Insulin pump therapy

Treatment for Type 1 Diabetes  includes ^5,6:

• Multiple daily insulin injections via pen or insulin pump.
• Carbohydrate counting.
• Frequent self-monitoring of blood glucose (SMBG).
• A healthy diet.
• Regular exercise and the maintenance of a healthy weight.

The main therapeutic options for patients include multiple daily injections (MDI) and Insulin Pump Therapy, also known as Continuous Subcutaneous Insulin Infusion (CSII).

A large body of observational data shows that CSII enables the reduction of HbA1c and hypoglycemia, with associated improvements in diabetes-related quality of life ³. The goal is to keep blood sugar levels as close to normal as possible to prevent complications. Your daytime blood sugar levels before meals should be between 3.9 to 7.2 mmol/L and no higher than 10 mmol/L two hours after eating ⁴. Diabetes management can feel overwhelming, especially in the beginning, but you are not alone. Your diabetes treatment team will work with you to keep your blood sugar levels at optimal levels. 

VitalAire supports those patients with the therapeutic strategy best suited to them.

Injections

A fine needle and syringe or an insulin pen – available in disposable or refillable varieties – is used to inject insulin under your skin. Needles are also available in a variety of sizes, so you can find one most comfortable for you.

If you choose injections, you will likely need a mixture of insulin types to use. Multiple daily injections that include a long-acting insulin, such as Lantus or Levemir, combined with a rapid-acting insulin, such as Apidra, Humolog or Novolog, more closely mimic the body's normal use of insulin than older regimens requiring just one or two insulin shots a day. Three or more insulin injections a day have been shown to improve blood sugar levels ^2,4,5.

Insulin pump

An insulin pump, about the size of a deck of cards, comprises a tube connecting a reservoir of insulin to a cannula inserted under the skin of your abdomen. This pump can be worn on your waistband, in your pocket, or with a specifically designed belt.

Pumps are programmed to dispense a specific, continuous dose of rapid-acting insulin, known as your basal rate, which replaces whatever long-acting insulin you were using to maintain blood glucose levels between meals and overnight ^4,8.

Programme the pump with the number of carbohydrates you are eating and your current blood sugar and it will give you a "bolus" dose of insulin to cover your meal and correct your blood sugar if elevated. Research has found an insulin pump can be more effective than injections at controlling blood sugar levels in some people ^4,8.

Indications  include ⁹:

• An elevated HbA1c and variability in your glucose levels.
• Fear of hypoglycaemia, nocturnal/recurrent hypoglycaemia, and unawareness of hypoglycaemia. Since the insulin pump is programmed according to individual needs, hypoglycemia is less common.
• Pregnancy/Pre-pregnancy.
• Recurrent Diabetic ketoacidosis (DKA)/recurrent hospitalizations).
• Needle phobia or large number of insulin injections.
• Dawn Phenomenon – a surge of hormones the body produces around 4-5 am daily.
• Gastroparesis – a condition in which the stomach can't empty food properly.
• If you require flexibility in the daily management of your diabetes, the insulin pump allows advance programming of the insulin dose according to the planned activity (occupational, physical, meal times, sleep).
• Low insulin requirements.
• Inability to self-administer insulin (pre-school/grade school).
• Inability to predict food or meal intake (infant/toddler).

Patient requirements ^9:

• Monitors blood glucose at least 4x per day.
• Efficient at counting carbohydrates.
• Complies with medical follow-ups.

Depending on the type of insulin therapy you require – twice daily injections, multiple daily injections or insulin pump – you need to check and record your blood sugar level at least – but preferably more often – four times a day. Be sure to wash your hands first ⁴.

The American Diabetes Association recommends testing blood sugar levels before meals and snacks, before bed, before exercising or driving, or whenever you suspect your blood sugar may be low. Careful monitoring is the only way to keep your blood sugar levels within your target range ⁴.

Even if you take insulin and eat on a rigid schedule, your blood sugar levels can change unpredictably. Your diabetes treatment team will teach you how food, activity, illness, medications, stress, hormonal changes and alcohol can all affect the amount of sugar in your blood.

A tiny electrode called a glucose sensor is inserted under the skin to measure glucose levels in tissue fluid. It is connected to a transmitter that sends the information via wireless radio frequency to a device. The device can detect and notify you if your glucose is reaching a high or low limit. The latest Medtronic CGM systems can actually alert you before you reach your glucose limits ⁷. 

CGM provides you with ⁷:

• The direction your glucose levels are going.
• Early notification of oncoming lows and highs.
• Alerts for lows or highs while you are sleeping or anytime.
• Insights into how food, physical activity, medication and illness impact your diabetes.
• CGM can provide valuable information at crucial points during the day, including before and during exercise, prior to driving, before test/exam-taking and in the middle of the night. It is still required to check blood glucose levels with a fingerstick before therapy adjustment.

CGM is not considered a replacement method for tracking blood sugar, but an additional tool.

By understanding how your glucose levels change during the course of a day, you can adjust your food, exercise, medication and insulin levels accordingly. You can take action based on whether your glucose is too high or too low. Increased awareness of your glucose levels over time lowers the risks of complications such as blindness, heart attack, kidney failure and amputation ⁹.

VitalAire can provide you with one of the following insulin pumps:

1. MiniMed 640G – SAP (Sensor Augmented Pump) with Smartguard technology.
2. MiniMed Paradigm Veo – SAP with Low glucose suspend functionality.
3. Paradigm 722.

Please contact us to enquire which insulin pump is available on your medical aid option.

Cutting down on animal products and refined carbohydrates such as white bread or sweets, is recommended for everyone.

You will need to learn how to count your carbohydrates so that you can give yourself enough insulin to metabolize them. A registered dietitian can help you create a meal plan in keeping with your health goals, food preferences and lifestyle.

With your doctor's permission, choose activities you enjoy, such as walking, swimming, or biking. Flexibility and strength training exercises are important too. If you have not been active for a while, build up gradually and make 30 minutes of aerobic exercise part of your daily routine. The goal for children is at least an hour of activity a day.

Physical activity lowers blood sugar, often long after your workout. Blood sugar level should be checked more often when beginning a new activity in case you need to adjust your meal plan or insulin doses. Your doctor or diabetes educator can show you how to set a temporary basal rate on an insulin pump to keep your blood sugar from dropping.

1. Pickup JC1, Sutton AJ 2008 Severe hypoglycaemia and glycaemic control in Type 1 diabetes: meta-analysis of multiple daily insulin injections compared with continuous subcutaneous insulin infusion Jul;25(7):765-74.

2. Treating Type 1 Diabetes http://www.nhs.uk/Conditions/Diabetes-type1/Pages/Treatment.aspx

3. Joshi M1, Choudhary P Multiple Daily Injections OR Insulin Pump Therapy: Choosing the Best Option for Your Patient-An Evidence-based Approach 2015 Oct;15(10):81.

4. Diseases and Conditions Type 1 Diabetes http://www.mayoclinic.org/diseases-conditions/type-1-diabetes/basics/treatment/con-20019573

5. Standards of medical care in diabetes — 2014. Diabetes Care. 2014;37:s14.

6. Papadakis MA, ed., et al. Current Medical Diagnosis and Treatment 2014. 53rd ed. New York, N.Y.: The McGraw-Hill Companies; 2014.                  http://www.accessmedicine.com/resourceTOC.aspx?resourceID=1. Accessed April 27, 2014

7. The basics of Insulin Pump Therapy http://www.medtronicdiabetes.com

8. Bode BW, Khyllo J, Kaufman FR; Pumping Protocol: A Guide to Insulin Pump Therapy initiation.

9. http://www.medtronic.eu/your-health/diabetes/device/continuous-glucose-monitor/benefits-risks/index.htm