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Adjusting Insulin Pump Settings

9501183-011

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Objective

Introduce principles, tools and methodology for adjusting insulin pump settings

Key Points• Adjusting Pump Settings is a systematic, logical process• Basic Principles - Similar to adjustment decisions in other regimens

– Basal Rate (Basal), – Carbohydrate Ratio (Bolus), – Insulin Sensitivity Factor (Correction)

• Medtronic Tools – “Pumping Protocol” by Dr. Bruce Bode– Logbook Practice Sheets– CareLink Therapy Management Software– Adjustment & Fine-tuning Workshop

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Current Data Collection Methodology

Monday87-218-152- 66Tuesday 57--132-66

Wednesday53-308-155Thursday

3am: 55 / 200 /90

Saturday70-200

Friday73-208-105

“Use Whatever You Can Get!”

Logbooks / Logsheets Notepads, sticky notes, napkins, envelopes

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Adjustment Phase – Patient Guidelines

• Check BGs Regularly– Pre-meal, 2-hrs post-meal, bedtime and mid-sleep

• Eat low-fat meals (with known carb content)– Avoid snacks (during adjustment phase)

• Use Bolus Wizard Calculator– Calculates Bolus– Tracks Active Insulin– Captures Data

• Records time and amount of bolus, carb intake, etc.

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Adjustment Phase – Clinician Guidelines

• Use standardized log-sheets or specified reports• Be systematic and analytical

– Divide days into segments • (bedtime to 3am; 3am to 7am; pre- to post meal; post- to pre-meal)

• Evaluate BGs every 2-3 days– Upload pump -- Fax log-sheets -- Office visit

• Evaluate based on: cause-and-effect and repeated patterns

• Make one (no more than two) adjustments at a time

• Confirm Setting Adjustments – Review BGs 2-3 days post adjustment

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Primary Factors

• Basal Rates

• Carbohydrate Ratios

• Insulin Sensitivity Factors

Adjustment Parameters

Secondary Factors

• Target Ranges

• Active Insulin Time

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Blood Glucose Flow Sheet

BG

BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPost-BrkfstPre-BrkfstNocturnalDate:Time

Total Bolus

Post-Brkfst

Corr. Bolus

Total Bolus

BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPre-BrkfstNocturnalDate:Time

Carb GramsBG

Food Bolus

Carb Grams

Corr. BolusFood BolusCarb GramsBGTime

BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPost-BrkfstPre-BrkfstNocturnalDate:

Time RateBasal Rate: 1) 12 am o.60 u / hr___

2) ______ ___________3) ______ ___________

Patient:____________________________________ DOB:______________________Date:______________________ Phone: (H) _________________________________ (Wk) ______________________ /__________________________

Carb Ratio: (B) ________ (L)_________ (D)____________

Sensitivity Factor: = ___________mg/dL per 1 unit of insulin

BG Target Ranges: Daytime: ______mg/dL – _________mg/dL

Nighttime:_______mg/dl – ________mg/dL

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Blood Glucose Flow Sheet

BG

BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPost-BrkfstPre-BrkfstNocturnalDate:Time

Total Bolus

Post-Brkfst

Corr. Bolus

Total Bolus

BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPre-BrkfstNocturnalDate:Time

Carb GramsBG

Food Bolus

Carb Grams

Corr. BolusFood BolusCarb GramsBGTime

BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPost-BrkfstPre-BrkfstNocturnalDate:

Patient:____________________________________ DOB:______________________Date:______________________ Phone: (H) _________________________________ (Wk) ______________________ /__________________________

Look across to review the “Cause & Effect” of the day’s events

Look down

forrepeated

“Patterns”

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Focus on Overnight Basal Rate First

• Eliminates risk of nocturnal hypoglycemia– Allows patient to sleep through the night

• Patient begins day with normal BG– Allows for better evaluation of daytime basal rates

and carbohydrate ratios when patient is not correcting high or low fasting BGs

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Overnight Basal Rate

NOTE: BG should always be >100mg/dL at bedtimeNOTE: BG should always be >100mg/dL at bedtime

• Divide night into time periods– (bedtime to mid-sleep) (mid-sleep to wake-up)

• Evaluate overnight glucose control by comparing BG values across time periods

• Adjust basal rate based on rise or fall pattern Adjustment Guidelines

Goal: BG stays within target range through the night

– No more than 30mg/dL change from bedtime to morning

• If BG rises >30 mg/dL: Increase basal rate by 10%-20%

• If BG falls >30 mg/dL: Decrease basal rate by 10%-20%

• Start time of adjusted basal rate should begin 2-3 hours prior to the observed rise or fall in glucose

Adjustment GuidelinesGoal: BG stays within target range through the night

– No more than 30mg/dL change from bedtime to morning

• If BG rises >30 mg/dL: Increase basal rate by 10%-20%

• If BG falls >30 mg/dL: Decrease basal rate by 10%-20%

• Start time of adjusted basal rate should begin 2-3 hours prior to the observed rise or fall in glucose

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Total BolusCorr. BolusFood BolusCarb GramsBGTime

Post-BrkfstPre-BrkfstNocturnalBedtimeDate:

121 117 92

• Maintain stable BG during fasting state

• Allow patients to postpone / skip meals / sleep late

Properly Set Basal Rates: 0.6

0.60.6

0.6

0.60.60.60.6

0.6

0.60.6

0.6Verifying Overnight: Basal Rates

Basal Rate: 12am @ 0.6 u

11:00 pm 3:00 am 6:30 am

Stable Stable

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Corr. Bolus

Carb Grams

Food Bolus

1221388412882135180108BG

BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPost-BrkfstPre-BrkfstNocturnalDate:11:008:306:002:2012:008:456:303:00Time

Total Bolus

Post-Brkfst

Corr. Bolus

Total Bolus

BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPre-BrkfstNocturnalDate:11:008:306:002:2012:008:456:303:00Time

Carb Grams1211409013389127192122BG

Food Bolus

Total Bolus

Corr. BolusFood BolusCarb Grams

1181428012885130188118BG11:008:306:002:2012:008:456:303:00Time

BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPost-BrkfstPre-BrkfstNocturnalDate:

---

---

---

---

123

11:05

Bedtime

Basal Rate: 12am 0.6

Stable Rising

Basal Rate: 12am 0.63am 0.7 7am 0.6

Overnight Basal Rates

Stable Rising

Stable Rising

Consistent Rise >30mg/dL over 3 days– Dawn Phenomenon

What would you adjust?

Bedtime3am 3amMorning

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Insulin to Carbohydrate Ratio Adjustments

Compare the pre-meal BG to the 2-hr post-meal BG

Adjustment Guidelines:

• If the 2-hour post-meal BG is > 60mg/dL above pre-meal– Decrease the carbohydrate ratio by 10-20%

• If the 2-hour post-meal BG is <30mg/dL above pre-meal– Increase the carbohydrate ratio by 10-20%

Adjustment Guidelines:

• If the 2-hour post-meal BG is > 60mg/dL above pre-meal– Decrease the carbohydrate ratio by 10-20%

• If the 2-hour post-meal BG is <30mg/dL above pre-meal– Increase the carbohydrate ratio by 10-20%

GOAL

Post-meal BG should be ~ 30–60mg/dL higher than pre-meal BG

GOAL

Post-meal BG should be ~ 30–60mg/dL higher than pre-meal BG

14128144911228521292112BG

BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPost-BrkfstPre-BrkfstNocturnalDate:11:308:206:002:4012:309:457:303:15Time

Total Bolus

Post-Brkfst

----0.3-----0.10.7u-0.2Corr. Bolus

Total Bolus

BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPre-BrkfstNocturnalDate:10:458:456:302:3012:159:207:103:05Time

756045Carb Grams125132851339220590115BG

5.0u6.03.0Food Bolus

Carb Grams

-------- 0.2----0.2+ 0.5- 0.3---Corr. Bolus------7.5---6.5---6.0---Food Bolus------75---65---60---Carb Grams

120130871259019488110BG11:008:306:002:2012:009:157:003:00Time

BedtimePost-DinnerPre-DinnerPost-LunchPre-LunchPost-BrkfstPre-BrkfstNocturnalDate:

Carb Ratio: 1:10Basal Rates: 12am 0.63am 0.77am 0.6

Rising

Carb Ratio: (B) 1:8 (L) 1:10 (D) 1:10

Carbohydrate Ratios

Stable Stable

Pre-meal to Post-meal

Rising

Rising

Stable Stable

Stable Stable

What would you adjust?

Consistently high post (B) : Within normal ranges post (L) & (D)

Lowering the carb ratio increases the meal bolus. Ex: 60 grams 1:10 = 6.0 u 1:8 = 7.5u

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OvernightBreakfast DinnerLunch

Logbook Report

Red = Lows

Gold = Highs

Look across to review the “Cause & Effect” of the day’s events

Look down

forrepeated

“Patterns”

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Carb Ratio: 1:10

Rising

Carb Ratio: (B) 1:8 (L) 1:10 (D) 1:10

Overnight Basal Rate Carbohydrate Ratios

Stable

What would you adjust?

Consistently high post (B) : Within normal ranges post (L) & (D)

Overnight Breakfast Lunch

Stable

Logbook Report

Stable Rising Stable

Stable Rising Stable

Lowering the carb ratio increases the meal bolus. Ex: 60 grams 1:10 = 6.0 u 1:8 = 7.5u

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Adjusting Pump Settings: A Logical Systematic Process

1) Gather Information

2) Interpret and Analyze Data

3) Adjust VariablesTraditional information•Log-book•Verbal communication• Meter & Pump downloads

Medtronic Technologies • CareLink Software

• Personal (web-based)• Professional

• Solutions Software

Primary Factors•Basal rate•Carbohydrate Ratio•Sensitivity Factor

Secondary Factors •BG Target Range•Active Insulin Time

•Traditional Meter BG Interpretation• Diabetes Therapy Management Software Analysis

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Medtronic Diabetes18000 Devonshire StreetNorthridge, CA 91325www.medtronicdiabetes.com 1-800-646-4633