Diabetes and the Pump Vacation, Revisited
Apparently our colleague, Ann Bartlett, touched a very sensitive nerve in her most recent blog about "the pump vacation." I have read the more than 30 comments addressed to her insightful blog and I wanted to chime in with professional (and at times, anecdotal) comments. As I have discussed in a previous blog, there is more than one-way to manage diabetes: the key is insulin. The layers of complexity inherent regarding insulin pump therapy sometimes lead to "user fatigue." It is therefore, important to remember that the employment of only one regime of insulin therapy may not always be appropriate depending on current lifestyle, season, activity, or ...whatever.
I was trying to think just why Ann's blog provoked so many responses. I have several ideas. Firstly, I think that healthcare providers are partly responsible. We may suggest a form of insulin therapy and imply that it is the best way to go. Perhaps, the regime is the latest, greatest, and most popular regime and published in a well-respected medical journal that is founded on evidence-based medicine. Indeed, basal/bolus therapy (multiple injections or insulin pump) is based on the physiologic action of the pancreas. However, this regime may not be appropriate for the individual at the present time due to extraneous factors. Secondly, most people with type 1 diabetes are up-to-date with current research and insulin regimes and want to utilize the best regimes to date. If, for some reason, they have difficulty (site issues, hypertrophy, high or low blood sugars. etc.), many (patient or parents) internalize the problems and feel that they are doing something wrong. Many will just give up and feel frustrated.
Our diabetes team confronts these issues on a daily basis. We feel that there is no wrong regime and will work with the patient and family until we get it right for individual needs and lifestyle. Sometimes, sadly, we (myself or the diabetes team) are partly to blame: we get so excited about how the pump will improve lifestyle choices, flexibility, etc., that we forget to access just how the actual pump user may feel. (I should say that at Children's National Medical Center, all children and teens desirous of pump therapy must go through several classes and a psychological screening to ensure that they want the pump and are not being pressured into it by peers or others.) It is often several years later when we discover that what was initially seen as a "magical" form of diabetes management becomes routine and still requires a great amount of personal attention to details. Alas, the insulin pump, despite all the fabulous enhancements, still does not cure diabetes; and until we have the closed feedback loop with the continuous glucose sensor and insulin pump, blood glucose monitoring and button pushing will be necessary. Indeed, most research studies have demonstrated improvement in A1c and blood sugars after six months of pump therapy (or basal/bolus therapy). After several years, many children and teens return to baseline or slightly above. Diabetes self-care skills remain essential in any form of insulin therapy.
Many of our patients who have been on insulin pump therapy wish to take a "break." Some do so because of the summer in which they take off their pump for extended periods of time; some because their bodies need a "rest" from the infusion sets and some - just because.... We, as a team, never insist that our kids stay (or go back) on the pump if they do not wish to. Often, I only find out when the teen (or child) is "acting out" or not performing the necessary diabetes pump related tasks that they are doing so subconsciously in order for me to remove the pump! Usually, this revelation is at the cost of much emotional turmoil and tears... and relief.
I often suggest "pump vacations" to my patients over the summer, during athletic competitions (if they are anxious the pump can be managed well with appropriate assistance for all sports), and if, for whatever reason, they need a break. If we insist that a child or teen stay on the pump without his full endorsement, we will not be acting in his best interests and pump therapy will not be successful. At Children's National our Diabetes Program Coordinator, a nurse and clinical diabetes educator with type 1 diabetes, employs pump therapy during the weekdays when she works with families and multiple injections with basal insulin on the weekends. She feels that her skin sites are given a rest and she has all her diabetes related stuff easily available at home. It works for her!
In summary, it is difficult enough to "act like a pancreas" with either insulin pump therapy or multiple daily injections. Why make it even more stressful to worry about which regime is "right?" It is most important to determine which insulin therapy is right for you at any given time; keeping in mind that circumstances change and that you can change insulin regimes at your will.
Coming up soon: How do you combine insulin pump therapy and multiple daily injections?