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The Growing Future of Diabetes:
Insulin Pump Therapy in Type 1 and 2 Diabetes
Sarah Dombrowski, PharmD, BCACP
Pennsylvania Pharmacists Association
10/20/18
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Objectives
At the completion of this activity, the participant will be able to:
• Discuss current insulin pump and continuous glucose monitoring options
for patients and identify appropriate patients for insulin pump therapy
• Describe pharmacists’ roles in insulin pump therapy across hospital,
community and ambulatory care pharmacy
• Utilize insulin pump reports to assess blood sugar control and adjust
patient pump settings when given a patient case
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Insulin Pump Basics
• Electromechanical device that mimics the body’s natural insulin secretion
• More physiologic than multiple daily injections (MDI)
• Pump holds and delivers the insulin
• Patient does not require injection of any insulin via needle/syringe
• Insulin lispro, aspart, and glulisine preferred (regular insulin possible)
• Delivers rapid-acting insulin in two ways:
• Preset continuous basal rates
• Boluses at mealtimes and as needed (manual)
• Infusion site to be changed every 3 days
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Insulin Pump Basics
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Diabetes Pump Outcomes
Insulin pump therapy allows for better glucose control than MDI by
• Breaking insulin resistance and reducing insulin dose (esp. Type 2)
• In general, 20% reduction in TDD of insulin for patients switching from MDI to pump
• Improving blood glucose control and lowering A1c
• Limiting excess weight gain associated with MDI
• Reducing the frequency of severe hypoglycemia
• Especially when combined with continuous glucose monitoring
• Improving patient engagement in their diabetes management
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Type 2 Diabetes Pump Outcomes
Patient Feedback
“So happy I made the switch to pump – so convenient and not sticking myself 5 times a day”
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Continuous Glucose Monitoring (CGM) Basics
• Device worn continuously by patient
• Needle or canula sits under patient’s skin
• Glucose readings are taken from interstitial fluid
• Sensor glucose follows blood glucose
• Sensor and blood glucose readings will rarely match and are expected to be different
• A greater difference will be seen when glucose is changing quickly
• Provides continuous picture of glucose levels
• Must more data for patient and provider than fingersticks alone
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CGM + Pump - Prevention of low blood sugars
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Available Products Insulin Delivery and
Continuous Glucose Monitoring
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Current Continuous Glucose Monitor Options
Medtronic iPro 2 with Enlite Sensor
Dexcom G5 Mobile
Dexcom G6
Medtronic Guardian Connect
Medtronic Guardian Sensor 3
Freestyle Libre
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Medtronic iPro 2 with Enlite Sensor
• Professional GCM – placed by physician practice
• Used by physician to gather data on patients’ glucose levels
• Does not interface in real time with any device
• Tests glucose every 5 minutes
• Records glucose for up to 6 days
• Must be calibrated at least 2 times per day with fingersticks
• No predictive alerts or alerts for caregivers
• Worn on abdomen
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Dexcom G5 Mobile
• Personal CGM
• Interfaces with Dexcom receiver, smart device
• Tests glucose every 5 minutes
• Needs to be changed every 10 days
• Does not require calibration with fingersticks
• For use in patients with Type 1 or 2 diabetes ages 2 yo and up
• Alerts for high or low glucose thresholds
• Includes alerts for up to 5 caregivers
• Worn on abdomen or upper buttocks (pediatric only)
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Dexcom G6
• Personal CGM
• Interfaces with Dexcom receiver, smart device, or insulin pumps (t:slim and Omnipod)
• Tests glucose every 5 minutes
• Needs to be changed every 10 days
• Does not require calibration with fingersticks
• For use in patients with Type 1 or 2 diabetes ages 2 yo and up
• Alerts for high or low glucose thresholds
• Includes alerts for up to 5 caregivers
• Worn on abdomen or upper buttocks (pediatric only)
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Medtronic Guardian Sensor 3
• Personal CGM
• Interfaces with Medtronic 670G pump
• Tests glucose every 5 minutes
• Needs to be changed every 7 days
• Must be calibrated 2-4 times per day with fingersticks
• For use in patients with Type 1 or 2 diabetes ages 14 and up on 670G
insulin pump
• Predictive alerts – 10-60 minutes before a low or high
• Does not include alerts for caregivers
• Worn on abdomen
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Medtronic Guardian Connect
• Personal CGM
• Interfaces with Apple smart devices (Android interface in development)
• Tests glucose every 5 minutes
• Needs to be changed every 7 days
• Must be calibrated 2-4 times per day with fingersticks
• For use in patients with Type 1 or 2 diabetes ages 14-75 yo on insulin
• Predictive alerts – 10-60 minutes before a low or high
• Includes alerts for caregivers
• Worn on abdomen
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Freestyle Libre
• Personal CGM
• Interfaces with Freestyle Libre reader
• Tests glucose every 15 minutes
• Needs to be changed every 10 days
• Does not require calibrations with fingersticks
• For use in patients with Type 1 or 2 diabetes over 18 yo
• No alerts for lows/highs
• Does not include alerts for caregivers
• Worn on back of arm
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Insulin pumps
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Current Insulin Pump Options
Omnipod Dash System
Tandem t:slim X2
Medtronic 630G
Medtronic 670G Hybrid Closed Loop System
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Omnipod Dash
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Tandem t:slim X2
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Patient-Centered Approach to Insulin Pumps and
CGMs
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Pump Patient Selection
• Motivated to achieve normoglycemia
• Performs self-care responsibilities associated with diabetes
• Technical ability to monitor glucose and operate insulin pump
• Intellectual ability to learn and retain information
• Effective coping patterns
• Availability of support systems
• Financial resources to cover cost of therapy
Adapted from the American Association of Diabetes Educators Position
Statement
on Education for Continuous Subcutaneous Insulin Infusion Pump Users.
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Factors to consider in recommending a pump or CGM
• Patient age
• Type 1 versus Type 2 diabetes
• Current medication regimen
• Dexterity
• Cognition
• Body type
• Activity and occupation
• Insurance coverage
• Patient goals of care
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Consider Differences in Pumps and CGMs
• Tubing versus tubeless
• Insertion site location
• Needle versus canula
• Angle of insertion for infusion set
• User interface
• Open loop versus hybrid closed loop systems
• Special technology features and communication with other
devices
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Customizability for Patient
• Delivery settings
• Basal Rates
• Carb ratio or fixed meal bolus
• Sensitivity factor
• Active insulin time
• Goal blood glucose range
• Differences in pump supplies (depends on the pump)
• Type of infusion set
• Length of tubing
• Length of canula
• Size of reservoir
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Pharmacist Roles in Insulin Pump Management
Across Healthcare Continuum
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Hospital Pharmacists
• Consider pre-op recommendations
• Assess patient understanding and management of pump
• ISMP Safe Management of Patients with an External Subcutaneous Insulin Pump During
Hospitalization
• Keep patient connected to pump when possible
• AACE and the ACE encouraged not to discontinue an insulin pump, but rather to consult specialist
if the patient cannot manage his/her own pump
• Understand how to access delivery settings on patient’s pump to determine insulin rates if
need to transition to subcutaneous/IV insulin
• Ensure patient is able to restart pump upon discharge
• Change in settings?
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Community Pharmacists
• Understand basics of insulin pumps and where to refer patients
• Assess patient understanding and compliance
• Patients should only be using short- or rapid-acting insulin in insulin pump
• Patient may have long-acting insulin and needles/syringes on hold for emergencies
• Ensure patient’s prescription matches actual use
• Patient needs enough insulin in each fill for use + filling tubing and canula (if applicable)
• Help patient understand treatment of high and low blood sugars
• Partner with pump companies to improve patient access
• American Diabetes Association (ADA): CSII (continuous subcutaneous insulin infusion) should be
“prescribed, implemented, and followed by a skilled professional team familiar with CSII therapy
and capable of supporting the patient.”
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Ambulatory Care Pharmacists
• Can take primary role in management in partnership with Endocrinology/Primary Care
• Monitor blood glucose and continuous glucose monitoring
• Adjust insulin pump settings (with Collaborative practice agreements)
• Train new pump patients (contract with company)
• Online and in clinic instruction
• Observe 1-2 trainings with company trainer
• Train 1-2 patients independently with trainer observation
• Pass written certification exam
• Staff education
• Opportunities for payment
• Face to face
• Telephonic/telemedicine?
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Sample Reports and Patient Cases
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Patient 1
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Patient 2
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Patient 3
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Patient 4
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Patient 5
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Patient 6
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Summary
• Current insulin pump and continuous glucose monitoring options for
patients
• Appropriate patients for insulin pump therapy
• Pharmacists’ roles in insulin pump therapy
• Hospital
• Community
• Ambulatory care pharmacy
• Modification of pump settings to optimize patient outcomes
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References
Boyd LC and Boyd ST. Insulin Pump Therapy Training and Management: An Opportunity for Community
Pharmacists. J Man Care Pharm. 2008;14(8): 790-794.
Reece SW, Hamby Williams CL. Insulin Pump Class: Back to the Basics of Pump Therapy. Diabetes
Spectrum. 2014;27(2):135-140.
Smetzer J (ed), Cohen M (ed), Shastay A (ed), et al. Safe Management of Patients with an External
Subcutaneous Insulin Pump During Hospitalization. ISMP. Oct 20 2016;21(21):1-5.
ISMP. Managing Hospitalized Patients with Ambulatory Pumps: Part 2- Recommendations for the Use
of Insulin Pumps During Hospitalization. ISMP Medication Safety Alert. Oct 20 2016.
https://www.ismp.org/resources/managing-hospitalized-patients-ambulatory-pumps-part-2-
guidelines-use-insulin-pumps
Insulin Pump Therapy Resources - Educator Tools Providing Guidance on Pump and Sensor Training.
American Association of Diabetes Educators. https://www.diabeteseducator.org/practice/educator-
tools/ipt-resources
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Product Sites (for healthcare professionals)
https://professional.medtronicdiabetes.com/
https://provider.dexcom.com/
http://provider.myfreestyle.com/
https://www.myomnipod.com/healthcareproviders
https://www.tandemdiabetes.com/providers
