Ask The Expert
Insulin

I'm pleased to tell you that there are numerous resources available to help you make your decision. For those readers who are unfamiliar with insulin pumps, I'll provide a brief description, but note that you can learn more from the resources listed below.

An Insulin Pump is a battery-powered device, about the size of a pager, that delivers insulin continuously (very small amounts are delivered every few minutes) into your body (called a basal rate), and also delivers a larger dose of insulin (called a bolus) to cover the food you eat, or to correct a high blood glucose. Pumps are designed to hold approximately 3 days worth of insulin, although this will depend on the total amount of insulin a person requires, and the insulin used is either rapid or short-acting insulin. The insulin is delivered thru an infusion set-a thin plastic tubing with a needle or soft cannula at the end, that is inserted under the skin in the same area that you inject your insulin. Most people use the abdomen for their infusion site. The needle/cannula is taped to the skin and is changed approximately every 3 days.

Misconceptions:

• Pumps are easier and automatic: Some people think a pump is an "artificial pancreas"-that it is implanted in the body and automatically measures the blood glucose and delivers the proper insulin dose. While this is the ultimate goal of technology, called a "closed loop system," that device is not yet available. Insulin pumps are called an "open loop system" meaning that you still need to test your blood glucose and tell the pump what dose to deliver. In other words, the pump does not have a mind of its own. Naturally this also means that you need to test at least 4 times (and often more) to make sure the pump is working properly.
• Pumps increase the risk of hypoglycemia: Because of the continuous supply of insulin provided, some people fear they will get too low, but actually, it is the exact opposite. The risk of hypoglycemia is reduced on the pump, due to both the stable nature of clear, rapid-acting insulins, as well as the smaller, continuous and precise dose delivered by the pump. In fact, a history of frequent hypoglycemia or erratic blood glucose levels is a strong reason to choose a pump. Pumps have numerous safety checks and alarms that prevent a pump from over-delivering insulin. In addition, most pumps have an "auto-off" feature that can be preset to sound an alarm and stop delivery of insulin after a certain number of hours if no button is pressed for a particular length of time.
• Pumps are the "magic bullet" that will solve all your blood sugar problems: If only it were that simple. Each person with diabetes is a little different-and even with frequent testing and fine-tuning, some people are not able to attain the "perfect" control they desire.

Pros of Insulin Pumps:

• Improved blood glucose control with reduced risk of hypoglycemia or widely fluctuating blood glucose levels: The pump delivers more predictable insulin because it only uses "clear" insulin, i.e. rapid or short-acting insulin. It is known that "clear" insulins are more stable and predictable than "cloudy" insulins. Cloudy insulins, such as NPH (Neutral Protamine Hagedorn), Lente, or Ultralente, can vary considerably from day-to-day in terms of their absorption and peak. According to the 2003 American Diabetes Association 3rd edition of Intensive Diabetes Management, insulin absorption and action can vary by 50% from person to person, and by 25% in the same person from one day to the next. (Note that Lente and Ultralente insulins have now been discontinued). Furthermore, it is safer and more physiologic to have only a small amount of insulin in your system at a time—which is similar to a person without diabetes.
• Possible reversal of hypoglycemia unawareness: While frequent hypoglycemia can cause hypoglycemia unawareness, studies have shown that by improving glucose control and eliminating the severe fluctuations, some people are able to regain their ability to recognize hypoglycemia.
• Easier weight management: With traditional insulin injections, many people find themselves "feeding their insulin" or "eating to keep up with their insulin" meaning that they are required to eat on time, especially when insulin is peaking, to prevent hypoglycemia. Pumps allow you to vary your basal rates so you aren't required to snack as often.
• Increased flexibility in lifestyle without frequent injections: As you know, it is a challenge to control your schedule, activity, food intake, and emotions, while trying to match these factors to the proper insulin dose. You can program the pump with varying basal rates to control the dawn phenomenon as well as other periods of the day where your body's rhythms require more or less insulin. Likewise, when the basal rates are set correctly, you can delay or miss a meal without the risk of hypoglycemia; you can set a temporary reduction in the basal rate for unexpected exercise; you can easily bolus anytime you want to eat a meal/snack as well as when you want to correct a high glucose-without having to give an injection.
• Easier management with travel/time zone changes or variable work schedules-related to the issues described above.
• Increased accuracy and precision in dosing: Because pumps can deliver insulin in tenths (and sometimes hundredths) of units, you have the potential to finely tune your diabetes with more accurate insulin-to-carbohydrate ratios and high glucose correction factors.
• Ability to customize your bolus: Pumps offer various options for handling prolonged meals, gastroparesis, or slowly absorbed food such as pizza or other high-fat meals-you can deliver a regular bolus, a square-wave or extended bolus (extended over a certain period of time) or a combination bolus (a combination of an immediate bolus plus an extended bolus).
• Improved physical and emotional well-being: While this is anecdotal, frequent comments I have heard at insulin pump clubs were: "My spouse is so glad I went on the pump-he/she says I'm more fun to be around;" or, "I never knew how badly I felt before-i.e. “I didn't realize that the fluctuating blood glucose levels had such an effect on my energy and emotions-I feel like a new person."
• Ability to achieve the best control possible: While previous studies showed control on pumps to be the same as when using multiple shots, recent studies showed that pumps were superior to multiple shots in both teens and adults; pumps are also becoming increasingly popular in toddlers and children. Due to this improved control, many pregnant women with diabetes choose to use an insulin pump to provide the best possible environment for the developing fetus.

Cons of Insulin Pumps:

• Risk of ketoacidosis (DKA) from pump malfunction or insulin absorption problems: As you know, if insulin is unavailable, blood glucose rapidly rises; as fat breaks down to attempt to provide your body with energy, ketones are released as a by-product; the combination of high glucose, dehydration, and excess ketones can result in a dangerous and potentially fatal condition called ketoacidosis. While DKA is also a risk with traditional insulin injections, the risk is somewhat less in that case due to the "safety net" of still having some leftover insulin circulating , especially from the long-acting insulin. In other words, with traditional shots, if you were late with a shot or missed a shot, you would be less likely to rapidly go into DKA because you would still have several hours' worth of long-acting insulin on board. In contrast, with an insulin pump, if the insulin supply were suddenly disrupted (from a clogged catheter, dislodged needle or a pump malfunction), there is very little insulin left in your system so you could rapidly run out of insulin and rapidly progress to a state of severe hyperglycemia or DKA.
• Frequent blood glucose monitoring is mandatory: Due to the above risk of DKA, you are required to test 4 times/day at a minimum-and even hourly if you have unexpected hyperglycemia. Also, because there is such great potential to really fine-tune your control, you will be asked at times to do frequent testing to verify that your basal rates are set correctly, as well as your insulin- to- carbohydrate ratio and bolus correction factor.
• Trouble-shooting skills are required-along with a well-trained, interested and available diabetes team: As you can understand from the above information, you must learn extra details about pumps, as well as how to fine-tune your control. Naturally this means that you need a doctor, diabetes educator and dietitian who understand insulin pump therapy and are accessible to help you achieve the best control possible.
• Risk of skin infections at the catheter site: Although not common, skin infections can occur. While infections are usually mild, if left ignored, they can become serious, even requiring hospitalization-yet this is almost always considered totally avoidable.
• Cost: Insulin pumps, along with the continuing cost of supplies, are expensive. While many insurance plans cover this, some do not, and/or they only cover a portion of the cost.
• Psychological concerns: As you mentioned in your question, it is natural to have some misgivings about being "connected to something" all the time. While pumps have dramatically reduced in size over the years, and truly look just like a cell phone or pager, their inconvenience and visibility are still a concern for some people. Others choose to hide the pump under clothing or in a pocket. Regardless, these are common and valid concerns, although most people find that the pump's many benefits overcome the possible negative aspects.

So now what?

• I hope you will study this information and explore all the resources below-as well as meet with your diabetes team to discuss your concerns.
• Ask your diabetes team if there is an insulin pump club in your area - many clinics have such a support group that meets periodically, and generally this group is intended for those using insulin pumps and also for those interested in the prospect. Such a group would enable you to meet many "pumpers" to hear their opinions and experiences.
• If there is no pump club in your area, perhaps your diabetes team can introduce you to other insulin pump users.
• Consider joining a chat room.
• Obtain information from all the pump companies before you make your decision-first ask your diabetes team, who may have packets and videos or DVDs of information for each pump; if not, each pump company provides very helpful information to help you decide if their particular pump is for you. The pump companies also have designated staff to help determine if and how much your insurance will cover. Each website listed below has a toll-free number you can call to request more information.

As you can tell, an insulin pump can be a great tool to help you improve your diabetes control and maintain a normal lifestyle. There are many resources available to help you learn more about your options. Whether or not you decide to use an insulin pump, keep learning all you can about managing your diabetes to keep you healthy and enjoying life.