By: Alan Schorr
Recent developments in the treatment of diabetes mellitus have shown that “tight” control and intensive therapy are necessary to prevent complications, increased morbidity and mortality. We are all familiar with the findings of the DCCT and various UKPDS studies and sub-studies. The importance of these “landmark” studies does not need any further discussion atthis time.
One of the intensive treatment modalities is CSII— continuous subcutaneous insulin infusion, or insulin pump therapy. Use of insulin pump therapy in individuals with type 2 has provoked controversy and debate among endocrinologists, internists, family physicians, primary care physicians and insurance companies. However, there is nodebate regarding its efficacy.
At the present time, approximately 20 percent of my patients with type 2 are using insulin pump therapy. Making the decision to use pump therapy is similar for type2 and type 1 patients. These patients
- desire improved glucose control.
- desire more lifestyle flexibility.
- are tired of taking multiple shots each day.
- will make a commitment to “work” in order to be successful with insulin pump therapy.
Concerned About Too Much Insulin
One of the major concerns endocrinologists and primary care physicians have with our type 2 patients is the amount of insulin required. Insulin resistance, particularly in those patients with obesity and other factors implicated in the “metabolic syndrome,” is of great concern to the individual patient. Patients are sometimes fearful of using “too much” insulin and the subsequent weight gain associated with insulin therapy, as well as of possible cardiac implications with insulin resistance and insulin therapy.
My opinion—which is not documented in published studies but based only on anecdotal evidence in my practice—is that insulin pump therapy reduces the amount of insulin needed to maintain glucose control. In addition, with the use of only one type of insulin, insulin pump therapy more closely mimics physiologically the secretion of insulin that happens with a normally functioning endocrine pancreas.
Improvement in glucose control in your type 2 patients will lead to a decrease in cardiovascular risk for morbidity and mortality.
Affects the Relationship With Patients
Initiation of insulin pump therapy usually leads to a change in the relationship between the patient’s endocrinologist, family physician and the patient. Pump therapy requires constant contact with the endocrinologist. It also requires more frequent evaluation of glucose levels. Most of my patients send me their blood glucose results every two to three days, either via fax, phone or secure e-mail. Patients also need encouragement with pump therapy; they may contact the office with their concerns regardingalarms, use of various sets and mechanical difficulties.
It is imperative that physicians, especially endocrinologists, be familiar with the various pumps, including their software and alarm codes. They must be able to “troubleshoot” if a problem arises. Patients will often contact their doctor first rather than call the pump manufacturer’s customer support number. Patients depend on their endocrinologist to assist them with problemsinvolving pump therapy.
The patients’ family physician or internist must be involved in the process when type 2 patients start on pump therapy. Many physicians consider pump therapy as a therapy of “last resort,” reserved for the patient who cannot be controlled with any other type of insulin therapy. Early use of pump therapy is sometimes discouraged because of concerns about the complexity of the treatment modality—such as the amount of time involved ininitiation and maintenance of the therapy.
The patient’s family physician or internist can be instrumental in the patient’s success with pump therapy by providing additional support for the patient and family members. If the family physician or internist and the endocrinologist maintain good communication, the patient can benefit from improved glucose control, having early intervention if problems arise, and from having a healthcare team involved in the patient’s care. The team approach is essential to the patient’s success in achieving glucosestability and control.
Consider Pump Therapy for Any Type 2 Who Wants Better BGs
It is my opinion that insulin pump therapy is markedly underutilized in patients with type 2 diabetes and that it should be considered for any patient who desires better glucose control and is willing to make the effort needed and to work with his orher primary physician and endocrinological team.
“Many insulin-using type 2 patients have done exceptionally well on pump therapy. Similar to type 1 patients, an insulin pump provides type 2 patients who use insulin with greater freedom, flexibility and quality of life. Since an insulin pump delivers precise increments of insulin, which is absorbed predictably by the body, a pump can provide better glucose control for many patients. In addition, today’s ‘smart pumps’ keep track of insulin used by the body, helping patients avoid insulinstacking, which can cause hypoglycemia.”
Alan O. Marcus
Global Medical Director
“Uncontrolled blood sugars are the enemy, regardless of whether a patient suffers from type 1 or type 2 diabetes. Reducing the volatility of blood sugars has proven to be as important as reducing A1Cs. As pump therapy enables patients to better match their insulin to their ever-changing metabolic needs, why not provide the same opportunities to insulin-requiring type 2 patients who are just as vulnerableto the risks of long-term complications?”
Executive Vice President, Marketing, Sales and Clinical Affairs
“Insulin pump therapy for patients with type 2 diabetes requiring intensive insulin management is becoming an increasingly viable and effective option in our attempt to optimize their control and prevent disease-related complications.”
Luigi Meneghini, MD, MBA
Director, Diabetes Research Institute
Diabetes Treatment Center
Nipro Diabetes Systems