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August 21, 2002

Insulin Pumps

Question from Arizona, USA:

I am 16 years old, and I have had type 1 diabetes for almost two years. I take four to five shots (Lantus and NovoLog with the InDuo system) a day, but my sugars are either low or so high my meter can't read them. It seems I never have a normal level, and my last A1c was 9.%. I asked my doctor for a pump, but said no because my A1c was too high. Even though, the rest of my diabetes team wants me on a pump, they can't get my doctor to sign for it. I really want to lower my A1c, but the shots don't seem to be working. This is really irritating, and every time I am at the doctor she tells me I need to lower my A1c, but that's about it. Is there another reason my doctor won't let me on a pump?

Answer:

I can’t tell you why your glucose readings are so inconsistent or what are the perceived barriers for your progressing onto an insulin pump.

The InDuo is a fine system. The NovoLog that you use in the insulin doser functions as a bolus insulin to cover the meals. The Lantus (insulin glargine) (also a fine insulin) functions as the “always-around” or basal insulin. This is to try to mimic what happens in folks who do not have diabetes. The pancreas always makes “some” insulin (basal) and then more is produced with meals (bolus). How much does the pancreas make with meals? It depends on what you eat! If for breakfast, you just have a couple of strips of bacon and coffee, not a lot of insulin is required compared to a breakfast of OJ, pancakes, syrup, oatmeal and milk! This stresses the extreme importance of carb counting appropriately when you are on this type of basal/bolus insulin regimen.

An insulin pump is also a basal/bolus regimen. I would add that my practice is such that if my patients can’t successfully follow a basal/bolus plan with insulins like Lantus with NovoLog, I am very, very hesitant to graduate them on to a pump. A pump is very expensive (about $5000) and it is not an artificial pancreas (meaning it won’t automatically change the insulin dosage simply because of a high or low glucose. It changes the dose based on the time of day that you programmed it to change), and it works on the basal/bolus plan. A pump is a lot of work — it is not less work. Blood sugars should be checked before meals and often two hours after meals (to ascertain whether the “bolus” was correct.).

You perhaps should check glucose readings two hours after meals now to guide you on your dosages of NovoLog. Do you have such a guide or ratio of how much insulin to take based on your food intake? So perhaps, like in baseball spring training, and early football practices, or tennis/golf lessons, you should go back to the basics with your diabetes team and review techniques on your meal plan, carb counting, insulin injection technique, etc. Many a time, I have found a patient in poor control who seemingly was doing things correctly until we found a flaw in some technique — this is most often an issue with following a meal plan correctly and consistently.

DS