DIABETES CAREAll people with Type 1 Diabetes and some with Type 2 Diabetes mellitus, at some point of time, require insulin to control their blood glucose levels. Syringes and pens are presently the most popular insulin delivery devices. Though in use for more than four decades, insulin pumps are now being more frequently utilised, because they can continuously infuse insulin, replicating the physiological secretion from a normal human pancreas..Some of the studies involving use of insulin pumps have shown added benefits like improving quality of life, normalizing sugars in widely fluctuating Diabetes, improving sexual function, and alleviating neuropathic discomfort. In India 80 per cent of insulin pump users are people with Type 2 Diabetes.I intend to share my conversation with one of my patients who agreed to use an insulin pump after putting a host of relevant questions to me that went as follows: What is an insulin pump?An insulin pump, a small mechanical pager- like device, is worn externally and could be easily clipped to a belt or slipped in a pocket. Virtually pain-free, a flexible tube (catheter), placed below the abdominal skin, is taped in place to deliver insulin 24 hours a day.According to the pump wearer's programmed plan, small amount of insulin (basal rate) is released between meals and overnights and a higher rate of insulin (bolus rate) is released prior to eating a larger meal. It is easily disconnected during bathing or swimming. Insulin doses are separated into:. Basal rates. Bolus doses to cover carbohydrate in meals. Correction or supplemental dosesBasal insulin is delivered continuously over 24 hours to keep blood glucose levels in range between meals and overnight. Bolus dose (additional insulin) can be given at the time of meals with a push of a button. More dosage of insulin can be given if needed to cover the already elevated sugars or unplanned excess intake of carbohydrate.A traditional pump includes a pump, a disposable reservoir for insulin located inside the pump, a disposable infusion set, including a cannula for subcutaneous insertion (under the skin) and a tubing system to interface the insulin reservoir to the cannula. How is a pump placed?Insulin pump is designed for convenience so even the options how to wear it depends on patient convenience. You can buy a pump case or it can be attached to a waistband, pocket, bra, garter belt, sock or underwear. You can also tuck any excess tubing into the waistband of your underwear or pants. When you sleep, you could try laying the pump next to you on the bed. You could even try wearing it on a waistband, armband, leg band or clip it to the blanket, sheet, pyjamas with a belt clip.Showering and bathing are other instances when you should know where to put your insulin pump. Although insulin pumps are water resistant, they should not be set directly in the water. Instead, you can disconnect it. All insulin pumps have a disconnect port for activities, such as swimming, bathing or showering. Some pumps can be placed on the side of the tub or in a soap tray. There are also special cases you can buy. You can hang these cases from your neck or from a shower curtain hook.What is a ’smart’ insulin pump?Now a days, most pumps come with built-in bolus calculators that help figureout how much insulin people with Diabetes need at mealtime based on their glucose levels and the amount of carbohydrates they are eating. Smart pumps consider the amount of insulin still “active” in a patient's body (insulin on board, IOB) prior torecommending an insulin dosage. This helps to avert potentially dangerous hypoglycaemia episodes caused when too much insulin is delivered. Smart insulin pumps are designed to simplify insulin delivery and improve quality of life of people with Diabetes.The pump can be worn around the waist in a pump case or attached to a belt, in a pocket, or on an armband. There are a variety of custom-made accessories available so one can carry one's insulin pump with style.What are the types of insulin pumps?In general, there are two types of pump devices:Traditional insulin pumps have, as mentioned earlier, an insulin reservoir (or container) and pumping mechanism, and attach to the body with tubing and an infusion set. The pump body contains buttons that allow the user to program insulin delivery for meals, specific types of basal rates, or suspend the insulin infusion, if necessary.Insulin patch pumps are worn directly on the body and have a reservoir, pumping mechanism, and infusion set inside a small case. A separate device that allows programming of insulin delivery for meals from the patch controls patch pumps wirelessly. Many pumps connect wirelessly with blood glucose meters, which measure blood sugar levels using a drop of blood from one's fingertip. Some pumps connect wirelessly with continuous glucose monitoring devices, which are placed beneath the skin and monitor blood sugar levels all day long.Pumps vary in how much insulin they hold, whether or not the pump has a touch screen or is waterproof, and have a variety of advanced features as well as safety features. Safety and user features may include programmable bolus, customizable reminders, alerts for missed bolus dose or missed glucose measurement, and alarms in the event of a blockage that prevents the continuous infusion of the insulin through the pump. One of the integrated systems that combine insulin pump and continuous glucose monitoring sensor can also be programmed to suspend insulin delivery if the glucose level reaches a preset low threshold level.What is an artificial pancreas glucose control system?The artificial pancreas, also known as closed-loop control, is an “all-in-one” Diabetes management system that tracks blood glucose levels using a continuous glucose monitor (CGM) and automatically delivers the hormone insulin when needed using an insulin pump.What are dual-hormone artificial pancreas systems?A dual-hormone artificial pancreas (AP) system achieves closed-loop glycaemic control by subcutaneous infusion of insulin and of glucagon in response to glucose values detected by a continuous glucose monitoring device. Glucagon leads to a rapid conversion of the stored form of glucose in the liver called hepatic glycogen into glucose which is then released into the bloodstream. To counter the insulin action when blood glucose shows a tendency to fall, glucagon is given as mini-boluses, this helps to prevent or to treat any imminent hypoglycaemia.What are the parts of an insulin pump?Traditional insulin pumps contain three main parts:Pump - Traditional insulin pumps are battery powered and contain an insulin reservoir (or container), pumping mechanism, and buttons or touch screen to program insulin delivery. Pumps send insulin through tubing into an infusion set that delivers the insulin to the body of a person with Diabetes.Tubing - A thin plastic tube (catheter) is connected to the insulin reservoir and insulin flows into the subcutaneous tissue through the infusion set. There are several length sizes of tubing length. They are chosen based on how person with Diabetes wear the insulin pump. For example, longer tubing may be good for people who wear their pump far from the infusion set.Infusion set - Infusions sets are made of Teflon or steel and attached to the user's skin with an adhesive patch. On the underside of the infusion set is a short thin tube (cannula) that is inserted into the skin with a small needle that is housed within the cannula to deliver insulin into a layer of fatty tissue. After insertion, the needle is removed and the thin cannula is left behind under the skin. The set is usually implanted around the stomach area, but can be placed on the thigh, hips, upper arms, or buttocks.There are a variety of infusion sets to choose from, and the Diabetes care team can help person with Diabetes choose what is best for them based on their body contour, lifestyle, and a variety of other factors. Infusion sets fall into two categories:Angled sets - These are inserted at a 30 to 45 degree angle to the surface of the skin; in general, these have longer cannulas.Athletes, thin or muscular people, pregnant women and active children may prefer these types of angled sets. Angled sets allow for view of the cannula at the insertion site, identifying signs of redness and potential infections at the insertion site.Straight sets - These are inserted at a90 degree angle to the surface of the skin. They have shorter needles, and may be preferred by people when they insert the set on the arms, or in hard to reach areas, such as the buttocks. Also, people who are afraid of needles can use this type of set with an insertion device that hides the needle. Adhesive tapes such as 3M™ Tegaderm™ and Micropore are required to keep the infusion set in place.What are the advantages of using an insulin pump? . Eliminates individual insulin injections. Delivers insulin more accurately than injections. Improves HbA1c. Fewer large swings in your blood glucose levels. Delivery of bolus insulin easier. Insulin pumps allow you to be flexible about when and what you eat. Reduces chances of severe low blood glucose episodes. Eliminates unpredictable effects of intermediate- or long-acting insulin. Allows you to exercise without having to eat large amounts of carbohydrateWhat are the disadvantages of using an insulin pump? . Can cause weight gain. Can cause diabetic ketoacidosis (DKA) if your catheter comes out and you don't get insulin for hours. Expensive. Can be bothersome since you are attached to the pump most of the time. Can require a hospital stay or maybe a full day in the outpatient centre to be traineLike any other modalities of treatment insulin pump also has its own advantages and disadvantages. In practice we see that people with Diabetes are more comfortable with the pump. The disadvantages are quickly forgotten. If you prefer, there is always an option to go back to pen devices or to the conventional insulin delivery systems. Cost of operating the pump is the main disadvantage but if you can afford it then insulin pump is the best choice available to get away from pricks.Who are the ideal candidates for insulin pump therapy?Many people with Diabetes can qualify for insulin pump therapy. They are:. People with Diabetes whose blood glucose levels aren't well controlled. People who are injecting insulin four or five times a day may want to consider the convenience of a pump. People who can check their blood sugar several times a day (using a calibrated glucometer) can make timely changes to regulate blood sugar levels if they use an insulin pump. Adults with irregular schedules might also benefit from a pump: it can be programmed to provide insulin on a schedule that matches body's usual needsIs insulin pump therapy appropriate for me?Insulin pumps work well for many people, but they aren't right for every person with Diabetes. All potential candidates must have the ability to handle the technical and mechanical functions of the pump. The insulin pump is a tool of diabetes management, and is only as effective as the person using it.If a person with Diabetes decides to use the insulin pump, it is important for them to have realistic expectations and they mustknow that it's an ongoing responsibility. Potential pump users will have to undergo formal training on how to fill a pump reservoir, prime tubing, select an infusion site, change an infusion set, disconnect the device, change the pump's batteries every one to two weeks, calculate and program basal and bolus doses, troubleshoot potential problems, create backup plans in case of pump failure, and prevent diabetic ketoacidosis.A person with Diabetes will need to be prepared to do his/her blood checks regularly and enter food (carbohydrate) amounts into the pump to calculate the correct insulin dose. Unlike with insulin injections, a person with Diabetes will have to make sure that the insulin delivery rate is set appropriately, change the infusion tubing regularly to prevent blockages and has enough insulin in the storage chamber to cover the individual's insulin needs.Clinical studies have proven that insulin pumps can reduce severe hypoglycemia by up to 85 per cent and mild-to-moderate hypoglycemia by nearly 60 percent, compared to multiple daily injections. .Questions to ask yourself Finally, I believe, the following are some important questions that every person with Diabetes considering use of an insulin pump should answer to oneself before embracing this state of the art therapeutic gadget:. Am I ready for a pump?. Am I ready to be glued to a device 24 hours a day for insulin delivery?. Can the insulin pump prove to be a magic wand for me?. Am I comfortable with the technology?. Will I be able to manage testing blood sugar 4-6 times/day and/or continuous glucose monitor, counting all my carbs, calculating bolus and correction dose of insulin consistently and communicating with my Diabetes Team on a regular basis?To conclude I leave you with this - “Our God is good and goodness will triumph! His love for Man's a-never-failing -PUMP!”(Dr. John Celes, 2003) Dr V. K. Abichandani is a Diabetes and Endocrine Physician in Ahmedabad.Disclaimer: The editorial team of Diabetes Health have no conflict of interest to disclose. They do not endorse, support or recommend any particular product or device. Readers are requested to check with their doctors before using any application or device.