Insulin Pump Therapy in Older Adults

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Insulin Pump Therapy in Older Adults

Joshua Akers, PharmD Candidate, 2007

College of Pharmacy

Washington State University

Spokane, WA

Phone: 509-432-3332

Email: [email protected]

and

Stephen M. Setter, PharmD, CDE, CGP, DVM**

Associate Professor of Pharmacotherapy

College of Pharmacy

Washington State University

Elder Services

Spokane, WA 99217

Phone: 509-489-9283

FAX: 509-458-7450

Email: [email protected]

**Corresponding Author

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Introduction

It is currently estimated that roughly 18.2 million people in the U.S. have diabetes

(1), a number

expected to grow as our population ages. Diabetes is a progressive disease with many patients

eventually requiring insulin therapy. Searching for improved ways to administer insulin is

worthwhile as many people with diabetes balk at the idea of injecting insulin. While insulin

injections are the most traditional method of administering insulin, there are other options.

Newer advances such as inhaled insulin and jet injectors are available for use, though they may

not be appropriate for all individuals. The other alternative is an older but constantly advancing

technology that attempts to mimic pancreatic insulin release, the insulin pump.

Insulin Pumps

Purchasing an insulin pump is a major life decision for any individual with diabetes. Insulin

pumps assist patients in gaining improved blood glucose control while providing a freer lifestyle.

An insulin pump is a small device, about the size of a beeper or cell phone, which is generally

worn on a person’s waistline. The pump is connected to the body through a catheter and line of

tubing, referred to as the “infusion set”. All but one of the available pumps, the Insulet

Omnipod®, requires an infusion set.

The pump works by delivering a continuous basal insulin dose and by administering premeal

bolus doses. The basal dose is given throughout a 24 hour period to cover glucose levels

overnight and between meals. Depending on the pump, this basal dose can be adjusted in

different ways and can have preset programs that allow the basal rate to be easily altered. The

bolus dose is given prior to meals to cover post-meal blood glucose excursions. One of the

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advantages to an insulin pump is that a bolus dose can be given with the push of a couple

buttons, making it much more convenient to administer insulin.

Rapid-acting insulin analogs such as Humalog®, Novolog®, or Apidra® or short-acting Regular

human insulin can be used in pumps. The individual must refill their insulin pump themselves

with whatever insulin that they and their physician have decided as most appropriate.

Fortunately, most insulin pumps are equipped with a low-insulin alarm to help people remember

to refill their insulin cartridge.

Choosing an insulin pump

There are certain criteria that are important in choosing an insulin pump. According to the

American Diabetes Association, the most important criteria are(2):

• Cosmetic Attractiveness

• Clinically desirable features

• Ease of Use

• Safety Features

• Durability

• Availability of service and training

• Water Resistance

(4)

These are all important things to consider when thinking about starting insulin pump therapy.

However, older persons may consider certain things more important when determining the best

pump for them. Specific questions to consider include:

• Is it going to be too heavy for me to wear?

• How will I remember when to check my glucose and when to inject a bolus dose?

• I don’t know how to count carbs, can the pump help me do this?

• How will I know when to change the batteries?

• I have poor eyesight, is the screen large enough to read? Are there any features to help

me see?

• What if I forget that I already gave myself a dose? Will the pump help prevent me from

injecting too much?

• I have trouble with arthritis and using smaller devices, is there anything that can help me

enter bolus dosing and blood glucose values?

• How will I know if the pump is operating correctly?

• Some of these new pumps I hear about seem so technical. Is there something simple to

use?

• I’m on Medicare and need to watch how much I spend. How much will these pumps cost

me?

• Are the supplies easy to purchase?

While there is no one pump that can provide an answer for each of these questions, the pumps

available all have features that can assist older individuals in administering insulin. Features

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such as audio bolusing, remote controls, beaming technology, and insulin-on-board are a few

examples of things that can help. Thus it becomes important for each individual to decide on

what is most important to them when choosing an insulin pump. Older patients along with their

health care provider and/or certified diabetes educator can then assist with making the best and

most informed decision possible.

The accompanying table is a summary of the insulin pump products that are currently available

for purchase in the U.S. While this table is not an all-inclusive guide to every aspect of every

pump, it does provide basic information to assist in identifying the various features of the

available pumps. It also provides answers to some questions regarding insulin pumps, highlights

unique features, and provides considerations for older populations, as well as listing the cost.

This table is a reference only and should not be the only tool used in determining the most

appropriate pump, nor does it cover differences between infusion sets. To find out more

information about any pump, please contact the manufacturer directly.

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Explanation of select terms used in the chart

*Insulin on Board (IOB) – this is a feature that monitors how long insulin is active in the body

based on user defined settings. This allows people to tailor their dosing based on their own

insulin sensitivity.

*Connection – The standard infusion set utilizes a luer-lock connection. If a different connection

is indicated, then a special infusion set must be used for that pump.

*Basal Programs – these are basal programs that alter the rate at which basal insulin is delivered.

For example, a person could have one basal program for sleeping, and another program for when

they exercise, and another for working. These preset programs allow for easier and faster

switching of a person’s basal rate, thus individualizing their insulin therapy.

*Bolus Increments – controls the units by which a bolus dose is measured. This is generally

entered manually (directly on the pump), though some pumps allow the bolus dose to be entered

by audio (speak the desired dose into the pump) or by remote (small remote allowing more

discretion in using the pump).

*Bolus Duration – the rate at which a bolus is given can be very important if someone does not

tolerate a dose being injected too fast. It also can be important to control the insulin delivery for

people with gastroparesis or if a high fat meal is consumed. Different pumps provide many

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different options and it is important to choose a pump that is comfortable and best fits your

lifestyle.

*Carbohydrate dosing program – some pumps will automatically calculate a bolus dose based on

the amount of carbohydrates (carbs) being consumed. Most require a patient to count the carbs

they’re eating, though some newer pumps allow patients to simply enter the food. The pump can

then calculate the dose, thus removing the need to count carb intake.

*Blood glucose testing from monitor – this is the incorporation of a blood glucose testing system

with the pump itself. Currently only 2 systems have this feature, the Insulet Omnipod® and the

Medtronic Paradigm® system if used with the REAL-time® system.

*Cost Consideration – all prices for pumps are for the cash price only. Different insurance

companies may have different pricing, so the pricing may be drastically different depending on a

person’s specific insurance plan.

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References

1. Centers for Disease Control and Prevention. National diabetes fact sheet: general

information and national estimates on diabetes in the United States, 2003. Rev ed.

Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease

Control and Prevention, 2004.

2. American Diabetes Association. Position Statement: Continuous Subcutaneous Insulin

Infusion. Diabetes Care. 2002; 25:S116

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Insulin Pump System

Animas – IR 1000

Animas – IR 1200

Animas – IR 1250

Size (inches)

3.5x 2.2 x 0.7 2.9 x 2.0 x 0.76 2.9 x 2.0 x 0.76

Weight (oz)

3.8 3.1 3.1

Insulin Holding

Capacity (mL)

3 2 2

Connection

Luer-Lok Luer-Lok Luer-Lok

Screen Size, Backlight

(Y/N)

N/A, Yes 1.5 in

2

, No 1.5 in2, No (contrast control)

Color Availability

Interchangeable cover allows wide assortment of colors and

styles

Wide assortment of colors and

styles Silver, Blue, Black

Basal Range

0.05 – 9.9U/hr 0.025 – 25U/hr 0.025 – 25U/hr

Basal Programs

Up to 4 personalized programs Up to 4 personalized programs Up to 4 personalized programs

Basal Delivery

Every 3 minutes Every 3 minutes Every 3 minutes

Bolus Increments

0.1U Manual

0.5U & 1.0U Audio

0.05U Manual 0.1U, 0.5U & 1.0U Audio

Bolus Duration

Immediate (8 sec), extended _{(1/2 – 4 hours), or combo} Immediate (8 sec), extended _{(1/2 – 4 hours), or combo} Immediate (8 sec), extended _{(1/2 – 4 hours), or combo}

Battery Type/Life

Four 357 silver oxide _{6-8 weeks} One AA Lithium, 6-8 weeks _{One AA Alkaline, shorter} One AA Lithium, 6-8 weeks _{One AA Alkaline, shorter}

Low Battery Alert?

Yes Yes Yes

Insulin on board

Feature? (Y/N)

No Yes Yes

Built-in Carbohydrate

dosing program? (Y/N)

No Yes Yes

Blood glucose testing by

monitor? (Y/N)

No No No

Memory

255 boluses & 255 total daily _doses 600 boluses,120 total daily doses _{& 270 basals} 600 boluses,120 total daily doses _{& 270 basals}

Downloadable Records?

(Y/N)

Yes Yes Yes

Water Resistant? (Y/N)

Yes Yes Yes

Low-Insulin Alarm?

(Y/N)

Yes

Yes, user may set level for the alarm

Line-Occlusion Alarm?

(Y/N)

Yes Yes Yes

Over-Delivery Alarm?

(Y/N)

No, only redundant safety features

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Insulin Pump System

Animas – IR 1000

Animas – IR 1200

Animas – IR 1250

Unique Features

• Various covers, designs, etc. available to make the pump unique to the individual

• Insulin gauge allows for partial fills of insulin cartridge

• Various covers, designs, etc. available to make the pump unique to the individual • BG & Mealtime bolus alarms

• Screen contrast control • BG & Mealtime bolus

alarms

• Ability to store carb info and create meals up to 9 items • Can upload music files to use

as alarms

Geriatric Feasibility

•

Small screen size makes visibility difficult

•

Any Luer Lok set available makes infusion set supply purchases easier

•

Multiple Alarm systems increase safety and alert user of various IP issues

•

Changing batteries more difficult with smaller, less common battery.

•

Larger insulin resevoir resulting in cartridge change every 3 days decreases opportunities to miss doses

•

Patient still must remember to test their glucose daily, not automatic from pump

•

Various redundant safety features make it a durable and reliable pump

•

Audio bolus allows for less error in pump controls

•

Larger screen size better for visibility, though font still small

•

Carbohydrate bolus calculator helpful if user understands how to count carbs

•

Patient still must remember to test their glucose daily, though alarms present to assist in remembering

•

Self-priming makes set-up easier for patient

•

Larger screen size and contrast control better for visibility,

•

Carbohydrate Food memory better as it can be tailored to patients meal trends

•

Self-priming makes set-up easier for patient

• Cost Considerations

• $5,475

•

Any Luer Lok infusion set allows for shopping for best deal

•

Insurance more likely to pay

•

Still must have glucose meter and regularly replace strips and lancets

• $5,975

•

• $5,975

•

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Insulin Pump System

Disetronic – Spirit

Insulet - Omnipod

Deltec - Cozmo

Size (inches)

3.2 x 2.2 x 0.8 inches Pod: 1.6 x 2.4 x 0.7

PDM: 2.6 x 4.3 x 1.0 3.2 x 1.8 x 0.9

Weight (oz)

2.8 Pod: 1.2

PDM: 4.0 3.3

Insulin Holding

Capacity (mL)

3.15 2 3

Connection

Luer-Lok Built-in to Pod (no tubing) Luer-Lok

Screen Size/Backlight

(Y/N)

N/A, yes 1.75 in

2

, yes 1.35 in2, Yes

Color Availability

30 different colors and styles Pod: white

PDM: silver Blue, Black, Purple

Basal Range

0.1 – 25 U/hr 0.05 – 30U/hr 0.05 – 35U/hr

Basal Programs

5 different personalized _programs Up to 7 different personalized _programs 4 different personalized _programs

Basal Delivery

Every 3 minutes N/A Every 3 minutes

Bolus Increments

0.1U, 0.2U, 0.5U, 1.0U & 2.0U 0.05U, 0.1U, 0.5U & 1.0U 0.05U

Bolus Duration

Immediate (5 sec), or Extended (15min. – 24 hrs.), or

combo

N/A 1 – 5 minutes

Battery Type/Life

One alkaline AA, ~3 weeks Two alkaline AAA, ~4 weeks One alkaline AAA, ~30 days

Low Battery Alert?

Yes Yes Yes

Insulin on board

Feature? (Y/N)

No Yes Yes

Built-in Carbohydrate

dosing program (Y/N)

Yes, in PDA Yes Yes

Blood glucose testing

by monitor? (Y/N)

No Yes, Freestyle Monitor No

Memory

Last 30 alerts, errors, boluses, daily insulin totals, and temporary basal rate changes

90 day memory (up to 5400

records) 4000 Events

Downloadable

Records? (Y/N)

Yes Yes Yes

Water Resistant?

(Y/N)

Yes Yes Yes

Low-Insulin Alarm?

(Y/N)

Yes No Yes

Line-Occlusion

Alarm? (Y/N)

Yes N/A Yes

Over-Delivery Alarm?

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Insulin Pump System

Disetronic – Spirit

Insulet - Omnipod

Deltec - Cozmo

Unique Features

• Reversible screen allows pump to be worn multiple ways

• System comes with either Zire 31 or Palm Treo 650 PDA and Accu-Chek BG monitor

• Equipped with wireless capabilities

• Carb database and controller included in Palm device • 12 different language

settings possible

• Automatic priming feature

• Unique technology gets rid of tubing associated with pump • Integrated Freestyle system

makes BG testing much easier

• Small and very lightweight. Lightest and smallest available on market • Automatic insertion and

priming

• BG results automatically converted into bolus calculations

• Carbohydrate library to assist in bolus dosing

• Includes CoZmonitor that uses Freestyle technology for BG testing that attaches to the pump and can send BG results directly to pump • Can work on beep or vibrate

mode

• Glucose testing alarms to ensure regular testing

Geriatric Feasibility

•

PDA technology could be confusing and excessive

•

Screen size appears small, but backlight could help with visibility

•

Carbohydrate database useful if user understands how to utilize it

•

Patient still must remember to test their glucose daily, not automatic from pump (though alarm may be present to help)

•

Larger insulin resevoir resulting in cartridge change every 3 days decreases opportunities to miss doses

•

Multiple on-screen icons, vibrations, beeps, and sounds to assist in operation

•

PDM technology simpler than a PDA, but could still be confusing

•

Large screen and font makes visibility much easier than any other pump

•

Carbohydrate database useful if user understands how to utilize it

•

No need to learn to use multiple systems

•

Automatic BG testing and bolus calculation makes use easier

•

System dependent on PDM which could be problematic if patient loses the PDM

•

Safety concerns over lost PDM, removal of Pod, or malfunctioning of Pod not addressed

•

No tubing to get caught, lower chance of pulling out insulin pump

•

Patient does not have to refill insulin cartridge

•

Larger insulin resevoir (712) resulting in cartridge change every 3 days decreases opportunities to miss doses

•

Carb bolus doing available, but patient must be able to count carbs

•

• Requires PC for certain history features which could be problematic

• IOB could help prevent over-bolusing

Cost Considerations

•

Purchasing pump, PDA, and monitor could make for a very expensive system

• $800 for the PDM

•

$325 for 10 pack of pods (~30 day supply)

•

No infusion set purchases need to be made

• $5,595 (includes BG meter)

•

Still must regularly replace strips and lancets for glucose meter

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Insulin Pump System

Medtronic – Paradigm

522/722

Nipro - Amigo

DANA – Diabecare II

Size (inches)

522: 3.0 x 2.0 x 0.8 _{722: 3.6 x 2.0 x 0.8} 3.2 x 2.1 x 0.9 3.0 x 1.8 x 0.74

Weight (oz)

3.5 3.1 1.8

Insulin Holding

Capacity (mL)

522: 1.76 722: 3 3 3

Connection

Specific proprietary sets Luer-Lok Proprietary DANA set

Screen Size/Backlight

(Y/N)

1.2 in

2

, yes N/A, Yes N/A, Yes

Color Availability

Clear, Blue, Smoke, Purple Midnight, Flamingo, Pacific,

Grape, Snow, Solar Black, Gray, Blue, Ivory

Basal Range

0.05U – 35.0U/hr 0.05 – 10U/hr 0.1 – 16U/hr

Basal Programs

3 different personalized programs Up to 4 different personalized

programs 1 personalized programs

Basal Delivery

0.1U Pulses Every 3 or 15 minutes Every 4 minutes

Bolus Increments

_{0.5U & 1.0U Audio or Remote}0.1U, 0.5U & 1.0U Manual 0.1U 0.1U

Bolus Duration

Immediate pulse, extended pulse, _{or combo}

Immediate (5 or 15 sec), Extended (15min – 6 hours), or

combo

8 sec

Battery Type/Life

One alkaline AAA, 3-4 weeks One CR2 Camera battery, 4-6 weeks

Proprietary DANA battery, 2 – 3 months

Low Battery Alert?

Yes N/A Yes

Insulin on board

Feature? (Y/N)

Yes Yes Yes

Built-in Carbohydrate

dosing program (Y/N)

Yes Yes No

Blood glucose testing

by monitor? (Y/N)

Yes (If purchased with

REAL-time upgrade) No No

Memory

90 Days 90 Days 50 boluses, Primes, total daily

doses & last 12 alarms

Downloadable

Records? (Y/N)

Yes Yes Yes

Water Resistant?

(Y/N)

Yes Yes Yes

Low-Insulin Alarm?

(Y/N)

Yes Yes Yes

Line-Occlusion

Alarm? (Y/N)

Yes Yes Yes

Over-Delivery Alarm?

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Insulin Pump System

Medtronic – Paradigm

522/722

Nipro - Amigo

DANA – Diabecare II

Unique Features

• Optional remote control • Can work on beep or vibrate

mode

• REAL-time BG monitoring takes a BG reading every 5 minutes. This result is sent to the pump for constant BG monitoring including BG trends throughout the day • Can view previous 31 days of

pump activity on pump screen

• Sleek casing design to help avoid snags on clothing • Glucose testing alarms to

ensure regular testing

• Preset meal boluses can be utilized for breakfast, lunch, and/or dinner

• Glucose testing alarms to ensure regular testing • Optional wireless remote

Geriatric Feasibility

•

Multiple visual & audio Alarm systems increase safety and alert user of various IP issues

•

Constant testing removes need for multiple devices

•

No indicator on remote as to how much bolus dose entered

•

Constant monitoring allows for much greater control on basal and bolus dosing

•

REAL-time alarms go off on preset glucose levels. Could greatly reduce instances of hypo- or hyperglycemia

•

Specific infusion set, battery purchases and special ordering could make supply acquisition difficult and confusing

•

Poor resolution on screen could make visibility difficult

Cost Considerations

•

$6,195 for pump

•

$999 for Real-time

•

Only specific infusion sets usable limits options

•

Will still need to buy supplies for REAL-time testing, increasing expenses

•

REAL-time system costs extra and may not be covered by insurance

•

~$5,495

•

• ~$3,700

•

Can only use DANA infusion sets, limiting purchasing options

•

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