should this patient be on insulin pump tuan quach staff specialist john hunter hospital
TRANSCRIPT
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Should this patient be on insulin pump
Tuan Quach
Staff Specialist
John Hunter Hospital
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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
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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
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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
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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
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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
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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.
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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
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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%
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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
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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
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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%
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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
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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
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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
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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
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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)
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Causes of high BGL in early AM
• Lantus running out
• Eating too much late at night
• Dawn phenomena
• Somogyi’s effect
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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
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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.
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Novorapid
Time
06001200 1800 2400
1.5unit/hr
1.2unit/hr0.6unit/hr
Basal rate can be programmed to over come the Dawn’ phenomena
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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
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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
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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
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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
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Keys to have successful insulin pump patients
• Patient selection
• Education process: before and after
• Supports/ Follow up
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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
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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
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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
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Contraindication
• Absolute:– Severe psychiatric illness– Severe progressive proliferative retinopathy
• Relative contraindication– Not monitoring– Poor basic diabetes education
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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
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Pump team
• Educator
• Dietitian
• Endocrinologist
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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
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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
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Insulin pump and resources
• Insulin pump treatment is costly
• Insulin pump takes up significant resources
• Shortage of educator with pump expertise
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Thank you