Introduction To Pumping Starting And Success



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Introduction To Pumping Starting And Success

  • John Walsh, P.A., C.D.E. North County Endocrine 700 West El Norte Pkwy Escondido, CA 92126 (760) 743-1431 or The Diabetes Mall (619) 497-0900 jwalsh@diabetesnet.com


Highlights

  • Why Pump?

  • Who’s A Candidate?

  • Pump Basics

  • Brands And Features

  • Smart Pump Advantages

  • Infusion Sets

  • How To Start

  • Settings That Affect Control

  • Wrap Up



Origins

  • The first insulin pumps appeared in 1978 when large portable chemotherapy pumps were converted to deliver insulin

  • Autosyringe AS2C and Harvard Apparatus Mill Hill Infuser were early models

  • Used large 50 ml syringe that required users to dilute insulin to U-36 or U-18

  • Had only one basal rate and no memory



Reasons To Use A Pump



Better Control –> Fewer Complications



Poor Control Remains A Problem



Exposure Versus Variability



The Challenge Of Diabetes Bringing the A1c down smoothly takes effort



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, shiftwork

  • 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.



Poor control, high A1c, wide BG excursions

  • Poor control, high A1c, wide BG excursions

  • Nocturnal or frequent lows, hypo unawareness

  • Frequent hospitalization/DKA

  • Insulin sensitivity

  • Varied or intense exercise/activity

  • Dawn phenomenon, gastroparesis, pregnancy

  • Varied work or school schedule, travel

  • Insulin resistance, Type 2 diabetes



Who Is A Pump Candidate?



Candidate Requirements

  • Realistic expectations

  • Willing to monitor at least 4 times a day and keep records

  • Counts carbs or otherwise able to quantify food intake for meals

  • Willing to solve problems using diabetes management skills

  • Comes to clinic for follow up



Expectations



Benefits For Infants & Toddlers

  • Little ones are ideal pump candidates if parents are

  • Delay or split boluses for fussy eaters

  • Faster insulin adjustment for erratic activity

  • Precise dosing – 0.025 basal and 0.05 bolus – assists infants who cannot convey hypoglycemia Sxs and have frequent illnesses

  • Secure between shoulder blades and use lock out to avoid self dosing



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



Pump Basics



Terms

  • Basal –background insulin released slowly through the day

  • Bolus – a quick release of insulin

    • Carb bolus – covers carbs
    • Correction bolus – lowers high readings
  • Bolus On Board (BOB) – bolus insulin still active from recent boluses

  • TDD – total daily dose of insulin (all basals and boluses)



Basals And Boluses

  • A pump more easily matches the realities of daily life.



Basal: MDI versus Pump

  • Lantus or Levemir





Brands And Features



Insulin Pumps – 2007

  • Accu-Chek Spirit

  • Animas 2020

  • Deltec CozMore 1800

  • Insulet Omnipod

  • Medtronic Paradigm x22

  • Sooil Dana Diabecare IISG



Things To Consider In Choosing A Pump

  • Look, feel, color

  • Features: reminders, child block, waterproofing

  • Basal and bolus increments

  • Infusion set choices

  • Customer support

  • Access to history and ease of data downloads and analyses

  • Accessories: meter, covers, cases, PDA, smart phone



Accu-Chek Spirit

  • Boluses based on BG not on BOB

  • 300 units

  • 0.1 u basal & bolus increments

  • Reversible display

  • Side-mounted tactile buttons

  • Accu-Chek Pump Configuration Software

  • IR (direct line) control from optional Palm PDA or smartphone

  • Database of 1,000 Calorie King foods in PDA



Animas 2020

  • High contrast color screen for easy viewing

  • Smallest mainstream pump

  • Smallest basal rate increment – 0.025 u

  • Waterproof – 12 ft for 24 hrs

  • ezCarb meal bolus calculator

  • ezBG correction bolus calculator

  • ezBolus shortcut to give bolus



Deltec Cozmo

  • Most features:

    • HypoManager, Weekly Schedule, Missed Meal Bolus, Disconnect Bolus, Basal Test, Meal Maker with CozFoods, Therapy Effectiveness
  • Most flexible setup

  • Direct BG entry from attachable Freestyle meter

  • 300 units

  • 0.05 unit basal and bolus increments

  • Accurate bolus calculations

  • IR download

  • Best for blind or visually impaired



Insulet Omnipod

  • No tubing for easy wear

  • Automatic cannula insertion and priming

  • 200 units

  • Limited to 72-80 hrs use

  • Watertight

  • Controlled by PDM or smartphone

    • 1000 food database


Medtronic Paradigm

  • CGM displays BG, 3 hr trend, trend arrow, and advance warning of lows and highs

  • Considered least accurate CGM for detection of lows

  • Simple interface, less scrolling

  • BD meter transmits BG directly

  • Proprietary infusion sets

  • History of carbs, TDD, %basal, %carb, %correction

  • CareLink online software



Pump + Meter Or Continuous Monitor

  • With direct BG entry

    • Deltec Cozmo + Freestyle CoZmonitor
    • Omnipod + Freestyle
    • Paradigm + BD Logic
    • Dana Diabecare IISG
  • With continuous monitor display

    • Medtronic 5/722 + Paradigm RT
  • Planned continuous monitor displays

    • Abbott Navigator with Deltec Cozmo and Insulet Omnipod
    • Animas and Lifescan
    • AccuChek pump and monitor


CGM Benefits

  • Increased sense of security

  • Immediate feedback – look and learn

  • Improves control when used

  • Worth out of pocket cost for many

  • One unit available for about “a Starbucks a day”

  • Reimbursement gradually catching on



Look And Learn

  • Excess night basal or bedtime bolus

  • Breakfast bolus too small or too late

  • Lunch bolus too small or afternoon basal too low



Pump Advantages



Advantages Of A Smart Pump

  • Automatic carb and correction calculations based on:

    • Preprogrammed carb and correction factors
    • Glucose targets
    • Duration of insulin action to avoid insulin stacking
  • Easy to check history, basal/bolus balance, and correction bolus %

  • Direct glucose entry from meter or continuous monitor

  • Helpful reminders and alerts, weekly schedule, alternate basal profiles



Helps Prevent Lows

  • Better bolus accuracy with carb and correction factors

  • Less insulin stacking due to tracking BOB after boluses are given

  • A glucose test can reveal the current deficit – carb or insulin

  • Faster reduction in insulin level for exercise

  • Smaller pool of insulin under skin lessens risk of a large release in hot tub or weather

  • More predictable insulin action

  • Proper dosing is required!



Helpful Reminders

  • Reminders (alarms) to

    • test BG after a bolus
    • test BG after a low reading
    • test BG after a high reading
    • give a bolus at certain time or certain period of the day
    • warn when bolus delivery was not completed, etc.
    • change infusion site
    • warn of low reservoir (20, 10, 5 and 0 units with an extra 10 “hidden” units for use in basal delivery)


Infusion Sets



Infusion Sets

  • Five varieties:

    • Self-contained (Omnipod)
    • Slanted Teflon
    • Straight-in Teflon
    • Slanted metal
    • Straight-in metal
  • Three connections:

    • Luer lock pumps: ~ 25 varieties
    • Paradigm: ~ 4 varieties
    • Omnipod: 1, auto-inserted


Infusion Sets And Inserters Infusion set/site problems are a common cause for unexplained highs



Use Sterile Technique For Site Prep

  • 30% of people are constant staph carriers and 25% are intermittent. MRSA is now common. Prevent infections:

    • Wash hands
    • Sterilize skin with IV Prep
    • Place bio-occlusive IV3000 over site
    • Insert infusion set through IV 3000
    • Steps for staph carriers:
    • Use antiseptic soap all over body once every 1-2 weeks
    • Occasionally, apply bacitracin ointment to inside of nose


Tape The Tubing!!!

  • One inch tape over the infusion line stops tugging

    • Tape stops tunnelling – movement of teflon nder skin allows insulin to tunnel to the surface, causing unexplained highs
    • Less skin irritation from movement
    • Prevents pull outs
  • At tug time, lose tape not insulin!



Pump Start



Prepare For Pump Start

  • Use basal/bolus approach first with injections

  • Use accurate carb counts

  • Read Pumping Insulin and pump manual

  • Practice with your pump as soon as it arrives

  • View CD/DVD as you practice with your pump

  • Get training in pump operation and troubleshooting



Preparation

  • Ask how to discontinue your long-acting insulin

  • Determine start-up settings for TDD, basal/bolus balance, carb and correction factors, and DIA

  • Get prescriptions for insulin, test strips, IV Prep, IV 3000 dressings, etc.

  • Have contacts for MD, CDE, pump company, pump rep, other pumpers



Steps To Success

  • Test often

  • Keep great records (Smart Charts, download, etc)

  • Take a bolus for every bite

    • except when carbs are used to raise a low BG
    • or when eating to compensate for exercise
  • Take boluses early

  • Write down a reason for every high and low

  • Change infusion site on schedule and whenever unexpected highs occur



Steps To Control

  • Stop lows first

  • Set a realistic DIA

  • Determine an optimum TDD

  • Set and test basals

  • Determine starting carb factor with 450 Rule (450/TDD) and correction factor with 2000 Rule (2000/TDD)

  • Periodically check basal/bolus balance

  • Look for and correct unwanted patterns



Stop Lows First Better control and more stability

  • Mild lows cause followup lows

  • Small epinephrine release makes muscles sensitive to insulin

  • Can lead to another low as much as 36 hours after the first

  • More carbs than usual are needed



Find Your Optimum Doses!

  • Start with an accurate TDD –

  • 1. How much total insulin do you average a day?

  • 2. Adjust the TDD – are highs or lows primary problem?

  • Stay in basal/bolus balance – 50/50 or 45-65% as basal

  • Use the 500 and 2000 Rules to estimate starting carb and correction factors

  • Then adjust your basal and bolus doses

    • TEST your blood glucose
    • LOOK for blood sugar patterns
    • ADJUST basals and boluses from your patterns


Find Basals And Boluses From Starting TDD



Duration Of Insulin Action (DIA) Time

  • An accurate DIA time is critical to success on a smart pump

  • Current research suggests that DIA times are NOT different between children and adults

    • Shorter for those more sensitive to insulin, but NOT children in general
  • But immediate factors can affect insulin action time:

    • Shorter with activity and exercise
    • Shorter in hot weather
    • Longer with fat in diet


DIA Tips

  • If your pump often suggests boluses that you know are not enough, do not shorten your DIA– it is usually NOT the problem

  • Instead, ask what is causing the highs and where more insulin is needed – in basal rates, in carb boluses, or both

  • Exercise or activity can mobilize insulin faster but DO NOT shorten the DIA for occasional activity. Instead:

      • lower boluses or basals ahead of time for planned activities
      • or eat more carbs or lower basals for unplanned activities
  • A low basal rate makes the DIA appear SHORT!



Bolus Size (Relative To Wt) Affects The DIA Measured as units per kg(2.2 lb)

  • Larger boluses have a longer duration of action.

  • For 50 kg (110 lb) person:

    • 0.3 u/kg = 15 u
    • 15 u/kg = 7.5 u
    • 0.075 u/kg = 3.75 u


Recommendations For DIA Times

  • DIAs on current pumps can be set from 2 to 8 hours. An inaccurate DIA can significantly impact control.



When Major Control Problems Occur

  • Adjust your TDD

    • Determine the current TDD
    • Lower it:
      • For frequent lows
      • If both highs AND lows occur – which comes first?
    • Raise it:
      • For a high A1c or a high average BG on your meter
    • While keeping basal rates and the daily carb bolus total balanced


Adjust The TDD For A High Avg. BG or A1c Example: someone with a TDD of 35 units and few lows. A1c = 9%, so more insulin is needed: about 3.2 units.



Change Your TDD For

  • A change in diet

  • A loss or gain in weight

  • Seasonal changes

  • An overall change in activity

  • Starting/stopping a sport

  • Vacation

  • Growth or start of puberty

  • Menses



Look For Patterns

  • Frequent highs

  • Frequent lows

  • High at B/L/D/Bed

  • Low at B/L/D/Bed

  • Low to high

  • High to low



Basal/Bolus Balance



Basal Rates Should keep the blood sugar flat overnight or when a meal is skipped Relatively easy to test



Set & Test Basals First



How Many Basal Rates?

  • Percentage of pumpers who use 1 to 10 basals per day from self reports of several hundred pumpers at insulin-pumpers.org





Test Carb And Correction Factors After Basals



Glycemic Index: Different Carbs Have Different Speeds



Duration Of Carb Action

  • Most carbs have most of their affect within 1 to 2.5 hours

  • But delay can occur with complex carbs, more fat content, etc



Carb Counting

  • Accounts for half the day’s control

  • Accuracy allows boluses to match carbs for post-meal control and a significantly lower A1c

  • Made easier with automatic carb bolus calculations by pump



Pump As Carb Counter

  • Pump or external controller contains user-selected food list for accurate carb counting

  • Easy carb calculation

  • More accurate boluses

  • Available in Animas 2020, Deltec Cozmo, PDM for Omnipod, and PDA for Spirit



Carb Factor

  • Carb factor – how many grams of carb are covered by 1 unit

  • Carb bolus is based on:

    • Your carb factor
    • How many grams of carbs you plan to eat
    • Your BG allows a correction bolus determination
    • Amount of BOB still active (ALSO determined from BG!)
  • A pump can determine the bolus needed for a meal when the carb count and the carb factor are accurate

  • Visit your dietician to learn!



Check Your Carb Boluses

  • Does your carb factor work for LARGE meals? – half your weight (lbs) as grams of carb

  • Are carb counts accurate?

  • Are boluses given 20 min before meals when the glucose is normal?



An Accurate Carb Factor

  • Returns the blood sugar:

    • to within 30 mg/dl (1.7 mmol) of where it started
    • by the time selected for your duration of insulion action (DIA)
    • with no lows within 5 hours after carb bolus given


Carb Bolus Varieties

  • Normal carb bolus

    • Bolus taken immediately – most meals
  • Extended or square wave bolus

    • Bolus extended over time – gastroparesis
  • Combo or dual wave bolus

    • Some now, some later – bean burrito, some pastas and pizzas, Symlin


Most Carbs Much Faster Than “Rapid” Insulin



Importance Of Bolus Timing

  • Figure shows rapid insulin injected 0 min, 30 min, and 60 minutes before a meal

  • Normal glucose and insulin profiles are shown in the shaded areas



Bolus Timing Depends On Glucose



Missed Boluses Cause High A1cs

  • Start well– give a bolus for every bite!

  • Use pump reminders or other reminder

  • Review pump history once a week and work toward increasing the number of boluses

  • Work toward solutions without blame



Correction Factor

  • Correction Factor – how many mg/dl (or mmol) the BG falls per unit of insulin

  • Lets a smart pump determine the bolus needed to bring a high blood sugar to target

  • Test to ensure accuracy – Does a correction bolus lower a high glucose safely to your target in 4-5 hrs?



When BG Goes High, Keep All Culprits In Mind

  • Bad infusion set or site

  • Bad insulin

  • Inaccurate carb counts

  • Rebound from stress hormones

  • Empty refrigerator syndrome

  • Hypobolusemia

  • Stress

  • Pain



Bottom Line

  • If you don’t have great control on a smart pump, your pump settings are likely off.



Where Next?

  • Faster insulins – Biodel Viaject

  • Can the loop be totally closed?

  • Dual delivery pumps



Wrap Up

  • Pumps offer the latest technology for precise insulin delivery

  • Benefits include more flexibility, less hypoglycemia, less glucose exposure and variability, and a healthier life

  • Requires commitment & responsibility

  • Training and follow-up is required to ensure safe and effective treatment

  • Make the commitment to health. Start pumping!



Questions And Discussion




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