Insulin Pump Therapy (supplement)
Contents
1. 1 Is motivated pump therapy requires a strong desire to improve one s health and is a time investment for weeks or months in advance and during the initiation of pump therapy Has realistic expectations a potential pump candidate must understand that the pump will not fix blood glucose variations automatically nor will it grant freedom from frequent SMBG self monitoring of blood glucose Demonstrates independent diabetes management a thorough knowledge of diabetes and its management and the ability to demonstrate appropriate self care behaviors provide the foundation for advanced self management skills required by pump users Is practicing counting carbohydrates has a willingness to practice the Carbohydrate CHO or carb Counting method and an understanding of insulin actions and pre meal bolus dosing calculations 146 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS 5 Has manual dexterity able to use buttons on the pump and has good visual acuity to see the screen 6 Has a good support system emotional support is crucial to the success of pump therapy 7 Demonstrates emotional stability a potential pumper must attend education sessions and attend to tasks that require routine attention The patient must keep physician appointments Poor Candidates for Pamp Therapy 1 Patients who are unwilling to comply with2. Dual Wave part of bolus is infused at onset of meal and remainder is infused slowly over several hours useful for high fat meal i e pizza Mexican food Adjusting Fine Tuning Dosage Empower patients to evaluate and adjust their BG Resume intensive monitoring if necessary i e 8 times a day Start with overnight basals promote low fat consistent carb content meals Introduce high fat meals after ICR has been established or corrected When high fat meals are consumed consider utilizing Dual Wave bolus Two hour postprandial glucose goals should be 30 points above preprandial BG Patient may require a different ICR for each meal BG targets should be determined by the provider and the patient and depending on age of the patient concomitant 151 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS conditions and the patients ability and willingness to achieve tight control of their diabetes POSSIBLE COMPLICATIONS OF PUMP THERAPY Hypoglycemia fewer episodes than with MDI Possible improvement in hypoglycemic unawareness Diabetic Ketoacidosis interruption in Humalog Novolog delivery can lead to high BG and DKA in 4 hours Patient must check BG 4 6 times a day Skin Infections meticulous skin care is necessary at infusion sites which must be rotated every 2 3 days Weight Gain could be a result of improved control or if p
3. I will also carry emergency supplies with me at all times including syringes in case my site becomes dislodged I will also wear identification stating that I have diabetes and wear an insulin pump This information will also include emergency contact my doctor s name and telephone number 162 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS LETTER OF MEDICAL NECESSITY Date RE Patient Name Phone Patient s date of birth Insurance identification To whom this may concern This letter serves as prescription and letter of medical necessity for the above referenced patient for an insulin infusion pump as a lifetime need Check the following Ll Patient has had diabetes for ___ years L Patient has the ability to regularly monitor blood glucose to_ times per day L Patient is motivated to achieve and maintain glycemic control and has the support needed to stay motivated Patient demonstrates compliance with dietary regimen Patient has attempted several different regimens and or has had multiple dose changes O L Patient s insulin regimen consists of to injections per day C O Patient uses the following type s of insulin Patient exhibits one or more of the following O Alclevel__ on __ __ L History of severe glycemic excursions and or L Nocturnal Hypoglycemia L Hypoglycemia unaware
4. It is helpful if the patient consumes the same amount of carbohydrate at each breakfast for 3 days same amount of carbohydrate at each lunch for 3 days etc 4 Amount of all food and beverage consumed as fat and protein moderately affect blood sugar With these records determine the amount of insulin the patient used to cover the carbohydrate consumed at each meal by dividing the total grams of carbohydrate by the number of units of insulin Example Consumed 60 g carbohydrate Injected bolused 5 u rapid acting insulin PPG is within 30 mg increase of pre meal blood glucose 60 5 12 Insulin to carbohydrate ratio 1 12 1 unit of insulin covers 12 g carbohydrate 155 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS CARBOHYDRATE COUNTING FOOD LOG Write down all food or drink you consume for at least 3 days Be sure to include portion sizes and the time you eat or drink Estimate the amount of carbohydrates in each meal and snack then record the amount of insulin you took Bring this log with you on appointments to the pump trainer or the dietitian BLOOD SUGAR DATE TIME 2 HRS PP FOOD GRAMS OF CARBS INSULIN BLOOD SUGAR DATE TIME 2 HRS PP GRAMS OF CARBS INSULIN BLOOD SUGAR DATE TIME 2 HRS PP FOOD GRAMS OF CARBS INSULIN 156 of 34 Insulin
5. Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS Calculating Total Grams of Carbohydrate in a Recipe To determine the amount of carbohydrates in a recipe 1 Make a table as noted below 2 List ALL the ingredients in the recipe 3 Using food labels or a nutrient composition book list the total grams of carbohydrate in each ingredient amount of fat and sodium can also be calculated 4 Total the grams of carbohydrate from all ingredients Divide the total grams of carbohydrate by the number of servings in the recipe 6 Note the total grams of carbohydrate PER SERVING on the recipe for future reference Recipe Name oo o Ingredient Amount c A e Grams of Fat Example Corn Pudding Makes 8 Servings Ingredient Amount c Sai p Grams of Fat Cornstarch 2 Tablespoons 14 0 Egg Substitute Y2 cup 2 0 Sugar Yo cup 100 0 Creamed Corn 16 oz can 60 0 Evaporated Skim Milk 16 oz can 60 0 TOTAL 236 0 Divide total carbohydrate by number of servings 236 8 45 This recipe has 29 5 grams of carbohydrate and zero 0 grams of fat per serving 157 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS IDENTIFYING AND MANAGING HYPERGLYCEMIA Sick Day Management Refer to Sick Day Guidelines in TDC Tool Kit During periods
6. a solid non fragrance antiperspirant around site or try other types of tape that are available Skin Tac H Polyskin Tegaderm Hypafix HyTape Dermicell SkinPrep Mastasol and toupee glue are other options to try N GOING OFF THE PUMP 1 Be sure you check with your doctor before disconnecting from the pump for any length of time 2 DO NOT disconnect for more than 1 2 hours unless you have the OK from MD 3 Reasons to go off the pump may be due to pump malfunction call 1 800 send pump the pump manufacturer will immediately send a loan pump until yours is repaired or replaced Another reason may be just a desire to have a vacation from the pump Time Off Pump Action 1 1 hrs No action unless CHO will be eaten or BG is high 114 5 hrs Before disconnecting give a bolus to replace 80 of the basal that will be lost Inject before eating using insulin to CHO Ratio DAYTIME ONLY Give injection before each meal by using your insulin to CHO ratio PLUS the basal insulin needed until the next meal 3 4 Days or More Inject fast acting insulin before each meal using your insulin to CHO ratio and correction factor for highs At bedtime inject Lantus to equal 1 5 X the basal rate used for the overnight period 172 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS TRAVELING 1 ALWAYS carry at least 1 weeks worth of extra supplie
7. follow up appointments 2 Patients who are unwilling to receive diabetes education 3 Patients who are unwilling to perform SMBG 8 times a day initially and then 4 6 times a day after CSII therapy is established 4 Patients who are unable or unwilling to count carbohydrates DETERMINING TOTAL DAILY DOSE AND BASAL RATE Method 1 Pre pump Total Daily Dose TDD Reduce pre pump Total Daily Dose by 25 Divide pump TDD in half 50 for basal 50 for bolus Method 2 Using Patients Weight Factor Weight lbs X 0 1 basal rate per hour Start with 1 basal rate per 24 hours Based on blood glucose results during the times listed below it may be necessary to implement additional basal rates based on patient s blood glucose BG 12 00 midnight 3 00 a m 3 00 a m 7 00 a m 7 00 a m 12 00 noon 12 00 noon 6 00 p m 6 00 p m 12 00 midnight Time Frame For Beginning Pump Therapy 1 1 2 months before pump start Assess whether or not patient meets the criteria for a pumper 147 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS MD writes orders for insulin pump therapy Contacts the insurance company for pre authorization of coverage Patient is seen by a CDE dietitian for carbohydrate counting instruction Patient is seen by the pump trainer for knowledge assessment and education as needed to include h
8. for general assessment and education 166 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS QUESTIONNAIRE Are you ready for pumping 1 How motivated are you to achieve good control Not very 0 1 2 3 4 5 very 2 How many times do you test every day 0 1 2 3 4 5 3 How many injections per day 0 1 2 3 4 5 4 Do you keep a record Yes 5 points No 0 points 5 Do you adjust your insulin for test results Yes 5 points No 0 points 6 Do you adjust your insulin for meals Yes 5 points No 0 points 7 Do you adjust insulin for highs Yes 5 points No 0 points 8 Do you adjust your insulin for exercise Yes 5 points No 0 points 9 Do you get regular Alc tests Yes 5 points No 0 points 10 Do you call your doctor when you have a problem Yes 5 points No 0 points 167 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS SCORING Score What It Means 0 9 Are you in charge or someone else 10 19 At least you re honest 20 29 Where can you improve 30 39 Just a few minor changes 40 49 How soon can you start 1 2 weeks before pump start 1 Patient watches video or DVD on pump use several times to begin familiarizing him herself with the pump 2 May attend Pump School via Internet 3 Meets with pump trainer for ba
9. of illness it may be more difficult to maintain good control of blood glucose Examples of illness or sick days include dental surgery colds sore throat mild infections nausea vomiting diarrhea or fever It is important to monitor blood glucose more frequently during a sick day and to take immediate action to prevent ketoacidosis Guidelines to follow Medication Never omit insulin Even if unable to eat insulin need continues and may increase Continue the basal dose of insulin and make additional corrections using the Correction Sensitivity Factor as needed Urine ketone testing can further guide the correction doses Blood Urine Testing Check blood glucose before usual mealtimes and every 2 to 4 hours keeping a written record of results Check urine for ketones if blood glucose is greater than 250 mg dL or as directed by the physician Fluids Meal Planning Consuming adequate fluids is important during illness Drink fluids every hour while awake and during blood glucose checks at night If able to eat drink non caloric beverages If unable to eat alternate non caloric beverages with those containing carbohydrate Consume 10 15 grams of carbohydrate every 1 2 hours Severe high blood glucose and ketoacidosis DKA are serious medical problems that sometimes occur in diabetes High blood glucose can exist for some time without triggering ketoacidosis Ketoacidosis begins only after insulin levels in the body go
10. that you have diabetes and are being treated with an insulin pump 160 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS APPENDIX PHYSICIAN S ORDERS FOR INSULIN PUMP START Patient Name Date Certified Pump Trainer These orders expire on Basal rates may be adjusted by 0 05 increments for BG above and or below Starting Basal Rate Profile Time Units per Hour 1 12 00 a m Starting Bolus Doses Insulin to Carbohydrate Ratio 1 unit per gms carbohydrate Insulin Sensitivity Ratio Correction Factor 1 unit of insulin will lower BG by mg dl Target Blood Glucose Levels 3 00 A M to Fasting to Before meals to After meals to Additional Instructions Physician s Signature 161 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS PATIENT INSULIN PUMP CONTRACT Patient Name Date Physician I understand as the patient it is my responsibility to 1 Maintain open communication with my physician dietitian and diabetes educator This will include recording and reporting my glucose levels carbohydrate intake exercise boluses basal rate changes and other information requested 2 Perform glucose testing as requested 3 Iwill change my infusion set every 2 to 3 days and follow the guidelines a
11. 150 units 10 points Carbohydrate Counting Carbohydrate counting is a meal planning approach that works well with insulin pump therapy It is a great way to add variety and flexibility in choices of meals and snacks Carbohydrate counting has been proven to help achieve better glucose control Generally carbohydrate is the main food group that increases blood sugar Protein has a sustaining effect and fat slows absorption It is essential that the patient understands and practices the techniques of carbohydrate counting prior to pump initiation Many references such as the materials included in Chapter 5 of Diabetes Life Skills Book or the Daily Meal Planning Guide by Eli Lilly are used by the CDE or Registered Dietitian to teach Carbohydrate Counting Tools needed to count carbs 1 Measuring cups 2 Food labels 3 Calculator 4 Carb counting book guide Carbohydrate containing foods include breads pasta rice other grains starchy vegetables potatoes corn peas crackers cereals fruit fresh canned frozen or juice milk yogurt amp ice cream cooked dried beans cake cookies pie sugar honey One serving is considered 15 grams of carbohydrate and is contained in 1 3 cup cooked rice beans or pasta 1 2 cup starchy vegetables like corn peas potato or cooked cereal 153 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHM
12. DIABETES TREATMENT ALGORITHMS Insulin Pump Bish tos Te Therapy AS Das State Health Services Introduction The goal of insulin delivery is to regulate blood glucose levels to achieve normoglycemia In someone without diabetes pancreatic B cells continuously secrete insulin throughout the day and night providing a continuous insulin infusion or basal amount In response to meals the pancreas provides bursts of insulin referred to as boluses Pump therapy is intended to more closely mimic this pancreatic function Continuous subcutaneous insulin infusion CSIJ utilizes only fast acting insulins Humalog Novolog and eliminates the use of long acting insulins NPH Ultralente Lantus Pumps can deliver insulin in 0 1 unit increments as a basal continuous flow between meals and through the night Basal rates can be increased or decreased at any point allowing for exercise illness skipped meals sensitivity to insulin and the dawn phenomenon Boluses of insulin can be delivered via the pump to provide insulin to compensate for carbohydrate intake and hyperglycemic episodes when needed Insulin pump therapy gives people with diabetes the freedom to enjoy life despite their chronic condition The value of an improved lifestyle increased flexibility and optimal diabetes control is obvious from the impact the insulin pump has made in the twenty five years since its inception The ability to control how and when insulin is d
13. S 1 slice bread or 1 tortilla 1 small piece of fruit 1 2 small banana or 1 2 cup light canned fruit 1 cup milk Using measuring cups and reading labels are highly recommended as the patient practices at home THE RULE OF 500 This method of determining the Insulin Carbohydrate ratio is based on Total Daily Insulin Dose TDD The TDD is divided into 500 and the result is the amount of carbohydrate that one unit of rapid or short acting insulin will cover The goal is to bring blood glucose levels into the target range 3 4 hours after the meal Example TDD is 36 units Glucose levels are within target range 500 36 13 8 round up to 14 or 15 Insulin to carbohydrate ratio is 1 15 1 unit of insulin covers 15 gm carbohydrate Some CDEs find that dividing 450 rather than 500 by the TDD is more accurate for short acting insulin and or for people who are more insulin resistant Insulin Sensitivity The Insulin Sensitivity Factor ISF is the amount of blood glucose reduced by 1 unit of rapid or short acting insulin over a 2 4 hour period Two commonly accepted formulas are used to determine the ISF the 1800 Rule and the 1500 Rule Endocrinologist Paul C Davidson MD developed the 1500 Rule With the introduction of rapid acting insulin John Walsh PA CDE modified the 1500 Rule into the 1800 Rule Generally the 1800 Rule is used for patients who are insulin sensitive or those who use rapid acting insulin and the 1500 Rul
14. asal half is boluses For basal divide half by 24 basal rate per hour Begin with 1 basal rate and adjust as needed Example TDD pre pump 50 units 50 25 38 new dose 38 2 19 19 units for boluses 19 units for basal 19 24 0 79 units per hour may round up to 0 8 units per hr 169 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS INSULIN TO CHO RATIO RULE OF 500 Divide 500 by the new total daily dose Example TDD 25 units 500 25 20 1 unit of insulin per 20 gms of CHO TDD 45 500 45 11 1 unit of insulin per 11 gms of CHO may round down to 10 for ease INSULIN CORRECTION FACTOR RULE OF 1500 Divide new TDD into 1500 Example TDD 45 units 1500 45 33 amount I unit of insulin will decrease glucose level by If target level is 100 and glucose level 289 mg dL how many units to get BG level to 100 289 100 189 189 points above target 189 33 5 7 units of insulin Used to correct for a high May be added to regular mealtime bolus if high occurs right before eating a meal MONITORING SCHEDULE For first few days to 2 weeks or until basals and boluses adjusted NWR WON Between 2 00 3 a m Dawn Phenomenon Fasting overnight basal Goal 70 100 mg dL 2 hours after each meal Goal 140 mg dL or less Before and after exercise Before driving If hypoglycemia is sus
15. atient liberalizes diet Initiation of CSII should be done by a Certified Pump Trainer CPT who is usually provided by the insulin pump manufacturer or a Certified Diabetes Educator CDE who has received specialized training in insulin pump therapy The various features of the pump should be demonstrated explained to the patient who should be provided with phone numbers of the insulin pump company and the provider The patient should be encouraged to keep detailed records of BG insulin dosage carb intake and other daily activities Table for Estimated Basal Rate and Insulin to Carbohydrate Ratio WEIGHT IN POUNDS BASAL INSULIN CARBOHYDRATE RATIO 100 0 3 to 0 5 1 unit 16 gms 110 0 3 to 0 5 1 unit 15 gms 120 0 4 to 0 6 1 unit 15 gms 130 0 4 to 0 6 1 unit 14 gms 140 0 5 to 0 7 1 unit 13 gms 150 0 5 to 0 7 1 unit 12 gms 160 0 6 to 0 8 1 unit 12 gms 170 0 6 to 0 8 1 unit 11 gms 180 0 7 to 0 9 1 unit 10 gms 190 0 8 to 1 0 1 unit 9 gms 200 0 9 to 1 1 1 unit 8 gms 152 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS Estimated Correction Factor CURRENT TDD CORRECTION FACTOR 10 units 150 points 20 units 75 points 25 units 60 points 30 units 50 points 40 units 38 points 50 units 30 points 60 units 25 points 75 units 20 points 100 units 15 points
16. e for patients who are insulin resistant or those who use short acting insulin The Rules calculate the ISF by dividing either 1800 or 1500 by the TDD Example TDD is 34 units 1800 34 52 9 ISF is 52 9 One unit of rapid acting insulin decreases glucose by 52 9 mg dL This can be rounded to 55 Another method of calculating the ISF is to use the general safe starting point of 1 unit 50 mg dL This method may work well with most lean to average adults 154 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS An alternative method for Insulin Carb ratio can be figured once the person s ISF is calculated multiplying it by 0 33 provides an insulin to carbohydrate ratio Example ISF is 55 mg dL 55 x 0 33 18 15 round to 18 Insulin to carb ratio is 1 18 1 unit of insulin covers 18 g of carbohydrate Verifying Insulin Carb Ratio and Insulin Sensitivity Prior to eating the bolus insulin dose is partially based on the insulin to carbohydrate ratio This ratio tells how many grams of carbohydrate are affected by one unit of insulin The ratios can be verified with one of the methods described below Method 1 Food diary insulin dose and SMBG information The pump user is to keep 3 days of records including 1 Fasting pre meal and 2 hour PPG results 2 Pre meal insulin doses 3 Amount of carbohydrate consumed at meals and other times
17. eal using your correction factor If you miss a day continue the plan the next day But try not to miss a day the sooner the plan is completed the sooner your basal rates will be set 149 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS PRE PUMP EDUCATION CHECKLIST Patient Name Date Certified Pump Trainer MD s Name Pump Model Serial UNDERSTANDING PUMP THERAPY Theory Q Meal Bolus Q Carb Counting Insulin Type O Insulin Sensitivity L Using Food Labels Basal Rate Correction Factor O Insulin to Carb Ratio L Proper Snacks Schedule L Safety Ll Proper Snacks Alc O Hypoglycemia L BG Checks HYPOGLYCEMIA PUMP THERAPY RESOURCES Protocol Rule of Fifteen L User s Guide Glucagon L Pump School Online L Websites HYPERGLYCEMIA WHEN TO CALL YOUR DOCTOR Protocol Ketone Testing WHEN TO CALL 24 HOUR HELP LINE Causes Signs and Symptoms Prevention SICK DAY MANAGEMENT Protocol Supplies Notes 150 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS DETERMINING BOLUSES Calculating Insulin Sensitivity Factor ISF Also may be referred to as the Insulin Correctio
18. ed ADJUSTING INSULIN TO CHO RATIO 1 Check 2 hours after each meal 2 If BGs not over 140 mg dL ratio correct if higher increase if lower decrease 3 May have 2 3 different ratios during the day may need 1 unit per 8 gms in a m 1 unit per 10 or 15 for lunch and dinner or 1 per 8 in a m 1 per 10 for lunch and 1 per 15 for dinner 171 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS ADJUSTING CORRECTION FACTOR 1 If hypoglycemia occurs after correcting for a high lower correction factor 2 If BG still high after 3 4 hours increase factor OTHER TIPS AND SAFETY 1 Change site every 2 3 days every other day with pregnancy ALWAYS do site changes in the MORNING NEVER at bedtime Check BG 2 hours after a site change to ensure the cath is placed correctly and pump is functioning properly Inspect site twice a day if swelling redness pain or drainage CHANGE SITE ALWAYS carry extra supplies with you in case the catheter gets dislodged ALWAYS have a supply of syringes on hand in case of pump malfunction ALWAYS wear identification stating you have Diabetes and wear an insulin pump A MOA D O N If you have 2 BGs over 240 mg dL in a row inject insulin according to the correction factor and CHANGE SITE Retest 2 hours after NEVER NEVER NEVER go to bed with a low battery 8 Ifyou perspire heavily may use
19. elivered provides the pumper with increased flexibility in scheduling their day to day activities For those people with erratic lifestyles a desire to achieve optimal glycemic control Alc lt 6 5 and prevent chronic complications the pump is an ideal choice INDICATIONS FOR PUMP THERAPY Clinical Indications Inadequate glycemic control with MDI Multiple Daily Injections therapy Recurrent severe hypoglycemia Recurrent hyperglycemia Hypoglycemia unawareness Dawn phenomenon Preconception Pregnancy Gastroparesis et Oy ae ee ee Early neuropathy or nephropathy when improvement in glucose control can reduce acceleration of complications gt Renal transplantation 145 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS Ti 12 13 14 15 16 Frequent DKA Uncontrolled diabetes Erratic Blood Glucose Prevent or delay complications Desire to improve lifestyle flexibility Alc greater than 6 5 Lifestyle indications l 2 Ja 4 Erratic schedule Varied work shifts Desire for improved flexibility Inconvenience of multiple daily injections Advantages of Pump Therapy ec i O More flexible lifestyle Improved overall control Prevent chronic complications Improved control during exercise and growth spurts Tight control during pregnancy Characteristics of Pump Candidates Ready willing and able
20. fer to RD for dietary counseling and CHO counting assessment Assess glucose meter skills Resources videos books pamphlets web sites Goal setting B Initial visit s prior to pump start RD ip 2 Data collection amp review weight food record Review of meal planning and CHO counting 3 Validate ability to count carbs at home at work or school at restaurants and 4 fast food locations Goal setting C Follow up visit day of pump start CDE 3 4 hours eS NO aS e a ee Pump specifics buttons syringe filling priming insertion technique Initial settings Problem solving alarms Restocking supplies Hypoglycemia and hyperglycemia management DKA prevention Review of tasks and follow up plan Status of goals and reinforcement of positive changes Resources videos books pamphlets web sites Goal setting 174 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS D The CDE will emphasize that regulating basal and bolus rates and determining insulin to carb ratios is essential until the blood sugars are within the preset goal ranges Telephone support for emergencies is available 24 hours per day E Follow up visit within one month or more frequently if needed CDE Data collection amp review blood sugar trends meter download Review basal amp bolus rates Review of site adequacy amp insertion technique Confirm comp
21. ia unawareness Preconception pregnancy Early chronic complications Organ transplant Patient desires better control pt ae ee ie Prevent chronic complications 165 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS OVERVIEW FOR PUMPING INSULIN Indications For Insulin Pamp Multiple episodes of severe hypoglycemia Erratic glucose levels brittle diabetes Early complications Organ transplant WR WN Pregnancy Advantages of The Pump More flexible lifestyle Improved overall control Prevent chronic complications Improve control during exercise and growth spurts VR WN Tight control during pregnancy Characteristics of Pump Candidate 1 Must be willing to monitor BG several times a day Must be willing to count carbohydrates Must have manual dexterity to use buttons on pump and have good visual acuity to see the screen Good support system Committed to self care Ability to problem solve Good basic knowledge of diabetes ea o Reasonable expectations of what the pump can do Time Line 1 2 months before pump start Assess patient s current knowledge about diabetes Assess whether or not patient meets the criteria for a pumper MD contacts the pump company and writes orders for the pump Patient is seen by dietitian for carbohydrate counting WR w NN H Patient is seen by the pump trainer
22. its per hour From to units per hour Pump Trainer Signature Date INSULIN PUMP CONTACTS Trainer Phone Alternate trainer Alternate phone 177 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS REFERENCES Bode BW Pumping Protocol A Physician s Guide to Insulin Pump Therapy Initiation Atlanta Diabetes Associates Atlanta Georgia Bolderman KM Putting Your Patients on the Pump American Diabetes Association 2002 Alexandria Virginia ISBN 1 58040 148 1 Frederickson L ed In The Insulin Pump Therapy Book Insights From The Experts MiniMed Technologies Los Angeles California 1995 ISBN 0 9647837 0 3 Walsh J amp Roberts R Pumping Insulin Everything You Need To Know For Success With An Insulin Pump 3rd edition ISBN 1 88480484 5 Amrhein James A MD and Hess B RN BSN CDE Optimizing Glycemic Control with Diabetes Technology AADE 29th Annual Meeting August 7 2002 Philadelphia Pennsylvania Brooks AM RN CDE St Marks Hospital Diabetes Center Salt Lake City Utah and Kulkarni K MS RD BC ADM CDE St Marks Hospital Diabetes Center Salt Lake City Utah Core Curriculum for Diabetes Education Fourth Edition Diabetes Management Therapies Chapter 6 pg 203 225 178 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp
23. letion of basal rate testing Sick day management DKA prevention Status of goals and reinforcement of positive changes ey Pee a Goal setting F Follow up visits with RD as needed Data collection amp review blood sugar trends food records Review of meal plan and carb counting Review of food adjustments for sick days and exercise Status of goals and reinforcement of positive changes DOA ek P H Goal setting G Follow up visits quarterly for first year then annually with CDE Data collection amp review blood sugar trends A1c results Self management review and problem solving Status of goals and reinforcement of positive changes Goal setting 2 ee DO If child movement toward independence in diabetes care 175 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS INSULIN PUMP FOLLOW UP Patient Name Date Certified Pump Trainer Pump Model Serial BASIC REVIEW SITE CHANGE PROTOCOL ADDITIONAL FEATURES INSTRUCTED NOTES BLOOD GLUCOSE RECORD DATE TIME BG CHO GRAMS INSULIN 176 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS Basal Rate Changes From 12 Midnight to units per hour From to units per hour From to un
24. n Factor ICF The Insulin Sensitivity Factor ISF is the amount of blood glucose reduced by 1 unit of rapid or short acting insulin over a 2 4 hour period Two commonly accepted formulas are used to determine the ISF the 1800 Rule and the 1500 Rule Endocrinologist Paul C Davidson MD developed the 1500 Rule With the introduction of rapid acting insulin John Walsh PA CDE modified the 1500 Rule into the 1800 Rule Generally the 1800 Rule is used for patients who are insulin sensitive or those who use rapid acting insulin and the 1500 Rule for patients who are insulin resistant or those who use short acting insulin The Rules calculate the ISF by dividing either 1800 or 1500 by the TDD Amount of Blood Glucose lowered by 1 unit of insulin 1800 Rule 1800 ISF TDD Note 1800 currently used with Humalog or Novolog instead of 1500 1500 Rule Calculating Insulin to Carb Ratio ICR This method of determining the Insulin Carbohydrate ratio is based on Total Daily Insulin Dose TDD The TDD is divided into 500 and the result is the amount of carbohydrate that one unit of rapid or short acting insulin will cover The goal is to bring blood glucose levels into the target range 3 4 hours after the meal Grams of carbs covered by 1 unit of insulin 500 Rule 500 ICR TDD TYPES OF BOLUSES Normal Bolus total bolus infused at onset of meal Square Wave total bolus infused slowly over several hours useful in cases of gastroparesis
25. ness LJ Extreme insulin sensitivity or low insulin req L Widely fluctuating blood glucose levels before meals e g pre prandial BG levels commonly exceed 140 mg dl and or are below 70 mg dl The range of these blood glucose levels is from _ toO_ L Dawn Phenomenon where fasting blood glucose often exceeds mg dl Ll Day to day schedule variations such as meal times work schedules or activity level confound the degree of regimentation required to self manage glycemia with Multiple daily injections Patient has been hospitalized or needed emergency assistance due to his her diabetes Patient has frequent hypoglycemic episodes up to times per week Pregnancy or preconception with a history of poor glycemic control OOOdd Secondary complications requiring tighter glycemic control to slow or stop progression of Ll Retinopathy LJ Neuropathy LJ Nephropathy L Other L Sub optimal glycemic and metabolic control post renal transplant Ll Patient has been fully informed of the risks and benefits of pump therapy 163 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS PHYSICIAN NOTES I certify that this information is complete and correct Physicians Signature I am an endocrinologist internist or diabetes specialist LI Yes LJ No l am prescribing an insulin infusion pump insulin pump supplies and diabetes supplies for the foll
26. owing patient The supplies may be refilled as necessary for one year Please dispense as written PHYSICIAN NAME PATIENT NAME PHYSICIAN STREET PATIENT STREET PHYSICIAN CITY STATE ZIP PATIENT CITY STATE ZIP PHYSICIAN SIGNATURE DATE MEDICAL LICENSE NUMBER UPIN NUMBER 164 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS INSURANCE COVERAGE FOR INSULIN PUMP THERAPY Private Insurance 1 Contact pump company with information about the patient A Insurance information B Indications that would require utilizing the insulin pump C Must be on multiple insulin injections 2 or more a day D Cover type 1 and some type 2 diabetes E Prescription from MD Medicare 1 Contact pump company with patients information 2 Must meet criteria for insulin pump therapy A C Peptide of less than 0 6 mcg L B Alc over 7 C Monitoring 4 times a day 3 Medicare pays 80 for pump and supplies Secondary insurance may cover the other 20 If Medicare denies coverage secondary may cover Medicaid 1 Contact pump company with insurance information 2 Must meet criteria for insulin pump therapy 2 Prescription from MD 4 Medicaid will cover 100 Indications for Insulin Pump Therapy 1 Unable to normalize glucose levels A Erratic glucose excursions B Alc over 7 Severe episodes of hypoglycemia or hypoglycem
27. pected ADJUSTING BASALS 4 DAY PLAN Overnight Basal I 2 First basal to be checked Eat regular dinner no later than 7 00 p m NO bedtime snack 170 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS BG bedtime should be 100 150 mg dL Test BG every 2 hours between supper and bedtime Midnight and 3 00 a m If BGs stay within 30 mg dl basal OK if more than 30 adjust Divide night into 3 test windows a BEDTIME 9 00 PM to midnight b NIGHT Midnight to 3 00 a m c DAWN 3 00 a m to 7 00 a m Afternoon Basal Eat breakfast and take bolus for food NO lunch NO bolus Check BG every 2 hours between breakfast to supper If BGs stay within 30 mg dl basal OK if not adjust Gy te BR WwW N Morning Basal 1 NO breakfast NO bolus 2 Test BG every 2 hrs from waking until lunch DO NOT SLEEP IN 3 IfBGs stay within 30 mg dl basal OK if not adjust Evening Basal 1 NO supper NO bolus 2 Test BG every 2 hrs between lunch amp bedtime snack at 10 00 p m 3 IfBGs stay within 30 mg dl basal OK if not adjust NOTE DO NOT fix a high glucose during the time you are checking your BGs every 2 hours Correct at the next scheduled meal using your correction factor If you miss a day continue the plan the next day May need to repeat the 4 Day Plan two or three times until the basal rates are correct
28. renuous are all causes of hypoglycemia Signs and Symptoms Shaking Sweating Weakness Anxiety Headache Blurred vision Dizziness Fast heartbeat Irritability Fatigue Rule of 15 1 Immediately stop activity and check glucose levels If driving immediately pull off the road 2 Ifno glucose meter is available treat regardless 3 Consume 15 gms of a fast acting carbohydrate e Y cup juice e 5 sugar cubes e 4 glucose tablets e 6 7 lifesavers e cup regular soda 8 oz skim milk e 2 tsp sugar e 8 9 jellybeans e 1 tube glucose gel 159 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS 4 Rest for 15 20 minutes Retest glucose if still below 70 mg dl repeat fast acting carbohydrate Or if no glucose meter is available and symptoms are still present repeat fast acting carbohydrate Continue steps 1 5 until glucose level is above 70 mg dl An extra snack consisting of a carbohydrate and protein may be needed if more than one treatment was required and no meal will be eaten within a half hour Examples are VY sandwich Cheese and crackers Peanut butter and crackers 8 If several hypoglycemic episodes occur at the same time over a few days the basal rate will need to be adjusted notify the pump trainer immediately ALWAYS carry a fast acting carbohydrate in a place that is easily accessible 10 ALWAYS wear identification stating
29. s on top of what you will normally use if you are staying for 2 weeks carry supplies for 3 weeks NEVER check your supplies in baggage CARRY them with you Carry snacks with you WEAR IDENTIFICATION stating you have diabetes and wear an insulin pump Remember to change the time on your pump if you will be crossing time zones ee p Gert a letter from your doctor explaining what to do for your diabetes listing medications and devices that you may use The letter should also state any food or medication allergies you may have Also get a prescription to carry with you for any medications you may need Know the name and number of an endocrinologist in the area where you re traveling may prove useful 7 Carry bottles of insulin IN THEIR BOXES with your name doctor s name your pharmacy s name and medication on a pre printed label 8 Contact your airline for any specifics different airlines have different rules regarding diabetes supplies don t be surprised 9 The pump can be worn through the scanner at the airport without causing it harm Dont call attention to it HOSPITALIZATIONS 1 Remove pump for X rays MRIs 2 Be prepared beforehand carry a letter from your endocrinologist with orders for you to keep the pump on check your own glucose levels and do your own adjustments 3 Ifyou are unable to care for the pump have a family member do so If you have no family with you the pump may be removed b
30. s set forth for proper 10 Patient s Signature Date pump management If hospitalized I will bring all the needed equipment from home to ensure I have enough supplies If I do not have the supplies it is my responsibility to make arrangements to obtain them I will follow the formulas for meal boluses and correction factors prescribed to me by my physician and or diabetes educator I will respond quickly and correctly to hypoglycemia and will report these to my health care team I understand the Rule of 15 to treat a low glucose with 15 grams of a fast acting carbohydrate retest in 15 minutes and repeat the sequence if necessary I will respond quickly to hyperglycemia and prevent DKA by following the rules for sick day management using my correction factor I will report to my diabetes care team as needed increase the frequency of monitoring and test my urine for ketones if my glucose is over 240 mg dl for 2 consecutive glucose readings I will not disconnect from the pump for longer than an hour If I desire a vacation from the pump I will first discuss this with my diabetes care team before doing so and follow their recommendations IfI am having any difficulty with either pump use or carbohydrate counting I will immediately call my diabetes care team for the proper assistance I will make sure that I have the proper supplies on hand at all times and that it is my responsibility to reorder supplies as I need them
31. sal bolus correction factor and insulin to CHO ratio Day before pump start 1 Discontinue use of long acting insulin 2 Continue injections of Humalog Novolog before meals 3 Use correction formula to cover for highs Day of pump start Eat breakfast and take fast acting insulin as usual Wear comfortable clothing preferably two piece outfits Allow 3 hours for training BROW N Bring with you Pump User s Manual Infusion sets at least 2 Cartridges at least 2 Skin prep Glucose meter strips lancets Alcohol wipes Insulin Novolog or Humalog Carbohydrate snack 2 Batteries 168 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS First day after beginning pump therapy 1 Call Pump Trainer with glucose readings and grams of carbohydrate 2 Begin 4 Day Plan Within 3 5 days after pump training 1 Come in to office for follow up 2 Continue 4 Day Plan until basal rates are adjusted correctly When basal rates correct 1 Adjust insulin to carb ratio 2 Begin 3 Day Plan 3 Call Pump Trainer with BG readings and CHO grams Weekly for 4 weeks 1 Call Pump Trainer with BG s and CHO grams for adjustment 2 Basals are adjusted first then boluses STARTING BEGINNING BASAL RATE Total Daily Pre pump Insulin x 75 Total Daily Insulin per Pump total pre pump dose minus 25 Divide the new dose by 2 Half is b
32. ut ONLY after the nurses have orders for insulin coverage DKA can occur much faster after disconnecting from the pump because there is no long acting insulin on board 4 The pump gives better control during and after surgery so ask doctors to allow that it stay connected As soon as possible after surgery ask to have the pump reconnected if it was discontinued during the surgery 5 Pregnant patients will need to move insertion site to the thigh area immediately after beginning labor and leave the pump connected during labor Insulin resistance dramatically decreases after the placenta is delivered so be prepared to decrease basal rates Basal rates will remain lower if the mother is breast feeding also 173 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS STANDARDS OF CARE DIABETES EDUCATION AND MANAGEMENT PROGRAM Insulin Pump Education Up to 8 Visits A Initial visit s prior to pump start CDE Dey ee Data collection amp review assessment of self management skills readiness to learn and barriers to learning Prerequisites for successful pumping a One month of multiple injection therapy with Lantus and Humalog or Novolog b Many BGs showing testing at least 4 times a day for one month c Knowledge of pump function through watching video or doing on online pump program Intro to pumps basal amp bolus rates insertion sites Re
33. very low When insulin is low glucose cannot be used as fuel Glucose is the body s first choice for energy but if not available due to inadequate insulin levels the body must start burning fat even though glucose is high in the blood Ketones are the by product of burning fat for energy and in high levels cause nausea and vomiting Vomiting in combination with high blood sugars can lead to dehydration Ketoacidosis can be triggered by 1 Illness 2 Infections 3 Pump Malfunction Loose Luer lock connection 158 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS Dislodged infusion set Site irritation or overuse Empty pump reservoir cartridge Expired insulin Incorrect bolus calculation Missed bolus doses Inadequately programmed basal rates A pump user needs to take a correction dosage using a syringe if spilling moderate to large ketones then change the infusion set Plenty of water should be consumed to help flush ketones from the body Call a physician for further instruction Causes IDENTIFYING AND MANAGING HYPOGLYCEMIA Glucose levels can drop to dangerously low levels if there is not a balance between food medication and activity It can occur very quickly and without warning Not eating properly delaying or skipping meals an error in medication dose or engaging in exercise that is too difficult or too st
34. ypoglycemia hyperglycemia and sick day management prevention of DKA patient s responsibilities and general knowledge regarding diabetes 2 1 2 weeks before pump start Patient watches video DVD on use of the pump several times to familiarize him herself with the pump May attend pump school via the Internet if available Meets with pump trainer for basal rates boluses insulin to carbohydrate ratio and insulin correction factor if not already done 3 Day before pump start Discontinue use of long acting insulin NPH Lantus Ultralente Continue injecting Novolog or Humalog before meals Use correction formula to cover for highs Day of pump start Eat breakfast and inject Humalog or Novolog as usual Wear comfortable loose fitting clothing preferably 2 piece outfit Allow 3 hours for training Bring supplies with you to include Pump User s Manual Infusion Sets at least 2 Cartridges at least 2 Skin Prep Glucose Meter Lancets Strips Alcohol Wipes Insulin Novolog or Humalog Batteries Carbohydrate Snack 5 First Day of Pump Therapy Begin Four Day Plan Call pump trainer with glucose levels and carbohydrate intake 6 When Four Day Plan completed Come into office for first follow up Patients MUST bring documentation of glucose readings boluses for elevated glucoses or meals diary of carbohydrate Intake Begin Three Day Plan 7 Within 1 2 da
35. ys after completing Three Day Plan Call pump trainer with readings Adjust basals boluses as needed 148 of 34 Insulin Pump Therapy See disclaimer at www tdctoolkit org algorithms_and_guidelines asp DIABETES TREATMENT ALGORITHMS 8 Weekly for four weeks Call pump trainer and report complete record Adjust basals insulin to carbohydrate ratios as needed Instruct on added features of the pump i e Dual and Square Wave Boluses utilizing temporary basal rate Easy Bolus Audio Bolus Adjust basal rates first based on fasting glucoses When fasting glucoses are at goal adjust boluses and or insulin to carbohydrate ratios to achieve pre and post meal glucose goals TESTING BASAL RATES FOUR DAY PLAN First Day 1 Eat supper by 7 p m 2 Skip a bedtime snack 3 Test blood sugar every 2 hours between supper and bedtime at 12 00 Midnight and at 3 00 a m 4 Record your results Second Day 1 Eat breakfast 2 Skip lunch 3 Test blood sugar every 2 hours between breakfast and supper 4 Record your results Third Day 1 Skip breakfast 2 Test blood sugar every 2 hours between waking up until lunch 3 DONOT SLEEP IN 4 Record your results Fourth Day 1 Skip supper 2 Test blood sugar every 2 hours between lunch and your bedtime snack at 10 00 p m 3 Record your results NOTE Do not fix a high blood sugar during the time you are checking every 2 hours Correct at your next scheduled m
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