Pumping Protocol - Amazon S3 Protocol - a Guide...Pumping Protocol A Guide to Insulin Pump Therapy...

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  • Pumping ProtocolA Guide to Insulin Pump Therapy Initiation

    Includes an introduction to continuous glucose monitoring (CGM) and therapy management software

    Innovating for life.

    Medical EducationAcademia

  • 1Table of Contents

    Table of Contents

    Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

    Insulin Pump Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

    Guidelines for Initial Pump Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

    Calculate Starting Doses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

    The Bolus Wizard Calculator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

    Adjusting Pump Settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

    Basal Rate Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

    Bolus Adjustments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

    Infusion Site Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

    DKA Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

    Unexplained High Glucose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

    Prevention of Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20

    Treatment of Hypoglycemia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

    Special Populations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .22

    Therapy Management Software . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

    Continuous Glucose Monitoring (CGM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32

    Forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

    References and Suggested Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .36

  • 2

    Bruce W. Bode, MD, FACEAn internationally known speaker and author on insulin pump therapy and continuous glucose monitoring, Dr. Bode, a graduate of Emory University School of Medicine, is in private practice with Atlanta Diabetes Associates. He is active in both the Georgia affiliate of the American Diabetes Association and the Juvenile Diabetes Research Foundation. Dr. Bode is also the editor of the American Diabetes Associations Medical Management of Type 1 Diabetes.

    Contributors

    Jennifer Kyllo, MDJennifer Kyllo, MD is the Medical Director of the McNeely Pediatric Diabetes Center and Endocrine Clinic at Childrens Hospitals and Clinics of Minnesota. She attended medical school at the University of Minnesota and completed her residency and fellowship at the University of Iowa. Her principal areas of interest include caring for children with diabetes and improving access to new diabetes technology for children.

    Francine R. Kaufman, MDFrancine Ratner Kaufman, MD is Chief Medical Officer and VP of Global Clinical, Medical and Health affairs at Medtronic Diabetes and a Distinguished Professor Emerita of Pediatrics and Communications at the Keck School of Medicine and the Annenberg School of Communications of the University of Southern California. Dr. Kaufman was president of the American Diabetes Association (2002-03), and serves on the Advisory Council of the Diabetes Branch of the NIH.

    While every reasonable precaution has been taken in the preparation of this guide, the author, sponsor and publisher assume no responsibility for errors or omissions, nor for the uses made of the materials contained herein and the decisions based on such use. This document does not contain all of the information necessary for the proper care and treatment of patients with diabetes. As such, no individual may rely on the information presented herein in forming a comprehensive treatment program or in treating any patient with diabetes. No warranties are made, expressed or implied, with regard to the contents of this work or to its applicability to specific patients or circumstances. Neither the author, sponsor, nor the publisher shall be liable for direct, indirect, special, incidental or consequential damages arising out of the use or inability to use the contents of this guide.

  • 3Purpose

    PurposeThis booklet is designed for clinicians who are just beginning to prescribe pump therapy, as well as those who already have experience and want to review the latest strategies for optimizing glycemic control with insulin pump therapy. It provides information on proper candidate selection and the indications and protocols for initiating insulin pump therapy. Guidelines for fine-tuning insulin doses and strategies for preventing insulin pump problems are also presented.

    Fundamental ConceptsOver the past three decades, insulin pump therapy has proven to be the most effective insulin regimen available for achieving tight glycemic control while minimizing the risk for hypoglycemia.1 It is readily used for the intensive management of adults, adolescents and children with type 1 diabetes and those with insulin-requiring type 2 diabetes.

    Effectiveness of insulin pump therapy is attributed to three fundamental principles:

    1. Pumps use only rapid-acting insulin for basal and bolus insulin requirements.

    Eliminating longer acting insulin helps improve glycemic control during fasting states because:

    Theaction/peaktimeofrapid-actinginsulinismorepredictableandreproduciblethan long-acting insulin.2

    Thetinybasaldosesthatarecontinuouslydeliveredovereachhouraremoreconsistentlyabsorbed by the body.

    2. Pumps deliver insulin in two ways, basal and bolus.

    Basal Insulin is a continuous infusion of insulin that is delivered automatically 24 hours a day. The purpose of basal insulin is to cover hepatic glucose production and to maintain glucose stability during fasting states (between meals and during sleep).

    Bolus Insulinisdeliveredon-demand,bythepatient,forfoodintakeand/ortocorrectglucose levels that are above the patients target range, delivered separately or together.

    Food Bolus: Insulin given to cover food or drink that contains carbohydrates.

    Correction Bolus: Insulin given to correct blood glucose (BG) levels that are abnormal.

    3. Medtronic pumps use a Bolus Wizard calculator.

    The Bolus Wizard calculator helps make diabetes management and bolus dosing easier and more accurate because it:

    Calculatesthebolusamountforthepatient,accordingtotheirpersonalizedsettings.

    Trackstheamountofactiveinsulinremainingfrompreviousboluses.

    Subtractsactiveinsulinfromcorrectiondosesbeforesuggestingthetotalbolusamount, which helps to prevent lows that result from the stacking of insulin.

    RecordsBGreadings,carbohydratesconsumed,unitsofinsulindeliveredandthetimeeachwas entered. Data can be downloaded into reports for easier, more accurate evaluation.

  • 4 Insulin Pump Therapy

    Insulin Pump Therapy

    Indications3-5Type 1 and insulin-requiring type 2 patients who are unable to achieve acceptable glycemic control, including those with:

    ElevatedA1C.

    Glycemicvariability.

    Recurrenthypoglycemia,nocturnalhypoglycemia,activity-inducedhypoglycemia and hypoglycemia unawareness.

    Pregnancy/Pre-pregnancy.

    Recurrentdiabeticketoacidosis(DKA)/recurrenthospitalizations.

    Dawnphenomenon.

    Gastroparesis.

    Patientpreference,meal-timingflexibilityandnormalizationoflifestyle.

    Lowinsulinrequirements(noteasilymeasuredviasyringe).

    Inabilitytoself-administerinsulin(pre-school/gradeschool).

    Inabilitytopredictfoodormealintake(infant/toddler).

    Patient Requirements5-10 Responsibleandpsychologicallystable

    Willingnesstomonitorbloodglucose(BG)aminimumoffourtimesaday

    Willingnesstoquantifyfoodintake

    Willingnesstocomplywithmedicalfollow-up

    Benefits3,4,7,11 Improvedglycemiccontrolanddecreasedglycemicvariability

    Improvedcontrolofdawnphenomenon

    Decreasedseverityandfrequencyofhypoglycemia

    Increasedflexibility,normalizationoflifestyleandsenseofwell-being

    Precautionary Areas