- 1 Intro to the Insulin Pump
- 2 Types of Insulin Pump
- 3 Advantages of Insulin Pump, and Disadvantages.
- 4 Causes of Low Blood Sugar
- 5 Unexpected High Blood Sugar ?
- 6 Troubleshooting Hyperglycemia
- 7 What are insulin pumps? What’s a basal rate?
- 8 Are you a candidate to pump insulin?
- 9 A day in the life of an insulin pumper
- 10 Emergency Insulin Pump Kit
This article covers the basics of a diabetes pump therapy right up to the advanced details. So pull up a chair and learn how this diabetes device can be liberating and alas, can be much work. How new insulin pump features mean new freedoms, if combined with the information to understand and use them safely.
Intro to the Insulin Pump
People are attracted to insulin pump therapy for many reasons – some may be misconceptions. Some people refuse pump therapy because they don’t fully understand its benefits over multiple daily injections. As a diabetes educator I’ve seen all scenarios. Even as a pumper myself, I originally refused the therapy years ago until a 12 year old convinced me to learn more. (Yes, how humbling). The intention of these pages is to provide information to help you make an informed decision about this therapy, together with your health care providers.
You might first ask yourself, “How do I think this therapy can help me?”, then review the links above and see if it can or cannot help. Of course, you might find new reasons for wanting to try pump therapy after reading them too. Regardless, go into pump therapy with eyes wide open so you’re aware of all it’s abilities, advantages and disadvantages.
Some quick facts:
- Pumps do not cure diabetes.
- Pump therapy is also called continuous subcutaneous insulin infusion or CSII.
- Continuous insulin infusion provides more ways to prevent high and low blood sugars than do injections.
- Diabetic pumps can be used in type 1 and type 2 diabetes.
- Pumps do not do all the work of managing diabetes for you.
- Successful CSII therapy is often more work than multiple daily injections.
Insulin pumps do not require surgery.
- Pumps are not appropriate for everyone with diabetes.
- Diabetic pumps can accommodate erratic and flexible lifestyles better than multiple daily injections.
- There is no age restriction for pumping insulin, as long as other factors are met.
A pump is a huge investment in money and your time and effort. It’s great that you are researching this therapy prior to jumping into it. It’s true that very few people give up pumping after having started, however, MANY do not realize the commitment required to gain the full benefits of this therapy. So many people could be achieving better results and better quality of life. Read on and inform yourself. Even if you decide against an insulin pump, you will have made an informed decision.
Types of Insulin Pump
With Tubes, Tubeless and Implantable
What types of insulin pumps to consider can be a difficult choice. There are various features available. However, one of the biggest differences in pumps is how they connect to the body. Pumps can require tubes (infusion sets) or “no tubes” like a “patch pump”. The latter is also known as untethered.
This page reviews the two ways that insulin pumps can connect to the body as well as lists the pump manufacturers for each. Implantable and closed-loop insulin pumps are briefly discussed, but not routinely available for purchase. Contact information for beta cell transplants (not an insulin pump) is also provided. Please note that not all types of insulin pumps are available in all countries.
Tethered / Connected by Tubing (Infusion Set)
The types of insulin pumps that are the most common are those that require tubing (infusion sets). These insulin pumps are also referred to as being tethered. Each pump is about the size of a pager and is worn on the outside of the body, for example in a pocket (or yes, in a bra!). Flexible, yet strong tubing (infusion set) connects the pump containing the insulin to the person. The insulin travels from a reservoir in the pump (180-300 units storage), down the tube and into a small amount of tubing under the skin called a cannula. The infusion set (tubing) is usually hidden under clothing; however in active individuals the tubing can sometimes be caught causing the cannula to rip out if not carefully managed.
Most tethered pumps offer some form of remote access to basic programming; for example, a remote control, handheld module or a paired specialty glucose meter may be able to send wireless signals to prompt the pump to deliver a bolus. Some of the manufactures of these types of insulin pumps that require tubing or infusion sets are (in alphabetical order):
- Animas Corporation: OneTouch Ping. Older models include IR 20/20, 1000, 1200 and 1250. Available in Canada.
- Fornia: makers of China’s Fornia insulin pump (not available in Canada).
- Medtronic or Minimed: makers of the Paradigm models including the Veo and various older models (502-522). Available in Canada.
- Nipro Diabetes Systems makers of the Nipro Amigo (not available in Canada).
- Rochemakers of the Accu-chek Combo Insulin pump – previously named the Spirit. Available in Canada. Note, RRoche purchased Disetronic a few years back. Disetronic’s old D-Tron and H-Tron models are no longer being marketed.
- SOOIL: makers of DANA Diabecare (not available in Canada).
- Tandom makers of T-Slim insulin pump (not available in Canada)
- Unitma Co Willcare Insulin Pump distributed by www.infusedmedical.com (not available in Canada)
- Note: Deltec or Smith’s Medical were the manufacturer of the Cozmo insulin pump; however this pump is no longer produced.
Patch / Untethered/ Tubeless Insulin Pumps
These types of insulin pumps sit directly on the skin with an adhesive. They are usually removed after 2-3 days and discarded (e.g.OmniPod; but not all brands are disposable). There is no tubing. The reservoir of insulin and the motor to move the insulin are included in the insulin pump that adheres to the skin. A hand-held device (usually with built in glucose meter) is used to wirelessly program in boluses and basal rates allowing for remote accessibility.
These insulin pumps have often been referred to as “Patch Pumps.” The word “Patch” may be misleading with the current products. They are generally bigger than what people consider as a “patch” although newer models are striving towards smaller units. OmniPod’s design is a three dimensional pod that “peels and sticks.” The cannula that goes under the skin is directly attached to underside of the pod.
Active individuals who are worried about “catching” tubing and ripping cannulas out or breaking the physical pump during a contact sport may be attracted to patch pumps. The expensive part of a patch pump is typically the handheld module (which can be left safely on the sidelines) whereas the attached pods are usually, as in the case of the Omnipod, disposable.
The types of insulin pumps available in this “patch pump” category are limited at this time, but the future looks promising as you’ll see if you review the other options below. The manufacturers for these types of insulin pumps in alphabetical order are: (note, some may not be to market yet)
- CellNovo: makers of CellNovo Insulin Pump which appears to be a hybrid allowing for a very short infusion set (e.g. a few centimeters or an inch) or a long one. (not available in Canada)
- Debiotech: makers of the Jewel Pump (not available in Canada)
- Insulet Corporation: makers of the Omnipod. (available in Canada) Internationally visit http://www.myomnipod.com/about-insulet/International/.
- Medingo (owned by Roche): makers of Solo Micro pump (not available in Canada)
- Valeritas: makers of V-Go insulin delivery devices (not available in Canada)
Implantable Insulin Pump
Types of insulin pumps that fall into this “implantable” category are not the usual form of insulin pump treatment. Implantable insulin pumps have primarily been restricted to use in research. However, a quick review of this article from the Netherlands shows that this country has had more experience with this modality of treatment in select individuals (about 57 over an 11 year period, still a small number compared to traditional insulin pump therapy). http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3423638/
An implantable pump is surgically implanted beneath the skin and the insulin is delivered into the peritoneal area (the space between the abdominal muscles and the organs). The reservoir of concentrated insulin is therefore also kept beneath the skin, but can be re-filled from the outside of the body using a large syringe. For more information on how implantable insulin pumps work, consider reviewing the journal paper by Haveman JW, Logtenberg SJ, Kleefstra N, Groenier KH, Bilo HJ, Blomme AM. Surgical aspects and complications of continuous intraperitoneal insulin infusion with an implantable pump. Langenbecks Arch Surg. 2010;395:65–71.
Closed Loop Insulin Pump
A closed loop insulin pump is the ultimate beta cell replacement that research aspires to creating. This type of pump is not currently commercially available. A “closed loop” system would allow blood glucose readings to stay in target without decision making on the part of the user. Such a system would have all the technology and hormones necessary to allow for real time measuring of blood glucose and real time response to those readings via delivery of hormones to prevent both hyperglycemia and hypoglycemia. A closed loop delivery system of insulin and glucogon is not currently available for marketing.
Beta Cell Transplants
Beta cell transplants (also known as the Edmonton Protocol) implant human beta cells, not machinery. Beta cell transplants are not insulin pumps. This procedure is mentioned here because many people who ask about insulin pumps also ask about beta cell transplants. For more information on this procedure and to learn who are potential candidates, please visit: http://www.islet.ca and http://adi.ualberta.ca/en/TheEdmontonProtocol.aspx.
Before You Decide on a Type of Insulin Pump
- Talk with your doctor, diabetes educator and health insurance company before choosing amongst these types of insulin pumps.
- Ask about any programming that limits the life-cycle of the pump (eg. does it stop working after so many years?)
- Play with the pump. Meet the reps and practice programming boluses, corrections, temporary basal rates. Use the calculators or wizards. Get the feel of the buttons. Do your eyes like the screen and letters?
- Know the features. Each pump has all the same basic features, although may perform them differently, but also has some unique features that make it stand out from the others. Again, play with those features don’t just assume the idea is “cool”. Sometimes the statement is true by trying to use the feature on the pump is not so easy or so “usable” for some folks.
- Will you be able to get supplies easily? Will the pharmacy order them in? Or do you have to order them online? Can you order supplies from your country and will there be border issues if you can’t?
- Ask about a cheaper price, or cheaper model and financing. One manufacturer may be offering a deal on their types of insulin pump. A competitor may match that deal if you ask. You won’t know till you try. And yes, I have had clients who try and who succeed.
Advantages of Insulin Pump, and Disadvantages.
Advantages of insulin pump therapy are many, and can vary depending on whom you talk to. Below you’ll find a list of both insulin pump advantages and disadvantages from the viewpoint of myself as an educator and pumper, and from other pumpers’ points of views. You’ll even see how pumps help people deal with their fear of hypoglycemia. There’s more to read than most websites as I’ve included real-life scenarios so you can better appreciate some of the points.
Advantages of Insulin Pump
- Flexible lifestyle: Sleep in, miss meals, avoid low if the basal insulin is properly set is one of the most appealing advantages. See comments in the point below about programmed basal insulin.
- Programmed basal insulin: An explanation first – Basal insulin works with the sugar that the liver makes over the day even when not eating. Basal or background insulin needs are very individual. Many people giving injections using NPH or Lantus or Levemir will have too much or too little background insulin on board at varying times of the day. For example, some people on injections find that if supper is late, their blood sugars start rising. This means there is not enough basal insulin to work with the sugar the liver is making at that time of the day. Or, they find that if they miss a meal they have hypoglycemia, meaning they have too much basal insulin on board. One of the advantages of insulin pump therapy is that the basal insulin is programmed to meet the individual’s needs so big excesses, or deficits in basal insulin, are eliminated. This allows people to miss meals, sleep in late etc without experiencing high or low blood sugar levels in most cases. So…if these past two weeks my blood sugars have been rising between 2 pm and 5 pm even if I don’t eat, I’ll program my pump to give me slightly more basal insulin for those hours only, every day. But just those hours – I don’t want more basal for the entire day. I can also have one basal pattern for a day shift and another for a night shift. Switching between them would only require the push of a few buttons. Yet more advantages. Below you see three basal patterns for three different people on a pump. Imagine how difficult it would be to try to meet their basal insulin needs with NPH, Lantus or Levemir.
- Temporary basal programs: prevent hypoglycemia. As an educator, this is one of the most underused but beneficial advantages of insulin pump therapy that I see. First, an explanation. Almost everyone on injections has at some time given their normal morning basal insulin, let’s say NPH, then started the day and realized “Wow! I’m busier than I thought I’d be,” and subsequently either experienced low blood sugar or had to eat and eat to prevent a low. Of course, if you could reach in and pull out some of that NPH you gave in the morning, that low sugar could be prevented. But alas, that can’t happen. Unless you’re on a pump. One of the advantages of insulin pumps is that background basal insulin is given as tiny doses of rapid insulin every 3 minutes or so. You have the ability to the insulin pump to, “Stop my normal basal insulin. Only give me 50% for the next 2 hours.” Or 60% for the next 3 hours. Whichever you choose. If your activity suddenly stops, or it doesn’t happen as you planned, you can return your basal insulin to normal with a few pushes of a button. This can significantly reduce hypoglycemia on active days. Basal insulin can also be programmed as increases too if it’s a lazy day or a sick day or a day you run high because of your menstrual cycle or even part of the day. There are advantages injections don’t easily have.
- Less risk of hypoglycemia or severe hypo:Primarily because of the two reasons directly above. It’s reassuring for people with diabetes to know that they can turn their background insulin off for a short period of time if they’re worried about a low or over gave insulin at meal. Although it might not be enough, it is still something they could not do when on injections. Pumpers can also reduce lows and their fear of lows by using the insulin-on-board feature, square or extended boluses (see below under variable blousing) and temporary reduced basal rates. The ability to reduce lows and their severity are significant and life changing advantages for some people.
- Precise dosing advantages: Give fractions of units. Meal boluses can include fractions of a unit – like 2.3 units. What? You don’t think you would need fractions of units? Well, maybe not you. But many people greatly benefit from being able to fine-tune their meal and basal doses to this extent because…sometimes one unit is just too much! This fine-tuning is one of the reasons pumpers can get better control. It helps lesson the fear of giving too much insulin and causing a low. Advantages of precise dosing are especially important in children or adults with small total daily doses of insulin.
- Variable bolusing: program insulin for pizza! Just what is variable bolusing, you ask? Imagine eating pizza. Do you have OK glucose readings 2 hr after pizza but then have glucose readings that rise, and rise and rise afterwards?? Dang that pizza for taking so long to digest. On a pump, you can program some of your meal insulin to be given now, and some to be given over a period of hours. You decide how much is given now, how much over a period of time and how long that period of time is. This is called a dual wave bolus or combination bolus. Dual wave boluses are also useful advantages for people who are fearful of giving all their meal insulin and correction at one time because “It just looks like too much insulin.” Their fear can be lessened if they give part of the insulin now and part over a time period. Then they can check their sugars hourly and stop the extended part of the bolus if they feel they don’t need it. Or…do you like lattes? It takes me an hour to drink mine but I can’t give all my insulin when I start or I’ll be low. So…I give a square or extended wave bolus. I program the insulin I need for my latte to be given over one hour. Clearly this is an advantage of insulin pumps that multiple daily injections would have a difficult time copying.
- Less erratic glucose levels, better control: One of the most identified advantages is that people usually get better blood sugar control on insulin pumps. Depends on the work put in and the individual. However, most people who start on insulin pump therapy experiences less dramatic swings in blood sugars and certainly less dramatic and less frequent hypoglycemia.
- Convenience: Diabetes is annoying so advantages that bring convenience are welcome. Your insulin is always with you, there in your pocket or bra or wherever you wear your insulin pump. It’s easy to nibble and give boluses as you go instead of having to get up and find your purse or insulin pen etc.
- Memory advantages: In case you ever forget if you gave your insulin for the meal or not, most pumps have a memory to scroll back through to view previous boluses.
- No multiple daily injections: You only need to insert a needle every 2-3 days when you put in a new infusion set. Usually that needle is removed and leaves behind that soft tubing called a canula.
- No more math:One of the advantages of insulin pumps is that most come with built in calculators and wizards. This means after telling it the number of grams carb you’re going to eat, the pump uses your insulin-to-carb formula to determine how many units are needed. The same is true if you input a blood sugar that is too high. It will use your formula you’ve previously inputted to determine how much insulin you need to fix that high. You can agree or disagree and change the amount of course.
- Remaining insulin on board: Have you ever nibbled and gave insulin repeatedly over an evening? Then gone to bed with a great blood sugar reading but wondered how much insulin you injected over the night and how much of that insulin was still on board working? One of the advantages of most pumps is that they’ll tell you the amount of active insulin still on board (Bolus on board, active insulin on board). If too many units are remaining, possible options to prevent a low could be to eat more carb or program a decreased temporary basal.
- Built in alarm clock: You can have set a number of times for your pump to alarm to remind you of something or to wake you – like for a 3:00 am glucose test.
- Continuous blood glucose monitoring: This is one of the advantages that is not present on all insulin pumps. Some pumps work together with continuous blood glucose monitors to show your blood sugar reading on the pump and to have the pump alarm if your blood sugars go too low or too high (you set the limits). There are limitations with these systems however for some people or some circumstances, they can be very useful for helping to spot trends and to avoid overnight lows. Medtronic’s next generation pump will supposedly offer the option of having the pump temporarily shut off if it senses blood sugars dropping too quickly (this is 2009).
- Advantages in timezones with traveling:Adjusting for time-zones when traveling on a pump is easy. When on injections, people often need to meet with their educator to discuss how to adjust their long acting basal insulins to avoid overlap or gaps. However on a pump people usually leave everything as is until they wake after their first night there – then change the pump time to local time.
- Improved quality of life: Many on insulin pumps would say that pumping has helped normalize their lives and improved the quality of their lives.
Disadvantages of Insulin Pump Therapy
- Cost: Not everyone can afford this therapy, especially if their health insurance does not cover it. Both the pump, it’s monthly supplies and especially continuous glucose sensor monitors if you want to use them, are all costly items.Pumps in 2009 are about $7300-7800 Canadian or US, with monthly supplies about $300 not including test strips. This is one of the primary disadvantages.
- Being attached: Yes, the insulin pump is worn to bed, to dances and under skimpy dresses. It’s worn 24 hrs a day unless temporarily removed for showers, swimming, heavy contact sports and intimate moments. Even then, it does not always have to be removed. Some people never accept the feel of having a device always on them, whereas others quickly loose sense of wearing it after a week. Be aware that most pump companies offer your money back up to 90 days after purchasing if you find this a disadvantage. There are various pump accessories available through the pump companies and other independent sites to help people incorporate the pump into formal wear, pajamas etc.
- Risk of DKA or sudden unexpected hyperglycemia: DKA is diabetic ketoacidosis. It occurs when there is not enough insulin to sufficiently use the glucose in the body and the fat stores are burned instead. At a certain point, the blood pH is affected and the blood becomes more acidic. This is a serious complication of diabetes and the biggest disadvantage re: safety. It can happen quicker on insulin pump therapy than on a regime with injections. Since there is no intermediate or long-acting insulin used in pump therapy, a problem with insulin absorption into the site or insulin infusion if the pump malfunctions or battery runs out could lead to high glucose levels and ketones quickly and possibly to DKA in as little as 5-6 hours in some people. Pumpers must be diligent with glucose testing and problem solving to keep themselves safe. Alarms will not always sound on the pump – for example – if an infusion site has been left in too long or is inflamed and is not absorbing the insulin because the site is inflamed the pump has no way of knowing this, as insulin is being delivered as usual. If however, the tubing is clogged then the pump will usually alarm to inform you.
- Frequent glucose testing: Most pumpers test a minimum of 4 times a day and often 8 times a day or more. This is both for safety and to maximize glucose control.
- Ketone testing: I typically see people on injections ignoring ketone testing when their blood glucose levels are high. I’ve noticed that in some pumpers who’ve done this, it takes them 5-8 hours to fix a high. In some cases I’ve seen longer. Each clinic has their own guidelines for how much extra insulin to give if ketones are present in a pumper, but the bottom line is, most people require extra insulin above and beyond their normal correction dose to fix a high reading if ketones are present. And usually that bolus is given by needle, not pump, to be sure it gets into good tissue. It saves time to check up front for ketones if you suspect a site absorption issue and give the extra insulin recommended by your doctor or eductor rather than correct a high with usual dose, correct again, correct again…. Be sure to ask your educator or physician how much extra insulin to take if you have ketones.
- Carb counting still done: Most people on pumps will benefit from keeping and indeed intensifying their carb counting. Many need to carb count to a pickier level since they don’t have excess insulin floating around from intermediate or long-acting basals.
- Bolus with all carb eaten: Some people on injections who eat but don’t need to give a dose of rapid insulin for a meal or snack because of excess NPH have a hard time remembering to bolus each time they eat carb food on a pump.
- Infusion site problems: Infusion sites should be rotated every 2-3 days and sooner if irritation occurs. Irritation and infection are more likely to occur if left in longer than this. Unfortunately, all of the sites that are currently used for normal needle injections are not always comfortable for putting in an infusion set. For example, most people find infusion sets to be uncomfortable if placed at the pant’s waistline rubbing against the pants, or down the midline, or a few inches below the underwire bra where it rubs when women bend or sit. It is easier for people on pumps to overuse a site and have it get lumpy and ineffective at absorbing insulin. Rotating infusion set sites is very important. Since most pumps come with tubing, this may mean creative camouflage of tubing if you were to place the set on the arm and experimenting with different infusion sets for different parts of the body perhaps.
- Carrying backup supplies: A battery, an infusion set, a few syringes and a small pen vial of insulin should be carried for backup in case the pump batteries go, the pump malfunctions or more commonly, the infusion set rips out or the insulin runs out. Yes, the pumps have low insulin supply alarms but life does happen. For some people, carrying the back-up kit is an annoyance and a pain however, it can pay off in preventing DKA.
- Frequent refilling if type 2 diabetes: Many people with type 2 diabetes are insulin resistant and require large doses of insulin. Because of this, the pump may have to be refilled every 1-2 days – both an inconvenience and an expense for some.
- Problem-solving: Successful and safe pumpers are good at problem solving both technical and medical problems with their diabetes. Some people find the technical parts and problem-solving boluses, insulin on board etc too difficult or too onerous.
- Goodbye bikini?? Pump bumps: Sometimes round pink bumps exist after infusion sets are removed. Some people find that changing their infusion sites sooner can help prevent this. Others find they get the pink dots even if they don’t get the bumps.
- Time demands: Many people do not improve their diabetes control to the extent they could because they don’t take the time to properly set their basal rates (meaning missing meals and resetting rates until blood sugar stays stable). This time could vary from 2 weeks to a few months. Also, basal rates should be checked again after about a year or anytime repeated unexpected highs or lows are showing a pattern. Although the expected advantages of insulin pumps is to have better blood sugar control, without the time and effort put in by the user, this just may not happen.
- The curious and the ignorant: If you have the insulin pump showing, or pull it out to use it or check it or tuck in your tubing, you just might end up with someone asking, “What’s that?” They might go on even further after they learn you have diabetes and say something like, “Should you be eating that?” These may or may not be an issue for you, depending on your mood and how you like to handle these people.
- Ripped out sets: Although advantages of insulin pumps include not having to inject a needle so often, sometimes infusion sets need replacing sooner than you anticipate. Like when they rip out. This could happen when whizzing past a kitchen cabinet and getting hooked on a knob, or whipping down your pants only to realize you had placed the set in your leg today. This doesn’t happen often for most people, sometimes not at all. But if you’re clumsy like me, it can occasionally happen twice in day. Be prepared, cause it’s not likely to happen at a convenient time. Or so my guests have learned as they’ve experienced my creative swearing while I’m whipping around the kitchen trying to be an iron chef while suddenly yanked back by my pump’s umbilical cord. Getting a pump? Get a sense of humor first. You’ll need it.
Causes of Low Blood Sugar
General & Insulin Pump Related
Low blood sugar in diabetes can be related to a number of factors. For the person on an insulin pump, there are even more variables to consider. Below are two lists. One for general causes of hypoglyemia in diabetes, the other for insulin pump related causes. Pumpers are advised to review both lists.
It’s important to find the reasons for hypoglycemia to try to prevent future episodes. However, it needs to be stated that sometimes the occasional low blood sugar seems to defy logic and explanation, no matter how hard you, the endocrinologist or diabetes educator seek a solution. Severe hypoglycemia, or even mild but chronic episodes of unexplained low blood sugar levels require in-depth investigation as another medical disorder may be involved.
Causes of Hypoglycemia in Diabetes
- Too much meal insulin or too little carbohydrate eaten (or too much diabetes medication)
- Insulin-to-carb ratio is inaccurate or the carb counting is inaccurate.
- Guessing doses needed instead of calculating insulin doses needed.
- Physical activity: unexpected or not accounted for with changes to medications or food. Could be activity from the previous day.
- Missed meal or snack (for those not on insulin pump therapy. Appropriate programming on pump therapy should safely allow people to miss meals and avoid snacks)
- Wrong timing of insulin / medication: Carbohydrate food eaten too long after the meal insulin (or medication)
- A low glycemic index meal; the carb gets in much later than the insulin (pumpers can ask their MDs about trying dual wave or combination boluses for these meals. Part of the insulin now, part slowly injected over a longer time frame.) Accidental injection in muscle
- Giving insulin too soon after last dose: It is common for people to “stack” correction doses trying to get their blood sugars down faster and then suffering a low later.
- Wrong dose: Accidental repeated dose or over-dose of insulin or medication. (Pumpers can avoid this by checking their bolus history and also review their ‘insulin on board’ or ‘bolus on board’ features. Depending on your pump, you may have to program in your blood sugar in the wizard as if you were going to give a bolus, but indicate 0 g carb to check the remaining insulin on board.)
- Stress (usually causes hyperglycemia, occasionally low in some people)
- Weight loss
- Renal disease: reduces the clearance of insulin from the blood.
- Gastroparesis (slow emptying gut) or dumping syndrome (too quick to empty)
- Diarrhea and vomiting from illness or antibiotic (can also cause high blood sugar or hyperglycemia)
- Menstrual cycle (some women experience low sugars when ovulating, others when actually menstruating and others not at all, perhaps the reverse.)
- Pregnancy (particularly in the first trimester and the end of the third trimester)
- Adrenal insufficiency: uncommon disorder more likely seen in type 1 than type 2, in which body makes too little of the hormone cortisol.
- Heat or rubbing at site of injection
- Diabetes is changing and meds or doses need to change. (For example, someone newly diagnosed with type 1 diabetes who experiences the “honeymoon” soon after diagnosis)
Insulin Pump Related Hypoglycemia
- Left-over NPH, N, Glargine or Levemir from just starting pump (we’ve actually found some people still appear to have reservoirs of these insulins for up to 2-4 days after starting the pump.)
- New infusion site (virgin site in particular. Eg. your first time with set in your arm.) Generally a good idea to avoid a set change before bed to avoid potential hypo or hyperglyemica. Best to check sugars a few hours after set change.
- Exercising the area with the infusion set (eg. site in arm and pumping iron).
- Basal, bolus or correction insulin needs changing.
- Stacking correction doses. Yes I know it was mentioned above but pumpers are more likely to stack.
- Stacking food boluses with a slightly less than perfect insulin-to-carb ratio (if you suddenly eat a much larger amount of carb then any tiny error is multiplied out).
- Effect of previous dual wave or combination bolus in the day
- Effect of previous increased temporary basal in the day
- Temporary increased basal is running, but you’ve forgotten about it.
- Priming of tubing while hooked up to pump or hooking up prior to stopping the prime.
- Accidental changes to basal rate (I’ve seen it!). Review your basal rates periodically and have them written on calendar or somewhere in case the pump settings are lost due to malfunction, battery out too long etc.
- Infusion set in muscle (I’ve seen it in a calf. Ouch.)
- Although extremely unlikely, the pump could mis-deliver in the case of a cracked case exposed to water. This happened a few times in the past. Frequently check your protective outer case for damage.
Pump Features to Help Prevent Hypoglycemia
Consider discussing the following features with your physician or health educator to determine if they’re appropriate to use to help prevent lows: temporary decreased basal, dual or combination bolus, square or extended bolus, pump alarm clock settings to remind you to test (eg. 0300 hr), pump alarms to remind you to test 2 hr after any bolus, insulin-on-board (or bolus-on-board or active insulin) and continuous blood glucose monitoring (although often gives delayed readings viewing the trend can often let you know if you are dropping quickly and at risk for a low, depending on your current glucose reading.
Treatment of Low Blood Sugar
The fastest treatment of low blood sugar is a glucose product. There are various types, so read the label and be sure to take enough. A standard treatment of hypoglycemia is 15 g glucose. However, talk with your doctor or educator to see if this needs to be individualized for you.
Some people who are sensitive to insulin (eg. someone with a correction factor of 1 unit to drop 4 mmol or an insulin to carb ratio of 1 ) might need more. A one unit mistake could drop you a lot. Likewise, the reverse could be true. It’s true that juice can also increase blood sugars, however because it is fructose based it is often about half the speed in fixing the low blood level than pure glucose tablets. Faster, in this case, is better.
Symptoms of Hypoglycemia
Typical early warning symptoms of hypoglycemia include shaking or trembling, sweating, sudden hunger, palpitations, anxiety while slightly later symptoms might include difficulty concentrating, weakness or tiredness, vision changes, dizziness, or headaches.
Symptoms can vary from individual to individual and even within the same person. Sometimes symptoms are vague and described as nothing more then “feeling different” or “feeling not quite right”. It’s important when on diabetes medication, especially insulin, to check blood sugar with any of these symptoms to verify if having a low blood sugar.
Symptoms of low blood sugar are warning signs and necessary to have if your readings drop below 4 mmol/L or 70 mg/dL. All too often people don’t treat lows if they don’t have symptoms. They don’t think it is a concern because they’ve “felt” other lows and treated those. Unfortunately, not treating lows can make it more likely to develop hypoglycemia unawareness – meaning not being able to sense the lows.
It is the low blood sugar levels themselves which can be dangerous, with or without symptoms. They dull reflex time (eg. if driving) and can predispose you to falls (yes, even you young ones who haven’t hit the age of 30 yet). Don’t be fooled by thinking “no symptoms so no problem”. This is much like me saying that my car’s fuel gauge is sitting on the red empty side and the fuel warning light is on but hey, the car has no symptoms. it is driving fine so I’ll ignore it.
If you do have hypoglycemia unawareness and are on insulin, there are processes that can help to retrain the body to sense low blood sugars sooner. Talk with doctor and medical team about this. They will likely begin by setting higher blood glucose targets for you. In the mean time, treat all low blood sugar levels quickly and with a glucose product.
Discuss frequency of hypoglycemia with your doctor and diabetes team. Sometimes, a mild low once a twice a week that is easily recognized, has an understandable (and hopefully preventable) cause and is quickly self-treated is not viewed as a concern. However, this decision and any relating to your safety must be made between you and your physician. You should meet with your doctor as soon as possible if you have a low blood sugar that required the help of someone else to treat.
Unexpected High Blood Sugar ?
There are many sneaky causes of high blood sugar, as people with diabetes well know. Understanding the reasons can reduce the frustration and help prevent future episodes. Everyone with diabetes could benefit from reading this list of causes for high blood sugar. Click here for this general list. For insulin pumpers, what follows are unique reasons for sudden hyperglycemia (high readings) when on an insulin pump.
Stay safe.Read the disclaimer.See your doctor for all medical advice.This site isn’t medical advice.
17 Causes of High Blood Sugar Related to Insulin Pumps
- Review all the reasons for diabetes-specific causes for high blood sugar if you haven’t already. Although not pump specific, they are often the primary reason for sudden hyperglycemia in the pump clients I see. Definitely review the insulin pump causes below, but not at the expense of forgetting about all the “non pump” causes.
- Cannula left in too long: This is by far the most common insulin-pump-related cause for hyperglycemia. Many people exceed the recommended 2-3 day wear for cannulas (the part of the infusion set that is under your skin). It doesn’t always pose a problem, however the more insulin you take the more of a problem it is likely to cause. Tissue that is irritated does not readily absorb insulin as well as it should. Sometimes the site looks pink, puffy and sometimes it looks fine, but will not absorb well. Some people are more likely to overlook a site problem if using a 90 degree (straight in) cannula as the infusion site can’t be seen as well as it can be with a 30 degree infusion set. This doesn’t mean you need to switch sets, only that you need to remember to change them rather than rely on looking at them to see how they are doing. Otherwise, you might put yourself at risk for high blood sugars, sore lumps or potential DKA. Checking and changing infusion sites regularly should be done regardless. See other reasons for this below.
- Large total daily doses of insulin: If you give bigger boluses or more insulin overall, like at Christmas due to the sweets etc, then your site may not last as long as it usually does for the same reasons listed in the point above. If changing the set more often due to eating more carbs during Christmas, Halloween or holidays is a concern due to cost, talk with your health care provider about giving bigger boluses by syringe or insulin pen and using the pump just for basal insulin during those periods in your life. The site will last longer.
- Forgetting to confirm a bolus: If you ask for a bolus by hitting a few buttons and not looking at the pump, the pump may beep or vibrate back to confirm the units you’ve asked for (eg. if you are not using the built in calculator). Usually, you have to hit a button after this to confirm the bolus. If you don’t, the pump can cancel the bolus (although usually you’ll get a few beeps to notify you that it did not give the bolus). If you have an unexplained high, check back in your bolus history to see if the bolus was actually delivered. For those of you not yet on a pump, you might be surprised (and relieved) to learn that there are various confirmatory steps in place to prevent accident delivery of insulin.
- Site irritation:This could be as simple as inflammation from your waistband on pants or as bad as a site infection. Site irritation, lumps or infections all negatively affect insulin absorption and can cause high blood sugar. And of course, infections require medical attention with antibiotics as the site gets extremely swollen and tender as it progresses.
- Large air bubbles in the tubing or reservoir: Air into fat tissue is not a big issue for safety but can be for high blood sugars. An air bubble of about an inch in length inside tubing is usually equal to about a unit of insulin for many of the infusion sets (be sure to check with the company). Depending on how sensitive you are to insulin, that could increase blood glucose readings. Of course, most air bubbles come from the insulin reservoir in the pump. Small champagne bubbles in the reservoir are usually not an issue and do not typically result in high blood sugar. Bigger bubbles often pose a bigger problem when the reservoir is nearer to being empty.
- Forgetting to re-connect pump: This could be after shower or intimate moments, and could result in DKA in a few hours (especially if going to be bed without reconnecting and sleeping through the night.)
- Ineffective connection of tubing to the hub or connector on the skin: No matter the infusion set, always gently tug the set when attached to the skin to be sure it is in.
- Infusion set ripped out:Most people would feel this. But… sometimes cannulas rip out during the night. This emphasizes the importance of testing glucose readings first thing in the morning to reduce the risk of DKA. For those whose sets don’t adhere well, a clear soft protective covering like Tegaderm can be placed over the infusion sites. Others may use a special adhesive product on the skin prior to inserting a cannula. Also consider using a safety loop of tape to reduce the risk of this happening. Where the tubing is attached to your skin, loop the tubing and place a strip of soft tape over the loop attaching it to your skin. Then if the tubing yanks, the tape and the loop are the first things to take the force and come undone but the canula is still in the skin.
- Not priming tubing when re-using it:Many sets allow for tubings to be re-used once. However, even though there is insulin in the tubing, still go through the entire normal set-up as if the tubing were new.
- Need for different type of bolusing:Some meals just don’t do well with the normal or standard bolus. Talk with your educator to see if you could benefit from using dual wave/combination boluses where some of your insulin is given right away and the rest over a period of time that you select. This works well for some people on pumps eating high fat meals like pizza and Chinese food.
- Previous decreased temporary basal or disconnect:Sometimes pumpers temporarily stop their basal, disconnect for a sport or use a temporary decreased basal. This is often done to reduce the risk of hypoglycemia but is sometimes one of the causes of high blood sugar later on. Remember, rapid insulin works in 15 minutes for some but has a duration of up to 4 hours in many people (although the later part of the action time is not strong). So any change you make now, could potentially affect you now and much later on. Oh, and sometimes people set a very long decreased temporary basal and simply forget.
- Accidental change or zeroing of basal rate:Sometimes people accidentally program their basal rate downwards when meaning to do a temporary basal. Keep a copy of your basal rates written on a calendar or journal just in case.
- Sweating off, tunneling, O-ring leaks, hub leaks…All very unique pump problems. Please see this page of diabetes.net for descriptions.http://www.diabetesnet.com/diabetes_technology/insulinpumps_problems1.php
- Insulin pump failure:Rare. But still possible. If happens, immediately call the 1-800# on back of pump for a replacement. To prevent or treat high blood sugar, be sure to have an emergency kit at home that has a prescription for your dose of backup basal insulin (eg. NPH, N, Glargine, Lantus etc) with either syringes or insulin pen. Be sure to have guidelines from your educator on how to manage high blood sugars and prevent DKA (diabetic ketoacidosis) if your pump fails.
Do not hesitate to seek urgent medical care if you are on an insulin pump and experience high blood sugars with ketones that you cannot manage or reduce yourself.
Everyone with diabetes should review this list of reasons for hyperglycemia. It can explain some, maybe many of those unexpected and frustrating high readings. If you’re on an insulin pump, also read the extra 15 ways insulin pumps can cause hyperglycemia.
Stay safe.Read the disclaimer.See your doctor for all medical advice.This site isn’t medical advice.
Causes of Hyperglycemia in Diabetes
- Food related. This can be anything from:
- eating more carbohydrate foods than normal;
- not realizing certain foods contain carb, which is very common;
- underestimating the carb in some foods;
- doing “wild-ass guessing” (eg. I know it’s carb, I’ll just give some insulin. Not sure how much carb, not sure how much insulin – ahhh – I’ll just give a unit or two);
- not bothering to consider which foods are carb foods;
- high glycemic index carbohydrate food: As an example, I always require more insulin when eating the same amount of carbohydrate from white bread than from say, my oatmeal. And yes, low glycemic index foods have been shown to lower blood sugar in both type 1 and type 2 diabetes. Again, everyone is different, so here is where the value of self glucose testing and record keeping comes into play.
- using an insulin-to-carb ratio incorrectly;
- using a ratio that you haven’t verified that works or sticking to an old ratio that just doesn’t work anymore (why or why are we so hesitant to change our old habit math?) or perhaps, if giving fast insulin with meals, talking to your educator to see if learning about carb counting and insulin-to-carb ratios is appropriate for managing your diabetes.
- Giving meal insulin or meal medication after the meal
- Forgotten medication or insulin
- Not enough meal insulin or meal medication: Again, some of these reasons may relate to number one above.
- Not giving a correction dose or enough of a correction dose:If your blood sugars are high before the meal and you give insulin just to cover the food, then chances are you will be high again later. Many people who take insulin with each meal need a “correction dose” or a “sensitivity factor”. This is basically a formula you use to determine how much extra bolus insulin (eg. regular, rapid insulin) is needed to drop the blood sugars into target. Or, put a different way, how much one unit of fast insulin will drop your high blood sugar level. Talk with your diabetes educator if you would like to learn more.
- Less physical activity than normal:Yes, bugger that it is, sometimes just missing one evening’s walk can do it. Although, more commonly, it takes missing 2-3 day’s worth to see a difference. But…not always. As an example, if I walk within 1/2 hr of breakfast then I need half my breakfast insulin. If I don’t walk one day – I need my full dose, even if I’ve walked the day before. Everyone is different.
- Technical or absorption problems with insulin delivery:
- Not doing air shot with insulin pen. You could
- Insulin at room temperature longer than 30 days (although most will find it still works fine into that second month but please, do take this into consideration as technically the insulin is shown to act well for only 30 days at room temperature or after the insulin vial has been punctured even if still refrigerated)
- Injecting into scarred tissue or overused injection areas
- Giving large boluses (doses) into one injection site (eg. 50 units or more. Usually, educators instruct clients to give these doses as 25 units given twice in two separated areas to allow for better absorption. See causes of hyperglycemia related to insulin pump use.
- Lumps or clots in the insulin or what looks like large flakes of dandruff. This means part of the insulin has denatured from either heat or extreme cold and should not be used.
- If cloudy insulin not mixed well prior drawing up and injecting. Although, this is more likely to cause a low early on followed by a high 12-16 hours later if too much fast insulin and not enough of the slowing suspension is given. Still, by the end of the vial, there may be too much concentrated slowing suspension resulting in erratic blood sugar levels.
- Stress:Don’t underestimate the effect of stress in causing high blood sugar levels.
- Illness or infection:I am constantly amazed at how the body can produce such vast amounts of glucose even before the signs of the cold appear – like 2 days before. Alas, some people weather colds and illness without experiencing high blood sugar.
- Ovulation or menstruation:Some women with diabetes mark their periods and times of ovulation on the calendar so they are better able to see if there is a pattern of how these affect blood glucose levels. Some women experience hyperglycemia during their period while others experience low sugars.
- Pregnancy, second or third trimester: The placenta plays a very large role in increasing the resistance to insulin, and hence increasing blood sugar levels. It is very common and normal in pregnant women with diabetes to see increased insulin needs due to hyperglycemia in these parts of the pregnancy. All pregnant women with diabetes should follow closely with their diabetes team and specialists. Because of this insulin resistance caused by the placenta, women without diabetes are generally screened for gestational diabetes sometime around 24 weeks gestation or as advised by their physician (ask about screening if you are pregnant and don’t already have diabetes ).
- Certain medications and illicit drugs:For example steroids, prednisone, large doses niacin can contribute to hyperglycemia. Talk with your pharmacist to learn the effect of any of your medications or supplements on blood sugars. Street drugs could have varying effects and of course could kill. Marijuana increases appetite, eating and hence blood sugars. (Please, just say “NO!” )
- Changes in diabetes: The body changes, so does diabetes. Although, usually these changes are gradual and don’t result in a sudden bout of high blood sugar readings. If you have recently been diagnosed with type 1 diabetes, then the honeymoon (the period in which you still have enough beta cells as they haven’t all been destroyed by your body) may be over. If you have type 2 diabetes, it could be that the beta cells are getting even more “tired” (called beta cell exhaustion), together with your liver making even more glucose than it should (especially overnight resulting in higher fasting readings) and the insulin being used poorly (insulin resistance).
- Adolescence:Growth hormones, particularly those in teenage boys with diabetes, can greatly increase blood sugars and insulin needs. Of course, so can performance steroids (stay away from those lads!)
- Certain medical conditions: If you already have diabetes, you don’t really need to consider these reasons for hyperglycemia, as likely your physician already has. Diabetes can be caused secondary to some medical disorders. People often read these disorders and start thinking the worst, but honestly, the vast majority of people diagnosed with hyperglycemia do not have these medical disorders: hemochromatosis, pancreatitis, pancreatic tumor, and a large list of inborn genetic defects and disorders that are associated with diabetes.
- Sometimes nothing makes sense! I would be remiss if I didn’t point out what everyone with diabetes already knows…sometimes logic defies the odd high blood sugar reading because really, we know so little about what is going on in the body. Although, I sometimes believe that some of the specialists fail acknowledge this point enough. Perhaps it’s because they devote their lives to helping, and the only way to do that is to find answers that make sense. Regardless, it is nice to know that two plus two does not always equal four. However, if hyperglycemia occurs on a regular basis then something needs to change (eg. medicine, insulin, activity) to help lower those glucose readings, even if you don’t know what’s causing them. Talk with your doctor to help you troubleshoot options for hyperglycemia.
What are insulin pumps? What’s a basal rate?
nsulin pumps are small electronic devices, slightly bigger than a pager, worn by people with type 1 or type 2 diabetes. Depending on the model, a pump holds 180-315 units of insulin. It is worn 24 hours a day, with some exceptions like showering, swimming and intimate moments when it’s taken off. It can be carried in a pocket, a bra, underwear…places are limited only by the imagination and comfort.
Diabetes pumps deliver insulin through a small tube placed under the skin (canula) that is replaced every 2-3 days. A reservoir holds the insulin inside the pump and is refilled when the insulin runs out (unless the pump is disposable, but most aren’t).
Pumps will automatically deliver background basal insulin (once programmed) and need to be manually programmed each meal or snack to deliver bolus insulin. Blood sugar testing and carb counting still need to be done.
Basal and bolus insulin
Insulin pumps deliver a tiny amount of rapid acting insulin every hour into fat tissue. This is called basal insulin. Larger amounts of rapid insulin are delivered on demand when the user decides it is needed, like for meals. This is called bolus insulin.
Basal or “background” insulin takes the place of NPH or Levemir or Lantus. No intermediate or long acting insulin is used in pump therapy. This basal insulin works with the sugar that the liver makes every hour to keep the blood sugars stable when not eating.
Setting Overnight Basal Rates
When starting pump therapy, each user programs the pump with the amount of basal insulin needed per hour for their individual needs to keep their blood sugars stable if not eating. This is often referred to as “setting the basal rates”. Each clinic has it’s own procedure for doing this but here is an example. Please follow with your medical team.
Overnight basal rates are usually tested and changed first. Typically this is done by starting with the same basal rate for each hour of the day, as an example 0.6 units per hour. This is determined by your doctor or health educator and based on your individual needs. To check overnight basal rates, the pumper will not usually eat after 9pm and will test blood glucose levels at midnight, 0300 hr, 0600 hr and 0900 hour. If blood sugars rise or drop too much in any of those time frames, the rate of basal insulin is adjusted for that period until blood sugars stay relatively the same.
For example, if blood sugars stay about the same from midnight to 0300 but rise from 0300 to 0600, then stay the same from 0600 to 0900, then the basal rate from 0300 to 0600 is slightly increased, as an example to 0.7 units per hour. The others are left alone. This is done until the person can have relatively stable blood glucose levels from bedtime, overnight till morning. Setting overnight basal rates can take people anywhere from 2 to 14 days or more depending on how many changes need to be made and rechecked and how many days people can manage waking up to check glucose levels.
Setting Daytime Basal Rates
Once overnight basal rates are set, daytime rates are checked. This is done by missing breakfast and checking blood sugars every 1-3 hours (the suggested duration varies between books, educators, physicians and the pumper’s personal preference.) If the glucose levels rise or fall too much then the rate is adjusted for those few hours until blood sugars stay stable when the meal is missed. Then onwards to missing lunch, and then supper.
Changing Basal Rates
Although basal rates may have been set when someone with diabetes started a pump, they typically need to be tweaked over time as the body and life changes.
Also, temporary basal rates can be programmed within a few seconds. So if someone is going power shopping or playing sports and wants to avoid a low blood sugar, the basal rate can temporarily be decreased by 50% for 2 hours, as an example. The % decrease or increase and the duration are all decided by the person with diabetes with advice from their health care team.
Being able to program the background insulin – and change your mind on a dime – is one of the biggest advantages of pumping. It allows you to sleep in, miss meals, play sports and prevent lows or greatly reduce the severity of them. Life with diabetes never seems to stay the same. Thankfully, insulin pumps can be programmed quickly to accommodate this.
What Don’t Insulin Pumps do?
- Insulin pumps don’t take your diabetes away.
- Pumps don’t automatically give you extra insulin if your blood sugar is high.
- Insulin pumps don’t automatically give you insulin for your meal until you tell them how many grams carb you are eating. Then the pump can help you do the calculations. You still make the ultimate decision about how much insulin to take for meals.
I suggest you read, a day in the life of an insulin pumper to get a feel for daily life with insulin pumps.
Are you a candidate to pump insulin?
Want to pump insulin? After learning the benefits of insulin pumps many people with diabetes want to start on one – immediately. However, they may be disappointed when they chat with their health care team and realize they may not be ready yet. Review what makes people safe candidates for this type of insulin therapy and discuss with your health care team. Each team may individualize the criteria below.
- Realistic expectations:What do you hope an insulin pump will do for you? Do you know enough about the advantages and disadvantages of insulin pump therapy to know if it will really do what you hope it will?
- Insurance coverage:For many people, the simple cost of a pump and it’s ongoing supplies may rule out the therapy if their insurance does not cover it. Does yours? In 2009 a pump costs approximately $7300-7800 Canadian or American. Ongoing supplies are about $300 per month. This does not include glucose test strips.
- Type 1 or type 2 diabetes taking insulin at least 3 times a day:Yes both types of diabetes are appropriate for pumping. However, if you only take insulin at night then pumping isn’t for you. Also, if you have type 2 diabetes and have very large total daily doses of insulin, the pump may not be practical as it holds only 180-315 units, depending on the brand. If you have to fill the pump often, the work and cost become unreasonable and the therapy becomes unsafe if the pump runs empty.
- Had diabetes for at least a year: Again, most clinics would say this although there may be people out there who have not had to do this. The rationale is that most people who pump insulin have type 1 diabetes. In the first year of diagnosis the body usually still makes insulin or is “honeymooning”. So…it is quite likely that if basal rates where determined during the first year, they would have to be reset when the honeymoon starts to end and reset again when it fully ends. This is simply too much work to go through both for the client and the clinic. Also, recently diagnosed clients may not be experienced enough in handling all the usual aspects of living with type 1 diabetes and troubleshooting.
- Some clinics (let’s hope not all) might say poor diabetes control:Some clinics may not endorse pump therapy unless your diabetes is poorly controlled. However, most clinics hopefully recognize the improved quality of life that can come when you pump insulin even if you’re well-controlled on injections currently.
- Are of any age:Again, clinics may all have their opinions on this. However, there are pumpers out there who are infants on up to their 80s. As long as these other conditions are met, age is not usually a consideration. Of note, pump controls can be locked so that infants and kids cannot inadvertently give themselves insulin or change programming.
- Adequate vision and dexterity with hands: Pumps are like little computers that need to be programmed so the screen must be visible and the buttons must be easy to handle.
- Demonstrate appropriate problem-solving skills with readiness to act on them:Either parents, caregivers or direct users who plan to pump insulin need to demonstrate understanding of insulin action, carbohydrate, plans to avoid lows and highs, past experience in dealing appropriately with highs and lows and the like. Pump issues like a dislodged infusion set need to be dealt with immediately no matter where and when it occurs. Procrastinators with respect to self-management of diabetes aren’t generally safe on pumps.
- Frequent glucose testing:Pumpers generally test minimum 4 times a day but more likely 8 times, possibly more when first starting the pump and setting basal rates. You must show that you are capable and willing to do this. There have been plenty of unfortunate incidents when pumpers have neglected testing frequently enough. If you’re specialist is hesitant to recommend a pump for you it may be an experience they’ve had with a previous client has made them cautious.
- Use insulin-to-carb ratios already:Most who pump insulin won’t maximize the benefit of the machine if they don’t do insulin to carb ratios. This means carbohydrate counting. Usually people know how many grams of carb they can eat per unit of rapid insulin prior to considering pump therapy. Although this number may change when they start the pump, they are familiar with the concept and usually well-practiced. There are a few pumpers who still like to eat consistent carb from meal to meal so don’t use ratios.
- Use a correction dose already: People should be comfortable with using a formula to determine how much extra insulin to take to fix a high glucose reading. This can be called correction formula or insulin sensitivity factor.
- Agreeable to being attached 24/7:You must be agreeable to wearing the pump and trying to troubleshoot outfits, pajamas and so on while hopefully not being too concerned with body image. Most people easily overcome their problems with wearing the pump. In fact, women have gotten pretty ingenious about hiding the pump in tight dresses. Keep in mind that most pumps have a 90 day money back policy (or 60 days from date of pump training) in case you are one of the few that can’t adapt. Be sure to check if you think this will be a concern for you.
- Be committed to spending time:Training to pump insulin and setting basal rates can be demanding for time so if you don’t have it to give, or can’t make room for it, it may not be the safest time to start on a pump.
If you are hoping to one day pump insulin, review your reasons for wanting it – then discuss with your health care team. Often it’s a great choice but just as often there are small changes that can be made to insulin regimes to accommodate people’s main wishes. Don’t be discouraged if your educator suggests you’re not yet ready for an insulin pump. Discuss developing a plan and date to meet the necessary criteria. Your desire to pump insulin may only be a few stepping stones away.
A day in the life of an insulin pumper
Here’s an example of a few days in the life of an insulin pumper. Of course, the examples could be endless and not everyone will do as much temporary programming in a day. Try to picture your day and how you might be using the pump. The intent of this page is to introduce some of the things pumpers could be doing, the decisions they make, some of the advantages and disadvantages of pumping. Just a reminder: don’t use any of this information as medical advice – check with your health care team.
06:00 Saturday Wake up. Realize it’s Saturday. Go back to sleep.
10:00 Wake up again. Test blood sugars, they’re fine. About the same blood sugars as what I went to bed with last night. Take pump off. Shower. Put pump back on. I count breakfast carbs and input into pump. I push a few buttons. Pump calculates my breakfast insulin dose. I agree so push another button. Pump gives me my insulin. I eat breakfast.
11:00 Friend calls and invites me to go to home show. I expect it’s huge with lots of walking so program my pump to give me only 50% of my basal insulin for the next 3 hours so I don’t get low while walking.
12:00 Small home show. We’re done already. Blood sugars are fine and I did walk some, but not much. I program my pump to go back to normal in half hour, instead of another two more hours since my walking is done.
2:00 Finally we get lunch. My friend has been chewing my ear off at a coffee shop for 2 hours. My blood sugars are actually a bit high as I’ve done nothing but sit and I really didn’t walk much at the home show. Program in the blood sugar, and the grams carb I’m going to eat. The pump does its calculations suggesting a correction and meal bolus dose. I agree and push another button.
3:00 . Check sugars. Still high. I want to nibble on fruit. Input blood sugar and grams of carb into pump. It suggests give nothing for a correction as plenty of insulin still on board but give 1.3 units for the fruit. I agree and push a button.
5:00 pm Check sugars to be sure I did come down. I’m fine.
8:00 Check sugars. They’re fine. Go to movie. Nibble on popcorn. Program some units to be given over 1.5 hours as that’s how long it takes me to eat my popcorn usually.
10:00 Nibble on nachos at friends. Give a few units by quick bolus as don’t want to look at pump or check sugars.
11:00 Nibble on more stuff at friends. Give a few units by quick bolus as don’t want to look at pump.
01:00 am Test sugar. It’s in target. Review active insulin on board. Oh my goodness –I still have 4 units that are working. I’ll be low if I don’t eat a bit. I eat some carb.
03:00 am Pump alarm wakes me. Insulin supply in the pump is low; there are 30 units left. That’s plenty to get me through the night. Sheesh. The life of an insulin pumper. Go back to sleep.
0800 Sunday Wake. Test sugar. It’s fine. Refill insulin pump. I need to change infusion set. Hmm…where can I put it? What will I be doing the next few days? I don’t want to choose a site that will get irritated or in the way. I make my choice, choose my set and insert it. Not eating breakfast yet as not hungry.
10:00 Test blood sugar to be sure new infusion set is OK. It is. Kinda hungry now so eat breakfast. Count carb. Input blood sugar. Review pump’s suggestion for insulin dose. Only give half since I’ll be gardening right after breakfast.
Noon Tests sugars. I’m low. Golly, I wasn’t expecting to garden for so long. I treat my low with glucose and then reduce my basal insulin by 50% as I’m still going to garden for the afternoon. Retest my sugars to be sure they come up – they do.
4:00 pm Done gardening. Missed lunch. Blood sugars OK. I put my pump back to normal basal rate. Eat early supper – count and input carb. I don’t agree with pump’s suggestion for units of insulin since I’ve been so physical. I give less.
8:00pm Tired. Watch TV. I’m thinking I’ll probably fall asleep watching TV and since I was so active during the day, I’m at risk for a low sugar during the night. I remind myself to think like an insulin pumper. I program my pump to give me only 70% of my night’s basal insulin. I also program in an alarm clock for 0200 to remind me to wake and check my sugars. I’m thinking if I garden tomorrow, I’ll put in a continuous glucose monitor because it will alarm when my blood sugars drop below my comfort zone.
Each day as an insulin pumper varies –that is the point of using the pump. To accommodate life’s ups and downs, although in reality the pump can provide some of it’s own ups and downs. Still, the work for many is worth the payoff.
Emergency Insulin Pump Kit
Are you prepared to handle an emergency or unexpected troubles with your insulin pump or diabetes? Do you have an emergency insulin pump kit? You really can’t afford not to.
- … your basal rates are accidentally deleted or changed? Do you have a copy?
- … you can’t find your pump after taking it off to swim or play hockey?
- … you need your spouse to pick up pump supplies from the house?
- … your blood glucose meter quits working?
- … you have to leave town unexpectedly for a few days?
- … you can’t get your blood sugars down and can’t stay awake?
- … you forget how to program in basal rates and need to make a change. Do you know where your insulin pump user manual is?
- Or any number of unexpected things that just happen in life – will you be prepared?
Be prepared if you wear an insulin pump!
Create an emergency insulin pump kit! I’m impressed with how this kit has helped so many of my clients in so many situations! Just collect the necessary information and supplies listed below into a box, or small piece of luggage or drawer in your house. Tell a family member or friend where you keep it. Keep a note on top of the kit clearly stating “insulin pump emergency kit” and a reminder to take insulin from the fridge if this kit needs to travel with you or to you. You’ll be surprised how often you’ll need to run to this kit for one thing or another. Keeping it all in one spot saves you frustration and helps keep you safe on the insulin pump!
Your “Emergency Insulin Pump Kit” should have:
- At least 2 infusion sets, 2 reservoirs (cartridges) for you insulin pump, 2 adhesives if used (eg. Tegaderm), because most of us at some point in time have forgot to order supplies in a timely fashion.
- Extra blood glucose meter with fresh batteries (replace them periodically) and lancets. You should have 2 working meters at home. Once I took my kit for a talk in the mountains and both my meters stopped working and needed batteries. So yes, now I keep batteries in the kit.
- Batteries for insulin pump (rotate them occasionally)
- Small supply of test strips separate from your usual monthly supply. Remember this is in case you have to grab this kit and run off for a day. Or you expectantly go through your normal supply quickly because of sudden high blood sugars or low ones. Rotate this stash of strips with your monthly order so you don’t have expired strips in the emergency kit.
- Ketone strips for urine or blood (need a special meter for this). Check the expiry date. Also be sure these vials have not been opened more than 3-4 months or whatever is advised on the label. You can fight and fight high glucose readings for hours unless you know you have ketones and need more insulin with the very first correction dose. Verify with your health professional how to determine correction doses if ketones are present.
- Syringes or insulin pen with pen needles
- Insulin dose plans for pump failure: talk with your health care professional and have a written plan in place in your insulin pump emergency kit
- Prevention of ketoacidosis guidelines or handout provided by your health care professional and specifics from your doctor about when you should call 911 or seek medical care. Also guidelines for managing sick days. Keep a list of symptoms of DKA.
- Glucose, like Dex 4 or BD tabs.
- Glucagon kit in case of severe hypoglycemia and your family needs to use on you or you need to use to prevent a serious low. Be sure instructions on how to use it are included. Also good to have your spouse or friend trained on how to use it. Discuss with your health care professional about how and when to use. Check with pharmacist about storage as it is usually stored at room temperature. Be sure to check periodically that it is not outdated. When you purchase the kit, check the expirey date and if outdating soon, request a different kit. I have had patients who received kits that outdated 2 months after purchasing. You will likely need a prescription to purchase this kit.
- Your pump manual: you’d be surprised how you can forget to program things if you haven’t done it for a while.
- Copy of your recent basal rates, insulin to carb ratios and correction doses (senstivity factor). Be sure to update this paper record whenever you make a change to them in your pump. If for some reason your pump zeros your basal rates, you’ll need to input them again.
- Letter from your health care professional to present to emergency doctor or doctor while in hospital (or when traveling) to explain what the ER staff should do and NOT do and who to call. Our letter lists all the endocrinologists in the city that would be capable of handing a pump emergency call.
- Your extra insulin pump parts or accessories that you rarely use but alas, may need one day and wonder where you put them.
- Phone numbers for:
- – 24 hr pharmacy for insulin
- – The 1-800# for your pump
- – Your physician and diabetes team or endocrinologist on call
- – A friend/family member’s cell or home number if you live alone, to inform them you’re having a rough time with diabetes. Ask them to call or come over periodically.
- – Nearest emergency room (include a map)
- – Any other numbers of importance and anything else your health care provider would like to see added to the kit
Ask pharmacist: Ask if a prescription is needed to buy insulin in an emergency. Sometimes a prescription is only needed if you want to have the cost covered by insurance. Eg. you can buy insulin over the counter in Alberta without a prescription. Otherwise, find out the name of a 24 hr pharmacy and leave a prescription on file for insulin just in case!
Keep these on you:
- An extra infusion set
- Glucose or some other fast carb
- A syringe and small penfill vial of insulin, in your wallet or purse. Insulin loses potency after about a month at room temperature, so you’ll need to replace the penfill vial every 30 days. Do not leave it in the car! It may freeze or get too hot from the sun.
- An emergency card for contact names
- Identification stating you have diabetes and wear an insulin pump
- If on Medtronic Pump carry their wallet card
Please don’t leave this site thinking an Emergency Insulin Pump Kit is just too much work. Start the kit with what you have at home already. It could keep small troubles from becoming large safety issues. One day you, or your spouse, will be glad for your preparation!