Insulin Pump Service


What is insulin pump therapy?

Insulin pump therapy is also called Continuous Subcutaneous Insulin infusion (CSII). The aim is to get better blood glucose control by mimicking how insulin is released in the body of people without diabetes. It is approved for insulin therapy in Type 1 diabetes only.
 
In a person without diabetes, the pancreas continually releases a low level of insulin throughout the day and night (called the ‘basal insulin’), with boosts of insulin released at meal times (called the bolus insulin).  People with type 1 diabetes do not produce any insulin at all. Their insulin is commonly given as injections of long-acting (basal) insulin one or twice a day as well as short-acting injections at mealtimes ('bolus' insulin) 3-4 times a day.
 
With insulin pump therapy, a small, battery-operated pump continually gives insulin through a fine tube, which is attached to a small needle (cannula) placed under the skin. The cannula under the skin is changed once every 2-3 days. You can then press controls or buttons on the pump to give the meal-time boosts of insulin. Because the pump delivery both your background and mealtime/correction insulin doses, it needs to be worn continuously day and night.  The pump is briefly only removed every 2-3 days to allow delivery set changes or occasionally for short periods of time to allow certain types of physical activity or bathing.
 
Who can get an insulin pump?

Continuous Subcutaneous Insulin infusion (CSII) therpay has been reappraised by NICE and guidance was published in August 2008 stating that: CSII therapy is recommended as a treatment option for children younger than 12 years with Type 1 Diabetes if MDI therapy is considered to be inappropriate and those receiving the treatment and their carers have the commitment and competency to use the therapy effectively.

CSII is recommended as a treatment option for adults (including pregnant women and women planning pregnancy) and children older than 12 years with Type 1 Diabetes Mellitus provided that MDI therapy has failed to provide adequate control of their diabetes, ie HbA1c greater than 8.5% or the repeated and unpredictable occurence of hypoglycaemia that creates anxiety and those receiving treatment and their carers have the commitment and competence to use the therapy effectively.

Criteria for allocation of insulin pumps is based on NICE guidelines and priority is judged on the features of hypoglycaemia unawareness, particularly when causing major hypoglycaemia episodes, pregnancy and need to optimise for pregnancy.

In the Western Trust, adult patients must have completed CHOICE Type 1 Education programme and children must have completed Carbohydrate Counting Education on 1:1 basis or attended CAWT CHOICE programme. These programmes provide education on self-management of Type 1 Diabetes and insulin adjustment skills for food and activity.

It is necessary to attend a pump assessment clinic with District Staff Nurse and Dietitian to discuss and review your diabetes management and complete an assessment form. It is important to ensure that you are using the appropriate skills to manage your diabetes.


How well established is insulin pump therapy?

Insulin pump therapy is now used by hundreds of thousands of people with diabetes throughout the world. The number of people using the pumps in the UK, particularly Northern Ireland is still quite small. This is partly because the treatment was not approved by NICE for NHS funding until 2003, and the UK.

Until 2010, very few people in the west of Northern Ireland were able to use insulin pump therapy and all of these people had to travel to Belfast for their Diabetes Care.  This is partly because The UK NICE guidance was not accepted by the NI Department of Health until 2009.  Funding to support the Diabetes Insulin Pump Service was first made available to us in the Western Trust in 2010 and we trained our first person on insulin pump early that year.  We had been given enough money only to start 22 adults across the Trust on  insulin pump therapy and we did this over the following two years (2010-2012).  In 2012 the Department of Health released enough money for us to start many more people on insulin pumps as part of a regional funding programme.  It is anticipated that these pumps will be used over a 3-5 year period.

What does an insulin pump look like?

There are a number of different pump makes and models. They all work in similar ways and most are about the size of a pager and are smaller than a mobile phone.

In the Western Trust, pumps from 3 different manufacturers are available.


Why is insulin pump therapy needed?

Insulin pumps are only needed in selected people with type 1 diabetes who are having continued problems with maintaining good blood glucose control on ‘best insulin injection treatments’. ‘Best insulin injection treatment’ is always tried before a trial of insulin pump therapy is considered and includes:

  • using new, long-acting insulin’s, such as glargine [Lantus] or detemir [Levemir] and adjusting doses according to patterns in your blood glucose. 
  • altering the injection of short-acting insulin at meals according to meal size and type, current blood glucose and planned physical activity;
  • frequent blood glucose testing at home and insulin dosage adjustment as necessary depending on your patterns. 
  • diabetes education (it is normally expected that you will have completed a flexible insulin dose adjustment course such as CHOICE, DAFNE or BERTIE).

What are the benefits and possible disadvantages of having insulin pump therapy?

Insulin pump therapy is not painful and most people find that wearing the pump 24-hours a day is not uncomfortable or inconvenient. You still need to check your blood glucose and act flexibly upon the results to match your insulin dose to your needs. You also need to change your subcutaneous insulin delivery set every 2-3 days.  Insulin pump therapy is likely to lower the number of severe hypoglycaemic episodes you have, though it may not completely stop them. Severe hypoglycaemia is when the blood glucose drops so low that a person is incapacitated and needs help from others.
 
In many people, pump therapy also:

  • lowers the swings in blood glucose throughout the day
  • improves the predictability in blood glucose levels from day-to-day; and
  • lowers the ‘dawn phenomenon’. This is a marked rise in the blood glucose in the few hours before breakfast. The pump can help can be programmed to automatically increase the basal insulin infusion rate during the night and therefore achieve better blood glucose control at this time.

Many people also find their general wellbeing and quality of life improves during insulin pump therapy.
 
Some people might feel that wearing a pump (though it is small and easily concealed) is more of an ‘advert of their diabetes’ than is treatment by injections.
 
You need to be aware that pump treatment requires a commitment and willingness to:

  • do regular and frequent blood glucose testing;
  • use the facilities that the pump has to adjust the insulin delivery as needed; and attend the Insulin Pump Clinic.

We will speak with you in more detail about the pros and cons of insulin pump therapy. Please feel free to ask us questions if you are uncertain.

Insulin pump therapy is not an artificial pancreas (not yet,anyway):It is important to realise that the insulin pump needs to be programmed by you with help from the doctor and nurse. The rates of insulin infusion used are guided by your needs (changing with food and exercise), and by the blood glucose tests that you perform. You would need to test your blood glucose at least four times a day to get the most out of pump therapy.

In the future, with advances in technology it may be possible to have an artificial pancreas where the insulin rates are automatically changed according to continuously measured glucose levels, thereby keeping the blood glucose at normal levels throughout the entire day. Research is being done to develop such devices at Guy’s Hospital and other centres, but it is not yet available for patient use and is likely to be several years before it can be used routinely.
 


What will happen once I am referred to the insulin pump clinic? 

You will usually be referred to the clinic by your hospital consultant if he/she is concerned that your diabetes is not well controlled and feels you may benefit from a trial of insulin pump therapy. Alternatively, you might have been started on insulin pump therapy at another hospital and need to have care and supervision at a centre with expertise in this treatment. During your visits to the clinic you will meet members of our team, including:

Consultants: Dr Neil Black, Dr Ahmed Helmy, Dr Athinyaa Thiraviaraj;

Diabetes Specialist Nurses: Sr Lisa King, Sr Eilish McIvor, Sr Mairead McClintock

Diabetes Dietitians: Lesley Hamilton; Nicky Perry and Siobhan Monaghan. 


Will my blood glucose always be well controlled if I am using the insulin pump?

Starting on insulin pump therapy is a trial. Because we have a strict selection procedure, most people who are chosen for an insulin pump trial have much better glucose control, manage the pump procedures very well and will be completely satisfied. However, improved control is not guaranteed. Some people who use the pump may have no improvement in their blood glucose control after a few months or find it difficult to cope with the demands of the pump programme. In some cases, a switch back to injections may be the most appropriate option. We find that few people who start insulin pump therapy switch back to using insulin injections. To help us make sure you are getting the maximum benefit from the insulin pump programme, please:

  • make every effort to attend your clinic appointments - if this is not possible, phone us as soon as possible so we can rearrange your appointment and give your original appointment to someone else.
  • commit to the treatment plan set out by the team;
  • tell us of any changes in your personal and treatment details.

Where can I get more information?

For more information about insulin pump therapy, please speak to your doctor or diabetes specialist nurse.
 
DIABETES UK
You may find the Diabetes UK position statement on insulin pump therapy interesting. it is available on this website:
www.diabetes.org.uk
 
INPUT is a patient-led support group
for people using insulin pumps.
Its website has useful links to other websites about diabetes and insulin pump therapy:
www.input.me.uk

RUNSWEET is a website and organisation which has specific useful information in relation to sport and diabetes, including insulin pumps: www.runsweet.com


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