INSULIN PUMP THERAPY

2011
 HISTORY OF DIABETES
► 1550 BC first described in an Egyptian manuscript as “the
passing of too much urine”.

► 2nd Century Greek Physician Aretaeus first used the word

Diabetes derived from the Greek meaning “siphon” or “to
go through” referring to urinary frequency.

► 17th Century English Anatomist and Physician first used the

word Mellitus from the Latin meaning “honey”.

► 1921-1923 insulin was discovered by Fredrick Banting and

Charles Best (Macleod and Collip).
 DIABETES TODAY
► Worldwide 346 million people with DM.
► >80% DM deaths occur in low and middle income
countries.
► Diabetes affects ~27million people in the U.S. or 8.7% of
the population.
► Leading cause of renal failure, new cases of blindness,
non-traumatic amputations in adults, and one of the major
contributing factors of heart disease and strokes.
► In 2010 it is estimated that health spending associated
with diabetes and prediabetes is about 194 billion dollars.
The cost is projected to rise to 500 billion dollars by 2020.
► CDC projects that by 2050, up to 1 in 3 Americans may
have DM.
 DIABETES TODAY
► In 2010, there were approximately 5800 board certified
endocrinologists in the U.S. of which an estimated 2000 of
those were involved in research or academics.
► The number of endocrinology fellowships have decreased
from 140 in 1987 to 122 in 2010.

►DIABETES IS TRULY A
PRIMARY CARE PROBLEM!!!!
Diagnosed and undiagnosed diabetes among people
aged 20 years or older in the U.S. in 2010

Group Number and

percentage
Age 20 or 25.6 million or
greater 11.3%
Age 65 or 10.9 million or
greater 26.9%
Men age 20 or 13 million or
greater 11.8%
Women age 20 12.6 million or
or greater 10.8%
Non-Hispanic 15.7 million or
Whites 10.2%
Non-Hispanic 4.9 million or
Blacks 18.7%
 Estimated percentage of people age 20 or older with diagnosed
and undiagnosed diabetes by age group in the U.S. 2005-2008

► 2011 National Diabetes Fact Sheet. CDC.

Estimated number of new cases of diagnosed diabetes
among people aged 20 or older in the U.S. 2010

► 2011 National Diabetes Fact Sheet. CDC.

 Rate of new cases of type 1 and type 2 diabetes among youth
aged < 20 years, by race/ethnicity U.S. 2002-2005

NHW = non-Hispanic whites; NHB = non-Hispanic blacks; H = Hispanics; API = Asians/Pacific Islanders;
AI = American Indians

► 2011 National Diabetes Fact Sheet. CDC.

 Treatment of diabetes in the U.S. 2007-2009

► 2011 National Diabetes Fact Sheet. CDC.

 HISTORY OF INSULIN PUMPS
► First introduced in the 1960’s by a Los Angeles Physician by the name of Dr.
Arnold Kadish.
 1974
► First non-portable computer controlled
insulin pump.
 1978
► Firstcommercially available portable insulin
pump called the Autosyringe “Big Blue
Brick”.
 1983
► Medtronic
releases the first small
programmable insulin pump into the
market.
 INSULIN PUMPS TODAY
► ACCU-CHEK SPIRIT – ROCHE

► AMIGO – NIPRO CORPORATION

► DANA DIABECARE 11S – SOAIL DEVELOPMENT

► MINIMED PARADIGM REVEL – MEDTRONIC

► OMNIPOD – INSULET CORPORATION

► ONE TOUCH PING – ANIMAS CORPORATION

 INDICATIONS FOR INSULIN PUMP
THERAPY
► INTERMITTENT INSULIN INJECTIONS ARE NOT
MEETING TREATMENT GOALS AND OUTCOME
MEASURES ARE SUBOPTIMAL, INCLUDING BUT NOT
LIMITED TO:
1. Frequent and unpredictable fluctuations in blood glucose
levels.
2. Patient perception that diabetes management impedes
the pursuit of personal or professional goals.
3. A1C >7.0-7.5%, accompanied by frequent severe
hypoglycemia (<55mg/dl).
4. Hypoglycemic events requiring third-party assistance or
interfering with work, school, or family obligations.
► 2009 The American Association of Diabetes Educators.
 INDICATIONS FOR INSULIN PUMP
THERAPY
► RECURRENT HYPOGLYCEMIA, NOCTURNAL
HYPOGLYCEMIA, ACTIVITY-INDUCED
HYPOGLYCEMIA AND HYPOGLYCEMIC
UNAWARENESS.
► PREGNANCY
► RECURRENT DIABETIC KETOACIDOSIS
► DAWN PHENOMENON
► GASTROPARESIS
► PATIENT PREFERENCE, MEAL-TIMING
FLEXIBILITY AND NORMALIZTION OF LIFESTYLE
INSULINS USED IN PUMP THERAPY

► HUMALOG
► NOVOLOG
► APIDRA
► HUMULIN U-500?
 KEY CONCEPTS
► BASAL INFUSION – PROVIDES CONTINUOUS INSULIN
INFUSION TO MIMIC THE PANCREAS IN THE FASTING
STATE.

► CARBOHYDRATE RATIO OR MEAL BOLUS – THE NUMBER

OF CARBOHYDRATE GRAMS COVERED BY 1 UNIT OF
INSULIN.

► INSULIN SENSITIVITY FACTOR – THE BLOOD GLUCOSE

(mg/dl) THAT IS LOWERED BY ONE UNIT OF INSULIN.
STARTING INSULIN PUMP THERAPY

► CALCULATETHE TOTAL DAILY DOSE (TDD)

INSULIN AND REDUCE THIS BY 10%.

FOR EXAMPLE – 60 KG FEMALE ON 30 UNITS OF

RAPID ACTING INSULIN (10U TID WITH MEALS)
AND 30 UNITS OF LONG ACTING INSULIN AT
BEDTIME.
TOTAL DAILY INSULIN 60 UNITS SUBTRACT 10%
= 54 UNITS TDD
 BASAL RATE
1. TAKE TDD AND DIVIDE BY 2.
54 UNITS/2 = 27 UNITS/DAY

2. DIVIDE THE TOTAL BASAL REQUIREMENT

BY 24 HOURS.
27/24 = ~1.15 UNITS/HR.
CARBOHYDRATE RATIO – 450 RULE

► 450 DIVIDE BY THE TDD

450/54 = ~8 THEREFORE 1 UNIT INSULIN

FOR EVERY 8 GRAMS CARBS.
 INSULIN SENSITIVITY FACTOR –
1700 RULE

► 1700 DIVIDE BY THE TDD

1700/54 = ~30 THEREFORE ONE UNIT OF

INSULIN LOWERS THE BLOOD GLUCOSE BY
30mg/dl.
 INSULIN PUMP SETTINGS
► BASAL INSULIN
0000 AT 1.15 UNITS/HR.
► CARB RATIO
0000 AT 8.
► INSULIN SENSITIVITY
0000 AT 30.
► BLOOD GLUCOSE TARGET
90-120mg/dl.
► ACTIVE INSULIN TIME
3HRS.
INFUSION SETS
INFUSION SITES
Pump Size and Battery Reservoir Infusion set Basal range Bolus range Food Interacts with Interacts with Details
weight database meter? CGMS?

ACCU-CHEK 3.2X2.2X0.8 (1) AA 315 unit Compatible From 0.1 to 0.1 to 25 Yes. No No Display can
SPIRIT - inches cartridge with all 25 units per units in Database flip 180
Roche 4oz with standard hour in 0.1 increments of includes over degrees for
battery, full Luer-lock unit 0.1, 0.2, 0.5, 900 easy reading.
reservoir, and connectors increments 1, and 2 preloaded Package
infusion units. common includes a
Extended or foods and backup pump
set multiwave 0.1 stores 1200

AMIGO – 3.28x2.18x (1) CR2 3 volt 200 unit Unomedical 0-30 units/hr Bolus No No No Pump casing
Nipro Corp. 0.93 inches lithium reservoir comfort only in 0.05 unit increments of is shatter and
4oz with increments .05units to 30 waterproof. 6
battery and units colors
full reservoir available

DANA 2.95x1.77x0. (1) 3.6 volt 300 unit Compatible From 0.01 to 0.1 to 10 No No No Menu uses
DIABECARE 75 inches DC lithium cartridge with Sooll 16 units per units in 0.1 icons instead
IIS – Sooil 1.8 oz infusion sets hour in 0.1 unit of words.
Development. without only unit increments. Available in 5
battery increments From 10 to colors
87 units in 1
unit
increments

MINIMED Model 523: (1) AAA Model 523: Compatible From 0.025 to 0.025 to 25 No Yes. The One Yes. The Real The Real
REVEL – 2x3x0.8 in. 176 unit with 35 units per units. Touch Time Revel is Time Revel
Medtronic 3.53 oz reservoir Medtronic hour in 0.025 Increments of Ultralink a uses a sensor
Diabetes infusion sets unit 0.025 units meter combination to wirelessly
Model 723: as well as increments up to 0.975 wirelessly pump and transmit
2x3.6x0.8 Model 723: sets from units. sends test CGM continuous
inches 176 or 300 select brands Increments of results to the glucose
3.81 oz unit reservoir 0.05 units for pump readings to
with battery amounts the pump
and full larger than
reservoir 0.975 units

OMNIPOD – Pod: Pod: Battery Pod includes Does not use From 0.05 to 0.05 to 30 Yes. PDM Yes. A No No tubing
Insulet Corp. 1.6x2.4x0.7 integrated built in tubing. Pod 30 units per units in contains FreeStyle required. Pod
inches reservoir that comes with a hour in 0.05 increments of more than blood glucose is used for 72
1.2oz with full PDM: (2) AAA holds 200 built in unit 0.05, 0.1, 0.5, 1,000 meter is built hours than
reservoir units infusion set, increments or 1 unit common into the PDM discarded.
PDM: cannula, and foods and Waterproof
2.5x4.5x1 automated their nutrition up to 8 feet
inch and inserter information deep.
4.4oz

ONE TOUCH Pump: Pump (1) 1.5 200 unit Compatible From 0.025 to 0.05 to 35 Yes. Meter Yes. Meter No Both meter
PING – 2x3.25x0.85 volt lithium cartridge with all 25 units per units in 0.05 remote stores remote sends remote and
Animas Corp. inches. 3.9oz AA or (1) AA standard, hour in 0.025 unit up to 500 results pump are
Meter: Luer-lock unit increments foods and wirelessly to fully
3.8x2.46x1.1 Meter: (2) connectors increments their nutrition pump functional.
2 inches and AAA information Waterproof
up to 12 feet
 References
1. Centers for Disease Control – 2011 National Diabetes Fact Sheet.
2. American Diabetes Association. Standards of Medical Care in Diabetes – 2011. Diabetes Care, Volume 34, Supplement 1, January 2011.
3. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for Developing a Diabetes Mellitus Comprehensive Care Plan. Copyright AACE 2011.
Endocrine Practice Volume 17, Supplement 2, March/April 2011.
4. American Association of Diabetes Educators Position Statement – Continuous Subcutaneous Insulin Therapy Using a Pump. AADE 2011.
5. American Association of Diabetes Educators – The Scope of Practice, Standards of Practice, and Standards of Professional Performance for Diabetes Educators. AADE 2011.
6. Diabetes Control and Complications Trial Research Group. The effectiveness of intensive treatment of diabetes on the development and progression of long term
complications in insulin dependent diabetes mellitus. New England Journal of Medicine. 1993;329:977-986.
7. Wainstein J, Metzger M, Boaz M, Minuchin O, Cohen Y, Yaffe A, et al. Insulin pump therapy versus multiple daily injections in obese type 2 diabetic patients. Diabetes
Medicine. 2005;22:1037-1046.
8. Pickup JC, Sutton AJ. Severe hypoglycemia and glycaemic control in type 1 diabetes: Meta-analysis of multiple daily insulin injections compared with continuous
subcutaneous insulin infusion. Diabetes Medicine. 2008;25:765-774.
9. Bergenstal RM, Tamborlane WV, Ahmann A, et al. Effectiveness of Sensor-Augmented Insulin Pump Therapy in Type 1 Diabetes. New England Journal of Medicine.
2010;363:311-320.
10. Nathan DM, Cleary PA, Backlund JY, Genuth SM, Lachin JM, Orchard TJ, et al. Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and
Complications Study Research Group: Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. New England Journal of Medicine.
2005;22:2643-2653.
11. Hoogma RP, Hammond PJ, Gomis R, et al. Comparison of the effects of continuous subcutaneous insulin infusion and NPH-based multiple daily insulin injections on
glycaemic control and quality of life: results of the 5 – nations trial. Diabetes Medicine. 2006;23:141-147.
12. Philip M, Batelino T, Rodriguez H, Danne T, Kaufman F, Consensus Forum Participants. Use of insulin pump therapy in pediatric age group. Diabetes Care. 2007:30:1653-
1662.
13. United Healthcare Medical Policy. Continuous Glucose Monitoring and Insulin Delivery for Managing Diabetes. Copyright 2011.
14. United Health – Center for health reform and modernization. November 2010.
15. Diabetes Forecast January 2011.
16. American Association of Diabetes Educators 2008 Consensus Summit. Insulin Pump Therapy.
17. Pumping Protocol by Bruce Bode M.D. 2008 Medtronic Minimed, Inc.
18. Animas Corporation.
19. Insulet Corporation.
20. Sooil Development.
21. Roche Insulin Delivery Systems.
22. Nipro Corporation.
23. Consultant. Diabetes and Prediabetes. Edward J. Shahady M.D. August 2011. Volume 51. Number 8.
24. Rizza RA, et al. Diabetes Care. 2003:26(5): 1545-1552.
25. Stewart AF. Journal of Clinical Endocrinology and Metabolism. 2008:93: 1164-1166.