Insulin pumps & diabetic retinopathy, with a case report

1. Insulin pumps & diabetic retinopathy, with a case report David Kinshuck

2. Why is an ophthalmologist interested in insulin pumps? • Prevention or slowing of retinopathy • retinopathy still disabling

3. This patient asked…would an insulin pump help me?

4. This patient asked…would an insulin pump help me? Answer given: help you & and your eyes if you achieve better control, and it is likely to improve your control,in the long term

5. What is an insulin pump? • Battery operated pump size of mobile phone • Worn eg round waist • Insulin in a vial is injected (through a tiny tube) into cannula inserted under the skin • pump is is programmed to deliver insulin constantly • patient determines rate • no other insulin injections, but still need to test glucose levels 4-6 x day (& adjust infusion rate) • ‘bolus’ insulin at meal times (amount  size of meal) • basal rates otherwise (variable rate) • much more flexibility over your life • change cannula every 2 days (disconnect to swim etc)

6. 1968 DOB, 1976 IDDM • 1998 background retinop, 6/5, 6/5 • 1999 proliferative, lots of laser, HbA1c 7.9% • works at ……………. husband very helpful/positive2000 indirect laser, sight worse = macular oedema, cannot drive • 6/24 then 6/60 both eyes • HbA1c 7.3%, but widely fluctuating sugars • Insulin pump 2000 • 2002 retinopathy not active, minor problems only, working 6/24, well, controlled Patient: 1

7. All photos 2000

13. A bad result……. • Each patient with poor sight makes you think • was the laser OK? • diabetic control………..could we have done better? • European centres with good results have 2 monthly patient/DSN contact………how can we improve without this? • These clinics laser 1% diabetic patients, versus UK average 10% (Gouda, Holland) • 1/365 nurse/adult patient ratio (Holland), Good Hope 1/1333

14. Identifying progression of retinopathy • Exudates/oedema =leakage • New Vessels • An ‘early’ sign =haemorrhages • An increase in any of these • Photos useful for haemorrhages especially

18. Progressing………why?

19. Retinopathy is linked to: DCCT study 1% HbA1c = 37% progression rate

20. Retinopathy is linked to: 1mmHg = 1.1% progression rate

21. Retinopathy is linked to:

22. Retinopathy is linked to: Genetic = 25% Retinopathy Family history heart disease, stroke, blood pressure

23. Retinopathy is linked to: Smoking 20/day = 300% progression rate Passive smoker gets 25% of the smoke

24. Retinopathy is linked to: Statin reduces heart problems by 25-50% (estimate) Treat even if normal, especially if there are exudates

25. Retinopathy is linked to: ACE inhibitors reduce retinopathy by 50%

26. Retinopathy is linked to:

27. Retinopathy is linked to: Retinopathy progression

28. Retinopathy is linked to: Renal function decrease

29. Retinopathy is linked to: pregnancy

30. Progressing, HbA1c > 7.0%Why? • Suitable regime?………… young patients on bd insulin? • Basal bolus, but sugars fluctuate, hypos • This patient read about pumps and bought one herself • Do I mention pumps? • First patient’s retinopathy halted • Insulin pumpers web site, advice from retinopathy experts at European meetings

31. www.insulin-pumpers.org

32. Balance motivation resources the wrong time or an unenthusiastic patient

33. Flexible dose insulin regime • Pump probably best for very dedicated (and rich) patients (HbA1c 6.0-7.0%), controversial • Best results are if you test your blood sugar 4-6 times a day, and adjust insulin • A typical new regime: lantus (glargine) longacting insulin for basal insulin; analogue for meals (lispro/novorapid) • 5% of patients are already on this new regime • Should be able to achieve HbA1c 7.0% with good nursing help, without dangerous hypos

34. Patient 2

37. Patient 2 • 1969 DOB, 1977 IDDM • professional, lives alone, sports++++ • 1995 background retinopathy, 6/5, 6/5 • 1995 proliferative, bd insulin • 1995-99 lots of laser, 6000/burns/eye • 2000 HbA1c 8.4% • 2000 vitreous haemorrhage • mediocre control/severe hypo • proliferation continues, laser • 2001 Insulin pump, well, controlled, happy • 2002 retinopathy not active • 6/9 driving/sports…some problems

38. Patient 3 • 1968 DOB, 1984 IDDM • 1998 background retinopathy, 6/5, 6/5 • 1999 HbA1c 9.7% (similar for years, alcohol++) • 2000 maculopathy lasered, 6/5 • 2001 proliferative, lots of laser, HbA1c 8.0 • 2002 struggled with pump, HbA1c 7.6 • Insulin pump, making wrong decisions re insulin, not in contact with other IDDM patients • got married, HbA1c 8.1 • ischaemic maculopathy, will get worse • ACE inhibitor • ?would starting pump while intellectual function better have helped

39. Patient 4 • 1966 DOB, 1971 IDDM • 1999 proliferative retinopathy++, 6/5, 6/5 • 1999, lots of laser, HbA1c 7.7%, • smoked and stopped re retinopathy • weight increased • ? Using insulin to diet/food issues • HbA1c 7.7%, but widely fluctuating sugars • Insulin pump, a real struggle • 2002 6/12, macular ischaemia still, 7.3% • retinopathy less active • would have had poor result without

40. What should we achieve? the wrong time unenthusiastic patient resources motivation Support people here Help change behaviour May have no choice to accept

41. Summary • 5 patients, have HbA1c about 1% less or fewer hypos • 4 with stable or nearly stable retinopathy • Many others not keen on pump • Hard work for 3, real struggle for 2 (& DSNs) • All have severe retinopathy scarring • Logically, better control earlier would be best • Improved decision making without retinopathy? (re patient adjusting own insulin) • 10 years behind European centres • Need 1-2 monthly contact with DSN • Desperately short of DSNs (& pumps)