin: 24.7U
114mg/dL 101
1.6520
4.4845
166
5.0060
78
2.7060
58Monday6/14/2010
Average (3):
Carbs: 134gBolus: 51%Insulin: 22.3U
97mg/dL
0.587
85
2.0525
2.6034
64
3.1538
2.7030
0.28
141Tuesday6/15/2010
Time change
< 70mg/dL
> 140mg/dL Multiple readings (most extreme shown)
Pump rewind
Suspend
Manual bolus or bolus with correction Skipped meal
Partial day
Other
Exercise
DinnerLunchBreakfast
6/2/2010 - 6/15/2010
Logbook (1 of 1)Data Sources: Paradigm Revel - 523
Daily Totals11 PM10 PM9 PM8 PM7 PM6 PM5 PM4 PM3 PM2 PM1 PM12 PM11 AM10 AM9 AM8 AM7 AM6 AM5 AM4 AM3 AM2 AM1 AM12 AM
Average (3):
Carbs: 118gBolus: 51%Insulin: 22.9U
160mg/dL
0.23
153
0.701.5018
2.0525
2.9530
147
0.10
180
1.3515
2.7030
Wednesday6/2/2010
Average (3):
Carbs: 161gBolus: 58%Insulin: 25.6U
190mg/dL
3.1525
214
2.0525
2.0024
3.0530
202
1.0512
0.385
153Thursday6/3/2010
Average (4):
Carbs: 108gBolus: 48%Insulin: 20.8U
133mg/dL
0.18
131
2.5030
0.85
192
3.3040
0.738
0.03
104
2.3030
105Friday6/4/2010
Average (6):
Carbs: 160gBolus: 58%Insulin: 28.1U
214mg/dL
2.0525
3.1538
174
1.20
286
1.25
266
0.8310
3.7545
0.637
Saturday6/5/2010
Average (5):
Carbs: 139gBolus: 54%Insulin: 23.7U
137mg/dL 110
1.2515
1.6520
1.3316
0.23
128 170
5.0060
0.75
168
2.5028
0.05
108Sunday6/6/2010
Average (3):
Carbs: 141gBolus: 56%Insulin: 24.6U
140mg/dL
1.1514
3.7545
1.60
247
3.1538
1.4516
63Monday6/7/2010
Average (5):
Carbs: 131gBolus: 56%Insulin: 23.9U
169mg/dL
0.23
156
0.8310
1.2515
3.1835
126
1.2515
2.5030
0.75
212
2.3526
1.00
223Tuesday6/8/2010
Average (6):
Carbs: 146gBolus: 50%Insulin: 21.8U
110mg/dL
0.5814
113
1.0012
3.8046
1.3032
75 99
1.0012
100
2.7030
114
0.50
161Wednesday6/9/2010
Average (6):
Carbs: 109gBolus: 49%Insulin: 21.2U
123mg/dL
1.3016
0.658
96
2.0525
0.75
205
2.5030
84
2.8530
132
0.20
124Thursday6/10/2010
Average (5):
Carbs: 108gBolus: 51%Insulin: 22.1U
147mg/dL
2.0525
1.75
261
0.658
3.7545
101
2.7030
0.30
136Friday6/11/2010
Average (7):
Carbs: 150gBolus: 56%Insulin: 26.5U
186mg/dL
3.7545
0.8310
1.6310
205
0.90
252
3.7545
0.38
147 167
3.0540
0.68
174Saturday6/12/2010
Average (4):
Carbs: 146gBolus: 51%Insulin: 23.3U
103mg/dL
1.0012
170
2.0030
2.5030
0.10
71
0.8310
3.3040
101
2.1524
71Sunday6/13/2010
Average (5):
Carbs: 185gBolus: 56%Insulin: 24.7U
114mg/dL 101
1.6520
4.4845
166
5.0060
78
2.7060
58Monday6/14/2010
Average (3):
Carbs: 134gBolus: 51%Insulin: 22.3U
97mg/dL
0.587
85
2.0525
2.6034
64
3.1538
2.7030
0.28
141Tuesday6/15/2010
Time change
< 70mg/dL
> 140mg/dL Multiple readings (most extreme shown)
Pump rewind
Suspend
Manual bolus or bolus with correction Skipped meal
Partial day
Other
Exercise
*Targets determined by provider during report setup
1
2
Provides logbook information in an hour-by-hour format to help identify repeated patterns and possible causes for glycemic excursions.
31Device Settings Report
Example of Device Settings Report
Basal Settings Displays the patient’s basal rates at the time the patient’s device was uploaded.
Bolus Settings Displays the patient’s bolus settings at the time the patient’s device was uploaded.
Sensor Settings Displays the patient’s sensor settings at the time the patient’s device was uploaded.
Utilities Displays the patient’s alert type and low reservoir warning settings at the time the patient’s device was uploaded.
Notes Section can be used to record notes for patient records, to provide comments and recommendationsforpatienttherapy,and/or to record documentation for health insurance providers.
2
3
4
5
1
Displays insulin pump and sensor settings.
Thursday 6/17/2010 7:56 AMDevice Settings Snapshot
OffBlood Glucose Reminder
OnDual/Square (Variable)
10.0 UMaximum Bolus
--Insulin Concentration
3:00Active Insulin Time(h:mm)
g, mg/dLUnits
OnBolus Wizard
Bolus
10.900 U24-HourTotal 8.713 U24-Hour
Total 12.188 U24-HourTotal
0.55022:00
0.42519:00
0.37516:00
0.4258:30
0.4256:00
0.5003:30
0.5501:00
0.5250:00
U/hrTIME
12.021:00
12.017:30
12.011:30
11.06:30
13.00:00
RatioTIME
9011:00
1205:00
950:00
SensitivityTIME
115 9022:00
100 805:00
115 900:00
HighLowTIME
mg/dLBG Units
0000000Transmitter ID
OnSensor
NoneGraph Timeout (h:mm)
0:20Missed Data/Weak Signal(h:mm)
140 70AUC Limit: Low | High
(mg/dL)
1:00Calibration (Alert) Repeat(h:mm)
0:30Calibration Reminder(h:mm)
--Auto Calibration
Pattern A Pattern B
Utilities
Sensor
Blood GlucoseTarget (mg/dL)
Insulin Sensitivity(mg/dL per U)
Carbohydrate Ratio(g/U)
0.37518:00
0.3258:00
0.3755:00
0.4003:30
0.4250:00
U/hrTIME
0.52519:00
0.42515:30
0.4756:30
0.5754:30
0.6001:00
0.5500:00
U/hrTIME
20 UAmount
Insulin UnitsLow Reservoir Warning
Beep MediumAlert Type
0.10 UEntry (Step)
OffEasy (Audio) Bolus
Percent of BasalTemp Basal Type
2.00 U/hrMaximum Basal Rate
Basal
Standard (active)
----
End(h:mm)
Start(h:mm)
Off
MissedBolus
Reminder
4.0 4.0Rate Alert: Fall | Rise
(mg/dL/min)
1515Low | High (mins)
OnPredictive Alert
1:300:20Alert Repeat
220 7522:00
175 756:00
200 750:00
High(mg/dL)
Low(mg/dL)TIME
OnGlucose
Alerts
Notes
Data Source: Paradigm Revel - 523
1 2 3
54
32
Recorder
Docking Station
ContinuousGlucoseMonitoring
Continuous glucose monitoring measures glucose levels in the interstitial fluid and provides a record of glucose readings 24 hours a day. These glucose tracings detail the patient’s daily glycemic control and provide insight into trends and patterns that are often missed with finger-stick monitoring alone. CGM technology can help clinicians and patients make more informed decisions regarding diabetes management.
There are two types of CGM systems: Professional and Personal.
Professional CGMProfessional CGM systems are owned and managed by healthcare providers and can be used on multiple patients. Each system consists of a glucose sensor (temporarily inserted into subcutaneous tissue and replaced after each use) and a small recording device that attaches to the sensor. These systems are designed for periodic use and provide detailed continuous glucose data for retrospective evaluation.
During the evaluation period, the patient’s glycemic levels (blinded to the patient) are recorded continuously. At the end of the evaluation period, the glucose data is uploaded by the healthcare providertoCareLink® iPro®, where it is compiled into reports.
These reports provide comprehensive information about glycemic control. Including:
•24-Hourcontinuousglucosetracingsfortheentireevaluationperiod
•Markersthatindicatemealtimesandmedicationstaken
•Overlaysofpost-prandial(breakfast,lunchanddinner)andovernightglucosetracings
•Hyper-andhypoglycemicareaunderthecurve(AUC)data
•Piechartssummarizingglycemiccontrolanddistributionofhyper-andhypoglycemia
These reports provide a historical review of glycemic trends and patterns, allowing clinicians to retrospectively and objectively evaluate a patient’s glucose control and make more informed therapy management decisions.
Continuous Glucose Monitoring (CGM)
ROUTINE USEConsiderquarterlyevaluations, as a compliment to A1C, for type 1 and type 2 .
PROCESS•HCPplacespatient onCGM.
•PatientwearsCGM 3daysandchecksBG 3 to 4 times/day .
•PatientreturnsfordownloadofCGMandglucose meter data .
•Datausedfor: - Glycemic evaluation . - Therapy modification . - Patient education and
consultation .
DOCKING STATIONCharges, downloads and troubleshoots the Recorder .
RECORDERRecords up to 288 sensor glucose readings every 24 hours .
33ContinuousGlucoseMonitoring
*Theinsulinpumpisindicatedforpersonsofallagesrequiringinsulin.TheREAL-TimeContinuousGlucoseMonitoringcomponentsoftheMiniMedParadigm®REAL-TimeInsulinPumpandContinuousGlucoseMonitoringSystemareindicatedforages7yearsorolder.Aversionof the product specially designed for children is indicated for patients ages 7 to 17 .
Glucose Sensor
Target Range
Trend Graph
Sensor Glucose Value
Trend Arrow
Transmitter
Continuous Glucose Monitoring (CGM)
Personal CGMPersonal CGM systems are owned and operated by the patient. These systems consist of the glucose sensors, a transmitter (sends glucose data to a monitor) and a small external monitor. The monitor displays the patient’s most recent glucose reading (updated every 5 minutes) and a continuous tracing of the past 24 hours of glucose readings. There are two types of Personal CGM: one is a stand-alone device, and the other is integrated into the insulin pump.
Indications for Personal CGM*
Patients on MDI or insulin pump therapy who check BG four or more times a day and who have:
•A1Cabovegoal(non-pregnancy>7%,preconception>6.5%,pregnancy>6%).
•Historyoffrequenthypoglycemiaorhypoglycemiaunawareness.
•Markedglucosevariabilitywithmultipleglucosereadingsoutsidethedesiredrange.
Patient Requirements for Starting CGM
The same as insulin pump therapy, plus:
•Willingnesstocalibratetheglucosesensoraminimumofthreetofourtimesaday.
•Willingnesstovalidatesensorglucose(SG)valueswithBGtestpriortomakingtreatmentdecisions.
Considerations Before Starting CGM
•Understandingofimportanceofglucosetrendsversus“point-in-time”BGvalues.
•Understandingofsensorglucose(SG)versusbloodglucose(BG)andthepotentialdifferences in the two values.
•Insurancecoverageorabilitytopayout-of-pocket.
The full benefit of CGM is best realized when current data and historical data are utilized in concert.
TARGET RANGEThe upper and lower glucose values a patient sets for the monitor to alarm when their glucose reaches that level .
SENSOR GLUCOSE VALUEThe patient’s most recent sensor glucose reading .
TREND GRAPHA tracing of the past 24 hours of glucose readings .
TREND ARROWAn arrow or arrows that indicate the direction and rate of glucose change .
34
BloodGlucoseLogSheet
Patient: _________________________________________________________________________ DOB: _____________________________
Phone:(Home)________________________________ (Work)_______________________________ /_______________________________ Time Rate
Basal Rate: 1. 12 A.M. _________
2. _________ _________
3. _________ _________
4. _________ _________
5. _________ _________
Date ______ /______ /______ 12A.M. 3A.M. Pre-Brkfst Post-Brkfst Pre-Lunch Post-Lunch Pre-Dinner Post-Dinner Bedtime
Time
Blood Glucose
Carb Grams
FoodDose
Correction Dose
Total Bolus
Date ______ /______ /______ 12A.M. 3A.M. Pre-Brkfst Post-Brkfst Pre-Lunch Post-Lunch Pre-Dinner Post-Dinner Bedtime
Time
Blood Glucose
Carb Grams
FoodDose
Correction Dose
Total Bolus
Date ______ /______ /______ 12A.M. 3A.M. Pre-Brkfst Post-Brkfst Pre-Lunch Post-Lunch Pre-Dinner Post-Dinner Bedtime
Time
Blood Glucose
Carb Grams
FoodDose
Correction Dose
Total Bolus
Date ______ /______ /______ 12A.M. 3A.M. Pre-Brkfst Post-Brkfst Pre-Lunch Post-Lunch Pre-Dinner Post-Dinner Bedtime
Time
Blood Glucose
Carb Grams
FoodDose
Correction Dose
Total Bolus
Date ______ /______ /______ 12A.M. 3A.M. Pre-Brkfst Post-Brkfst Pre-Lunch Post-Lunch Pre-Dinner Post-Dinner Bedtime
Time
Blood Glucose
Carb Grams
FoodDose
Correction Dose
Total Bolus
Notes:
Pumping ProtocolbyBruceBode,MD.©2008MedtronicMiniMed,Inc.Allrightsreserved.9402236-011042408
Meal Bolus: 1 Unit of insulin covers this many grams of carbohydrate. CarbRatio:(B)_______(L)_______(D)_______
Insulin Sensitivity Factor: 1 Unit of insulin lowers BG _______ mg/dL
(Current BG – Target) ÷ Sensitivity Factor = Correction Dose
BG Target Range: Daytime = _______mg/dL – _______mg/dL
BG Target Range: Nighttime = _______mg/dL – _______mg/dL
Faxto:______________________________________________
35
Meal Bolus: 1 Unit of insulin covers this many grams of carbohydrate. CarbRatio:(B)_______(L)_______(D)_______
Insulin Sensitivity Factor: 1 Unit of insulin lowers BG _______ mg/dL
(Current BG – Target) ÷ Sensitivity Factor = Correction Dose
BG Target Range: Daytime = _______mg/dL – _______mg/dL
BG Target Range: Nighttime = _______mg/dL – _______mg/dL
Faxto:
PumpModel: PumpSerialNumber:
Patient Name: Date:
DOB: Weight:
Current Regimen: = units
Pump Initiation SettingsPRESCRIBER’S INSTRUCTIONS TO PATIENT
Calculations for Insulin Pump Initiation Settings
Formula
Reduced Dose Injection Dose x 0 .75 = Reduced Dose
Weight(lbs.)x0.23=WeightDose
DailyCarbGrams÷TotalDailyBolus=CarbRatio
1700÷PumpTDD=InsulinSensitivityFactor
(ReducedDose+WeightDose)÷2=PumpTDD
PumpTDDx%Basal(40–50%)=TotalDailyBasal
TotalDailyBasal÷24hours=HourlyBasalRate
__________ units/day x 0 .75 = __________ units/day
__________ lbs . x 0 .23 units = __________ units/day
________grams÷_______units/day=_________grams/unit
1700÷__________units=__________mg/dL/1unit
(______units/day+_______units/day)÷2=______units/day
__________ units/day x _________ = __________ units/day
__________units÷24hours=__________units/hour
Weight Dose
Pump TDD
Total DailyBasalUnits
Initial Basal Rate
Insulin-to-Carb Ratio
Insulin Sensitivity Factor
Basal Rates
Time Rate1)_______@_______2)_______@_______3)_______@_______4)_______@_______5)_______@_______
Carb Ratio
(B)
(L)
(D)
Sensitivity Factor
ISF=_________mg/dL/1unit
Active Insulin Time___________ hours
Adults: 4-5 hoursChildren: 3-4 hoursPregnancy: 3-4 hours
Day NightAdultsandAdolescents(13+yrs): 90–100mg/dL 100–110mg/dLSchoolAge(6–12yrs): 90–110mg/dL 100–120mg/dLToddlertoPre-school(0–6yrs): 100–120mg/dL 110–130mg/dLHypoglycemiaUnawareness: 100–120mg/dL 110–130mg/dLPregnancy: 80–90mg/dL 90–90mg/dL
Bolus Wizard® Calculator Target Ranges
Day
_______—_______
Night
_______—_______
Pum
p TD
DBa
sal R
ate
ICR
ISF
Calculation
Pump Settings
Instructions for Adjustments•Ifnocturnal,fasting/pre-mealorbedtimeBG>target,increasebasal10–20%•Ifnocturnal,fasting/pre-mealorbedtimeBG<target,decreasebasal10–20%•Ifpost-mealBG>60mg/dLabovepre-mealBG,decreasecarbratioby10–20%•Ifpost-mealBG<30mg/dLabovepre-mealBG,increasecarbratioby10–20%
ElevatedBG:Verifytrends2–3daysbeforeadjustingLow BG: Consider immediate adjustment
Comments:94
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Total Daily Injection Dose
Reduced Dose
Pump TDD
Weight Dose
Pump TDD
Reduced Dose Weight Dose
Total Daily Basal
Total Daily Bolus
Pump TDD
% Basal
Initial Basal Rate
Insulin-to-Carb Ratio
InsulinSensitivityFactor
Adjustments should be made when BGs are outside of these ranges
Fasting/pre-meal:__________to__________mg/dL
Post-meal: __________ to __________ mg/dL
Bedtime: __________ to __________ mg/dL
Nocturnal: __________ to __________ mg/dL
12 a .m .
These instructions shall be valid for 6 months unless otherwise specified here: ______________months .
Total Daily Basal
Injection Dose
Weight
Daily Carbs
450÷PumpTDD=CarbRatio 450÷_______units/day=_________grams/unitPump TDD Insulin-to-Carb Ratio
Total DailyBolusUnits Pump TDD - Total Daily Basal = Total Daily Bolus ________ units/day - ________ units/day = ________ units/day
OR OR
Pump TDD Total Daily BolusTotal Daily Basal
Prescriber Name: Signature: Date:Call MD for severe low BG or ketones. Call Medtronic for technical issues at 800-646-4633. Pumping ProtocolbyBruceBode,MD.
MaxBasalRate:______units MaxBolus:______units
36 References and Suggested Reading
References1. Hoogma RP, Hammond PJ, Gomis R, et al. Comparison of the effects of continuous subcutaneous insulin infusion (CSII) and NPH-based multiple daily insulin injections
(MDI) on glycaemic control and quality of life: results of the 5-nations trial. Diabet Med.2006;23:141–147.
2.HeinemannL,WeyerC,RauhausM,HeinrichsS,HeiseT,etal.Variabilityofthemetaboliceffectofsolubleinsulinandtherapid-actinginsulinanaloginsulinaspart. Diabetes Care.1998;21:1910–1914
3. Boardman S, Greenwood R, Hammond P, on behalf of the Association of British Clinical Diabetologists (ABCD). ABCD position paper on insulin pumps. Practical Diabetes International.2007;78:149–158.
4.HellerS,KozlovskiP,KurtzhalsP.Insulin’s85thanniversary.2007;78:149–158.Diab Res Clin Pract.doi:10.1016/j.diabres.207.04.001.
5. Medical management of type 1 diabetes.In:BodeBW,ed.ToolsofTherapy–InsulinTreatment.4thed.AmericanDiabetesAssociation;2004;64–68.
6. Bode BW, Davidson PC, Tamborlane WV. Insulin pump therapy in the 21st century. Postgraduate Medicine Online. 2002;111(5) www.postgradmed.com. Accessed May 10, 2007.
7. American Diabetes Association. ADA position statement: continuous subcutaneous insulin infusion. Diabetes Care. 2004;27 (suppl1):http://patients.uptodate.com/print.asp?print=true&file=ada_guid/4656.AccessedMay10,2007.
8.BodeBW,DavidsonPC,FredricksonLP,GrossTM,SabbahHT.Diabetesmanagementinthenewmillenniumusinginsulinpumptherapy.Diabetes Metab Res Rev. Jan–Feb2002;18(suppl1):S14–20.
9. Fernandez MP, Marcus AO. Insulin pump therapy: acceptable alternative to injection therapy. Postgraduate Medicine.1996,99:125–132,141–144.
10. Keen H, Pickup J. Continuous subcutaneous insulin infusion at 25 years. Diabetes Care.2002;25:593–598.
11.BodeBW,GargS,HirschIB,etal.Continuoussubcutaneousinsulininfusion(CSII)ofinsulinaspartversusmultipledailyinjectionofinsulinaspart/insulin glargine in type 1 diabetic patients previously treated with CSII. Diabetes Care.2005;28:533–538.
12. Gross TM, Kayne D, King A, Rother C, Juth S. A bolus calculator is an effective means of controlling postprandial glycemia in patients on insulin pump therapy. Diab Technol Ther.2003;5:365–369.
13. Gabbe SG, Graves CR. Management of diabetes mellitus complicating pregnancy. Obstetrics and Gynecology. 2003;102(4):857-868.
Suggested Reading American College of Endocrinology Consensus Statement on Guidelines for Glycemic Control. Endocrine Practice.2002;8(suppl1):5–11.
BaileyT,EllisS,GargS,KaplanR,JovanovicL,SchwartzS,ZisserH.Improvementinglycemicexcursionswithatranscutaneous,real-timecontinuousglucosesensor. Diabetes Care.2006;29:44–50.
Bartnik M, Betteridge J, Cosentino F, et al. The Task Force of Diabetes and Cardiovascular Diseases of the European Society of Cardiology and of the European Association for the Study of Diabetes. Guidelines on diabetes, pre-diabetes, and cardiovascular diseases: full text. European Heart Journal.2007;9:195–668.
BartocciL,BolliG,BrunettiP,CordoniC,CostaE,DiVincenzoA,FanelliC,LeporeM,PampanelliS,PorcellatiF.Pharmacokineticsandpharmacodynamicsof subcutaneousinjectionoflong-actinghumaninsulinanalogglargine,NPHinsulinandultralentehumaninsulinandcontinuoussubcutaneousinfusionofinsulinLispro. Diabetes.2000;49:2142–2148.
Battelino T, Bolinder J, Bosi E, et al. Improved glycemic control in poorly controlled patients with type 1 diabetes using real-time continuous glucose monitoring. Diabetes Care.2006;29:2730–2732.
BodeBW,ClarkJG,DavidsonPC,FredricksonL,etal.Astatistically-basednomogramusedasateachingtoolforCSIIparameters.[Abstract2227]Diabetes & Metabolism. 2003;29.
Bode BW, Davidson P, Steed R. Reduction in severe hypoglycemia with long-term continuous subcutaneous insulin infusion in type 1 diabetes. Diabetes Care.1996;19:324–327.
Bode BW, Strange P. Efficacy, safety, and pump compatibility of insulin aspart used in continuous subcutaneous insulin infusion therapy in patients with type 1 diabetes. Diabetes Care.2001;24:69–72.
Boyer BA, Scheiner G. Characteristics of basal insulin requirements by age and gender in type 1 diabetes patients using insulin pump therapy. Diab Res Clin Pract.2005;69:14–21.
BrownleeM,HirschIB.Shouldminimalbloodglucosevariabilitybecomethegoldstandardofglycemiccontrol?J Diabetes Complications.2004;19:178–181.
CersosimoE.ResponsetoSchade:Topumpornottopump?Diabetes Care. 2003;26:967.
Cohen O, Basu R, Bock G, Man CD, Campioni M Basu A, Toffolo G, Cobelli C, Rizza RA. Cardiovascular and metabolic risk prediction of postprandial glycemic exposure. Diabetes Care.2006;29:2708–2713.
Diabetes Control and Complications Trial Research Group, The. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med.1993;329(14):977–986.
Epidemiology of Diabetes Interventions and Complications Research Group. Epidemiology of diabetes interventions and complications (EDIC). Diabetes Care.1999;22:99–111.
Franz MJ, Kulkarni K, eds. Hypoglycemia. In: Diabetes Management Therapies: A Core Curriculum for Diabetes Educators.Vol2.4thed.Chicago,IL:AmericanAssociation of Diabetes Educators; 2003:290.
HeiseT,etal.Lowerwithin-subjectvariabilityofinsulindetemirincomparisontoNPHinsulinandinsulinglargineinpeoplewithtype1diabetes.Diabetes.2004;53:1614–1620.Hirsch IB. Algorithms for care in adults using continuous glucose monitoring. J Diab Sci Technical.2007;1:126–129.
KovistoVA,HelveE,KaronenSL,PelkonenR,Yki-JävinenH.PathogenesisandpreventionofthedawnphenomenonindiabeticpatientstreatedwithCSII. Diabetes.1986;35:78–82.
Klonoff DC. Continuous glucose monitoring: roadmap for 21st century diabetes therapy. Diabetes Care.2005;28:1231–1239.
KrugerDF,MathesonD,ParkinCG,PonderS,SkylerJS.Isthereaplaceforinsulinpumptherapyinyourpractice?Clinical Diabetes.2007;25:50–56.
Kulkarni K, Tomky DM. Intensifying Insulin Therapy: Multiple Daily Injections to Pump Therapy.MensingC,ed.Chicago,IL:AmericanAssociationofDiabetesEducators. 2006.
PetersAL,RosenbergC.PatientEducation.In:DavidsonMB,ed.Diabetes Mellitus: Diagnosis and Treatment. 4th ed. Philadelphia, PA.: W.B. Saunders Company, A Division of HarcourtBrace&Company:1998:424.
Pickup,J.Areinsulinpumpsunderutilizedintype1diabetes?Yes.Diabetes Care.2006;29:1449–1452.
SchadeDS,ValentineV.Topumpornottopump?Diabetes Care.2002;25:2100–2102.
Wolpert H. Smart Pumping: A Practical Approach to the Insulin Pump. Alexandria, VA: American Diabetes Association; 2002.
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Medtronic, Inc. | Diabetes 18000 Devonshire Street Northridge, CA 91325 USATel: 1.800.646.4633
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