insulin & pumps

Insulin Pump Therapy: To Pump or Not to Pump Part I

Dr. Fran Cogen Health Pro June 23, 2008
  • I have done my research! After reading Health Central's DiabeTeens.com, along with questions and concerns from my own teen patients with diabetes, it appears that insulin pump therapy is a hot topic! As of June 14, the featured poll (how do you feel about the pump) results are: love it--51percent; hate it--9 percent; never tried it--40 percent. If 40 percent of our readers have no experience with the pump, then there are a lot of kids out there that need this information.

     

    The key to making any important decision, especially regarding your insulin management, is to learn as much as possible before making a choice. Knowledge is power! So, let's talk about your choices. Keep in mind (and this is very important) that there is no one RIGHT way to do things-including diabetes management. My own practice is to offer choices, provide medically correct information, discuss positives and negatives of each form of therapy, and support the decision of my teens. (Along with offering my very expert opinion, of course!)

     

    Your diabetes team has probably already discussed insulin choices with you and your family. Let's review the main forms of insulin treatment offered by most multidisciplinary diabetes teams throughout the country. Historically, prior to the introduction of the insulin pump, most children and teens were managed with 2 or 3 injections of NPH and regular insulin. For example, breakfast--NPH mixed with regular; dinner--regular; and bedtime--NPH. The rationale for this form of therapy was to provide background insulin when you were not eating (NPH) and regular insulin to cover breakfast and lunch, and dinner. The bedtime NPH was used to cover blood sugars overnight. Many kids are still treated with this regime, which is called conventional insulin therapy.

     

    In the 1990s, and especially after 2000, insulin pump therapy became extremely popular because it replaced injections and the size of the pump became smaller. In 2001, Lantus insulin (a true peakless, background insulin) became available and along with rapid acting analog insulin (humalog, novolog, and now apidra), patients had a fabulous way to combine background insulin when not eating with bolus insulin to cover food when eating. The insulin pump, which provides background insulin by continuous infusion along with additional insulin to cover carbs, is the automated form of basal bolus therapy. Whereas, Lantus (or Levemir- a new relatively peakless insulin) plus rapid acting insulin (humalog/novolog or apidra), can be considered the manual form of basal/bolus therapy. Both forms of treatment work in the same way, however one is done manually by shots (Lantus or Levemir/rapid acting insulin) and the other works automatically by the insulin pump.

     

    Keep in mind that there are necessary requirements for either form of basal/bolus therapy to be effective. Both forms require MORE work than conventional insulin therapy with NPH/regular. Why should someone even transition to basal/bolus therapy? Basal/bolus therapy (either by pump or multiple injections with Lantus/Levemir and rapid acting insulin) best imitates the way a pancreas produces insulin. Now you know why basal/bolus regimens are so beloved by your diabetes team.

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    So, what do you have to do before you transition to basal bolus therapy by injection or pump? Basically, you already have the skills--you just have to fine tune and really understand the importance of blood glucose monitoring and carbohydrate counting. Carbohydrate counting is key. How can you figure out how much insulin to give by injection or pump if you don't know the amount of carbs in a slice of pizza? (By the way, each brand of pizza has a different amount of carbs.) Also, how can you know how much extra (or less insulin) to give if you don't know your blood sugar? In order to use either form of basal/bolus therapy you need to know how to carbohydrate count effectively and to check blood sugars at least 4 times/day. You also need to able to give four or more shots a day (by pen or needle/syringe) if you choose the "manual" form of basal bolus therapy.

     

    Both forms of therapy are excellent. They lower hb A1C effectively, allow for flexibility of meal times/snacks, allow for correction of blood sugars when you are high, and enable you to skip meals if you wish (and sleep in...). Basically, you can be like the rest of the world as long as you check blood sugars frequently, count carbs when you eat, and give insulin accordingly. Researchers, however, have found that there is slightly less hypoglycemia (low blood sugars) with insulin pump therapy.

     

    Let's assume you are interested in transitioning to basal/bolus therapy and can't decide between manual (multiple injections) and automatic (pump)?

     

    Join us next week for Pump vs. Multiple Injections: Positives and Negatives.