Should this patient be on insulin pump

Tuan Quach

Staff Specialist

John Hunter Hospital

Case 1

• 19 year man shift worker; labourer

• Epilepsy: hypos induced

• Type one diabetes for 10 years

• Lantus 25 mane

• Novorapid 2-2.5 unit per exchange

• Monitors 4-8/day

• HbA1c about 8.5-8.9% for years

• No complications

Case 1

• Fear of hypos and seizure

• Erratic hours

• Good hypos awareness

• Try to keep BGL 8-12 mmol/L

• Frustrated with swing of BGLs

Case 1

• Attended intensive insulin education course ( empowerment course)– Update about basic insulin therapy– Hypos/ sick day management– Review carb counting; correction

• Still not improved 3 months later :– Still run BGL 8-12 mmol/L– More stability

Case1• Pre-pump education

– Expectations of pump– Benefits and harm with pump– Types of pump

• Pump started successfully

• Follow up with educator and physician weekly then monthly for on going adjustment/ advance pump skills

• Achieved HbA1c 8.0% for the first time with no hypos

Advantages Of Pumps Over MDI

• More reliable insulin action

• Fewer missed/skipped doses

• Precision – 0.05 u versus 0.5 u

• Automatic dose calculations

• Less insulin stacking

A More Normal Lifestyle• Flexible mealtimes

• Less hypoglycemia

• Flexible insulin delivery for exercise, skipping meals, erratic schedules, shift work

• Less hassle with travel and time zones

• Increased sense of well being

• Less anxiety while staying on schedule

• Plus reminders, history, accurate dose calculations, etc.

The Challenge Of DiabetesBringing the A1c down smoothly takes

effort

……for this you need ADVANCED therapyfor this you need ADVANCED therapy

(5.5)

(11.1)

(16.7)

Normal A1C 4%–6%

BG

L (

mm

ol)

0800 1200 1800 0800

Uncontrolled A1C ~9%

A1C ~6%

“Controlled” A1C <7%

Time of Day

Poor Control Remains A Problem

HbA1c

10%

9%

8%

7%

6%

ADA

EASD/AACE

ADA = American Diabetes Assoc., IDF = Inter. Diabetes Federation, EASD is European Assoc. for the Study of Diabetes, AACE = American Association of Clinical Endocrinologists

Novo Nordisk Type 2 diabetes market research, Roper StarchWright A., Burden et al, Diabetes Care 2002; 25:330–336Turner RC, Cull et al, JAMA 1999; 281:2005–2012

2/3 with diabetes (and most pumpers) remain out of control

Avg. A1c in TYPE 1sAvg. A1c on Pumps

Goal A1c

5%

Benefits of insulin pump

• Reduction in HbA1c 0.2-0.6%

• Reduction of blood glucose by 1 mmol/L

• Reduction of daily insulin dose by 14%

• Reduction of server hypos

• Improvement in quality of life

Case 2• Miss JL

• 18 years old transition form paediatrician

• DM 1 for 7 years

• Has been on pump for 3 years

• Good diabetes control when she was younger

• Left school moved in with much older boyfriend

Case 2

• Binge alcohol and smokes

• Experimented with drugs

• Eating and sleeping pattern erratics

• No monitor; not bolusing; not changing line

• DKA 3-5 times per year

• Poor attendance to clinic

• HbA1c >10%

Case 2

• Persuaded to take off pump

• Re-educated on Lantus and Novorapid

• Re-enforced that Lantus is important to prevent DKA

• Perhaps only take Novorapid when remembered

• No further admission for DKA for the past 2 years

Transition patient

• Often very good control when still living at home; parents cook; supervise insulin

• Often have very poor basic diabetes skills

• Often have very poor insulin/pump skills

• Adolescent issues

• Chronic illness behaviour : psychological dependency on the pump

Risk of DKA and pump

• Theoretical risk as pump only have short acting insulin and no long acting

• With interruption of insulin pump within 4-6 hours DKA can be precipitated

• Often in patient who does not monitor BGL

• No different rates of DKA in trials compare MDI vs CSII

Benefits For Kids & Teens

• Better for growth spurts, hormone changes in puberty, Dawn Phenomenon

• Easy to cover snacks

• TDD and bolus history available to ensure consistent dosing

• Fast adjustments of basals and boluses for changes in activity/exercise

• Lessens impact of BG swings on top of peer pressure, struggle for independence, mood swings, college, and issues with alcohol, sex, drugs

Case 3

• 35 years old executive; DM I 15 years

• No complications

• Travels lots

• Lantus insulin 30 mane (0700)

• Novorapid 3 units per exchange

• HbA1c 8.2%

• Problem: high BGL on waking ( 12-16 mmol/L)

Causes of high BGL in early AM

• Lantus running out

• Eating too much late at night

• Dawn phenomena

• Somogyi’s effect

Dawn phenomena

• BGL raise in the early hour of the morning

• Normal diurnal rhythm : BP ;PR; Temp…

• Part of other hormones: cortisol; adrenaline

• Can be difficult problem in diabetes

• Can be managed by split dose basal insulin

• May need insulin pump: basal dose can be programmed

Case 3

• Patient was confirmed to have Dawn phenomena by repeated overnight testing

• Splitting of Lantus dose was partially helping

• Patient travels makes control harder

• Insulin pump was initiated after extensive education process: problem corrected.

Novorapid

Time

06001200 1800 2400

1.5unit/hr

1.2unit/hr0.6unit/hr

Basal rate can be programmed to over come the Dawn’ phenomena

Somogyi’s effects

• Hyperglycaemia follow a hypos• Responding to stress hormones of a hypos :

cortisol; sympathetic hormones; growth hoemones

• Nocturnal or early am hypoglycaemia may manifest as early am high BGL

• Always ask patient to set alarm and check BGLs early am before change insulin

Groups of patient that may benefit from pump therapy

• Dawn phenomena• Frequent hypos• Hypo-unawareness• Small TDD; ‘brittle’ diabetes• Injection site problems• Variable meal time; work; exercise• Pregnancy• Young adolescent • Gastroparesis

Type 1 pregnancy and Pump

• Preconception tightening up of HbA1c 6-7% lower risk of foetal malformation

• Improvement of glycaemia through pregnancy can lower marternal and foetal complications

• Minimize risk of hypos as patient tend to run BGL a lot lower

Lipodystrophy and insulin absorption

• 20% to 50% of MDI patient

• Increased variability in insulin absorption

• Induced variability in glycaemia

• 20% variability of insulin absorption for each administration

• Pump can over come this problem

Keys to have successful insulin pump patients

• Patient selection

• Education process: before and after

• Supports/ Follow up

Patient selection

• Patient has be willing and able to be on pump

• Motivated to have self management

• Commitment to have a partnership with the pump team

• Other clinical criteria as above

RCT indication for pump efficacy

• HbA1c persistently elevated despite intensify MDI (A)

• Recurrent hypoglycaemia (A)

• Marked glycaemic variability (B)

• No evidence for type 2 diabetes

ExpectationsUnrealistic Realistic

The pump will cure my diabetes I will feel better

Poorly controlled diabetes make me depressed; pump will fix my depression

I need to get treatment for depression

I won’t have to test as much I must monitor very frequently

I can eat anything I want I will have more freedom with my food choices

My blood sugar will be perfect I will have better control with fewer lows

It will be as easy to learn as a meter

It will take time to learn and adjust to the pump

Contraindication

• Absolute:– Severe psychiatric illness– Severe progressive proliferative retinopathy

• Relative contraindication– Not monitoring– Poor basic diabetes education

Three stages of insulin pump initiation

• Diabetes education– Basal-bolus concept– Carb counting competency– Hypos; sick day management

• Education of technical aspect of pump:– Infusion set; line changes– Pump function; programming

• Follow up:– Ongoing education/ adjustment– Advance pump skills– Emergency plan; supports

Pump team

• Educator

• Dietitian

• Endocrinologist

Follow up plan: more education

• Regular contacts with educator: review line changes; pump rates

• Monthly visit with physician until stable

• Care link; internet; phone

• Texting; Email; Facebook

• All need emergency plan:– Check BGL 1-2 hours after line changes– High BGL management– Low BGL management

Emergency plan• Severe hypos: ( <2.5 mmol/L+need help)

– stop/suspend pump

– Treat hypos and review cause

– Restart pump only when BGL>4.0mmol/L

• Hyperglycaemia: persistent BGL>12-15– Correction boluses via pen

– Line change

• Pre-DKA/DKA– Sick day plan

– Present to ED prepared to suspend pump

– Patient need to be aware of own total basal in pump

Insulin pump and resources

• Insulin pump treatment is costly

• Insulin pump takes up significant resources

• Shortage of educator with pump expertise

Thank you