Introduction to pumping starting and success
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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 [email protected] Highlights. Why Pump?

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Introduction to pumping starting and success

Introduction To PumpingStarting 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 [email protected]

Healthcare Across Borders - September 2003


Highlights

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

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

Reasons To Use A Pump

Healthcare Across Borders - September 2003


Better control fewer complications

Better Control –> Fewer Complications

76%

Risk Reduction

59%

Risk Reduction

39%

Risk Reduction

54%

Risk Reduction

64%

Risk Reduction

60

  • 55.0

50

Conventional

Intensive

Cumulative Incidence (%)

40

30

29.8

  • 23.9

20

16.4

10

  • 13.4

13.0

7.9

  • 5.1

5.0

2.5

0

Retinopathy

Laser Rx1

Micro-

Albuminuria2

Clinical

Progression1

albuminuria2

Neuropathy3

DCCT Research Group, Ophthalmology. 1995;102:647-661

DCCT Research Group, Kidney Int. 1995;47:1703-1720

DCCT Research Group. AnnIntern Med. 1995;122:561-568.

Healthcare Across Borders - September 2003


Poor control remains a problem

Poor Control Remains A Problem

HbA1c

2/3with diabetes (and most pumpers) remain out of control

10%

Avg. A1c in TYPE 1s

9%

Avg. A1c on Pumps

8%

ADA

7%

Goal A1c

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


Exposure versus variability

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.

Variability or Swing =

Standard deviation or GlycoMark test

Exposure or Average =

A1c or avg. BG from meter

Healthcare Across Borders - September 2003


The challenge of diabetes bringing the a1c down smoothly takes effort

Uncontrolled A1C ~9%

Time of Day

The Challenge Of DiabetesBringing the A1c down smoothly takes effort

300 (16.7)

“Controlled” A1C <7%

BG in mg/dL (mmol)

200 (11.1)

A1C ~6%

100 (5.5)

Normal A1C 4%–6%

0800

1200

1800

0800

…for this you need ADVANCED therapy

Healthcare Across Borders - September 2003


Advantages of pumps over mdi

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

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.


Introduction to pumping starting and success

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

Why Physicians Recommend Pumps

Healthcare Across Borders - September 2003


Who is a pump candidate

Who Is A Pump Candidate?

Healthcare Across Borders - September 2003


Candidate requirements

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

Expectations

Healthcare Across Borders - September 2003


Benefits for infants toddlers

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

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

Pump Basics

Healthcare Across Borders - September 2003


Terms

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

Basals And Boluses

  • A pump more easily matches the realities of daily life.

bolus

basal

Healthcare Across Borders - September 2003


Basal mdi versus pump

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


Introduction to pumping starting and success

More Testing –> Lower A1cData From 378 People On Pumps

Atlanta Diabetes Associates study:

378 patients sorted from a database of 591

Pumps=MM 511 or earlier

BG Target=100

C peptide <0.1

HbA1c=5.99+5.32 / (BGpd+1.39)

ADA:

< 7%%

AACE:

< 6.5%

P. Davidson et al: Diabetes 53 (suppl 2): abstract 430-P, 2004

Healthcare Across Borders - September 2003


Brands and features

Brands And Features

Healthcare Across Borders - September 2003


Insulin pumps 2007

Insulin Pumps – 2007

  • Accu-Chek Spirit

  • Animas 2020

  • Deltec CozMore 1800

  • Insulet Omnipod

  • Medtronic Paradigm x22

  • Sooil Dana Diabecare IISG

Pump info at www.diabetesnet.com/diabetes_technology/

Healthcare Across Borders - September 2003


Things to consider in choosing a pump

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

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

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

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

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

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

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

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

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

Pump Advantages

Healthcare Across Borders - September 2003


Advantages of a smart pump

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

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

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

Infusion Sets

Healthcare Across Borders - September 2003


Infusion sets1

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

Infusion Sets And InsertersInfusion set/site problems are a common cause for unexplained highs

Disetronic Rapid-D

Smith’s Medical Cleo

Medtronic Sil-serter

Quik-serter

Animas Inset

Healthcare Across Borders - September 2003


Use sterile technique for site prep

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

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!

Photo courtesy of [email protected]

Healthcare Across Borders - September 2003


Pump start

Pump Start

Healthcare Across Borders - September 2003


Prepare for pump start

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 andtroubleshooting

Healthcare Across Borders - September 2003


Preparation

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

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

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

Stop Lows FirstBetter 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

To stop lows, lower the TDD!!!

Healthcare Across Borders - September 2003


Find your optimum doses

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

Find Basals And Boluses From Starting TDD

StartingCarb Factor Corr. Factor TDD 50% Basal 500 Rule 200 Rule

20 u0.42 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

40 u 0.83 u/h 13 grams 50 mg/dl

50 u 1.04 u/h 10 grams 40 mg/dl

60 u1.25 u/h 8 grams 33 mg/dl

3.1 mmol

An accurate TDD solves most control problems!

Healthcare Across Borders - September 2003


Duration of insulin action dia time

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

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

Bolus Size (Relative To Wt) Affects The DIAMeasured as units per kg(2.2 lb)

  • Larger boluses have a longer duration of action.

  • 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

How long a bolus will lower the BG:

4 hrs

Becker et al. Diabetes. 2005; 54 (Suppl. 1): 1367P

Healthcare Across Borders - September 2003


Recommendations for dia times

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

When Major Control Problems Occur

Adjust your TDD

  • Determine the current TDD

  • Lower it:

    • For frequent lows

    • If both highs AND lows occur – which comes first?

  • Raise it:

    • For a high A1c or a high average BG on your meter

  • While keeping basal rates and the daily carb bolus total balanced

TDDtoo low

or too high?

Healthcare Across Borders - September 2003


Introduction to pumping starting and success

Adjust The TDD For A High Avg. BG or A1cExample: someone with a TDD of 35 units and few lows. A1c = 9%, so more insulin is needed: about 3.2 units.

© Pumping Insulin, 2006

Healthcare Across Borders - September 2003


Change your tdd for

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

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

Basal/Bolus Balance

Healthcare Across Borders - September 2003


Introduction to pumping starting and success

Basal RatesShould keep the blood sugar flat overnight or when a meal is skippedRelatively easy to test

See Pumping Insulinfor details

Healthcare Across Borders - September 2003


Set test basals first

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)

50% basal is a good place to start for adults and many children

40 - 65%

Basal

30 - 55%

Bolus

Test Basal Rates First

© Pumping Insulin, 2006

Healthcare Across Borders - September 2003


How many basal rates

How Many Basal Rates?

  • Percentage of pumpers who use 1 to 10 basals per day from self reports of several hundred pumpers at insulin-pumpers.org

%

One basal rate may work in children, while the complex metabolism of puberty often requires multiple rates

Healthcare Across Borders - September 2003


Introduction to pumping starting and success

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 Carb And Correction Factors After Basals

Test Basal Rates First

450 / TDD =

Carb Factor

2000 / TDD =

Correction Factor

Then Test Carb & Correction Factors

© Pumping Insulin, 2006

Healthcare Across Borders - September 2003


Glycemic index different carbs have different speeds

Glycemic Index: Different Carbs Have Different Speeds

From Gary Scheiner, MS, CDE

Healthcare Across Borders - September 2003


Duration of carb action

Duration Of Carb Action

  • 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

Pump As Carb Counter

Healthcare Across Borders - September 2003


Carb factor

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

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

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

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.

From Pumping Insulin

Healthcare Across Borders - September 2003


Importance of bolus timing

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

Bolus Timing Depends On Glucose

Healthcare Across Borders - September 2003


Missed boluses cause high a1cs

Missed Boluses Cause High A1cs

  • Start well– give a bolus for every bite!

  • Use pump reminders or other reminder

  • Review pump history once a week and work toward increasing the number of boluses

  • Work toward solutions without blame

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

  • 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

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

BG

Healthcare Across Borders - September 2003


Bottom line

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

Where Next?

  • Faster insulins – Biodel Viaject

  • Can the loop be totally closed?

  • Dual delivery pumps

Healthcare Across Borders - September 2003


Wrap up

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

Questions And Discussion

Healthcare Across Borders - September 2003


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