June 25, 1999
Daily Care, Insulin Pumps
Question from Pueblo, Colorado, USA:
I have had Type 1 diabetes for the last 32 years (now age 43). I have been striving for the ideal insulin therapy, which in my opinion, would be ideal basal coverage, without insufficient or excessive insulin activity between meals, while using lispro insulin at meals (carbo counting). I am using U at dinner, N at bedtime, and lispro at all meals (as well as correcting for high sugars when needed). I have two questions: one concerning nighttime control, and the second concerning insulin pumps, insurance, and US laws.
I have a terrible time with night control. When the basal level from the U is correct during the day, it is excessive at night (between bed and 3 A.M.), necessitating large bedtime snacks. Most nights I check sugars at 3 A.M., and determine if my bedtime N is correct, by seeing if the sugars go up or down significantly before morning (3 A.M. to 6 or 7 A.M.). When the N is “tuned”, I get very little change in sugars from 3am to morning, but sometimes the U is excessive from bedtime to 3 A.M.! It is the night time that is causing my HbA1c readings to be bad (usually greater than 9), and it’s a hard problem to solve! I am knowledgeable in the sciences, and work writing scientific data analysis software at my employer. I have been able to overlay the insulin activity curves, to “see” the insulin activity throughout the day – but cannot figure out a better combination of shots and insulins to fit my situation.
On top of the nighttime control problems, I try to ride my bicycle when I can, and when I do, that alters the dawn phenomenon, requiring changing the insulin schedule. Where I live, the weather commonly prevents me from regular bike riding, so I ride when the weather is favorable only. I also fear night hypos, so when things get unstable (insulin dose), I tend to try to stay a bit high, rather than risk hypos.
Any suggestions short of an insulin pump?
I really think an insulin pump would provide the best solution for my first question — provided I can afford it! I have heard of certain diabetes laws being passed in the US, but don’t know the details. I am on an HMO insurance plan. Do you know if they will cover insulin pumps? I recall seeing some news media picture of a diabetic with Newt Gingrich, explaining about similar problems as mine, and how the insulin pump (or a cure!) are the best solutions to the problem. I was under the impression that Congress passed some laws regarding insulin pumps, etc.
Answer:
It is clear from what you write that you are making great efforts to achieve meticulous control; but that you have had some problems especially with hypoglycemia at night and that as a result you have an A1c of 9% which is really too high, though of course I don’t know the normal range for your laboratory.
It is always difficult to advise on insulin regimens by e-mail and so you must keep in touch with your doctor over any changes which you plan. As I see it, the combination of lispro insulin [Humalog� brand] at mealtime with Ultralente at suppertime and NPH at bedtime is inviting nocturnal hypoglycemia. It also involves you in taking three insulins and interrupting sleep for a blood sugar. The intensive insulin regimen that has worked best here would be to give the UL at bedtime and no NPH but also to try taking Lispro just after your meals so that you can adjust the dose for the pre-meal blood sugar and to match your appetite. This way you can maintain an insulin level at night that should keep you clear of early morning hypoglycemia; but would make you rather more dependant on variable doses of Lispro at meal time for daytime control. It is important to keep on with vigorous exercise and perhaps you could join a gym to find some weather-resistant way of making exercise more consistent. Another regimen that is used in younger patients is to give Lispro and NPH at breakfast, Lispro with the mid-afternoon snack and again with supper and finally NPH again at bedtime.
I talked to our Medical Social Worker about the financial aspects of paying for pumps in Colorado. First of all insurance companies are now required to pay for testing supplies (i.e. syringes, testing strips, etc), but they are not yet obliged to fund pumps. In fact some insurance plans do, provided that the need is certified at one of the Centers that they use. I don’t know about your plan and you would have to call them. I agree though that a pump might work very well for you, provided you could get experienced care during the early stages of using it.
DOB
Additional comments from Dr. Quick:
If your insurance plan initially balks at paying for a pump, don’t give up. Have your endocrinologist write a detailed letter of medical necessity. Frequently, with enough evidence of need, even stubborn HMO’s will eventually yield to medical logic. (It might take several tries over several months to get through, however!)
WWQ
