Insulin Pump Therapy
|
|
- Martin Cameron
- 7 years ago
- Views:
Transcription
1 Introduction The first insulin pumps, or continuous subcutaneous insulin infusion systems (CSII), were introduced in These early pumps were the size of a backpack and were unreliable. Since then, insulin pump therapy has made significant strides. Today insulin pumps are battery-operated devices the size of a cell phone, and when used in the appropriate population they allow for a more physiologic insulin delivery and may provide better blood sugar control. Currently, approximately 20% to 30% of patients with type 1 diabetes and less than 1% of patients with type 2 diabetes use insulin pumps. 1,2 However, insulin pumps are becoming more commonly used in patients with type 2 diabetes. This document discusses the basics of insulin pump therapy. Detail-Document # This Detail-Document accompanies the related article published in PHARMACIST S LETTER / PRESCRIBER S LETTER December 2010 ~ Volume 26 ~ Number Insulin Pump Therapy sugar by ten (0.6) to 60 mg/dl (3.3 mmol/l). The higher the number, the more sensitive a patient is to insulin. Dawn phenomenon increase in basal insulin requirements in the early morning hours, in response to an increase in cortisol, growth hormone, glucagon, and adrenaline. In children younger than 12 years of age, a reverse dawn phenomenon may be seen. In children, blood glucose levels are higher in the late evening and early morning (9 pm to 3 am) and then decline in the early morning to early evening (3 am to 6 pm). Dual wave/combination bolus a method where a fraction of the bolus insulin dose is administered immediately, at the start of the meal, and the remaining bolus dose is administered over a period of time, for example one to three hours. This is thought to more closely mimic the body s endogenous first- and second-phase insulin release that occurs in response to carbohydrate ingestion. Insulin to carbohydrate ratio calculations to assist in programming the amount of insulin bolus to cover carbohydrate ingestion. Square wave/extended bolus a dose of insulin which is delivered over a specified time period, for example 30 minutes. This is used for the ingestion of high-fat or high-protein meals or in patients with gastroparesis. Stacking a phenomenon which occurs when two insulin doses are given in close proximity. For example, a patient who administers a bolus Terminology In order to understand insulin pump therapy, there are a number of terms which must be understood. 3,4 Basal rate the amount of insulin needed to meet metabolic needs and maintain blood glucose levels between meals and at night. Bolus insulin delivery insulin doses calculated for meals, snacks, and to correct for elevated blood glucose levels. Bolus-on-board a feature of insulin pumps which estimates the amount of insulin remaining from the previous dose. This prevents stacking. Carbohydrate factor number of carbohydrates (in grams) that one unit of insulin for a meal, but has a snack two hours later will will cover or blunt. For example, in most patients, require additional insulin. However, insulin the carbohydrate factor is between five and 20. In remaining from the mealtime dose must be a patient who is sensitive to insulin, the considered when deciding the bolus dose needed carbohydrate factor may be 20, meaning that one for the snack. unit of insulin will cover 20 grams of ingested Total daily dose total of all the insulin carbohydrate. required in a 24-hour period. Correction factor the number of points (mg/dl or mmol/l) blood glucose drops for each Insulin Pumps unit of rapid-acting insulin. The correction factor Insulin pumps are designed to better mimic typically varies between ten (0.6) and 60 (3.3), physiologic endogenous insulin secretion. In a meaning that one unit of insulin reduces blood
2 (Detail-Document #261203: Page 2 of 7) person without diabetes, the pancreas secretes a basal amount of insulin throughout the day and similar information, insulin pump therapy appears justified for basal-bolus insulin therapy in patients night. This basal rate can vary. 5 For example, the with type 1 DM who are not adequately controlled rate of basal insulin is higher during the early morning hours (usually between 4 am and 9 am) in response to increases in cortisol, glucagon, adrenaline, and growth hormone. Following the ingestion of food, the pancreas rapidly releases a bolus of insulin initially, followed by a gradual release of insulin over the next one to three hours (also known as first- and second-phase insulin release). 4 Patients using an insulin pump are able to with multiple daily doses of insulin. 9 Information regarding the use of insulin pump therapy in patients with type 2 diabetes is limited. In a review of four randomized controlled trials in patients with type 2 DM, no difference in A1C or hypoglycemic events was noted in patients using multiple daily doses of insulin compared with insulin pump therapy. However, a nonsignificant trend in reduced insulin requirements was found in patients who used insulin pump therapy. 10 receive insulin more closely mimicking endogenous insulin release than those who use multiple daily injectable doses of insulin. Most Patient Population Appropriate patient selection is vital to the insulin pumps use rapid-acting insulin success of insulin pump therapy. 1 Insulin pump preparations (lispro [Humalog], aspart [NovoLog, NovoRapid in Canada], glulisine [Apidra]). Technically regular insulin can be used in a pump, but it is not ideal because it is absorbed too slowly therapy is not appropriate for all patients with diabetes. Rather, the ideal patient would be a patient with type 1 diabetes or a patient with type 2 diabetes and absolute insulin deficiency who to mimic physiological pancreatic function. Also, desires tighter glucose control. 1,2 Patients should in insulin pumps rapid-acting insulin may provide be administering at least four insulin injections better glycemic control without increasing daily and should be self-monitoring blood glucose hypoglycemia compared to regular insulin. 6 Lastly, most newer insulin pumps (MiniMed Paradigm Revel, etc) are tested using rapid-acting insulin analogs rather than regular insulin. Currently available pumps are able to provide multiple basal insulin rates at specific time frames, depending on time of day and other factors such as illness, exercise, and menstrual cycle. In addition, more recent pumps calculate an appropriate insulin bolus dose based on at least four times daily. Patients must be motivated, willing, intellectually and physically able, and be comfortable with the technology. In addition, patients should be willing and able to learn carbohydrate counting, and understand insulin adjustment and correction factors. They must have demonstrated excellent compliance in the past and be willing, at least initially, to maintain frequent contact with members of the healthcare team. 1 carbohydrate content, correction factor, and carbohydrate factor. Bolus insulin doses can be Indications for Insulin Pump Therapy delivered in a variety of manners including There are a variety of situations where more immediate bolus, dual wave/combination bolus, or physiologic delivery of insulin is necessary. 5 square wave/extended bolus. 1,7,8 These include: A number of clinical studies have compared Failure to achieve targeted A1C. One reason multiple daily doses of insulin with insulin pump patients may remain hyperglycemic is fear of therapy in patients with type 1 diabetes. A review hypoglycemia. By using insulin pump of 23 studies involving 976 patients found a therapy, patients can more closely tailor their significantly lower A1C in insulin pump patients insulin regimen to their nutritional intake and of approximately 0.3% [95% confidence exercise, thereby avoiding hypoglycemia. interval, 0.1 to 0.4%]. In addition, patients who Also, by using a basal, peakless dose, used insulin pumps had greater improvements in hypoglycemic reactions are reduced. quality-of-life measures. Severe hypoglycemia Exercise. Patients are often instructed to appeared to be reduced in users of insulin pump avoid exercise while insulin is peaking. This therapy, although no difference between regimens can be problematic in patients who administer was observed for the frequency of less severe multiple daily doses. With pump therapy, hypoglycemia. Based on this review and other
3 (Detail-Document #261203: Page 3 of 7) patients can suspend therapy and/or reduce the basal rate during exercise 16 to avoid hypoglycemia. Dawn phenomenon. In patients who experience dawn phenomenon, insulin pump therapy can be used to avoid this. By programming an increased basal rate of the pump during the early morning hours, hyperglycemia can be avoided. Pregnancy. Insulin pump therapy has been successfully used in pregnant patients with type 1 diabetes, 16 type 2 diabetes, and gestational diabetes. Insulin pump therapy allows tight glycemic control thereby preventing glycemic-related fetal malformations and obstetric complications. Gastroparesis. Gastroparesis can make blood glucose levels erratic and unpredictable. Pump therapy can be used to deliver bolus insulin doses over an extended period of time to better match the slowed absorption caused by gastroparesis. Changing work/meal schedules. Patients who work different shifts often have difficulty with glucose control. With insulin pump therapy, patients can adjust the basal rates depending on the shifts, allowing improved glucose control. Pediatric patients. Pediatric patients may require minute insulin doses such as 0.1 units of bolus insulin or basal rate alterations of 0.05 units. Using an insulin pump, these minute doses can be easily accommodated. Advantages and Disadvantages of Insulin Pump Therapy Insulin pump therapy is associated with a number of advantages and disadvantages. 1,4,5 With appropriate use, insulin pump therapy more closely mimics physiologic insulin release which may lead to tighter, more precise glucose control, less glycemic variability, and prevention of the dawn phenomenon. Tighter control of diabetes has been shown to reduce the risk of microvascular and macrovascular complications associated with diabetes. 11 In addition, pump therapy may be associated with a reduction in severe hypoglycemia and nocturnal hypoglycemia. 1,4,5 Newer pumps include built-in warning systems and alarms when glucose levels are low. Fewer episodes of hypoglycemia can lead to improved quality of life. 1,4,5 A major disadvantage of insulin pump therapy is the cost. Insulin pumps can exceed $6000 to $7000. In addition, supplies such as tubing and cartridges and for glucose monitoring are needed every month. Infusion site reactions (dermatitis, infection) and the risk of diabetic ketoacidosis must be considered. Because the patient is using only short- or rapid-acting insulin, even a temporary interruption of therapy can lead to diabetic ketoacidosis within a few hours. Patients who choose to use an insulin pump must be highly motivated and competent, and must accept the fact that they are tethered to the pump. This is a common psychosocial limitation, especially in adolescents who do not want others to know they have diabetes. 1,4,5 How to Choose a Pump Once a patient decides to use an insulin pump, the decision of which pump to use must be made. All marketed insulin pumps are reliable, but vary slightly in terms of features. 9,10 Questions to consider include: Is it waterproof? Most pumps are water resistant, but the duration and depth of water vary. How much does the insulin reservoir hold? Currently marketed pumps vary from 176 units to 315 units of rapid-acting insulin. What is the minimum basal increment? The basal increment varies from units to 0.1 units. For a child requiring very small dosage adjustments, a pump with unit increment may be desired. How many basal rates can be programmed? Currently available meters vary. For example, the insulin pump allows three patterns with up to 48 rates each and the OmniPod insulin pump allows for seven patterns with up to 24 rates. What is the bolus range? Insulin pumps typically start at a lower range of 0.05 to 0.1 units and can give as much as 10 to 35 units, depending on the pump. Boluses are administered over one to 40 seconds depending on the pump. Boluses can be
4 administered in a variety of methods including normal, extended, dual wave, or square wave depending on the meter. How much does the unit weigh? Pumps weigh between 3.8 ounces and 4.4 ounces including a full reservoir and batteries. What types of batteries are needed? Insulin pumps use AA, AAA, 1.5 volt lithium, or 3.6 volt lithium batteries. These batteries last between two to six weeks. What type of infusion set is used? Some insulin pumps are compatible with any brand of Luer-Lok tubing, while others only work with tubing made for that specific pump. The OmniPod insulin pump does not use tubing, but rather the pod has a built in infusion set, cannula, and inserter. The entire unit is discarded every 72 hours. Is there a food database programmed into the pump to assist with carbohydrate counting? Some pumps include a database of between 500 and 1,000 common foods which can assist a patient in determining carbohydrate values. However, not all pumps have this feature. Does it interact with a blood glucose meter? Some pumps will wirelessly transmit blood glucose information to a blood glucose meter, while the OmniPod insulin pump has a built-in glucose meter. Name of Insulin Pump Accu-Chek Spirit Amigo Dana Diabetescare IIS Deltec Cosmos (discontinued, but in use until warranty expiration) MiniMed Paradigm 522 MiniMed Paradigm 722 (Detail-Document #261203: Page 4 of 7) However, none of these meters are able to calculate an insulin dose and tell the pump how much insulin to administer. The patient must still input insulin dosing information into the pump at every meal or snack. Does it use continuous glucose monitoring? One pump (MiniMed Paradigm Revel) has continuous glucose monitoring equipment which can be purchased separately. This monitoring system can be set to alarm when blood glucose levels are too high or low. How complex is the meter? Most pumps will list the number of steps necessary to program a bolus or basal rate. Currently available meters typically require three to four steps for a single bolus. For a tworate basal pattern, pumps vary between nine and 13 steps. What is the memory? Memory varies considerably between the meters. For example, some meters maintain the last 90 events, while others retain 90 days (up to 5400 records) of data. The table below lists the available insulin pumps, including manufacturer contact information. 7,8 Manufacturer and Contact Information Disetronic Medical Systems (Roche) Nipro Diabetes Systems Sooil Smiths Medical
5 (Detail-Document #261203: Page 5 of 7) Name of Insulin Pump MiniMed Paradigm Revel MiniMed Paradigm VEO OmniPod One Touch Ping Solo MicroPump Getting Started on Insulin Pump Therapy Initiating insulin pump therapy requires extensive patient education and training, close follow-up, and dosage adjustments. Most adult patients can start insulin pump therapy as outpatients, but children are sometimes hospitalized during the initiation period. 1,4,5,12 Patients who are starting insulin pump therapy should stop all intermediate- and long-acting insulin 12 to 24 hours prior to pump initiation. Hyperglycemia can be treated with short- or rapid-acting insulin. Initial doses are calculated based on the total daily insulin doses prior to pump therapy. Because insulin pump users typically require less insulin, the calculated daily insulin dose should then be reduced by 10% to 20%. In general, 40% to 50% of the calculated insulin pump dose should be given as basal insulin and the remaining dose is delivered as pre-meal boluses. Basal rates throughout the day can be calculated by having a patient fast for a meal and determining the basal insulin rate that prevents a 30 mg/dl (1.7 mmol/l) or more increase or decrease in blood sugar. Patients should vary the meal that is skipped to determine different basal rates throughout the day and night. Pre-meal bolus doses can be determined by the preprandial glucose concentrations as well as the carbohydrate content of the meal, carbohydrate factor, insulin to carbohydrate factor, activity level after the meal, and prior experience. Following initiation, close monitoring is necessary to adjust insulin doses appropriately. 1,4,5 Manufacturer and Contact Information Insulet Corporation Animas (Johnson and Johnson) Mendingo 800-SOLO-4YOU Patients should understand the importance of regularly monitoring blood sugar values (at least four to six times a day). In addition, insulin pump therapy requires extensive attention to details to continually input data into the pump regarding meals and snacks, exercise and activity, blood sugar values, etc. Patients should be instructed to change the catheter site every two to three days. Failure to rotate the insertion site can lead to scar tissue formation and subsequent variations in insulin absorption and blood sugars values. Insulin Pumps in the Hospital Patients receiving insulin pump therapy may be hospitalized for an acute situation. According to the American Diabetes Association, pump therapy can be continued during hospitalization, as long as the patient has adequate oral intake and is able to self-manage their care. Patients must record insulin doses which then becomes part of the medical record. It is important that the patient s medical chart clearly states that the patient is using an insulin pump, especially if the patient is having surgery. Also, patients must remove the pump prior to any electromagnetic procedures such as an MRI. In patients who are too ill to self-manage their insulin pumps, appropriate subcutaneous insulin doses should be determined and administered until insulin pump therapy can be resumed. 13 Reimbursement and Training Medicare and most insurance companies will cover at least part of the expenses associated with
6 insulin pump therapy as long as specific criteria are met. Patients must be insulin-dependent and have a fasting C-peptide level of 110% or less of the laboratory s lower limit of normal or demonstrate beta-cell autoantibodies. The concurrent fasting glucose level must be 225 mg/dl (12.5 mmol/l) or lower. 14 In addition, the patient must have documentation of at least one of the following: A1C greater than 7%, recurrent hypoglycemia, wide fluctuations of blood glucose before mealtimes, or the dawn phenomenon. 1 Pharmacists and other healthcare professionals can receive pump training from pump manufacturers such as and Animas. Some pharmacists who are certified pump trainers then receive reimbursement from the pump company for initially training and managing patients for up to two months. Typically pharmacists who attend these programs have credentialing such as Certified Diabetes Educator (CDE) certification or Board Certification in Advanced Diabetes Management (BC-ADM). In the U.S., additional patient training beyond the two month period provided by the pump company may be reimbursed under diabetes and selfmanagement codes (Healthcare Common Procedure Coding system codes G0108 and G0109) if the healthcare professional works in an American Diabetes Association-recognized program. 14,15 Users of this document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national organizations. Information and Internet links in this article were current as of the date of publication. Project Leader in preparation of this Detail- Document: Neeta Bahal O Mara, Pharm.D., BCPS References 1. Grunberger G, Bailey TS, Cohen AJ, et al. Statement by the American Association of Clinical Endocrinologists Consensus Panel on insulin pump management. September/October (Detail-Document #261203: Page 6 of 7) ment.pdf. (Accessed November 11, 2010). 2. Wittlin SD. Treating the spectrum of type 2 diabetes: emphasis on insulin pump therapy. Diabetes Educ 2006;32:39S-46S. 3. Bradley BA. Insulin pump basics. Diabetes Health /insulin-pump-basics. (Accessed November 11, 2010). 4. Potti LG, Haines ST. Continuous subcutaneous insulin infusion therapy: a primer on insulin pumps. J Am Pharm Assoc 2009;49:e White RD. Insulin pump therapy (continuous subcutaneous insulin infusion). Prim Care 2007;34: Radermecker RP, Scheen AJ. Continuous subcutaneous insulin infusion with short-acting insulin analogues or human regular insulin: efficacy, safety, quality of life, and costeffectiveness. Diabetes Metab Res Rev 2004;20: Anon. Insulin pumps and infusion sets. Diabetes Forecast Consumer s Guide. (Accessed November 11, 2010). 8. Anon. Insulin pumps. Insulin_Pumps_Chart-Diabetes_Health_2010.pdf. (Accessed November 11, 2010). 9. Misso ML, Egberts KJ, Page M, et al. Continuous subcutaneous insulin infusion (CSII) versus multiple insulin injections for type 1 diabetes mellitus. Cochrane Database Syst Rev 2010; (1):CD Monami M, Lamanna C, Marchionni N, Mannucci E. Continuous subcutaneous insulin infusion versus multiple daily insulin injections in type 2 diabetes: A meta-analysis. Exp Clin Endocrinol Diabetes 2009;117: The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329: Scheiner G, Sobel RJ, Smith DE, et al. American Association of Diabetes Educators. Insulin pump therapy: guidelines for successful outcomes. September _resources/pdf/insulin_pump_white_paper.pdf. (Accessed November 11, 2010). 13. American Diabetes Association. Standards of medical care in diabetes Diabetes Care 2010;33(Suppl 1):S Centers for Medicare and Medicaid Services. Medicare National Coverage Determinations Manual. (Revision 124, September 24, 2010). 1_Part4.pdf. (Accessed November 11, 2010). 15. Boyd LC, Boyd ST. Insulin pump therapy training and management: an opportunity for community pharmacists. J Manag Care Pharm 2008;14:790-4.
7 (Detail-Document #261203: Page 7 of 7) 16. Canadian Diabetes Association. Clinical practice guidelines for the prevention and management of diabetes in Canada (2008). Can J Diabetes 2008;32(Suppl 1):S1-S201. Cite this Detail-Document as follows: Insulin pump therapy. Pharmacist s Letter/Prescriber s Letter 2010;26(12): Evidence and Advice You Can Trust 3120 West March Lane, P.O. Box 8190, Stockton, CA ~ TEL (209) ~ FAX (209) Subscribers to Pharmacist s Letter and Prescriber s Letter can get Detail-Documents, like this one, on any topic covered in any issue by going to or
Continuous Subcutaneous Insulin Infusion (CSII)
IMPORTANCE OF FOCUS CSII (Insulin pumps) have been used for more than 35 years. In the U.S. in 2005, the level of insulin pump penetration was estimated at 20 to 30% in patients with type 1 diabetes mellitus
More informationIntensive Insulin Therapy in Diabetes Management
Intensive Insulin Therapy in Diabetes Management Lillian F. Lien, MD Medical Director, Duke Inpatient Diabetes Management Assistant Professor of Medicine Division of Endocrinology, Metabolism, & Nutrition
More informationBOLUS INSULIN DOSAGES H. Peter Chase, MD and Erin Cobry, BS
CHAPTER 6: BOLUS INSULIN DOSAGES H. Peter Chase, MD and Erin Cobry, BS WHAT IS BOLUS INSULIN? Bolus insulin dosages refer to the quick bursts of insulin given to cover the carbohydrates in meals or snacks
More informationInsulin Pump Therapy and Continuous Glucose Sensor Use in the Management of Diabetes Mellitus
Insulin Pump Therapy and Continuous Glucose Sensor Use in the Management of Diabetes Mellitus Louis Haenel, IV, DO, FACOI, FACE Endocrinology Roper Hospital Charleston, SC Dr. Louis Haenel IV has disclosed
More informationGet Primed on Pumps: A beginners guide to Insulin Pump Therapy
Get Primed on Pumps: A beginners guide to Insulin Pump Therapy Advantages of insulin pump therapy There are many advantages to using an insulin pump. Anyone can do it with the right training and support.
More informationAlternative method for delivering insulin using continuous subcutaneous insulin infusion (CSII) open loop system
ISHP Spring CE Conference April 12, 2015 St. Luke s Medical Center Randi Lynn Griffiths, PharmD Clinical outpatient pharmacist Boise VA Medical Center Boise, Idaho Alternative method for delivering insulin
More informationCLASS OBJECTIVES. Describe the history of insulin discovery List types of insulin Define indications and dosages Review case studies
Insulins CLASS OBJECTIVES Describe the history of insulin discovery List types of insulin Define indications and dosages Review case studies INVENTION OF INSULIN 1921 The first stills used to make insulin
More informationObjectives PERINATAL INSULIN PUMPS: BASICS FOR NURSES. Historical Perspective. Insulin Pumps in Pregnancy. Insulin Pumps in the US
Objectives PERINATAL INSULIN PUMPS: BASICS FOR NURSES Jo M. Kendrick, APN BC, CDE jkendric@utmck.edu Describe indications and contraindications for insulin pump use in hospitalized patients Differentiate
More informationMedical Policy An independent licensee of the Blue Cross Blue Shield Association
Afrezza Page 1 of 6 Medical Policy An independent licensee of the Blue Cross Blue Shield Association Title: Afrezza (human insulin) Prime Therapeutics will review Prior Authorization requests Prior Authorization
More informationDiabetes and Technology. Disclosures Certified Insulin Pump Trainer for: Animas Medtronic Diabetes Omnipod. Rebecca Ray, MSN, APRN, FNP-C
Diabetes and Technology Rebecca Ray, MSN, APRN, FNP-C Insulin Pump Therapy and Continuous Glucose Monitoring In Patients with Type 2 Diabetes Page 1 Disclosures Certified Insulin Pump Trainer for: Animas
More informationInitiation and Adjustment of Insulin Regimens for Type 2 Diabetes
PL Detail-Document #300128 This Detail-Document accompanies the related article published in PHARMACIST S LETTER / PRESCRIBER S LETTER January 2014 Initiation and Adjustment of Insulin Regimens for Type
More informationBasal and Bolus Insulin 7/16/2014. Jackie Aday RN, BSN, CDE Jeni Neighbors RN, BSN, CDE. BASAL: Small amount of insulin infused every few minutes
Jackie Aday RN, BSN, CDE Jeni Neighbors RN, BSN, CDE Insulin Pump Therapy Open looped system in which a small amount of insulin is continuously infused through a cannula or needle (basal rate) Larger doses
More informationStarting patients on the V-Go Disposable Insulin Delivery Device
Starting patients on the V-Go Disposable Insulin Delivery Device A simple guide for your practice For adult patients with Type 2 diabetes on basal insulin who need to take the next step Identify appropriate
More informationInsulin Infusion Pumps
Medical Coverage Policy Insulin Infusion Pumps EFFECTIVE DATE: 09/01/2004 POLICY LAST UPDATED: 08/06/2013 OVERVIEW The policy addresses insulin infusion pumps that are worn externally and those that are
More informationInsulin Pump Therapy in Older Adults
Insulin Pump Therapy in Older Adults Joshua Akers, PharmD Candidate, 2007 College of Pharmacy Washington State University Spokane, WA Phone: 509-432-3332 Email: akersjoshua@hotmail.com and Stephen M. Setter,
More informationInsulin Pump Management and Continuous Glucose Monitoring Systems (CGMS)
Insulin Pump Management and Continuous Glucose Monitoring Systems (CGMS) Faith Daily, RN, BSN, CDE, CPT Certified Diabetes Educator/Insulin Pump Trainer August 16, 2014 Why Pump Therapy? Mimics normal
More information4/7/2015 CONFLICT OF INTEREST DISCLOSURE OBJECTIVES. Conflicts of Interest None Heather Rush. Heather M. Rush, APRN, CDE Louisville, KY
Heather M. Rush, APRN, CDE Louisville, KY CONFLICT OF INTEREST DISCLOSURE Conflicts of Interest None Heather Rush A conflict of interest exists when an individual is in a position to profit directly or
More informationTypes of insulin and How to Use Them
Diabetes and Insulin Pumps Amy S. Pullen Pharm.D ISHP Spring Meeting April 2012 Objectives Describe the different types of insulin used in diabetes Identify the types of insulin that are compatible with
More informationMANAGEMENT OF TYPE - 1 DIABETES MELLITUS
MANAGEMENT OF TYPE - 1 DIABETES MELLITUS INVESTIGATIONS AND TREATMENT MANSI NAIK VII SEMESTER INVESTIGATIONS FASTING BLOOD SUGAR PLASMA GLUCOSE HEMOGLOBIN A 1c SYMPTOMS OF TYPE 1 DIABETES MELLITUS Polyuria
More informationMEDICAL COVERAGE POLICY. SERVICE: Insulin Pump and Continuous Glucose Monitoring. PRIOR AUTHORIZATION: Required. POLICY:
Important note Even though this policy may indicate that a particular service or supply may be considered covered, this conclusion is not based upon the terms of your particular benefit plan. Each benefit
More informationHealth Professional s. Guide to INSULIN PUMP THERAPY
Health Professional s Guide to INSULIN PUMP THERAPY Table of Contents Introduction Presenting Insulin Pump Therapy to Your Patients When Your Patient Chooses the Pump Estimates for Starting Insulin Pump
More informationINPATIENT DIABETES MANAGEMENT Robert J. Rushakoff, MD Professor of Medicine Director, Inpatient Diabetes University of California, San Francisco
INPATIENT DIABETES MANAGEMENT Robert J. Rushakoff, MD Professor of Medicine Director, Inpatient Diabetes University of California, San Francisco CLINICAL RECOGNITION Background: Appropriate inpatient glycemic
More informationIntensifying Insulin Therapy
Intensifying Insulin Therapy Rick Hess, PharmD, CDE, BC-ADM Associate Professor Gatton College of Pharmacy, Department of Pharmacy Practice East Tennessee State University Johnson City, Tennessee Learning
More informationGlycemic Control Initiative: Insulin Order Set Changes Hypoglycemia Nursing Protocol
Glycemic Control Initiative: Insulin Order Set Changes Hypoglycemia Nursing Protocol Ruth LaCasse Kalish, RPh Department of Pharmacy Objectives Review the current practice at UConn Health with sliding
More informationSARASOTA MEMORIAL HOSPITAL
SARASOTA MEMORIAL HOSPITAL TITLE: NURSING PROCEDURE MANAGEMENT OF PATIENT S OWN INSULIN PUMP/CONTINUOUS SUBCUTANEOUS INSULIN INFUSION PUMP (dia13) DATE: REVIEWED: PAGES: 08/84 10/15 1 of 7 PS1094 ISSUED
More informationLead Clinician(S) (DATE) Approved by Diabetes Directorate on: Approved by Medicines Safety Group on: This guideline should not be used after end of:
Guideline for members of the diabetes team and dietetic department for advising on insulin dose adjustment and teaching the skills of insulin dose adjustment to adults with type 1 or type 2 diabetes mellitus
More informationSmart Pumping with Insulin Pumps
Smart Pumping with Insulin Pumps Rita Ketay RN, CDE, Ed.M, BC-ADM Dartmouth Hitchcock Medical Center During this discussion we will: * Review the DCCT recommendations; * Define smart pumping ; * Discuss
More informationTaking Insulin Pumps to School. Rachel Calendo, MS, RN, CPNP, CDE, Martha Cuevas, RN, BSN, CPT
Taking Insulin Pumps to School Rachel Calendo, MS, RN, CPNP, CDE, Martha Cuevas, RN, BSN, CPT Insulin Pumps Today A micro-computer, about the size of a pager Programmed to deliver both a preset amount
More informationInsulin: Breaking Barriers Enhancing Therapies. Jerry Meece, RPh, FACA, CDE jmeece12@cooke.net
Insulin: Breaking Barriers Enhancing Therapies Jerry Meece, RPh, FACA, CDE jmeece12@cooke.net Questions To Address Who are candidates for insulin? When do we start insulin? How do the different types of
More informationDiabetes Medications: Insulin Therapy
Diabetes Medications: Insulin Therapy Courtesy Univ Texas San Antonio Eric L. Johnson, M.D. Department of Family and Community Medicine Diabetes and Insulin Type 1 Diabetes Autoimmune destruction of beta
More informationOptimizing Insulin Therapy. Calculating Insulin to Carbohydrate Ratios and Correction/Sensitivity Factors
Optimizing Insulin Therapy Calculating Insulin to Carbohydrate Ratios and Correction/Sensitivity Factors Introduction Diabetes management, and particularly self-management, has come a long way. Unfortunately,
More informationIntensifying Insulin In Type 2 Diabetes
Intensifying Insulin In Type 2 Diabetes Eric L. Johnson, M.D. Associate Professor Department of Family and Community Medicine University of North Dakota School of Medicine and Health Sciences Assistant
More informationCriteria: CWQI HCS-123 (This criteria is consistent with CMS guidelines for External Infusion Insulin Pumps)
Moda Health Plan, Inc. Medical Necessity Criteria Subject: Origination Date: 05/15 Revision Date(s): 05/2015 Developed By: Medical Criteria Committee 06/24/2015 External Infusion Insulin Pumps Page 1 of
More informationCSII. Continuous Subcutaneous Insulin Infusion Therapy. An Overview of. A Continuing Education Monograph for Physicians, Pharmacists, and Nurses
An Overview of Continuous Subcutaneous Insulin Infusion Therapy A Continuing Education Monograph for Physicians, Pharmacists, and Nurses CSII This continuing education activity can also be completed online
More informationby Rodney Lorenz, MD and Janet Silverstein, MD
Managing Insulin Requirements at School by Rodney Lorenz, MD and Janet Silverstein, MD Introduction Multiple advances over the past decade have revolutionized treatment of diabetes in youth. Two fundamental
More informationThe Diabetes Self Management Insulin Pump Therapy Program
The Diabetes Self Management Insulin Pump Therapy Program Is part of a Nationally recognized program taught by CPT s Offers classes during the daytime in a three part series: PRE-PUMP CLASS SALINE START
More informationInsulin Initiation and Intensification
Insulin Initiation and Intensification ANDREW S. RHINEHART, MD, FACP, CDE MEDICAL DIRECTOR AND DIABETOLOGIST JOHNSTON MEMORIAL DIABETES CARE CENTER Objectives Understand the pharmacodynamics and pharmacokinetics
More informationContinuous subcutaneous insulin infusion therapy: A primer on insulin pumps
Continuous subcutaneous insulin infusion therapy: A primer on insulin pumps Lakshmi G. Potti and Stuart T. Haines Abstract Objective: To summarize the role, benefits, and risks of continuous subcutaneous
More informationPrior Authorization Guideline
Prior Authorization Guideline Guideline: PC - Apidra, Levemir Therapeutic Class: Hormones and Synthetic Substitutes Therapeutic Sub-Class: Antidiabetic Agents Client: CA, CO, NV, OK, OR, WA and AZ Approval
More informationINSULIN INTENSIFICATION: Taking Care to the Next Level
INSULIN INTENSIFICATION: Taking Care to the Next Level By J. Robin Conway M.D., Diabetes Clinic, Smiths Falls, ON www.diabetesclinic.ca Type 2 Diabetes is an increasing problem in our society, due largely
More informationInsulin Pumps in Diabetes Management By Rita Carey Rubin, MS, RD, CDE. Suggested CDR Learning Codes: 5190, 5400, 5410, 5420; Level 2
Insulin Pumps in Diabetes Management By Rita Carey Rubin, MS, RD, CDE Suggested CDR Learning Codes: 5190, 5400, 5410, 5420; Level 2 Controlling diabetes is one of the most important challenges facing patients
More informationWhy is Insulin so Important?
Insulin Therapy Why is Insulin so Important? If the glucose stays in your blood it doesn t do your cells (body) any good The glucose has to get inside the cells for the body to use it What Does Insulin
More informationBASAL BOLUS INSULIN FOR MEDICAL- SURGICAL INPATIENTS
BASAL BOLUS INSULIN FOR MEDICAL- SURGICAL INPATIENTS C O N T A C T D I A B E T E S S E R V I C E S F O R M O R E I N F O R M A T I O N 8 4 7-9 1 7-6 9 0 7 THIS SLIDE PRESENTATION WAS PREPARED BY SUE DROGOS,
More informationUse of Continuous Subcutaneous Insulin Infusion (CSII) Pumps in Hospitalized Patients Policy and Procedure
Purpose: To ensure safe and accurate administration of insulin for patients using their own external continuous subcutaneous insulin infusion pump during hospitalization. Definitions: Insulin pump: An
More informationA guidebook for people with diabetes
A guidebook for people with diabetes This booklet is designed to supplement, not replace, your doctor s advice. Please consult your doctor if you have any questions about what you read. You ll learn how
More informationDiabetes. New Trends Presented by Barbara Obst RN MS August 2008
Diabetes New Trends Presented by Barbara Obst RN MS August 2008 What is Diabetes Diabetes is a condition characterized by high levels of glucose. The glucose circulates in your blood and serves as the
More informationCalculating Insulin Dose
Calculating Insulin Dose First, some basic things to know about insulin: Approximately 40-50% of the total daily insulin dose is to replace insulin overnight, when you are fasting and between meals. This
More informationby Rodney Lorenz, MD and Janet Silverstein, MD
Managing Insulin Requirements at School by Rodney Lorenz, MD and Janet Silverstein, MD Introduction Multiple advances over the past decade have revolutionized treatment of diabetes in youth. Two fundamental
More informationTherapy Insulin Practical guide to Health Care Providers Quick Reference F Diabetes Mellitus in Type 2
Ministry of Health, Malaysia 2010 First published March 2011 Perkhidmatan Diabetes dan Endokrinologi Kementerian Kesihatan Malaysia Practical guide to Insulin Therapy in Type 2 Diabetes Mellitus Quick
More informationIntroduction. We hope this guide will aide you and your staff in creating a safe and supportive environment for your students challenged by diabetes.
Introduction Diabetes is a chronic disease that affects the body s ability to metabolize food. The body converts much of the food we eat into glucose, the body s main source of energy. Glucose is carried
More informationtips Insulin Pump Users 1 Early detection of insulin deprivation in continuous subcutaneous 2 Population Study of Pediatric Ketoacidosis in Sweden:
tips Top International Publications Selection Insulin Pump Users Early detection of insulin deprivation in continuous subcutaneous insulin infusion-treated Patients with TD Population Study of Pediatric
More informationDiabetes: When To Treat With Insulin and Treatment Goals
Diabetes: When To Treat With Insulin and Treatment Goals Lanita. S. White, Pharm.D. Director, UAMS 12 th Street Health and Wellness Center Assistant Professor of Pharmacy Practice, UAMS College of Pharmacy
More informationPump Therapy Indications:
Insulin Pumping Getting Started March 7, 2008 Clinical Pearls To understand the rational behind pump therapy To explore patient preferences for and against insulin pump therapy Realistic expectations for
More informationInsulin Pump Therapy Is It Right for You? Compliments of Novo Nordisk Pharmaceuticals, Inc.
Insulin Pump Therapy Is It Right for You? Compliments of Novo Nordisk Pharmaceuticals, Inc. Who should consider the insulin pump option? More and more people with diabetes are switching from injecting
More information10 to 30 minutes ½ to 3 hours 3 to 5 hours. 30 60 minutes 1 to 5 hours 8 hours. 1 to 4 hours
Insulin Action There are several types of insulin. They are classified by how long they act: very fast, fast, slow and very slow acting. Each type of insulin has a certain time period in which it works.
More informationInsulin onset, peak and duration of action
Insulin onset, peak and duration of action Insulin was first discovered in the early 190 s. Before then, diabetes could not be treated. Insulin was then taken from cow and pig pancreases, but nearly all
More informationThe What, Why, Who & How of Insulin Pumps. Bridget Lydon May 2014
The What, Why, Who & How of Insulin Pumps Bridget Lydon May 2014 Topics WHAT is an insulin pump HOW a pump works WHY use a pump WHO should use a pump Pharmac criteria for funded pumps All began back in
More informationInsulin T Y P E 1 T Y P E 2
T Y P E 1 T Y P E 2 INSULIN There are many different insulins for many different situations and lifestyles. This section should help you and your doctor decide which insulin or insulins are best for you.
More informationSchool Nurse Role in Care and Management of the Child with Diabetes in Colorado Schools and Child Care Settings Position Statement 1 POSITION It is
Schools and Child Care Settings Position Statement 1 POSITION It is the position of the Colorado Diabetes Resource Nurses that the school nurse is the only school staff member who has the skills, knowledge
More informationInsulin Therapy In Type 2 DM. Sources of support. Agenda. Michael Fischer, M.D., M.S. The underuse of insulin Insulin definition and types
Insulin Therapy In Type 2 DM Michael Fischer, M.D., M.S. Sources of support NaRCAD is supported by a grant from the Agency for Healthcare Research and Quality My current research projects are funded by
More informationINSULINThere are. T y p e 1 T y p e 2. many different insulins for
T y p e 1 T y p e 2 INSULINThere are many different insulins for Characteristics The three characteristics of insulin are: Onset. The length of time before insulin reaches the bloodstream and begins lowering
More informationThere seem to be inconsistencies regarding diabetic management in
Society of Ambulatory Anesthesia (SAMBA) Consensus Statement on Perioperative Blood Glucose Management in Diabetic Patients Undergoing Ambulatory Surgery Review of the consensus statement and additional
More informationA Reference Guide for School Nurses. with the Medtronic MiniMed Insulin Pump
A Reference Guide for School Nurses with the Medtronic MiniMed Insulin Pump Table Of Contents I Table of Contents The Medtronic MiniMed Insulin Pump A Reference Guide for School Nurses For the 522, 722,
More informationHow To Manage Diabetes
INSULIN PUMPS PHYSIOLOGIC INSULIN SECRETION Daniel L. Metzger, MD, FAAP, FRCPC INSULIN PUMP INFUSION SETS BOLUS BASAL Breakfast Bed Dinner Snack Lunch Breakfast BRANDS OF PUMPS ADVANTAGES I ANIMAS MINIMED
More informationInsulin Pump Therapy
CHILDREN S SERVICES Insulin Pump Therapy These guidelines are not intended for starting a patient on an insulin pump. They are intended to give staff not part of the diabetic team information regarding
More informationManaging the Hospitalized Patient on Insulin: Care Transition. Catie Prinzing MSN, APRN, CNS
Managing the Hospitalized Patient on Insulin: Care Transition Catie Prinzing MSN, APRN, CNS Diabetes and Hospitalization People with DM are hospitalized 3x more frequently than patients without diabetes
More informationA new insulin order form should be completed for subsequent changes to type of insulin and/or frequency of administration
of nurse A new insulin order form should be completed for subsequent changes to type of insulin and/or frequency of administration 1. Check times for point of care meter blood glucose testing. Pre-Breakfast
More informationDiabetes Fundamentals
Diabetes Fundamentals Prevalence of Diabetes in the U.S. Undiagnosed 10.7% of all people 20+ 23.1% of all people 60+ (12.2 million) Slide provided by Roche Diagnostics Sources: ADA, WHO statistics Prevalence
More informationThe OmniPod Insulin Management System
Caregiver GUIDE The OmniPod Insulin Management System The OmniPod is an easy-to-use, two-part insulin delivery system. If you are a school nurse, daycare provider, or other secondary caregiver for someone
More informationRight Insulin Regimen
Focus on CME at l Université McGill University de Montréal What is the Right Insulin Regimen for my Patient? Jean-Pierre Hallé, MD, FRCPC, and Donald Breton, MD, FRCPC What can I do to improve my patient
More informationOFFICE OF CATHOLIC SCHOOLS DIOCESE OF ARLINGTON DIABETES MEDICAL MANAGEMENT PLAN Page 1 of 5 TO BE COMPLETED BY PARENT OR GUARDIAN
PART I OFFICE OF CATHOLIC SCHOOLS DIOCESE OF ARLINGTON DIABETES MEDICAL MANAGEMENT PLAN Page 1 of 5 TO BE COMPLETED BY PARENT OR GUARDIAN Student School Date of Birth Date of Diagnosis Grade/ Teacher Physical
More informationExternal Insulin Pumps Corporate Medical Policy
External Insulin Pumps Corporate Medical Policy File name: External Insulin Pumps File code: UM.DME.02 Origination: 4/2006 Last Review: 02/2014 (ICD-10 remediation only) Next Review: 10/2014 Effective
More informationALVIN INDEPENDENT SCHOOL DISTRICT Diabetes Medical Management Plan
ALVIN INDEPENDENT SCHOOL DISTRICT Diabetes Medical Management Plan of Plan: School Year (must be current): This plan should be completed by the student s personal health care team and parents/guardian.
More informationInpatient Guidelines: Insulin Infusion Pump Management
Inpatient Guidelines: Insulin Infusion Pump Management Developed by the Statewide Diabetes Clinical Network Steering Committee July 2012 Clinical Access and Redesign Unit Table of Contents Purpose...4
More informationDiabetes mellitus 1 عبد هللا الزعبي. pharmacology. Shatha Khalil Shahwan. 1 P a g e
Diabetes mellitus 1 pharmacology عبد هللا الزعبي 1 P a g e 4 Shatha Khalil Shahwan Diabetes mellitus The goals of the treatment of diabetes 1. Treating symptoms 2. Treating and Preventing acute complications
More informationINSULIN AND INCRETIN THERAPIES: WHAT COMBINATIONS ARE RIGHT FOR YOUR PATIENT?
INSULIN AND INCRETIN THERAPIES: WHAT COMBINATIONS ARE RIGHT FOR YOUR PATIENT? MARTHA M. BRINSKO, MSN, ANP-BC CHARLOTTE COMMUNITY HEALTH CLINIC CHARLOTTE, NC Diagnosed and undiagnosed diabetes in the United
More informationBasal Rate Testing Blood sugar is affected at any time by 1) basal insulin 2) food (carbohydrate) intake 3) bolus insulin (meal time and correction)
Basal Rate Testing Blood sugar is affected at any time by 1) basal insulin 2) food (carbohydrate) intake 3) bolus insulin (meal time and correction) 4) activity and 5) other factors such as stress and
More informationObjectives. What Is Diabetes? 1/26/2015. Carbs & Meds & Meters, Oh My!: Diabetes in Pregnancy
Carbs & Meds & Meters, Oh My!: Diabetes in Pregnancy Jan Tisdale RD, MPH, CDE Nutritionist / Certified Diabetes Educator UAB School of Medicine OB/GYN Maternal-Fetal Medicine 02/2015 Objectives Review
More informationGlycaemic Control in Adults with Type 1 Diabetes
Glycaemic Control in Adults with Type 1 Diabetes Aim(s) and objective(s) This document aims to provide guidance on good clinical practice in managing glycaemic control in adult patients with Type 1 Diabetes
More informationClinical Policy Title: Disposable Continuous Subcutaneous Insulin Infusion Pumps
Clinical Policy Title: Disposable Continuous Subcutaneous Insulin Infusion Pumps Clinical Policy Number: 06.02.01 Effective Date: March 1, 2014 Initial Review Date: Nov. 20 th, 2013 Most Recent Review
More informationThe table below logs the history of the steps in development of the document.
Paediatric Insulin Pumps Version: 0.4 Committee Approved by: Clinical Cabinet Date Approved 5 February 2014 Author: Responsible Directorate: Janet Wilson Strategy and Commissioning (Children s) Date issued:
More informationINSULIN ALGORITHM FOR TYPE 2 DIABETES MELLITUS IN CHILDREN 1 AND ADULTS
Publication # 45-11647 Targets*
More informationInsulin therapy in various type 1 diabetes patients workshop
Insulin therapy in various type 1 diabetes patients workshop Bruce H.R. Wolffenbuttel, MD PhD Dept of Endocrinology, UMC Groningen website: www.umcg.net & www.gmed.nl Twitter: @bhrw Case no. 1 Male of
More informationInsulin Pens & Improving Patient Adherence
Insulin Pens & Improving Patient Adherence Bonnie Pepon, RN, BSN, CDE Certified Diabetes Educator Conemaugh Diabetes Institute Kip Benko, MD FACEP Asst Clinical Professor University of Pittsburgh School
More informationCertified Product Trainer INFORMATION MANUAL
Certified Product Trainer INFORMATION MANUAL WELCOME Thank you for your interest in becoming a Medtronic Certified Product Trainer (CPT). We are pleased that you have been selected to partner with us to
More informationClinical and cost-effectiveness of continuous subcutaneous insulin infusion therapy in diabetes.
PROTOCOL Clinical and cost-effectiveness of continuous subcutaneous insulin infusion therapy in diabetes. A. This the revised protocol (April 2002) B. Review team Contact for correspondence: Dr Jill Colquitt
More informationInsulin pen start checklist
Insulin pen start checklist Topic Instruction Date & Initials 1. Cognitive Assessment 2. Insulin Delivery loading appropriate mixing priming shot dialing up dose delivery of insulin 3. Insulin type/action
More informationAbdulaziz Al-Subaie. Anfal Al-Shalwi
Abdulaziz Al-Subaie Anfal Al-Shalwi Introduction what is diabetes mellitus? A chronic metabolic disorder characterized by high blood glucose level caused by insulin deficiency and sometimes accompanied
More informationMedical Coverage Policy Glucose Monitoring Systems sad
Medical Coverage Policy Glucose Monitoring Systems sad EFFECTIVE DATE: 03 03 2009 POLICY LAST UPDATED: 01 17 2012 OVERVIEW This policy addresses several methods of monitoring blood glucose: the glucometer,
More information2. What Should Advocates Know About Diabetes? O
2. What Should Advocates Know About Diabetes? O ften a school district s failure to properly address the needs of a student with diabetes is due not to bad faith, but to ignorance or a lack of accurate
More informationFinally, the right fit for your insulin needs. www.tandemdiabetes.com
Finally, the right fit for your insulin needs. www.tandemdiabetes.com (Actual Size) For convenience and ease of use, the t:flex TM Insulin Pump just fits. It is designed to help make your day-to-day insulin
More informationInsulin Algorithm for Type 2 Diabetes Mellitus in Children and Adults
Insulin Algorithm for Type 2 Diabetes Mellitus in Children and Adults Stock # 45-11647 Revised 10/28/10 Glycemic Goals 1,2 Individualize goal based on patient risk factors A1c 6%
More informationInsulin Pump Therapy. Jen Block, MSN, RN, CDE Stanford University Department of Pediatric Endocrinology
Insulin Pump Therapy Jen Block, MSN, RN, CDE Stanford University Department of Pediatric Endocrinology Disclosures Member of Clinical Advisory Panel for Tandem Work on a variety of clinical trials funded
More information2010 Partners & Peers for Diabetes Care, Inc. www.partnersandpeers.org
Without a working knowledge of the way insulin works in your body it is very difficult to effectively manage diabetes... Kind of like driving a car without knowing how to use the gas pedal and brakes...
More informationINSULIN PRODUCTS. Jack DeRuiter
INSULIN PRODUCTS Jack DeRuiter The number and types of insulin preparations available in the United States is constantly changing, thus students should refer to recent drug resources for a current list
More informationDiabetes Management and Treatment Plan for School (For the insulin pump student)
Lafayette School Corporation Health Services Diabetes Management and Treatment Plan for School (For the insulin pump student) Effective Dates: This plan should be complete by the student s personal health
More informationThe Basics of Insulin Pump Therapy
The Basics of Insulin Pump Therapy Table of Contents The Basics of Insulin Pump Therapy Introduction Welcome... 3 Chapter 1 Balancing Glucose and Insulin............................. 10 Section 1: Glucose,
More informationInsulin Pump Therapy during Pregnancy and Birth
Approvals: Specialist Group: Miss F Ashworth, Dr I Gallen, Dr J Ahmed Maternity Guidelines Group: V1 Dec 2012 Directorate Board: V1 Jan 2013 Clinical Guidelines Subgroup: July 2011 MSLC: V1 Nov 2012 Equality
More informationDiabetes Mellitus. Melissa Meredith M.D. Diabetes Mellitus
Melissa Meredith M.D. Diabetes mellitus is a group of metabolic diseases characterized by high blood glucose resulting from defects in insulin secretion, insulin action, or both Diabetes is a chronic,
More informationDiabetes Health Care Plan
The Public Schools of Brookline School Health Services of Plan: Diabetes Health Care Plan To be completed by the student s health care team and parents/guardian. Plan will be kept with the school nurse
More information