Zachary Slezak VansickleWriting 150January 30, 2018 A pregnant woman passes out for the second time during her pregnancy because she could not regulate her blood sugar levels. She was experiencing low blood sugar or hypoglycemia. Her blood sugar was so low that it was not detectable on a glucose meter. This woman began her pregnancy by taking six or more insulin injections a day just to keep her blood sugar level below 150 mg/dl so her baby would not suffer any complications from her diabetes. When she passed out for the third time her endocrinologist decided to put her on an insulin pump. An insulin pump is a computerized mechanical device about the size of a deck of cards that pumps short acting insulin through a length of tubing to a small catheter that is inserted into the subcutaneous tissue. Insulin is pumped continually at a preset basal rate interrupted only by a bolus of insulin the wearer programs to give at meal times based on the amount of carbohydrates eaten. This insulin pump was a God send for this woman and a life saver for her baby. She went on to complete her pregnancy and had a healthy baby boy, me. My mother swears that if she did not get an insulin pump when she did that I would not be the healthy man I am today. That was nineteen years ago and the insulin pump that saved my life is now obsolete. My mother now has her fourth insulin pump, which is a state of the art Medtronic Minimed 670g. A healthy pregnancy with diabetes is a challenge but thanks to advances in diabetes treatment such as the insulin pump, management is much easier. Modern insulin pump technology has soared into the future with new significant developments that could have fully automated and independent insulin pumps that could one day become a replacement pancreas and change the lives of people with diabetes forever. With diabetes becoming such a major health epidemic all over the world, the need for technological innovation is now. Insulin delivery with pumps, also known as continuous subcutaneous insulin infusion (CSH), was introduced almost a half century ago. These pumps utilize rapid-acting insulin in a preset amount determined by the patient’s endocrinologist at a continuous basal rate. The hope is that the pumps actions mimic those of a normal functioning pancreas better than injections. Most Type 1 diabetics have a pancreas that no longer produces insulin, making oral hypoglycemic medications ineffective. Thus the need for replacement insulin from either injection or insulin pump. Fine-tuned “pancreas replacement” promises to be one of the many avenues that offers hope for people suffering from diabetes. “Pump technology has progressed to the level of precisely mimicking physiological demands. Programmable insulin administration in basal and bolus fashion is integrated and augmented with glucose biosensors to provide real-time, data driven glycemic control” (McAdams and Rizvi). This affords the diabetic patient the freedom of not having to stick their finger with a lancet 5-6 times a day to acquire a drop of blood to check their blood glucose. Insulin pumps work by delivering insulin by a continuous infusion through a tubing system connected subcutaneously to an area of choice, which is replaced every 3-4 days. Since only rapid acting insulin is used a preset basal rate, which is determined by a 24 hour glucose profile, is tailored to each specific patient. These basal rates are set for specific time periods and can be modified according to glucose readings. For example, my mother uses three different basal rates over a 24 hour period because her blood sugar fluctuates at different times of the day depending on her level of activity. At night her basal rate is at the lowest rate because she is sleeping but in the morning when she is most active it is higher and her evening rate is a moderation of the two. It took her and her endocrinologist years of trial and error to figure out which settings worked best for her. These settings of course can be changed at any time and often are due to activity, stress, and illness. Patients can deliver bolus insulin which infuses over a few minutes to cover high blood glucose levels or meals. Bolus insulin for meals is determined by the patient according to the carbohydrate content of food. The pump accurately dispenses the amount of the bolus to cover carbohydrates and food according to a preset carbohydrate sensitivity ratio determined by the endocrinologist and programmed into the pump. Same thing goes for covering high blood glucose levels. “With phenomenal advances in self-monitoring of blood glucose, meters are able to communicate the readings directly and wirelessly to the pump via infrared technology, thus eliminating the extra step of manual entry of the glucose value into the pump by the patient” (McAdams and Rizvi). In conjunction with a continuous glucose monitor or CGM insulin pumps can deliver precise dosages of insulin. The CGM is a small sensor that is inserted subcutaneously, usually on your belly or arm. It is a separate device from the insulin pump and it measures the glucose found in the fluid between cells. It detects and provides continuous insight into glucose levels throughout the day and night. This sensor wirelessly sends the glucose data to the insulin pump which then automatically adjusts the pumps basal rates to target a specified blood glucose level. You can see your glucose level anytime at a glance. CGMs are always on and recording glucose levels, whether you are working, showering, exercising, or sleeping. An alarm can sound when your glucose level goes too low or too high. This alarm can be especially helpful if your glucose drops dangerously low overnight or during exercise. “Efforts are underway to integrate the two technologies, from “sensor-augmented” and “sensor-driven” pumps to a fully-automated and independent sensing-and-delivery system” (McAdams and Rizvi). An automated insulin delivery system is in the cure family. It cures the burden of diabetes maintenance. The disease is not gone but it is not the same as it was before. There are many potential benefits of insulin pump therapy. It mimics normal pancreatic function better than injections. Since the pump delivers predictable and precise continuous insulin delivery it is better able to regulate glucose levels versus insulin injections. Pumps give their users increased flexibility in daily living with regards to mealtimes, travel, work and activity. When injecting insulin with a syringe, it had to be injected approximately 30 minutes before mealtime and skipped during certain activities. This required planning ahead with spontaneity out of the question. Tighter blood glucose control with the reduction of hypoglycemic episodes is a particularly important benefit of pump therapy. Maintaining a proper HbA1c, glycated hemoglobin, is important to the prevention of diabetes related complications. “glycated hemoglobin is a protein within red blood cells that carries oxygen throughout your body, joins with glucose in the blood becoming ‘glycated’. By measuring HbA1c, clinicians are able to get an overall picture of what the average blood sugar levels have been over a period of roughly three months” ( ). For people with diabetes this is important as the higher the HbA1c, the greater the risk of developing complications. Overall improvement of quality of life is perhaps the most important benefit to pump therapy. Eliminating the worry, work, stress and responsibility of diabetes management is very beneficial. Some issues related to insulin pump therapy consist of mechanical malfunction, skin infection or irritation at the catheter site, interruption of insulin supply due to kinking or tubing blockage and cost. Mechanical malfunction can consist of errors when delivery is either suspended without warning or an unsolicited bolus is given. These errors could result in severe harm or even death. In the nineteen years that my mother has had an insulin pump not once had she had a harmful malfunction. There would be times when her pump would just stop working but she was always prepared with back up syringes to deliver her insulin by injection. A simple call to the pump manufacturer to explain the situation was all that was needed to have a new replacement pump on its way the next day. Irritation at the catheter insertion site can sometimes happen if the catheter is left in too long or the site is not properly cleaned before insertion. Removing the catheter, rotating insertion sites and cleansing the area with an alcohol wipe prior to insertion usually helps with skin irritation. As a safeguard, an alarm beeps whenever there is an interruption from insulin delivery due to kinked tubing or blockage. To remedy the situation remove the catheter and change the tubing. Many insurance companies cover the cost of insulin pumps and pump supplies. A prescription is required from your endocrinologist stating why there is a need for pump therapy. Usually a recent record of blood glucose levels along with an HbA1c level is also helpful to speed up the process. Once pump therapy is ordered a diabetes educator is provided to instruct upon proper insertion technique, usage, trouble shooting and any question you may have. There are many factors to consider before jumping into insulin pump therapy. Careful patient selection is one of the most important factors that predicts the success of insulin pumps. Are you ready to be attached to a device 24 hours a day seven days a week? Insulin pumps require a full time commitment. If you are not comfortable wearing an insulin pump and trusting your pump to do the job it was intended for you may not be ready. Change is hard for many people and even though the process may improve quality of life some people are not ready to let go of total control. You have to be able to put faith in the pump, your endocrinologist and yourself in order to be a successful pump wearer. You also need to have realistic expectations. The pump is not a “magic pill” that will solve all of your blood glucose problems. You still have to change your pump and tubing regularly and responsibly in order to maintain therapeutic blood glucose management. This step into the future with modern pump technology may not be what everyone requires but for my mother and those like her it cannot come fast enough. I look forward to the day that my mother can achieve optimal glucose control without the worry and with the flexibility that the development of a fully automated substitute pancreas can provide.