Lesli Staton, MS,RD,CDE. Diabetes Care Consultant, Insulin Pump Specialist

1. The Power of the Pump Optimizing Diabetes Control with your Insulin Pump Presented by: Lesli Staton, MS,RD,CDE

3. The Power of Basal Rates The goal is to try and duplicate the body’s natural pattern of insulin secretion. 24 hour background or continuous insulin delivery covering glucose released by the liver. Most pumpers have between 2 to 10 basal rates changes throughout a 24 hour period. Blood glucose should remain relatively stable when fasting if basal rates are set appropriately. Basal patterns must be isolated in order to evaluate……

7. Alternate Basal Profile Now Anna utilizes a separate basal pattern designed specifically for this activity. Anna switches to her “yoga” basal pattern every M,W, and F, eliminating the need for extra carb and calories. Anna practices yoga every Monday, Wednesday and Friday from 6pm to 8pm. Before starting on the pump, Anna needed to eat an extra 60g carb before the class to avoid hypoglycemia. in Practice

8. Alternate Basal Profile Cal utilizes his alternate basal pattern feature by switching to a pre-set weekend basal every Friday night and then back to his standard basal profile on Sunday evening. Meet Cal, banker by week, cowboy by weekend…..every weekend. Because Cal is very active on the ranch, his weekend basal insulin requirements are far less than what is needed on weekdays at the office. in Practice

10. Temporary Basal Rate Jake is a “skateboard junkie”. He often meets his friends after school, but not always at the same time or day. He has experienced low BG in the past while skateboarding but knows that if he takes his pump off, BG creeps up too high. Using a temporary basal rate, Jake can reduce his basal before the activity, during the activity and about 1-2 hours following the activity without permanently altering his standard profile. in Practice

11. The Power of the Bolus A rapid surge of insulin delivered at will by pumper “on demand” Covers carbohydrate and corrects for highs by using internal pump calculator Smart pump features allows the pumper to fine-tune bolus delivery by using customized ratios

12. Insulin to Carb Ratio (ICR) The amount of insulin needed to cover carbohydrate This feature creates more flexibility by allowing the pumper to eat just about any carb at any given time More specifically, the ratio of the amount of carb (in grams) that 1 unit of insulin will cover

13. Insulin to Carb Ratio (ICR) An accurate ICR returns BG to within 30 mg/dl of your starting BG within 3-5 hours after eating Example: Using a 1:15 ICR, you eat 60 grams of carb… 60/15 = 4 units Total carbs are divided by the ICR to determine insulin dose ICR varies from person to person and should be tested

15. Evaluate Your ICR 300 200 100 0 Hours 1 2 3 4 5 Healthy range showing small surge 1-2 hours after meal. BG at 4 and 5 hours within 30 mg/dl of starting BG BG in mg/dl

17. Insulin Sensitivity Factor (ISF) The amount of insulin required to bring BG to goal More specifically, the ratio representing how much much one unit of rapid-acting insulin will drop BG. Often referred to as a correction factor. This feature creates more flexibility by allowing the pumper to adjust or correct BG at any given time

20. Timing Your Meal Bolus It is very important that bolusing occurs before the meal. Carb has an immediate effect on BG while rapid insulin reacts in 10-20 minutes. Bolus-as-you-go. To avoid the old trap of “feeding your insulin”, bolus for carb throughout the meal. Be sure to get at least half of the anticipated amount before starting the meal. To maximize results, bolus 10-15 min before meal. If dining out, wait until meal is served.

22. Disconnect What: Basal insulin is redistributed as a bolus allowing the pumper up to 4 hours off pump. When: Pump failure or the pumper may desire time off of pump for activities. How: Pumper determines amount of time to disconnect. Basal insulin is calculated and reduced if necessary then taken as bolus to cover basal needs. Pump is disconnected. Do not reconnect to pump until bolused insulin has cleared (4-5 hours). Insulin stacking could occur. Discuss with healthcare provider.

23. Disconnect Amy is planning a day at the beach and would like to be “untethered” from her pump for the day. Her basal rates are as follows: 12a .85, 3a .95, 7a .80, 9p .85. Amy arrives at the beach at 10a. She calculates her 4 hour basal insulin needs as 3.20 u (0.80 x 4). She anticipates activity so reduces the dose by half. Amy checks her blood sugar and corrects if needed. She then boluses 1.60 units through her pump, disconnects and places her pump in a dry, room temperature environment. Amy continues to check her BG regularly. After lunch, Amy continues this schedule by calculating further anticipated missed basal insulin and reducing the dose for activity. At 2pm, Amy is ready for lunch. She re-attaches her pump, tests her BG and boluses for correction if needed plus the amount needed to cover lunch. in Practice

24. Super Bolus What: The Super Bolus is a creative method for maximizing BG control by bolusing the basal insulin to cover carb. When: High glycemic foods consistently causing post meal spikes and possible delayed hypoglycemia. How: Basal insulin is reallocated and added to the pre-meal bolus thus intensifying the amount of upfront insulin.

25. Super Bolus Jim loves his wives home-made bread. Problem is that it consistently spikes his BG and causes delayed hypoglycemia . Using a “Super Bolus”, Jim maximizes his outcomes. Before indulging in a 45g slice of bread, he adds 3 hours of basal rate to the total and turns off basal delivery. With an ICR of 1:15 and a basal rate of 1.1u/hr, Jim boluses 6.3u for the bread. He uses the temp basal feature to zero out his basal rate for the following 3 hours. In Practice

26. Insulin on Board Bolus on Board Feature that prevents pump from stacking insulin by tracking previous bolus and adjusting for any residual amount. Insulin on board Bolus on board Active insulin Duration of active insulin Typically set for 3-4 hours Be familiar with your pump and how it calculates BOB Pumps vary

28. Basic Concepts Revisited Carb Counting All the therapeutic features presented here are futile if carbs are not counted accurately. Practice, practice, practice Take a class, visit with a dietitian, weigh, measure, plan . Blood Glucose Testing Insulin Pump Therapy requires a significant amount of BG testing: fasting, premeal, post meal, bedtime, 3am Accuracy is critical. Insure that strips are current. Use control solution. Select a high quality product.

29. Stay Informed