Insulin Pump Therapy: To Pump or Not to Pump Part 2 - Pump vs. Multiple Injections
I hope after last week’s blog that you are now in the position to make an educated decision about which form of basal/bolus therapy is or is not for you. Only you, your family, and diabetes team can make that decision. In all honesty, I believe that, in the end, it must be up to YOU to decide what will work best with your lifestyle, support network, and personality. Let’s discuss the benefits and disadvantages of the pump and multiple injections.
1. No more shots (unless the pump malfunctions, which they do sometimes; or if you have ketones)
2. Less hypoglycemia
3. Gives insulin before and during meal as needed
4. More flexibility of different basal (background) insulin rates depending on the time of day (you may need more insulin between 3 and 7 am, for example)
5. Calculations of insulin can be programmed in your pump–you just tell it how many carbs you are eating and your current blood sugar
6. Ability to extend insulin over a period of time especially when you eat the fun stuff (pizza, ice cream, pasta, etc.)
7. Eventual possibility of combining the pump with a continuous glucose sensor in an effort to mimic an artificial pancreas
8. If there is a problem with high or low blood sugars, generally you can fix it very quickly (extra insulin, temporary basal rates, suspension of pump)
9. Your health care team can obtain insulin information from the pump (which is good for us, but may not be good for you)
10. Cool factor (The pump really does look cool with its different colors, alarms, etc.)
1. Wearing it all the time (you can disconnect when you take a shower or when you are playing football etc., but need to reconnect to give some insulin no longer than an hour)
2. Change the catheter that is inserted under the skin into the subcutaneous fat (a tiny thin plastic straw-like device that connects to the tubing that connects to the pump) at least every three days, sometimes more
3. Pump malfunctions (the machine can break, tubing kinks, your friend pulls the catheter out by accident, you pull it out inadvertently, the screen cracks, computer glitch… you get the idea)
4. Having to pay more attention to blood sugars and checking them frequently because if the pump malfunctions you have no background insulin and you can get high REAL fast and therefore get ketones incredibly quickly, which can lead to diabetic ketoacidosis
5. Needing a back-up plan if pump breaks
6. Needing extra supplies such as catheters, tubing, insulin, etc.
7. Potential of infection around the catheter sites (especially if you don’t change them at least every 3 days)
8. Running out of catheter sites due to frequent use
Finally, you really have to know what you are doing. This means you need lots of training with the pump company representatives and in a diabetes program like mine at Children’s. At my institution patients consult with our designated pump nurse at time of pump start and frequently thereafter. We don’t let you fly solo–we are your co-pilots at all times
If this doesn’t sound great to you, you should consider manual basal bolus therapy.
MULTIPLE INJECTION POSITIVES (basal insulin plus rapid acting insulin):
1. Body not attached to life-sustaining equipment
2. Use of neat insulin pens: dial up the dose, inject, done
3. Long acting insulin (Lantus-1 shot/day, Levemir-2 shots/day) is on board., which means that if you accidentally forget to give insulin for lunch, you STILL have background insulin available so you won’t necessarily develop ketones quickly
4. Less equipment than all that pump gear
5. No equipment malfunctions (unless you forgot your meter, etc.)
6. Less daily routines (changing catheters, running out of insulin in the pump, alarms etc…)
7. Sports (don’t have to take pump off)
MULTIPLE INJECTION NEGATIVES:
1. There are many shots (if you do it correctly and bolus for all carbs)
2. Need to plan ahead and determine how much you plan to eat so that you do not have to give more than one insulin injection per meal or snack
3. Less flexibility of background insulin–only one “basal” rate–if Lantus; 2 basal rates if Levemir
4. Need to give rapid acting insulin before meals to be most effective
5. Still need to check blood sugars at least 4 times/day
6. If there is an omission of long acting insulin (Lantus or Levemir) then you need to give insulin at least every 3-4 hours
7. Still need to manually count carbs and use insulin/carb ratios, correction factors, etc. (although the pump does it for you automatically if you program it correctly)
I also recommend close follow-up with your diabetes team for dosage adjustments.
Still not sure? That is ok. You can also do a combination of the two forms of basal bolus therapy. In fact, Svati discussed going on a pump holiday. A pump holiday is when you take a vacation from the automatic pump and use manual basal bolus therapy. You already know how to do that. You just give shots based on the same principles and concepts that are applicable to the pump. A pump holiday is great in the summer when you are swimming and don’t want equipment attached to your swimsuit or don’t want your $5,000 device in the sun. Therefore, you can ditch the pump for the summer and go back on it when school starts. Your diabetes team can easily help you with that transition. We do it all the time: even if someone needs a break for any reason: prom, whitewater rafting, ski trip, etc.
The key is to remember to choose the form of insulin therapy that works for you, which may mean making different choices at different times of your life. It is important to voice your concerns to your diabetes healthcare professionals, so that they know what is in your best interests. Feel free to send me any questions or comments. I am happy to help.
Fran Cogen, M.D., C.D.E., is the director of the Childhood and Adolescent Diabetes Program at Children’s National Health System. She wrote about diabetes for HealthCentral.