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Dr Aidin Rawshani

Insulin pump for the treatment of diabetes

Treatment with insulin pump

What is an insulin pump?

Insulin has been used to treat diabetes since the 1920s. Since insulin cannot be eaten or drunk (insulin is destroyed in the stomach and intestines), it must be injected. With the help of insulin syringes and pens, insulin is injected into the fat under the skin. The vast majority of people receiving insulin use pens (insulin pens) to inject the insulin. Using an insulin pump means you have to stab yourself several times a day. The vast majority of people with diabetes find it difficult to have to stab yourself several times a day to get your insulin. In 1992 came the first insulin pump, which revolutionized the use of insulin. An insulin pump is a small pump that enters insulin into the subcutaneous fat via a tube and needle that can last for a long time. The insulin pump pumps fast acting insulin continuously during the day. Today we know that insulin pump is the best method for obtaining a good blood sugar. This is extremely important for a person with diabetes. The insulin pump improves blood sugar and usually provides an improved quality of life.

The following picture shows an insulin pump on the left and an insulin pen on the right. With the pump, fast acting insulin is administered continuously, but at a low dose. Extra doses can be given with meals.

How good are insulin pumps?

Treatment with an insulin pump has been shown to be better than normal insulin syringes (insulin pens). In addition, the pump results in less insulin during the day (insulin requirement decreases). Several researchers consider it important to keep insulin doses down because insulin is a hormone that affects many functions in the body. However, you should not worry about your total dose of insulin as it is much more important to try to have a good (i. e. as normal as possible) blood sugar.

There are studies that show that people with insulin pump have a lower risk of complications, including more serious complications. Although there are no major studies with long follow-up, the insulin pump is likely to reduce the risk of complications as the insulin pump leads to better blood sugar (lower HbA1c) and less fluctuations in blood sugar.

Today’s insulin pumps consist of the following components:

  • The insulin pump.
  • Battery with service life of several weeks and electronic functions that control the operation of the pump.
  • Disposable containers for insulin.
  • Piping system for connecting insulin containers to the cannula.
  • Most modern insulin pumps have a monitor and controls to allow the user to determine the dose and time of insulin.

How does the insulin pump work?

An insulin pump has an insulin reservoir that usually contains 150 to 300 units of fast-acting insulin. The container needs to be replaced when the insulin is exhausted. The pump injects a constant dose with insulin. That is, a small amount of insulin is injected uninterrupted. This amount is tailored to You. In addition to the continuous supply of insulin, you should add extra insulin (bolus doses) during meals. The basal dose and meal doses can be adjusted via the pump settings.

How is the quality of life affected by insulin pump?

Patients with insulin pump experience that treatment is extremely flexible and pleasant, especially when used with continuous glucose measurement (CGM) and carbohydrate counting. Unfortunately, there are too few people with type 1 diabetes who have an insulin pump. The majority of all people with type 1 diabetes still have insulin syringes. There are large variations within the country regarding the use of insulin pump. In large cities, and especially where there are university hospitals, insulin pump is more common. Children and young people with diabetes tend to receive insulin pump more often than adults.

Is insulin pump only for people with type 1 diabetes?

People with type 2 diabetes may also be offered an insulin pump. However, it is rare for people with type 2 diabetes to be offered an insulin pump and this, as a rule, depends on the cost of the pump. Insulin pumps are very expensive and in most county councils are reserved for people with type 1 diabetes.

Insulin pump reduces the number of blood sugar falls and improves HbA1c

Blood sugar drop (hypoglycaemia) is very difficult for people with diabetes, especially type 1 diabetes. Hypoglycaemia, as well as concerns about hypoglycaemia, leads to lower quality of life, anxiety and psychosocial problems. Almost all people with type 1 diabetes suffer from hypoglycaemia from time to time and up to 25% do not feel hypoglycaemia, which can lead to severe hypoglycaemia. In fact, hypoglycemia and concern about hypoglycemia are one of the main reasons why people with diabetes do not achieve good blood glucose control.

Some people with diabetes have problems with swinging blood sugar. These individuals usually prefer to have slightly elevated blood sugar, as it is easier to avoid hypoglycaemia if the blood sugar is slightly high. Unfortunately, high blood sugar leads to complications in the long term.

People who experience recurrent hypoglycaemia should be particularly vigilant as these are at risk of severe hypoglycaemia with loss of consciousness and coma.

Here are two pictures illustrating the difference between insulin pump and insulin pens. Note that with insulin pump, blood sugar becomes smoother and also lower over time.

Repeated insulin injections daily involve injecting fast-acting insulin before meals and long-acting insulin once or twice daily. This type of treatment leads to the fact that some people find it difficult to control their blood sugar. This is manifested by pronounced fluctuations in blood sugar, repeated blood sugar falls (even at night), high blood sugar levels in the morning (“dawn phenomenon”) and high blood sugar during fasting.

Insulin pump allows a stable infusion (continuous injection) of fast-acting insulin from a portable insulin pump. The speed can be adjusted according to your insulin requirement. The figure shows how blood sugar stabilizes and the number of episodes of blood sugar fall and blood sugar increases is reduced. This also leads to lower long-term blood sugar (HbA1c)

Advantages of insulin pump

The insulin pump tries to mimic the body’s way of dosing insulin. The human own insulin acts immediately and is uninterrupted (in a low dose) from the pancreas (pancreas). During meals, larger amounts of insulin are released to allow the body to take care of nutrients (especially carbohydrates) in food. The insulin pump delivers small doses of fast-acting insulin continuously.

Studies have shown that blood sugar is significantly improved. HbA1 drops approximately 5 mmol/mol. Studies show that people using insulin pump have a 42% lower risk of cardiovascular disease and a 27% lower risk of premature death compared to those using insulin pens (however, this study was not a clinical trial).

The need for insulin drops by about 10-20% when switching from insulin syringes to insulin pump.

In general, insulin pump leads to the following:

  • Smoother blood sugar levels
  • Fewer fluctuations in blood sugar levels
  • Improved long-term blood sugar (HbA1c)
  • Fewer blood sugar falls and lower blood sugar rises

Thus, the insulin pump leads to a decrease in blood sugar while reducing the risk of falling blood sugar (hypoglycaemia). This is undeniably a good treatment and it explains why people with an insulin pump get an improved quality of life. The insulin pump provides a better quality of life in both type 1 diabetes and type 2 diabetes.

Because the insulin pump contains fast-acting insulin, it is usually easier to adjust the dose according to the activity (meal, workout).

The insulin pump records blood sugar levels during the night and adapts insulin doses to counter a condition called dawn phenomenon, which means that blood sugar fluctuations and lower blood sugar during the night.

Many people with diabetes experience that insulin pump is more convenient and more discreet than injection with a syringe. It is nothing unusual for people with diabetes not dare to inject insulin in social contexts. With an insulin pump, the dosage becomes more discreet and makes it easier for those who otherwise have difficulty injecting insulin among other people.

Insulin pumps make it possible to deliver more accurate amounts of insulin than can be injected using a syringe, this is particularly beneficial for young children where precise insulin doses are important.

Treatment leads to better blood sugar and long-term blood sugar (HbA1c), which reduces the risk of complications of diabetes.

Several insulin pumps have the functions to upload data that the pump records to a computer or mobile phone showing diagrams for trend analysis. These figures can often be instructive and educational. In this way, an individual with type 1 diabetes can have an idea of various causes that may contribute to hypo- and hyperglycaemia and fluctuations in blood sugar.

Although the insulin pump is expensive, it is believed that it will lead to savings (in healthcare) in the long term because insulin pump is likely to lead to better health.

Insulin pump can be combined with a continuous glucose measurement (CGM). However, some insulin pumps are semi-automatic and regulate insulin delivery in case of decreasing or low blood sugar levels.

Disadvantages of insulin pump

Approximately 20% of all people receiving an insulin pump continue to have problems with blood sugar falls or high blood sugar increases. Then consideration should be given to using a CGM (continuous glucose meter). Continuous glucose measurement (CGM) means that you have a sensor that is glued to your arm. The sensor has a needle that is inserted into the skin and the needle measures the sugar content. The sugar content in the skin and subcutaneous fat is approximately the same as the sugar content in the blood. With a CGM, blood sugar can be recorded continuously for several days and you can see the values on a screen, or on your smartphone.

Another disadvantage of insulin pump is that patients have a higher risk of developing the dreaded complication ketoacidosis if the pump fails.

The following reasons may lead to insulin pumps not working properly:

  • The battery is dead
  • Insulin is unusable due to heat exposure
  • The insulin reservoir is empty (ie the insulin is exhausted)
  • Insulin leaks from the insulin tube
  • The needle has become bent, preventing adequate insulin delivery.

Many people who use an insulin pump are therefore even more careful to control their blood sugar. Therefore, it can be extra comfortable to have a CGM, which makes you have a very good track of your blood sugar.

Since the insulin pump has to be carried constantly, certain activities have to be planned. The pump can be damaged by contact sports and liquids. Therefore, it may be advisable to have additional insulin (insulin syringes/pens) if you are to perform an activity that is at risk of damaging the pump.

Technical problems with insulin pumps occur which means that you can return the pump. Fortunately, most pump manufacturers offer a new pump within 24 hours, but during that time you have to return to using insulin syringes.

Modern insulin pumps

Several of the new insulin pumps can perform safety checks automatically during the day.

Remember to change the position of the needle

Patients using an insulin pump may experience scar tissue or thickening where the needle is located. This is due to the fact that insulin is an anabolic hormone that leads to the growth of adipose tissue. So you can get fat tubers where the cannula has been sitting. Fatty tubers are harmless but heal slowly. In addition, skin areas with fat tubers have less absorption of insulin (in fact, fat tubers may be so pronounced that the insulin is not even absorbed). Therefore, be sure to change the position of the needle at regular intervals. If you experience allergic skin reactions where the adhesive of the needle has been placed, you should also change the place.

How much does an insulin pump cost?

Insulin pumps and accessories can be much more expensive than insulin syringes. Several pumps cost tens of thousands of crowns annually. It is your healthcare provider who should pay for the insulin pump. However, it is also your healthcare provider who decides whether or not to have an insulin pump.

What is the availability of treatment with an insulin pump?

The use of insulin pumps increases due to the following reasons:

  • Patients’ quality of life increases.
  • Easier to achieve intensive treatment
  • More accurate delivery of very small doses necessary for younger children.
  • Growing support among doctors and insurance companies due to the benefits and reduced risk of diabetic complications.
  • Easier to monitor blood glucose levels and determine which factors affect blood sugar increases and blood sugar fall.

In Sweden, approximately 20% of all adult patients with type 1 diabetes, insulin pump is used.

Indications for insulin pump therapy

People wishing to switch to an insulin pump should first try daily insulin injections, both direct-acting and long-acting insulin, before starting pump therapy. Patients wishing to switch to insulin pump should be thoroughly familiar with the recording of ketones in the blood or urine to quickly detect whether ketones accumulate in the blood before people develop the complication ketoacidosis

Physicians treating patients with type 1 diabetes should consider switching to insulin pump if the patient exhibits long-term blood sugar (HbA1c) above 57 mmol/mol or has not achieved their individual targets despite optimal treatment with insulin pens and self-control.

People who have high blood sugar in the morning (dawn phenomenon) are recommended to adjust the insulin dose in the evening or food intake to help correct the increase in blood sugar, if these corrections are not successful, the treating physician should consider insulin pump treatment.

People with type 1 diabetes who have experienced repeated hypoglycaemic episodes that persist despite reduced insulin doses may also be offered an insulin pump. Several people with type 1 diabetes have a low body mass index (BMI) and require small insulin doses, but even small doses of insulin may result in hypoglycaemia or significant fluctuations in blood sugar. Glycemic variation is a term commonly used in diabetes care, it aims to describe blood sugar fluctuations in a person. Research shows that glycemic variation is disadvantageous and contributes to cardiovascular diseases, just like elevated long-term blood sugar (HbA1c).

Persons offered treatment with insulin pump must undergo training to manage the insulin pump. The individual must be provided with sufficient knowledge about insulin pump technology, replacement of insulin reservoirs, recording of ketones and sugar (glucose) in the blood, and how to deal with any problems with the pump.

The most important factor in the success of patients switching from insulin syringes to insulin pump is blood sugar levels before switching to insulin pump. Research studies have observed that people who use insulin syringes and have poor blood sugar levels benefit most from switching to insulin pump.

Guidelines from various diabetes organizations for insulin pump treatment

A 2008 meta-analysis showed that the frequency of severe hypoglycaemia was greater in subjects with multiple daily insulin injections compared to those with insulin pump. In the UK, healthcare services recommend that people with persistent blood sugar levels around 70 mmol/mol or higher, while France uses a threshold of 58 mmol/mol or higher. An organization called NICE (The National Institute for Health and Care Excellence) recommends insulin therapy for adults at 70 mmol/mol or higher.

Guidelines from the American Society for Diabetes (ADA) recommend insulin pump therapy for elevated long-term blood sugar that does not improve after intensive insulin treatment with syringes, or frequent and unpredictable fluctuations in blood sugar. Many believe that these indications are not sufficiently defined and believe that patients with frequent hypoglycemia or hyperglycemia should be offered pump therapy.

Many pediatricians consider several daily insulin injections impractical or unpleasant for some children, because children may not be able or do not want to inject insulin in school. Therefore, some experts suggest that children with type 1 diabetes can be offered pump therapy without first having failed glycemic control with insulin syringes.

Initiating insulin pump therapy

Insulin pump therapy should be initiated in a specialised hospital with a team consisting of a doctor, diabetes nurse and a dietician trained in insulin pump therapy. Initiation of pump therapy by primary care professionals is not recommended. It is important that the patient is willing and motivated to use the insulin pump.

Initiation of insulin pump therapy is generally contraindicated when a specialized team is not available, when the patient is unwilling or unable to use the pump, or when the patient has major psychiatric problems.

Insulin in pump treatment

Insulin used in insulin pumps is always fast-acting meal insulin (Apidra, Humalog, Novorapid).

Information for patients with insulin pump

The anterior abdominal wall is the usual infusion site, the outer thighs, arms, hips and buttocks can be used but generally have slower insulin absorption. Areas with broken skin, adipose tissue (lipohypertrophy) or scarring should be avoided. The infusion needle should be changed every 2 to 3 days and rotated to a new anatomical site – just like the insulin injection site should be varied to avoid lipohypertrophy.

Studies have shown that people who do not move the insulin pump or injection area after 3 days have impaired glycemic control and increased risk of infection at the site.

Patients with an insulin pump who become acutely ill and hospitalized should not count on staff always knowing how to handle insulin pumps. Therefore, most patients with insulin pump usually have written information in their wallet or stored elsewhere where it says that the patient is being treated with an insulin pump.

If patients with an insulin pump develop diabetic coma or ketoacidosis, the pump must be temporarily removed and the patient must switch to normal injection therapy with fast-acting and long-acting insulin.

Patients with an insulin pump who develop inexplicably high blood sugar levels should also switch to injection treatment with syringes until the cause of changes in blood sugar levels is determined

Is it possible to exercise with an insulin pump

Exercise is very healthy! Physical activity lowers blood sugar and increases insulin sensitivity, which leads to a decrease in daily doses of insulin. In addition, factors for the cardiovascular system are positively affected if you move regularly. Additionally, improvements in harmful fats such as triglycerides and LDL cholesterol are seen which decrease and the beneficial HDL cholesterol increases.

For people with type 1 diabetes, almost all types of exercise are possible. When swimming, martial arts and contact sports, the insulin pump must be removed and the needle must be pulled out. Individuals with an insulin pump may reduce the basic dose of insulin for a specified period of time, preferably a short time before the workout. The reduction in the basic dose depends on the duration of the exercise and the type of training the person performs. There is no rule of thumb as to how much to lower the basic dose, the reduction is individual.

People with type 1 diabetes are recommended to measure blood sugar before and after the exercise; if blood sugar levels are elevated, the person should also check the levels of ketones in the urine. Do not start training with too low blood sugar levels, blood sugar at the start should be between 8-10.0 mmol/l.

Technical failure of the insulin pump

People with insulin pumps should report broken pumps to their diabetic clinic that reports the deviation to the insulin pump company, which then reports the failure to the Swedish Medicines Agency. In case of technical errors resulting in serious complications for the patient, the diabetes clinic should also report the matter to the Medical Engineering Unit and IVO (Inspectorate for Care and Care).

Causes of malfunction of the insulin pump

Patients and healthcare professionals need a checklist of possible causes of unexplained blood sugar rise (hyperglycaemia). Common causes of malfunctioning are problems with the needle (curved, blocked or leaking), problems at the infusion site (infection or lipohypertrophy), pump failure (low battery, inactive insulin or other mechanical/electrical failure with the pump).

To terminate treatment with insulin pump

In patients with insulin pump therapy who have not benefited from an improvement in long-term blood sugar, lower blood sugar drop rates and less glycaemic variation, treatment should be discontinued. People with insulin pump should evaluate the effectiveness of treatment at least every year.

Conditions that may affect a person’s ability to manage his insulin pump, such as stroke, dementia or other newly emerging diseases, should be discussed with the attending physician who may consider discontinuation of insulin pump therapy.

The first 6 months are an initial phase where clinical visits or contact with healthcare professionals may become frequent, after which most patients receiving insulin pump therapy do not have to be observed as regularly.

In consultation with the patient, insulin pump therapy should be discontinued if the patient wishes to return to the treatment regimen with several daily insulin injections. However, in most cases, the interruption rate is only about 5% or less.

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