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!