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RE: [IPk] Pump or New Insulin

Dear Graham,

I had a bit of a debate like this before I went on a pump.

The long actining insulin analogue is fine if you require the same amount of
background insulin all of the time. I was splitting my long acting insulin
(insulatard) into 2 doses - one in the morning and one in the evening. As
the doses were wildly different and I was still having night time hypos, it
was fairly clear that a constant baseline of insulin was not going to solve
the problem. Having said that there is a reasonable amount of evidence that
glargine can improve control in many people.

The short-acting insulin analogues are really good from the point of view
that you only have to inject just before you eat or even afterwards (so
don't end up eating to satisfy your insulin). They also have the advantage
of a rapid peak of insulin so that you don't have loads of insulin hanging
around making you hypo a few hours after you have eaten. I found that I
could be a lot more flexible with when I ate because of this (for me
skipping meals wasn't easy, but it was possible). Even if you do end up
getting a pump, it is probably a good idea to have experience of these
insulins as they are what most people use in the pump.

The NICE guidelines say 'MDI therapy (including using insulin glargine when
it's appropriate) has failed'. To me this implies that you can go on a pump
without having tried glargine, however I think it is MUCH easier to get
funding if you have tried it and failed, and if your diabetes team think it
is appropriate it is probably at least worth a trial. The NICE guidelines
also define failure as an inability to maintain blood glucoses within
recommended levels without having 'disabling hypoglycaemaia'. This means
that they have repeated and unpredictable hypoglycaemix episodes for which
they need help from other people, and which make them anxious about the
episodes occuring again and significantly spoil their way of life. Your
HbA1c should also be >7.5. I think these are pretty crap rules myself as
I've never had help from others to deal with hypos but have had very
frequent, disruptive hypos, but that's the guideline anyway.

It depends how much training you are offered when you switch over to the
analogue insulins as to whether you get similar training to on the pump.
Certainly at my Diabetes centre they are now running the DAFNE course to
teach people how to carb count and manage exercise etc better. Essentially
the emphasis is on creating your own set of rules that you use to determine
doses based on what you eat and what you are doing. However, when I went on
a short-acting insulin analogue 4 years ago there was no such training (I'm
pretty sure things have changed in most places though).

Remember the ONLY real way of saving money is to prevent the complications
of diabetes - I'm sure in the long term that pumps are cost-effective if MDI
is not sufficient to maintain the level of control required to prevent the

Don't knock the fact that you centre haven't put anyone on a pump. I am one
of the first at my diabetes centre and although people are trying hard it is
rarely possible to get a quick answer on anything. Yes, there has to be a
first patient but I personally think it is essential to make sure that the
centre is keen to start a pump program as it will be a lot of hard work on
their part as well as yours.

How long you trial for is up to you and your team. As with any time in you
regime it will take a bit of getting used to (but a pump would too). It's
probably best to see how it goes and not determine a length of trial. What
might be useful is to use a continuous glucose monitoring system (CGMS) if
your centre has one of those. I haven't used one yet, but am hoping to find
out exactly what happens to my BGs over the day. It might be useful when you
come to evaluate the success (or otherwise!) of MDI.

Personally, although I love my pump and would not be without it (the though
of going back on MDI fills me with horror and I really hope I never have
to!), it might well be worth your while giving these insulins a go. To be
honest, wearing a pump isn't a big deal but if I could achieve the same
level of control with injections I would.

I hope all this helps (sorry I have to go to work now!)

Best wishes,
IDDM 6+, pumper 4months

-----Original Message-----
From: email @ redacted [mailto:email @ redacted]On
Behalf Of email @ redacted
Sent: 25 April 2003 08:01
To: email @ redacted
Subject: [IPk] Pump or New Insulin

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 I was to speak to a Diabetes Specialist Nurse at my clinic earlier this
about going on a pump. However, she recommended that I try new (analogue?)
insulins first.

Her reasons are:

 The new long acting insulins do not have the inconsistent absorption their
predecessors had. Also, as they last for a full 24 hours, you are, in
being treated the same way as if you were on a pump as the long acting
acts as basal insulin.

 The new short acting insulins get into your system much more quickly, so
don't have to inject until you have your meal and can increase/reduce the
insulin as appropriate. (This is effectively a bolus, as in the pumping
This also means that a delay in eating is not a problem.

 For the NICE guidelines to be applied in a case you have to have tried the
insulins unsuccessfully.

 Much of the training for using the new insulins is the same as for going
onto a
pump, so if I ended up on a pump I would already know much of the day-to-day
aspects of the regime and would only have to learn about the pump itself.

If the new insulins work it will, potentially, save us a lot of money.

 The nurse added that, since the clinic started using theses new insulins in
this way, they haven't put anyone onto a pump.

 I would be very grateful for all your comments about this. I'd also like
regarding how long I should trial the new insulins before deciding whether
stay on them or move on to a pump (if a trial on these insulins is the best

Many thanks,

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