Endocrinology Metabolism

Diabetes and the Use of Insulin Pumps

Is the Patient a Candidate for Insulin Pump Therapy?

Based on a large body of evidence that supports the reduction in the number of microvascular, macrovascular and neuropathic complications with successful intensive diabetes management, the American Diabetes Association (ADA) recommends target A1c levels of <7.0% in adults. The International Society of Pediatric and Adolescent Diabetes (ISPAD) recommends target A1c levels of <7.5% in children.

Currently, the ADA recommends intensive insulin therapy through either continuous subcutaneous insulin infusion (CSII) or multiple (3+) daily injections of insulin (multiple daily injection, MDI) to obtain optimal glycemic control. Between these two modalities, the benefits of CSII with respect to lowering A1c, reducing severe hypoglycemia, and improving quality of life make the use of CSII well worth any additional costs. Insulin pumps have been used in the United States for more than 30 years, with an estimated 20%-30% of type 1 diabetes patients using them and <1% of type 2 diabetes patients utilizing them.

Adult Candidates for Insulin Pump Therapy

General adult candidates are patients searching for a more flexible treatment plan who are unable to achieve optimal control with injection regimens, either related to unpredictable and varying schedules and activity levels or who have noted limitations in control when using multiple daily injections.

Specific candidates are patients who, despite frequent blood sugar monitoring and consistent and appropriate insulin administration, may:

  • Have type 1 DM or absolute insulin deficient type 2 DM

  • Have hemoglobin A1c levels >7.0%

  • Suffer from frequent episodes of hypoglycemia (including possible severe hypoglycemia and hypoglycemic

  • unawareness).

  • Experience erratic glucose extremes including episodes of diabetic ketoacidosis (DKA)

  • Feel that insulin management with multiple daily injections is limiting to daily living and overarching life goals

  • Suffer from extremes of insulin action including severe sensitivity or severe resistance

  • Have pronounced "dawn phenomenon"

  • Special situations such as before and during pregnancy, with children, competitive athletes and adolescents with eating disorders.

Pediatric Candidates for Insulin Pump Therapy

It is as important to evaluate the family/support unit for the child as it is to evaluate the child for appropriateness for CSII. Indications in pediatrics are similar to those in adults:

  • Elevated A1c levels on injection therapy

  • Recurrent, severe hypoglycemic episodes

  • Very young children

  • Wide fluctuations in glucose levels, regardless of A1c

  • Current treatment is not compatible with lifestyle needs

  • Presence of microvascular complications and/or risk factors for these complications

  • May be of benefit in specific populations: athletes, patients with pronounced dawn effect, patients with pronounced needle phobia, ketosis-prone patients and pregnant teens (when care is delivered by OB/Diabetes team with expertise in use of CSII in pregnancy)

The Appropriate Candidate/Caregiver Will Demonstrate the Following:

  • Reasonable expectations of pump therapy, including that it requires as much time as, if not more than, MDI

  • Motivation to achieve improved glycemic control

  • Checks blood sugar a minimum of 4 times daily (but optimally 6+ times per day)

  • Competency with carbohydrate counting

  • Good working knowledge of basic diabetes education- including how to test and treat hypoglycemia, how to follow up on hyperglycemia, sick day guidelines, and when to call the provider

  • Interest in technology and desire to undergo pump training

  • Willingness to continuously wear a pager sized device on their person attached via tubing or a tubeless pod that attaches directly to the skin

  • The manual dexterity to insert insulin pump sites and press buttons on the pump

  • The visual acuity to properly insert pump sites and read pump screen

  • Expectations of frequent follow-up with diabetes provider(s)

  • Does not have current untreated anxiety, depression or other cognitive issues that may interfere with ability to appropriately manage insulin pump therapy (including co-morbid medical conditions that can affect cognition, such as renal failure, medication sedation or post-chemotherapy).

An insulin pump is NOT the answer for patients who demonstrate limited diabetes education and/or poor self-management or for patients who expect the pump to "take over" diabetes care.

How does an insulin pump work?

Current models of insulin pumps are the size of small cell phones or pagers, are powered by AA or AAA batteries and use only rapid-acting insulin (aspart, lispro, or glulisine) or U-500 regular insulin. For most rapid-acting insulin, most insulin activity occurs within the first 3 hours after injection.

  • Most models use a large syringe- like cartridge or reservoir to hold several days' worth of insulin

  • The cartridge/reservoir is attached to a length of tubing (18-42 inches) that then attaches to a small (6-17 mm) Teflon or steel needle catheter (entire unit is called the infusion set)

  • Teflon/steel needle catheter is inserted into the subcutaneous tissue (most commonly buttocks, abdomen or upper leg/hip) and secured with an adhesive patch that is part of the infusion set

  • Teflon catheter should be changed every 3 days and it is recommended that steel needle sets be changed every 2 days

  • Currently an alternative model, called a "patch" pump is also available: insulin and mechanics to deliver it are all encased in a small, disposable pod that is directly attached to the skin - insulin is dosed via wireless link with a hand-held device that is manipulated by the patient

  • All pumps deliver insulin in 2 ways: basal and bolus delivery

  • Pumps are NOT fully automatic; basal insulin will be delivered automatically, but bolus insulin (approximately 50% of daily needs) MUST be programmed by wearer.

Basal Insulin Delivery

  • Designed to keep blood glucose levels steady during overnight and between meals.

  • Regulates the rate of hepatic glucose production during fasting. It is NOT designed to cover food-related insulin needs.

  • Basal rates are programmed in units/hr, but hourly totals are divided into mini-pulses every few minutes. (Thus, the pump must be worn at nearly all times).

  • Most pumps have the ability to program multiple rates throughout the day to account for circadian variation in insulin needs.

  • Most pumps can save multiple different basal patterns (patient must toggle back and forth between patterns) - which is useful for patients with widely varying daily schedules - such as shift workers, weekend athletes or adolescents who sleep late on the weekends.

Bolus Insulin Delivery

  • Immediate burst of insulin manually entered by the wearer to be delivered "in the moment" for meals and/or to correct hyperglycemia

  • 2 types of boluses: meal and correction

Meal bolus

  • Ideally delivered 15-20 minutes before eating meal/snack to minimize post-prandial rise in BG

    • Delivery may also be done during or after meal if situation warrants such as with a picky eater, a new type of food, or pre-meal

Hypoglycemia

  • Covers carbohydrate content of a meal or snack

  • Most pumps have meal bolus calculators, other pumps require patients to enter insulin dose to be delivered

  • Meal Bolus Calculator:

  • Pump is pre-programmed with an Insulin-to-carbohydrate ratio (ICR or the # grams of carbohydrate that 1 unit of insulin will cover), which is determined by the pump prescriber

  • Patient enters total number of carbohydrates from the meal or snack into the bolus calculator, which will determine a recommended dose of insulin based on the ICR

  • Patient must confirm result from bolus calculator and may adjust amount based on current circumstances

Correction bolus

  • Designed to return glucose levels to the established target range

  • Most pumps have correction bolus calculator; others require patients to enter insulin dose to be delivered

Correction bolus calculator

  • Pump is pre-programmed with an Insulin Sensitivity Factor (ISF) or Correction Factor (the number of BG points that 1 unit of insulin drops the BG) and a target blood glucose range, which acts as the goal for the mathematical determination of the correction bolus

  • Wearer enters current BG value into pump (some pump models come with BG monitor which wirelessly pre-populates pump with current BG value)

  • Most current pump models allow for correction of a BG value that is either above or below target: for values above target - an additional insulin dose is calculated to bring down BG; for values below target - insulin is subtracted from meal bolus to raise BG

  • Most pumps have a feature that prevents wearers from taking too many boluses too close together - this feature can be set to "lock-out" patients from taking full boluses for a period of time, generally 2-6 hours after a previous bolus (see Managing Insulin Pumps Section for a discussion of stacking)

Additional Features of Insulin Pumps

Temporary Rates

  • Allow for temporary increase/decrease to basal rates without having to change saved settings

  • Useful in dealing with unexpected events such as during or after exercise (decrease in current rate), illness (increase in rate), stress (increase in rate), or prolonged hypoglycemia (decrease in rate) or hyperglycemia (increase in rate)

  • Programmed for a set duration of time (0.5-72 hours depending on pump model) and either in units/hr or more commonly as a percentage of the current rates (e.g., "doubling the basal rate" is programmed either as 200% or +100% depending on the pump model)

  • Pump will automatically resume normal basal rates at end of set time

  • Can easily be cancelled before pre-set time expires if user desires to do so

Custom Bolus Functions

  • There are alternate delivery options which can change the way a meal bolus is delivered

Extended Bolus

  • Extends the delivery of the meal bolus over a specific length of time

  • Wearer determines the length of time over which the bolus should be delivered, generally 30 minutes - 6 hours

  • Works well with foods that are low on the glycemic index or are full of fiber or for situations where eating is done over a prolonged period such as with a holiday meal or buffet

Combination Bolus

  • Combines normal bolus with extended bolus to allow some of the insulin bolus to be delivered immediately and the rest to be delivered over a prolonged period

  • Wearer must determine amount of insulin to be delivered "up front" and the length of time over which to deliver the remaining amount

  • Often programmed as a percentage split (e.g., 50% now and 50% over X hours)

  • Works well with high-fat foods or meals where the fat content of the food can significantly slow the absorption of the carbohydrate content

  • May be useful for patients with Gastroparesis; start with 50% upfront and remaining 50% over 2-4 hours and titrate based on BG results

Continuous Glucose Monitoring (CGM)

  • It is only relatively recently that CGM devices have become commercially available, and there is currently only one insulin pump model available in which the pump acts as the receiver for the CGM data. However, there are a number of other manufacturers looking to wed these two technologies into one unit. CGM devices are comprised of a transcutaneous probe that generates an electrical current depending on the concentration of glucose in the interstitial fluid. The probe is connected to a transmitter that sits on the skin surface and wirelessly transmits the current data to a nearby receiver that converts the electrical current data into glucose concentrations. CGM devices provide glucose levels every few minutes as well as information regarding glucose trends both "in the moment" and over 1-24 hour periods (see chapter on Diabetes and Continuous Glucose Monitoring).

  • Current CGM systems are designed to "fill in the gap" between fingerstick glucose checks- does NOT replace BG testing

  • Inherent "lag time" between interstitial glucose levels and blood glucose levels

    • This lag can become more pronounced during times of acute BG changes

  • Data from CGM may be used to alter insulin doses in real-time and retrospectively

  • Requires additional intensive education of pump wearer/caregiver on how best to utilize the sensor data

Starting a Patient on Pump Therapy

Clinical Systems for Success

Successful implementation of pump therapy requires not only a motivated and educated patient, but also a diabetes care team with comfort and expertise in the start-up and management of patients on insulin pumps. Ideally, the diabetes care team is comprised of many disciplines including diabetologists/endocrinologists, advanced practice providers (NP/PA), Certified Diabetes Educators (CDE), pump trainers, and nutritionists.

Insurance Issues and Ordering Process

Ensure that the patient has medical insurance and/or the financial means to allow both purchase of the pump and continued coverage of the associated medical supplies. Without insurance, the pump itself can cost up to $6,000, and supply costs are estimated at $200-$400 per month (in addition to the usual insulin and blood glucose strip costs). Typically, the pump is covered by durable medical and at least partially covered by most major insurance companies. Additionally The Medicare Insulin Pump Coverage Act of 1999 states that Medicare will pay for an insulin pump if the patient is type 1 and meets particular criteria, including the presence of islet cell antibodies or low c-peptide levels.

Once a pump model is decided upon (see section below) the ordering process is typically initiated by the medical provider. The pump manufacturer will then reach out to the patient's insurance and to the patient themselves to clarify how the costs of the pump will be covered and to arrange payment of co-pays or deductibles. The insulin pump is typically shipped to the patient's home, unless otherwise specified. Training typically takes place next. Training procedures can vary from practice to practice.

Choosing an Insulin Pump Model

There are many different types of insulin pumps available from a variety of manufacturers.

Diabetes Forecast (reference in section below) provides an annual guide to all currently available pump models. Each manufacturer has both written and online information available. Many also have "virtual" pumps online that allow patients to "test drive" various pump models. The bullet points below highlight some of the factors to be considered when choosing an insulin pump model:

  • Clinician comfort and expertise with a particular model: this should be one of the primary considerations when choosing a pump. The prescribing clinician is the professional resource with regard to pump adjustments and functions, and should thus be very comfortable with the functions of the pump

  • Size of reservoir/cartridge: does the patient have a large total daily dose requirement?

  • Small basal/bolus capability: does patient have low insulin needs and require a basal rate of 0.025-0.05 unit?

  • Comfort with estimating carbohydrate content of foods: some pumps have food/carbohydrate content look-up functionality integrated into the pump itself

  • Remote control: some pump models have the ability to bolus from a remote (versus directly on the pump unit)

  • CGM capability: currently only one model integrates the pump and CGM receiver into one unit

  • This decreases the device burden for patients with type 1 diabetes

  • Display size/color: Color screens or larger displays may be beneficial to people with vision issues

  • Complete lack of tubing: there is currently only one model of "patch" pump that completely eliminates the need for any tubing

  • Waterproof vs water resistant: Waterproof pumps may be appropriate for people who work/play in a water environment

  • Other languages: is the patient's primary language something other than English?

Education Evaluation

Patient and/or caregiver should demonstrate competency in the following areas prior to initiating therapy:

  • Carbohydrate counting/accurate estimation

  • Ability and motivation to check BG levels at least 6 times daily

  • Basic principles of basal/bolus therapy; BG target levels, insulin action

  • Identification and management of hypo-/hyperglycemia

  • Sick day management with CSII

  • Exercise management with CSII

  • Identification and management of pump/infusion site failure

  • Mechanics of pump function, insertion and maintenance of infusion sites

Follow-up assessment and "refresher" educational activities should be completed following CSII initiation

Determining Initial Insulin Pump Settings

  • Calculate the patient's approximate total daily dose (TDD) of insulin.

  • In adults, multiply patient's current weight (in kilograms) by 0.7 (adolescents may require a calculation with 1.0 to account for increased insulin resistance whereas elderly patients should start with 0.5 unit/kg as they produce less endogenous glucose) OR

  • Average patient's total daily insulin use via injection over a 14-day period and then reduce this total by 10-20% to account for pharmacokinetic differences between CSII and MDI, especially if patient has A1c in target range and/or history of frequent hypoglycemia

Basal Rates

  • Divide the TDD by 40%-50% and then divide this amount by 24 hours to derive initial basal rate settings

  • In adults the initial rates can be set at a flat rate and adjusted as necessary based on blood sugar readings (including a midnight and 3 am test) or 20% can be initially deducted from the starting rate for the 12 am rate to account for the fact that the majority of adults require approximately 20% less insulin between 1 am-3 am than between 5 am-7 am.

  • For patients with pronounced "dawn phenomenon", overnight basal rate can be increased by 10%-20% at 3 am .

  • Basal rates for young children may total 30%-50% of TDD and may have more circadian fluctuation than adults

  • Adolescents often need increased basal insulin 5-9 am and again in later afternoon

Young children often need increased basal insulin from 9 pm-12 midnight

Meal Bolus Settings

  • If patient already on basal bolus therapy with MDI, it is possible to use their current insulin-to-carbohydrate ratios

  • You can also determine a starting carbohydrate-to-insulin ratio by dividing 500 by the TDD

  • Adjustments can be made to original settings by monitoring blood sugars 2 hours after meals. If these numbers are out of target, the carbohydrate ratio should be made more aggressive by lowering the number, typically in increments of 2-3 grams of carbohydrate.

  • For example, if a patient had an insulin-to-carbohydrate ratio of 1:18 for breakfast but each 2-hour postprandial number was over 180, it would be advised to change the breakfast insulin-to-carbohydrate ratio to make it more aggressive (meaning more insulin will be given for breakfast meal). Changing it to 1:15 and reevaluating would be a good place to start.

Correction Bolus and Blood Glucose Target Settings

  • If patient is currently on basal/bolus therapy you can use the current correction for pump settings

  • You can also derive it by dividing 1700 by the TDD.

  • Adjustments can be made by analyzing if the patient comes back into target 2 hours after giving a correction for a high blood sugar (is easier to do if analyzing situations where a food bolus was not also involved)

  • Typically recommended correction target of 100 mg/dL for most pump wearers (may choose to use higher target overnight of 120 mg/dL)

  • Targets may be less aggressive for elderly, very young children or other individuals at risk for hypoglycemia

Initial Follow-up Recommendations

  • Daily initial follow-up with pump trainer and/or member of diabetes care team

  • Follow-up clinic visit with member of diabetes care team within 3-14 days after initiation of CSII

  • Education "consults" (phone, email, or face-to-face) at least every 1-2 weeks, progressing to PRN basis

  • Once successful transition is made to CSII, return to quarterly clinic visit schedule

  • "24-hour" access to CSII/diabetes specialist for urgent situations

Discontinuing Pump Therapy

Unfortunately, insulin pump therapy may not work for every patient started on a pump. Indications for discontinuing pump therapy either temporarily or permanently include:

  • Patient preference, after pros and cons of continuing CSII vs transition to other method of insulin delivery are discussed

  • Frequent infusion site infections

  • Repeated episodes of diabetic ketoacidosis (DKA) due to pump mis-management

  • Intentional mis-use of pump; missed boluses, inadequate BG testing, missed site changes

If it is determined that pump therapy is no longer an option, ideally the patient is switched to basal/bolus therapy using MDI.

  • The total daily basal dose is replaced with 1-2 injections of long-acting glargine or detemir insulin:

  • Both the ICR and ISF from the pump may be used to calculate doses for rapid-acting boluses

  • If patient is resistant to the required 4+ injections of insulin needed for success with MDI, combinations of other insulins may need to be employed to provide the patient with the necessary 24-hour insulin coverage.

  • Because insulin absorption can be different between MDI and CSII, frequent BG testing (including overnight) should be done to assess the need for dose adjustments

Managing Patients with Type 1 Diabetes on an Insulin Pump

This section is meant to provide general information and guidelines on the management of patients using insulin pumps and should not replace care from or consultation with diabetes care providers who are experts in insulin pump therapy. Ideally, the patient is managed by a diabetes care team and is seen regularly by members of that team.

Upon initiation of insulin pump therapy, it is recommended that patients have face-to-face follow-up with their diabetes care providers within the first 3-14 days after starting.

As with patients on MDI, insulin doses for patients on insulin pumps should be adjusted regularly. Adjustments are made whenever BG patterns indicate a need. Typically, a pattern is established over a period of several days before changes are made, thus minimizing the potential for "chasing" BG levels. Once a change is made, the effectiveness of this change should be determined over several more days. The need for constant adjustments to meet the needs of the growing child and adolescent is the hallmark of insulin treatment in pediatrics.

Adjusting Basal Rates

  • Change the basal rate that occurs 2-3 hours before the abnormal BG levels are seen

  • Adjustments typically made in 10% increments, rounding to nearest 0.1 unit or 0.05 unit, depending on pump model

  • Alternative adjustment strategy: Increments of 0.1 units for those whose hourly rate is >1 unit/hr, 0.05 unit for those whose hourly rate is 0.5-1 unit/hr, and 0.025 unit for those whose hourly rate is <0.05 unit/hr

  • Elevations in fasting BG levels are typically caused by inadequate basal insulin

  • Patient may need to test BG at 2-3 am for several nights to better determine which basal rate should be changed

  • Daytime can be more difficult to determine need to adjust basal vs. bolus insulin: typically start w/ basal adjustment if abnormal BG occurs more than 2-3 hours after a meal

  • Basal testing: technique to determine whether glucose levels remain in range when the patient skips a meal or eats a carbohydrate-free meal and BG is monitored every 2 hours until the next meal (May be difficult and/or unrealistic for some patients to complete this)

Adjusting Meal Boluses

  • Test the 2-hour postprandial (2-hr PP) BG level to evaluate effectiveness of meal bolus

  • 2 hours after meal target of <160-180 mg/dL

    • Consider accuracy in carb counting as one cause for bolus ineffectiveness

    • Increase ratio to decrease amount of insulin given with bolus (e.g., change in ratio from 1:15 grams to 1:18 grams)

    • Decrease ratio to increase the amount of insulin given with bolus (e.g., change in ratio from 1:15 grams to 1:12 grams)

    • Adjustments typically made in 10%-20% increments

Adjusting Correction Boluses

  • Test BG 2 hr after correction dose to determine effectiveness of correction bolus

  • When given as part of a meal bolus for correction of hyperglycemia, BG by next meal should be close to target range

  • BG should be close to target range programmed into the pump at the 2-hour mark

  • Increase ratio to decrease the amount of insulin given with bolus (e.g., change in ratio from 1:50 mg/dL to 1:65 mg/dL)

  • Decrease ratio to increase the amount of insulin given with bolus (e.g., change in ratio from 1:50 mg.dL to 1:35 mg/dL)

  • Adjustments typically made in 10%-20% increments.

Managing Hypoglycemia

Hypoglycemia is virtually unavoidable in the treatment of type 1 diabetes. However, pump therapy is associated with less hypoglycemia, specifically, fewer episodes of severe hypoglycemia. Hypoglycemia is defined as a BG <70 mg/dL, although some patients with a history of hypoglycemia unawareness, autonomic neuropathy or at extremes ends of the age spectrum may benefit from beginning treatment for hypoglycemia at a higher threshold.

Causes

Too much insulin/not enough food, unplanned exercise, delayed effects of afternoon exercise, or stacking boluses (see next section)Treatment

  • 10-15 grams of fast-acting carbohydrates; 4 ounces juice or regular soda, 3-4 glucose tablets, 3-4 Starbursts

  • Treatment should not include any protein/fat as this will slow the absorption of the glucose

  • Additional carbohydrates that may be consumed over and above initial 10-15 grams should be followed by a meal bolus to prevent rebound hyperglycemia

  • Allow 20 minutes for treatment to work before re-testing BG, if remains below threshold at this time, repeat treatment until BG rises

  • If hypoglycemia occurs at mealtime

    • Treatment with fast-acting carbohydrates can be taken - but should NOT be included in meal bolus

    • For mild hypoglycemia, some patients may elect to forgo treatment with fast-acting carbohydrates and subtract 10-15 grams from meal total

    • Many pumps also offer a reverse correction feature where insulin is subtracted from a meal bolus when BG falls below the lower range of the target level

Stacking: Delivering repeated boluses of insulin (particularly correction boluses) too close together

  • Occurs when patients follow the "more is better" philosophy and give multiple correction boluses in too short a time frame, likely leading to hypoglycemia several hours later.

  • Studies show that it can take 90-130 minutes to reach full peak effect from an insulin bolus.

  • Patients may check BG at 60-minute mark and see an inadequate improvement in level and deliver an additional bolus.

  • Prevention is key - ensure patient comprehends insulin action/effect, instruct patient to wait 2 hours before re-checking BG level, set insulin action/duration feature on insulin pump and instruct patient NOT to override pump

Managing Hyperglycemia

Hyperglycemia is virtually unavoidable in the treatment of type 1 diabetes. Pump therapy offers the ability to correct acute rises in glucose levels in a timely manner.

Causes

Too little insulin/too much food, sedentary lifestyle, stress, illness

Treatment

  • Deliver correction bolus (if no other bolus has been delivered within the last 2 hours)

  • Allow at least 2 hours before repeating BG (to ensure that peak effect of insulin has occurred)

  • Consider use of temporary rate to increase basal rates, especially with stress or illness - start with 25%-50% increase over 3-4 hours and have patient evaluate effect

  • Review and re-educate regarding carbohydrate counting

Diabetic Ketoacidosis (DKA) Prevention

Insulin pump therapy is a known risk factor for DKA; therefore, special attention must be given to situations of acute, prolonged hyperglycemia. Interruption of insulin delivery will result in urinary and blood ketones in 4-6 hours. One of the most common causes of delivery interruption is failure of the subcutaneous catheter - either disconnection, dislodgement or kinking. Patients should rely on BG testing results and not presence/absence of pump alarms to indicate that there is an issue with insulin delivery.

Recommendations for the treatment of acute, prolonged hyperglycemia 2 consecutive BG levels >250 mg/dL, at least 2 hrs apart) include:

  • Check urinary/blood ketone levels

  • Administer correction dose of rapid acting insulin via SQ injection (determine dose using pump bolus calculator)

  • Change infusion site (regardless of when last change was done)

  • Evaluate pump function: confirm insulin delivery - disconnect tubing and program test bolus;

  • Consider contacting pump manufacturer customer service (number listed on back of pump) if pump appears not to function properly

  • If ketones present, consider temporary increase in basal rates:

    • Increase of 25%-50% for 2-3 hours for moderate ketones (>1.0-1.6 mmol/L)

    • Increase of 50%-100% for 2-3 hours for large ketones (1.6->= 3.0 mmol/L)

  • Encourage hydration with sugar-free fluids

  • Repeat BG in 2-3 hours

  • Remains >250 mg/dL

    • Instruct patient to contact diabetes specialist for further evaluation

    • Consider giving double correction via injection

    • Consider continuing temporary basal rate

  • BG <250 mg/dL

    • Continue hydration

    • Continue to monitor ketones until clear

    • Continue close monitoring of BG for several hours until levels stabilize, and monitor for hypoglycemia

  • Patient should have back-up supplies, including: ketone strip, batteries, infusion sets, rapid and long-acting insulin vials and/or pens, syringes, or pen needles, and copy of current pump setting - these should always be available

  • If pump malfunctions, patient may need to return to MDI until pump can be replaced (contact pump manufacturer immediately to facilitate timely replacement)

Downloading Pump/Data Retrieval

  • Retrieving data from a pump can be a helpful and time-saving tool for the clinician and patient.

  • All pumps currently on the market can be uploaded through either use of a special cable and software downloaded on a specific computer or through a web-based interface that uses a USB to wirelessly upload the pump and associated meters (data can then be exported or printed if downloaded on specific device or viewed remotely if done with web-based software).

  • The specific pump company can provide the actual software and downloading tools as well as patient instruction on how to use the technology.

  • Providers may want to ask their pump patients to upload their pump the night before their visit and also bring reports for efficiency and efficacy.

  • Once the pump is uploaded, a variety of reports can be viewed, including; current device settings, logbook reports that show blood sugar numbers and carbohydrate amounts entered into the pump as well as the amount of insulin delivered (helpful to review when making dose adjustments). Reports will outline pump events such as suspensions, alarms, temporary basal rates, rewinding the pump, and cannula filling (helpful when assessing compliance). Statistical reports use a variety of modalities such as line charts, pie charts and graphs to display minimum/maximum and average blood sugars, boluses and basal information. These can often be broken down by time of day or meal for better assessment of control and need for changes.

Special Situations

Hospital care considerations

Emergency care

  • Contact diabetes care specialist as quickly as possible.

  • Do NOT discontinue pump unless diabetes specialist has directed its removal and an alternative source of insulin is available.

  • Evaluate BG and ketone status as early as possible.

  • Use caution when initiating glucose-containing intravenous fluids.

Inpatient care

  • The American Diabetes Association supports the use of insulin pumps in patients who are able to provide their own diabetes self-management while admitted to a hospital: "Patients who use [CSII]...can be candidates for diabetes self-management in the hospital, provided they have the mental and physical capacity to do so."

  • Personnel with expertise in pump therapy should be available in all hospitals.

  • Nursing staff caring for patients on pumps should document basal and bolus insulin doses at least daily.

  • For stable patients, BG targets for hospital stay should be <140 mg/dL before meals and <180 mg/dL for random glucose tests. These targets may be tightened or loosened depending on individual needs.

Radiological Tests

  • ALL insulin pumps should be removed prior to patients undergoing any radiologic test.

  • If patient requires prolonged imaging and will need to be disconnected for longer than 1-2 hours, an alternate source of insulin (such as SQ injection) will need to be initiated.

Surgery

  • Collaboration among anesthesiologists, surgeons, and diabetes specialists to determine perioperative diabetes management

  • For short/minor procedures (<1 hr), pump may be left on and basal rates continue to infuse

  • Secure infusion set with additional tape for added protection during surgery

  • If pump is discontinued, an alternate source of insulin MUST be used

  • Frequent BG monitoring should be cornerstone of perioperative diabetes management

  • Patients/caregivers should be in contact with diabetes specialists to determine preoperative diabetes management

Travel

General Recommendations

  • Bring 2-3 times the amount of insulin pump supplies and insulin typically necessary for trip length

  • Bring back-up long-acting insulin and syringes or long-acting insulin pens and short-acting insulin pens

  • If traveling via plane, obtain a travel letter from diabetes team explaining necessity of carrying supplies on the person at all times

  • Pack all supplies in carry-on luggage

  • The pump should not go through airport x-ray machines (it is ok to pass through the metal detector)

  • If full-body scanner is being utilized at airport, notify authorities of use of medical device prior to walk-through

  • It is safe to wear pumps in full functioning mode during air travel

Exercise

Exercise is associated with an increased risk of hypoglycemia secondary to enhanced insulin sensitivity. Consequently, to avoid hypoglycemia, adjustments in carbohydrate intake or insulin delivery must occur.

  • BG monitoring should occur before, during, and after activity.

  • Disconnecting or suspending basal rates may be useful, but caution should be taken to ensure hyperglycemia does not occur.

  • Insulin pumps can be removed for up to 2 hours before insulin deficiency begins to occur.

  • Myriad strategies are available to deal with exercise, depending on particular effect in patient. Some patients experience hypoglycemia during exercise, others immediately following and still others not until several hours later - patients can see an exercise effect 7-11 hours after completing exercise.

  • Suggested strategies include (but are not limited to): reducing meal bolus for meal preceding exercise session, lowering basal rates for 1-2 hours prior to activity, lowering overnight basal by 10%-20% following late afternoon/evening activity, consuming small snack (without meal bolus) just prior to exercise, hydrating with sugar containing fluid during activity.

Water Activities

  • Check with the particular pump company to see if the pump is waterproof.

  • Typically, patients disconnect for showers and swimming (the site itself can be immersed and exposed to water).

Sick Days

  • In the event that someone is ill and not eating, the body still requires insulin to counteract increases in glucose and ketone production by the liver due to increased secretion of stress hormones (cortisol, glucagon, growth hormone, epinephrine/norepinephrine).

  • Never suspend insulin delivery or disconnect a pump when a patient is ill.

  • Being ill can put patients at risk for developing DKA; therefore, it is very important to advise patients to check for ketones and monitor blood sugar every 2-4 hours around-the-clock, even if the blood sugar is in normal range.

  • If ketones are present, see section on DKA prevention.

  • If vomiting is present without ketones: avoid solid foods until vomiting subsides, gradually start liquids (sugar free if blood sugar >150, with sugar if <150); begin with 1 tablespoon every 10 minutes. Increase slowly as tolerated. Resume intake of bland solids after 1-2 hours with no vomiting.

  • Advise patients to call diabetes healthcare team urgently or seek emergency care with moderate or large ketones, persistent nausea, low blood sugar with nausea and/or vomiting and any signs or symptoms of DKA such as abdominal pain, chest pain, altered consciousness, deep breathing.

Drugs that Can Affect Blood Sugar and May Require Temporary or Permanent Dose Adjustments

  • Beta-adrenergic antagonists: May alter physiologic and subjective symptoms of hypoglycemia, can potentially decrease tissue sensitivity to insulin

  • Corticosteroids: Can raise blood sugars through increased gluconeogenesis; transient insulin resistance

  • Estrogen products (typically higher doses): Can possibly raise blood sugars

  • Ethanol: intrinsic hypoglycemic effect; impairs gluconeogenesis

  • Vitamin B3 (niacin): May increase blood sugar

  • Thiazide diuretics (high dose): May increase blood sugar

What’s the Evidence?/References

Laffel, L. "Sick-day management in type 1 diabetes". Endocr Metab Clin NA. vol. 29. 2000. pp. 707-23.

(Comprehensive explanation of sick day management and the gives more details on differences of testing ketones through urine versus serum.)

Moghissi, ES, Korytokowski, MT, DiNardo, M. " American Association of Clinical Endocrinologists and American Diabetes Association Consensus Statement on Inpatient Glycemic Control". Diabetes Care. vol. 32. 2009. pp. 1119-31.

(Sets forth recommendations for glycemic targets for inpatient glycemic control and for management of hyperglycemia/hypoglycemia as well as providing review of theoretical underpinnings.)

General Diabetes and Pump Guidelines

"American Diabetes Association. Standards of medical care in diabetes". Diabetes Care. vol. 34. 2011. pp. S11-S61.

(Provides a review of comprehensive diabetes management recommendations for both T1D and T2D.)

Franz, MJ. " Core Curriculum for Diabetes Educators".

(Detailed overview of pathophysiology of diabetes, current treatment strategies and self-management education.)

Grunberger, G, Bailey, TS, Cohen, AJ, Flood, TM, Handelsman, Y. "AACE Insulin Pump Management Task Force. Statement by the American Association of Clinical Endocrinologists Consensus Panel of Insulin Pump Management". Endocrine Practice. vol. 16. 2010.

(Review of theoretical underpinnings of CSII as well as information on use in various populations and recommendations for patient, practice and educational requirements.)

Moshe, R, Battelino, T, Rodriguez, H, Danne, T, Kaufman, F. " Use of insulin pump therapy in the pediatric age-group. Consensus statement from the European Society for Pediatric Endocrinology, the Lawson Wilkins Pediatric Endocrine Society, and the International Society for Pediatric and Adolescent Diabetes, endorsed by the American Diabetes Association and the European Association for the Study of Diabetes". Diabetes Care. vol. 30. 2007. pp. 1653-62.

(Comprehensive review of use of CSII in pediatrics. Provides concrete recommendations for initiation and management of CSII in pediatric patients.)

Scheiner, G, Sobel, R, Smith, D, Pick, A, Kruger, D, King, J, Green, K. " Insulin pump therapy guidelines for successful outcomes". Diab Educ. vol. 35. 2009. pp. 29S-41S.

(Comprehensive review of rationale for CSII. Provides concrete recommendations for patient selection and start-up as well as practical pearls for ongoing management of CSII.)

http://forecast.diabetes.org/magazine/features/2011-consumer-guide.

(Provides a comprehensive review of current, commercially available pumps as well as other diabetes-related technologies.)

Management Guidelines and Special Situations

Betts, P, Brink, S, Silink, M, Swift, PGF, Wolfsdorf, J, Hanas, R. "Management of children and adolescents with diabetes requiring surgery". Pediatr Diab. vol. 10. 2009. pp. 169-74.

(Focuses on perioperative management of diabetes, both CSII and MDI. Provides specific information regarding preoperative adjustment of insulin doses and IV fluid management.)

Bode, BW, Fredrickson, L. "Establishing and verifying basal rates; Davidson PC, Bolus & supplemental insulin". The Insulin Pump Therapy Book. MiniMed Inc.. 1995.

(Describes the process of choosing initial pump settings in type 1 diabetic patients.)

Brink, S, Laffel, L, Likitmaskul, S. "Sick day management in children and adolescents with diabetes". Pediatr Diab. vol. 10. 2009. pp. 146-53.

(Reviews specific guidelines and rationale for care of children or adolescents with type 1 diabetes when they are ill.)
You must be a registered member of ONA to post a comment.

Sign Up for Free e-newsletters

Regimen and Drug Listings

GET FULL LISTINGS OF TREATMENT Regimens and Drug INFORMATION

Bone Cancer Regimens Drugs
Brain Cancer Regimens Drugs
Breast Cancer Regimens Drugs
Endocrine Cancer Regimens Drugs
Gastrointestinal Cancer Regimens Drugs
Genitourinary Cancer Regimens Drugs
Gynecologic Cancer Regimens Drugs
Head and Neck Cancer Regimens Drugs
Hematologic Cancer Regimens Drugs
Lung Cancer Regimens Drugs
Other Cancers Regimens
Rare Cancers Regimens
Skin Cancer Regimens Drugs