Insulin Pumps from an Ophthalmologists Perspective

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Insulin pumps diabetic retinopathy, with a case
report
David Kinshuck
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Why is an ophthalmologist interested in insulin
pumps?

• Prevention or slowing of retinopathy
• retinopathy still disabling

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This patient askedwould an insulin pump help me?
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This patient askedwould 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
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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)

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Patient 1

• 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

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All photos 2000
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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 contacthow 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

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Identifying progression of retinopathy

• Exudates/oedema leakage

• New Vessels

• An early sign haemorrhages

• An increase in any of these
• Photos useful for haemorrhages especially

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Progressingwhy?
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Retinopathy is linked to
DCCT study
1 HbA1c 37 progression rate
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Retinopathy is linked to
1mmHg 1.1 progression rate
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Retinopathy is linked to
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Retinopathy is linked to
Genetic 25 Retinopathy
Family history heart disease, stroke, blood
pressure
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Retinopathy is linked to
Smoking 20/day 300 progression rate
Passive smoker gets 25 of the smoke
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Retinopathy is linked to
Statin reduces heart problems by 25-50 (estimate)
Treat even if normal, especially if there are
exudates
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Retinopathy is linked to
ACE inhibitors reduce retinopathy by 50
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Retinopathy is linked to
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Retinopathy is linked to
Retinopathy progression
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Retinopathy is linked to
Renal function decrease
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Retinopathy is linked to
pregnancy
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Progressing, HbA1c gt 7.0Why?

• 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 patients retinopathy halted
• Insulin pumpers web site, advice from retinopathy
  experts at European meetings

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www.insulin-pumpers.org
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Balance
resources
the wrong time or an unenthusiastic patient

• motivation

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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

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Patient 2
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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/sportssome problems

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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

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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

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