Insulin Pump Therapy – A Shared Journey

1. Insulin Pump Therapy –A Shared Journey Heather Maxwell Diabetes Specialist Nurse Insulin Pump Service Greater Glasgow & Clyde

2. NICE Guidance No.57 “Insulin pump therapy is considered as a treatment option for people with Type1 diabetes for whom multiple dose insulin therapy has failed and who have the commitment and competence to use CSII therapy effectively” Feb 2003

3. NICE Guidelines • Unable to achieve an HbA1c of <7.5% (<6.5% with microalbuminuria) with disabling hypoglycaemia • Failed MDI (using basal analogue insulin where appropriate) • CSII should be initiated only by a trained specialist team…physician, DSN and dietitian

4. NICE Appraisal Document on CSII • CSII an option for all adults (including pregnancy and adolescents • MDI has failed using insulin analogues • CSII recommended for younger children <11yrs • People who experience Hypoglycaemia resulting in persistent anxiety that is associated with poor quality of life • HbA1c >8.5% alone is indication for CSII • CSII not recommended for people with Type 2 diabetes

5. Insulin Pump Implementation Process Referral/Assessment NICE criteria Watch DVD…experiences shared Final decision made by pat. Choose pump & place order for pump Pre-pump preparation Attend CHO counting session Pump start date/pump button practice • Pump start day… (0930hr-14.00hr) DSN led • Intensive training in basic aspects of using the pump • Discuss suitable infusion set…pump on…lunch • Understanding basal and bolus rates • Guidelines for Hyperglycaemia treatment • Guidelines for Hypoglycaemia treatment • Guidelines for sick day rules • Blood glucose targets and adjustment of basal rates

6. Pump start day continued… Discuss HCP/pump user communication over next 48 hours Contact numbers given All paper work completed Discuss number of blood glucose tests required over 48 hours Follow Up Appt for patient on day 3 Assess blood glucose readings Discuss difficulties over last 24 hours Pump user re-site infusion set and re-start pump Follow Up Review diabetes management on pump Confirm if patient wishing to continue pump therapy Reflective diary discussion (QOL) Follow up appointment at pump and routine clinic Letter to GP Document in notes Questionnaire (when audit necessary)

7. Benefits of Insulin Pump Therapy • Decreased variability of insulin absorption • Absorption of long acting insulin via injection varies by up to 52% • Accounts for up to 80% day to day variation in BG • Absorption of rapid acting insulin via pump varies < 3% *(Insulin reduced by 30% on first day) • Infusion set in one site 2/3 days

8. Pump Therapy • Mimics physiological • insulin requirements • Reduced insulin requirements • Lower plasma insulin levels • Flexibility in lifestyle

9. Exact dosing of insulin • Basal rates changed half hourly • Adjusted in 0.05 unit increments • Temporary basal feature • Boluses calculated on BG level, CHO, insulin sensitivity, active insulin • Boluses -immediate or protracted • Can be adjusted in 0.1unit increments

10. The Process of Transition Denial What impact will this have? How will it affect me? This can work At last something’s Going to change Disillusionment I’m off..... This is not for me! Can I cope? Change? What change? I can see things getting better Moving forward There’s more to this than I thought Happiness What have I got myself into? I’ll make this work If it kills me! Fear Anxiety Gradual acceptance Threat Depression Hostility

11. 400 Day 1: ICT Day 2: ICT 300 Tissue Glucose (mg/dl) 200 100 Day 3: CSII 0 400 800 1200 1600 2000 2400 Blood Glucose Profiles with CSII Glucose measurements over 72 hours in the change phase from MDI to CSII A. Behre u.a.: 36. DDG Tagung Aachen, Abstract 19-01 in Diabetes und Stoffw. 10 Suppl.1 (2001), 126

12. Any Questions?