Plentiful options yield important questions in evaluating insulin pump therapy initiation
SAN FRANCISCO — Insulin pump therapy is an increasingly popular diabetes treatment strategy. Diabetes care providers should discuss with patients the options available, the potential benefits of the technology and possible roadblocks to use, according to a presenter at the American Diabetes Association 79th Scientific Sessions.
“We’re not slowing down,” Samantha Lange, BS, a professional research assistant and certified diabetes educator at the Barbara Davis Center for Diabetes at the University of Colorado, said during the presentation. “Our technology is increasing very rapidly, so it’s important as providers to understand what these systems can offer individuals and how do we really customize what the system offers to the individual.”
Although these therapies have been shown to improve outcomes and provide additional benefits in terms of flexibility and efficacy with special populations, such as children and active adults, insulin pump therapy is not for everyone, Lange said.
“Is insulin pump therapy beneficial for all individuals with diabetes? I don’t think I can answer this simply in one presentation, … but insulin pump therapy can be beneficial for everyone,” Lange said. “Whether it’s the right therapy is a different question.”
To answer this question, Lange said, physicians and other health care providers must discuss with their patients both parties’ expectations and goals for the therapy. A deeper dive into a patient’s routine can also elucidate important pros and cons of prescribing insulin pump therapy while addressing potential barriers. Whether these can be modified or not, is also critical, according to Lange.
If insulin pump therapy is considered a good strategy for a patient, there are three options currently on the market, Lange said, including traditional and sensor-augmented pumps and advanced therapies such as predictive low glucose suspend or PLGS devices.
One type of traditional option includes “pod-type” devices, such as the Insulet Omnipod Dash, which is comprised of an insulin pod that attaches to the skin and is controlled by a user interface on a mobile device. Lange suggested that these can be excellent options for children and adolescents, as the style allows them to remain active while their parents are able to monitor and treat when necessary. Lange also noted that these traditional devices can be useful for patients who may be reluctant to use an insulin pump due to a fear of needles.
However, the positives must be weighed with drawbacks, Lange said, such as including potential skin irritation from the adhesive that attaches the pod. Also, providers must assess a patient’s total insulin needs when considering this type of pump, as those who require more insulin each day can end up having to change their pod on a daily basis. Outlining these details before therapy onset is important for success.
Another traditional device option is tube insulin pumps. These eliminate the need for multiple interfaces by maintaining all information and input on a single system. There are three types of infusion sets, including the 90-degree angle set, which simplifies insertion; the steel canula set, which also makes inserting simple but requires multiple adhesives and can be “intimidating,” according to Lange; and the 45-degree angle infusion set, which is less simple but gives a patient a better chance at avoiding infusion site failures when used properly. As with the pod pumps, ensuring the user has realistic expectations for the device and the provider has an understanding of how a patient already manages their diabetes will yield better results, Lange said.
Beyond traditional insulin pump options, sensor-augmented pumps can be attractive. These require wearing two devices — the pump itself and a continuous glucose monitor, for example, the Tandem t-slim X2 with the Dexcom G6. Lange noted that while this setup can present a patient with even more data to work with, it can create “information overload,” particularly since these device types can create numerous alerts that must be addressed. Lange recommended that providers discuss where alert thresholds are set and a patient’s comfort with not only addressing them, but adjusting them as needed. In addition, these devices can require finger pricks to calibrate, so being transparent about that with patients is important.
Sensor-augmented pumps can be further enhanced with the addition of low-suspend options, which will stop insulin dosing when glucose levels fall below a recommended threshold as indicated by the CGM. Lange said that this can alleviate some of the pressure on a patient by allowing the device to correct without manual input.
The low-suspend options can be upgraded with predictive low glucose suspend technology or PLGS. Like the sensor augmented pump itself, PLGS devices are made up of a pump and CGM but have the added benefit of an algorithm with the pump that can further reduce stress related with diabetes management. The algorithm anticipates when a patient will have reduced CGM values and cause the pump to suspend insulin dosing until glucose returns to acceptable levels. This interaction does not necessarily go on without user knowledge, but Lange advised against frequent alerts to combat potential increases in diabetes distress while completing the primary objective of the device.
“There’s no action that the individual has to take. It’s preventing a low. They don’t have to treat. They’re fine right now, and they’ll be alerted when they are low,” Lange said. “There [are] so many alarms and alerts and buzzes all over our world today. Try to do one or two less for people who are using insulin pump therapy.”
Just because this is a more automated system does not mean that patients should be left in the dark. Lange said that providers should teach users about how, when and why insulin suspension will occur and ensure that they can accept this type of automation. These are in addition to the primary questions that need to be asked and evaluated with all insulin pump therapies.
“It’s important to have a good expectation for your patient. Get on the same page before they start these technologies so that you can progress together as our technology progresses. Remember to consider common barriers with patients, such as infusion site failures and skin considerations, and then utilize advance features as a patient grows with their pump,” Lange said. “I charge you to ask yourself: What are the other considerations that should be made as our technology develops?” – by Phil Neuffer
Lange S, et al. Individualizing Insulin Pump Selection Patient-by-Patient. Presented at: American Diabetes Association 79th Scientific Sessions; June 7-11, San Francisco.
Disclosure: Lange reports a relevant financial relationship with Medtronic MiniMed.