Think Like a Pancreas

by Gary Scheiner

  Selecting a pump is a matter of personal preference. All pumps have a set of basic features that allow safe, precise delivery of basal and bolus insulin. Beyond that, a slew of buzzers and whistles, ranging from built-in bolus dose calculators to electronic links with meters and CGM devices, can be found. Shop around for the pump with the features you desire. Besides the list of manufacturers and websites in the Resources section of this book, check out the thorough pump comparisons found at http://integrateddiabetes.com/p_compar.shtml.

  In general, the features that are most important to consider when selecting a pump are as follows:

  •Reservoir volume: Does it hold enough insulin to last you at least three days (the typical cycle for infusion-set changes)?

  •Readability: Is the screen bright and sharp enough for you to read the details easily?

  •Bolus amounts: Are the bolus increments (largest and smallest) suitable to your usual needs?

  •Calculation features: Does the pump’s bolus calculator allow you to enter your exact dosing formulas (insulin-to-carb ratios, target BGs, correction factors, duration of insulin action) without having to round off or compromise?

  •Alarms: Can you hear or feel the alarms when they go off?

  •Water resistance: Do you require a pump that is fully waterproof?

  •Linkage: Do you want or need a pump that links electronically to a blood glucose meter or continuous glucose monitor?

  •Wearability: Is the size of the pump and clip/attachment configured well for you?

  •Coverage: Perhaps this is a good place to start. Check to see if your health insurance will only cover certain pumps or if the choice is yours.

  Having a pump with the features you prefer can certainly make life more convenient, but as is the case with any instrument used to deliver insulin, achieving successful control has as much to do with the skills of the user as it does with the device.

  Other Medications to Support the Insulin

  Many people feel that just because they are taking insulin, all the other diabetes medications can’t do them any good. Whether you have type 1 or type 2 diabetes, the other medications can make quite a difference.

  For anyone who takes mealtime insulin and is experiencing aftermeal blood sugar spikes, pramlintide (brand name Symlin) injections can provide significant improvement. As described in Chapter 3, Symlin can also help curb hunger for those trying to lose weight.

  Metformin can also be used along with insulin. Because it blunts the liver’s secretion of glucose into the bloodstream, metformin tablets can improve fasting blood sugar and reduce overall insulin requirements in people with either type 1 or type 2 diabetes, particularly those who are insulin resistant (requiring larger-than-normal doses).

  For those who are highly insulin resistant, insulin sensitizing agents (thiazoladinediones) may provide some relief from very large insulin requirements. Just remember, though: If you have type 1 diabetes, none of these supplementary treatments will eliminate your need for insulin, but they may reduce the doses required to manage your diabetes.

  A Modern Glucose Monitoring System

  Without question, diabetes management requires frequent blood glucose monitoring. Trying to manage your diabetes without checking your blood sugar regularly is like driving a car with your eyes closed. You might be okay for a short while, but before long you’re going to crash and burn.

  The Blood Glucose Meter

  Because you’re likely to be checking quite often, look for a meter that is fast (some take as little as five seconds), simple to use (fewer steps means less chance for user error), downloadable to a computer (and with substantial memory), and easy on your blood supply (1 microliter or less is ideal; some require as little as .3 microliters). Many meters now are codeless, which means they don’t require you to update the code number on the meter for each new vial of test strips.

  The good news is that modern glucose meters are all reasonably accurate and unaffected by most over-the-counter medications. They also operate in wide temperature ranges and at varying altitudes. However, if you need to check your blood sugar under extreme environmental conditions, contact the various manufacturers (listed in Chapter 10) to find one that will work best.

  Most modern blood glucose meters are fast, compact, easy to use, and require very little blood.

  Some meters have taken on the look and feel of minicomputers. Personally, I’m not a big fan of meters that allow entry of event markers and data such as insulin doses and carbs consumed because entering this type of information usually takes way too long and the data is displayed (either on screen or through a computer download) in a way that makes proper analysis difficult.

  With the advent of meters that require very small blood samples, virtually painless alternate-site testing (taking blood samples from places other than the sensitive fingertips) has become a reality. However, be aware that alternate-site testing rarely works with meters that require one microliter of blood or more. Also, readings taken from the arm or leg may lag several minutes behind readings taken from the fingertips, so if you suspect that your blood sugar is dropping or rising quickly, a sample taken from the fingertip will provide a more accurate reading than will a sample taken from alternate sites.

  Another feature that is new to some blood glucose meters is the ability to also check for ketones in a blood sample. The advantage of this system is that ketones will appear in the blood a few hours before they show up in the urine, and the meter provides a specific numerical value for the ketone level rather than simply small, moderate, or large. Abbott and Nova Biomedical make such meters. (See Chapter 10.)

  Regardless of the meter you choose, having more than one is beneficial. Most meter companies will send you extra meters at no charge, assuming that you will continue to purchase and use their test strips. Personally, I keep a meter in each of the places where I am likely to do my testing—bedside, kitchen, desk at work, and gym bag. I don’t keep one in the car because test strips can spoil easily at very high and low temperatures. Instead, I keep one in my briefcase for testing before I drive home from the office.

  The Lancet

  Oh, how far we’ve come since the “guillotine” days of yesteryear. Obtaining an adequate drop of blood with minimal discomfort is all about the tools and techniques you use. Lancets, like syringe needles, come in varying gauges. And like needles, the larger the gauge, the thinner (and less painful) the lancet. Look for 33-gauge (or larger) lancets. In fact, lancets as thin as 36-gauge are available for very young children. (See Chapter 10.)

  The lancet you choose does make a difference.

  And whatever you do, don’t just poke your finger with the lancet by hand. That virtually guarantees a painful fingerstick and buildup of scar tissue. Use a lancing device that has an adjustable depth setting. Start with the lowest/shallowest depth possible and see if you can conjure up a sufficient drop of blood with a little bit of “milking.” If that doesn’t work, go to the next setting and so on until you obtain a sufficient drop. That’s the setting you should go with—and not a speck deeper. For alternate-site testing, it is best to use a lancing pen that has a clear cap (so that you can see when a sufficient drop appears) and a thinner head than those used on the fingertips.

  Downloading Software

  Virtually all modern blood glucose meters are downloadable to a PC running in a Windows operating system; many are also downloadable to a Mac if it has Windows-compatibility software. The meters themselves attach a time and date stamp to each glucose value so that you can generate graphs, charts, and statistics. Of course, it helps if the meter’s clock and calendar are set properly, so check these before doing a download. (Nothing ticks me off more than doing a complete download and data analysis only to find that the a.m. and p.m. are backward!)

  Meter downloading software is usually free of charge, available on the meter company’s website or by obtaining the software on a CD. Download cables, which plug into your computer’s USB port, are either
free or modestly priced. Some connect directly to your meter; others use infrared or radio signals to communicate with your meter. We’ll discuss what to do with the data obtained from your download in the Skills section later in this chapter.

  A Continuous Glucose Monitor

  Imagine buying a book that you’ve been dying to read and then only reading the first page of each chapter. Now imagine going to a movie that you’ve been dying to see and then spending 90 percent of your time in line at the concession stand, or listening to your favorite song through a broken headset that loses the connection every couple of seconds.

  Continuous glucose monitors reveal the full story behind our blood sugar levels.

  This is what life is like for those who only check blood glucose levels using a fingerstick meter a few times a day. We receive select bits of information, but we’re missing the big picture—the full context of what is going on.

  Now we can learn the full story. Continuous glucose monitors (CGMs) display updated information every couple minutes. They also provide trend graphs, warning alarms, and downloadable reports.

  All of the currently available CGM systems utilize a thin filament inserted just below the skin to detect glucose in the interstitial fluid (fluid between fat cells). The information from the sensor is transmitted via radio signals to a handheld receiver, which displays an estimate of the current glucose level. Trend graphs, direction arrows, and high/low alerts are also provided. In some cases, the sensor information can be displayed right on an insulin pump. All CGM systems require occasional calibration by way of fingerstick readings. Even though they are not as precise as blood glucose meters (the sensors are generally within about 15 percent of fingerstick values), they still offer considerable value to the user.

  One of the key benefits of CGM is the ability to detect approaching high or low glucose levels. Although they may not detect every high and low, CGMs provide an early warning for the vast majority—and much earlier than most people can feel them on their own. The trend arrows/graphs give us the ability to forecast where the glucose is headed so that appropriate decisions can be made regarding food, activity, and insulin/medication. For example, you would probably act differently if you knew that a bedtime reading was 100 mg/dl (5.5 mmol/l) and dropping quickly as opposed to the same value but steady.

  CGM sensors include a tiny filament that is inserted just below the skin as well as an attachable radio transmitter.

  All CGM receivers are downloadable for analyzing overall statistics and trends. The downloaded data can be used to measure the magnitude of postmeal spikes, test the effectiveness of basal insulin, evaluate postmeal and postexercise patterns, detect nighttime lows or rebounds, and measure the precise action curve for rapid-acting insulin. Research has shown that those who use their CGM consistently tend to have fewer (and less severe) lows and improvements in their A1c, along with less variability in their glucose levels. Those who don’t use them on a consistent basis may benefit while wearing them but tend to see little in terms of long-term improvements.

  Why would anyone not use a CGM all the time? Well, they do have a few drawbacks. Inserting the sensor can be a bit awkward and uncomfortable, and having something stuck on the skin all the time bothers some people. There are periods of inaccuracy and occasional false alarms, and there is inherent lag time in any CGM system (their readings lag about ten minutes behind actual blood glucose values). Many people prefer not to carry around the receiver wherever they go. However, there is a growing movement toward linking the sensors and transmitters with devices such as insulin pumps, smart phones, and other common handheld devices.

  And finally, there are costs: Even with insurance coverage, there are usually copays and deductibles that you must meet.

  To know if CGM is right for you, especially without trying one first, is difficult. Insurance coverage for the systems and disposable sensors has improved considerably over the past few years. The CGM companies all offer a thirty-day return policy, so, from that standpoint, there is little risk. My practice (Integrated Diabetes Services) also provides CGM system trials for one to two weeks, with follow-up analysis of the data.

  So before dismissing the whole idea, remember this: When home blood glucose meters first came out, many people were skeptical of them as well!

  A Supportive Health Care Team

  We’ve all heard the saying, “A lawyer who defends himself has an idiot for a client.” The same holds true for anyone who neglects to call on the expertise of health care professionals for proper diabetes care.

  Surrounding yourself with a quality health care team is like putting together a winning basketball team. Each player has a role, yet all should work collaboratively for your benefit. Your job is to assemble the team and hold them accountable for doing their jobs. That means you may have to fire or trade some players from time to time, but that’s okay. Unless you’re winning championships every year, getting a fresh perspective once in a while helps.

  One approach is to go with a preassembled team of diabetes professionals. The American Diabetes Association keeps a list of “recognized diabetes self-management programs,” most of which feature a multidisciplinary group of diabetes-care specialists. Although there are many quality providers not included on the list, the American Diabetes Association has recognized all the programs on the list for meeting national standards for diabetes education and treatment. For an updated list go to http://professional.diabetes.org/erp_list.aspx, or call 800-342-2383.

  Otherwise, look for the following to create your own team of diabetes health care all-stars:

  A certified diabetes educator. A CDE is often a nurse or dietitian, but he or she can also be a pharmacist, exercise physiologist, physician, mental health counselor, or anyone in the health care field with advanced training in diabetes management. Your CDE should be able to coach you through the complexities of living day to day with diabetes. CDEs are expert teachers as well as skilled clinicians. If you can find a CDE (or physician) who also has diabetes, you can tap into a gold mine of both personal and professional experience. To locate a CDE in your area, talk to your doctor or visit the American Association of Diabetes Educators’ CDE network at http://www.diabeteseducator.org/DiabetesEducation/Find.html. My practice provides the services of skilled CDEs with a direct personal link to diabetes via phone and the Internet as well as in person. Visit www.integrateddiabetes.com, or call 877-735-3648 for information.

  A physician. Different physicians have different levels of expertise in treating diabetes. Endocrinologists typically have the most experience and skill in diabetes care. However, some endocrinologists specialize in treating other endocrine disorders (e.g., pituitary or thyroid problems) or are more adept at treating non-insulin-using type 2s than those who utilize intensive insulin therapy. Internal medicine doctors (internists) usually treat a variety of chronic health conditions, diabetes being just one of them. Some internists have a great deal of expertise in treating diabetes; others tend to refer their insulin-using patients elsewhere. General practitioners (family doctors) typically treat many short- and long-term illnesses and have only a basic understanding of how to manage diabetes.

  Look for a physician who is board certified; this ensures that they receive continuing education and are updated on the latest treatment methods. To find a board-certified physician, visit the American Board of Medical Specialties website at www.abms.org. Regardless of the type of physician you hire, he or she is ultimately responsible for screening for complications, prescribing the necessary tests and medications, intervening in case of a crisis, keeping you abreast of the latest developments in diabetes care, and making sure that your control is on track. If your physician is not meeting these minimum criteria, fails to answer your questions to your satisfaction, or does not support your pursuit of new technologies, management approaches, or other health care specialists, consider looking for someone else.

  A registered dietitian. Given the heavy influence that food has on diabet
es control, it pays to have a nutrition expert in your corner. An RD can work with you to increase your knowledge and skills in carbohydrate counting, weight control, sports nutrition, special occasion dining, vegetarian meal planning, alcohol safety, and dietary management of conditions such as hypertension, gluten intolerance, and elevated cholesterol. To find an RD who specializes in diabetes, contact the American Dietetic Association at 800-877-1600, or visit www.eatright.org/public (click on the “find a nutrition professional” icon).

  A mental health counselor. With all the pressure placed on people with diabetes to manage blood sugar levels while still taking care of everything else life throws at us, a mental health counselor can be a valuable member of your health care team. Mental health professionals—social workers, psychologists, and psychiatrists—can help with issues such as stress, depression, eating disorders, sleep disturbances, obsessive/compulsive behaviors, anxieties, relationship difficulties, financial hardship, and job discrimination. In most cases, psychological issues must be dealt with before you can do an effective job managing your diabetes. So if you are experiencing issues that may be interfering with your ability to take proper care of yourself, don’t hesitate to ask your physician for a referral to a mental health professional.

  The exercise specialist. Exercise remains a hot topic in diabetes because of all the benefits it has to offer. However, you can also get yourself in hot water if you exercise improperly. Severe hypoglycemia, acute injuries, and worsening of diabetic complications are among the risks that people with diabetes who exercise face. An exercise physiologist is a health professional who understands the physical, psychological, and metabolic effects of exercise. He or she can help you design an exercise plan, formulate strategies to prevent hypoglycemia, manage blood sugars during sports/competitive activities, and reduce your risk for injuries and other complications. Look for an exercise physiologist who is also a diabetes educator; many ADA-recognized diabetes centers and programs affiliated with large medical institutions offer the services of exercise physiologists.