Insulin Pumps

How many children in the Western Isles have pumps?
Currently 4 young people with diabetes are on pump therapy

Should all children be on a pump?
In short, no. Many children and families would not wish a pump even if one is offered and many would be unsuitable for a wide variety of reasons including not monitoring often enough or acting appropriately on the results.

How are pump candidates chosen?
Candidates for pump therapy are chosen on the basis of clinical need. In NHS Western Isles we have developed a system of bringing details of possible candidates to a regular multidisciplinary meeting where the whole team will discuss the pros and cons.

How much does a pump cost?
The average cost of an insulin pump is around £2500-2800 with annual supply costs (excluding insulin) of about £1500.

Why can't we choose the pump make we prefer?
There are two reasons for this; one financial and the other practical. The NHS in Scotland always wishes to get best value for money so ran a procurement for insulin pumps. This limits the range of technology available unless a strong clinical case is made for something else. From a practical perspective, it is important that the staff supporting patients on pumps are fully familiar with the buttons, nomenclature and detail of how the products work. Therefore, we have deliberately limited our use to very few pumps.

Once you are started on a pump is that it for good?
If a pump works well for a patient and family and diabetes control is good then pump therapy will continue but, especially in teenage years, some patients will decide that they no longer wish to be on a pump. Additionally, and where the pump has been supplied by the NHS, if the clinical outcome is unsatisfactory e.g. poor control, inadequate monitoring etc. the Team reserves the right to withdraw the pump. Such a step would not be taken without prolonged discussion with the family and strenuous efforts to improve the situation.

Are there any pre-requisites to using a pump?
Yes, it is essential that anyone thinking about starting pump therapy is already competent at carbohydrate counting and would normally have been using multiple injection (basal-bolus) therapy for some time. In addition the patient/family will have demonstrated that they have the skills in monitoring blood sugars, adjusting insulin etc. that will be essential for safe pump use.

How long does it take to learn to use a pump?
In NHS WI, a structured 'pump start' takes a week and during this time the patient and parents would be obliged to attend hospital for several formal teaching sessions. Beyond this, the speed at which the details are learned and grasped varies but support is supplied daily or weekly until this point is reached. In most cases recently we have used email extensively for the sharing of detailed blood glucose and insulin dose information. This is done on the explicit understanding that email is not a secure form of communication so no sensitive information will be exchanged this way.

I've heard pumps can be dangerous. Is this true?
Yes, while properly managed pump therapy can be very effective and is safe, lax practices can be dangerous. Unlike injected insulin, which remains active for some time, a pump delivers such small amounts only a very tiny insulin depot is in the body. Not testing blood glucose for 12 hours could easily mean a displaced cannula is not noticed. Keto-acidosis can then develop very quickly as no insulin is being infused.

Does a pump mean that I will never have to give injections again?
No. When things are going well, no conventional insulin injections with a pen or syringe are required. However, if your blood glucose goes high and you have ketones, it is important to have insulin by injection until you have sorted out whether the pump is working properly. Also, you may want to have a break from the pump (e.g. for a holiday), so have to go back to conventional injections for a while.

The following few questions are pump-specific and are included here only for general information as the terms may be heard in clinic or seen in literature.

What is a Wizard?
Different manufacturers use different terms but a 'wizard' is a piece of software in the pump that does a clever calculation of the recommended insulin dose based upon many factors including the current blood glucose, what carbohydrate is to be eaten, exercise performed and what recent insulin has been given

What is insulin sensitivity?
Insulin Sensitivity measures how well someone responds to a insulin, and describes the fall in blood glucose for each unit of insulin taken.

What is insulin on-board?
Since insulin is being administered continuously by a pump and boluses (individual doses) are taken with food, it would be possible for doses to "build-up" and cause hypoglycaemia. The insulin on-board function therefore keeps track of previous doses and ensures that not too much is given with next dose.

How does a pump give fast and slow acting insulin?
It doesn't. It only gives fast acting insulin. By having a very slowly delivered background (basal) rate that can be changed as necessary, the pump copies or mimics the way the body keeps producing insulin when we are not eating. Although a fast acting insulin is being delivered, the slow rate means it works more like a long acting insulin (which actually works by entering the bloodstream slowly) With snacks and meals pulses (boluses) of the same insulin are given rather like conventional mealtime injections.