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August 25, 2010

Daily Care, Insulin Pumps

Question from Cleveland, Ohio, USA:

My son was diagnosed with type 1 diabetes on May 31, 2010. I just read about insulin pump therapy and my diabetes team is not telling us no, but they're not saying yes either. My son's A1c was at 8.2 on August 6. Basically, they are saying that if he's doing well on his current insulin injection therapy, we should leave well enough alone. But, we had many lows during the night and cut down to one dose. His numbers were slowly starting to creep up again so he's back to three shots, which makes me concerned about him going low again. So, should I push the doctors to change him to pump therapy?

Answer:

Your son has only had type 1 diabetes for a little more than two months. You are still “newbies” into this diagnosis, still learning some important diabetes nuances! Your son has probably recently entered his so-called diabetes “honeymoon” whereby glucoses are fairly easy to control (despite any occasional meal indiscretions). Although you didn’t denote your son’s insulin regimen, I will presume that he has been placed on a basal-bolus insulin plan using a long-acting insulin (such as glargine [Lantus] or detemir [Levemir]) as the basal insulin and then a rapid-acting insulin (such as aspart [NovoLog], lispro [Humalog], or glulisine [Apidra]) as the bolus insulin. Such a regimen is designed to try to mimic physiologic insulin administration and has the same principles as insulin pump therapy (whereby the rapid-acting insulin is given as a low dose continuous infusion as the basal, and then one manually gives extra rapid insulin via the pump for meals and corrections).

Too often people seem to think that an insulin pump is an “artificial pancreas” thereby obviating the need for glucose checking or the need for “human thinking” about dosing adjustments. The pump does not (yet) automatically know the blood sugar and does not automatically know the carbohydrate intake and does not know the patient’s current activities. If you are learning and practicing carbohydrate counting skills, and the patient is becoming very competent at this, too, and then won’t mind being attached to a small medical device essentially 24 hours a day, then insulin pumping may well be in your future! I’m sure that your pediatric endocrinologist supports pumping. But, you’ve got to walk before you run.

I am unaware of any studies that clearly prove benefits of early insulin pumping on the overall long term complication rates on diabetes. Some centers start pumping earlier than others. There was a recent study from Europe that looked at the use of pumping at the beginning of diagnosis of type 1 diabetes. It is true that intensive insulin therapy, be that by pump OR by injection – both providing basal-bolus insulin as described above – does improve incidence and rates of some important potential complications.

In my practice, I typically will consider pumping around six months into the diagnosis after families have demonstrated that carbohydrate counting, correction adjustments, and diabetes management in general, have become second nature. Why don’t you talk to your diabetes team members and get an idea of any timeframe that they might have? I think you will find that there will be a proper time.

DS