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Re: [IPk] Balance article - full text
>From "Balance", the magazine of the British Diabetic Association, July
Pumping the Insulin
Improved control and freedom from injections, but at what price?
Jenny Bryan looks at tbe pros and cons of insulin pumps
"In our experience, people who use insulin pumps have better
glucose control and feel better in themselves. But we need to show
that there are worthwhile long and short term benefits so that the
NHS will pay for the pumps", explains Sandra Dudley, diabetes
nurse specialist at Harrogate District Hospital.
Optimal glucose control, with minimal swings in levels - just what
insulin pumps are designed to achieve has been shown consistently
to have significant benefits in delaying the onset and slowing the
progression of long term complications of diabetes.
Yet, in the UK, only about 150 people use insulin pumps to treat
their diabetes. This compares with some 50,000 in the USA, where
insurance companies routinely reimburse people for the cost of the
device and the cartridges and infusion kits if their HbA1c is over
seven or they have frequent glucose control problems despite daily
multi-dosing with insulin.
In this country, diabetes specialists must beg and borrow the
£1,000-£2,000 for equipment and £1,000 for disposables per
patient. As a result, NHS pumps generally go to 'last resort
patients' with very poor glucose control. Other, less needy people
have to pay for the equipment themselves.
Different approaches to pumps
There are two types of pumps: continuous subcutaneous
insulin infusion (CSII) pumps and implantable insulin
infusion (IPII) pumps. Both pumps have shown improved
and stable blood glucose con~ trol compared to injection
regimes. Optimal glucose control with minimal
fluctuations, has consistently shown significant
benefits in slowing the onset/progression of longterm
diabetic complications such as eye and heart disease,
nerve and kidney damage.
IP11 pumps are in limited use and still under
development as part of extended clinical trials, so this
article concentrates on the use of CSII pumps.
Singing their praises
But pump users consistently say how much better they
feel, even when their blood glucose was previously
relatively well controlled with injections.
Opera singer, John Neale describes his life as pre- and
post-pump. "I always had moderately good control of my
diabetes and I never turned up in Accident and
Emergency. But I didn't have very good night time
control and I often woke up feeling tired and
depressed," he explains.
Now, he wakes up alert and ready to go in the morning,
and the change in his mood when he started using a pump
18 months ago was so noticeable that colleagues at work
asked what had happened to him.
"What I see as a bad day now was a good day before. I
also lost weight, my acne cleared up and my athlete's
foot and thrush went for good," says John.
Most importantly, from a career perspective, his voice
made the transition from baritone to tenor. "I had
started to hit what we call vocal crisis and it appeared
that my voice needed to move from baritone to tenor. But
it wasn't well balanced and there were problems. Once I
got my diabetes under better control with the pump, I
made the change to tenor," he explains.
Student, Eleanor Biddle, tells a similar story of
tighter glucose control, more energy and a general sense
of feeling more motivated about life since she switched
to an insulin pump 12 months ago.
She has to think long and hard for any disadvantages:
"At first, I wasn't sure about having to carry the pump
everywhere with me, but I don't notice it now, any more
than I do carrying a handbag. I just put it in the back
pocket of my jeans or, if I'm wearing a skirt, in a
pouch on my leg."
The advantages and disadvantages of insulin pumps,
according to users.
* Tighter glucose control, with potential for reduced
complications of diabetes
* Improved well being
* Small weight loss
* Relief of diabetes-related symptoms, eg thrush
* Potential for cost savings in hospitalisation and
need for medical care
* Continued reliance on external device
* Need to change insulin cartridges/infusion sets
* Blood glucose tests four times a day
* Sophisticated programming may be too complicated
for some people
* Initial cost of pump and continuing cost of
* increased risk of ketoacidosis
* Need for diabetes team back-up and support
* Risk of infusion site problems, such as infections
and insulin allergies.
How do insulin pumps work?
Insulin pumps have been around for about 20 years. The
first devices were larger and more cumbersome than the
pager-size devices on the market today. They were
mechanical and had to be manually operated to deliver
the insulin. Sometimes they leaked and some people
developed skin reactions to the fine tubes which deliver
the insulin into the body. In addition, there were
concerns over the increased risk of hypoglycaemia and
Today's devices are much more sophisticated and use the
latest microchip technology. A needle or cannula is
inserted under the skin, usually on the abdomen, and
insulin pumped into the abdominal cavity from a
reservoir in the device through a thin plastic tube.
The device is programmed to give a background (basal)
rate of insulin around the clock, and the patient can
deliver a larger (bolus) dose before meals, matched to
the amount of food they eat. If necessary, the basal
rate can be changed, for example, if the user is taking
exercise and needs less insulin or is ill and needs to
increase their insulin dose.
Training and support
Sandra Dudley explains that people can't just put on a
pump and forget about their diabetes. Users need
considerable training before switching to a pump and
back up and support afterwards. They need to test their
blood glucose three or four times a day and the infusion
set has to be changed every two or three days.
Not least, users need to be able to distinguish high
blood glucose levels between high blood glucose levels
caused by over-eating and those arising from mechanical
problems with the pump not releasing sufficient insulin
"High blood glucose levels arising from eating too much
won't be associated with ketones in the urine," Sandra
explains. "But if there's something wrong with the pump
and not enough insulin is getting through, there will be
ketones in the urine, with potentially serious
consequences. But it's not something I've seen with our
pumps," she adds.
Some people find the pump intrusive at first - it fits
on a belt or in a pocket - but they quickly get used to
it. At night it can be put beside the bed or in a pyjama
pocket, and it can be hung outside the shower or bath
during washing. Pumps can be disconnected for short
periods while swimming or kept in a protective case
during outdoor sports such as climbing or whitewater
Although committed pump users revel in the high-tech
programming of their devices and the fine control they
can have over their diabetes, some specialists believe
that the sophistication of today's microchip pumps may
be limiting their more widespread use.
Dr John Pickup, reader in chemical pathology at Guy's
Hospital, London, was involved in researching the
original pumps in the early 1980s. He believes that if
today's pumps could be made cheaper and simpler to use
they would be much more attractive to hard-up health
authorities and busy clinics,
"We need another leap forward in the technology to give
us a cheap, simple device that costs about £50-£100 and
so can be bought much like a home blood glucose
machine," he suggests.
Dr Pickup explains that, in reality, most people only
need one or two rates of insulin infusion from their
pumps and these could be accommodated in a much less
sophisticated machine than those currently on the
"Such a move would bring down the cost of the device,
make it suitable for a wide variety of technically and
non-technically minded people, and so boost the number
of people who would be suitable for treatment." he says.
Help and information
The INsulin PUmp Therapy (INPUT) group has been set up
to raise funds for pumps and provide information for
people with diabetes in the Bournemouth area. For more
information write to INPUT at 90 Everton Road, Hordle,
Lymington, Hampshire SO41 0FD. Tel: 01425 629773.
mailto:email @ redacted
Insulin Pumpers website http://www.insulin-pumpers.org/
for mail subscription assistance, contact: HELP@insulin-pumpers.org