Insulin pumps & diabetic retinopathy

David Kinshuck

Why is an ophthalmologist interested in insulin pumps?

Prevention or slowing of retinopathy

retinopathy still disabling

This patient asked…would an insulin pump help me?

This patient asked…would an insulin pump help me?

Answer given: help you & and your eyes if you achieve better control, and it is likely to improve your control,in the long term

Patient: LB 1968 DOB, 1976 IDDM 1998 background retinop, 6/5, 6/5 1999 proliferative, lots of laser, HbA1c 7.9% works at ……………. husband very

helpful/positive2000 indirect laser, sight worse = macular oedema, cannot drive

6/24 then 6/60 both eyes HbA1c 7.3%, but widely fluctuating sugars Insulin pump 6/24, well, controlled 2002 retinopathy not active,

minor problems only, working

A bad result…….

Each patient with poor sight makes you think

• was the laser OK?

•diabetic control………..could we have done better?

•European centres with good results have 2 monthly patient/DSN contact………how can we improve without this?

•These clinics laser 1% diabetic patients, versus UK average 10% (Gouda, Holland)

•1/365 nurse/adult patient ratio (Holland), Good Hope 1/1333

Identifying progression of retinopathy

Exudates/oedema =leakage

New Vessels

An ‘early’ sign =haemorrhages

An increase in any of thesePhotos useful for haemorrhages especially

Progressing………why?

Retinopathy is linked to:

1% HbA1c =

37% progression rate

Retinopathy is linked to:

1mmHg =

1.1% progression rate

Retinopathy is linked to:

Retinopathy is linked to:

Genetic = 25% RetinopathyFamily history heart disease, stroke, blood pressure

Retinopathy is linked to:

Smoking 20/day =

300% progression rate

Passive smoker gets 25% of the smoke

Retinopathy is linked to:

Statin reduces heart problems by

25-50% (estimate)

Treat even if normal, especially if there are exudates

Retinopathy is linked to:

ACE inhibitors reduce retinopathy by 50%

Retinopathy is linked to:

Progressing, HbA1c > 7.0%Why?

Suitable regime?………… young patients on bd insulin?

Basal bolus, but sugars fluctuate, hypos This patient read about pumps and bought one

herself, 4 others bought pumps at my suggestion

Do I mention pumps? First patient’s retinopathy halted Insulin pumpers web site, advice from

retinopathy experts at European meetings

www.insulin-pumpers.org

Balance

motivation

resources

the wrong time or an unenthusiastic patient

Flexible dose insulin regime

Pump might be best for very dedicated (and rich) patients (HbA1c 6.0-7.0%), controversial

Best results are if you test your blood sugar 4-6 times a day, and adjust insulin

A typical new regime: lantus (glargine) longacting insulin for basal insulin; analogue for meals (lispro/novorapid)

Should be able to achieve 7.0% with good nursing help, without dangerous hypos

Patient 2: JW

Patient 2: JW

1969 DOB, 1977 IDDM professional, lives alone, sports++++ 1995 background retinopathy, 6/5, 6/5 1995 proliferative, bd insulin 1995-99 lots of laser, 6000/burns/eye 2000 HbA1c 8.4% 2000 vitreous haemorrhage mediocre control/severe hypo proliferation continues, laser 2001 Insulin pump, well, controlled, happy 2002 retinopathy not active 6/9 driving/sports…some problems

Patient 3: BB

1968 DOB, 1984 IDDM 1998 background retinopathy, 6/5, 6/5 1999 HbA1c 9.7%

(similar for years, alcohol++) 2000 maculopathy lasered, 6/5 2001 proliferative, lots of laser, HbA1c 8.0 2002 struggled with pump, HbA1c 7.6 Insulin pump, making wrong decisions re

insulin, not in contact with other IDDM patients got married, HbA1c 8.1 ischaemic maculopathy, will get worse ACE inhibitor ?would starting pump while intellectual

function better have helped

Patient 4: EB

1966 DOB, 1971 IDDM 1999 proliferative retinopathy++, 6/5, 6/5 1999, lots of laser, HbA1c 7.7%, conciliation officer, one child, smoked and stopped re retinopathy weight increased ? Using insulin to diet/food issues HbA1c 7.7%, but widely fluctuating sugars Insulin pump, a real struggle 2002 6/12, macular ischaemia still, 7.3% retinopathy less active would have had poor result without

Patient 5: PP

1963 DOB, 1978 IDDM 1998 proliferative retinopathy+, 6/5, 6/5 Council, regular lifestyle lots of laser, HbA1c 7.7%,

still ischaemic retinal haemorrhages 2000 HbA1c 6.9%, lots of hypos Ultratard: very long acting insulin, widely

fluctuating sugars, many hypos a day

changed to insulatard, new baby

2001 HbA1c 7.4%, but still widely fluctuating sugars, BP 160 systolic

2002 Insulin pump 6/6, one retinal microaneursym, stable

2001

What should we achieve?

motivation

resourcesthe wrong time

unenthusiastic patient

Support people here

Help change behaviourMay have no

choice to accept

Summary

5 patients, have HbA1c about 1% less or fewer hypos4 with stable or nearly stable retinopathyMany others not keen on pumpHard work for 3, real struggle for 2 (& DSNs)All have severe retinopathy scarring

Logically, better control earlier would be bestImproved decision making without retinopathy?

(re patient adjusting own insulin) 10 years behind European centresNeed 1-2 monthly contact with DSNDesperately short of DSNs (& pumps)