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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
               infusion sets

             * 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

     Too complicated?

          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.

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Insulin Pumpers website http://www.insulin-pumpers.org/
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