Introduction To Pumping
Starting And Success
Children With Diabetes
Toronto, August 17, 2007
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
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
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 –>
Healthcare Across Borders - September 2003
Reasons To Use A Pump
Healthcare Across Borders - September 2003
Cumulative Incidence (%)
Better Control –> Fewer Complications
60
50
76%
59%
39%
54%
64%
Risk Reduction
Risk Reduction
Risk Reduction
Risk Reduction
Risk Reduction
•55.0
Conventional
Intensive
40
30
29.8
•23.9
20
16.4
10
•13.4
13.0
7.9
0
•5.1
2.5
5.0
Retinopathy Laser Rx1
MicroAlbuminuria2
Clinical
albuminuria2
Neuropathy3
Progression1
1.
2.
3.
DCCT Research Group, Ophthalmology. 1995;102:647-661
DCCT Research Group, Kidney Int. 1995;47:1703-1720
Healthcare
- September
2003
DCCT Research
Group.Across
Ann Borders
Intern Med.
1995;122:561-568.
HbA1c
Poor Control Remains A Problem
2/3 with diabetes (and most pumpers)
10%
remain out of control
9%
Avg. A1c on Pumps
8%
Goal A1c
ADA
7%
EASD/AACE
6%
5%
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 Starch
Wright A., Burden et al, Diabetes Care 2002; 25:330–336
Turner RC, Cull et al, JAMA 1999; 281:2005–2012
Healthcare Across Borders - September 2003
Avg. A1c in
TYPE 1s
Exposure Versus Variability
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.
400
380
360
Variability or Swing =
340
Standard deviation or GlycoMark test
320
300
glucose (mg/dl)
280
260
Exposure or Average =
240
220
A1c or avg. BG from meter
200
180
160
140
120
100
80
60
40
2:00 PM 3:00 PM 4:00 PM 5:00 PM 6:00 PM 7:00 PM 8:00 PM 9:00 PM
10:00
PM
11:00 PM
12:00
AM
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
Healthcare Across Borders - September 2003
10:00
AM
11:00
AM
12:00
PM
1:00 PM 2:00 PM
The Challenge Of Diabetes
BG in mg/dL (mmol)
Bringing the A1c down smoothly takes effort
300 (16.7)
Uncontrolled A1C ~9%
“Controlled” A1C <7%
200 (11.1)
A1C ~6%
100 (5.5)
Normal A1C 4%–6%
0800
1200
1800
0800
Time of Day
…for this you need ADVANCED therapy
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
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.
Why Physicians Recommend Pumps
 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
Healthcare Across Borders - September 2003
Who Is A Pump Candidate?
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
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
Back Buddy
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
Pump Basics
Healthcare Across Borders - September 2003
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)
Healthcare Across Borders - September 2003
Basals And Boluses
bolus
basal
A pump more easily matches the realities of daily life.
Healthcare Across Borders - September 2003
Basal: MDI versus Pump
Lantus or Levemir
Pump
2:00
7:00
12:00
16:00
20:00
24:00
7:00
Time
Basal insulin delivery from a pump provides a better and faster
match for life’s needs
Healthcare Across Borders - September 2003
More Testing –> Lower A1c
Data From 378 People On Pumps
12
Atlanta Diabetes Associates study:
378 patients sorted from a database of 591
Pumps=MM 511 or earlier
BG Target=100
C peptide <0.1
11
HbA1c
10
9
ADA:
< 7%%
8
7
HbA1c=5.99+5.32 / (BGpd+1.39)
AACE:
< 6.5%
6
5
4
0
2
4
6
8
10
SMBG Frequency (BG per day)
12
14
Healthcare
Across Borders
September 2003
P.
Davidson
et al: -Diabetes
53 (suppl 2): abstract 430-P, 2004
Brands And Features
Healthcare Across Borders - September 2003
Insulin Pumps – 2007
Accu-Chek Spirit
Animas 2020
Deltec CozMore 1800
Insulet Omnipod
Medtronic Paradigm x22
Sooil Dana
Diabecare IISG
Healthcare Across Borders - September 2003
Pump info at www.diabetesnet.com/diabetes_technology/
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
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
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
Current Feature
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
Pump Advantages
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
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!
Healthcare Across Borders - September 2003
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)
Healthcare Across Borders - September 2003
Infusion Sets
Healthcare Across Borders - September 2003
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
A reliable and comfortable infusion set is critical
to success on a pump.
Healthcare Across Borders - September 2003
Infusion Sets And Inserters
Infusion set/site problems are a common cause
for unexplained highs
Disetronic Rapid-D
Smith’s Medical Cleo
Medtronic Sil-serter
Animas Inset
Healthcare Across Borders - September 2003
Quik-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
Healthcare Across Borders - September 2003
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!
Across
- September 2003
Photo Healthcare
courtesy
ofBorders
kerri@sixuntilme.com
Pump Start
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
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
Severe lows cause highs
Higher stress hormone release
makes glucose rise for 6-10 hrs
Excess carb intake leads to highs
Boluses may be reduced/skipped
More insulin than usual needed
Healthcarelows,
Across Borders
- Septemberthe
2003
To stop
lower
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 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
Healthcare Across Borders - September 2003
Find Basals And Boluses From Starting TDD
Starting
TDD
50% Basal
Carb Factor
500 Rule
Corr. Factor
200 Rule
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 3.1 mmol
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
Healthcare
Across
Borders - September
An accurate
TDD
solves
most2003
control problems!
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
Healthcare Across Borders - September 2003
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!
Healthcare Across Borders - September 2003
Bolus Size (Relative To Wt) Affects The DIA
Measured as units per kg(2.2 lb)
How long a bolus will lower the BG:
Larger boluses have a
longer duration of action.
4 hrs
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
Becker et al. Diabetes. 2005; 54 (Suppl. 1): 1367P
Healthcare Across Borders - September 2003
Recommendations For DIA Times
DIAs on current
pumps can be set
from 2 to 8 hours.
An inaccurate DIA
can significantly
impact control.
Mudaliar et al: Diabetes Care, 22: 1501, 1999
Healthcare Across Borders - September 2003
When Major Control Problems Occur
TDD too low
Adjust your TDD
or too high?
1. Determine the current TDD
2. 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 meter
4. While keeping basal rates and the daily carb bolus total
balanced
Healthcare Across Borders - September 2003
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.
Healthcare Across Borders - September 2003
© 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
Healthcare Across Borders - September 2003
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 %
Healthcare Across Borders - September 2003
Basal/Bolus Balance
< 50% Basal
Duration < 5 yrs
Thin
Physically active
High carb/low fat diet
~ 50% Basal
> 50% Basal
Most people
Duration > 5 yrs
Puberty
Less active
Insulin resistant
Low carb diet
Healthcare Across Borders - September 2003
Basal Rates
Should keep the blood sugar flat overnight or
when a meal is skipped
Relatively easy to test
See Pumping Insulin for details
Healthcare Across Borders - September 2003
Set & Test Basals First
In reducing TDD,
take into account
A1c, history of
highs or lows
Pre-Pump TDD
More Accurate TDD
(55-95% of Pre-Pump Dose)
40 - 65%
30 - 55%
Basal
Bolus
50% basal is a
good place to
start for adults
and many
children
Test Basal Rates First
Healthcare Across Borders - September 2003
© Pumping Insulin, 2006
How Many Basal Rates?
25
Percentage of pumpers
who use 1 to 10
basals per day from
self reports of several
hundred pumpers at
insulin-pumpers.org
20
15
% 10
5
0
Number of Basals
1
2
3
4
5
6
7
8
9
10
One basal rate may work in children, while the complex metabolism
of puberty often requires multiple rates
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
Test Carb And Correction Factors After Basals
Test Basal Rates First
450 / TDD =
Carb Factor
2000 / TDD =
Correction Factor
Then Test Carb & Correction Factors
Healthcare Across Borders - September 2003
© Pumping Insulin, 2006
Glycemic Index:
Different Carbs Have Different Speeds
Fast
Average
Slow
Breads/Crackers
Salty Snacks
Potatoes
Rice
Cereals
Sugary Candies
Fruit
Juice
Pizza
Soup
Cake
Pasta
Legumes
Salad Veggies
Dairy
Chocolate
From Gary Scheiner, MS, CDE
Healthcare Across Borders - September 2003
Duration Of Carb Action
High GI
Med GI
Low GI
0 hrs
1 hr
2 hrs
3 hrs
4 hrs
Most carbs have most of their affect within 1 to 2.5 hours
But delay can occur with complex carbs, more fat content, etc
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
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!
Healthcare Across Borders - September 2003
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 #
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
Most Carbs Much Faster Than “Rapid” Insulin
One hour after a meal, half of a meal’s
glucose rise has occurred, but 80% of
rapid insulin activity remains
Time over which most meals affect the BG
% bolus activity remaining
Take Home:
Bolus 15 to 30 minutes before meals
Use extended and boluses sparingly.
Healthcare Across Borders - September 2003
From Pumping 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
Healthcare Across Borders - September 2003
Bolus Timing Depends On Glucose
Premeal
Bolus Timing
BG
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
Healthcare Across Borders - September 2003
Missed Boluses Cause High A1cs
9.4
9.3
9.2
9.1
9
8.9
8.8
8.7
8.6
8.5
8.4
8.3
• Start well– give a bolus for every
bite!
• Use pump reminders or other
reminder
Control
+Rmindr
• Review pump history once a
week and work toward increasing
the number of boluses
• Work toward solutions without
blame
Before
6 mos
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
Healthcare Across Borders - September 2003
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?
Healthcare Across Borders - September 2003
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
Healthcare Across Borders - September 2003
BG
Bottom Line
If you don’t have great control on a smart pump,
your pump settings are likely off.
Healthcare Across Borders - September 2003
Where Next?
Faster insulins – Biodel Viaject
Can the loop be totally closed?
Dual delivery pumps
Healthcare Across Borders - September 2003
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!
Healthcare Across Borders - September 2003
Questions And Discussion
Healthcare Across Borders - September 2003