Is an insulin pump just another insulin delivery device?

tim2000s

Expert
Retired Moderator
Messages
8,934
Type of diabetes
Type 1
Treatment type
Other
In the UK, people are put on MDI first, then a pump if they really need it. But does it matter which way we give people insulin? Do you need to start on injections then move to a pump, or would it be legitimate to simply start people on pumps?

After all, when we start a person on MDI, they are started with a guessed basal and bolus amount. It would be no different on a pump, just using fast acting insulin only, and would provide far greater flexibility as someone moved through the honeymoon period.

I reckon it doesn't matter, and that if you were to start someone on a pump they'd do as well as someone on MDI (appropriate training being applied in both cases, of course!). What do you think?
 
D

Deleted Account

Guest
Physically, I agree but ...

Psychologically, I see them very different.
When I was first diagnosed, there was a lot to take on board - insulin for the rest of your life, hypos, calculating insulin doses, different types of insulin, BG measurements, what's a "good BG", what's not, complications, ...
If you then added : you are going to be physically attached to this device for the rest of your life, it will be show when you swim, when you are intimate with someone .. for the first time, it is very expensive, you have to look after it, there is a possibility it may fail so you have to be ready with a backup which is something that is really important for you to know about even though you may never need it, you have to be really accurate with your insulin dose calculation for food, for corrections, for background insulin, ...
My mid-30 year old brain would have struggled to cope with all of that. I have no idea what it would have done as a teenager or early twenties.

I can see insulin pens becoming the training wheels for pumps in the future or perhaps pumps may get easier (and cheaper) but I am very glad to have had a few years to learn the ropes of diabetes management before starting my pump.
 

therower

Well-Known Member
Messages
3,922
Type of diabetes
Type 1
Treatment type
Insulin
I’ve been on mdi all my diabetic life. It’s become my way of doing it and I’d be loathed to change.
I’m more than happy with my control and my HbA1C ‘s reflect that. As someone of an age I struggle with new technology :) and the thought of learning and taking on board all that a pump would require is enough to keep me on mdi’s.
Looking at the bigger picture though I know full well that pumps are a great way of living and controlling type 1. For someone new to diabetes, especially the younger generation, I think pumps should be the go to option. All the extra input would be second nature as any other methods wouldn’t come into consideration.
 

DunePlodder

Well-Known Member
Messages
861
Type of diabetes
Type 1
Treatment type
Insulin
I agree with @helensaramay & @therower. I do think though that for a generation used to smart phones, a pump like a Tandem t:slim X2 would hold no fears.
Having said that, a period of using MDI does provide important experience.
Also being a less technological option, MDI (& the knowledge of how to use it) offers an essential basic back up in case of pump problems.
I would agree with you that, money concerns aside, the NHS should be offering the pumps sooner rather than later.
 

novorapidboi26

Well-Known Member
Messages
2,828
Type of diabetes
Type 1
Treatment type
Pump
I can see the argument that it is just another delivery device.....

as long all diabetics get the same basic skills set to adjust their own doses then both methods can be used just as good......even if one becomes unalienable it wont matter...

same goes for CGM or Libre.......get the basics sorted and it will become a brilliant tool...
 
  • Like
Reactions: tim2000s and Knikki

NicoleC1971

BANNED
Messages
3,451
Type of diabetes
Type 1
Treatment type
Pump
Had both pump and MDI and agree that there is no magic bullet however since there are certain technical advantages to only having a drip of insulin going in every hour i.e. less severe hypos and dosing errors.
I am more interested in the myth that all type 1s can achieve normal blood sugars merely by matching insulin to carbs....Maybe some of us get good HBA1cs but we still have highs and lows outside of normal range.
Therefore I think the delivery mechanism is not so important as getting affordable closed loop systems.
 

kitedoc

Well-Known Member
Messages
4,783
Type of diabetes
Type 1
Treatment type
Pump
Dislikes
black jelly beans
My personal viewpoint for my answer is not as health professional advice or opinion.

In one sense the form of insulin therapy may depend on whether you are looking at someone just diagnosed with TID, compared to someone who becomes insulin-dependent after some years on other diabetes therapy. ( e.g. the usual situation with someone diagnosed with LADA).

The 30 year follow up paper on the DCCT/EDIC study, https://doi/10.2337/d13-2112 points out, and reiterates previous reports, that the degree of BSL control in first 6 1/2 years of diagnosis of TID is crucial to the degree of diabetes complications, both mico- and macrovascular, in the future of that TID's life.

The better the control the lower the incidence of complications and that effect continues even if BSLs control is not fully maintained after say the first 10 years. Hence the reason for my second paragraph.

In terms of BSL control, not just by HBAIC measurement but also by range of BSL variation which cgm can measure, one person might do better on MDI for that time of at least 6 1/2 years and ? preferably longer, another better on an insulin pump.

Healthcare costs are a consideration on a regional and country level of course when comparing MDI vs insulin pump with some studies suggesting intensive MDI with 1/2 unit pen measurements giving as good results as insulin pump therapy (i cannot locate the reference at the the moment).

My wish is that insulin pump therapy with cgm be prioritised into several areas, one being for the first 10 years of every newly diagnosed TID with children and pregnant mothers receiving the top priority in that grouping

But as always politics enters into such decisions but i contend that the potential savings that better diabetes control early on and expected by application of the DCCT and EDIC study results provides considerable health cost savings.
But of course few politicians think beyond the next election cycle.

If Dawn phenomenon is a problem then an insulin pump might be a better choice first up also, as well as for those particularly hypo-prone.
I am yet to be convinced that looping is necessarily better than not looping on a pump particularly on the currently popular high carb diets so readily promulgated to most newcomers.

The other thing I personally believe is that a low carb, and possibly including a ketogenic diet, as part of that beginning of a TID on insulin, with careful monitoring say, with cgm if affordable, is the best way to achieve all the best outcomes revealed by the DCCT and follow up EDIC study results.

Of course DCCT and EDIC were not about diet per se but research on the potential benefits of low carb high fat/protein diets and ketogenic diet for many diabetics, T2 and T1, is promising. I contend that diet and insulin are intricately related and this relationship can influence the choice of insulin delivery.

Because intensive insulin therapy in the DCCT led to many more hypos in that group compared to the conventional treatment group it is noteworthy that surveys of those on low carb diets as per Dr Bernstein's protocol (see drludwig.com blog) have shown the lowest incidence of hypos and the best HBAICs and lowest incidence of damaging BSL excursions of any survey/study of TIDs so far.

And insulin pumps were a common delivery system used in the afore-mentioned survey but I am unaware of how many may or may not have been using looping (if any).
 
Last edited:

tim2000s

Expert
Retired Moderator
Messages
8,934
Type of diabetes
Type 1
Treatment type
Other
@helensaramay - I see this response over and over, and I think it's endemic amongst health professionals.

Leaving cost aside, the issue is that it is a retrospective view of living with insulin based on "How it's always been done".

The key at diagnosis is to help someone lower their glucose levels and maintain those levels safely. If you put someone on a pump immediately at diagnosis, teach them about the small amounts of insulin it can deliver and how to use it, and provide a positive overview of the benefits of doing so, it's rather different to the model we have of learning about different types of insulin, etc. Psychologically then, if it's what you are taught from diagnosis, then why should it be additionally onerous? It's the same argument that's given about CGM or Flash from diagnosis.

I personally don't understand, when people need really small doses of insulin, and more adjustability due to remaining insulin production, why pumps don't make sense at first, and the limited studies of immediate use of CSII seem to show good outcomes, although with small cohorts, e.g. https://www.ncbi.nlm.nih.gov/pubmed/17109598.

It sits squarely in the same view as "You only deserve a pump because there's something you can't manage easily on MDI", which much of the NHS pump provision works from. I get that those with long term use of injections may be adverse to using pumps for various reasons (including attachment to a device), but I do think that we don't help ourselves in how we talk about and discuss these different types of insulin delivery and approaches to living with type 1 when people are first diagnosed.
 
  • Like
Reactions: Leeannea

porl69

Well-Known Member
Messages
3,647
Type of diabetes
Type 1
Treatment type
Insulin
Dislikes
Stupid people
Interesting point @tim2000s
I just started a pump after 48 years on MDI. I looked into pumps around 15 odd years ago and the technology was not as good as it is now (obviously) the pumps were a little large at that time as well. So when my dietitian suggested a pump i initially said no. It wasn't 'until I really looked into them that I saw the benefits they offered. So glad I did now as my A1C is the lowest it has been in over 30 years. BUT it is a LOT to learn/take in even for a veteran like me.
Being diagnosed type1 is a massive shock to the system (I can't remember as I was too young) I could see the benefits of a pump rather than MDI to start with BUT you hacve be be super accurate with carb counting etc with a pump whereas you can be a bit flexible with MDI
 

slip

Well-Known Member
Messages
3,523
Type of diabetes
Type 1
Treatment type
Insulin
BUT you hacve be be super accurate with carb counting etc with a pump whereas you can be a bit flexible with MDI

ummmm.............Sorry Porl69 but that comment doesn't make sense to me, at least. One of the main 'selling' points of a pump is the flexibility over MDI - apart from being able to just push a button to add a bit more bolus correction when required you have the ability to change the basal rate where as on MDI once you've injected your basal theres no going back for at least 12hrs or longer with some of the extra long acting ones now available. :)
 
  • Like
Reactions: Fairygodmother

porl69

Well-Known Member
Messages
3,647
Type of diabetes
Type 1
Treatment type
Insulin
Dislikes
Stupid people
ummmm.............Sorry Porl69 but that comment doesn't make sense to me, at least. One of the main 'selling' points of a pump is the flexibility over MDI - apart from being able to just push a button to add a bit more bolus correction when required you have the ability to change the basal rate where as on MDI once you've injected your basal theres no going back for at least 12hrs or longer with some of the extra long acting ones now available. :)

The flexibility with the basal is brilliant. Different times of the day we do need more or less basal and that is a massive win for me.
The really small doses of bolus with food really means you have to be accurate with carb counting. Yes it is easy to give yourself another small dose of insulin BUT your BGs have gone up by then.
 

kitedoc

Well-Known Member
Messages
4,783
Type of diabetes
Type 1
Treatment type
Pump
Dislikes
black jelly beans
Having been diagnosed in 1966, the option of an insulin pump, cgm, even glucose meters was impossible. And there is this stubbornness and wish to be independent which led to me resisting the move to a pump til much later than i could have

I see this will to be as independent as possible as one of the hindrances that we as patients/ consumers sometimes cause well-meaning health professionals, as @tim2000s.may be alluding to.

In terms of acceptance of insulin pumps at diagnosis, children seem to take to them like ducks to water to quote a phrase. Those older might be more hesitant but that does to mean that it is impossible. I think financial strictures and criteria to limit the numbers eligible to use pumps are Government-inspired plus inflexibility in some doctoras to iniate pump therpay early. I have personally witnessed this latter attitude over and over.

. If doctors have been trained to start TIDs on insulin injections and wait until something goes wrong before the pump is suggested then the utility of the pump and the potential for improved control in that important first 6 1/2 years is often missed..

However i contend that the best HBAICs and lowest bsl excursions require a LOW carb diet in addition to either pump or insulin injection therapy to maximise that potential in the first 6 1/2 years for a more complication -free future.
 
  • Like
Reactions: Leeannea

Leeannea

Well-Known Member
Messages
131
Type of diabetes
LADA
Brilliant thread @tim2000s! Really interesting. There is such a diversity opinions, all valid. Throwing my own view into the mix, I think the newly diagnosed should start on a pump. People, especially the young are adaptable to and accepting of technology. To me it is like making learner drivers start with a push bike as a car might be too tricky and expensive Cheers Leeanne
 

becca59

Well-Known Member
Messages
2,856
Type of diabetes
Type 1
Treatment type
Insulin
We are all different. MDI for me is perfect. A pump was suggested for me very early on as I have DP issues. The thought of being attached to something full time filled me with horror. (Ironical as I now wear a self funded Libre) I am now not eligible as I have worked **** hard to sort out my issues through the Libre, lower carbing and pro active management. Still wouldn’t want one anyway. I do think that people should have the choice throughout their diabetic life though. And especially children.
 
Messages
18,448
Type of diabetes
Type 1
Treatment type
Insulin
Dislikes
Bullies, Liars, Trolls and dishonest cruel people
I am still on MDI and a pump has been mentioned to me more than once. Tbh, being diagnosed with type 1 is a lot to take on board when first diagnosed, I also had such a lot going on especially coping with being a single parent. MDI still suits me, but I won't say never to a pump if it is beneficial to me managing my diabetes.
 
  • Like
Reactions: kitedoc

Fairygodmother

Well-Known Member
Messages
4,045
Type of diabetes
Type 1
Treatment type
Insulin
Dislikes
Bigotry, reliance on unsupported 'facts', unkindness, unfairness.
It would be great if pumps were available for those who wanted one, libre too. I’m still on MDI and still frustrated by the need to give two Foot on the Floor boluses, one and a half hours apart (no, increased breakfast bolus beckons in a hypo). If the second FotF bolus is due when I’m driving then I need a correction dose later. It would be lovely too to be able to up the delivery towards the end of the afternoon.
But, I can’t afford to self fund a pump. And each time I ask for one I’m told my results don’t warrant it. I ask every year.
However, I remember one or two people on the Dafne course who had difficulty with the maths of carb counting and dosing, and who also found it took longer to apply variations to their use of bolus and basal. Despite the wish that we all have the potential to thrive some will possibly need long term support.
 
  • Like
Reactions: porl69

kitedoc

Well-Known Member
Messages
4,783
Type of diabetes
Type 1
Treatment type
Pump
Dislikes
black jelly beans
The hoops one is made to jump through to obtain an insulin pump is a way to ration them.
So in a sense you are punished by doing the upmost to stay in control, though i recall @Mel dCP was awarded a pump by demonstrating the numerous injections she needed to take per day just to keep in control.
But otherwise to jump through the hoops one might be tempted to let the HBAiC rise up to ? Above 7 % or 53 mmol/l, or have they changed the level of the bar to a higher value?
 

Leeannea

Well-Known Member
Messages
131
Type of diabetes
LADA
It would be great if pumps were available for those who wanted one, libre too. I’m still on MDI and still frustrated by the need to give two Foot on the Floor boluses, one and a half hours apart (no, increased breakfast bolus beckons in a hypo). If the second FotF bolus is due when I’m driving then I need a correction dose later. It would be lovely too to be able to up the delivery towards the end of the afternoon.
But, I can’t afford to self fund a pump. And each time I ask for one I’m told my results don’t warrant it. I ask every year.
However, I remember one or two people on the Dafne course who had difficulty with the maths of carb counting and dosing, and who also found it took longer to apply variations to their use of bolus and basal. Despite the wish that we all have the potential to thrive some will possibly need long term support.

Wo! That is exactly me in the morning! Reassuring that I have company. Cheers. Leeanne
 

Marie 2

Well-Known Member
Messages
2,394
Type of diabetes
LADA
Treatment type
Pump
I love my pump and my CGM. The pump allows much better adjustment for my DP, I give myself whatever insulin I need, even a small amount now, which I wasn't likely to do on shots. A lot of time I would try to give a shot to cover my meal and a snack, or if it was a small amount, just skip dosing for it (I still maintained at the time a 6.8-7.0% A1C). So for me a pump has kept me much more even keel. My total insulin for the day is about 55 units a day, which is less than when I wasn't on a pump.

I am a firm believer you don't have to low carb to get good control. With all the benefits of fruits, vegetables and whole grains for a "normal" person, why would they not be good for a diabetic? I do not low carb, I eat what I want, I am a vegan and consider my diet very healthy, with pineapples, mangoes, bananas, any veggies and whole grains as much as I want. My last A1C was 6%, which I am very happy about. I was 6.4% A1C for years which I was also completely happy about too. (I believe the Dexcom, instead of the Libre has helped me lower this more)

I am in the US, so I didn't have to have poor control to be able to qualify for a pump or a CGM.
 
  • Like
Reactions: EllieM
D

Deleted Account

Guest
Whilst I don't believe pumps (or CGM or Libre) should be a reward for active diabetes management and I don't think we should have to jump through lots of loops, I believe money should be spent on treatments for people that get the most out of them.
Most of my diabetes related conversations are with people on this forum; people interested in and care about managing their diabetes. Therefore, it is easy to forget about the people with type 1 who don't have the interest/motivation/intellect to manage their condition.
My DSN was recently discussing some of her "patients". I use quotes because they rarely turn up to appointments or they turn up and lie about their results or don't listen to the advice they are given or they stop taking their insulin or just blindly follow the instructions about doses without making adjustments for illness/exercise/different meals.
Thankfully, I have no other conditions to compare with diabetes but it is not a easy condition to manage. It takes time to understand, it takes effort to work out what is happening, it takes brain power we can't always spare, ... We cannot just take a tablet twice a day and get on with our lives.

Ignoring the expense, if we could given everyone with type 1 diabetes a pump, would it help or hinder these people who don't have the interest/motivation/ intellect?
I imagine it would help some but I expect the numbers would be small. If you are not willing to do basal testing, the variable basal on a pump would not help. If you cannot (or will not) carb count, small insulin doses would be of little value. If you panic when your BG goes very high, you may struggle if your pump fails. If you don't like changing the insulin cartridge in a pen, you will hate changing a pump set.

I believe insulin pumps should be made available to more people and, maybe some will benefit from a pump right at the start. But, although I agree with the points @tim2000s makes, I don't think they should be handed out like pens.

Some of my pump dislikes (e.g. being attached all the time) may be less of an issue if I had one from the start. But I still think it requires more effort than many brains are able to spare when dealing with a new diagnosis of a chronic condition.

Great topic for thought and discussion though. Thanks for starting it.