INSULIN INFUSION PUMP

1. INSULIN INFUSION PUMP Seminar by; Vemula Praveen Kumar M.pharmacy II semester (Pharmaceutics) University College of Pharmaceutical Sciences, Kakatiya University, Warangal.

2. CONTENTS • Introduction to insulin infusion pumps (pump) • How to choose a pump and infusion set • Working of pump • Use of pump • Formulas that help • Site & site supplies • Advantages &disadvantages with pumps • Problems with pump & site • Helpful habits & attributes • Conclusion • References

3. About insulin • Insulin is a hormone, normally produced by pancreas • Low levels of insulin (basal insulin) are required to block the uncontrolled breakdown of fats and glycogen into energy substrates for the body • High levels of insulin(bolus insulin) stimulate the storage of sugar in muscle and fat.

4. Insulin Infusion Pump • Insulin infusion Pump(IIP) is an external battery-powered device that delivers insulin at regularly scheduled intervals, day and night (through a short, flexible plastic tube inserted just under the skin), into the body at a programmed rate to control blood sugars

5. Insulin release pattern R/Lispro/Aspart Endogenous insulin Three Injection Regimen Insulin Effect Ultralente D B L

6. Insulin release pattern Endogenous insulin CSII or IIP Insulin Effect D B L Continuous delivery through the IIP, more closely mimics the natural secretion of insulin from the pancreas.

7. Insulin Infusion Pumps • Fairly recent technology. • Generally fairly easy to use. • Requires close patient involvement. • More thinking and monitoring than insulin by syringe. • 3,00,000 users worldwide. • Operation is very simple, because the interface is similar to a cell phone keypad.

8. Where Pumps Began • Started ~1978 with conversion of portable chemotherapy pumps to delivery of insulin • The Auto syringe AS2C and Harvard Apparatus Mill Hill Infuser were first • Single basal, no memory • 50 ml syringe on pump exterior 1978 Autosyringe AS2C –>

9. 1977Blood Glucose Meter

10. Block Diagram of IIP

11. When To Consider A Pump • More than 3 injections per day • Tired of multiple injections • Frequent or severe hypoglycemia • Hypoglycemia unawareness • DKA hospital admission • Require small, precise doses • Less risk of complications

12. Terms • Basal Rate: that which is flowing between meals or boluses • Bolus: sudden increase such as to adjust for a meal or abnormal sugar • Suspend: to stop the basal rate for some time • Infusion set: the cannula and tubing that goes from pump to skin and SQ tissue

13. Types of Pump • Open loop: User gathers sugar data and adjusts flow rates for activity, diet, other changes in sugar • Closed loop: The device checks sugar and adjusts insulin infusion • Pumps use short acting insulin • Disappears faster • Acts faster, so adjustments made faster

14. First Steps Toward A Pump • Keep detailed records • Consider your (and your child’s) motivation • Acceptance issues, family support • Look at available pumps • Which pump(s) does your insurance cover? • How your pump works • When to increase and decrease basals and boluses • How to adjust for high GI foods, extra activity

15. Things To Consider while selecting a pump • Look, feel, color • Features: reminders, child block, waterproofing • Size of basal and bolus increments • Infusion set choices • Safety • Customer support • History • Ease of data analysis • Add-ons: meters, covers

16. Pump Companies • Animas R1200 • Dana Diabecare III • Deltec Cozmo • Medtronic Paradigm • Nipro Amigo • Roche/Disetronic

17. Working of IIP • The pump is programmed to deliver a constant background rate of insulin called a basal rate, which may change at various times during the day, to closely match the individual’s needs. • Typically, the basal rate does not need to be changed often, once the person’s blood glucose patterns are known. • There may be some variation due to changing sleep / wake schedules or monthly hormonal changes. • These changes can be accommodated quite easily with the pump and therefore achieve better blood sugar control than insulin injections

18. Working of IIP • A lead screw and nut (describes as a “drive rod”) that would compress the syringe to inject the insulin. • The lead screw pushes down on the drive rod, which is actually a complex machined plastic plunger. • The precision fit of the lead screw and nut not only ensures the proper performance of the pump, it creates sealing features that help maintain a strict separation between the medication and the pump parts.

19. Before IIP Using • Everyone is nervous • Read, read, read Pumping Insulin, Kids Insulin Pumps And You (Animas), and information booklets, visit websites • www.myomnipod.com • www.minimed.com etc, etc ... • Do lots of recording before and after start • Start to play with pump as soon as it arrives • Get telephone contacts: MD, CDE, pump company, pump rep.

20. IIP sites & Site Preparation • Prevents pump bumps, infection, and abscess • Steps • Wash the hands • Sterilize the skin – IV Prep • Use bio-occlusive adhesive – IV 3000 • Insert the set • Use safety tape IIP sites

21. Site Supplies • Emla cream (Rx, 30 min wait) or ice cube • Set inserter: ezSerter, Quick-Serter, Sil-Serter, Sof-Serter • Adhesive: IV-3000, Hypafix, Tegaderm • Tape: Micropore, Durapore, Band-Aid Blister Relief (wicking) • Sweating aid: Mastisol Spray (Detachol for removal), Skin Tac, Tincture of Benzoin, Skin Prep • Adhesive removal: Uni-Solve, Allkare

22. Use of IIP • The tube and needle are referred to as an “infusion set.” • Infusion sets • Straight-In Teflon: Cleo, Inset, Ultra flex, Quik-Set • Easier to insert at variety of depths (6, 8, 9 mm) • Angled Teflon (Comfort, Tender, Easy): • Longer is more secure • Adjust angle to reach fat • Metal needles (Rapid-D or bent needle) • As comfortable and often more reliable • Very short, multi-needle infusion sets expected soon

23. Infusion Sets And Inserters Disetronic Rapid-D Smith’s Medical Cleo Animas Inset Quik-serter

24. Crab counting • Carbohydrate counting is an effective way to control insulin regimens by means of giving only enough insulin to cover the grams of carbohydrate ingested. With an insulin pump, you simply add up your carbohydrates ingested, and insert the number into the pump—just like a calculator. • The pump then figures out, based on your programmed ratio, how much insulin is needed to cover your carbohydrates • Allows precise matching of carbs with boluses • Glycemic index, saturated fat, and high protein all play a role, but grams of carb is what controls the blood sugar after a meal • Easy!

25. Carb Counting • How To Count Carbs • Food labels Check portion size • Books Dr’s Pocket Guide, Health Cheques • Keeps blood sugar normal after meals

26. The formula for calculating a correction dose is as follows: • 1. Add the total daily dose (include both basal and bolus amounts) and then divide 1,800 by that number. The result is the decrease in glucose (mg/dl) one would achieve with 1 unit of insulin as a correction dose. • 1,800/Total Insulin Dose = Decrease in Glucose (mg/dl) per 1 unit of insulin (This is the “insulin sensitivity factor.”) • 2. Calculate the number of units of insulin needed based on the current glucose level and planned carbohydrate intake. Patients should test their glucose levels 2–3 hours after delivering the bolus to assess the outcome. • Example:J.D. normally takes 30 units of insulin per day: 15 units as basal and • 15 units as bolus (5 units with each meal) • 1,800/30 = 60 (insulin sensitivity factor)

27. A correction dose of 1 unit of insulin would be expected to decrease the blood glucose by 60 mg/dl. Patients should be taught to use their insulin sensitivity factor (this can be modified to ± 25%), as follows: • Blood Glucose – Target/Sensitivity = Correction Dose • If the premeal glucose is 198 mg/dl (~ 90 mg/dl above the premeal target of 110 mg/dl), the patient would need to add 1.5 units of insulin to the bolus insulin dose. • (198 – 110)/60 = 1.5 units • J.D. would then add 1.5 units to his meal bolus dose to lower his glucose into his target range. • It is important to note that this is just a starting point that must be assessed with follow-up blood glucose readings after the correction bolus is given

28. 500 Rule To Find Carb Factor • Gives grams of carb covered by one unit of Humalog or Novolog • 500 Rule provides a close estimate of carb factor if the TDD is accurate • 500 / TDD = grams of carb per unit of insulin • Example: • Person’s TDD = 50 units • 500/50 = 10 grams of carb covered by 1 unit of Humalog or Novolog • Post meal readings stay normal! 1 gram of carb raises the BG 4 to 7 points!

29. 2000 Rule To Find Correction Factor • Gives how far your blood glucose is likely to fall per unit of insulin over 5 hours • 2000 / TDD = # mg/dl your BG will fall per unit • Example Person’s TDD = 25 units 2000/25 = an 80 mg/dl drop per unit of H or Nov • 1600, 1800, 2000, or 2200 may be divided by TDD to get point drop per unit • 1800 provides a good average - • 1600 Rule is more aggressive and gives more insulin, • while a 2000 or 2200 Rule gives less insulin

30. New Devices • Data storage and download • Easy recording of BGs, insulin, carbs • Automatic carb counting • Pattern recognition • Insulin dose guidance • Data analysis to improve control • Feedback that encourages use

31. Pump — Meter Combos • CozMonitor from Deltec and Therasense • Disetronic and Roche • Medtronic 512 and BD Paradigm Link • Animas and Life scan • Dana Diabecare III and Dana meter Sensor-augmented pump consisting of a Guardian RT sensor (A), which is attached to a Minilink transmitter (B) and they communicate with an insulin infusion pump (C).

32. The Big Three • Medtronic Minimed Paradigm 508, 512 / 515*, 712 / 715* • Animas Corp. IR1000, IR1200*, IR1250* • Smiths Medical Deltec Cosmo* “Smart” Pumps • Insulin pump software will calculate mealtime insulin (bolus) based on: • Current blood glucose • Carbohydrate content of the meal • Previous bolus (time and size) *smart pump technology

33. Advantages • Precise doses, as small as 0.025 u, can be given • Reminders • Little risk of infection • A freer lifestyle • Easier dose determinations • Improved blood sugars • Flexibility in meal timing and size • Ability to exercise without losing control • Peace of mind • Family activities are no longer tied to one person’s needs • Easier handling of illness, travel, or camping

34. Insulin Infusion Pumps and Exercise: • Normalize the glycemic and metabolic responses because insulin levels can be easily increased, decreased, or maintained at basal levels. • In anticipation of exercise, insulin bolus can be adjusted. • Self Blood Glucose Monitoring (SBGM) - important and helpful.

35. Disadvantages of IIP • 10-15 minute delay in onset of insulin action • Infusion site needs changing for every 3-4 days • Always wearing a device • Size of the infusion pump • Vulnerability to trauma or disruption at the infusion site • Must be removed for water sports

36. Most Pump Problems Occur In • First week • First month • First 6 months Problems are most likely when unexpected or inconvenient

37. Setup tips Leaks O-rings Hub Line Clogs Site infections Allergies Bleeding onto skin inside needle under skin Pump bumps Dislodged infusion set Occasional Pump Problems Some frustration at times is normal!

38. Will Your Pump Alarm? Yes Yes Yes Yes Yes No No No No • Low battery • Mechanical problem • Empty reservoir • Clog • Forgotten bolus • Leak • Bleeding • Bad programming • Dislodged infusion set

39. Pumps don’t detect: • Disconnection • Air in line • Infection • Leaks • Abnormal tissue sites Infusion Site Problems: Tissue abnormality • Redness / pain / heat • Hard tissue / scarring • Kinked cannula • Old site • Improper depth / too near muscle / wrong angle • Air in line • Tube disconnected

40. Problems with Infusion Pumps • Out of insulin? • Is the pump leaking? • Is the connection between the tubing and the pump cartridge tight? • Is the hub connection cracked? • Can you smell insulin anywhere? (hint: Insulin smells like Band Aids) • Do the pump motor arms (MiniMed) or piston rod (Disetronic) move freely?

41. Stocking of IIP • Extra stock: • Keep refrigerated (36° - 46°F). Discard after expiration • Current bottle in use: • can be used for ~30 days at room temp • (59°- 68°F optimally, below 86°F)

42. Helpful Attitudes And Habits • Be blatant about your diabetes • A pump is a tool, not a cure • Take a bolus for every bite • Change site as directed • Look for a solution for every problem • BG Test often

43. Conclusion • A pump offers the latest technology for precise insulin delivery • "Making the insulin pump available to Medicare beneficiaries will improve the quality of their lives. The infusion pump offers them a choice to better control their condition so that they are more active and productive," • Benefits include more flexibility, less hypoglycemia, improved control, and a longer, healthier lifespan • Make the commitment and start pumping!

44. If you are diabetic & use and Make ur life

45. References • A Randomized Trial Comparing Continuous Subcutaneous Insulin Infusion of Insulin Aspart Versus Insulin Lispro, DIABETES CARE, VOLUME 31, NUMBER 2, FEBRUARY 2008 • Insulin pump use in pediatrics, DIABETES CARE, VOLUME 30, NUMBER 6, JUNE 2007 • Classification of Distinct Baseline Insulin Infusion Patterns in Children and Adolescents With Type 1 Diabetes on Continuous Subcutaneous Insulin Infusion Therapy, DIABETES CARE, VOLUME 30, NUMBER 3, MARCH 2007 • Comparison of apolipoprotein B100 metabolism between continuous subcutaneous and intraperitoneal insulin therapy in Type 1 diabetes, Journal of Clinical Endocrinology & Metabolism. published August 9, 2005 as doi:10.1210/jc.2005-0989 • Bret berner, Steven M.Dinh: Electornically Controllede Drug Delivery. • Attia, N.; Jones, T.W.; Holcombe, J.; and Tamborlane, W.V.: “Comparison of human regular and lispro insulins after interruption of continuous subcutaneous insulin infusion and in the treatment of acutely decompensated IDDM”. Diabetes Care, Vol. 21, No. 5: pp. 817–21, 1998. • Comparison of Quality of Life in Diabetics Using Insulin Injection Therapy versus Subcutaneous Insulin Infusion Therapy by Katie Michele Reynolds et al 2007 Ypsilanti, Michigan

46. References • McCall A. In: Insulin Therapy. Leahy J, Cefalu W, eds. New York, NY: Marcel Dekker, Inc; 2002:193 • Jay S. Skyler, MD, MACP; Steven Ponder, MD, FAAP, CDE Is There a Place for Insulin Pump Therapy in Your Practice? Volume 25, Number 2, 2007 • CLINICAL DIABETES • www.delteccozmo.com • www.diabeticcare.com • www.childrenwithdiabetes.com • www.diabetesnet.com • www.animascorp.com • www.myomnipod.com • www.minimed.com

47. THANK YOU