Insulin Pump Therapy
Bruce W. Bode, MD
and
Sandra Weber, MD
Goals of Targeted Insulin Therapy
(Intensive/Physiologic/Flexible)
•
•
•
•

Maintain near-normal glycemia
Avoid short-term...
Physiological Serum Insulin
Secretion Profile
Plasma insulin ( µU/ml)

75

Breakfast

Lunch

Dinner

50

25

4:00

8:00

1...
Basal/Bolus Treatment Program with
Rapid-acting and Long-acting Analogs
Breakfast

Lunch

Plasma insulin

Aspart
or
Lispro...
Variable Basal Rate:
CSII Program

Plasma insulin

Breakfast

Lunch

Dinner

Bolus Bolus

Bolus

Basal infusion
4:00

8:00...
Metabolic Advantages with CSII
• Improved glycemic control
• Better pharmacokinetic delivery of
insulin
— Less hypoglycemi...
Photograph reproduced with permission of manufacturer.
Pump Infusion Sets
Current Pump Therapy
Indications
•

Diagnosed with diabetes
(even new-onset type 1 diabetes)

•

Need to normalize blood g...
CSII
Factors Affecting A1C
• Monitoring
— A1C = 8.3 - (0.21 x BG per day)

• Recording 7.4 vs 7.8
• Diet practiced
— CHO: ...
Initial Adult Dosage: Calculations
Starting doses
• Based on pre-pump total daily dose (TDD)

 reduce TDD by 25% to 30% f...
Target BG Ranges for CSII
• Normal
—Preprandial:
—1 hr postprandial:

70 - 140 mg/dl
<160 mg/dl

• Hypoglycemic unawarenes...
Initial Adult Dosage: Calculations
Basal rate
• 45% to 50% of pump TDD
• Divide total basal by 24 hours to
decide on hourl...
Basal Dose Adjustment Overnight
Rule of 30:
Check BG
 Bedtime
 12 AM
 3 AM
 6AM
Adjust overnight basal if readings
var...
Basal Dose Adjustment Overnight
• Adults often need an increase in basal rate
in the “Dawn” hours (4 am to 9 am)
• Childre...
Variable Basal Rate: CSII Program

Plasma insulin

Breakfast

Lunch

Dinner

Bolus Bolus

Bolus

Basal infusion
4:00

8:00...
Basal Dose Adjustment Daytime
Rule of 30:
Check BG
Before usual meal time
Skip meal
Every 2 hrs (for 6 hrs)
Adjust dayt...
Bolus Dose Calculations
Meal (food) Bolus Method 1
• Test BG before meal
• Give pre-determined insulin dose for
pre-determ...
Estimating the
Carbohydrate to Insulin Ratio (CIR)
Individually determined
• CIR = (2.8 x wgt in lbs) / TDD
• Anywhere fro...
Correction Bolus
• Must determine how much glucose is
lowered by 1 U of rapid-acting insulin
• This number is known as the...
Correction Bolus Formula
Current BG - Ideal BG
Glucose Correction Factor
Example:
—Current BG: 220 mg/dL
—Ideal BG:
100 mg...
If A1C is Not to Goal
Must look at:
• SMBG frequency
and recording
• Diet practiced
—Do they know what
they are eating?
—D...
Case Study # 1
•
•
•
•

GL, male, age 39
Type 1 X 8 years
A1C= 7%; recent increase from 6%
CSII basal rates: 12 am 1.0 u/h...
Modal Day View
Milk choc 15g; 8u

Cheese / Crackers
20 g; 3units

6u

Ice Cream; 3 u

2u; 57 g CHO
Juice box; no insulin

80 CHO; 7u

30 ...
Most common bolusing errors
• Under-estimation of carbohydrates
consumed (CHO bolus)
• Over-correction of post-prandial
el...
Bolus: Source of Errors
• “Inability” to count carbs correctly
— Lack of knowledge, skill
— Lack of time
— Too much work

...
The Major Problems
♦ Up until now we have not taken the
active insulin issue into
consideration
♦ The math involved with t...
Smart Pumps
Bolus Wizard Calculator : meterentered

)))

)
)))))
)))

)

Paradigm 512™

Paradigm Link™

• Monitor sends BG value to pu...
Insulin Activity Over Time
Insulin Activity (GIR)

700
Rapid Acting
Regular

600
500
400
300
200
100
0

0

1

2

3

4

5

...
Adjusting for Active Insulin:
How smart pumps do it

Percent Remaining

100
Rapid Acting
Regular
80

60

40

20

0

0

1

...
Bolus Wizard Set Up Screen
Wizard:
Wizard:
Carb Units:
Carb Units:
Carb Ratios:
Carb Ratios:
BG Units:
BG Units:
Sensitivi...
For This System To Work
♦ It is critical the target, basal doses,
the correction doses, and the
carbohydrate ratios are ac...
Do Smart Pumps Enable Others To
Go To CSII?
• YES
• All patients with diabetes not at goal
are candidates for Insulin Pump...
Summary
• Insulin pump therapy offers improved
glucose control with less risk of
hypoglycemia and an improvement in
qualit...
Questions
• For a copy or viewing of these
slides, contact
• WWW.adaendo.com
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Ada pump tharapy 1st work shop may 14th, 2004

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Insulin Pump Therapy - Bruce W. Bode, MD and Sandra Weber, MD

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  • Patient must have last meal 4 hours prior
  • Patient must have last meal 4 hours prior
  • Figuring out how to dose correctly for food and/or correction is one of the key challenges in the intensive management of diabetes.
    These common bolusing errors can occur with either MDI therapy or pump therapy.
    The first obvious opportunity for error occurs because many people under-estimate the amount of carbohydrate they plan to consume, which leads to the next problem…..
    When a post-meal blood glucose is elevated, people may take too much correction insulin and inadvertently end up later with hypoglycemia. This over-correction can happen when the correction dose “stacks” on the insulin that is still active in the body from a previous dose.
    Unfortunately, the traditional methods used to avoid “insulin stacking” rely upon crude formulae designed to be as simple and practical as possible.
    Because pump therapy offers the benefit of delivering insulin without the discomfort and hassle of shots, pump wearers may administer more frequent doses of insulin than those using injection therapy. As a result, that in order avoid hypoglycemia caused by over-correcting for high blood glucoses, pump users may need to keep track of active insulin from multiple boluses.
  • WAG, very simlilar to “seat of the pants”, it’s Wild Ass Guess
    Bruce Bode uses this quite a bit
  • By looking at a number of published studies, including data from insulin manufacturers, two consensus insulin action curves were established.
    The red line shows rapid-acting analog insulin. The blue line shows regular human recombinant insulin.
    To determine insulin action over time, the “area under the curve” for each of these lines are used in a mathematical calculation.
  • Slide appears with just the 2 insulin action lines
    What you see here is 100% of the insulin is remaining when the dose is administered. We can also see how the “percent remaining” declines over time. Because insulin action is not linear, these are not straight lines.
    Click once: The green line to 4 hours appears
    If a straight-line 25% per hour assumption is used as shown here, which would presum all the insulin is completely gone in 4 hours, it may look relatively close …..
    Click again: The first orange oval appears
    However, you can identify the opportunity for unintended insulin stacking which can occur when the patient is taking multiple boluses within a short period of time.
    Click again: The green line to 3 hours appears
    Now, if you assume the complete insulin dose is gone in 3 hours as shown in this green line…..
    Click again: The second orange oval appears
    Then, you can immediately identify that a correction dose for an elevated blood glucose would not consider all this insulin that is still active in the body, according to the published on insulin dynamics represented in these red and blue curves. A correction dose based on this 3-hour formula risks over-correcting, which can cause hypoglycemia. (A 5 unit dose after 3 hours would still have 2 units active remaining.
  • I need it, hopefully you will ok this, I won’t spend much time
  • Ada pump tharapy 1st work shop may 14th, 2004

    1. 1. Insulin Pump Therapy Bruce W. Bode, MD and Sandra Weber, MD
    2. 2. Goals of Targeted Insulin Therapy (Intensive/Physiologic/Flexible) • • • • Maintain near-normal glycemia Avoid short-term crisis Minimize long-term complications Improve the quality of life 0 12 Hours 24
    3. 3. Physiological Serum Insulin Secretion Profile Plasma insulin ( µU/ml) 75 Breakfast Lunch Dinner 50 25 4:00 8:00 12:00 16:00 Time 20:00 24:00 4:00 8:00
    4. 4. Basal/Bolus Treatment Program with Rapid-acting and Long-acting Analogs Breakfast Lunch Plasma insulin Aspart or Lispro Dinner Aspart or Lispro Aspart or Lispro Glargine 4:00 8:00 12:00 16:00 Time 20:00 24:00 4:00 8:00
    5. 5. Variable Basal Rate: CSII Program Plasma insulin Breakfast Lunch Dinner Bolus Bolus Bolus Basal infusion 4:00 8:00 12:00 16:00 Time 20:00 24:00 4:00 8:00
    6. 6. Metabolic Advantages with CSII • Improved glycemic control • Better pharmacokinetic delivery of insulin — Less hypoglycemia — Less insulin required • Improved quality of life
    7. 7. Photograph reproduced with permission of manufacturer.
    8. 8. Pump Infusion Sets
    9. 9. Current Pump Therapy Indications • Diagnosed with diabetes (even new-onset type 1 diabetes) • Need to normalize blood glucose — A1C > 6.5% — Glycemic excursions — Hypoglycemia • Need for flexible insulin program
    10. 10. CSII Factors Affecting A1C • Monitoring — A1C = 8.3 - (0.21 x BG per day) • Recording 7.4 vs 7.8 • Diet practiced — CHO: 7.2 — Fixed: 7.5 — WAG: 8.0 • Insulin type (Aspart) Bode et al. Diabetes 1999;48 Suppl 1:264 Bode et al. Diabetes Care 2002;25 439
    11. 11. Initial Adult Dosage: Calculations Starting doses • Based on pre-pump total daily dose (TDD)  reduce TDD by 25% to 30% for pump TDD • Calculated based on weight  0.24 x weight in lb (0.53 x weight in kg) Bode BW, et al. Diabetes. 1999;48(suppl 1):84. Bell D, Ovalle F. Endocr Pract. 2000;6:357-360. Crawford LM. Endocr Pract. 2000;6:239-243.
    12. 12. Target BG Ranges for CSII • Normal —Preprandial: —1 hr postprandial: 70 - 140 mg/dl <160 mg/dl • Hypoglycemic unawareness —Preprandial: 100 - 160 mg/dl • Pregnant —Preprandial: —1 hr postprandial: 60 - 90 mg/dl <120 mg/dl Individually set for each patient Fanelli CG et al., Diabetologia 1994, 37:1265-76. Jovanovich L, AMJObGynec 1991, 164:103-11.
    13. 13. Initial Adult Dosage: Calculations Basal rate • 45% to 50% of pump TDD • Divide total basal by 24 hours to decide on hourly basal • Start with only 1 basal rate • See how it goes before adding basals
    14. 14. Basal Dose Adjustment Overnight Rule of 30: Check BG  Bedtime  12 AM  3 AM  6AM Adjust overnight basal if readings vary > 30 mg/dl
    15. 15. Basal Dose Adjustment Overnight • Adults often need an increase in basal rate in the “Dawn” hours (4 am to 9 am) • Children often need an increase in basal rate earlier starting at 10 pm to 2 am
    16. 16. Variable Basal Rate: CSII Program Plasma insulin Breakfast Lunch Dinner Bolus Bolus Bolus Basal infusion 4:00 8:00 12:00 16:00 Time 20:00 24:00 4:00 8:00
    17. 17. Basal Dose Adjustment Daytime Rule of 30: Check BG Before usual meal time Skip meal Every 2 hrs (for 6 hrs) Adjust daytime basal if readings vary > 30 mg/dl
    18. 18. Bolus Dose Calculations Meal (food) Bolus Method 1 • Test BG before meal • Give pre-determined insulin dose for pre-determined CHO content • Test BG after meal • Goal < 60 mg/dl rise post meal or < 160 mg/dl
    19. 19. Estimating the Carbohydrate to Insulin Ratio (CIR) Individually determined • CIR = (2.8 x wgt in lbs) / TDD • Anywhere from 5 to 25 g CHO is covered by 1 unit of insulin Davidson et al: Diabetes Tech & Therap. April 2003
    20. 20. Correction Bolus • Must determine how much glucose is lowered by 1 U of rapid-acting insulin • This number is known as the correction factor (CF) • Use the 1700 rule to estimate the CF • CF=1700 divided by TDD example: if TDD=36 U, then CF=1700/36=≈50, meaning 1 U will lower the BG ≈50 mg/dL
    21. 21. Correction Bolus Formula Current BG - Ideal BG Glucose Correction Factor Example: —Current BG: 220 mg/dL —Ideal BG: 100 mg/dL —Glucose CF: 50 mg/dL 220 - 100 = 2.4 U 50
    22. 22. If A1C is Not to Goal Must look at: • SMBG frequency and recording • Diet practiced —Do they know what they are eating? —Do they bolus for all food and snacks? • Infusion site areas —Are they in areas of lipohypertrophy? • Other factors: —Fear of low BG —Overtreatment of low BG
    23. 23. Case Study # 1 • • • • GL, male, age 39 Type 1 X 8 years A1C= 7%; recent increase from 6% CSII basal rates: 12 am 1.0 u/h; 4:30 am 1.6 u/h; 11:30 am 1.0 u/h • Insulin: carbohydrate ratio =1u : 10 grams • Correction Factor: BG - 100 divided by 40 • CGMS done to assist with improving overall glycemic control
    24. 24. Modal Day View
    25. 25. Milk choc 15g; 8u Cheese / Crackers 20 g; 3units 6u Ice Cream; 3 u 2u; 57 g CHO Juice box; no insulin 80 CHO; 7u 30 gm CHO; Heavy Exercise
    26. 26. Most common bolusing errors • Under-estimation of carbohydrates consumed (CHO bolus) • Over-correction of post-prandial elevations (CF bolus) — Remaining unused, active insulin — Stacking of boluses
    27. 27. Bolus: Source of Errors • “Inability” to count carbs correctly — Lack of knowledge, skill — Lack of time — Too much work • Incorrect use of SMBG number • Incorrect math in calculation • “WAG” estimations
    28. 28. The Major Problems ♦ Up until now we have not taken the active insulin issue into consideration ♦ The math involved with this has become too complicated, and it would be impossible to accurately calculate the active insulin without assistance
    29. 29. Smart Pumps
    30. 30. Bolus Wizard Calculator : meterentered ))) ) ))))) ))) ) Paradigm 512™ Paradigm Link™ • Monitor sends BG value to pump via radio waves : No transcribing error • Enter carbohydrate intake into pump • “Bolus Wizard” calculates suggested dose
    31. 31. Insulin Activity Over Time Insulin Activity (GIR) 700 Rapid Acting Regular 600 500 400 300 200 100 0 0 1 2 3 4 5 6 Time (hrs) Insulin Pharmacodynamic Data Adapted from Henry R: Diabetes Care 1999 7 8
    32. 32. Adjusting for Active Insulin: How smart pumps do it Percent Remaining 100 Rapid Acting Regular 80 60 40 20 0 0 1 2 3 4 Time (hrs) 5 6 7 8
    33. 33. Bolus Wizard Set Up Screen Wizard: Wizard: Carb Units: Carb Units: Carb Ratios: Carb Ratios: BG Units: BG Units: Sensitivity: Sensitivity: BG Target: BG Target: On On grams grams 10 10 mg/dl mg/dl 50 50 100 100
    34. 34. For This System To Work ♦ It is critical the target, basal doses, the correction doses, and the carbohydrate ratios are accurate ♦ Understanding how to match carbohydrate amounts with insulin is critical
    35. 35. Do Smart Pumps Enable Others To Go To CSII? • YES • All patients with diabetes not at goal are candidates for Insulin Pump Therapy - Type 1 any age - Type 2 - Diabetes in Pregnancy
    36. 36. Summary • Insulin pump therapy offers improved glucose control with less risk of hypoglycemia and an improvement in quality of life • Appropriate candidate selection, training, and follow-up ensures safe and effective therapy
    37. 37. Questions • For a copy or viewing of these slides, contact • WWW.adaendo.com
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