Diabetes Technologies

Insulin Pump Therapy

Beverly Thomassian, RN, MPH, BC-ADM, CDE
President, Diabetes Education Services
Diabetes Technologies – Insulin Pumps
 1. Describe critical teaching content before starting
insulin pump therapy
 2. Discuss strategies to determine and fine-tune
insulin pump basal rates.
 3. Discuss how to determine and fine tune bolus rates
including coverage for carbs and hyperglycemia.
 4. State important safety measures to prevent
hyperglycemic crises.
 5. List inpatient considerations for insulin pump
therapy and CGMs
Conflict of Interest and Resources
 Coach Bev has no conflict of interest
 Technology field is rapidly changing
 Photos in slide set are from Pixabay – not actual clients
 Resources
 AADE Practice Paper 2018- Continuous Subcutaneous Insulin Infusion (CSII)
Without and With Sensor Integration
 AADE Practice Paper 2018- Diabetes Educator Role in Continuous Glucose
Monitoring
 Company web sites – virtual demo
 AADE – DANA Diabetes Advanced Network Access www.diabeteseducator.org
Need to be AADE Member to access
 Diabetes Forecast Consumer Guide 2019
 Pumping Insulin by John Walsh, PA, CDE – Diabetes Mall
 Gary Scheiner, MS, CDE – Integrated Diabetes Services
ADA Standard 7- Diabetes Technology
 Diabetes technology is the term
used to describe the hardware,
devices and software that
people with diabetes use to
help self-manage their diabetes
and improve quality of life.
 Advances in technology will
continue to revolutionize and
improve the way diabetes care
is delivered.
Diabetes Technology – Topics
 This rapid change in the technology landscape
can make it difficult and confusing for diabetes
educators and providers to keep up to date.
 Insulin delivery methods
 Insulin syringes, pens, disposable patch, pumps
 Setting and evaluating basal and bolus settings
 Inpatient management
 Traveling with technology
 Continuous glucose monitoring
Insulin pump Geography Variations
 Due to health disparities,
adoption of insulin pump
therapy varies across
geographic and socioeconomic
landscapes.
 Disadvantaged groups have
less access to insulin pumps
and associated technologies. 
 These disparities need to be
addressed along with insulin
affordability.
Pre Pump Knowledge / Education
 Establishment of Goals
 Competence in Carb counting
 Insulin Carb Ratios (ICR) & Correction
or sensitivity factor (CF)
 Ability to manage hyper and
hypoglycemia
 Self-adjust insulin
 Carbs
 Correction
 Physical activity
Pre Pump Knowledge / Education
 Ability to fill and insert
cartridge/reservoir and insert and
change infusion sets
 Ability to detect infusion set and site
issues
 Manage sick days, exercise and travel
 Trouble shoot and ability to solve
pump issues
 Understand BG Data
 Hypo prevention and treatment
 Basic of basal bolus therapy and how
to switch back to injections if needed
Lifestyle Indications and Attributes
 Erratic schedule
 Varied work shifts
 Frequent travel
 Desire for flexibility
 Tired of MDI
 Athletes
 Temporary basal adjust
 Disconnect options
 Waterproof options
LifeStyle Indications for Candidate or Parents of
Pump Wearer
 Parents and caretakers must
have a thorough understanding
and willingness and time to
understand the pump and work
with team to problem solve
 Willingness to work with
healthcare provider during pre-
pump training
 Adequate insurance benefits or
personal resources
LifeStyle Indications for Candidate or Parents of
Pump Wearer
 Physical ability
 View pump
 Fill and replace insulin cartridge
 Insert an infusion set
 Wear the pump
 Perform technical functions
 Emotional stability and
adequate emotional support
from family or others
Caregiver education about pumps
 Key Topics
 Hypo detection /treatment
 Hyperglycemia trouble
shooting
 Basic bolus procedure
 Cartridge set change
process
 Understand what alarms
mean
 History recall
Poll Question 3
 Teenagers benefit from insulin
pump therapy for the following
reason.
 A. Can increase insulin rate to cover
for alcohol intake.
 B. Decreased risk of glucose
emergencies
 C. Greater dependence on parents
 D. Match insulin to hormone swings
Toddlers benefit
 Delayed blousing for fussy eaters
 Dosing precision 10ths or 20ths of a
unit
 Reduced hypo risk
 Lockout features

 Teens
 Basal patterns for hormonal swings
 Historical data records/
downloading / app sharing
 Easy snack coverage
 Greater independence
 Technical coolness
Written Plan for Pump Use
 Blood glucose checks or CGM
Checks
 Record keeping of BG, Carbs,
insulin, activity and other issues
 Site-change guidelines
 Restart injections if needed
 When to check ketones and
action to take
 Hypoglycemia and Hyperglycemia
treatment guidelines
Example – On 30 units /weighs 70kg
 Method 1
 TDD x 0.75
 30 units x 0.75 = 22.5
 Method 2
 Pt wt kg x 0.50
 70kg x 0.50 = 35
 Final daily dose
 A1c 6.3% - Method 1
 A1c 9.2% - Method 2
TDD = Total Daily Dose  A1c 7.5 – Avg 1&2 (28.75)
TDI = Total Daily Insulin
Example – JR injects TDI of TDI , A1c 6.7%
 30 x.75 = 22.5 units total
daily dose
 22.5 x 0.5 = 11.25 units
for basal
 11.25 divided by 24 hrs =
0.47 units/hr (basal rate)
Basal insulin
 Drip of rapid insulin very few
minutes
 If basal rate is set correctly, stable
BG between meals and hs
 Can skip delay meals
 Deliveredauto on 24 hour cycle
 Temporary adjustments may
include:
 lower basal insulin during exercise
 increase during sick days
Role of basal insulin in pumps
 Keep glucose steady
 On average, 5 different basal segments needed
 Basal insulin rate not correct
 Glucose rises or falls even when not eating
 Fasting glucose is elevated or low
 Correction bolus does not get glucose to target
 To prevent hypoglycemia, no coverage for snacks
 If person is eating to cover for in-between meal
hypoglycemia
Basal Insulin Needs
 Dawn phenomena
 Higher needs from 3-7am
for adults
 Kids from Midnight to 7am
Basal rate can be adjusted
to match sleep and work
schedule
 Traveling – change
clock in pump to match
new time
Typical Basal Needs

Gary Scheiner, MS, CDE

Basal Insulin Dosing – Beyond Basics
 Active, healthy
 35-45% of total daily insulin
 Less active, lower carb intake
 45-55% of total daily insulin
 Percentage may increase during puberty
 Tends to decrease with advanced age
 Sleep and growth patterns have major
influence
Basal Rate Testing
 No food or bolus insulin for 4 hours
prior
 No eating during test
 No calories, water and decaf diet drinks ok
 Avoid high-fat food immediately prior
 No alcohol for 12 hours prior
 In case of glucose < 70, eat and stop test
 If glucose > 250, stop test and bolus
 Maintain normal activity
 Avoid during illness, if taking steroids
Monitoring Basal Test
 Onlyuse fingertip
 Check every 1-2 hours (daytime)
 Check every 2-3 hours (overnight)
 CGM to collect data very helpful
 Reliable data trends
 Can download or photograph 6-12 hour screen
 Adjust basal if rise or falls more than 30 points
 Double check no outside events
Adjusting basal rates – think ahead
Takes time for basal rate
to affect glucose
 For children: change in   Current basal level (units /hr)

basal rate 1 hour prior   0.0 – 0.45 0.5 – 1.2 >1.2

to rising or falling Modest Rise/Fall

(30-60 mg/dl)
 
.05
 
0.1
 
0.2

glucose
 For adults: change in      
Large Rise/Fall
basal rate 2 hour prior (>60 mg/dl) 0.1 0.15 0.3

to rising or falling
glucose
 Repeat basal test after
adjustment
Problem solving
 If basal or bolus is more than
65%, usually indicates need
to recalculate
 Prevent missed boluses
 1 missed meal bolus over a month
raises A1c 0.5%
 Get in habit of pre-blousing
 Use reminder alerts on pumps
Bolus Rates - Same for each meal to start
 Bolus rates
 CHO Ratio
 Start with 1:15 or
 450 divided by TDD= I:C Ratio
 Correction/sensitivity
 1700 divided by TDD
 Target Range: 95-140 mg/dl
 Active insulin/insulin On Board
 3-6 hours
Example – JR injects 30 TDI, A1c 6.7%
 30 x.75 = 22.5 units total daily
dose
 22.5 x 0.5 = 11.25 units for
basal
 11.25 divided by 24 hrs = 0.47
units/hr (basal rate)
 450 divided by 22.5 = 20/ CHO
Ratio
Carb to Insulin Ratios
 Dose based on:
 Grams of carb in meal
 Insulin carb ratio or fixed dose
 Right dose?
 Brings glucose to prebolus glucose level within 3-4 hours
 If BG rises more than 60 points 2 hours post meal, needs
adjustment
 If BG falls more than 30 points 2 hours post meal, may
need adjustment
 Adjust in small increments (10-20% ideal)
Calculating Bolus insulin
 Based on glucose and carb MySugr app mysugr.com

data entered by user

 Built in bolus calculator
 Insulin on board prevents
stacking
 Rate of delivery can be
extended
 Insulin delivery hx stored in
pump
Active Insulin time - IOB
 How much “insulin on board” IOB to prevent
stacking and hypoglycemia
 Typical time is 4 hours*
 Typical active insulin time is 3-5 hours
 Action time shorter in leaner, young, active
individuals in hot climates
 Set at 6-8 hours for those with renal disease or
using regular insulin
 Careful monitoring or CGM to eval if bolus rates set
correctly
Pumps have built in bolus calculators
 Based on glucose and carb
data entered by user
 Bolus Estimate Details ICR 1:15 gms
Correction 1unit for 50
Total 6.0 U Target BG 100
Food intake 75 gms Active insulin on board
BG 200 (IOB) subtracted from the
Food Dose 5.0 U correction
Correction Dose 2.0 U
Insulin-On-Board 1.0 U 75 gms carb/15 = 5 units
(Based on BG and Carbs Correction 200-100 = 100/50 = 2 units
entered by user.) IOB = 1 unit
7 units – 1 units = 6 units
How much insulin would this person need?
 Plans to eat 45 gms Carb Snack
 BG is 150
Bolus Estimate Details ICR 1:15 gms
Correction 1unit for 50
Total U Target BG 100
Food intake 45 gms Active insulin on board
BG 150 (IOB) subtracted from the
Food Dose ?.0 U correction
Correction Dose ?.0 U
Insulin-On-Board 2.0 U 45 gms carb/15 = ?units
(Based on BG and Carbs Correction 150 -100 = ?units
entered by user.) IOB = 2 unit
Total insulin = ? units
Poll Question 4
 For case study, how much insulin?
 A. 3 units
 B. 2 units
 C. 4 units
 D. Determine activity first
How much insulin would this person need?
 Plans to eat 45 gms Carb Snack
 BG is 150
Bolus Estimate Details ICR 1:15 gms
Correction 1unit for 50
Total 2.0 U Target BG 100
Food intake 45 gms Active insulin on board
BG 150 (IOB) subtracted from the
Food Dose 3.0 U correction
Correction Dose 1.0 U
Insulin-On-Board 2.0 U 45 gms carb/15 = 3 units
(Based on BG and Carbs Correction 150 -100 = 50/50 1 unit
entered by user.) IOB = 2 unit
4 units – 2 units = 2 units
Not using insulin bolus ratios?
 Fixed dosing
 Take half of total daily
dose, reduce by 25% and
divide by number of meals
to get fixed dose per meal
 Calculate insulin sensitivity
correction factor
 1700 by total daily insulin
 No target – choose
acceptable target
Advanced Pump Features
 Prolonged bolus for
 Gastroparesis, amylin, GLP-1
Receptor Agonists
 Advanced Basal Features
 Temporary basal rates
 Secondary, tertiary programs
 Custom alerts
 Data downloads
Prolonged bolus
 Standard bolus  Purpose
 Delivered within a few  Match insulin to
minutes absorption of food
 Peaks in one hour  Works well with slowly
 Lasts for four hours digested food
 Prolonged bolus  Applications
 Delivered over a couple  Large portions
of hours  Slow consumption
 Peak delay  Gastroparesis
 Duration extended  Use of incretin mimetics
Prolonged bolus
 Square/extended  Dual/combo/
 None of the bolus is combination bolus
delivered up front  30% delivered up front,
 Common timing is 1-2 the rest of bolus over
hours after start of meal the next several hours.
 Can last for up to 8  Lasts about 5 hours
hours
Insulin coverage for protein?
 Most of time, protein won’t
affect glucose
 If person on low carb diet,
protein may start impacting
blood glucose levels
 Bolus for 50% of protein grams
 If large protein portion
(more than 50g) extended
bolus for additional 20-30gs
of carb
Insulin Sensitivity – Correction Factor
 Amount that 1 unit of insulin is expected to lower
glucose
 Based on average Total Daily Insulin (TDI) Dose
(basal + bolus)
 The more insulin used, the lower the sensitivity
 Sensitivity varies by day
 Determined by dividing TDI into:
 1500 – aggressive or regular insulin
 1700 – common approach for analogs
 2000 – conservative approach
Correction Insulin Example
Correction Factor Fine-Tuning
Mathematical Approach
Example Person on TDI of 50 units

Correction Scale Sensitivity mg/dl

Aggressive
(1500) 1500 / TDI 30
Common
(1700) 1700 / TDI 34
Conservative
(2000) 2000 / TDI 40
Example – JR injects 30 TDI, A1c 6.7%
 30 x.75 = 22.5 units total daily dose
 22.5 x 0.5 = 11.25 units for basal
 11.25 divided by 24 hrs = 0.47
units/hr (basal rate)
 450 divided by 22.5 = 20/ CHO Ratio
 1700 divided by 22.5 = 75 /
correction
 1:20 I:C Ratio
 1:75 Correction
Transition from MDI to pump
 Best in am, not travel,
outpatient setting okay
 Wean person off injections
 NPH, hold am dose
 Glargine, detemir- take day before,
if evening hold is best.
 Degludec – take ½ usual dose day
before if am, if evening, omit.
Safety guidelines
 Review signs and treatment
of hypo
 Do not suspend pump when low,
unless no treatment available
 Diabetes Ketoacidosis
 Those with negative c-peptide at
higher risk
 Insulin pump interruption for 2-3
hours can lead to DKA
 Provide education to prevent,
detect and reverse
Poll Question 4A
 AL is on an insulin pump. Her BG at 10am is
108, at 11am, 219 and noon 298. She has not
eaten anything since breakfast. What is best
action?
 A. Program insulin pump to deliver 3 units
bolus stat
 B. Increase basal rate starting at 8am
 C. Go to emergency room
 D. Check for ketones
Disconnecting from Pump
 BG rises about 1 mg/dl a
minute when disconnected
 Avoid extended disconnection
since can lead to ketones and
hyperglycemia
 Strategies
 Short term disconnection < 1 hour
 Bolus to replace missed basal insulin
 Long term >1 hour and bolus missed
basal insulin hourly
 Protective caps usually not necessary
Prevent DKA and Hyperglycemia
 Eval sites for malabsorption, make sure to change site
and infusion sets every 2-3 days
 Protect insulin from overheating
 Tubing or infusion set clogs – change site
 Check for leaks, smell for insulin, use angled sets
 Make sure to purge air bubbles before priming tube
 Inspect daily for dislodgement
 Priming insulin tubing when changing infusion set
 Extended pump suspension or disconnect (limit to one
hour, carry syringes at all times)
Hospital Stay for Pumpers
 Staff need to assess:
 How long using pump?
 Who adjusts pump settings?
 What type of insulin is used?
 How much insulin is in pump now?
 When is next site change? Who does it?
 Basal rates? I:C ratios? Correction?
 Have your supplies?
 When usually check BG or CGM?
Hospital Stay - Need orders
 Backup plan in case pump can’t be used
 Don’t stop pump without administering
rapid insulin first (or IV insulin).
 Designate surrogate programmer(s)
 Specify frequency and carb count for
meals/snacks
 Keep pump and programmer outside
room during MRI, CT Scan, Xray.
 Remove infusion set and sensor for MRI
 Don’t aim Echo/US transducer at pump
Pumpers Responsibility in Hospital
 Provide own pump (and sensor)
supplies
 Change pump reservoirs and
infusion sets
 Provide staff with SMBG and
insulin doses
 Notify staff of adjustments to
standard doses
 Respond to alarms
Backup Plan if pump isn’t working
 Immediate basal insulin
injection
 Mealtime rapid insulin
injection
 Keep written log of I:C ratios,
correction and meal boluses
 Keep log of off-pump activity
 Resume pump when basal
insulin wears off
Action in Case of Hyperglycemia for Pump Users

• Unexplained
hyperglycemia Check for
Ketones

• Ketone
negative
Bolus with pump

• Ketone Inject insulin

positive Drink H20
Change out
pump
Ketone Testing Options
 Urine ketostix or diastix
 More than 15 mg/dl = positive ketones
 Blood sampling
 Novamax or Precision Xtra blood meter
 More than 0.5 mmol/l β – hydroxybutyrate
indicates action and insulin needed

https://www.novabio.us/nova-max-plus/
When to contact clinical staff
 Severe or repeated hypo
 Ketosis
 Signs of infection
 Call pump company if technical
difficulties
 See pt in 1-2 weeks, download
device, troubleshooting
 At 3-4 weeks review more
advanced features
Thank You
 Please email us with any
questions.
 [email protected]
 www.diabetesed.net