In 1989 we started a special clinic for insulinpump patients in our hospital. At that stagewe had four patients who were treated byinsulin pumps and who were seen monthlyat a special clinic by a diabetes nurse specialistand a dietitian.

At the same time, we started courses forour insulin-treated patients (types 1 and 2)with education about flexible insulin therapy.These courses were held in the evenings andwere given by a diabetes nurse specialist, adietitian and myself. Over the next six years,we changed all our patients to flexible insulintreatment. Over the years, the amount ofwork involved changed the structure of ourorganisation and we now have six diabetesnurse specialists, two dietitians and one diab-etologist (myself ).

Over the same period of time, we beganto put all the women patients who wantedto become pregnant on insulin pump therapy.At first, these patients stayed in the clinic forfive days but in 1993 we treated our firstpatient in an outpatient clinic, with goodresults. As a result of this positive experience,we changed our policy and now every patientwho wants to be treated as an outpatient hasthat option. To start with, all outpatientswould visit the clinic daily to see the diabetesnurse specialist and diabetologist. Nowadays,patients will visit the clinic every two or threedays but will have daily contact with us byphone, fax or e-mail.

Many of our patients were initially notwell regulated, in terms of their HbA1cs, thefrequency of hypoglycaemic episodes andfluctuations in blood glucose values. How-ever, due to our positive experiences withinsulin pumps in our female patients and thesatisfaction they expressed regarding theirflexibility, every year we have increased thenumber of patients using these devices.

Currently, we have 270 patients in totalon insulin pumps – 220 type 1 patients, 48type 2 patients and two patients who havehad a total pancreatectomy. In general theirHbA1cs are similar to those receiving flexibleinsulin therapy (mean HbA1c levels for

Organising and running a pump service in The NetherlandsDr Roel Hoogma

Consultant Endocrinologist, Groene Hart Zieckenhuis, Gouda, The Netherlands

patients on pumps and patients on flexibleinsulin therapy are 7.2% and 7.6% respect-ively) and their qualities of life are compar-able. Over the past 11 years, we have hadonly one pump patient with diabetic ketoac-idosis (DKA) who needed treating in hospital.Other cases of DKA have been treated bythe patients themselves or together with adiabetologist, who is on call 24 hours a day.Our diabetes specialist nurses have a 24 hourduty scheme so that, in cases of emergency,all our patients can get in touch with aprofessional and receive appropriate advicewithout the need for hospital admission.

Our pregnant patients have had excellentresults using a pump. The mean HbA1c levelsbefore and during pregnancy were 6.5% and6.1% respectively. The outcomes for thebabies have been good – there have been nocongenital malformations, only one stillbirthand almost 7.5% macrosomias in a total of45 pregnancies. All pregnant diabetic patientshave had the opportunity to return to flexibleinsulin injections, but only one patient hasreverted. The remaining patients are stillusing insulin pumps.

The indications for insulin pump therapyin our clinic have changed over the years.There is an increasing emphasis on lifestyleissues, hypoglycaemias and hypoglycaemiaunawareness.

DiscussionAre there any additional problems in peopleusing pumps who have type 2 diabetes?They use higher doses of insulin but theresults are better with less fluctuations. Mostof the problems used to be after breakfastbut with pumps these do not occur becausewe can increase the basal rate early in themorning – about six o’ clock.

If you put all your resources into one approach,you will produce good results anyway. Why doyou give the credit to the pump rather thanyour teamwork?Not all our growing number of patients are

on pumps and they all receive good care. Butwe have found that there are many patientswhose fluctuations and blood sugar valuescannot be regulated with flexible insulin treat-ment, which involves up to eight injections(and finger pricks) a day. This is awful forthem. Once they have got over the initialpsychological barrier to the pump theyinvariably ask us why did we not start themon it five years earlier!

Bernie Zinman: In Toronto we use the term‘intensive diabetes management’ rather than‘intensive insulin therapy’ as clearly insulin isonly one component of a programme involvingcarbohydrate counting, self-monitoring andempowerment etc. But if you don’t have amechanism for adjusting therapy several timesthrough the day, it won’t work.

I agree.

Do you take the approach that all your type 2patients should be on multiple insulin injectionsor CSII, or do you have a step care approachstarting with oral agents, then oral agents plusinsulin then intensive insulin?

By the time we see our type 2 patients –from the GP – they have already been onoral agents but do not have well regulateddiabetes; HbA1c is <7.5%. So we start withan education programme and intensive insu-lin treatment straightaway.

Bernie Zinman: We find, in Canada, thatour type 2 patients dread the step to insulin. Sowe start with a gradual approach, using pillsplus insulin. After that, each step becomes easier.

We find that one reason why our type 2patients are afraid of insulin is because theysee it as a punishment. Their GPs tell themthat if they don’t take their pills and don’tlose weight etc, they will have to see thediabetologist. So we tell them that if theytake insulin they will live longer and thatovercomes the problem.

Pract Diab Int June 2001 Vol. 18 No. 5 Supplement Copyright © 2001 John Wiley & Sons, Ltd. S7

S U P P L E M E N T T O P R A C T I C A L D I A B E T E SI N T E R N A T I O N A L

New horizons in insulin pump therapy

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