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January 22, 2010

Daily Care, Insulin

Question from Isle of Man, United Kingdom:

What is the suggested formula for calculating a return to MDI from pump therapy either for short term in cases of pump failure and for longer term return to MDI?


From: DTeam Staff

My suggestion for returning to multiple daily injections – while maintaining a basal-bolus approach – following pump therapy assumes that the patient has insulin glargine (Lantus) available. In fact, my approach is that I DO NOT place patients on pumps until they have successfully completed an MDI program with Lantus and their rapid-acting insulin (Humalog, NovoLog, Apidra) and furthermore, request that pump patients maintain some up-to-date Lantus at home for emergency use in case of pump failure/problems. In this manner, during the brief (<72 hours) it should take to replace the pump, families can just go back to their MDI program before pumping without too much loss of control. But, if time has passed and no one can recall document the pre-pump basal dosing, I do the following: Add up (or review from the pump) the TOTAL BASAL insulin dose the pump is programmed to deliver. This is now the dose of Lantus to give (typically one daily dose). (Some clinicians will adjust this dose a little, but I don't because I assume that any loss of glycemic control will be very minor and very limited while the pump is being replaced, but I emphasize that glucose levels should be checked very often such as before and two hours after meals and then at bedtime and maybe 3 a.m.) Remember, there may be some overlap of insulin depending on when the pump is replaced and activated again so I tolerate some higher targets in order to avoid lows. If Lantus were not available and/or the patient had experience with the other long-acting insulin (detemir/Levemir), then the same approach would typically apply. If there were only intermediate-acting NPH insulin available as the "long-lasting" insulin, then more calculations are required. The boluses of rapid-acting insulin can be the same by injection as it was provided via the pump with the same insulin-to-carbohydrate ratios. Your letter suggests that the patient is not followed by a pediatric endocrinologist. It may be a good idea to establish a relationship with such a consultant, especially as that professional may have a different approach and you should ask their approach as well. DS