Health Professional S Guide To INSULIN PUMP THERAPY

Health Professional’sGuide to INSULINPUMP THERAPY

Table of ContentsIntroductionPresenting Insulin Pump Therapy to Your PatientsWhen Your Patient Chooses the PumpEstimates for Starting Insulin Pump ParametersMD Orders for Insulin Pump ParametersWhen Your Patient Starts on InsulinWhen Your Patient is Ready to Fine-Tune the Pump ParametersFine Tuning the Overnight Basal Rate WorksheetTesting the Overnight Basal RateFine-Tuning the Daytime Basal Rate WorksheetTesting the Daytime Basal RateFine-Tuning the Evening Basal Rate WorksheetTesting the Evening Basal RateFine-Tuning the Meal Bolus WorksheetTesting the Meal BolusFine-Tuning the Correction Bolus WorksheetTesting the Correction BolusTroubleshooting for Insulin Pump PatientsRecommended Patient Follow-Up

INTRODUCTIONThis guide is a companion tool for thepractice of insulin pump therapy. It isdesigned to assist you in the process ofinsulin pump initiation, to serve as aresource for the determination ofappropriate pump parameters and toprovide suggestions for the adjustmentof basal and bolus insulin.Managing a patient on an insulin pumprequires the same basic skills asmanaging a patient on multiple injectiontherapy. However, since the insulinpump separates the insulin used asbackground, or basal insulin, from theinsulin needed for meal and correctionsboluses, insulin can be more exactlymatched to the metabolic need.Insulin pump therapy allows for bloodglucose patterns such as those seen inthe “dawn phenomenon” to be treated byProgramming an additional basal rate:telling the pump to deliver more or lessinsulin for a specified period of time at aparticular time of day or night. Mealand correction boluses are determinedwithout having to take into account oflong-acting insulin. In addition, thevariability in the absorption of longacting insulin is removed, reducing thesubsequent fluctuations in blood glucosevalues that are experienced in multipleinjection therapy.This guide will walk you through thebasic for initiating and fine-tuninginsulin pump therapy.

PRESENTING INSULIN PUMP THERAPYTO YOUR PATIENTSIt is our suggestion that you introducethe possibility of using an insulin pumpto all of your patients who requireinsulin therapy. Even patients beginninginjection therapy may be a candidate fora pump. Let them know that there aretwo different methods of taking insulinand describe the differences. Somephysicians like to prescribe the pumpand others prefer to introduce it as anoption. Either way, the patient needs to“buy-in” to the idea of using a pump.FREQUENTLY ASKED QUESTIONS:“What Are The Advantages Of InsulinPump Therapy?”Discuss all: Reductioninbloodglucosefluctuations by more exact matchingof insulin to individual need. (Forexample,forthe“dawnphenomenon”.) Reductioninhypoglycemicunawareness. Not having to take insulin injectionsat a prescribed time of day. Greater flexibility in meal timing andfood choices.“Will my Diabetes be BetterControlled?”Probably, because it will be easier tomatch your insulin to your blood glucosevalues.“Is It Surgically Implanted?”No! The pump is a small beeper-sizecomputer. Insulin is delivered through aFlexible tube attached to a catheter thatis placed just beneath you skin, usuallyin the abdominal area. You change thissite every 2-3 days.“Where Do I Wear The Pump?”A complete line of cases and accessoriesareavailablefromthepumpmanufacturer and there are a number ofaftermarket organizations who alsomanufacture accessories . Many peoplewear it in their pocket or under theirclothes.“Can I Ever Take The Pump Off?”The pump easily disconnects. You cantake it off for about an hour. If you wantto take it off for a longer time, you willneed to take insulin injections during thetime the pump is off.“Will I Gain Weight On The Pump?”With better diabetes control, there maybe a tendency to gain weight. However,greater flexibility in timing of meals andfood choices with the pump allows youto manage weight easier than oninjection therapy.“Who Will Teach Me How To Use ThePump?”A certified pump trainer will teach youthe technical aspects of the pump andprovide you with all the diabetes selfmanagement skills necessary to use thepump. The pump manufacturer also hasa 24-Hour Pump Help Line for you touse whenever you have a question.

PRESENTING INSULIN PUMP THERAPYTO YOUR PATIENTS (CON’T.)ADDITIONALLY:MANY PEOPLE ARE INITIALLYRESISTANT TO INSULIN THERAPY FORVERY PERSONAL REASONS.Issues such as body image or feeling thatthe pump will be a constant reminder ofdiabetes may be resolved through frankdiscussion or through meeting otherpump wearers.NOTE:It is important to continue to discuss theinsulin pump during each office visit.Many patients take a while to agree touse a pump. Suggest that the patientattend a Pump Support Group in yourarea or have your local Diabetes NurseSpecialist talk with the patient. You mayalso want to ask another pumper tocontact the patient to discuss theirexperience with the pump.

WHEN YOUR PATIENTCHOOSES THE PUMPWhen your patient chooses to begininsulin pump therapy, there are severaltasks to complete in order for the patientto acquire the pump, be thoroughlyeducated on its use and begin usinginsulin init. Your local Pump Representative willprepare the necessary paperwork tosubmit to the insurance carrier forreimbursement. They will then be incontact with the patient regarding therequired co-payments and otherpertinent insurance issues.After the pump is approved, thepump will be shipped along with allthe necessary pump supplies.You may choose to have a certifiedpump educator assist you in trainingthe patient on the technical aspects ofthe pump and the necessary diabeteseducational skills necessary forinsulin pump therapy. For thistraining, the patient will need an InsulinPump Workbook to guide them throughthe training process. The workbookcomes with a daily blood glucose journalto record ongoing blood glucose dataand a bolus calculator to assist thecalculation of meal and correction bolusamounts. You may also choose to have thepump educator start the patient oninsulin in the pump. The pumptraining nurse will contact you forthe necessary information to beginthis process. Please fill out thePhysician Orders for Insulin PumpParameters and fax them to thenurse. The nurse will then call to coordinate the patient’s start date.Choose a time when you will beavailable by phone to work with thepatient on insulin adjustments.

ESTIMATES FOR STARTINGINSULIN PUMP PARAMETERS* These have not been verified through scientific studies.Physicians must use professional judgement in prescribing proper dosage.PRE-PUMPTOTAL DAILYDOSEWEIGHT in lbsBASALRATEUnits per hourMEALBOLUS1 unit bolus foreachgrams CHO23-28 u29-31 u32-35 u36-38 u39-41 u42-44 u45-47 u48-51 u52-54 u55-57 u58-60 u61-63 u64-66 170-189190-199200-209210-219220-229230 ORRECTIONBOLUSI unit bolus foreach 31.2Can be calculated from pre-pump total daily dose or weight. Use lower calculation forstarting insulin pump parameters.BASAL RATE CALCULATIONPre-pump total daily dose, reduces by 25%, divided by 2, (1/2 for total basal, ½ for totalbolus), divided by 24 (hours in the day) estimated hourly basal rate.or0.1 unit per pound of body weight per day divided by 24 hours estimated hourly basalrate.MEAL BOLUS CALCULATION (THE 500 RULE)500 divided by current total daily insulin 1 unit per grams of carbohydrateCORRECTION BOLUS CALCULATION (THE 1500 RULE)1500 divided by current total daily insulin.

MD ORDERS FORINSULIN PUMP PARAMETERSPatients NameDateBASAL RATEMost people begin with one basal rate to determine initial basal need.Basal Rate #1:Start TimeUnits per Hour:Basal Rate #2:Basal Rate #3:Basal Rate #4:Start TimeStart TimeStart TimeUnits per Hour:Units per Hour:Units per Hour:MEAL BOLUSCarbohydrate Ratio: 1.0 unit of insulin for grams of CHOCORRECTION BOLUS1.0 unit of insulin will lower BG by approximately mmol/LBLOOD GLUCOSE TARGETSBefore Meals:2 Hours after Meals:Bedtime:Overnight:MD SIGNATUREto (3.9 to 7.8 mmol/L)less than (10.4 mmol/L)greater than (5.6 mmol/L)greater than (5.0 mmol/L)

WHEN YOUR PATIENTSTARTS ON INSULINIf the pump trainer nurse starts yourpatient on insulin, your patients will beinstructed to call your office with theirblood glucose values every three daysunless there is a frequent or prolongedhypoglycemia or hyperglycemia, inwhich case they will be instructed to callyou immediately.Your patients will be using the bloodglucose journal provided with theirworkbook. Initially they will be testing8 times a day: before and after meals,before bed and overnight.There are several ways to collect yourpatients’ blood glucose values: Your assistant can write the bloodglucose values down for yourreview. Your patients can fax the values toyou or your assistant. Your patients can use a bloodglucose meter in which the valuescan be downloaded by a modem onthe patients telephone.When you receive the blood glucoseinformation, evaluate it as you wouldany self-management of blood glucoseinformation. Take into account whenthe blood glucose rises or falls and atwhat time of day or night. If the change occurs before a meal, itcan most likely be attributed to thebasal rate. If the change occurs two to fourhours after a meal, it can most likelybe attributed to the bolus before thatmeal. Following are general rulesfor making adjustments from bloodglucose information.NOTE:Make small adjustments initially toevaluate your patient’s response to thechange.ADJUSTING THE BASAL RATE:The goal is for the blood glucose toremain within 1.7 mmol/L of the targetblood glucose value in the fasting state. Change the basal rate by .1 to .2units per hour over the period of timethe blood glucose is too high or toolow. For example, if the blood glucoserises after 3 AM and drops after 9AM, raise the basal rate by .1 unitper hour from 3 – 9 AM and evaluatethe effect the next night.

WHEN YOUR PATIENTSTARTS ON INSULIN (CON’T.)ADJUSTING THE MEAL BOLUS:The goal is for the blood glucose to risenot more than 2.8 mmol/L 2 hours aftera meal. The meal bolus is based on theinsulin to carbohydrate ratio: one unit ofinsulin to a determined number of gramsof carbohydrate. Raise or lower the number of gramsof carbohydrate covered by one unitof insulin. Make small adjustments:1 to 2 grams of carbohydrate foreach adjustment. For example, if the insulin tocarbohydrate ratio is 1:15 and theblood glucose two hours after is onlylmmol/L above the pre-mealblood glucose, adjust the insulin tocarbohydrate to 1:16 or 1:17.ADJUSTING THE CORRECTION BOLUS:The goal is for the blood glucose toreturn to within 1.7 mmol/L of the targetblood glucose within 4 hours of giving acorrection bolus. The correction bolus isbased on the insulin sensitivity factor:the mmol/L one unit of insulin willlower the blood glucose. Raise or lower the mmol/L one unitof insulin should drop the bloodglucose. Make small adjustments: .3- .6 mmol/L for each adjustment.For example, if the insulin sensitivityfactor is 1 unit for every 2.8 mmol/Labove target and the blood glucose 4hours later after giving a correctionbolus is ? mmol/L lower than target,adjust the insulin sensitivity factor to1 unit for every 3.1 – 3.4 mmol/L.NOTE:The goal of adjusting the insulin pumpparameters at this stage is to keep yourpatient from experiencing hyperglycemiaor hypoglycemia. In the beginning, it isprudent to set the target blood glucose alittle higher than ideal and acceptgreater fluctuation in blood glucosevalues than usual. After the patientadjusts to wearing the pump and iscomfortable with its use, we will assistyou in steps to fine-tune the insulin pumpparameters.