Insulin Pump Therapy

Dr. Bahlul Ben Masaud

Consultant at diabetes and endocrinology center
Tripoli-Libya
Diploma 2-3-2024
 1-Introduction

1- In type 1 diabetes, destruction of the pancreatic β cells

causes insufficient insulin production and life-long

dependency on exogenous insulin administration.

2- before the insulin discovery everyone with type 1

diabetes died within weeks to years because of acute

complications.
 1-Introduction ,insulin discovery

Insulin discovery in the

early 1921 (Banting & Best)

transformed diabetes from

a fatal condition to treatable

(but not curable) disease

First successful use of insulin in diabetes

-On 11 January 1922, Leonard Thompson,

a 14-year-old boy with diabetes, who lay dying at
the Toronto General Hospital, was given the first
injection of insulin.
Leonard lived a relatively healthy life for 13 years
before dying of pneumonia (no Rx still at that
time ).
3- Possible ideal solutions of this problem:

A- physiological ( still difficult)

A- Human pancreas transplantation: because of the
shortage of donors and problems of immune rejection it
is limited to selected patients.

B- β-cell transplantation has been accomplished

successfully in humans, but the large number of β –cells
required and immune rejection are obstacles.
3- Possible replacement solutions

B- Biochemical (artificial pancreas or closed loop ) :

A useful artificial pancreas must have all the components of

the feedback loop to mimic the normal pancreas function .
1- a DEVICE or insulin pump to deliver the insulin= CSII
2- glucose monitoring system (sensor )= CGM with real-
time BG values
3- control system to ensure that exactly the right amount
of insulin at the right time is dispensed = ALGORITHM
Which communicate both of them
 What are the types of insulin
regimen used?
A-conventional (traditional)insulin therapy
-2 doses of premixed insulin
-3 doses of premixed insulin

B-intensive insulin therapy

1-multiple daily insulin therapy (4 doses) MDI.
=basal bolus regime
2-use of insulin pump therapy.
7
 Which insulin regime is better ?

DCCT DCCT = DIABETES CONTROL AND

COMPLICATIONS TRIAL

UKDPS UKPDS = UNITED KINGDOM

PROSPECTIVE DIABETES STUDY
9
 Better Control –> Fewer Complications
& risk reduction
76% 59% 39% 54% 64%
60 Risk Reduction Risk Reduction Risk Reduction Risk Reduction Risk Reduction
Cumulative Incidence (%)

55.0•
50
Conventional
40 Intensive

30
29.8

20 23.9•

16.4
10 13.0 13.4•
7.9
5.1• 5.0
0 2.5

Retinopathy Laser Rx1 Micro- Albuminuria

2
Clinical
Progression albuminuria2 Neuropathy3

1. DCCT Research Group, Ophthalmology. 1995;102:647-661

2. DCCT Research Group, Kidney Int. 1995;47:1703-1720
3. DCCT Research Group. Ann Intern Med. 1995;122:561-568.
 What is the best insulin regime ?
1-That best that meets the patients needs (individualization).

2-That simulate the physiological pancreatic insulin

secretion (basal & bolus ways ).

3-That controls hyperglycemia with less hypoglycemia &

low glucose variability

4-At the End leads to normal lifestyle with no complications.

insulin program “defines” patients lifestyle.

11
PHARMACOLOGIC APPROACHES TO GLYCEMIC
TREATMENT- ADA-RECOMMENDATIONS

Pharmacologic Therapy for Type 1 Diabetes

9.1-Most people with type 1 diabetes should be treated with
multiple daily injections of prandial and basal insulin, or
continuous subcutaneous insulin infusion. A
9.2 -Most individuals with type 1 diabetes should use rapid-
acting insulin analogs to reduce hypoglycemia risk. A
9.3 Patients with type 1 diabetes should be trained to match
prandial insulin doses to carbohydrate intake, premeal
blood glucose, and anticipated physical activity (FIT). C
 Applications of intensive insulin therapy

1-CSII =insulin pump basal bolus therapy(MDI)

therapy

BASAL INSULIN

MEAL INSULIN
 History of insulin pumps

CSII = continuous subcutaneous insulin infusion

 Start of pump Evolution
1920s

1921 1923

Dr Arnold kadesh
1960s

1963

1976
 History of the Insulin pump
• The first insulin pump was developed in 1963 by
Dr. Arnold Kadesh.

• 1976 Dean Kamen invented the first wearable

insulin pump.

• 1980’s insulin pumps start to enter the market.

• Minimed and Disetronic.

• MiniMed 502 first popular insulin pump.

• 2003 MiniMed 512 first insulin pump to monitor

glucose levels.
 Auto Syringe AS*6 c
1979-1980

-Auto syringe AS2C and Harvard -

Apparatus Mill Hill Infuser were
early models
-Used large 50 ml syringe
Had only one basal rate and no
memory
Early Insulin Pumps
 What happened after DCCT results ?
1990

CGM

In 2000s rapid evolution of pump technology & development of

CGMs. Integration of pump with CGM for pump suspend.
What is an insulin pump ?
 is a small, digital, computerized , battery operated device

 continuously delivers insulin through a small catheter inserted

into the subcutaneous tissue , secured in place on the skin with
adhesive (referred to as an “infusion set” or “infusion cannula”).

 the infusion set connects to the pump by plastic tubing,

 insulin infuses from the pump through the tubing to the infusion
set cannula and into the subcutaneous fat tissue (some pumps
are tubeless )
 Insulin Infusion set
inserter

Tube Cannula

Reservoir Insulin
 Basic of Insulin pumps
 All pumps have the same basic components and deliver a pre-
programmed basal rate and then are programmed to give bolus
insulin on demand for food or high blood glucose levels
 The differences are the additional features such as no tubing,
color screen, built in CHO database, ability to bolus from the
meter, integrated CGM, waterproof, etc.
 Components of insulin pumps:
 Reservoir to hold 3 days worth of insulin
 Motor to push the insulin into the patient
 Menu-driven operating system
 Battery and casing
 All but OmniPod also have an infusion set (tubing) to get the
insulin from the reservoir to the patient.
Pharmacokinetics of insulin pump
• Uses only immediate acting insulin (rapid acting )
Like Aspart-Lispro or Glulisine
More predictable absorption

• Uses one injection site (change of canula in 3 days )

Reduces variations in absorption
• Eliminates most of the subcutaneous insulin depot
Closest match with physiologic needs
Indications of insulin pump
1-individuals with T1 diabetes who have high rates of
hypoglycemia or hypoglycemic unawareness
2-individulas who are not meeting glycemic targets
3-pregnancy ,preconception
4-individuals with Gastroparesis
5-individuals on MDI with good glycemic control but who
desire more flexibility to improve their quality of life &
treatment satisfaction
6-Dawn phenomena 7-insulin sensitivity
8-uncontrolled type 2 individuals

Insulin pump therapy may be beneficial for all

individuals with type 1 diabetes, regardless of age
 Practical Benefits of
Pump Basal Delivery:
 Stable BG between meals & overnight

 Can skip/delay meals without dropping

 Can vary sleep & work schedules

 Fewer issues with travel/time zone changes

 Can correct for dawn effect

 No long-acting insulin (more consistent insulin action)

 Immediate, temporary basal adjustments possible

 Practical Benefits of
Bolusing with a Pump
 Can dose very precisely (.o1 or .05 units)

 Convenient to give insulin anytime, anywhere

 “Unused Insulin” adjustment prevents stacking of boluses

 Rate of delivery can be extended

 Insulin delivery history stored in pump

 One needle stick every 3 days (approx)

 Built-in bolus calculator

 what offers insulin pump over MDI?

• 1-Difference in basal insulin ( type and method )

• 2-Difference in bolus insulin (method )

To
pump
To MDI
 1-Basal Insulin: pump versus MDI

LONG ACTING (Glargine or Degludec ) (MDI)

Rapid insulin (PUMP )

Dawn time

2:00 7:00 12:00 16:00 20:00 24:00 7:00

Time
Basal insulin delivery from a pump provides a better and
faster match for life’s needs and mimics the physiological
pancreas secretion
Insulin pump provides flexibility in basal rates
during fasting / and non fasting periods in Ramadan

Basal insulin

1.50 1.4
1.05 1.0

0.95
0.85 0.65

12 17 18 20 24
00 05 08
 Characters of basal insulin by pump therapy

 Pumps can deliver insulin in 0.01 unit increments as a basal

rate which is a special offer for children and insulin sensitive
patients .

 Presence of temporary basal feature allow the user to

temporarily increased or decreased the basal rate in relation
to the acute situation at any point,( programmed exercise,
illness, dawn period) .
2-Meal insulin options = Carb Bolus Varieties
can be delivered in increments of 0.025 units

=standard

High Fat meals

Gastroparesis
open buffet
 The pump delivers basal and bolus insulin precisely and can be
easily customized as needed to meet individual requirements.

6.0
Bolus insulin delivery
5.0 Basal insulin delivery Basal reduced to
Units of insulin

help prevent
Dual Wave™
Bolus for Lunch nocturnal
4.0
hypoglycemia

Basal
3.0
programmed to
Temporary basal Dinner
help prevent bolus
during walking to
2.0
dawn
help prevent
phenomenon
hypoglycemia
1.0

0
12 Am 4 Am 8 Am 12 Pm 4 Pm 8 Pm 12 Am
 C- Bolus wizard calculator :
1- Calculates the bolus amount for the patient, according to their
personalized settings (ICR , ISF ,Active insulin time ,glucose target ) .

2- Tracks the amount of active insulin remaining from previous

boluses.

3- Subtracts active insulin from correction doses before suggesting the

total bolus amount which helps to prevent lows that result from the
stacking of insulin consumed, units of insulin delivered and the time
each (BOB =bolus on board )

4- Record BG readings ,carbohydrates was entered.

5-Data can be downloaded in to reports for easier more accurate

evaluation.
 Brands available :

Omni pod (tubeless)

Minimed –Medtronic-sensor

Accu chek spirit combo-

no sensor
 Overview of insulin pump technology
• A-open loop system (no automated insulin
delivery).
1- conventional (traditional ) insulin pump.
2- Sensory Augmented insulin pump
 A-with no hypoglycemia defense
 B-with hypoglycemia defense
 -threshold (Low) suspend
 - predictive low suspend

• B-closed loop system = Artificial pancreas

(partially or fully automated insulin delivery )
 Overview of insulin pump technology
A-open loop system
1- conventional (traditional ) insulin pump.
 -no insulin automation .
 -user should give his insulin bolus doses for
meals and correction of hyperglycemia.
 -user or provider should adjust the basal insulin
program.
 B-2-Sensory Augment with hypoglycemia defense
threshold (Low) suspend predictive low suspend

-integrated with real time CGM , integrated with real time CGM
-insulin suspend when low -insulin is suspended before
glucose pre seated reading reaching the preseated lower
reached. threshold limit by 30 minutes
-pump restart when blood sugar (protection from hypos)
rise above the threshold -pump restart automatically
when blood sugar rise above
the threshold

Medtronic Mini Med 530 G Medtronic Meni Med 640 G

B-closed loop system=
artificial pancreas
 Concept of Artificial pancreas
• Is an automated insulin delivery system
composed of

1. Continuous insulin delivery system(pump).

2. Real-time continuous glucose monitoring system(
CGM)
3. Control algorithm that automatically increase or
decrease the continuous subcutaneous basal
insulin based on real-time sensor glucose levels
within a preprogrammed target limits(main
difference from conventional pump therapy)
 Components of artificial pancreas

2 CGM sensor 3 CGM receiver

Continuous glucose monitoring (CGM) CGM receiver displays the updated
sensor is inserted under the skin to readings as graphs and trends minute-
continuously measure glucose by-minute, and translates the readings
concentrations in the patient’s cells from USB to Bluetooth

1 Insulin pump
The CAD communicates with a body-
worn insulin pump that automatically
administers the correct insulin dose via
a cannula inserted under the skin

4 Control algorithm device (CAD)

Readings are sent to a control algorithm device
(CAD) - eg a smartphone, tablet or PC - where
an algorithm analyses them and calculates the
correct insulin dose, if required
 Examples of artificial pancreas
(PLGS)
T:slim inulin pump Mini-med 670 G

Suspend insulin by prediction of Suspend insulin by prediction of

Hypoglycemia hypoglycemia
Fully Automated basal & bolus Automated basal insulin adjustment
insulin adjustment (once hourly) Patient still should give boluses for
No Patient intervention. meals and correction
 2-MiniMed 780G
fully automated hybrid closed
loop(AHCL)

1. Automated basal insulin correction.

2. Automated bolus correction for
hyperglycemia every 5 min .
3. Approved for use for age (7) or
more.
4. Has sensor with predictive low
suspend property
Medtronic 780 g
 Categories of closed loop systems

1. Single hormone (insulin) systems

A. Pumps that contain only insulin for

hyperglycemia control .

2. Bihormonal systems containing both insulin

and glucagon (or Amylin).for hyperglycemia

and hypoglycemia correction.
Bi-hormonal bionic pancreas
 Tubeless insulin pumps
1-Insulet OmniPod
 Tubeless insulin pumps
2-simple Patch pump for type 2 DM
VGO
Pump calculations
 Calculation of starting doses
A-pump total daily dose = PTDD
1-reduced dose= prepump dialy dose × 0.75
2-weight dose = WT÷ 2
PTDD = (reduced dose + weight dose ) ÷ 2
 Calculation of starting doses
B-Total daily basal dose = PTDD × 40-50 %
C- Pump hourly basal rate = total basal dose ÷ 24
= hourly basal rate =X/h

Time block Hourly dose

0:00- 4:00 - Reduce dose by=0.05
4:00- 7:00 Increase dose by=0.05
7:00-12:00 The same dose =X
12:00- 18:00 Reduce by =0.05
18:00-24 The same dose=X
 Calculation of starting doses
D-Insulin –to- Carbohydrate Ratio = ICR
Definition :is the number the of carbohydrate
grams covered by one unit of insulin

ICR used to calculate food bolus amounts.

 Calculation of starting doses
D-Insulin –to- Carbohydrate Ratio = ICR
Calculations :
Method 1 ICR= 450 ÷ PTDD
Method 2 ICR from previous FIT

Patients often require more than one ICR to obtain

optimal post–prandial control.
Different ICRs can be programmed to different
times in the calculator.
 Calculation of starting doses
D-Insulin Sensitivity Factor = ISF
Definition :how much mg/dl blood glucose
lowered by one unit of insulin .

ISF used to calculate correction bolus amounts .

 Calculation of starting doses
D-Insulin Sensitivity Factor = ISF
Calculations :-
Method 1 1700 ÷ PTDD
Method 2 ISF from previous FIT

Patients may have a different ISF for different

time segments .
The Bolus Wizard Calculator (BWC)
parameters for meal & correction doses
Settings (5)
1-Cab Unit Grams
2- ICR
3- ISF
4-BG target range
5-Active insulin time
 The Bolus Wizard Calculator (BWC)
Active insulin time

-The length of time rapid acting insulin can lowers the BG-
-insulin remaining from previous boluses that continues to
have a pharmacodynamic effect and the potential to
lower glucose.
Active insulin time for analogs 3-4 hours
The Bolus Wizard Calculator (BWC)
BG Target Range
the range of glucose values the bolus Wizard uses to
determine if a correction dose needs to be calculated

Used by the calculator to calculate the correction dose .

Recommended Adult BG Target :-
Day BG Target=90-100 Night BG Target=100-110
By hypoglycemia unawareness D=100-120 N=110-130
Pregnancy D=80-90 N=90-90
‫شكرا ً لحسن االستماع‬
‫لكً ال ننسى أهل الفضل‬
‫‪Mini-Med 530 G‬‬

‫( رحمها هللا)‬ ‫د‪ .‬سعاد البوصٌري‬

‫‪Mini-Med 640 G‬‬