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Insulin Pump Therapy and Type 2 Diabetes-What are your thoughts?

Sep 02, 2011

If you are following our blog, you may have seen in earlier entries that I attended the first “Virtual Meeting” this year since I was not able to attend the meeting in person. So far, it has been great to be able take the sessions when it's convenient for me over the last few weeks. I could log in at 11pm at night when my son was sleeping or during clinic if a patient did not show.

One session that I attended was, “Using Insulin Pump Therapy in Poorly Controlled Type 2 Diabetes.” It was presented by Phyllis Wolff-McDonagh DNP, ANP, CPNP, CDE. She stated that 85% of the A1C goals are not met and because of poor control leading to multiple complications, we need take a closer look at more tightly controlled therapies. Many studies have been done on Type 1 and pumps, and we know they are a very effective way to control diabetes. However, very few studies have been done on Type 2 diabetes and pumps, and it is not as popular to find a person with Type 2 diabetes on a pump.

She did a cost comparison that I found very interesting. For patients with Type 2 diabetes using a large amount of basal insulin (over 150 units/day), the cost of multiple daily injections as $41,1000 and for pump patients it was $28,826. The total cost for a Type 2 patient using large amounts of insulin on a pump was actually lower than that of multiple daily injections. She also discussed that it is harder to find guidelines for dosing patients with Type 2 diabetes on pumps since it is less common. In their practice, they find that using a TZD with a pump works well for Type 2 patients and gave examples of doing with and without at TZD on board.

Of course probably the biggest barrier to more Type 2 patients getting pumps would be insurance reimbursement. Medicare uses C-peptide values to determine pump eligibility. This works better for Type 1 patients, but for Type 2 patients, c-peptide levels are usually within normal limits or higher since the body is overproducing insulin with insulin resistance. Using c-peptide levels to determine pump candidates is not a good marker in the patient with Type 2 diabetes. She suggested that we need to have more advocacy to determine pump eligibility in Type 2 patients and insurance reimbursement. Not only will this most likely result in better control and less long term complications and costs, but also for patients on a high dose of insulin it could actually save insurance companies money.

She also discussed the pros and cons of using U-500 insulin, especially for those who are very overweight and experience high levels of insulin resistance resulting in a very high dose of insulin. Since U-500 is five times more concentrated than U-100 (standard), you reduce dosing by one fifth. Converting someone from U-100 to U-500 can get quite complex and confusing since it is so different than what we are used to.

This session was extremely interesting, and I would recommend taking it if you are interested. Register for the Virtual Meeting here. The pdf of the slides are under “Resources” in the virtual meeting section.

Did you attend this session at Annual Meeting or access it in the Virtual Meeting? Do you think more Type 2 patients should be on pumps? Should we change the eligibility markers? What is your experience with U-500 insulin? I would love to hear your thoughts!

3 comments

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  1. Sep 19, 2011

    Amy, I have to say I was not able to attend this session but was very interested. I do work for a Insulin Pump company and I want to disclose this from the beginning however my job is doing case management with new pumpers and adjusting insulin doses for the first month after starting their pump so I am not in the business of selling our pump outright. That being said I have lots of Type 2 pts on pumps and many using U500 even though it is considered "off label" and we do not encourage it's use but have been working with these pts and they usually get great results. When I was in hospital outpatient practice I was relucant to start pumps on Type 2 pts who were not motivated to test more frequently than ac and bedtime and who seemed to struggle with carb counting. When I started working in bg management I had an eye opening expereince. Many pts simply by getting a more accurate basal rate seemed to get better results. BGs even out and if they can do the carb counting and cover food approprately they do really well. I can usually get a Type 2 on a pump stable with 80% of bgs within target within about 2 wks. Many pts using U500 still seem to need a lot of insulin and exhibit all the signs of extreme insulin resistance and even with oral agents for this added they require large doses. Cost wise I have not done the math but logically it follows that if you can use a concentrated insulin and fill the cartridge less frequently and have smaller bolus and basal amounts it is going to save money. Since U500 insulin is Regular insulin it also has a longer life and so pts correct less for bgs and more for food. The confusion with U500 insulin is minimized with pump use since it does the calculations for pts so there is no confusion with taking wrong doses.
  2. Sep 13, 2011

    I have helped many T2's start successful insulin pump therapy. Most were people testing frequently, counting carbs, using C:I and CF's already. Some were people who were unable to count carbs but could do 'exchanges' or even a 'menu' for insulin dosing (count your oatmeal as '2', your 8 oz. of milk as '1', etc) and they all did well with the pump. If it can be covered by insurance, it is a great tool for many people who have Type 2. I do not have as much experience w/'poorly controlled' T2's starting on pumps, however. We also use more and more U-500. It seems to really work very well in the insulin resistant groups using a few hundred units/day who still have high A1C's. Another fabulous combo is Victoza and U-500. Some people can take both injections in the morning and not need any other injections later in the day (convenient for those who 'forget' to take the later in the day injections. This, of course, only works on the group of T2-ers who's BGs only go up when they eat, but their fastings are relatively easy to control. We recommend writing the dose for U-500 as 'Take ___ insulin syringe units of U-500 before ____ and ____. ____ insulin syringe units of U-500 is equal to ____ mL.' This clear instruction provides both the patient and pharmacy guidance. We use a table, similar to what Lilly has available, to help us keep the dosing straight. Where I worked before I moved to Iowa - we even had a couple of T2's on pumps WITH U-500. :o)
  3. Sep 12, 2011

    I am an insulin pump trainer for MiniMedtronic and in the practice that I was doing a lot of training for most of my patients were type 2 and they did very well.

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