powerpoint presentation - starting on an insulin pump, april 2007

Healthcare Across Borders - September 2003

Introduction To PumpingIntroduction To PumpingStarting And SuccessStarting And Success

John Walsh, P.A., C.D.E.John Walsh, P.A., C.D.E.North County Endocrine North County Endocrine 700 West El Norte Pkwy 700 West El Norte Pkwy

Escondido, CA 92126Escondido, CA 92126 (760) 743-1431 (760) 743-1431

or The Diabetes Mall or The Diabetes Mall (619) 497-0900 (619) 497-0900

[email protected]@diabetesnet.com

Children With Diabetes Children With Diabetes Toronto, August 17, 2007Toronto, August 17, 2007


HighlightsWhy 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

1976 Biostator (top) and 1978 Autosyringe AS2C –>


Reasons To Use A Pump


Better Control –> Fewer Complications

•55.0

29.8

•23.9

•5.1

•13.413.07.9

16.4

5.02.50

10

20

30

40

50

60

RetinopathyProgression1

Laser Rx1 Micro-albuminuria2

Albuminuria2 ClinicalNeuropathy3

ConventionalIntensive

76%76%Risk ReductionRisk Reduction





Cum

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ive

Inci

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e (%

)

1. DCCT Research Group, Ophthalmology. 1995;102:647-6612. DCCT Research Group, Kidney Int. 1995;47:1703-17203. DCCT Research Group. Ann Intern Med. 1995;122:561-568.


Poor Control Remains A Problem HbA1c

10%

9%

8%

7%

6%

ADAEASD/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%


Exposure Versus Variability

40

60

80

100

120

140

160

180

200

220

240

260

280

300

320

340

360

380

400

2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM 10:00PM

11:00 PM 12:00AM

1:00 AM 2:00 AM 3:00 AM 4:00 AM 5:00 AM 6:00 AM 7:00 AM 8:00 AM 9:00 AM 10:00AM

11:00AM

12:00PM

1:00 PM 2:00 PM

glucose (mg/dl)

One day’s tests every 30-60 min with usual meals and insulin. The DCCT proved that exposure to high blood glucose was

damaging. New emphasis is on glucose variability.

Exposure or Average =

Variability or Swing =

A1c or avg. BG from meter

Standard deviation or GlycoMark test


The Challenge Of DiabetesBringing the A1c down smoothly takes effort

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

100 (5.5)

200 (11.1)

300 (16.7)

Normal A1C 4%–6%

BG in

mg/

dL (

mm

ol)

0800 1200 1800 0800

Uncontrolled A1C ~9%

A1C ~6%

“Controlled” A1C <7%

Time of Day


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

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

Why Physicians Recommend Pumps


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

Unrealistic Realistic

The pump will cure my diabetes I will feel better

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


Benefits For Infants & Toddlers

Little ones are ideal pump candidates if parents areDelay or split boluses for fussy eatersFaster 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

Back Buddy

http://www.diabetesnet.com/ishop/product_info.php?products_id=682


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.

bolus

basal


Basal: MDI versus Pump

Lantus or Levemir

PumpPump

2:00 16:00 20:00 24:00 7:0012:007:00

Time

Basal insulin delivery from a pump provides a better and faster match for life’s needs


4

5

6

7

8

9

10

11

12

0 2 4 6 8 10 12 14SMBG Frequency (BG per day)

HbA1c

HbA1c=5.99+5.32 / (BGpd+1.39)

Atlanta Diabetes Associates study:378 patients sorted from a database of 591 Pumps=MM 511 or earlierBG Target=100C peptide <0.1

More Testing –> Lower A1cData From 378 People On Pumps

ADA:< 7%% AACE:

< 6.5%

P. Davidson et al: Diabetes 53 (suppl 2): abstract 430-P, 2004


Brands And Features


Insulin Pumps – 2007

Pump info at www.diabetesnet.com/diabetes_technology/

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

Current Feature

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 factorsLess insulin stacking due to tracking

BOB after boluses are givenA glucose test can reveal the current

deficit – carb or insulinFaster reduction in insulin level for exerciseSmaller pool of insulin under skin lessens

risk of a large release in hot tub or weatherMore 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 SetsFive 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

A reliable and comfortable infusion set is critical to success on a pump.


Infusion Sets And InsertersInfusion set/site problems are a common cause

for unexplained highs

Smith’s Medical CleoSmith’s Medical Cleo

Medtronic Sil-serterMedtronic Sil-serter

Disetronic Rapid-DDisetronic Rapid-D

Animas InsetAnimas Inset Quik-serterQuik-serter


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!

Photo courtesy of [email protected]


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 andtroubleshooting


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 FirstBetter control and more stability

Mild lows cause followup lows Small epinephrine release makes

muscles sensitive to insulinCan lead to another low as much

as 36 hours after the firstMore carbs than usual are needed

Severe lows cause highsHigher stress hormone release

makes glucose rise for 6-10 hrsExcess carb intake leads to highs Boluses may be reduced/skippedMore insulin than usual needed

To stop lows, lower the TDD!!!


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 basalUse the 500 and 2000 Rules to estimate starting carb and

correction factorsThen adjust your basal and bolus doses

TEST your blood glucoseLOOK for blood sugar patternsADJUST basals and boluses from your patterns


20 u 0.42 u/h 25 grams 100 mg/dl

25 u 0.52 u/h 20 grams 80 mg/dl

30 u 0.63 u/h 17 grams 67 mg/dl

35 u 0.73 u/h 14 grams 57 mg/dl

40 u 0.83 u/h 13 grams 50 mg/dl

50 u 1.04 u/h 10 grams 40 mg/dl

60 u 1.25 u/h 8 grams 33 mg/dl

Find Basals And Boluses From Starting TDD

Starting Carb Factor Corr. Factor TDD 50% Basal 500 Rule 200 Rule

An accurate TDD solves most control problems!

3.1 mmol


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 DIAMeasured 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 u15 u/kg = 7.5 u0.075 u/kg = 3.75 u

Becker et al. Diabetes. 2005; 54 (Suppl. 1): 1367P

4 hrs

How long a bolus will lower the BG:


Recommendations For DIA Times

Mudaliar et al: Diabetes Care, 22: 1501, 1999

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 TDD1. Determine the current TDD2. Lower it:

• For frequent lows• If both highs AND lows occur

– which comes first?3. Raise it:

• For a high A1c or a high average BG on your meter4. While keeping basal rates and the daily carb bolus total

balanced

TDD too low or too high?


Adjust The TDD For A High Avg. BG or A1cExample: someone with a TDD of 35 units and few lows.

A1c = 9%, so more insulin is needed: about 3.2 units.

© Pumping Insulin, 2006© Pumping Insulin, 2006


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

Check Insulin Use• Similar TDDs day to day• Basal/Bolus balance• Correction bolus %


Basal/Bolus Balance

< 50% Basal ~ 50% Basal > 50% Basal

Duration < 5 yrs ThinPhysically activeHigh carb/low fat diet

Most people Duration > 5 yrsPubertyLess activeInsulin resistantLow carb diet


Basal Rates

Should keep the blood sugar flat overnight or when a meal is skipped

Relatively easy to test

See See Pumping InsulinPumping Insulin for detailsfor details


Set & Test Basals First

40 - 65%Basal

Pre-Pump TDD

More Accurate TDD(55-95% of Pre-Pump Dose)

30 - 55%Bolus

In reducing TDD, take into account A1c, history of highs or lows

50% basal is a good place to start for adults and many children

Test Basal Rates First



How Many Basal Rates?

0

5

10

15

20

25

Number of Basals

1 2 3 4 5 6 7 8 9 10

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

%

One basal rate may work in children, while the complex metabolism of puberty often requires multiple rates


Basal Tips

• 50% Rule: basals usually make up 40 to 65% of an accurate TDD

• Basal rates will be similar through the day, such as between 0.45 and 0.7, or between 1.0 and 1.4

• Adjust basal rate in small steps – 0.05 to 0.1 u/hr

• Change basals 3 to 8 hours before need arises


Test Carb And Correction Factors After Basals

Test Basal Rates First

2000 / TDD =Correction Factor

Then Test Carb & Correction Factors

450 / TDD =Carb Factor



Glycemic Index: Different Carbs Have Different Speeds

From Gary Scheiner, MS, CDEFrom Gary Scheiner, MS, CDE

FastBreads/Crackers

Salty SnacksPotatoes

RiceCereals

Sugary Candies

SlowPasta

LegumesSalad Veggies

DairyChocolate

AverageFruitJuicePizzaSoupCake


Duration Of Carb Action

Most carbs have most of their affect within 1 to 2.5 hoursBut delay can occur with complex carbs, more fat content, etc

0 hrs 1 hr 2 hrs 3 hrs 4 hrs

High GIMed GILow GI


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 FactorCarb 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?

For frequent lows after meals –> raise carb factor #

For frequent highs after meals –> lower carb factor #


Carb Bolus Varieties

Normal carb bolusBolus taken immediately – most meals

Extended or square wave bolusBolus extended over time – gastroparesis

Combo or dual wave bolusSome now, some later – bean burrito,

some pastas and pizzas, Symlin


Most Carbs Much Faster Than “Rapid” Insulin

% bolus activity remaining

From From Pumping InsulinPumping Insulin

Take Home: Bolus 15 to 30 minutes before meals Use extended and boluses sparingly.

Time over which most meals affect the BG

One hour after a meal, half of a meal’s glucose rise has occurred, but 80% of rapid insulin activity remains


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

Premeal BG Bolus Timing

Low Use fast carbs, check BOB, and give carb bolus at start of meal

Normal Bolus 15 to 20 minutes before meal

High Give carb bolus and correction boluses early but don’t forget to eat!

Check blood sugar 2 hours later to verify dose


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

8.38.48.58.68.78.88.9

99.19.29.39.4

Before 6 mos

Control+Rmindr

48 youth in poor control (A1c > 8%). All put on a Deltec Cozmo pump, with half using reminders. Significant reduction for reminder at 3 mos but no difference after 6 mos.

H. Peter Chase et al: Diabetes Care 29:1012-1015, 2006


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

BG


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

http://www.diabetesnet.com/ishop/product_info.php?products_id=691

powerpoint presentation - starting on an insulin pump, april 2007

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