Insulin pump and continuous glucose monitoring system

Chapter 1

The pump includes a programmable WEAK SIGNAL alert that notifies you when one or more expected
transmissions were not received as expected by the pump. (The pump will also issue a LOST SENSOR alert
if communication is interrupted for an extended period of time.)
Communication problems can usually be resolved by:
•
ensuring that there is less than 6 feet (1.8 meters) between the receiving device and transmitter, to
include RF glucose meters;
•
turning off or moving away from other RF transmitting devices; or
•
reorienting or relocating the transmitter or receiving device, or both.
Communications problems may also occur due to cellular telephone interference. Testing conducted with
several different cellular telephones indicates that, while a glucose value is being transmitted, using a cell
phone within 12 inches (31 cm) of receiving devices, transmitters or RF glucose meters can interfere with
reception of the transmitted values. In the event of such interference, normal communication can be re-
established by:
•
turning the cell phone off; or
•
keeping the cell phone at least 12 inches (31 cm) away from the receiving device, transmitter or
glucose meter when a glucose measurement is being transmitted.
If you have questions, please contact the 24 Hour HelpLine.
Introduction
12

Introduction to pump therapy
Theory of insulin pump therapy
Insulin pumps deliver insulin closer to the way the human pancreas delivers insulin than any other method
of treating diabetes.
All people, with or without diabetes, need background insulin for normal functions of the body without
food. They also need a dose of insulin on demand - when food is eaten. People without diabetes can trust
that their pancreas will produce this insulin for them. People with diabetes need to take insulin in a way
that is most like the way a pancreas produces it.
Most people with diabetes who take more than one daily injection, use long-acting insulin. This takes care
of their background insulin needs. They take fast-acting insulin for food. When using an insulin pump, only
fast-acting insulin is used. You control when and at what rate your insulin is delivered.
Insulin pump therapy allows you to set a basal rate, or background insulin. This is delivered all throughout
the day and night for normal body function without food. When you exercise, you can reduce the basal
rate so that your blood glucose (BG) does not drop too low. When you are sick or have an infection, you
can increase the basal rate. This will keep your BG from going up too high.
Insulin pump therapy allows you to give a bolus, or dose of insulin on demand - when you eat. You can also
increase or decrease your meal bolus based on the foods you choose to eat. A bolus may also be used to
lower an elevated BG. This is called a correction bolus.
The Paradigm pump also contains an optional feature called the Bolus Wizard. This does the math for the
required bolus amount based on your personal settings. The Bolus Wizard will use your BG reading,
carbohydrate intake, and active insulin when coming up with your bolus amount.
Remember, the pump uses only fast-acting insulin. This means you will not need to follow as rigid a
schedule as you did before. There is no long-acting insulin telling you when you should eat or when you
will need more insulin.
Sound exciting? It is exciting because not only can you manage your blood glucose more easily, your
lifestyle can be easier too.
Introduction to pump therapy
13
Chapter 2

As long as you are ready to learn how to use the pump, the pump can work for you.
Understanding pump therapy
If you are new to pump therapy, you will need the following data from your healthcare professional.
Gather this before going to your pump start appointment. If you are unsure, contact your healthcare
professional or pump trainer for guidance.
Basal rate
Basal insulin is needed to maintain your target glucose values when you are not eating. Your pump allows
up to 48 basal rates to be programmed. Your healthcare professional may only have you program one or
two basal rates when you start pump therapy.
Meal bolus
Deliver a meal bolus before eating carbohydrates. Your insulin to carbohydrate ratio is the amount of
insulin required to cover a given number of carbohydrates or exchanges. This ratio gives you an idea of
how much of an insulin bolus you should take when eating carbohydrates.
Gram counting
1.0 unit of insulin for __________ grams of carbohydrate
Exchange counting
__________ units of insulin for each carbohydrate exchange
BG targets
The Bolus Wizard will use your BG targets to calculate a correction dose. Keeping your BG within target
range is key to living well with diabetes. Your healthcare professional should help you decide these
targets.
Introduction to pump therapy
14

Insulin sensitivity
Insulin sensitivity is used to decide a correction bolus for a high BG. This is how much your blood glucose
will be dropped with 1 unit of insulin.
1 unit of insulin will lower BG __________ mg/dL (mmol/L).
Active Insulin
Active insulin is the bolus insulin that has already been delivered to your body, but has not yet been used.
The pump considers your active insulin time setting in determining any active insulin still in your body
from prior boluses. This may help prevent hypoglycemia caused by over-correcting for high blood glucose.
Blood glucose and A1C testing
When you check your blood glucose with a meter, you measure blood glucose at the moment you perform
the test. This number gives you key feedback for making present and day-to-day adjustments in your
diabetes management. The A1C test, done at your doctor's, shows you your average blood glucose over the
last 60 to 90 days. Both blood glucose and A1C testing are necessary for good diabetes management.
BG testing
With any insulin therapy, you must monitor your blood glucose four to six times a day. With insulin pump
therapy, blood glucose testing gives you correct feedback. It also allows you to make prompt changes
based on the results. It alerts you to high blood glucose readings that need changing. It allows you to
adjust your insulin to carbohydrate ratio for certain foods. Your pump only uses fast-acting insulin; as a
result, you have no long-acting insulin as a back-up. Therefore, if your insulin delivery is disrupted on
pump therapy, your blood glucose can go dangerously high fairly fast. This can happen much faster than it
could when you were using daily injections with long-acting insulin. Blood glucose testing is needed to
alert you to high blood glucose so you can prevent diabetic ketoacidosis (DKA).
A1C
A1C testing also plays a key part in diabetes management. Sustained high BG levels can cause serious long-
term problems. These problems may be prevented and/or delayed if you maintain your blood glucose
levels close to normal. The best measure of your overall blood glucose is the A1C test. It has been proven
that an A1C level of 7.0 or less greatly reduces the risk of problems from diabetes. But, any reduction in
A1C is a plus. ADA Clinical Practice Recommendations state that your A1C should be tested at least every
three months by your healthcare professional.
Introduction to pump therapy
15
Chapter 2

Your healthcare professional will rely on the results of your blood glucose tests to make changes in your
pump settings. The results of your A1C tests are used to assess your overall blood glucose control.
If you are on pump therapy, you must test your BG at least:
•
Upon waking up
•
Before each meal
•
At bedtime
•
If you feel nauseous
•
One hour after any BG above 250 mg/dL (13.9 mmol/L)
Below are target guidelines from the American Diabetes Association for adults with diabetes. Consult your
healthcare professional to find out what your targets should be.
Summary of recommendations for adults with diabetes mellitus
Glycemic control A1C
<7.0 percent
Preprandial plasma glucose (before meals)
90-130 mg/dL (5.0-7.2 mmol/L)
Peak postprandial plasma glucose (1-2 hours after meals)
<180 mg/dL (<10.0 mmol/L)
Correlation between A1C level and blood glucose levels
Mean plasma glucose
A1C (percent)
mg/dL
mmol/L
6
135
7.5
7
170
9.5
8
205
11.5
9
240
13.5
10
275
15.5
11
310
17.5
Introduction to pump therapy
16

Correlation between A1C level and blood glucose levels
Mean plasma glucose
A1C (percent)
mg/dL
mmol/L
12
345
19.5
American Diabetes Association. Diabetes Care. “Tests of Glycemia in Diabetes.” &
“Standards of Medical Care.” Vol. 31, Supplement 1, January 2008. S18.
Low blood glucose (hypoglycemia)
Low blood glucose can occur while using the pump for the same reasons it can while using daily injections:
•
not enough food
•
too much insulin
•
more exercise than usual
•
drinking alcoholic beverages
As you know, you cannot always avoid low blood glucose. It is important that you create a routine to
follow when your BG is low. If you have a routine, you will have something ready to treat a low BG. This
makes it less likely you will over-treat and cause your blood glucose to go up too much.
It is best to use something that you can always carry with you. Choose a food that is all carbohydrate
because it will be fast acting. Avoid using high fat foods such as chocolate. They will not work fast enough,
and you may also end up over-treating your lows. When treating hypoglycemia, start with 15 grams of fast
acting carbohydrates. Do not keep eating until you feel better. Eat the required amount and stop. The
feelings will pass and you will be grateful that you did not overdo it.
Some people with diabetes know when their blood glucose is low and some do not. If you are not aware of
hypoglycemia, it is important to test your blood glucose more often. Everyone with diabetes should test
before driving a car to assure safety on the road. Blood glucose should be above 100 mg/dL (5.6 mmol/L)
before driving and at bedtime.
Tip: 
We suggest that you use glucose tablets to treat a low. These tablets contain a known, pre-
measured amount of carbohydrate, and are in handy packages that you can carry in your pocket, purse, or
car.
 
Introduction to pump therapy
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Chapter 2

Hypoglycemia protocol: the rule of 15
Check with your healthcare professional for guidelines on treating your low BG. The following instructions
are commonly used to treat a BG that is 70 mg/dL (3.9 mmol/L) or lower:
1
Eat 15 grams of fast acting carbohydrate.
2
Check BG again in 15 minutes; if not above 70 mg/dL (3.9 mmol/L), repeat treatment.
3
Check BG again in 15 minutes; if still not above 70 mg/dL (3.9 mmol/L), repeat treatment again.
4
Contact your healthcare professional if your BG is still not above 70 mg/dL (3.9 mmol/L).
Introduction to pump therapy
18

These items have 15 grams of fast acting carbohydrates:
•
Glucose tablets (three, 5-gram tablets or four, 4-gram tablets)
•
4 oz. of juice or soda (not diet)
•
6-7 Life Savers
®
 (hard candies)
•
1 tablespoon of table sugar or honey
High blood glucose (hyperglycemia)
High blood glucose can occur while using the pump for the same reasons it can while using daily injections:
•
Too much food
•
Not enough insulin
•
Loss of insulin strength
•
Disruption of insulin delivery from the pump
The goal of treating hyperglycemia is to prevent Diabetic Ketoacidosis (DKA) and delay or prevent diabetes
problems due to high blood glucose over a lengthy period of time.
If for any reason you are not getting the proper amount of insulin, your blood glucose rises quickly. This
can occur with insulin pump therapy from the disruption of insulin delivery. This happens from the infusion
set coming out, clogs, or leaks, or insulin not being absorbed right.
Since the pump only delivers fast-acting insulin, hyperglycemia can occur rapidly. Your healthcare
professional will give you data needed for you to determine your correction bolus. This correction dose is
based on your insulin sensitivity.
It is vital that you know these guidelines in the hyperglycemia protocol.
Hyperglycemia protocol
If one blood glucose reading is above 250 mg/dL (13.9 mmol/L):
•
Take a correction bolus right away.
•
Test BG in one hour.
Introduction to pump therapy
19
Chapter 2

If the second blood glucose is above 250 mg/dL (13.9 mmol/L):
•
Take an insulin injection by syringe (not through the pump). The amount should be the same as if you
were taking a correction bolus.
•
Change the entire infusion set system (new reservoir, infusion set, and cannula). Consider changing the
insulin vial if you believe that the insulin is no longer stable.
•
Check urine for ketones and call your healthcare professional if ketones are present.
•
Drink liquid with no calories every 30 minutes (for example: 8 oz. diet ginger ale, broth, water).
•
Test blood glucose every two hours and keep taking correction insulin until blood glucose reaches
target.
•
Call your healthcare professional if your blood glucose and urine ketones remain high or you are
unable to drink.
Treating hyperglycemia from illness or infection through insulin pump therapy will be discussed on the
following pages.
Diabetes ketoacidosis (DKA)
DKA results from untreated hyperglycemia. DKA is a serious medical problem that needs treatment right
away. The insulin pump therapy uses only fast-acting insulin, so DKA can occur rapidly if insulin delivery is
disrupted. It is important that you understand these guidelines.
Preventing DKA
If you have nausea or vomiting, immediately check your blood glucose and ketones. If your blood glucose is
above 250 mg/dL (13.9 mmol/L) and/or ketones are present:
•
Take an injection of fast-acting or regular-acting insulin with a syringe (not through the pump). The
amount should be the same as if you were taking a correction bolus. If ketones are present, more
insulin may be needed. Contact your healthcare professional for guidelines for insulin doses especially
when ketones are present.
•
Change the entire infusion set system (new reservoir, infusion set, and cannula). Consider changing the
insulin vial if you believe that the insulin is no longer stable.
•
Call your healthcare professional.
•
Troubleshoot the pump. If help is needed, please call our 24 Hour HelpLine for assistance.
•
Drink liquids with no calories every 30 minutes (for example: 8 oz. diet ginger ale, broth, water).
•
Check your blood glucose and ketones in one hour.
•
Continue to take insulin as discussed with your healthcare professional.
Introduction to pump therapy
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•
Call your healthcare professional right away if your blood glucose and ketones are not decreasing, or
you cannot drink fluids.
•
Continue to test blood glucose and ketones. Continue to take correction insulin injections as told until
your blood glucose reaches your target level.
•
If your blood glucose is less than 200 mg/dL (11.1 mmol/L) and ketones are present, drink liquids with
calories. Some examples of caloric fluids are juice and non-diet soda. Also, extra insulin may be
needed. Contact your healthcare professional for guidelines for insulin doses when ketones are
present.
Tip: 
You should have a meter, glucose strips, and ketones strips handy at all times. This way you are
always ready to test your blood glucose and ketones.
 
Sick day management
Managing diabetes during an illness or infection requires frequent blood glucose and urine
ketone testing. Illness and infection put extra stress on the body and often raise blood
glucose. The insulin pump allows you to make changes. It lets you quickly and easily
respond to blood glucose changes due to illness and infection.
Even if you are not able to eat, you need insulin. Depending on blood glucose testing, you
may or may not need to adjust your basal insulin to cover your needs. You may also need
to take frequent correction boluses during illness.
Sick day protocol
•
Test your blood glucose every two hours, 24 hours a day.
•
Check urine ketones every time you urinate.
•
If you are throwing up and/or have ketones, you must call your healthcare professional. They will give
you the proper treatment with fluids and insulin to avoid DKA.
•
Consult your healthcare professional about taking more insulin if your blood glucose is 250 mg/dL
(13.9 mmol/L) or higher. Also take more insulin when ketones are fair or large.
•
Keep exact records of your blood glucose values, ketones, medication, temperature and all other
signs.
•
Keep in mind that you need more insulin and fluids when there are urine ketones. This is true even if
your blood glucose is within your target range.
Introduction to pump therapy
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Chapter 2

Sick day supplies
You should have the supplies listed below in the house at all times, and carry them with you when you
travel:
•
Fluids that have sugar (regular soda, juice, jello) to replace solid food.
•
Sugar-free liquids (diet drinks, bouillon, water) for replacing lost fluids.
•
Thermometer.
•
Sugar free medicine for fever, cough, congestion, nausea and vomiting.
•
Extra blood glucose and ketone strips.
•
Glucagon emergency kit in case of severe hypoglycemia. This can be used if you cannot eat or are
unconscious.
Caring for your diabetes when you are sick is worthwhile and can be a challenge. If you are too sick to
watch your diabetes carefully, ask a friend or family member to help. If there is no one to help you, ask
your healthcare professional for help.
Nutrition
Good nutrition and making healthy choices are important for everyone. Additionally, for those with
diabetes, it is more important to know the nutrient content in food, and how the nutrients affect blood
glucose.
Carbohydrates have the most effect on blood glucose, notably within a few hours of being eaten. Counting
carbohydrates allows you to match your insulin dose to the food you are eating. This is your insulin to
carbohydrate ratio. Although fat and protein can affect your blood glucose when eaten in large amounts,
carbohydrates affect blood glucose the most.
Consult with your healthcare professional for your personal nutritional guidelines.
Carbohydrate counting
With insulin pump therapy, you must take a bolus for the carbohydrates you eat. You need to count the
carbohydrates you plan to eat to see how much insulin to take.
There are two basic methods to count carbohydrates, and in truth, they are very much alike. Many people
use parts of both of the two methods.
Introduction to pump therapy
22

Carbohydrate gram counting
With this method, you add up the exact number of grams of carbohydrate in each meal. Food labels, food
list and meal planning books are great tools for carbohydrate gram counting.
Carbohydrate exchange system
This method uses food groups called exchange groups. One exchange with carbohydrate has about 15
grams of carbohydrate.
1 bread exchange
1 fruit exchange
1 milk exchange
15 grams carbohydrate
15 grams carbohydrate
12 to 15 grams carbohydrate
Foods with carbohydrates include:
•
starches and starchy vegetables
•
fruits and fruit juices
•
milk and milk products
•
sugars and foods with sugar
Facts on the nutrition labels on packaged food will help you to figure how much carbohydrate is in a
certain food. There are a number of paperback books that list the grams of carbohydrates in many foods.
These books are very helpful when you are eating foods without labels or are eating out. Also, if you know
the exchange system, you can count carbohydrate exchanges.
Your healthcare professional will give you an insulin to carbohydrate ratio at the start. This will be a place
to begin. It may need to be changed based on the results of your blood glucose readings after you eat.
Determining your meal bolus based on carbohydrate counting is not an exact science. Sometimes it takes
trial and error to come up with the correct meal bolus for certain foods. If you are not sure how some
foods affect your blood glucose, test your blood glucose two hours after eating. If your reading is too high
or too low, adjust your meal bolus the next time you make that food choice.
As you start to learn carbohydrate counting, try to assess the carbohydrates in the food you are eating.
Then look at the food labels to see how close you are.
Reading a food label
Use the Serving Size and Total Carbohydrates information on the food label to determine how many total
grams of carbohydrate you will be eating. Then, use the insulin to carbohydrate ratio prescribed by your
healthcare professional. This allows you to figure out how much insulin to take for the foods you eat.
Introduction to pump therapy
23
Chapter 2

The following food label shows 12 grams of carbohydrates for each 1 piece serving. If your carbohydrate
ratio is 1 unit of insulin for every 12 grams of carbohydrate, you would need 1 unit of insulin for each 1
piece serving of this food.