Pump Therapy Candidate Assessment

Continuous Subcutaneous Insulin Infusion (CSII) Without and With Sensor Integration (PDF Download)

Assessing the Readiness of Pump Therapy Candidates

Assessment of the person with diabetes (PWD) is important in ensuring success with pump therapy. The diabetes care and education specialist must evaluate the physical and psychological readiness of each pump candidate to assume the responsibilities and challenges of pump therapy.

There are a number of clinical and lifestyle indicators and desired attributes that should be considered when performing a thorough assessment of whether a person is an appropriate candidate for insulin pump therapy. Some private insurance providers and all government-based insurers require additional documentation, such as a specific fasting blood glucose and C-peptide levels or antibody results.⁵

Clinical Indications for Insulin Pump Use

• Persons with Type 1 diabetes or Type 2 diabetes requiring frequent multiple daily injections
• Inadequate glycemic management despite optimized multiple daily injection therapy
• High glucose variability
• Elevated A1C
• Recurrent, severe or unpredictable hypoglycemia
• Nocturnal hypoglycemia
• Hypoglycemia unawareness
• Recurrent hyperglycemia
• Dawn phenomenon
• Preconception planning
• Pregnancy
• Extreme insulin sensitivity
• Gastroparesis
• Early neuropathy or nephropathy
• Renal transplantation
• Potentially persons with needle phobia
• Lifestyle Indications
• Erratic schedule
• Varied work shifts
• Frequent travel
• Desire for flexibility
• Inconvenience of multiple daily injections

Desired Attributes of a Pump Candidate (and/or parent(s) of pump candidate)

• Motivation to succeed, as pump therapy requires readiness, preparedness and time investment before and during initiation
• Realistic expectations of the capabilities of pump therapy
• Demonstration of independent diabetes management and knowledge of the basics of diabetes education, including all topics listed in the National Standards for Diabetes Self-Management

Education and Support⁶

• Ability to problem solve potential challenges with pump or infusion set malfunctions and how to maintain continuous insulin care in those circumstances
• Ability to accept and deal with challenges that arise and check blood glucose levels consistently throughout the day or utilize CGM^{7, 11}
• Capacity to learn, practice and understand insulin pump therapy parameters such as insulin-to-carbohydrate ratios (ICR), correction or sensitivity factors (CF), and the application of the parameters to determine appropriate insulin dosing adjustments in response to hypoglycemia, hyperglycemia, stress, exercise and other personal parameters
• Physical ability to view the pump screen and hear the alarms; dexterity to insert or charge the pump battery, fill and replace the insulin cartridge/reservoir in the pump; insert an infusion set; wear the pump; and perform the technical functions⁵
• Emotional stability and adequate emotional support from family or significant others
• Parents and caretakers must have a thorough understanding of pump therapy and willingness to spend the time needed to work with their child and health care professionals, when applicable
• Patience and willingness to work with their health care provider during the time of pre-pump training and initiation; when appropriate basal rates, insulin-to-carbohydrate ratios and correction (sensitivity) factors are being determined
• Adequate insurance benefits or personal resources to afford the cost of the pump and necessary supplies

Although these attributes are desired, they are not “requirements” for pump use. Diabetes care and education specialists are uniquely qualified to assist individuals in overcoming limitations or deficits to achieve optimal outcomes.

Regular assessments should be done to evaluate changes in a PWD’s clinical condition, motivation, abilities and life circumstances that may necessitate the need to reconsider appropriateness of pump therapy.

Considerations for Discontinuing an Insulin Pump

• Lack of insurance or means to pay for an insulin pump and pump supplies
• Change in physical or mental capacity to manage an insulin pump
• Any suicidal ideation

References:

^{1. Bergenstal R, Tamorlane W, Ahmann A et al. Effectiveness of sensor-augmented insulin-pump therapy in Type 1 diabetes. N Engl J Med. 2010:363:311-320. 2. Bally L, Hood T and Hovorka R. Closed-loop for Type 1 diabetes-an introduction and appraisal for the generalist. BMC Medicine. 2-17:15:14. Accessed 8/26/2017/ 3. Heinemann L, Fleming G, Petrie J et al. Insulin Pump Risks and Benefits: A Clinical Appraisal of Pump Safety Standards, Adverse Event Reporting, and Research Needs A Joint Statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group. Diabetes Care 2015;38:716–722. 4. Grunberger G, Abelseth J, Bailey T, et al. (2014) Consensus Statement by the American Association of Clinical Endocrinologists/American College of Endocrinology Insulin Pump Management Task Force. Endocrine Practice: 2014:20(5) 463-489. 5. Decision Memo for Insulin Pump: C-Peptide Levels as a Criterion for Use (CAG-00092R) available: https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=109&. Accessed 9/6/2017 6. Beck J, Greenwood D, Blanton L et al. 2017 National Standards for Diabetes Self-Management Education and Support. https://doi.org/10.2337/dci17-0025. Accessed 9/9/2017. 7. Walsh J, Roberts R. Pumping Insulin: Everything for Success on an Insulin Pump and CGM. 6th Edition. Torrey Pines Press, 2016 8. McCrea, D. A Primer on Insulin Pump Therapy for Health Care Providers. Nurs Clin N Am 52 (2017) 553–564. 9. Bolderman K. “Pump Start-Up” in Putting Your Patients on the Pump. Alexandria VA: American Diabetes Association 2013. 10. Standards of Medical Care in Diabetes--2017. Diabetes Care. 2017;40 Suppl 1:S48-57. 11. Handelsman Y, Mechanick JI, Blonde L, et al. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan. Endocr Pract. 2011;17 Suppl 2:1-53. 12. Clayton-Jeter H. Contributing Factors to Insulin Pump Errors in Children, Adolescents and Adults Available: http://www.fda.gov/forhealthprofessionals/articlesofinterest/ucm295562.htm. Accessed February 13, 2014. 13. Aldasouqi S and Reed A. Pitfalls of insulin pump clocks: technical glitches that may potentially affect medical care in patient with diabetes. J Diabetes Sci Technol 2014;8(6):1215-1220. 14. Evert AB, Insulin pump therapy troubleshooting for optimal performance. Empower. 2015;7(4):23-24 15. Guilhem I, Leguerrier AM, Lecordier F, et al. Technical risks with subcutaneous insulin infusion. Diabetes Metab. 2006;32(3):279-284. 16. Maahs D, Horton L and Chase H. The use of insulin pumps in youth with Type 1 diabetes. Diabetes Technol Ther 2010;12(suppl1):S59-65. 17. Cornish A, Chase HP. Navigating airport security with an insulin pump and/or sensor. Diabetes Technol Ther. 2012;14(11):984-985. 18. American Diabetes Association. Fact Sheet – Air Travel and Diabetes Available: http://www.diabetes.org/living-with-diabetes/know-your-rights/discrimination/publicaccommodations/air-traveland-diabetes/what-can-i-bring-with-me.html?referrer=https://www.google.com/. Accessed 9/10/2017 19. Diabetes care in the school and day care setting. Diabetes Care. 2014;37 Suppl 1:S91-96. 20. McCrea D. Management of the hospitalized diabetes patient with an insulin pump. Crit Care Nurs Clin North Am. 2013;25(1):111-121. 21. Boyle ME, Seifert KM, Beer KA, et al. Guidelines for application of continuous subcutaneous insulin infusion (insulin pump) therapy in the perioperative period. J Diabetes Sci Technol. 2012;6(1):184- 190. 22. Buchko BL, Artz B, Dayhoff S, et al. Improving care of patients with insulin pumps during hospitalization: translating the evidence. J Nurs Care Qual. 2012;27(4):333-340. 23. Rodbard D. Continuous Glucose Monitoring: A Review of Successes, Challenges and Opportunities. Diabetes Technol Ther. 2016;18(Suppl2):S2-3-S2-13. 24. https://www.diabeteseducator.org/practice/practice-documents/practice-papers © Copyright © 2021 Association of Diabetes Care & Education Specialists. All rights reserved Reproduction or republication strictly prohibited without prior written permission 13 25. Bergenstal RM1, Tamborlane WV, Ahmann A, et al STAR 3 Study Group. Sensor-augmented pump therapy for A1C reduction (START 3) Study: results from the 6 month continuation phase. Diabetes Care. 2011;34(11):2403-5. 26. Abraham MB1,2, Nicholas JA1,3, Smith GJ3 et al; PLGM Study Group. Reduction in Hypoglycemia With the Predictive Low-Glucose Management System: A Long-Term Randomized Controlled Trial in Adolescents With Type 1 Diabetes. Diabetes Care. 2017;Nov 30. pii: dc171604. doi: 10.2337/dc17- 1604. [Epub ahead of print] 27. Forlenza G, Raghinaru D, Cameron F, et al. Predictive hyperglycemia and hypoglycemia minimization: In-home double-blind randomized controlled evaluation in children and young adolescents. Pediatric Diabetes. 2017;1-9. 28. Breton M, Chernavvsky D, Forlenza G et al. Closed-loop control during intense prolonged outdoor exercise in adolescents with Type 1 diabetes: the artificial pancreas ski study. Diabetes Care. 2017:40(12):1644-50. 12. 29. Tauschmann M, Thabit H, Bally L, et al. Closed-loop insulin delivery in suboptimally controlled Type 1 diabetes: a multicentre 12-week randomised trial. Lancet. 2018:13:92. 30. OpenAPS.Outcomes. Downloaded 3/2/2021. 31. Standards of Medical Care in Diabetes-2021Diabetes Care. 2021;44 Suppl 1:S89 32. Danne T, Nimri R, Battelino R et al. International consensus of use of continuous glucose monitoring. Diabetes Care. 2017:40(12):1631-1640. 33. Chase P and Messner L. Understanding insulin pumps, continuous glucose monitors and the artificial pancreas (3rd ed). 2016. Children’s Diabetes Foundation at Denver, Colorado. 34. Wallia A, Umpierrez G, Rushakoff R et al. Consensus statement on inpatient use of continuous glucose monitoring. J. Diabetes Sci Technol. 2017:11(5);1036-1041. 35. Shapiro A. FDA approval of nonadjunctive use of continuous glucose monitors for insulin dosing: A potential risky decision. JAMA. 2017:318(16);1541-1542. 36. Rinker J, Dickinson J, Litchmanb M et al. Diabetes Educator. 2018:44(3):260-268.}