Insulin Therapy in Type 2 Diabetes - Episode 13
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Not all ATPs [authorized treating physicians] are not going to have familiarity with insulin pumps. We know they exist and that they’re like glucometers. There are hundreds of them. When we’re thinking about pumps, can you walk us through some of what’s out there? When you get a consultation referral, how do you then stratify and say, “This is what I’m leaning toward?” If you could, start with what we have, what’s on the market, and what our options are.
Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: I’m a big fan of patient choice: knowing their options, knowing the different types of technologies out there, and being able to make an informed choice on that. When we think about insulin pumps and smart pumps, which are pumps that can do things like calculate insulin doses based on carbohydrate ratios or correction factors and keep track of active insulin time, that’s another benefit that we didn’t talk about. This avoids the phenomenon of stacking insulin where that glucose is high, and a person has the urge to keep giving more. Pumps help to prevent that too because they keep track of how much insulin is working, so a person can make an informed decision if they need to take more insulin or not.
We essentially have 3 main pumps. One is the Omnipod pump, and that is considered a patch pump or a pod. It does not have tubing, and it is controlled through something called a PDM [personal diabetes manager], which is where a person would be able to calculate their insulin doses. We then have the Tandem insulin pump, which is a tubed pump. It has a touch screen, and that has potential integration with the Dexcom CGM [continuous glucose monitoring], and that also has the smart technology to be able to calculate the doses and keep track of active insulin. We then have Medtronic. The 630G in particular has FDA approval for people with type 2 diabetes. That is integrated with Medtronic’s Guardian 3 Sensor with their CGM and has the ability to be able to suspend insulin based on a certain glucose threshold if it’s combined with that sensor. For example, if someone is low, they set it for 70 mg/dL. If they reach that, the insulin would stop that infusion to prevent worsening hypoglycemia.
Stephen A. Brunton, MD, FAAFP: My daughter has type 1 diabetes. As a parent, knowing that there is that suspend feature is helpful because you worry at night that you’re not going to know that they’re going low. The fact that you have a peripheral brain that’s doing it for you is very reassuring for parents.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: With that feature, I can see how that provides comfort for not only the patient but also the extended care team, in this case a parent or a loved one. Diana, I want to go back to a point you mentioned about connectivity. Can you unpack the 630G?
Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: One thing I also didn’t say is that with all these pumps, the amazingness is that you can download the data and see what the person is doing. It’s unlike with typical injections where you have no information, and you’re just asking a person, “How many doses do you think you missed?” I can’t tell you how many of my patients have said to me, “I wasn’t sure if I took my mealtime insulin, so I wasn’t sure if I should take it and risk double dosing or if I should just miss it.” What’s great about having an insulin pump is that you can look in the history and see whether the person took the dose. As a clinician, we can download that data, and we can tell how the glucose varied according to the amount of insulin the person was getting. We’re seeing what their breakdown is between that basal insulin, that background insulin, and the bolus insulin doses that they’re given.
To talk specifically about the 630G, when a person is wearing the sensor, the CGM, the Medtronic, is a 7-day sensor wear, and they’re wearing their pump, so they’re communicating directly with each other. A person on their pump can see those CGM readings. It’s certainly easier in terms of bolus insulin dosing for meals because you know exactly what the glucose is. You can use that in those calculations. The other key features are getting those alerts. You can customize it to a certain low or high level to know when that’s happening and be able to take action. That low threshold is really key, and it can be customized. Some people may want to set that at 80 or 90 mg/dL, so they’re alerted to it early and try to minimize. What we’ve seen in practice is that this is groundbreaking in terms of being able to reduce hypoglycemia and be much safer for our patients.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: One thing I can just tell from your excitement is that we can go back and forth and geek out over all these different features. With a simple thing regarding connectivity, we see it in all aspects of our other lives: in our home, our car, and all these other things, and we’re now seeing it in some of patient care aspects.