Insulin pump therapy

Continuous subcutaneous insulin pump therapy, a newer modality of treatment in both type 1 and 2 treatment.

1. Insulin Pump Therapy Presented by Dr. Lala Shourav Das DEM Student Department of Endocrinology BIRDEM

2. Case Scenario (1) M rs. X, a 51 years old home maker, suffering from type 2 DM for past 3 years is on oral antidiabetic drugs (Metformin + Vildagliptin) along with multiple insulin Injection therapy. Her Problems: Fluctuation of Blood glucose levels (eg: 5-6 mmol/L in fasting, 16-19 mmol/L in AL) High HbA1c level: 10.8% H/O Mid night hypoglycemia Difficulty in taking different insulin doses in different times of the day.

3. Case Scenario (2) M aster Y, 13 years old Type 1 diabetic for 2 years, active, school going young patient with lots of daily physical activity (like cycling, playing football etc.) in currently on multiple insulin injection therapy. His parents complaints about: Fluctuation of Blood glucose levels, particularly after physical activity. High HbA1C level (Always above 10%) H/O Hypoglycemic episodes.

4. What more we can do for these type of patients? Diabetic Education Nutritional Advice Life style modification Adjustment of Drug regimen And if possible… Maybe an artificial “Pancreas”??? Insulin Pumps

5. What is insulin pump? An insulin pump is a medical device used for the administration of insulin in the treatment of diabetes mellitus, also known as continuous subcutaneous insulin infusion therapy . A traditional pumps includes : the pump (including controls, processing module, and batteries). a disposable reservoir for insulin (inside the pump). a disposable infusion set, including a cannula for subcutaneous insertion (under the skin) and a tubing system to interface the insulin reservoir to the cannula.

6. I nsulin pump therapy: Advantages VS disadvantages Disadvantages: Costly. (BD: 1.6 Lac to 8 lac approximately) Need education, Training and motivation to operate. Risk of DKA if pump failure occurs. In sick days, management might not appropriate. Advantages : Better glycemic control and control of variability by dosing insulin accurately. No need of multiple daily insulin injection. Only rapid acting insulin is used. Avoidance of Dawn’s Phenomenon. Carbohydrate counting to improve the dietary restriction significantly. Improved Quality of Life ( QoL ).

7. Goal of therapy Realistic Goals & Expectations: Better Glucose Control Flexibility in life style Avoidance of frequent hypoglycemia Able to do exercise without having hypoglycemia Unrealistic Goals: Don’t need Insulin for treatment Don’t want to monitor Blood glucose ever again. Don’t have to worry about diabetes and don’t need to carry diabetes supplies anymore.

8. Building up patient’s confidence Myths Facts You have to know a lot about technology to use a pump Successfully managing your glucose with pump is often as easy as entering blood sugar and meal information then pressing enter. Pump will stop patient from being active With sturdy design and ability to be tightly secured to body, insulin pumps allow you to participate physical activity you enjoy. Wearing a insulin pump is uncomfortable and painful The pump infusion site should not cause any pain. Most of the patients even forget they are wearing pump until then need to deliver a bolus dose. Pump is a constant reminder of Diabetes According to study, pump give patients confidence, level of control and flexibility that no other insulin regimen can provide.

9. Indication of Insulin Pump therapy Elevated A1C Glycemic Variability Recurrent Hypoglycemia, Nocturnal Hypoglycemia, Activity Induced Hypoglycemia. Recurrent DKA/Hospitalizations. Large total daily dose. Meal time Flexibility. Gastroparesis. Inability to self administer insulin (Pre-school/Grade School) Inability to Predict Food or meal intake (Infant/Toddler)

10. Initiation of Insulin pump therapy Patient’s need to be trained up regarding insulin pump therapy. Phase 1: Introduction to insulin pump therapy. Balancing glucose and insulin Managing pump therapy How to calculate boluses Phase 2: Start insulin pump, along with support from pump manufacturing company’s health care provider’s assistance. Phase 3: Ongoing support from Doctor and Health care provider and monitor response and feedback. Phase 4: Continuing education.

11. Insulin doses in pump therapy: Total Daily Dose: The total amount of insulin (Basal + Bolus) delivered by insulin pump each day. Basal Insulin: A continuous infusion of insulin to cover hepatic glucose production. (NB: Short acting insulin is used) Bolus Insulin: Insulin given on demand to control meal related glucose peak. Total Daily Basal: Total amount of basal insulin delivered over 24 hours. Total Daily Bolus: Total Amount of bolus (Food + Correction) delivered over 24 hours.

12. Calculate Total Daily Dose:

13. Calculate Total Daily Basal & Bolus

14. Calculating Basal Rate

15. Bolus Dose adjustment (Method: Simple Dosing)

16. Bolus Dose adjustment (Method: Carbohydrate Counting) Insulin sensitivity factor (ISF) : also known as correction factor, which means how much 1 unit of insulin will lower BG during the duration of insulin action. Insulin to Carb ratio: means how many gram of carbs are treated by 1 unit of insulin.

17. Bolus Dose adjustment (Method: Carbohydrate Counting) Divide by 18 to get value in mmol/L/1unit

18. Calculating Bolus Dose

19. Insulin Pump Settings Calculation Form

20. Insulin Pump setting adjustment form

21. Experience from an early adopter of insulin pump therapy in Bangladesh

22. Prof. Md. Faruque Pathan sir is one of the early adopter of insulin pump therapy since it’s introduction by Medtronic in Bangladesh.

23. Experience shared: Significant reduction of daily insulin requirement after switching to insulin pump therapy (~20U TDD) from Basal Bolus therapy (20U Basal + 24 unit Bolus). Easy adjustment and comfortable, suits with busy life style. Total cost: Insulin related cost has been reduced as only short acting insulin in needed and due to reduction of dose. Accessories like delivery system costs approximately 5000/6000 taka per month. Device: Over the period of use, once device needed to be replaced and battery needed to be replaced on 1-3 monthly basis. Sick day management: only uses basal therapy and low dose of bolus if needed. Barrier of implementation: High cost and lack of motivation.

24. Insulin Pump manufacturers Pump System/Device Manufacturers Accu-Chek Spirit Combo Roche Diagnostics MiniMed ® 530G, 630G and MiniMed ™ 670G ( The world’s first hybrid closed loop system. FDA approved) Medtronic diabetes Dana Diabecare II Sooil Tandem t:slim Insulin Pump Tandem Diabetes Care

25. In the end, we can only hope insulin pump therapy will one day become a cost effective and user friendly medical regimen of diabetes for the low income population of developing countries like Bangladesh. With Dr. Scott W. Lee, MD & Prof. Faruque Pathan Sir, on a workshop arranged by Medtronic.

26. Reference: ADA guideline, 2018 Davidson's Principles and Practice of Medicine 23rd Edition 2018 UpToDate.com Diabetesnet.com Medtronic Diabetes , A Simplified Guide to Insulin Pump Therapy Initiation and Medical Management. PDF : https://go.spyluv.com/medtronics

27. Thank you.