Pumping How Do I Start?

1. Pumping How Do I Start? John Walsh, P.A. Author: Pumping Insulin, Using Insulin (619) 497-0900 www.diabetesnet.com

2. What We’ll Cover • Introduction to pumps • Advantages of pumping • Am I a candidate? • How to choose a pump and infusion set • What is needed to start • Importance of data • Site preparation • Troubleshooting • Formulas that help • Smart features

3. Where Pumps Began • Started ~1978 with conversion of portable chemotherapy pumps to delivery of insulin • The Autosyringe AS2C and Harvard Apparatus Mill Hill Infuser were first • Single basal, no memory • 50 ml syringe on pump exterior • Required dilution of insulin to U-36 or U-18 1976 Biostator (top) and 1978 Autosyringe AS2C –>

4. The Basal-Bolus Concept

5. Advantages • Flexibility in meal timing & size • Eat when you want to • Faster adjustment of insulin for exercise • Family activities are no longer tied to one person’s needs • Easier handling of illness, travel, or camping

6. AdvantagesMore Consistent Insulin Action • The same dose of NPH insulin given to the same individual varies by 25% from day to day • Order of variablility: NPH > Lente > Lantus > Detemir • A pump has less variable insulin delivery at 3%

7. Advantages • Precise doses, as small as 0.025 u, can be given • Manages the Dawn Phenomenon • Improves control during growth spurts and adolescence • Reminders

8. Who Is A Good Pump Candidate?

9. Why Choose A Pump? • A freer lifestyle • Easier dose determinations • Improved blood sugars • Flexibility in meal timing and size • Ability to exercise without losing control • Peace of mind

10. When To Consider A Pump • More than 3 injections per day • Tired of multiple injections • Frequent or severe hypoglycemia • Hypoglycemia unawareness • Elevated A1c • DKA or ER/hospital admission • Strong Dawn Phenomenon • Require small, precise doses • Less risk of complications

11. Pro Less work Simplified insulin dosing Precise delivery Greater impact in those with highest starting A1c Slightly less insulin use per day Con More DKA More severe hypoglycemia A1c levels and frequency of DKA & hypoglycemia are similar to ICT Insulin Pump

12. What It Takes To Succeed • A personal desire for better control • Willing to adjust insulin doses to carb count, test results, and activity • Willing to monitor at least 4 times a day • Willing to keep an accurate record of BGs, boluses, and carb counts • Committed to solve problems and adapt lifestyle as needed

13. Success For Kids On Pumps • Supervision is required: kids BEGIN to develop self care skills at about age 10 • Family support is essential: an adult who can go to school, etc. • Communication with a health care team that is committed to pumps • Adequate insurance and financial resources • Assistance and support from teachers, friends, babysitters, grandparents, siblings

14. Features For Infants & Toddlers • Little ones are ideal pump candidates if the parents are • Delay or split boluses for fussy eaters • Small, user-friendly pumps offer precise dosing (0.05, 0.025, or 0.01 unit increments) • Lock out • Worn between shoulder blades • If a toddler likes to remove the infusion set, let them know what comes out must go right back in

15. Help For Kids & Teens • Growth spurts • Dawn Phenomenon • Easy coverage of snacks • TDD and bolus history can be checked to ensure consistent dosing • Faster adjustment of basals and boluses for changes in activity, etc

16. Special Teen Concerns • Dating • Wearing, sharing • Alcohol • Eating disorders • Fast foods • Fabrication • Sleeping-in

17. Personal Effort Those who expect a pump to manage their diabetes for them will fail to optimize their own therapy. Learn how to adjust your basals and boluses for an excellent A1c!

18. First Steps Toward A Pump • Keep detailed records • Consider your (and your child’s) motivation • Peer group, acceptance issues, family support • Look at available pumps • Which pump(s) does your insurance cover? • Talk with your doctor about a prescription • Visit a dietician to learn carb counting

19. What To Learn • How your pump works • How to count carbs • How to interpret BG results and see BG patterns • When to increase and decrease basals and boluses • How to adjust for high GI foods, extra activity

20. How ToChoose A Pump

21. Pump Companies Who sell or plan to sell pumps in the US: • Animas R1200 • Dana Diabecare III • Deltec Cozmo • Medtronic Paradigm • Nipro Amigo • Roche/Disetronic Visit www.diabetesnet.com/diabetes_technology/

22. Things To Consider • Look, feel, color • Features: reminders, child block, waterproofing • Size of basal and bolus increments • Infusion set choices • Safety and reliability • Customer support • History • Ease of data analysis • Add-ons: meters, covers, cases

23. Today’s Smart Pumps • Easy dose calculations with Carb Factor and Correction Factor • Precise insulin dosing (0.05 units or better) to allow basal rates to be set up for Dawn Phenomenon, etc. • Tracks BOB to avoid insulin stacking • Reminders

24. Today’s Pumps • When control is poor or varies greatly on one of today’s pumps, the pump settings are incorrect. • Test and reset basal rates, carb and correction factors until you have good control. • Garbage in…..

25. How To Choose An Infusion Set

26. Infusion Sets • Straight-In Teflon: Cleo, Inset, Ultraflex, Quik-Set • Easier to insert, variety of depths (6, 8, 9 mm) • Angled Teflon (Comfort, Tender, Easy, Silhouette): • Fewer failures • Insertion site is visible • Longer is more secure • Adjust angle to reach fat • Metal needles (Rapid-D or bent needle) • As comfortable and often more reliable • Very short, multi-needle infusion sets expected soon

27. Infusion Sets And Inserters Disetronic Rapid-D Smith’s Medical Cleo Animas Inset Medtronic Sil-serter Quik-serter

28. Site Supplies • Emla cream (Rx, 30 min wait) or ice cube • Set inserter: Cleo and Inset are self-contained, ezSerter, Quick-Serter, Sil-Serter, Sof-Serter • Adhesive: IV-3000, Hypafix, Tegaderm • Stickies: Skin Tac-H, Skin Prep • Tape: Micropore, Durapore, Band-Aid Blister Relief (wicking) • Sweating aid: Mastisol Spray (Detachol for removal), Skin Tac, Tincture of Benzoin, Skin Prep • Adhesive removal: Uni-Solve, Allkare

29. School Supplies • Meter, lancets, test strips • Glucagon, glucose tablets, or crackers for lows • Spare insulin, syringes or insulin pen • Spare infusion set and pump batteries • Ketostix or Precision Xtra to test for ketones • Information card with insulin-to-carb ratio, formula for corrections • Telephone numbers of parents, health care providers, and pump manufacturer's help line

30. How To Start

31. Starting On A Pump • Everyone is nervous • Read, read, read • Pumping Insulin, Kids Insulin Pumps And You (Animas), www.childrenwithdiabetes.com, www.pumps4kids.ca, etc, etc • Do lots of recording before and after start • Start to play with pump as soon as it arrives • Saline practice helps • Get telephone contacts: MD, CDE, pump company, pump rep, other parents

32. Helpful Attitudes And Habits • Be blatant about your diabetes • A pump is a tool, not a cure • Take a bolus for every bite • Change site as directed • Look for a solution for every problem • Write down a reason for every low and high • Test often

33. John’s Pump Rules • Total Daily Dose = weight in lbs / 4 • Basal Dose = 50% to 60% of TDD • Carb Factor = 500 / TDD • Correction Factor = 2000 / TDD • BG target = 90 to 120 mg/dl • Basal target = +/- 30 mg/dl • BOB = 20% per hour • Correction boluses = < 8% of TDD J Walsh and R Roberts: Pumping Insulin, 2005

34. Starting Insulin Doses J Walsh and R Roberts: Pumping Insulin, 2005

35. Carb Counting And Recording As Ways To Lower The A1c

36. Steps For A Better A1c • Carb counting – 0.6% • Givivg boluses based on an accurate carb count – 0.3% • Recording test results, carb intake, insulin doses, & activity – 0.5% • Monitoring often – 0.5-2.0% • Bolusing often – 0.5-2.0% • Contacting your doctor or adjusting your own doses when you encounter unwanted BGs

37. Carb Counting • Allows precise matching of carbs with boluses • Glycemic index, saturated fat, and high protein all play a role, but grams of carb is what controls the blood sugar after a meal • Easy!

38. fruit/fruit juice breads/bagels cereals crackers grains muffins rice potatoes/yams vegetables dessert/cookies/cake/pie ice cream/frozen dessert sweetened beverages milk/yogurt (not cheese) beer/wine honey/syrup/molasses jams/jellys/preserves -ose foods like sucrose (table sugar) Where Carbs Come From 1 gram of carb raises the BG 4 to 7 points!

39. How To Count Carbs • Food labels • Check portion size • Books • Dr’s Pocket Guide, Health Cheques • A gram scale plus carb factors • Carb factors are available in Pumping Insulin and are built into scales like the Salter computer gram scale

40. Blood Sugar Testing – 1921

41. Blood Sugar Testing – 2004

42. Blood Sugar Testing – 2004 “I just don't write down (log) anything. I hate to take the time to do it. I'd rather have a machine talk for me. I think it revolves around partial general laziness, as well as the constant reminder of being different from everyone else. I know other diabetics who won't even test when they're out with friends. They hate ….” The Artiste 6/28/04

43. Charting Improves Control • Needed to solve problems • Basis for better diabetes health care • ~0.5% drop in A1c Smart Charts Blood sugar, insulin, food, activity, stress

44. Better Charts, Better A1c • Charts • My Other CheckBook • Software • Meter companies • Internet: myhealthchannel.com • Pump Control Software • Meters, PDAs & Pumps • Pump: Deltec, Disetronic, Animas, Medtronic • Meter: BD, Therasense, Lifescan, Boerhinger

45. Analyze Carb Boluses • Count carbs • Give carb bolus • Eat • Record BGs • Analyze BGs • Balance better next time

46. Match Your Carbs With Boluses • Accounts for HALF the day’s control! • Keeps blood sugar normal after meals • Requires accurate carb counting and an accurate carb factor • 500 Rule provides a close estimate of carb factor if the TDD is accurate

47. 500 Rule To Find Carb Factor • Gives grams of carb covered by one unit of Humalog or Novolog • 500 / TDD = grams of carb per unit of insulin • Example: • Person’s TDD = 50 units • 500/50 = 10 grams of carb covered by 1 unit of Humalog or Novolog • Postmeal readings stay normal!

48. 2000 Rule To Find Correction Factor • Gives how far your blood glucose is likely to fall per unit of insulin over 5 hours • 2000 / TDD = # mg/dl your BG will fall per unit Example: • Person’s TDD = 25 units • 2000/25 = an 80 mg/dl drop per unit of H or Nov Adapted from 1500 Rule by Dr. Paul Davidson, Atlanta, GA

49. 2000 Rule 1600, 1800, 2000, or 2200 may be divided by TDD to get point drop per unit 1800 provides a good average --- 1600 Rule is more aggressive and gives more insulin, while a 2000 or 2200 Rule gives less insulin

50. New Devices • Data storage and download • Easy recording of BGs, insulin, carbs, activity • Automatic carb counting • Pattern recognition • Insulin dose guidance • Data analysis to improve control • Feedback that encourages use