Putting Your Patients on the Pump - Karen M. Bolderman

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to use. It took several minutes to get a reading on a dial the size of a bathroom scale, but this device signified a huge step forward in diabetes monitoring. When insulin pumps became clinically available, I actively championed their use, although the early ones were the size of an Uzi.

      Over the years, pump technology has progressed at a steady pace, with the addition of new ways to deliver insulin, better integration with meters either as built in or by infrared communication, and with use of continuous glucose sensors. All of this brings the hope of a true closed-loop system.

      In spite of these improvements in technology, selecting patients for pumps and starting patients on pumps still requires a great deal of education, training, and time, along with knowledge on the part of the healthcare provider.

      I have known Karen Bolderman since she began working for me as a diabetes educator 30 years ago. After several years, Karen and I began working together again at the Geckle Diabetes and Nutrition Center at Greater Baltimore Medical Center, where we are working to integrate diabetes care in and out of the hospital.

      For us this is déjà vu all over again. We work together to teach patients about pumps, get them started, and manage their diabetes post initiation. With Karen’s knowledge and personal experience, starting and training patients on pumps, managing patients in the hospital, and following patients on pumps makes my life much easier. I look forward to a continued partnership with Karen in our attempts to improve diabetes care.

      Karen has done a marvelous job with the details of insulin pumps in this edition of Putting Your Patient on the Pump. This book will make everyone’s job of utilizing insulin pumps more understandable and practicable.

      Read ahead and enjoy.

      James H. Mersey, MD Director, Endocrinology and Metabolism, Medical Director, Geckle Diabetes and Nutrition Center Greater Baltimore Medical Center Assistant Professor of Medicine, The Johns Hopkins University School of Medicine Clinical Associate Professor of Medicine, University of Maryland School of Medicine, Baltimore, Maryland

      Insulin pump therapy gives people with diabetes the freedom to enjoy life, despite their chronic condition. The value and importance of having freedom are obvious from the impact this innovative technology has made in the past several decades. The insulin pump is now a common, integral component of diabetes management. Technological improvements and advances have made the insulin pump a desirable and useful tool in the management of diabetes.

      As long-term insulin pump wearers with type 1 diabetes and healthcare professionals who have learned much from our colleagues and countless other “pumpers,” the contributors to the second edition of Putting Your Patients on the Pump have a unique perspective and understanding of what constitutes practical, useful information. Collectively, the four of us have lived with type 1 diabetes for over 165 years. Most of these years have been spent with an insulin pump. It is our hope that this book will help healthcare professionals with expertise in diabetes care and education successfully start and maintain diabetes patients on insulin pump therapy. We believe that even experienced clinicians will find the information, tips, and resources helpful.

      We hope this book provides user-friendly information from our combined practical experience and supports the extra efforts diabetes healthcare professionals must make to help their patients achieve success using an insulin pump.

       Karen M. Bolderman, RD, LDN, CDE

      Chapter 1 Insulin Pump Therapy Advantages and Disadvantages

       Karen M. Bolderman, RD, LDN, CDE

      Insulin pump therapy is in its fifth decade and is gaining wider popularity. In the U.S., an estimated 20–30% of patients with type 1 diabetes and <1% of insulin-treated patients with type 2 diabetes use an insulin pump (HSBC Global Research 2005). As of this writing, the most current data indicate that there are over 375,000 patients with type 1 diabetes (up from approximately 130,000 in 2002) now using an insulin pump (U.S. Food and Drug Administration, General Hospital and Personal Use Medical Devices Panel 2010). Insulin pump therapy requires fewer “injections” compared with multiple daily injection (MDI) therapy; an infusion site is changed every 2–3 days, for an average of about 152 infusion site insertions/year, while MDI therapy results in about 1,460 injections/year (based on 4/day). Until research yields a practical way to replace lost β-cell function in diabetes, the insulin pump provides the most elegant method of insulin replacement. In its best application, pump therapy is a rare win–win situation in diabetes in terms of glycemic control and personal freedom.

      An insulin pump is a wonderful diabetes management tool, but as with any tool, the pump is only as good as the patient’s ability to use it. Clinicians have a responsibility to carefully screen and provide access to educational resources to all patients who express an interest in pump therapy. When patients are mismatched with the pump or the pump regimen, loss of control may occur and potential benefits are lost or nullified.

      Successful pump therapy is more likely with motivated and conscientious patients. Regardless of what many patients first think, the pump patient must perform frequent self-monitoring of blood glucose (SMBG), learn how to use their data, and understand how to use their insulin pump to ensure proper pump function and improve or achieve desired glucose control (American Diabetes Association 2004). Also, the patient must calculate food-related bolus insulin doses based on individualized insulin-to-carbohydrate ratios as well as bolus doses to decrease hyperglycemia based on individualized insulin correction (sensitivity) factors.

      Insulin pump: A small, programmable, battery-powered device worn externally that delivers insulin in tiny continuous amounts (basal doses) and in larger amounts for meals or hyperglycemia (bolus doses). The pump is attached to the patient by either an infusion set consisting of long, thin flexible tubing with a catheter (or needle) on the end that is inserted subcutaneously into the patient, OR, a tubing-free (“patch”) pump is directly attached to the patient with a subcutaneous needle-inserted catheter and self-adhesive tape. The user programs and operates the pump or the pump’s remote control device to deliver insulin doses that match individual needs. An insulin pump does not automatically calculate the amount of insulin needed; patients and healthcare professionals work together to calculate the patient’s daily insulin amounts, and the pump is then programmed by the patient to deliver insulin based on the person’s specific requirements.

      For People with Type 1 Diabetes

      • Improves glycemic control by delivering an individualized basal rate supplemented with bolus doses to match the patient’s intake and correct any hyperglycemia. Erratic glucose fluctuations can potentially be reduced.

      • Offers precise dosage delivery in basal rates as low as 0.025 units/h and bolus doses in exact whole, tenth, and twentieth-unit doses.

      • Can manage the dawn phenomenon by delivering a higher basal rate during the dawn hours.

      • Can control glucose during and after exercise by delivering a lower basal rate.

      • Has the potential to decrease the risk of hypoglycemia by allowing patients to individualize insulin doses to match their requirements hour by hour.

      • May lessen or reverse hypoglycemia unawareness by decreasing the incidence of hypoglycemia.

      • Allows incremental, precise doses to match growth spurts in children and adolescents and to manage people who are insulin sensitive.

      • Improves management of patients with gastroparesis by adding the option of splitting and/or extending bolus delivery over time to match delayed absorption of nutrients.

      • Can match delayed gastric emptying observed with the use of pramlintide, or with the consumption of high-fat foods, by extending bolus delivery over time.

      • Eliminates the

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