INSULIN PUMPS

An insulin pump is a device that delivers insulin to your body in small amounts. The pump is attached to your body via a tube and a plastic needle (cannula). An insulin pump can also be wireless. Then it sits directly on your skin and you don't need a separate infusion set. At Diabeter, our patients achieve the best results with a combination of insulin pump and CGM. 

Insulin pump with infusion set (tube plus needle)

The pump uses electronics to continuously deliver short-acting insulin. We call this the basal insulin. If you inject insulin, then this basal insulin is comparable to the long-acting insulin that you inject once a day. The advantage now is that you can adjust your basal insulin at different times of the day according to your needs.  Often your blood glucose level can be better regulated when using a pump than when injecting insulin.

Bolus

You can deliver an extra amount of insulin at any time with a single key press. This is called a bolus. You do this when you eat something that contains carbohydrates, or to "correct" high blood glucose levels.  The dosing of that extra insulin is done via a built-in computer (bolus calculator or bolus wizard) that allows for very precise control. Although that extra insulin is calculated automatically, giving the bolus ("bolus") is done by you. Your glucose levels remain most stable if you measure and correct 6 to 8 times (sometimes more). If you had to do this with the pen, you would have to bolus about eight times. This is more comfortable and easier with the pump.

Why choose pump or pen therapy?

Our motto in advising our patients is that the form of insulin delivery should suit you, but increasingly we will advise you to use diabetes technology to achieve your desired goals. We know by now, that the more you use technology, the better your diabetes goals and guidelines can be achieved, such as an HbA1c of 7%. 
Before starting insulin pump therapy, we, as practitioners, impose some conditions on your knowledge of diabetes control, such as carbohydrate counting, uploading your blood glucose values to us at least every four weeks and, not unimportantly, keeping in touch with your diabetes team. 

Insulin pump benefits:

• With the insulin pump you can generally achieve better glucose control than with insulin injections
• You can adjust the amount of basal insulin as needed. For example, when you exercise you can reduce the basal insulin. This is much more convenient than having to eat all the time to avoid getting a hypo.
• You are less tied to eating in a fixed pattern: main meal with a maximum amount of carbohydrates in between. With the pump, you bolus for everything you eat. The bolus calculator in the insulin pump calculates the exact amount of insulin to deliver for the number of carbohydrates you enter.  It is true that your regulation succeeds more easily if you don't eat KH all day and have to bolus often for this. So there are limits...
• Young children don't need as much insulin yet. So the dosage of the insulin is very precise. With the pump you can give smaller amounts of insulin and dose better than with syringes. Finally, you inject with half units and not like the pump that even counts with steps of 0.025 units. This does make controlling the diabetes easier.
• You can set the pump much more precisely than you can with a pen. Your insulin needs can vary. During the night, for example, your insulin needs are not the same all hours. Especially in adolescents of adolescent age you see that the insulin requirement increases at the end of the night. We call this the Dawn phenomenon. With pen therapy, you can't accommodate this. You can see this in the high values when you get up in the morning. Pretty annoying when you always spray your insulin correctly and still end up with high values.  This can be a reason to switch to pump therapy.

Important to realize when using an insulin pump:

• There is something about your body that you can see clearly and that raises questions for those around you.
• You have to bolus for everything you eat. This means that you always have to think about it, even at times when it might not be convenient or when you have many other things on your mind. 
• The pump's operation can malfunction for any reason. If the insulin does not enter properly, for example due to a kink/clog in the tube, you can become very ill due to excessively high glucose levels. This is called a ketoacidosis. So you have to be very aware of your glucose levels and be really careful with your pump, the tube and the cannula.

With the insulin pump, you can generally achieve better glucose control than with injections, but you have to do something to do that. Unfortunately, the pump doesn't work by itself yet. Meanwhile, technology is advancing by leaps and bounds, as we see with the Tandem T:Slim X2, and the Medtronic 780G. These pumps can take over a lot from you, both with a threatening low blood sugar and with a threatening high blood sugar. Developments in diabetes technology are rapid and our medical team follows them closely. So it is very important to be well informed by your team. What is not appropriate now may change completely in a year.

The different types of insulin pumps:

Pumps to administer your insulin come in different shapes and sizes, with and without tubing.

On the website of diabetesexperts.nl there is a guide to choosing an insulin pump. You can find this guide here.  Note: the diabetes nurse can tell you something more specific about these insulin pumps. You discuss with her or him what you want to achieve after switching to the pump. Less hypo, for example. Together with your diabetes nurse you decide which one suits you and your goals best.

In our October 2020 livestream we focused extensively on the new generation of insulin pumps, which work together with a continuous glucose meter (CGM). Diabetes technology is developing rapidly, so we will have this topic in our livestreams regularly. You can find all the livestreams here. 

OPERATION OF INSULIN PUMP

A little more about how the insulin pump works. The pump, as mentioned, is a device with electronics, a battery, and an ampule to put the insulin in. A transparent flexible tube is connected to the pump. You connect this tube to the part that is in the skin. This is a plastic needle (cannula) that is left behind after you insert it with a shooting system.

The insulin in the pump, along with the needle, must be replaced regularly. This is necessary because the cannula is compromised by your body's defenses. To your body it looks like a splinter, something that doesn't belong to your body and so your body tries to get it out. In addition, you'll see that insulin is also not doing its job properly after a few days. After all, insulin is a protein and a characteristic of it is that it doesn't hold up well at higher but also very low temperatures. If you wear the pump close to your body this will increase the temperature of the insulin. Our advice is therefore: replace your infusion set every other day on fixed days. For example, the Monday, Wednesday and Friday. The weekend not for a while. You will see that this will benefit your glucose regulation.

Of course, it can happen that you forget to change the needle. You're busy and you just don't get around to it. Or you don't like the chore and put it off. Then there's a trick that will keep you from procrastinating or forgetting: adjust your amount of insulin to the insulin requirement for two days. If you run out of insulin, you do need to replace your infusion set along with your ampule of insulin. This is an extra push.

What if you do forget or there is a kink in the cannula?

The insulin used in the pump is ultra short acting. In practice, this means that you can go without insulin for a maximum of about two hours (provided you are well regulated otherwise it is even shorter). If after those two hours there is still no insulin, then your body will switch to a different combustion. After all, you always need fuel and without the insulin, the fuel glucose does not reach the cells. The body therefore switches to 'plan b': Fats and proteins are now burned. As a result of this waste, so-called ketones are produced. You can measure these ketones with a ketone meter. If you have a pump, you will also get the ketone meter to check if your body has not started this kind of combustion. Why is this important? Ketones are not good for your body. They make you sick: you get nauseous, tired and start vomiting.

You're actually measuring a high blood glucose level or one that rises very sharply to a high value and if you have the meter, the ketones as well. Your body needs to get insulin in as soon as possible. So also call the emergency line of your treatment team to discuss what to do. Don't wait too long with this.

How to prevent ketoacidosis

If you measure regularly and change the cannula in the event of high values that do not fall properly, the risk of ketoacidosis is fortunately not very great. As a Diabeter patient you will find the step-by-step plan in the therapy email you receive when you upload your pump. Even if you have just changed your cannula and your blood sugars remain high, the advice is to change it. The place where you place your cannula is also very important. Alternating well prevents you from getting fat deposits or scars. The latter in particular can easily cause the cannula to kink. Finally, make sure your insulin doesn't get too hot or cold. If in doubt just contact your team, that's what we're here for.

Where do you carry your pump?

A very practical issue is where you leave your pump. Our diabetes nurses often get questions about this. Again, we're happy to give you some places and options.

With a wireless pump

You can carry the wireless pump in various places. Your abdomen is of course a possibility, but also your upper arms, upper legs or lower back can be good places for you. Make sure that your pump can still be operated properly ????. You can discuss the locations with your diabetes nurse. There are also various straps and bags on the market for the wireless Omnipod. These allow you to "customize" your pump a bit to your liking.

For an insulin pump with a tube

With a clamp

A clamp allows you to clip the pump to the top of your waistband or to your pocket. For women, the center of the bra is often used. Clamps can be ordered from your diabetes device supplier.

With a strap, pocket or belt pouch

Special protective bands can also be ordered for your waist, thigh or arm. The manufacturer of your insulin pump has special accessories for this, which fit well and, if necessary, have anti-slip features.

Again, there are special solutions for women to wear their insulin pump in the bra. For example, with a bra pouch with clamp.  With a pump bag, you can give your pump a more conspicuous place by wearing it on your waistband via a clip or strap. Pump bags are available in many styles through your device provider.

In addition to your device provider and the manufacturer of your insulin pump, there are also many companies that supply bags, covers and straps. You can easily find them on the Internet.  There is also a lot for children to find: from cheerful pump bags with unicorns on them to sturdy denim fabric.

Show me your pump!

Miss Idaho from 2014 wore her insulin pump during the bikini round in the finals of the Miss pageant. She started the hashtag #showmeyourpump on social media, which received a huge response. She became an inspiration to many people with type 1 diabetes.