Insulin Pump What to tell your patient!!

Prakash Abraham

Isla Fairley

                            

                                                 

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Present generation pumps

•Paradigm (Medtronic £2750)

•Animas (Johnson & Johnson, £2600)

•Spirit (Roche, £2375)

•Deltec Cozmo (Smiths Medical, £2750)

Insulin Pump Usage: Grampian ~2% vs UK 4%

What does the pump do?

2008 NICE recommendations

• Disabling hypoglycaemia (repeated and unpredictable occurrence of hypos that result in persistent anxiety about recurrence and adverse quality of life)

• HBA1c > 8.5% despite high level of care

• Children <12 (where MDI impractical) and should have a trial of MDI between 12-18years.

Who can consider the pump 1

Patient characteristics

• Type 1 DM

• Basal bolus regime

• Well motivated

• Cope with CHO counting (DAFNE)

• Monitoring at least 4 times

• No evidence of Psychological illness

Who can consider the pump 2

Disease characteristics

• Frequent hypoglycaemia

• Hypoglycaemia unawareness

• Gastroparesis

• Poor control

• Marked dawn phenomenon

New Aspects to consider for pump

• Carbohydrate Ratios – DAFNE (Dose adjustment for normal eating)

• Insulin Sensitivity / Correction doses– DAFNE

• Basal Rates (Additional to DAFNE)– 1 basal injection to potentially 48 choices– Fasting at different times to titrate

Carbohydrate/ Insulin Ratio

• number of grams CHO covered by 1 unit insulin

• The 500 Rule: 500 divided by total daily dose equals CHO ratio.

• Usually 10-15

• May vary at different times of the day.

4

8

12

16

Insulin sensitivity

• how much 1 unit of insulin lowers bg over 2-4 hours

• Correction dose

• The 100 rule: 100 / total daily insulin dose

• May vary at different times of the day

8

4

12

16

An overnight drop of upto 2mmol/l is OK

5

10

15

What does the pump involve?

• Insulin set changes every 2-3 days

• Correction doses– Insulin sensitivity to be checked at different

times

• Carbohydrate ratios– Monitor Meal Bolus rates for each of the

meals

What does the pump involve?

• Basal rates to be checked– Skip breakfast for overnight rate– Skip lunch for daytime rate– Skip dinner for evening rate

• Takes 3-6 months of work to get the various rates and ratios sorted.

• Then work out weekends, more active days etc

Assessment

• Interview with DSN/Doctor/Dietitian

• Confirm eligibility and motivation

• CHO counting (DAFNE course)

• Pump demonstration

• Dummy pump (CGMS) to carry for 2 days

• Pump panel for funding decision

Pump Start

• First week: Intensive (Days off Work)

• Patient Contract

• QOL (PAID) / Hypo questionnaires

• First 3 months: 3 to 6 visits to Diabetes Resource Room, then at 6 & 12 months

• Pump clinic: 4.5 /9 /15 months then ~4 monthly

• (CGMS)

Patient contract

Initial Pump Support Variations

• Two of the new starts in 2007• MT

– 4 months: Phone calls 2 weekly– emails 2 weekly– 9 appointments (3 with Doctor)

• GN– 6 month: 3 phone calls– 3 emails– 3 appointments (2 with doctor)

Disadvantages• Wearing a device

• Essential to check BMs minimum 4 times a day. Risk of DKA as only short acting insulin

• Work involved in assessing rates and ratios.

Advantages

• Minimise Hypoglycaemia

• Less variability in blood sugars

• More precise insulin dosing

• Flexibility to change basal rates depending on activity

• Quality of Life

Summary of profiles over 3 days

CSII NOT for everyone

Effort vs Reward