Insulin Pump Therapy in Senior Patients

It is estimated that about 18.2 millionpeople in the United States have diabetes,¹ a number that is expected togrow as the population ages. Diabetes isa progressive disease, with manypatients eventually requiring insulin therapy.Searching for improved ways toadminister insulin is a worthwhile pursuit,as many people with diabetes balkat the idea of injecting insulin. Althoughinsulin injections are the most conventionalmethod of administering insulin,there are other, less objectionable options.Newer advances such as inhaledinsulin, insulin pens, and jet injectors areavailable for use, although they may notbe appropriate for all individuals. Anotheralternative is an older but constantlyadvancing technology that attempts tomimic pancreatic insulin release, theinsulin pump.

Insulin Pumps

Purchasing an insulin pumpis a major life decision for anyindividual with diabetes. Insulinpumps help patientsgain improved blood glucosecontrol while providing amore flexible lifestyle. Aninsulin pump is a smalldevice, about the size of abeeper or cell phone, which isgenerally worn on a patient'swaistline. The pump is connectedto the body through acatheter and line of tubing,referred to as the "infusion set."Mostpumps require an infusion set.

Insulin pumps work by delivering acontinuous basal insulin dose andadministering premeal bolus doses. Thebasal dose is given throughout a 24-hourperiod to cover glucose levels overnightand between meals. Depending on thepump, this basal dosecan be adjusted in differentways and canhave preset programsthat allow the basal rateto be easily altered. Forexample, patients couldhave one basal programfor sleeping, anotherprogram for when theyexercise, and anotherfor working. The bolusdose is given prior tomeals to cover carbohydratesconsumed inmeals and snacks, thuspreventing or minimizingpostmeal blood glucoseexcursions. One ofthe advantages of aninsulin pump is that a bolus dose can begiven with the push of a few buttons,making it much more convenient toadminister insulin.

Rapid-acting insulin analogs such asHumalog, NovoLog, or Apidra,or short-acting regular humaninsulin can be used in pumps.Individuals must refill theirinsulin pumps themselveswith whatever insulin theyand their physicians havedecided is most appropriate.Fortunately, most insulinpumps are equipped with alow-insulin alarm to help peopleremember to refill theirinsulin cartridge.

Choosing an Insulin Pump

There are certain criteria that are essentialin choosing an insulin pump.According to the American Diabetes Association,the most important criteria are²:

• Availability of service and training
• Clinically desirable features
• Cosmetic attractiveness
• Durability
• Ease of use
• Safety features
• Water resistance

These are all significant aspects toconsider when thinking about startinginsulin pump therapy. Older patients,however, may consider certain aspectsmore important than others when determiningthe best pump for them. Specificquestions to consider include:

• Is it going to be too heavy for me towear?
• How will I remember when to checkmy glucose and when to inject abolus dose?
• I don't know how to count carbs. Canthe pump help me do this?
• How will I know when to change thebatteries?
• I have poor eyesight. Is the screen large enough to read? Arethere any features to help me see it better?
• What if I forget that I already gave myself a dose? Will thepump help prevent me from injecting too much?
• I have trouble with arthritis and using smaller devices. Is thereanything that can help me enter bolus dosing and blood glucosevalues?
• How will I know if the pump is operating correctly?
• Some of these new pumps I hear about seem so technical. Isthere something simple to use?
• I'm on Medicare and need to watch how much money Ispend. How much will these pumps cost me?
• Are the supplies easy to purchase?

Although there is no one pump thatcan provide an answer for each of thesequestions, the available pumps all havefeatures that can assist older patients inadministering insulin. Features such asaudio bolusing, remote controls, beamingtechnology, and insulin on board area few examples. Although these featuresmay assist with the administration ofinsulin, it is also possible to use only thebasic programs of the pump, such asbolus and basal dosing. Thus, individualsmust decide on what is most important to them when choosingan insulin pump. Older patients, along with their health careprovider and/or certified diabetes educator, can then assist withmaking the best and most informed decision possible.

Mr. Akers is a PharmD candidate atWashington State University College ofPharmacy, Spokane,Wash. Dr. Setter isan associate professor of pharmacotherapyat Washington StateUniversity College of Pharmacy,Elder Services.

References

1. Centers for Disease Control and Prevention. National diabetes fact sheet: generalinformation and national estimates on diabetes in the United States, 2003. Rev ed.Atlanta, GA: US Department of Health and Human Services, Centers for Disease Controland Prevention, 2004.

2. American Diabetes Association. Position Statement: Continuous Subcutaneous InsulinInfusion. Diabetes Care. 2002;25:S116.