the “future” chapter. I also owe much to my former personal physician, G. William Benedict, MD (d, 2006) for his guidance and patience in putting me on my first pump many years ago. And to the select group of the many other patients and physicians who influenced my decision to begin pump therapy and help others make the same decision, I would also like to acknowledge: Riccardo Calafiore, MD; Richard E. Berger, MD, FACP, FACE; and John P. Comstock, MD. I am also thankful to Frank Weller (d, 1997); Scott Fischell; Cindy Shump, RN, MS, MSN, CRNP, CDE; Amy Mersey, RN; Zoe (Heineman) Myers, MA; James A. Dicke, MD; Joanna B. Tyzack, MD; Fran R. Cogen, MD, CDE; Ruth S. Horowitz, MD; and Philip A. Levin, MD, for their dedication and contributions to the field of diabetes and insulin pump therapy.
A special thank you goes out to the reviewers Davida Kruger, MSN, APRN, CDE; Joan Hill, RD, CDE; and Dr. James H. Mersey for kindly providing their time and expertise.
I want to thank the American Diabetes Association for providing me with the opportunity to write the second edition of this book. I am especially indebted to Victor Van Beuren, Acquisitions Editor, for his patience, wisdom, and unending support, and book editor Rebekah Renshaw for her dedicated editorial work and insight.
I extend gratitude also to my loving, very smart, and very patient husband Tom and my extraordinary parents. Additionally, I thank my dear siblings and their spouses, nephews, and nieces for their constant support and encouragement. Thanks also to my professional colleagues through my years as a pump therapy diabetes educator. I am indebted to the countless pump patients with whom I have had the privilege and pleasure to work with and learn from. Their contribution to my knowledge of diabetes has been of untold value, for which I am most grateful.
Karen M. Bolderman, RD, LDN, CDE
I have been an endocrinologist involved in the management of diabetes for the past 35 years. I began before glucose meters existed. In 1977 when I started the Diabetes Clinic at The Johns Hopkins University School of Medicine, Ames gave me the first Dextrometer to use. It took several minutes to get a reading on a dial the size of a bathroom scale, but this device signified a huge step forward in diabetes monitoring. When insulin pumps became clinically available, I actively championed their use, although the early ones were the size of an Uzi.
Over the years, pump technology has progressed at a steady pace, with the addition of new ways to deliver insulin, better integration with meters either as built in or by infrared communication, and with use of continuous glucose sensors. All of this brings the hope of a true closed-loop system.
In spite of these improvements in technology, selecting patients for pumps and starting patients on pumps still requires a great deal of education, training, and time, along with knowledge on the part of the healthcare provider.
I have known Karen Bolderman since she began working for me as a diabetes educator 30 years ago. After several years, Karen and I began working together again at the Geckle Diabetes and Nutrition Center at Greater Baltimore Medical Center, where we are working to integrate diabetes care in and out of the hospital.
For us this is déjà vu all over again. We work together to teach patients about pumps, get them started, and manage their diabetes post initiation. With Karen’s knowledge and personal experience, starting and training patients on pumps, managing patients in the hospital, and following patients on pumps makes my life much easier. I look forward to a continued partnership with Karen in our attempts to improve diabetes care.
Karen has done a marvelous job with the details of insulin pumps in this edition of Putting Your Patient on the Pump. This book will make everyone’s job of utilizing insulin pumps more understandable and practicable.
Read ahead and enjoy.
James H. Mersey, MD Director, Endocrinology and Metabolism, Medical Director, Geckle Diabetes and Nutrition Center Greater Baltimore Medical Center Assistant Professor of Medicine, The Johns Hopkins University School of Medicine Clinical Associate Professor of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
Insulin pump therapy gives people with diabetes the freedom to enjoy life, despite their chronic condition. The value and importance of having freedom are obvious from the impact this innovative technology has made in the past several decades. The insulin pump is now a common, integral component of diabetes management. Technological improvements and advances have made the insulin pump a desirable and useful tool in the management of diabetes.
As long-term insulin pump wearers with type 1 diabetes and healthcare professionals who have learned much from our colleagues and countless other “pumpers,” the contributors to the second edition of Putting Your Patients on the Pump have a unique perspective and understanding of what constitutes practical, useful information. Collectively, the four of us have lived with type 1 diabetes for over 165 years. Most of these years have been spent with an insulin pump. It is our hope that this book will help healthcare professionals with expertise in diabetes care and education successfully start and maintain diabetes patients on insulin pump therapy. We believe that even experienced clinicians will find the information, tips, and resources helpful.
We hope this book provides user-friendly information from our combined practical experience and supports the extra efforts diabetes healthcare professionals must make to help their patients achieve success using an insulin pump.
Karen M. Bolderman, RD, LDN, CDE
Chapter 1 Insulin Pump Therapy Advantages and Disadvantages
Karen M. Bolderman, RD, LDN, CDE
Insulin pump therapy is in its fifth decade and is gaining wider popularity. In the U.S., an estimated 20–30% of patients with type 1 diabetes and <1% of insulin-treated patients with type 2 diabetes use an insulin pump (HSBC Global Research 2005). As of this writing, the most current data indicate that there are over 375,000 patients with type 1 diabetes (up from approximately 130,000 in 2002) now using an insulin pump (U.S. Food and Drug Administration, General Hospital and Personal Use Medical Devices Panel 2010). Insulin pump therapy requires fewer “injections” compared with multiple daily injection (MDI) therapy; an infusion site is changed every 2–3 days, for an average of about 152 infusion site insertions/year, while MDI therapy results in about 1,460 injections/year (based on 4/day). Until research yields a practical way to replace lost β-cell function in diabetes, the insulin pump provides the most elegant method of insulin replacement. In its best application, pump therapy is a rare win–win situation in diabetes in terms of glycemic control and personal freedom.
An insulin pump is a wonderful diabetes management tool, but as with any tool, the pump is only as good as the patient’s ability to use it. Clinicians have a responsibility to carefully screen and provide access to educational resources to all patients who express an interest in pump therapy. When patients are mismatched with the pump or the pump regimen, loss of control may occur and potential benefits are lost or nullified.
Successful pump therapy is more likely with motivated and conscientious patients. Regardless of what many patients first think, the pump patient must perform frequent self-monitoring of blood glucose (SMBG), learn how to use their data, and understand how to use their insulin pump to ensure proper pump function and improve or achieve desired glucose control (American Diabetes Association 2004). Also, the patient must calculate food-related bolus insulin doses based on individualized insulin-to-carbohydrate
