What Is Insulin Pump Therapy?
What Is An Insulin Pump?
An insulin pump is a computerised, battery operated insulin delivery device consisting of:
- the main pump unit (similar to a small mobile phone)
- a disposable insulin reservoir (the cartridge)
- a long, thin piece of tubing with a needle or cannula at one end (the infusion set)
A few insulin pumps, e.g. the Dana i, also have some sort of remote control function (The Dana i allows for your smartphone to become the remote control via the AnyDana apps). The Dana i insulin pump is only available through the NHS, please discuss the applicability of this treatment option with your health care team.
How Does It Work?
To use the pump, the cartridge is filled with fast-acting insulin and fitted inside the pump. The needle or cannula is inserted under the skin and held in place with the adhesive patch which fixes to the surrounding skin.
The other end of the tube is connected to the pump which then delivers insulin through this infusion set according to its programming.
Pump Training
New pump users receive training and support both from their health care team and from Advanced Therapeutics (UK) Ltd UK trainers to help them get to grips with managing their own insulin doses.
The insulin pump standalone does not measure glucose levels and produce insulin automatically, for that you would need Dana CamAPS® FX. Continuous Subcutaneous Insulin Infusion (CSII) remains the most natural form of insulin delivery available today with Insulin Pump Therapy and Hybrid Closed Loop Therapy both benefitting from this insulin infusion method.
How Do I Get A Pump?
First you need to discuss pump therapy with your health care team. If it is decided that you would benefit from pump therapy, you may first need to undertake a program of flexible (multiple) injection therapy, including carbohydrate counting. If your control does not improve sufficiently, pump therapy may then be offered.
Pumps are funded through your secondary care provider, based on a clinical decision made by your health care consultant.
In order for the NHS to fund an Insulin Pump you must conform to the NICE (the National Institute for Health and Clinical Excellence) Guidelines.
NICE publishes three versions of its technology appraisal guidance. You can download these documents as follows:
- The full guidance on the appraisal (the recommendations and a summary of all the evidence).
- A quick reference guide – a short version for healthcare professionals.
- Understanding NICE guidance – a description of the guidance written for people with a specific condition and their careers.
Note: If you conform with the criteria contained within the NICE Guidelines and are having difficulty in obtaining the approval or your health care team or securing funding from your Clinical Commissioning Group (CCG), you may wish to contact INPUT Patient Advocacy for advice and support.
What Are The Benefits?
Insulin Pump Therapy provides an effective means of achieving near-normoglycaemia in people with Type 1 diabetes. As an intensive treatment option it offers a number of advantages over conventional Insulin Therapy.
Natural Supply Of Insulin
An insulin pump provides a continuous supply of insulin throughout the day and night (basal insulin) and extra boosts are given before eating (bolus insulin). The basal insulin takes care of your background insulin needs and the bolus insulin is tailored to your food intake. So, the insulin pump will give you the most natural method of insulin delivery.
Reliable Supply Of Insulin
The basal insulin is supplied as a very small amount every few minutes and only short acting insulin is used with a pump. This means that there are no problems with variable absorption of insulin and those unpredictable swings in glucose levels can be avoided.
Insulin Supply Tailored To Your Needs
The amount of background insulin – the basal rate – can be set at different levels through the day and night, according to your own needs. This means that you can have the pump automatically deliver more background insulin when you need it – in the early hours of the morning, for example – just as the body would naturally provide it. Using an insulin pump can ensure stable glucose levels through the night, coping with the dawn effect, but without increasing the risk of nighttime hypos.
Eat What You Want, When You Want
The continuous trickle of basal insulin also takes care of your daytime needs when you are not eating. At mealtimes, or if you fancy a snack, you set the pump to deliver extra insulin. The amount of insulin – the bolus dose – can be tailored exactly to what you eat and how much of it. When you choose to eat is up to you.
Sleep In At Weekends
The basal insulin continuously supplied by the pump will keep glucose levels steady throughout the night and into the day without any input from you. This means that you can sleep in and not have to worry about glucose levels rising. You can eat breakfast when, or if, you choose to.
Exercise Spontaneously
The basal rate can be altered temporarily at any time. So, if you suddenly decide to go for a jog, or you are unexpectedly invited to play a game of tennis, you can simply decrease the basal rate whilst you exercise. This means that you no longer need to plan exercise in advance or eat large amounts of carbohydrate beforehand in order to avoid hypoglycaemia.
Adapt Your Insulin To Your Changing Needs
In addition, using an insulin pump can help you to cope more effectively with increased glucose levels that frequently accompany periods of stress or illness. Travelling, too, is made a whole lot easier, especially on long haul journeys and when you need to adapt to new time zones.
Tight Control Without More Hypos
With a pump, you can tailor your insulin supply to fit your exact needs. In this way it is possible to achieve tight control of glucose levels without having to increase the risk of hypos.
No Need For Multiple Injections
The pump is worn all the time and all the insulin is delivered through a fine plastic tube (known as the infusion set), which is inserted under the skin (usually in the abdomen). There is no need for any injections, once the infusion set is in place. The infusion set msut be replaced every 2-3 days.
The insulin pump provides the most accurate, precise and flexible system of insulin delivery currently available. Insulin pump therapy gives you the freedom to live life to the full, whilst keeping glucose levels stable and well controlled.
Is An Insulin Pump For You?
Firstly, it is important that you do not have unrealistic expectations about Insulin Pump Therapy. The pump does not automatically adjust insulin levels and it does not measure your glucose levels. You have to do this yourself; to make it work, you need to be highly motivated and willing to take on the responsibility of looking after your Type 1 diabetes on a day-to-day basis.
The pump is not a solution to everyone’s problems but there are many people who may benefit enormously from using an Insulin Pump.
Does your glucose control need improving?
If you are having problems achieving your glucose targets using an insulin injection regimen, you may wish to consider using an Insulin Pump. Insulin Pump therapy provides the most natural form of insulin treatment and can be tailored especially to meet your own individual needs. Many people suffer from wide swings in glucose levels due to unpredictable absorption of insulin (especially longer acting insulin) from the injection site. Only short acting insulin is used with an insulin pump and this is supplied in small quantities throughout the day and night. Insulin delivery via a pump is accurate and reliable.
Do you have problems with hypos?
One of the main drawbacks of tightening up control is an increased risk of hypoglycaemia and some people on insulin injections are prone to sudden or severe hypos. Often, hypos are caused by injected insulin ‘peaking’ at certain times of the day. Sometimes hypos are caused by increased absorption of insulin from its ‘depot’ beneath the skin – this is often in response to exercise. Using an Insulin Pump to provide small amounts of insulin regularly means that these problems are overcome and the risk of hypoglycaemia can be reduced.
Tight control can also reduce the early warning signs of hypoglycaemia. However, Insulin Pump therapy tends to keep glucose levels stable and, with slightly higher glucose targets, sometimes early warning signs can actually be recovered.
Are you pregnant, or planning a pregnancy?
Tight control is very important for women with Type 1 diabetes both before and during pregnancy. If you are pregnant, or planning to have a baby then you should consider Insulin Pump Therapy as a means of normalising your glucose levels without severely restricting your daily activities.
Do you suffer from the ‘dawn effect’?
Some people have trouble with high glucose levels in the morning caused by an increased need for insulin during the early hours. This is very hard to combat with conventional insulin injections without causing hypoglycaemia earlier on in the night. An Insulin Pump can be programmed to deliver more insulin just when the body needs it and this is the most effective way to overcome the problems caused by the ‘dawn effect’.
Do you lead a particularly variable and/or active lifestyle? Are you a shift worker?
If you lead a varied lifestyle, or you are a shift worker, then keeping your glucose levels well controlled can be very problematic. Day-to-day changes in mealtimes or activity levels are hard to accommodate with conventional insulin injection therapy. With a pump, however, you are no longer tied to a specific routine and you can take each day as it comes without your control suffering as a result.
Your Role In Insulin Pump Therapy
The pump is not a cure for Type 1 diabetes, in that it doesn’t measure glucose levels and then decide how much insulin you need. You will have to perform frequent glucose tests and decide on the insulin doses yourself. You will need to learn how to assess the carbohydrate content of different foods in order to give yourself just the right amount of insulin to take care of what you eat. You will also be responsible for changing the infusion set regularly.
Glucose Monitoring
Glucose monitoring is an important part of any insulin therapy; however, in pump therapy frequent testing (generally 4 – 6 times a day) is essential. This is to ensure that your glucose levels are well controlled and so that any potential problems are picked up early.
Testing at 2 – 3 am for 2 – 3 days initially then once every couple of weeks is also essential, to make sure that your nighttime insulin supply is right.
Not only will you need to test frequently, you will also need to learn how to use the test results to keep your glucose levels well controlled.
Avoiding Diabetic Ketoacidosis (DKA)
People using insulin injections to control their Type 1 diabetes usually have some residual insulin lying under the skin. If an injection is delayed or missed this residual insulin helps to prevent diabetic ketoacidosis (DKA) from developing quickly.
If you are using an Insulin Pump, however, and your insulin supply is stopped, you have no reserves to fall back on and your glucose levels will rise quickly. If the body is completely deprived of insulin, DKA will develop rapidly and you could be in danger.
Insulin supply from the pump can be interrupted if the infusion set becomes dislodged or blocked – it is your responsibility to be on the lookout for these potential problems. It is wise to carry some spare insulin and a syringe or pen with you, in case you encounter problems with your pump. Keep a spare battery or two handy as well.
Testing glucose levels regularly throughout the day means that high levels can be detected early on. Having been alerted to the problem you can take prompt action before things get serious.
Carbohydrate Assessment
In order to be able to accurately match your bolus insulin doses with the food that you eat you will need to learn how to assess the carbohydrate content of various foods. It may sound like hard work at first, but once you’ve got the hang of it you will be able to glance at a plate of food and quite accurately assess how much carbohydrate is there and how much insulin you will need to ‘cover’ it. Don’t worry – you don’t have to weigh all your food; it is simply a question of educated guesswork. Reference books and food labels will help to guide you.
Insulin Doses
You will receive training and instruction in how to program the pump and vary both your basal and bolus insulin doses according to your needs. You will need to learn how to calculate your bolus doses to cover the food that you eat and to correct high glucose levels. You will also need to know how and when to adjust the basal rate.
Pump Maintenance
Your pump will require very little maintenance. However, you will need to re-fill the reservoir with insulin few days, depending on how much insulin you use. The batteries will probably need changing approximately every 2-3 months.
Changing The Infusion Set
The infusion set needs to be changed every 2 – 3 days. It should also be changed if you have unexpected or unexplained high glucose levels. The insertion site (the place where the needle or cannula is inserted into your body) should be rotated to avoid hardening of the skin in the area. You will need to check the insertion site regularly and make sure that it is not red or inflamed, as these are signs of possible infection.
Everyday Life With A Pump
Wearing An Insulin Pump
The pump is worn all of the time, usually attached to a belt, hidden in a trouser pocket or worn discreetly under clothing.
A range of accessories are available for pumps, including smart leather pouches, plastic clip cases and protective nylon cases. Special bra, thigh and leg pouches are available for women and there are also a number of straps and belts available which are particularly handy for swimming and sporting activities.
Operating The Pump
Using the pump is easy. It can even be operated ‘by feel’ through clothing. At the press of a button you can give yourself a pre-meal bolus of insulin, or change your basal rate for a couple of hours to accommodate some exercise. You can also easily check the amount of insulin remaining in the cartridge and look at recent bolus doses (how much insulin was given and when).
All operations are shown on the LCD display and confirmed by an audible ‘beep’. There is a few seconds wait before the instructions are carried out – this gives you time to check your programming and correct any mistakes you have accidentally made. If you feel self-conscious, or do not wish to draw attention to yourself, then the beeps can easily be muted; the pump will then only sound in the case of an alarm.
Swimming, Bathing, Showering
Although the pump is waterproof, there are several options when swimming, bathing or taking a shower. The pump can actually be disconnected for short periods, leaving the cannula in place. A special plastic pouch is available for showering that can be hung around the neck, or on the showerhead. If you are taking a bath, you can simply place the pump on the floor beside the bath, draping the infusion set tubing over the side of the bath.
Sport And Exercise
Wearing an Insulin Pump does not preclude you from taking part in a wide variety of sports and activities, including water sports. In fact, pump therapy can help you incorporate exercise into your life more easily compared with insulin injection regimens. The basal rate can easily be reduced for an hour or two, without having to change the programming. The normal basal rate can be resumed at any time.
Sleep
The infusion set comes with long lengths of tubing so you can place the pump beside the bed or under the pillow and still have plenty of room to manoeuvre. Some people prefer to slip the pump into a pocket in their pyjamas or nightgown – this allows you to move about as much as you like. The infusion set is rarely dislodged during sleeping, even in those who tend to sleep on their stomach.
The pump provides a continuous background supply of insulin throughout the day and night. If your insulin needs are higher in the early hours of the morning then the basal rate is set accordingly for that time. You can sleep in and miss or delay breakfast, without having to worry about high glucose levels as a result.
Sexual Intimacy
The infusion set is securely attached to your body and should not interfere with sexual intimacy. However, the easy disconnect system allows the pump to be removed temporarily and this option is preferred by many pump users. A small bolus of insulin can be given beforehand to compensate, if you anticipate being disconnected for a while. Of course, at nighttime, you should remember to reconnect yourself to the pump before falling asleep!
Illness
Insulin needs are often greater during periods of illness or infection. This can be easily dealt with by temporarily increasing the basal rate.
Travel
All people with Insulin Pumps can enjoy problem-free travel. In particular, you do not have to worry about the timing of your next meal – a common concern for those people on more restrictive insulin injection regimens. Even challenging trips to distant places pose no special problems. Travelling across time zones and adjusting to new mealtimes is made easier with an Insulin Pump. Having reached your destination the clock in the pump can be altered to the new time if you have different basal rates set over the 24-hour period.
Security checks at airports do not affect the performance of Insulin Pumps and often the pumps are not even picked up by airport metal detectors. Your diabetic identification and/or a letter from your doctor stating that the pump is a piece of medical equipment vital for your survival will avoid any difficulties that you may encounter with airport security staff.
Insulin Treatment Of Type 1 Diabetes
Normal Insulin Production
In non-diabetic people, insulin is automatically released from the pancreas in response to a rise in glucose levels following a meal. This allows the glucose to be taken up by the body’s cells where it is either used straight away, or stored (mostly in the liver or muscles) for later. So, in the presence of insulin, glucose is removed from the blood and the glucose level drops again. Just the right amount of insulin is produced to keep the glucose level within normal limits. In addition to this, small amounts of insulin are continuously produced between meals and overnight, in order to keep the body ticking over.
Insulin Therapy for People with Type 1 Diabetes
People with Type 1 diabetes produce no insulin and therefore depend on insulin injections to stay alive. (People with Type 2 diabetes usually produce some insulin and many are treated with diet and tablets that enable them to make better use of the insulin that they produce.) The aim of Type 1 diabetes management is to keep glucose levels close to normal. For those people who require insulin, this means coordinating insulin injections with meals and snacks, whilst counterbalancing the effects of activity levels.
There are a number of ways in which insulin is used to treat people with Type 1 diabetes:-
- Conventional Therapy
- Intensive Therapy
- Insulin Pump Therapy (also known as continuous subcutaneous insulin infusion or CSII)
Conventional Therapy
Conventional therapy usually consists of two insulin injections a day. Each injection contains some short acting insulin and some intermediate or long acting insulin. In theory, short acting insulin at breakfast supplies insulin for the morning and long acting insulin at breakfast supplies insulin for the afternoon. Then, short acting insulin in the early evening supplies insulin for that evening and long acting insulin in the early evening supplies insulin for overnight. Separate doses of short and long acting insulin can be drawn up together into the same syringe. Alternatively, a number of ready mixed insulins are available that contain short and long acting insulin in fixed proportions. Conventional therapy offers the advantage of not having to inject at lunchtime and some people may see this as a bonus. However, the major drawback of conventional therapy is the lack of flexibility; timing of meals is dictated by the injection routine. Also, if pre-mixed insulins are used, there is no room for altering the dosage of short or long acting insulin independently from the other – another mixture needs to be used. In addition, the insulin injections tend not to match the body’s natural daily needs for insulin.
Intensive Therapy
Intensive therapy usually involves Multiple Daily Injections (i.e. 3 or more) of insulin (and is sometimes referred to as ‘MDI’). Long acting insulin (e.g. Isophane or Glargine) is given once (or sometimes twice) daily and quick acting insulin is given before each meal. In theory, the long acting insulin supplies the body’s background needs, whilst the short acting insulin ‘covers’ meals. This type of injection regimen aims to provide a more natural supply of insulin supply and increases flexibility in terms of mealtimes. However, the long acting insulin often fails to provide the appropriate ‘background’ insulin needs leading to erratic swings in glucose levels.
Insulin Pump Therapy
Rather than injecting the insulin, it can be supplied by a small pump, which is worn all the time. The insulin is delivered to the body through a fine tube with a needle or cannula that sits under the skin. The pump mimics the function of the pancreas in that it provides a steady supply of ‘background’ or basal insulin and extra spurts or bolus doses of insulin are given before eating. The basal supply of insulin through the day can be altered so that it is in tune with your own body’s individual needs. The basal insulin keeps the glucose levels stable in-between meals and overnight. The bolus doses are specifically tailored to food intake. With Insulin Pump Therapy there is no need to plan meals and activities around insulin injections. Although the pump does not measure glucose levels and produce insulin automatically – you have to test your own glucose levels and programme the pump yourself – Insulin Pump Therapy is the most natural form of insulin treatment available today.
Insulin Pump Therapy is also known as continuous subcutaneous insulin infusion (CSII).
