Insulin Pump Therapy
Gary Scheiner MS, CDE
Integrated Diabetes Services
333 E. Lancaster Ave., Suite 204
Wynnewood, PA 19096
(877) 735-3648
Gary@integrateddiabetes.com
www.integrateddiabetes.com
101
Insulin Pump Therapy 101
 How
Pumps Work
 Pros & Cons
 Strategies for Success
Q & A
What A Pump IS

Beeper-sized,
battery-operated.

A way of giving
insulin.

Worn externally.

Programmable for
individual needs.
Pump Evolution
1970s
Pump Evolution

1970s
Pump Evolution

1970s


1980s
Pump Evolution
Modern Day Insulin Pumps
Insulin Used In Pumps

Rapid-Acting Analogs are Preferred
 Aspart
(Novolog)
 Lispro
(Humalog
 Glulisine

(Apidra)
Modes of Delivery
 Basal
 Bolus
Basal Insulin

Steady “Drip” of Insulin

Matches Glucose Released by Liver

Meets Body’s Basic Energy Needs

May Need Different Settings at Different Times of Day
12:00 AM
9:00 PM
6:00 PM
3:00 PM
12:00 PM
9:00 AM
6:00 AM
3:00 AM
12:00 AM
Units
per
hour
2
1.8
1.6
1.4
1.2
1
0.8
0.6
0.4
0.2
0
12:00 AM
11:00 PM
10:00 PM
9:00 PM
8:00 PM
7:00 PM
6:00 PM
5:00 PM
4:00 PM
3:00 PM
2:00 PM
1:00 PM
12:00 PM
11:00 AM
10:00 AM
9:00 AM
8:00 AM
7:00 AM
6:00 AM
5:00 AM
4:00 AM
3:00 AM
2:00 AM
1:00 AM
12:00 AM
Bolus Insulin

Given to “cover” carbs in meals and snacks.

Used to “correct” high blood glucose levels
Insulin Infusion
(aka “getting under your skin”)

Durable, clog-resistant tubing
carries insulin from the pump to
the infusion set*.

The infusion set delivers insulin
into the fatty layer below the skin.

Set uses either a flexible plastic
catheter (canula) or a steel needle.

Almost always disconnectable near
the infusion site.
* OmniPod does not have tubing;
it attaches directly to the skin.
Infusion Set Types
Infusion sets vary by:
 Angle
of insertion
 Canula length
 Plastic vs. steel
 Tubing length
Infusion Set Insertion

Soft plastic canula inserted by way of an
introducer needle.

Mechanical “inserters” are available for some
types of insusion sets.
Clinical Advantages of
Pump Therapy

Reduction in HbA1c1

Less BG Variability2

Reduction in duration,
frequency and severity of
hypoglycemia3

Better psychosocial
outcomes & quality of life4
Clinical Advantages of
Pump Therapy
1
Bode et al; Diabetes Care 1996; 19:324-7
Weinzimmer et al; Pediatrics 2004; 114: 1601-5
5 Nations Trial; Diabetologia 2004; 47 (1): #82
DeVries et al; Diabetes Care 2002; 25:2074-80
2
DeVries et al. Diabetes Care. 2002 Nov; 25(11):2074–80
Diabetes Nutr Metab. 2004 Apr;17(2):84-9
N. Weintraub et al: Arch Pediatr Adolesc Med. 158: 677-684,
2004
3
Hissa et al; Endocrine Practice 2002: 8; 411-416
DeVries et al. Diabetes Care. 2002 Nov; 25(11):2074–80.
Rudolph and Hirsh; Endocrine Practice 2002: 8; 401-405
Siegel et al; Diabetes Care 2004; 27: 3022-3.
5 Nations Trial; Diabetologia 2004; 47 (1): #82
4
Peyrot and Rubin; Diabetes Care 2005; 28: 53-58
McMahon et al; DiabeticMedicine 2005; 22:92-96
Bruttomesso et al 2002; 19:628-634
Shapiro, 1984; Skyler, 1982
References
Practical Benefits:
Pump Basal Aspects
NPH (nighttime only)
Avg. Basal Needs
12am
3am
6am
9am
12pm
3pm
6pm
9pm
12am
6pm
9pm
12am
6pm
9pm
12am
NPH (morning and night)
12am
3am
6am
9am
12pm
3pm
6pm
9pm
12am
Pump Basal Delivery
12am
3am
6am
9am
12pm
3pm
Lantus or Levemir
12am
3am
6am
9am
12pm
3pm
6pm
9pm
12am
12am
3am
6am
9am
12pm
3pm
Practical Benefits:
Pump Basal Aspects
Avg.
Basal Needs
NPH
(nighttime
only)
Potential Problems:
12am
3am
6am
9am
12pm
3pm
6pm
9pm
12am
 Too much in middle of
the night?
 Too little late in the
day?
 General Inconsistency
Practical Benefits:
Pump Basal Aspects
Potential Problems:
Basal and
Needs
NPHAvg.
(morning
night)
 Too much in middle of
the night?
12am
3am
6am
9am
12pm
3pm
6pm
9pm
12am
 Midday peak requires
consistent mealtimes
 Poor coverage of
post-lunch peak
 General Inconsistency
Practical Benefits:
Pump Basal Aspects
Avg. Basal
Needs
Lantus
or Levemir
Potential Problems:
12am
3am
6am
9am
12pm
3pm
6pm
9pm
12am
 Failure to offset dawn
phenomenon
 Too much in middle of
the day?
 1 shot May not last full
24 hrs
Practical Benefits:
Pump Basal Aspects
Pump
Avg. Basal
Basal Delivery
Needs
Basal insulin can be
matched to the body’s
daily needs.
12am
3am
6am
9am
12pm
3pm
6pm
9pm
12am
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 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
Bolus Calculator: Example
Estimate Details
Est total:
Food intake:
BG:
7.0 U
60 gr
6.0 U
Correction:
2.0 U
Active ins:
1.0 U
ESC to back up
ICR 1:10 gram
200 (11.1)
Food:
ACT to proceed
Automatically calculates
insulin bolus requirement
for the patient
200 (11.1) – 100 5.5 = 2.0 units
50 (2.8)
Active insulin is
subtracted from the
correction
What A Pump Is NOT

A cure for
diabetes.

A substitute for
blood glucose
monitoring & carb
counting.

As effective as a
healthy pancreas.
Potential 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?












Responsible
Pre-Pregnancy
Irregular Schedule
Endurance Athletes
Existing Complications
Difficulty w/BG Control
Frequent or Severe Lows
Insulin-Dependent (1 or 2)
Hypoglycemic Unawareness
Sensitivity to Small Insulin Doses
Possess Proper Self-Management Skills
Adequate Insurance or Financial Resources
Strategies for Success:
Pre-Pump Education

BG monitoring 4+ times/day

Detailed Record Keeping

Carbohydrate Gram Counting

Self-Adjustment of Insulin

Principles of Basal/Bolus Therapy
Strategies for Success:
Post-Pump Management

Frequent communication w/health care team

Basal Testing

Bolus/Correction dose fine-tuning

Activity adjustments

Application of advanced pump features

Persistent self-care (don’t miss boluses!)

Effective troubleshooting, prevention of DKA
Strategies for Success:
DKA Prevention
Unexplained
High Blood Sugar
Check for
Ketones
Ketones
Negative
Bolus w/Pump
BS Drops
O.K.
Ketones
Positive
BS Doesn’t Drop
1. Shot w/Syringe
2. Drink Water
3. Change Out Pump
Strategies for Success:
Pump Selection Criteria

Insulin Reservoir Volume

Screen Readability

Bolus Maximums &
Increments

Bolus Calculator Flexibilty

Alarm Distinction

Water-Tightness
Strategies for Success:
Pump Selection Criteria

Link w/Meter or CGM

Convenience Factors
(tubing, clip)

Infusion Set Options

Aesthetics

Out-Of-Pocket Costs
Strategies for Success:
Infusion Set Selection/Use
 Appropriate
 Correct
 Site
depth for body type
priming amount
preparation technique
 Frequency
 Proper
of change-outs  3 days
site rotation
Think Like A Pancreas!