Healthcare Across Borders - September 2003 Introduction To Pumping Introduction To Pumping Starting And Success Starting And Success John Walsh, P.A., John Walsh, P.A., C.D.E. C.D.E. North County North County Endocrine Endocrine 700 West El Norte 700 West El Norte Pkwy Pkwy Escondido, CA 92126 Escondido, CA 92126 (760) 743-1431 (760) 743-1431 or The Diabetes Mall or The Diabetes Mall (619) 497-0900 (619) 497-0900 [email protected][email protected]m Children With Diabetes Children With Diabetes Toronto, August 17, 2007 Toronto, August 17, 2007
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Healthcare Across Borders - September 2003 Introduction To Pumping Starting And Success John Walsh, P.A., C.D.E. North County Endocrine 700 West El Norte.
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Healthcare Across Borders - September 2003
Introduction To PumpingIntroduction To PumpingStarting And SuccessStarting And Success
John Walsh, P.A., C.D.E.John Walsh, P.A., C.D.E.North County Endocrine North County Endocrine 700 West El Norte Pkwy 700 West El Norte Pkwy
Escondido, CA 92126Escondido, CA 92126 (760) 743-1431 (760) 743-1431
or The Diabetes Mall or The Diabetes Mall (619) 497-0900 (619) 497-0900
Children With Diabetes Children With Diabetes Toronto, August 17, 2007Toronto, August 17, 2007
Healthcare Across Borders - September 2003
Highlights
Why Pump?
Who’s A Candidate?
Pump Basics
Brands And Features
Smart Pump Advantages
Infusion Sets
How To Start
Settings That Affect Control
Wrap Up
Healthcare Across Borders - September 2003
Origins
The first insulin pumps appeared in 1978 when large portable chemotherapy pumps were converted to deliver insulin
Autosyringe AS2C and Harvard Apparatus Mill Hill Infuser were early models
Used large 50 ml syringe that required users to dilute insulin to U-36 or U-18
Had only one basal rate and no memory
1976 Biostator (top) and 1978 Autosyringe AS2C –>
Healthcare Across Borders - September 2003
Reasons To Use A Pump
Healthcare Across Borders - September 2003
Better Control –> Fewer Complications
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40
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RetinopathyProgression1
Laser Rx1 Micro-albuminuria2
Albuminuria2 ClinicalNeuropathy3
Conventional
Intensive
76%76%Risk ReductionRisk Reduction
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1. DCCT Research Group, Ophthalmology. 1995;102:647-661
2. DCCT Research Group, Kidney Int. 1995;47:1703-1720
3. DCCT Research Group. Ann Intern Med. 1995;122:561-568.
Healthcare Across Borders - September 2003
Poor Control Remains A Problem HbA1c
10%
9%
8%
7%
6%
ADA
EASD/AACE
ADA = American Diabetes Assoc., IDF = Inter. Diabetes Federation, EASD is European Assoc. for the Study of Diabetes, AACE = American Association of Clinical Endocrinologists
Novo Nordisk Type 2 diabetes market research, Roper StarchWright A., Burden et al, Diabetes Care 2002; 25:330–336Turner RC, Cull et al, JAMA 1999; 281:2005–2012
2/3 with diabetes (and most pumpers) remain out of control
Glycemic Index: Different Carbs Have Different Speeds
From Gary Scheiner, MS, CDEFrom Gary Scheiner, MS, CDE
Fast
Breads/Crackers
Salty Snacks
Potatoes
Rice
Cereals
Sugary Candies
Slow
Pasta
Legumes
Salad Veggies
Dairy
Chocolate
Average
Fruit
Juice
Pizza
Soup
Cake
Healthcare Across Borders - September 2003
Duration Of Carb Action
Most carbs have most of their affect within 1 to 2.5 hours
But delay can occur with complex carbs, more fat content, etc
0 hrs 1 hr 2 hrs 3 hrs 4 hrs
High GI
Med GI
Low GI
Healthcare Across Borders - September 2003
Pump As Carb Counter
Pump or external controller contains user-selected food list for accurate carb counting
• Easy carb calculation• More accurate boluses
Available in Animas 2020, Deltec Cozmo, PDM for Omnipod, and PDA for Spirit
Healthcare Across Borders - September 2003
Carb Factor
Carb factor – how many grams of carb are covered by 1 unit
Carb bolus is based on:
• Your carb factor
• How many grams of carbs you plan to eat
• Your BG allows a correction bolus determination
• Amount of BOB still active (ALSO determined from BG!)
A pump can determine the bolus needed for a meal when the carb count and the carb factor are accurate
Visit your dietician to learn!
Healthcare Across Borders - September 2003
Check Your Carb Boluses
Does your carb factor work for LARGE meals? – half your weight (lbs) as grams of carb
Are carb counts accurate?
Are boluses given 20 min before meals when the glucose is normal?
For frequent lows after meals –> raise carb factor #
For frequent highs after meals –> lower carb factor #
Healthcare Across Borders - September 2003
Carb Bolus Varieties
Normal carb bolusBolus taken immediately – most meals
Extended or square wave bolusBolus extended over time – gastroparesis
Combo or dual wave bolusSome now, some later – bean burrito,
some pastas and pizzas, Symlin
Healthcare Across Borders - September 2003
Most Carbs Much Faster Than “Rapid” Insulin
% bolus activity remaining
From From Pumping InsulinPumping Insulin
Take Home: Bolus 15 to 30 minutes before meals Use extended and boluses sparingly.
Time over which most meals affect the BG
One hour after a meal, half of a meal’s glucose rise has occurred, but 80% of rapid insulin activity remains
Healthcare Across Borders - September 2003
Importance Of Bolus Timing
Figure shows rapid insulin injected 0 min, 30 min, and 60 minutes before a meal
Normal glucose and insulin profiles are shown in the shaded areas
Healthcare Across Borders - September 2003
Bolus Timing Depends On Glucose
Premeal BG
Bolus Timing
LowUse fast carbs, check BOB, and give carb bolus at start of meal
Normal Bolus 15 to 20 minutes before meal
HighGive carb bolus and correction boluses early but don’t forget to eat!
Check blood sugar 2 hours later to verify dose
Healthcare Across Borders - September 2003
Missed Boluses Cause High A1cs
• Start well– give a bolus for every bite!
• Use pump reminders or other reminder
• Review pump history once a week and work toward increasing the number of boluses
• Work toward solutions without blame
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8.88.9
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Before 6 mos
Control+Rmindr
48 youth in poor control (A1c > 8%). All put on a Deltec Cozmo pump, with half using reminders. Significant reduction for reminder at 3 mos but no difference after 6 mos.
H. Peter Chase et al: Diabetes Care 29:1012-1015, 2006
Healthcare Across Borders - September 2003
Correction Factor
Correction Factor – how many mg/dl (or mmol) the BG falls per unit of insulin
Lets a smart pump determine the bolus needed to bring a high blood sugar to target
Test to ensure accuracy – Does a correction bolus lower a high glucose safely to your target in 4-5 hrs?
Healthcare Across Borders - September 2003
When BG Goes High, Keep All Culprits In Mind
Bad infusion set or site
Bad insulin
Inaccurate carb counts
Rebound from stress hormones
Empty refrigerator syndrome
Hypobolusemia
Stress
Pain
BG
Healthcare Across Borders - September 2003
Bottom Line
If you don’t have great control on a smart pump, your pump settings are likely off.
Healthcare Across Borders - September 2003
Where Next?
Faster insulins – Biodel Viaject
Can the loop be totally closed?
Dual delivery pumps
Healthcare Across Borders - September 2003
Wrap Up
Pumps offer the latest technology for precise insulin delivery
Benefits include more flexibility, less hypoglycemia, less glucose exposure and variability, and a healthier life
Requires commitment & responsibility
Training and follow-up is required to ensure safe and effective treatment