If you have uncontrolled diabetes, does this disqualify you from using Pump therapy?

Type 1 and LADA
1

Hello, everyone~

I have a friend whose husband has Type 1 diabetes, for over 30 years now. He doesn’t have very good control right now, on MDI, with BGs regularly in the 400-500 range. He was recently admitted to the hospital for the BG issue and was also told his liver is failing. He is now on a zero fat and low calorie diet for the liver and they’re trying to decide how to treat it. In the meantime, I am encouraging them to check out the insulin pump, but the Dr. won’t even consider it because he’s in the 400-500 range.

I was wondering if anyone else has had this experience? If so, did you have to fight for the pump? I would think the Dr. would allow it because it would encourage greater BG control. If anyone has any recommendations I would appreciate it.

Thanks!
Jessica

2

I would suggest he change doctors. Unfortunately different doctors have different opinions of who should get a pump. Some doctors won’t give it to people with good control and others won’t give it to people with bad control. There are doctors that encourage people with bad control to get a pump. You have more flexibility with basal rates. If he wants one and his doctor is being a jerk, the only way he will get one is by changing doctors. There is really no reason at all that he should not have one if he wants it.

3

I just want to second Kelly’s comment. A pump isn’t a reward for doing a great job with MDI.

Maurie

4

I had a similar experience (in terms of BG, not the liver issue) and my doctor refused to write me a prescription for the pump. So I got a different doctor, and he said I was a perfect candidate and got me all set up in terms of paperwork that same day.

5

A NEW “doctor” comes to mind -grim, small smile-



I am NOT a fan of the pump, nor the CGM’s often. However, just to artificially reduce your friends BG nightmares, both would likely be extremely helpful…



Many so called medical professionals bring severe bias to their practice. There is NO guarantee between a pump and GUARANTEED better control… especially given the MANDATORY requirements of pump usage. Pumps are NOT for the disinterested or those who refuse being diabetics. Regardless until the technology is entirely “closed loop” and you or I cannot interfere, make the big/small ~ooopsy~ mistakes; forgetting to cover a snack, a meal… forgetting to test, etc.



Until then the technology is NOT sufficent to gain control.



If someone else is tweaking things, or better yet the technology does it without requiring our input at all … it will be a technology that demands some subservience to it.

Stuart

6

As long as this diabetic is willing to learn some pump basics, like how to change an infusion site, I see no good reason why a doctor should deny him access to a pump. In fact, it might generate a fresh motivation to learn about the finer points of BG control.

On the other hand, if this person has simply given up on regaining control of his blood glucose then an insulin pump will not be a “silver bullet.”

Sustained BGs in the 400-500 range place this person at serious risk of ketoacidosis - a life threatening condition. Maybe the doctor wants to get him down to more normal numbers before starting a new therapy.

7

I had to change doctors. My original one flat out refused to even disuss a pump with me due to my horrible control, even though I have trypanophobia (fear of injections) so trying to use syringes and pens was just causing anxiety atttacks and stress for me and I still couldn’t take my insulin. I called around and flat out asked each office if they would automatically disregard my interest in a pump if my numbers sucked, and when I got to Joslin, they said nope - if you want it we’ll help you get it. Long story short, they tried making me jump through other ridiculous hoops so I ended up going through Insulet and my GP, but I did get my pump and it has helped TREMENDOUSLY.
BUT…a few of the docs I spoke to reminded me that a pump is not a cure all. It’s not a magic device that will just automatically improve your numbers. You still have to want to improve. Most people with horrible control just don’t have the drive anymore (some never did to begin with). So they want you to bring your numbers down to prove that prescribing a pump would be worth it. That it would be a worthwhile investment. Same with insurance companies - if they’re going to spend all that money on a pump for you, they’re going to want to know that you’re going to put it to good use.
Of course my argument was always "If I could GET a 7% or lower a1c with SHOTS, I wouldn’t even CARE about getting a pump! The whole reason I want one is so I CAN get a lower a1c!"
Good luck to your friend’s husband!

8

I do think every case should be looked at individually. That being said, I have to be somewhat harsh. Having a pump certainly changes what had been a manual act into a “mostly” automated act. But if you have a patient who won’t bother to properly implement a simple MDI and carb count, a pump won’t help them. We are currently seeing a shift in how pumps are “awarded” to patients. In the early years, diabetics who had the poor blood sugar control were considered the “best” candidates, after all the should benefit the “most.” But as it turns out some of us, for whatever reason, can’t or won’t do any semblence of a proper MDI with consideration of what we eat. In those cases, the pump does not help.



The latest guidance from the American Association of Clinical Endochronologists (AACE), highlights this by noting that suitable pump candidates are those that “Patients with type 1 DM who do not reach glycemic goals despite adherence to a maximum MDI, non-CSII program” (non-CSII means non-pumping).



Without knowing the case specifics, I can’t really criticize the doctors position, nor suggest ways to advocate for a pump.

9

“Insulin Pumps are a privilege, not a right.” ???
Pumps are medical devices

10

Non-compliance can’t be fixed with a pump… my guess is that if your friend’s husband is having BG’s in the 400-500 range, that isn’t happening for “no reason”… with BG’s that high, something is happening beyond “D is just difficult”… either he’s skipping insulin (or not taking enough to match the food consumed), not testing, or a combination of the two.



For someone like that, pumping can be dangerous… I lost a site yesterday and ended up over 500. But since I test regularly I caught it early and I knew it was happening, I just had limited option to fix it until I got home becuase I didn’t have a spare infusion set with me (usually I do). Imagine what could happen if I just ignored that because I wasn’t testing, or just didn’t care… it would be a different story than simply taking some extra insulin when I got home.

11

Exactly, and they require a prescription, meaning a doctor has to approve their use. That makes using one a privilege, not a right. You can’t go anywhere and just demand to have one.

12

The whole pump criteria thing is a bit of a mystery to me. I have seen two endos at the practice I go to and got completely different messages. The first endo I saw (endo #1, and she’s the one I have been seeing for awhile) said I was a perfect candidate for a pump because my A1C was good and I was logging everything and generally keeping my blood sugars under control. Endo #1 said that because I am “compliant” and take good care of myself, and because I take very small amounts of insulin throughout the day, I should have no trouble getting approved for a pump. She was the one who brought it up to me and referred me to endo #2 in the practice, who is the endo who prescribes the pumps.

When I met with endo #2, she was less optimistic. She said that my A1C might be “too good” to get approved for a pump and that because I was being well managed on MDI, the insurance company was not likely to approve me. She also added that because I wasn’t having wild swings in my blood sugar and because I am on a low dose of insulin, that too would disqualify me for pump therapy. That said, she put in the request and my insurance approved it in under a week.

The CDE/dietician I met with also said I was a perfect candidate for the pump. She said that with my low insulin requirements, the pump would give me more options. Also, the CDE felt like the pump would help me get over my fears of “overdosing” myself on insulin (which causes me to eat very few carbs and take a minimal amount of insulin, which the CDE/dietician felt was not a good thing in my case). Endo #2 said that my low dose of insulin and very low basal requirements would mean that I would have all sorts of toruble with the tube clogging.

Thus far, I LOVE my pump. I’ve had no issues with clogging and the ability to give myself small doses of insulin is amazing. I personally think that this technology should be available to anyone willing to try it.

Now, here’s where your friend comes in - you have to be really willing to give pump therapy your full effort. If your friend’s diabetes is uncontrolled due to lack of effort, pump therapy would be very dangerous. However, if he’s having a hard time controlling it because he’s requiring large amounts of insulin or needs increments of insulin, the pump might help. But there’s definitely a learning curve there. The pump DOES NOT automate diabetes. It’s a good tool, but you have to really learn how to use it, and that learning curve can be significant for some people. It’s easy once you get the hang of it, but I spent many hours going through the manual and teaching myself how to do things so far. And I still have more to learn.

My experience with endos is basically that they generally don’t know what’s best for a particular patient. They like to think they do, but they don’t. You have to be really articulate at explaining what you want and why you want it. In addition, you have to be able to shop around if you don’t like the first answer AND you have to recognize that diabetes is largely a disease of self management. The endo cannot put food in your mouth and cannot inject you with insulin 24/7. You have to do these things on your own.

13

This is seeing the world in black and white.
Pump and injections are different kinds of therapy. Some people do better with injections, others are better off with a pump.
The only question is, what is better for the individual.

It also depends on the reasons someone has a poor control. If they keep forgetting (and/or skipping) to take insulin, a pump may even be the one solution they need - because it’s always there, it may help them to remember to actually take insulin.

But getting a bg that is always 400-500 down takes some effort. It wouldn’t surprise me if he felt low at 200 since he’s used to a higher bg. If he started on a pump now, the most important thing is to get a proper education on how it works - and how he is supposed to work with is.

If he thinks, he could do better with a pump, he should get the chance to try. There is not much to lose for him.

14

Thank you everyone for your responses, it’s given me a lot to think about and to pass on to my friend. I love my daughter’s pump and wish my friend could also have one, but I agree that my friend has bigger issues to deal with before getting a pump. I’m not sure if he carb counts since I don’t live in the same State, but I will try to speak with them and see better what the bigger issue is and if I can help. Thanks for taking time to respond.

Take care~
Jessica

15

I completely disagree that it would be money down the drain.

I was in the same place as he was, and the pump made all the difference in the world for me. When I was on MDI I constantly forgot to bolus for any food besides meals (so snacks sent me high) and was even forgetting my basal. I was a busy college student working full time and taking 18+ credits a semester and my diabetes was just not my top priority. I know it should have been…but it just wasn’t.

Having the pump was a way for me to ensure that I couldn’t forget my basal, and with setting alarms on it, was a way to remind me to test and bolus.

I had an A1c of 14. I now have an A1c of 5.6.

So to anyone who’s dismissing this as being a waste of time for this gentleman…that’s not completely guaranteed. It may help him in the way it did for me by giving him a helping hand in creating and instilling good diabetes-care habits.

16

for a doctor to prescribe pump therapy, they need to make sure the patient is testing at a minimum of 4-5 times per day. If not, if the person goes on pump therapy they are in danger of slipping into DKA easily if the site/pump fails (since no long-acting insulin is on board). I was told a few years ago that I “was not a candidate for the pump.” I just started pumping about three weeks ago now with a little more effort and a new endo (I moved, but my last one was actually better IMO). I also have been in tighter control recently on MDI and testing lots more (like 8-12x per day).

I would say it is important for your friend to realize why he is in the 400 to 500 range, work with his endo on dosing, carb counting, etc to keep his numbers down and then talk about the pump. Before going on the pump, it is important to show your endo (and yourself) that you are committed to the lifestyle (carb counting, figuring out dosages, basals, etc) that the pump requires.

17

If he’s forgetting shots as Kari mentions, perhaps a watch with an alarm beep would help. A cheap alternative to pump reminders.

Nothing magical about a pump. Being this out of range, pump or no pump, it takes work & commitment.

Of course, the issue is why he’s out of control now when he wasn’t in the past. All the mechanical devices available won’t help when someone has given up on taking care of himself. I can understand endos not prescribing pumps to some patients.

18

I have a really dumb question. If your friend is getting 400 BG levels. Why doesn’t he/she just increase their insulin intake as it’s quite obvious that they aren’t using enough insulin.

19

I really don’t think you are giving yourself credit for how much you turned things around. You don’t just get an A1c from a missed bolus here and there. And you don’t just get an A1c of 5.6 cause it is convenient to press a button to bolus. The pump may have helped, but in the end, “It was all Kari.”

20

I didn’t say that. Please don’t put words in my mouth.

I said it helped ME. In MY experience, I wasn’t caring enough for myself, because it was constantly slipping my mind or I was telling myself ‘I don’t have time for this’. The pump helped me retrain myself into better habits. I by no means NEED the pump now - I could go back to MDI and have good care habits (however, I have bad DP, so that isn’t something I’d ever want to deal with w/o a pump).

All I’m saying is that his control may be so bad because he has horrible care habits (which he obviously does, because otherwise his BGs wouldn’t be so high); he needs something to help train him in good care habits. What if the pump is that tool for him?

“Educating” him in a more traditional sense on what he should be doing may also be ‘money down the drain’, as you called the pump. I was ‘educated’ a million times when I was on MDI. Nothing stuck. In one ear out the other. I became very resistant to being lectured by doctors. Having the pump gave me a way to train myself in proper care of my body on my terms, and I find it a hell of a lot less of a hassle than MDI ever was.

So all I’m saying is that if this gentleman is in fact in the same place in terms of viewpoint on care as I was…it may help him.

But nowhere did I say his control is horrible because he’s not on a pump. Maybe you should read what I said again.