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Back: How do I initiate a discussion about insulin pumps for patients who are good candidates?

By: Timothy S. Reid, MD
Department of Family Medicine
Mercy Diabetes Center
Janesville, Wisconsin

Insulin pumps are something that I discuss frequently with patients in my practice.  Patients come to me realizing that they are interested in insulin pumping or they have been struggling with their diabetes for many years and are looking for alternatives.   This is a great opportunity for the whole Diabetes Care Team to make a difference for a patient.  I see this as a potential turning point for patients looking to improve their diabetes care.

Insulin and how it is dosed is something that has a great deal of emotional burden associated with it.  Patients come to you with so many diabetes legacy issues.  They will have had family members or friends that have used insulin.  How these people from the past did with their therapy will many times color the perceptions of the patient in front of you.  It is important to engage your patient in a discussion about these feelings and perceptions.  Often patients will have more mis-information about insulin and the results of therapy than truth.  It is an excellent time to listen to your patient, clear up mis-perceptions and guide them to a therapy that will allow them to achieve their diabetes goals.

The discussion of the various therapies for diabetes should begin early in the patient’s care.  We discuss lifestyle interventions including exercise and nutrition therapy.  We talk about the oral medications that are available and how they work to leverage your physiology.  We talk about the injectable therapy, which at this point includes the amylin analogs, GLP-1 agonists and insulin.  I help the patient understand that each of these therapies can be appropriate at different times in their diabetes experience.  I also explain that most patients, if they live long enough, will likely require insulin at some point.  This is not a failure or weakness in any way….it’s just how the disease works on our bodies. 

There are three methods of insulin deliver that are commonly used; vial and syringe, pens and pumps.  I describe the spectrum for patients not making any one therapy seem excessive or exotic.  There are advantages and disadvantages for each of these modes of delivery.  I try to learn as much as I can about the patient, their lifestyle, work and struggles that they have had with their diabetes.  This helps me guide the patient to the therapy that I think will be most appropriate for them.  It is important to speak to your patient with confidence at this point.  If you approach them with any sort of misgivings or tentativeness, you can really damage this process.  The patient wants to know that you believe in this therapy.  Otherwise, you will be validating the fears and uncertainty that they may be having about the use of insulin.

Insulin pumping is simply another form of insulin delivery.  Most often, patients will have some experience with injection therapy.  They will probably understand the limitations of this therapy better than you do.  They will know what happens if they miss a dose or take it at the wrong time.  They will know what it is like to chase insulin with food.  They will also know the limits of physical activity placed upon them with their particular form of insulin therapy.  Listen for these clues as you counsel your patient.  Insulin injections are given at specific times to match the insulin’s action curve to the patient’s physiology, exercise and nutrition.  If anything changes, you likely have to modify the patient’s lifestyle to avoid complications of hyper- or hypoglycemia. 

An insulin pump gives the patient a great deal more flexibility to adjust their insulin for the current situation.  It is possible to adjust the insulin up or down depending on circumstances.  The currently available insulin pumps work on the basal-bolus model of insulin delivery.  We take the patients current total daily dose of insulin and do a calculation to determine the initial insulin basal and bolus settings.  The basal insulin is programmed into the pump by the physician or certified pump trainer.  All of the modern insulin pumps have some form of a bolus insulin calculator.  You count the carbohydrate load of the meal you are about to consume and check a blood sugar with your meter.  Those two pieces of information are used to determine a bolus insulin dose.  All of the pumps give the patient the ability to modify this dose after it is calculated.  They can choose to accept or modify this dose based on their experience.

There are some real advantages to insulin delivery with a pump.  From the basal aspect, you can customize the insulin delivery curve to closely match the patient’s needs.  Many patients require little insulin at night but more early in the morning as the Dawn Phenomenon occurs.  They may require more insulin through the mid-day into evening.  They may require significantly more or less insulin on work days vs. weekends.  When patients exercise, it is possible to turn the insulin dose down to avoid hypoglycemia.  All of this is possible with the basal programming in an insulin pump.  On the bolus side, patients regain a great deal of control over their meals….both timing and amounts.  They simply check blood sugars and bolus when they eat instead of being tied to the curve of the last insulin bolus a few hours ago.  I tell patients that the difference is simple, they adjust the insulin to match their life instead of the other way around.  It is really liberating for patients who are frustrated with their injection experience.

It is important to counsel your patient that the insulin pump is a tool that must be worked.  You cannot place it and forget it.  This is not a safe way to pump.  You have to be willing to check blood sugars 6-8 times daily and run the numbers through the bolus calculator.  You have to be willing to do the catheter changes and maintenance.  The catheter must be changed every three days.  Vigilance is key.  We use all rapid acting insulin in an insulin pump.  If it fails, you have the remainder of the rapid acting insulin’s curve before you are going to be experiencing the results of insulin deficits.  In patients with Type 1 diabetes, this can include DKA or worse.  Patients with Type 2 diabetes will experience significant hyperglycemia.

The patients who are likely to succeed with insulin pump therapy are motivated to improve their diabetes care.  They are willing to do the pump maintenance.  They will check their blood sugars 6-8 times daily and use those numbers to manage their insulin pump.  The successful patient will apply the knowledge they have gained from the CDE and Dietitian to correctly count carbohydrates.  They will contact their diabetes team at appropriate intervals to make adjustments to their therapy.  These patients see the insulin pump as a tool and not a cure. 

Patients who make likely pump candidates include those who struggle with injection therapy.  Despite checking blood sugars, exercising and monitoring their nutrition, they simply don’t get the results for all of that hard work with the injections.  Many times a pump will improve the situation.  Patients who exercise regularly and experience low blood sugars as a result can benefit from pump therapy.  Patients who have varied lifestyles….shift work, travel across time zones, heavy physical work….all can potentially see improvements with insulin pumps.  Children can be ideal pump candidates.  They are encultured  to push buttons.  They have cell phones, I-pods, video games….they are not intimidated by a pump.  Patients who are pregnant with diabetes are also excellent candidates of insulin pump therapy.  The tight control necessary for successful pregnancy outcome can be achieved with insulin pump therapy.

The process of moving a patient to an insulin pump varies from center to center.  The process that we use involves initial counseling as part of the office visit for diabetes care.  We get to know the patient over a few office visits.  We send them home with folders for the various insulin pumps that are available.  I ask them to read up on insulin pumps and bring their questions back for the follow up visit.  If the patient is interested and seems appropriate we will schedule them with the Certified Diabetes Educator for more comprehensive insulin pump teaching.  We schedule the patient with the Registered Dietitian for carbohydrate counting and dietary teaching.  If the patient has significant reservations or I sense that there may be emotional or behavioral issues with insulin pumping, I will have them see the Clinical Psychologist.  After these tasks are accomplished and the patient remains viable for insulin pumping, we will forward the paperwork to the pump company for processing.  The patient receives their insulin pump and meets with the Certified Pump Trainer from the individual company. 

The after care for patients who start insulin pumps is critical.  We have them phone blood sugars daily for the first week.  I usually make very few adjustments for the first few days as a pattern of blood sugars develop on the initial settings.  After that, we make basal and bolus adjustments to match the patients physiology.  We see the patient back at one week, one month and then quarterly.  I give new pump patients my cell number.  I rarely get calls but the patients know they can get help if they need it.  All of the pump companies have 800 numbers for customer service.  If there is a technical problem with a pump, they are able to help troubleshoot the problem. 

Most of the insulin pump companies have download programs associated with their pumps.  There is a great deal of good information that can be gained by downloading insulin pumps.  The blood sugars that are coded into the pump are printed out in graphic and log form.  There are statistics and analysis pages that are available for review.  The pump data will show basal and bolus profiles as well as deviations from the program.  The patient’s pump behaviors can also be reviewed.  There are ways to see how often the pump is suspended, how frequently manual boluses are done and how frequently the blood sugars are done and acted upon.  This is an excellent tool to use during the office visit.  Many times the patients will review the data also and have insights that improve the overall understanding of the pump experience for that patient.  I recommend using the download function on each pump that you support in your practice. 

Insulin pumps are an important part of the spectrum of diabetes care that we can offer for our patients.  It is important as clinicians to become familiar with the features and capabilities of the insulin pumps that we see our patients wearing.  We are in an excellent position as part of their Diabetes Care Team to help them achieve their diabetes care goals.