Pump Basics Steps to Success

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Pump BasicsSteps to Success
Florida Academy of Physician Assistants Orlando,
FL March 1, 2013

• John Walsh, PA
• Advanced Metabolic Care Research
• 700 West El Norte Pkwy
• Escondido, CA 92126
• [phone] jwalsh_at_diabetesnet.com

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Disclosure

• Book sales all pump companies
• Advisory Boards Agamatrix, Tandem Diabetes,
  Unomedical
• Consultant Bayer, Accu-Chek, Medingo
• Speakers Bureau Tandem Diabetes
• Instructor JJ Diabetes Institute
• Sub-Investigator Glaxo Smith Kline, Animus,
  Sanofi-Aventis, Bayer, Biodel, Dexcom, Novo
  Nordisk
• Pump Trainer Accu-Chek, Animas, Medtronic
• Web Advertising Sanofi-Aventis, Sooil,
  Medtronic, Animas, Accu-Chek, Abbott, etc.

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Highlights

• Reasons To Use A Pump
• Whos A Candidate?
• Brands And Features
• CGMs
• Infusion Set Choices
• Pump Start
• The Future

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Talk The Talk

• TDD total daily dose of insulin (all basals
  and boluses)
• Basal background insulin released slowly
  through the day
• Bolus a quick release of insulin
• Carb bolus covers carbs
• Correction bolus lowers high readings
• Bolus On Board (BOB) bolus insulin still active
  from recent boluses
• Duration of Insulin Action (DIA) time that a
  bolus will lower BG used to measure BOB

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Reasons To Use A Pump
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Better Control gt Fewer Complications
76 Risk Reduction
59 Risk Reduction
39 Risk Reduction
54 Risk Reduction
64 Risk Reduction
60

• 55.0

50
Conventional
Cumulative Incidence ()
Intensive
40
30
29.8

• 23.9

20
16.4

• 13.4

10
13.0
7.9

• 5.1

5.0
2.5
0
Retinopathy
Laser Rx1
Micro-
Albuminuria2
Clinical
Progression1
albuminuria2
Neuropathy3

1. DCCT Research Group, Ophthalmology.
   1995102647-661
2. DCCT Research Group, Kidney Int.
   1995471703-1720
3. DCCT Research Group. Ann Intern Med.
   1995122561-568.

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Lower BGs Reduce Heart Attacks Nerve Damage

• EDIC study followed DCCT participants after it
  ended in 1993
• For over 12 years, A1c levels in intensive and
  conventional control groups have been identical
  7.9 (was 7.4 and 9.1).
• Heart attacks and strokes cut in half (46 vs 98)
  in intensive control, even though A1c levels were
  identical since DCCT end.
• Also 51 less neuropathy
• Take Home DCCT intensivecontrol provided 6 yr
  advantage.
• Near normal glucose is neededlong-term.

Avg A1c 7.9
1. EDIC Study Group presentation at 2005 ADA,
K.M. Venkat Narayan Clinical Diabetes 2488-89,
2006 2. Diabetes Care, Vol 29, No. 2, pp. 340-344
8
The Challenge Of DiabetesBringing the A1c down
smoothly takes effort
300 (16.7)
Controlled A1C lt7
BG in mg/dL (mmol)
200 (11.1)
A1C 6
100 (5.5)
Normal A1C 46
0800
1200
1800
0800
for this you need ADVANCED therapy
Courtesy Tim Bailey, MD, FACE, CPI
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Glucose Exposure Variability
Variability or Swing
Standard deviation or GlycoMark test
Exposure or Average
A1c or avg. BG from meter
Insulin pumps reduce both glucose exposure and
variability
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Many Things Affect The Glucose
InsulinAmylin
Exercise
Dawn Phenomenon
Insulin resistance
Eating
Stress
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No Blame For Maximum Gain

• Diabetes is a daily challenge
• Many things change the glucose
• Management can be confusing and difficult
• So
• Focus on problem solving for best results
• Positive discipline is needed kids and teens
  need regular monitoring (glucose and parental)

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Pump Advantages

• More reliable, precise insulin action
• Ease of use (fewer missed doses)
• Less insulin stacking
• Fewer lows, especially at night
• Easier to exercise
• Less glucose exposure and variability
• Less insulin
• Matches variable basal insulin need
• Less social limitation
• Better data access for HCPs and parents

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Basals And Boluses From Pump
Bolus
Flexible basal from pump
Flat basal from Lantus or Levemir

• A pumps basals and boluses provide a better match

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Basals And Boluses
Temp basal reductionfor exercise

• A pumps basal delivery provides a better match
  for lifes needs

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Better Control Of Dawn

• Glucose levels between 2 and 8 am in 12 type 1
  diabetics (mean age 30 2 years mean diabetes
  duration 11 2 years HbA1 8.9 0.3 ) on
  pumps compared to 8 healthy probands

Graphic from http//www.insulinpumptherapy.co.uk
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Less BG Variability, Less Insulin

• Graphic from http//www.insulinpumptherapy.co.uk

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CSII vs MDI in Adolescents

• Insulin pump therapy is an effective alternative
  to injection therapy in a large paediatric
  diabetes clinic setting. Even very young patients
  can utilise CSII to safely lower HbA1c levels.
• Improved diabetes control was achieved without
  increasing daily insulin doses and with a
  decrease in the frequency of severe hypoglycaemic
  events (p0.05 vs prepump, all three ages
  combined).
• Significant and consistent reduction in mean
  HbA1c levels after 12 months of CSII. (plt0.02 vs
  prepump).
• Remarkable effectiveness of CSII in our youngest
  patients indicates that childs age should not be
  a barrier

Boland et al 2000, n75
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Who Is A Pump Candidate?
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People Choose Pumps For

• Convenience
• Better lifestyle
• Less hypoglycemia
• Feeling better
• Flexible insulin delivery
  exercise, skipping meals
• Less hassle and anxiety with erratic schedule,
  college, shiftwork, travel, time zones
• Fewer long-term complications

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Ideal Pumper Requirements

• Willing and able to
• Check BG 4 or more times a day
• Count carbs or quantify food intake
• Keep written records or download meter/pump
• Solve problems
• Adjust basals and boluses
• Keep clinic appointments

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Frequent Monitoring For Success
Atlanta Diabetes Associates study 378 patients
sorted from a database of 591 PumpsMM 511 or
earlier BG Target100 C peptide lt0.1
HbA1c5.995.32 / (BGpd1.39)
ADA lt 7
AACE lt 6.5
P. Davidson et al Diabetes 53 (suppl 2)
abstract 430-P, 2004
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Infants Toddlers

• Little ones are ideal pump candidates
• Delay or split boluses for fussy eaters
• Fast insulin change for erratic activity
• Precise doses 0.025 basal and 0.05 bolus
  assists infants who cannot convey hypoglycemia
  symptoms and have frequent illnesses

Back Buddy
Pump between shoulder blades, lock-out to avoid
self dosing
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Kids Teens

• Better match for growth spurts, hormone
  changes in puberty, Dawn Phenomenon
• Easy snack coverage
• TDD and bolus history enable consistent dosing
  and monitoring by parents
• Fast basal and bolus adjustments for
  exercise
• Less impact of BG swings on top of peer pressure,
  struggle for independence, mood swings, college,
  and issues with alcohol, sex, drugs

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Un/Realistic Expectations
Unrealistic Realistic
The pump will cure my diabetes Ill feel better if I improve my control
I wont have to test as much I must monitor frequently
I can eat anything I want Ill have more freedom in my food choices
My blood sugar will be perfect I will have better control with fewer lows
It will be as easy to learn as a meter It takes time to learn and adjust a pump
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Pump Challenges

• Insulins still too slow
• Infusion sets can fail
• Steeper learning curve
• Hassles
• Trouble shooting
• Wearing devices
• More back-up supplies
• You must sometimes override bolus recommendations
  to outsmart smart pump

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Glucagon And Keto-Diastix

• Insulin Pump Essentials
• Glucagon
• Keto-Diastix

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Glucose Goals
Age-Appropriate A1c And Meter Goals Age-Appropriate A1c And Meter Goals Age-Appropriate A1c And Meter Goals
Age A1c Approx. Avg. Meter Glucose
Less than 6 7.5 to 8.5 168 to 197
6 to 12 8 or less 183 or less
Over 12 7.5 or less 168 or less
Over 19 7 or less 154 or less
AACE Over 19 6.5 or less 140 or less

• If only premeal readings are done, meter
  average needs to be lower than these values.

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Quick Glucose Goals
Quick Meter Goals Quick Meter Goals Quick Meter Goals Quick Meter Goals Quick Meter Goals
Age 0-6 yrs 6-12 yrs 12-19 Adult
Average meter BG lt 185 lt 175 lt 165 lt 155

• If only premeal readings are done, meter
  average needs to be lower than these values.

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Ways To Get To Goal
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Pump Brands And Features
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Which Pump? Consider

• Look, feel, color, skins, wearability
• Reminders, child block, waterproofing
• Basal and bolus increments
• Infusion set options
• Customer support
• History, ease of data download
  and analysis
• Meter and CGM integration, remote bolusing,
  covers, cases, PDA, smart phone

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Major U.S. Pumps 2009

Roche Accu-Chek Spirit (Combo)
Lifescan Animas Ping
Insulet Omnipod
Medtronic Paradigm 522/722 RT
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Accu-Chek Spirit

• Boluses based on BG, not BOB
• Strong motor and delivery
• 300 units
• 0.1 u basal bolus increments
• Tactile buttons
• Accu-Chek Pump Configuration Software with fast
  download
• Reversible display
• IR control from optional Palm or phone
• 1,000 Calorie King database in PDA

Future CGM Accu-Chek
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Animas One Touch Ping

• One Touch meter
• Auto BG entry
• Bolus directly from meter
• High contrast color screen
• Smallest basal increment, 0.025 u
• 200 units
• Waterproof 12 ft for 24 hrs
• ezCarb meal bolus calculator
• ezBG correction bolus calculator
• ezBolus shortcut to give bolus
• Carb/food database

Future CGM Dexcom
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Insulet Omnipod

• No tubing, easy wear
• Fewer infusion set problems ?
• Auto cannula insertion priming
• Remote bolus from controller
• Direct BG entry from Freestyle
• 200 units
• Only 72hr use (8 hrs basal)
• Watertight
• 1000 food database
• Smaller startup, larger overall cost

Future CGM Dexcom, Navigator
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Medtronic Paradigm

• Built-in CGM display eliminates one device
• Simple
• Direct BG entry from One Touch meter
• Proprietary infusion sets
• History via CareLink online software
• 176 or 300 units

Paradigm RT
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CGMs
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CGM Ingredients
Sensor
Receiver
Transmitter

• Dexcom sensor on left, Comfort infusion set on
  right from insulinfactor.com

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Cont. Glucose Monitoring (CGM) Systems
Abbott FreeStyle Navigator
DexCom SEVEN PLUS
Medtronic MiniMed Paradigm REAL-Time
Medtronic Guardian REAL-Time and I-Port also
available.
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CGM/Pump Alignments
Pump Animas Insulet Medtronic Accu-Chek
CGM Dexcom 7 Navigator Paradigm RT Accu-Chek
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Abbott FreeStyle Navigator

• 5-day sensor
• Glucose readings every 1 minute
• 10-hour warm-up period
• FreeStyle meter built into receiver

1. FreeStyle Navigator Product Fact Sheet.
Abbott Diabetes Care 2008. 2. FreeStyle
Navigator Product Brochure. Abbott Diabetes
Care 2007.
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Medtronic Paradigm RT System
CGM
Paradigm Insulin Pump
Paradigm REAL-Time System
(Model 522/722)
3-Day CGM
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DexComTM SEVEN Plus
7-Day CGM
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CGM Benefits

• Increased security from alarms alerts
• Immediate feedback look and learn
• BG trend provides moreinfo than static readings
• Control safety

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Trends Better Than Points
No clue what to do
Insight
Photo courtesy Bernard Farrell
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CGM Concerns

• Inaccurate at times
• Alarm overload
• CGM fingerstick value
• Lag time (some CGMs)
• Requires calibrations
• Fingerstick required before dosing
• Extra devices on and off skin
• Forget 12 to 25 year olds? (JDRF CGM Study)

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How Long To A Closed Loop?

• Still needed
• Faster insulins
• Better CGM accuracy
• Less sensor lag time
• Glucose control algorithms that wont fail
• Closing the loop will come in small steps over
  time

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Infusion Sets
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Infusion Sets

• Infusion sets, the weakest link, are a common
  source for unexplained highs
• Causes
• Poor set design
• Not using tape on infusion line
• Inadequate training
• Poor fit

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Infusion Sets

• Why infusion sets fail
• Partial/complete pullouts
• Leaking around Teflon to skin (common)
• Loose hub
• Pets
• Punctures
• Occlusions

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Infusion Set Choices

• Straight-In

• Slanted

• Metal

Rapid-D/Contact
Comfort/Tender/Silhouette
Inset
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Infusion Sets

• Three varieties
• Metal
• Slanted Teflon
• Straight-in Teflon
• Three connections
• Omnipod 1 auto-inserted
• Paradigm 4 varieties
• Luer lock 25 varieties

Pump success depends on reliable and comfortable
infusion sets
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Set Inserters
MiniMed Quik-serter
Deltec Cleo
Animas Inset
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Anchors Not Just For Boats!!!

• 1 tape on infusion line
• Stops movement of Teflon under the skin
• Stops unexplained highs from insulin leaksto
  skin surface
• Less irritation
• Prevents pull outs
• Tugs on Teflon
• Lose tape not insulin!

No anchor!
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Tapes

• 1 tapes
• Micropore
• Durapore
• Hypafix
• Blenderm

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Tackies

• Toupee glue
• Skin-Tac
• Mastisol
• Remove with Goo Gone or Detechol

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Sterile Technique For Site Prep

• Methicillin-resistant staph aureas (MRSA) is
  common 30 of people are constant staph
  carriers and 25 intermittent.
• PREVENT infection
• Wash hands
• Dont breathe on site
• Sterilize skin with IV Prep
• Place bio-occlusive IV3000 over site
• Insert infusion set through IV 3000
• Staph carriers can reduce or eliminate staph
• Use antiseptic soap over entire body once every
  1-2 weeks
• Periodically, apply bacitracin ointment to inside
  of nose

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Pump Start
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Prepare

• Use basal/bolus approach with injections
• Count carbs accurately
• Read Pumping Insulin manual
• Practice with pump as soon
  as it arrives
• View DVD as you practice with
  your pump
• Get training in operation andtroubleshooting

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Smart Pumps Arrive Dumb

• Pump settings must be individualized
• Basal rates, carb factor, correction factor, DIA
• For good boluses, the bolus calculator needs
• Current BG value
• Accurate CHO counting
• Dont become too dependent on your bolus
  calculator
• Use temp basals, combo boluses, etc. for
  appropriate situations

Both critical
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Prepare

• When to discontinue the long-
  acting insulin
• Prescriptions for insulin, test strips, IV Prep,
  IV 3000 dressings, etc.
• Contact info (phone, email) for MD, CDE, pump
  company, pump rep, other pumpers

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Initial Pump Settings

• TDD (total daily insulin dose)
• Basal/carb bolus balance
• Carb factor
• Correction factor
• DIA

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Steps For Success

• Test often
• Keep records (Smart Charts, download, etc)
• Find your optimum TDD
• Start basals as half of optimized TDD
• Determine starting carb factor with 450 Rule
  (450/TDD) and correction factor with 2000 Rule
  (2000/TDD)
• Use a realistic DIA 4 to 6 hrs
• Find solve reasons for highs and lows
• Change infusion sets on schedule and when
  unexplained highs occur

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Steps To Control

• Stop lows first
• Take a bolus for every bite
• Except for carbs used to treat a low BG
• Or for carbs used to compensate for exercise
• Check BG before every bolus Stop blind bolusing
• Bolus 15 to 30 min before meals if possible
• Periodically check basal/carb bolus balance
• Look for and correct unwanted patterns

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Stop Lows First
X highs caused by lows
X
X
X
X
X
X
X
Red line 80 mg/dl (3.3 mmol)
Frequent lows show this person needs less insulin
with new basal rates, carb factor and correction
factor derived from this Optimal TDD.
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Your TDD Needs To Change For

• Changes in diet
• Loss or gain of weight
• Seasons
• Changes in activity
• Seasonal sports
• Vacations
• Growth spurts
• Puberty and menses

Dont wait til the next doctors visit!
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Recommended DIA Times

• Set DIA to 4.5 to 6 hrs for accurate calculation
  of BOB and bolus doses

5 hr Linear
5 hr Curvilinear
Adapted fom Mudaliar et al Diabetes Care, 22
1501, 1999
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Duration Of Insulin Action (DIA)
Accurate boluses require an accurate DIA
DIA times less than 4 to 7 hrs hide the glucose-
lowering activity of boluses
Glucose-lowering Activity
6 hrs
0
4 hrs
2 hrs
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More On DIA

• Large doses (0.3 u/kg 15 u for 110 lb. person)
  of rapid insulin in 18 non-diabetic, obese
  people
• Med. doses (0.2 u/kg 10 u for 110 lb. person)

Regular
Apidra product handout, Rev. April 2004a
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DIA Tips

• DIA times NOT different between children and
  adults
• If your pump does not give enough bolus
  insulin, do NOT shorten the DIA to get larger
  boluses
• Look for the real reason
• a basal rate that is too low
• or a carb factor too high
• that makes your DIA SEEM SHORT!

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Basal RatesKeep the glucose flat overnight or
when a meal is skipped after the DIA time has
passedEasy to check dont eat
See Pumping Insulin 4th ed, 2006, for details
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How Many Basals?

• Percentage of pumpers who use 1 to 10 basals per
  day from self reports of several hundred pumpers
  at insulin-pumpers.org

One basal rate may work in children, while the
complex metabolism of puberty often requires
multiple rates in teens
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Basal Tips

• 50 Rule basals usually make up 40 to 65 of
  an accurate TDD
• Basal rates will be similar through the day,
  such as between 0.45 and 0.7, or between 1.0
  and 1.4
• For basal rate adjustments, modify in small
  steps usually 0.05 or 0.1 u/hr
• Change basals 3 to 8 hours before need arises
• Dont stop (suspend) pump longer than 30 min.

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Carb Counting

• Accounts for half the days control
• Use accurate carb counts to matchboluses and
  carbs for post-meal control and lower A1c
• Use automatic carb bolus calculations on pump

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Duration Of Carb Action

• Most carbs affect the BG only 1 to 2.5 hours
• More delay with complex carbs, more fiber, more
  fat, etc

Thanks to Gary Scheiner, MS, CDE
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Most Carbs Faster Than Insulin
One hour after a meal, half a meals glucose rise
is gone, but 80 of the rapid insulins
activity remains
Meals impact on BG
Time over which a bolus lowers the BG
Take Home Bolus 15 to 30 minutes before meals
Use extended boluses sparingly.
From Pumping Insulin
77
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

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Carb Correction Factors

• Starting carb factor
• Carb Factor 2.5 X Wt(lb)/TDD
• Starting correction factor
• Correction Factor 1900/TDD

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Carb Boluses

• Regular
• Taken immediately MOST meals
• Combo / dual wave
• Some now, some later good for burritos, pastas
  and pizzas, Symlin, Byetta, precose
• Extended / square wave
• All extended over time gastroparesis

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Missed Boluses Lead To High A1cs

• One missed bolus a week raises A1c almost 0.5
• Dont miss boluses
• Give a bolus for every bite!
• Use pump reminders
• Review pump history to increase number of boluses
  given each week
• Solve without blame

48 youth in poor control (A1c gt 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 291012-1015,
2006
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Carb Bolus Tips

• Does your carb factor work for LARGE carb meals,
  such as for a carb intake half your weight in
  lbs?
• Do you count carb accurately?
• Do you give boluses 20 min before meals when your
  glucose is normal?

For frequent lows after meals gt raise carb
factor For frequent highs after meals gt lower
carb factor
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Bottom Line

• If your smart pump does not give you great
  control
• Check your pump settings
• Check when and how you bolus
• And check your infusion sets.

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Wrap Up

• Pumps offer best technology for
  precise insulin delivery
• A more flexible and healthier life
  with less hypoglycemia
• Requires commitment, responsibility
• But good training and follow-up are required for
  an effective outcome
• So make the commitment to good health
• And pump well!

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The Future

• Pump technology continues to advance
• On the horizon
• Pumping and monitoring by cell phone
• Cooler styles
• Smaller sizes
• Improved human interface
• More helpful data analysis
• Gradual progress toward a closed loop

85
Questions Discussion