insulin pump therapy gary scheiner ms, cde integrated diabetes services 333 e. lancaster ave., suite...
TRANSCRIPT
Insulin Pump Therapy Insulin Pump Therapy
Gary Scheiner MS, CDEGary Scheiner MS, CDEIntegrated Diabetes ServicesIntegrated Diabetes Services
333 E. Lancaster Ave., Suite 204333 E. Lancaster Ave., Suite 204Wynnewood, PA 19096Wynnewood, PA 19096
(877) 735-3648(877) [email protected]@integrateddiabetes.comwww.integrateddiabetes.comwww.integrateddiabetes.com
101
Insulin Pump Therapy 101Insulin Pump Therapy 101
How Pumps WorkHow Pumps Work Pros & ConsPros & Cons Strategies for SuccessStrategies for Success Q & AQ & A
What A Pump ISWhat A Pump IS
Beeper-sized, Beeper-sized, battery-operated.battery-operated.
A way of giving A way of giving insulin.insulin.
Worn externally.Worn externally.
Programmable for Programmable for individual needs.individual needs.
Pump EvolutionPump Evolution
1970s1970s
Pump EvolutionPump Evolution
1970s1970s
Pump EvolutionPump Evolution
1970s1970s 1980s1980s
Pump EvolutionPump Evolution
Modern Day Insulin PumpsModern Day Insulin Pumps
Insulin Used In PumpsInsulin Used In Pumps
Rapid-Acting Analogs are PreferredRapid-Acting Analogs are Preferred Aspart (Novolog)Aspart (Novolog) Lispro (HumalogLispro (Humalog Glulisine (Apidra)Glulisine (Apidra)
Modes of DeliveryModes of Delivery BasalBasal BolusBolus
Basal InsulinBasal Insulin
Steady “Drip” of InsulinSteady “Drip” of Insulin Matches Glucose Released by LiverMatches Glucose Released by Liver Meets Body’s Basic Energy NeedsMeets Body’s Basic Energy Needs May Need Different Settings at Different Times of DayMay Need Different Settings at Different Times of Day
00.20.40.60.8
11.21.41.61.8
2
12
:00
AM
3:0
0 A
M
6:0
0 A
M
9:0
0 A
M
12
:00
PM
3:0
0 P
M
6:0
0 P
M
9:0
0 P
M
12
:00
AM
Units perhour
Bolus InsulinBolus Insulin
Given to “cover” carbs in meals and snacks.Given to “cover” carbs in meals and snacks.
Used to “correct” high blood glucose levels Used to “correct” high blood glucose levels
12
:00
AM
1:0
0 A
M
2:0
0 A
M
3:0
0 A
M
4:0
0 A
M
5:0
0 A
M
6:0
0 A
M
7:0
0 A
M
8:0
0 A
M
9:0
0 A
M
10
:00
AM
11
:00
AM
12
:00
PM
1:0
0 P
M
2:0
0 P
M
3:0
0 P
M
4:0
0 P
M
5:0
0 P
M
6:0
0 P
M
7:0
0 P
M
8:0
0 P
M
9:0
0 P
M
10
:00
PM
11
:00
PM
12
:00
AM
Insulin Infusion(aka “getting under your skin”)Insulin Infusion(aka “getting under your skin”)
Durable, clog-resistant tubing carries insulin from the pump to Durable, clog-resistant tubing carries insulin from the pump to the infusion set the infusion set**..
The infusion set delivers insulin into the fatty layer below the The infusion set delivers insulin into the fatty layer below the skin.skin.
Set uses either a flexible plastic catheter (canula) or a steel Set uses either a flexible plastic catheter (canula) or a steel needle.needle.
Almost always disconnectable near the infusion site.Almost always disconnectable near the infusion site.
* OmniPod does not have tubing; * OmniPod does not have tubing; it attaches directly to the skin. it attaches directly to the skin.
Infusion Set TypesInfusion Set Types
Infusion sets vary by:Infusion sets vary by: Angle of insertionAngle of insertion Canula lengthCanula length Plastic vs. steelPlastic vs. steel Tubing lengthTubing length
Infusion Set InsertionInfusion Set Insertion
Soft plastic canula inserted by way of an Soft plastic canula inserted by way of an introducer needle.introducer needle.
Mechanical “inserters” are available for some Mechanical “inserters” are available for some types of insusion sets.types of insusion sets.
Clinical Advantages of Pump TherapyClinical Advantages of Pump Therapy
Reduction in HbA1cReduction in HbA1c11
Less BG VariabilityLess BG Variability22
Reduction in duration, Reduction in duration, frequency and severity of frequency and severity of hypoglycemiahypoglycemia33
Better psychosocial Better psychosocial outcomes & quality of lifeoutcomes & quality of life44
Clinical Advantages of Pump TherapyClinical Advantages of Pump Therapy
11 Bode et al; Diabetes Care 1996; 19:324-7Bode et al; Diabetes Care 1996; 19:324-7Weinzimmer et al; Pediatrics 2004; 114: 1601-5Weinzimmer et al; Pediatrics 2004; 114: 1601-55 Nations Trial; Diabetologia 2004; 47 (1): #825 Nations Trial; Diabetologia 2004; 47 (1): #82DeVries et al; Diabetes Care 2002; 25:2074-80DeVries et al; Diabetes Care 2002; 25:2074-80
22 DeVries et al. Diabetes Care. 2002 Nov; 25(11):2074–80Diabetes Nutr Metab. 2004 Apr;17(2):84-9N. Weintraub et al: Arch Pediatr Adolesc Med. 158: 677-684,
2004
33 Hissa et al; Endocrine Practice 2002: 8; 411-416Hissa et al; Endocrine Practice 2002: 8; 411-416DeVries et al. Diabetes Care. 2002 Nov; 25(11):2074–80.Rudolph and Hirsh; Endocrine Practice 2002: 8; 401-405Rudolph and Hirsh; Endocrine Practice 2002: 8; 401-405Siegel et al; Diabetes Care 2004; 27: 3022-3.Siegel et al; Diabetes Care 2004; 27: 3022-3.5 Nations Trial; Diabetologia 2004; 47 (1): #825 Nations Trial; Diabetologia 2004; 47 (1): #82
4 4 Peyrot and Rubin; Diabetes Care 2005; 28: 53-58Peyrot and Rubin; Diabetes Care 2005; 28: 53-58McMahon et al; DiabeticMedicine 2005; 22:92-96McMahon et al; DiabeticMedicine 2005; 22:92-96Bruttomesso et al 2002; 19:628-634Bruttomesso et al 2002; 19:628-634Shapiro, 1984; Skyler, 1982Shapiro, 1984; Skyler, 1982
ReferencesReferences
Practical Benefits: Pump Basal Aspects Practical Benefits: Pump Basal Aspects
Avg. Basal Needs
12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am
Pump Basal Delivery
12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am
NPH (nighttime only)
12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am
NPH (morning and night)
12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am
Lantus or Levemir
12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am
Practical Benefits: Pump Basal Aspects Practical Benefits: Pump Basal Aspects
Avg. Basal Needs
12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am
NPH (nighttime only)
12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am
Potential Problems:Potential Problems:
Too much in middle of Too much in middle of the night?the night?
Too little late in the Too little late in the day?day?
General InconsistencyGeneral Inconsistency
Practical Benefits: Pump Basal Aspects Practical Benefits: Pump Basal Aspects
Avg. Basal Needs
12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am
NPH (morning and night)
12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am
Potential Problems:Potential Problems:
Too much in middle of Too much in middle of the night?the night?
Midday peak requires Midday peak requires consistent mealtimesconsistent mealtimes
Poor coverage of Poor coverage of post-lunch peakpost-lunch peak
General InconsistencyGeneral Inconsistency
Practical Benefits: Pump Basal Aspects Practical Benefits: Pump Basal Aspects
Avg. Basal Needs
12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am
Lantus or Levemir
12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am
Potential Problems:Potential Problems:
Failure to offset dawn Failure to offset dawn phenomenonphenomenon
Too much in middle of Too much in middle of the day?the day?
1 shot May not last full 1 shot May not last full 24 hrs24 hrs
Practical Benefits: Pump Basal Aspects Practical Benefits: Pump Basal Aspects
Avg. Basal Needs
12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am
Pump Basal Delivery
12am 3am 6am 9am 12pm 3pm 6pm 9pm 12am
Basal insulin can be Basal insulin can be matched to the body’s matched to the body’s daily needs.daily needs.
Practical Benefits of Pump Basal Delivery:Practical Benefits of Pump Basal Delivery:
Stable BG between meals & overnight
Can skip/delay meals without dropping
Can vary sleep & work schedules
Fewer issues with travel/time zone changes
Can correct for dawn effect
No long-acting insulins (more consistent insulin action)
Immediate, temporary basal adjustments possible
Practical Benefits of Bolusing with a PumpPractical Benefits of Bolusing with a Pump
Can dose very precisely (.1 or .05 units)
Convenient to give insulin anytime, anywhere
“Unused Insulin” adjustment prevents stacking of boluses
Rate of delivery can be extended
Insulin delivery history stored in pump
One needle stick every 3 days (approx)
Built-in bolus calculator
Estimate DetailsEst total:
Food intake:
BG:
Food:
Correction:
Active ins:
ACT to proceed
ESC to back up
Automatically calculates insulin bolus requirement
for the patient7.0 U
200 (11.1)
60 gr
2.0 U
ICR 1:10 gram
200 (11.1) – 100 5.5 = 2.0 units 50 (2.8)
6.0 U
1.0 U
Bolus Calculator: ExampleBolus Calculator: Example
Active insulin is subtracted from the correction
What A Pump Is NOTWhat A Pump Is NOT
A cure for A cure for diabetes.diabetes.
A substitute for A substitute for blood glucose blood glucose monitoring & carb monitoring & carb counting.counting.
As effective as a As effective as a healthy pancreas.healthy pancreas.
Potential Drawbacks to Pump TherapyPotential Drawbacks to Pump Therapy
Cost
Learning Curve
Extra Testing
Risk of Ketosis & DKA
Weight Gain Potential
Skin Irritation
Inconvenience
Time/Discomfort of Set Changes
Teaching & Follow-Up Required
What Makes A Good Pump Candidate?What Makes A Good Pump Candidate?
ResponsibleResponsible Pre-Pregnancy Pre-Pregnancy Irregular ScheduleIrregular Schedule Endurance Athletes Endurance Athletes Existing ComplicationsExisting Complications Difficulty w/BG ControlDifficulty w/BG Control Frequent or Severe LowsFrequent or Severe Lows Insulin-Dependent (1 or 2)Insulin-Dependent (1 or 2) Hypoglycemic Unawareness Hypoglycemic Unawareness Sensitivity to Small Insulin Doses Sensitivity to Small Insulin Doses Possess Proper Self-Management SkillsPossess Proper Self-Management Skills Adequate Insurance or Financial ResourcesAdequate Insurance or Financial Resources
Strategies for Success: Strategies for Success: Pre-Pump EducationPre-Pump EducationStrategies for Success: Strategies for Success: Pre-Pump EducationPre-Pump Education
BG monitoring 4+ times/dayBG monitoring 4+ times/day
Detailed Record KeepingDetailed Record Keeping
Carbohydrate Gram CountingCarbohydrate Gram Counting
Self-Adjustment of InsulinSelf-Adjustment of Insulin
Principles of Basal/Bolus TherapyPrinciples of Basal/Bolus Therapy
Strategies for Success: Strategies for Success: Post-Pump ManagementPost-Pump ManagementStrategies for Success: Strategies for Success: Post-Pump ManagementPost-Pump Management
Frequent communication w/health care teamFrequent communication w/health care team
Basal TestingBasal Testing
Bolus/Correction dose fine-tuningBolus/Correction dose fine-tuning
Activity adjustmentsActivity adjustments
Application of advanced pump featuresApplication of advanced pump features
Persistent self-care (don’t miss boluses!)Persistent self-care (don’t miss boluses!)
Effective troubleshooting, prevention of DKAEffective troubleshooting, prevention of DKA
Strategies for Success: Strategies for Success: DKA PreventionDKA PreventionStrategies for Success: Strategies for Success: DKA PreventionDKA Prevention
Unexplained High Blood Sugar
Check for Ketones
Ketones Ketones Negative Positive
Bolus w/Pump BS Doesn’t Drop 1. Shot w/Syringe
BS Drops 2. Drink Water 3. Change Out Pump
O.K.
Strategies for Success: Strategies for Success: Pump Selection CriteriaPump Selection CriteriaStrategies for Success: Strategies for Success: Pump Selection CriteriaPump Selection Criteria
Insulin Reservoir VolumeInsulin Reservoir Volume
Screen ReadabilityScreen Readability
Bolus Maximums & IncrementsBolus Maximums & Increments
Bolus Calculator FlexibiltyBolus Calculator Flexibilty
Alarm DistinctionAlarm Distinction
Water-TightnessWater-Tightness
Strategies for Success: Strategies for Success: Pump Selection CriteriaPump Selection CriteriaStrategies for Success: Strategies for Success: Pump Selection CriteriaPump Selection Criteria
Link w/Meter or CGMLink w/Meter or CGM
Convenience Factors Convenience Factors (tubing, clip)(tubing, clip)
Infusion Set OptionsInfusion Set Options
AestheticsAesthetics
Out-Of-Pocket CostsOut-Of-Pocket Costs
Strategies for Success: Strategies for Success: Infusion Set Selection/UseInfusion Set Selection/UseStrategies for Success: Strategies for Success: Infusion Set Selection/UseInfusion Set Selection/Use
Appropriate depth for body typeAppropriate depth for body type
Correct priming amountCorrect priming amount
Site preparation techniqueSite preparation technique
Frequency of change-outs Frequency of change-outs 3 days 3 days
Proper site rotationProper site rotation
Think Like A Pancreas!Think Like A Pancreas!