Insulin Pump What to tell your patient!!

1. Insulin PumpWhat to tell your patient!! Prakash Abraham Isla Fairley

4. Present generation pumps • Paradigm (Medtronic £2750) • Animas (Johnson & Johnson, £2600) • Spirit (Roche, £2375) • Deltec Cozmo (Smiths Medical, £2750)

5. Insulin Pump Usage: Grampian ~2% vs UK 4%

6. What does the pump do?

7. 2008 NICE recommendations • Disabling hypoglycaemia (repeated and unpredictable occurrence of hypos that result in persistent anxiety about recurrence and adverse quality of life) • HBA1c > 8.5% despite high level of care • Children <12 (where MDI impractical) and should have a trial of MDI between 12-18years.

8. Who can consider the pump 1 Patient characteristics • Type 1 DM • Basal bolus regime • Well motivated • Cope with CHO counting (DAFNE) • Monitoring at least 4 times • No evidence of Psychological illness

9. Who can consider the pump 2 Disease characteristics • Frequent hypoglycaemia • Hypoglycaemia unawareness • Gastroparesis • Poor control • Marked dawn phenomenon

10. New Aspects to consider for pump • Carbohydrate Ratios • DAFNE (Dose adjustment for normal eating) • Insulin Sensitivity / Correction doses • DAFNE • Basal Rates (Additional to DAFNE) • 1 basal injection to potentially 48 choices • Fasting at different times to titrate

11. Carbohydrate/ Insulin Ratio • number of grams CHO covered by 1 unit insulin • The 500 Rule: 500 divided by total daily dose equals CHO ratio. • Usually 10-15 • May vary at different times of the day.

13. 16 12 8 4

14. Insulin sensitivity • how much 1 unit of insulin lowers bg over 2-4 hours • Correction dose • The 100 rule: 100 / total daily insulin dose • May vary at different times of the day

16. 16 12 8 4

17. 15 10 5 An overnight drop of upto 2mmol/l is OK

19. What does the pump involve? • Insulin set changes every 2-3 days • Correction doses • Insulin sensitivity to be checked at different times • Carbohydrate ratios • Monitor Meal Bolus rates for each of the meals

20. What does the pump involve? • Basal rates to be checked • Skip breakfast for overnight rate • Skip lunch for daytime rate • Skip dinner for evening rate • Takes 3-6 months of work to get the various rates and ratios sorted. • Then work out weekends, more active days etc

21. Assessment • Interview with DSN/Doctor/Dietitian • Confirm eligibility and motivation • CHO counting (DAFNE course) • Pump demonstration • Dummy pump (CGMS) to carry for 2 days • Pump panel for funding decision

22. Pump Start • First week: Intensive (Days off Work) • Patient Contract • QOL (PAID) / Hypo questionnaires • First 3 months: 3 to 6 visits to Diabetes Resource Room, then at 6 & 12 months • Pump clinic: 4.5 /9 /15 months then ~4 monthly • (CGMS)

23. Patient contract

24. Initial Pump Support Variations • Two of the new starts in 2007 • MT • 4 months: Phone calls 2 weekly • emails 2 weekly • 9 appointments (3 with Doctor) • GN • 6 month: 3 phone calls • 3 emails • 3 appointments (2 with doctor)

25. Disadvantages • Wearing a device • Essential to check BMs minimum 4 times a day. Risk of DKA as only short acting insulin • Work involved in assessing rates and ratios.

26. Advantages • Minimise Hypoglycaemia • Less variability in blood sugars • More precise insulin dosing • Flexibility to change basal rates depending on activity • Quality of Life

27. Summary of profiles over 3 days

28. CSII NOT for everyone

29. Effort vs Reward