January 24, 2007

Pros and Cons of insulin pump therapy versus multiple injection therapy


Tuesday, January 24th 9pm est.
Gary Scheiner MS, CDE
Topic: Pros and Cons of insulin pump therapy versus multiple injection therapy

As both a Certified Diabetes Educator and diabetic for 20 years, Gary Scheiner knows the latest and best techniques for achieving optimal diabetes control. Gary earned a Bachelor of Arts in Psychology from Washington University in St. Louis, and a Master of Science in Exercise Physiology from Benedictine University. He received his diabetes training with the world renowned Joslin Diabetes Center. In addition to serving as a volunteer for the American Diabetes Association, Juvenile Diabetes Research Foundation, Diabetes Exercise & Sports Association and Setebaid Camping Services, Gary has authored two books (You Can Control Diabetes, 1997; and Think Like A Pancreas, 2004) and dozens of articles, and speaks at local and national meetings on diabetes, fitness and motivation. Gary received the 1997 William Martin Award for Outstanding Achievement in Patient Activities by the American Diabetes Association, the 1998 Allene Van Son Award for the development of effective diabetes teaching tools by the American Association of Diabetes Educators, and the 2003 Novo Nordisk Pharmaceuticals Research Grant Award for the study of basal insulin profiles in insulin pump users. Today, Gary owns and operates Integrated Diabetes Services, a private practice located in Wynnewood, PA (just outside of Philadelphia) specializing in intensive blood glucose control and lifestyle intervention for people with diabetes.

In addition to his office-based practice, he and his staff provide diabetes consultation throughout the country and abroad via phone, fax and the internet. He can be reached at 877-735-3648, or thought his web site: www.integrateddiabetes.com

[Scott] 6:14 pm: Well, just so the transcripts are complete, I will post an introduction borrowed from the message board. Gary Scheiner MS, CDE; Topic: Pros and Cons of insulin pump therapy versus multiple injection therapy;

As both a Certified Diabetes Educator and diabetic for 20 years, Gary Scheiner knows the latest and best techniques for achieving optimal diabetes control. Gary earned a Bachelor of Arts in Psychology from Washington University in St. Louis, and a Master of Science in Exercise Physiology

[Scott] 6:15 pm: In addition to his office-based practice, he and his staff provide diabetes consultation throughout the country and abroad via phone, fax and the internet. He can be reached at 877-735-3648, or through his web site: http://www.integrateddiabetes.com

[Scott] 6:16 pm: Perhaps the most important element, however, is the fact that Gary is himself a type 1 diabetic, so he understands the challenges we all face on a day to day basis

[Scheduled Chat Room]: Gary Scheiner has entered at 6:19 pm


[AllisonBlass] 6:21 pm: Good evening, everybody! Welcome to Diabetes Talkfest. My name is Allison and I will be your moderator for the evening. Tonight, our special guest is Gary Scheiner, CDE. Gary is a diabetes educator from Wynnewood, Pennsylvania. He has also had Type 1 diabetes for 20 years. Gary is the author of Think Like a Pancreas, a guidebook to living successfully with an insulin pump. Tonight, Gary will be talking about the pros and cons of multiple daily injections versus the insulin pump.

[AllisonBlass] 6:22 pm: Please do NOT post questions directly to Gary. Please send ALL questions to me, Allison, through a Private Message. All questions will be posted in the order they are received.

[AllisonBlass] 6:22 pm: Are you ready to go, Gary?

[Gary Scheiner] 6:22 pm: Yea. And don’t make Allison ask you twice. She’ll MESS YOU UP.

[AllisonBlass] 6:23 pm: Hey!

[AllisonBlass] 6:23 pm: I heard that!

[AllisonBlass] 6:23 pm: Let’s get this party started….

Bob asks: I would like to know his opinion of Dr Edelman’s “untethered” regimen, whereby most of the basal is taken as Lantus. The pool of long-acting insulin is alleged to cover a multitude of problems (lessen them) such as forgetting a bolus, defective site, etc… And one can be untethered for long periods.

[Gary Scheiner] 6:26 pm: The “Lantus for basal” and “pump for bolus” approach has its pros and cons. Yes, it means that you can disconnect for periods of time, since the injected Lantus is supplying basal insulin. And you are at little to no risk of DKA since there is always some insulin present.

[Gary Scheiner] 6:29 pm: But on the “con” side, it is difficult to simulate the pump’s basal delivery with Lantus. Providing higher and lower basal rates at various times of day is not easy to accomplish, and you cannot temporarily lower your basal rate for activity (the Lantus is ALWAYS there). Lantus is also not a truly “flat” insulin, and its duration of action can vary from day to day. One of the reasons to go on the pump is to eliminate the unpredictability of long-acting insulin, and this is like a step backward.

[Gary Scheiner] 6:31 pm: I also worry about the need to connect and disconnect so many times; the infusion sets aren’t made to handle that kind of workload.

[brensdad] 6:23 pm: Gary, I am 31 and on a pump, and my 1 year old is also on a
pump. Her endo wanted to use NPH, which in my opinion is the WORST thing to
give an infant. Why do so many doctors still use NPH?

[Gary Scheiner] 6:33 pm: I believe (and this is just my opinion) that many doctors still use NPH because it is what they are most “comfortable” with. Most physicians who are worth their salt are putting children, even as young as yours, onto a true “basal-bolus” insulin regimen with much success. I think that familiarity/experience with Lantus and pumps will lead to greater use and acceptance.

[Jon] 6:25 pm: When is an A1c too high to try an insulin pump?

[Gary Scheiner] 6:36 pm: Jon – The A1c level should have no bearing on whether or not you consider a pump. You could have an A1c of 6% with frequent lows and benefit as much as someone with an A1c of 10 who can’t seem to get a handle on things.

[Gary Scheiner] 6:37 pm: Jon, I believe that successful use of a pump depends on just a couple of things: An ability to count carbs, frequent blood glucose monitoring, decent record keeping, and a proven ability to self-adjust insulin doses intelligently. Adequate health insurance (or millions in the bank) helps also.

[gina] 6:26 pm: Have you had a lot of people go off the pump and what kind of regimen do you recommend once they are off the pump?

[Gary Scheiner] 6:42 pm: Out of about 1100 patient’s I’ve had go on the pump, maybe 10 have gone off. I attribute that to good preparation before going on, and good follow-up to manage the BGs properly. For those who go off, I suggest either NPH at nighttime only (for those with a distinct dawn phenomenon/basal increase in the early a.m.), or Lantus (for those with a relatively flat basal profile)… along with Novolog (via pen) at mealtimes.

[Scott] 6:30 pm: Gary, MDI (multiple daily injections) has some benefits as well – like being untethered to a machine, and some people do well with MDI. Any other reasons you can think of?

[Gary Scheiner] 6:45 pm: Good question, Scott. MDI involves very low risk of DKA, since there is always some long-acting insulin in the body. It is less costly than pump therapy, which is important for those without a decent health plan. In some cases, it can also help people to minimize the frequency of snacks, since a shot is required with almost every bit of carb intake. Pumpers sometimes lose site of the fact that a healthy diet is still important.

[Gary Scheiner] 6:46 pm: Hey, don’t pick on NPH. It’s actually pretty good as a nighttime insulin for those with a dawn phenomenon. I wouldn’t use it during the day, but overnight it can work pretty well.

[lruyf] 6:31 pm: I have a son that goes to a catholic school. the nurse that works there will not let anyone be trained to take care of his diabetes. They use the phone to call me all the time. The nurse is only there 2 days of the week. What can I do?

[Gary Scheiner] 6:49 pm: Lruyf (I’m not even going to TRY to pronounce that!), you are certainly caught between a rock and a hard place. Private schools can provide as much or as little nursing care as they choose. Your choice of school has to take into account the level of care they will provide. They are under no legal obligation to train ancillary staff on diabetes care, and I’m not sure it’s in your best interest to have them do so… especially if they have a negative attitude about it. (more…)

[Gary Scheiner] 6:49 pm: Unless you’re willing to bear the brunt of the work, you might want to consider another school.

Bob asks: There is an equation says that the higher one’s hba1c when they start pumping, the more improvement they can expect. In fact, starting HBA1c is “the” predictor of improvement. Seems to work… I was 6.5 A1C when I started pumping and saw NO improvement. What are your thoughts?

[Gary Scheiner] 6:51 pm: Bob, you’re absolutely right. In my practice, we see little reduction in A1c for those who start out below 7%. What we do see is a reduction in the frequency of hypoglycemic episodes. For those with higher A1c levels, we see an average reduction of about 1.5%. Here’s a hint: if your A1c is pretty good and you want it even better, start looking to lower your POSTPRANDIAL blood sugars!

[shay1948] 6:30 pm: Child on insulin pump, 8 years old. School calls mother every time they need to calculate the insulin dosage for a snack or for a correction for high blood glucose. Can’t the school do that without contacting the mother. There is a school nurse, but the nurse is not there every day.

[Gary Scheiner] 6:54 pm: Shay – I’d say you have a couple of options. 1: Get your child upgraded to one of the new pumps that calculates all that stuff automatically. 2: Make them a chart on Excel that shows the dosage based on BG and Carbs eaten (I have one that I can e-mail you if you like). 3: Let them call you. That’s where having a cell phone is great. If it was me, I would want to be called just to verify that what they are doing is correct.

30 cc asks: I have heard Lantus, over time, becomes less effective. Is this true? If so, Why? I mean Lantus works somewhat less as well after extended use and varies from person to person. Lantus used id in date and good.

[Gary Scheiner] 6:57 pm: 30CC (weren’t you a band from the 70s?) – I have never heard or read about Lantus losing its effectiveness the longer it is used. Everyone’s body changes over time, and doses may need to be adjusted, but that does not mean that the insulin is any less effective.

[Jon] 6:43 pm: I just read Think Like A Pancreas, are you planning to write any more books like this?

[Gary Scheiner] 6:58 pm: Jon – why? Are you planning to protest?

[Jon] 6:58 pm: no, I loved the book

[Jon] 6:58 pm: I am hoping for more

[Gary Scheiner] 7:00 pm: Actually, I am just getting started on a book called “The Ultimate Guide to Accurate Carb Counting” — it’s a combination teaching guide and comprehensive listing with total carbs, fiber grams and sugar alcohols.

[BobMN Pumper] 6:59 pm: I read that some now feel that Alzheimer’s is a form of diabetes… the brain cells allegedly not using glucose effectively and thereafter atrophying. Interesting theory?

[BobMN Pumper] 7:04 pm: the article seemed to think that maybe there was some other kind of “insulin” needed to allow the blood glucose to get into brain cells (like a cold chisel, maybe, to get into mine)

[gina] 7:01 pm: do you think that the pump is for everyone?

[Gary Scheiner] 7:08 pm: Nah… my kids don’t have diabetes, so I wouldn’t get one for them.

[Scott] 7:07 pm: Is there any type of person who pumping DOESN’T work well for, Gary? I did very well on MDI, and did not find pumping delivered much incremental benefit. Is that because I had good luck on MDI?

[Gary Scheiner] 7:10 pm: Seriously, it is NOT for everyone. Some people manage to achieve very nice control on multiple shots and don’t mind the inconveniences, so there is little to gain. Others lack the skills or sense of discipline to use one responsibly. I wouldn’t recommend it to them either. For everyone else who takes insulin, it is certainly worth considering.

[30cc] 7:02 pm: Q: How much greater is the risk for DKA expressed as a % when using a pump, as compared to MDI? Have considered a pump, but the risk seems to make the offer less desirable.

[Gary Scheiner] 7:12 pm: 30cc – The risk can’t be expressed as a percentage, but it can be minimized by learning to troubleshoot effectively. That means having a pump trainer, physician or CDE who really knows their stuff and is willing to spend the time to teach you right.

[Kelly] 7:06 pm: what do you think of the omnipod? I used it in research and didn’t care much for it.

[Gary Scheiner] 7:12 pm: By the way, it might interest you guys to know that the “OmniPod” isn’t scheduled for official distribution to the public until April. They kinda pulled the cart before the horse.

[Gary Scheiner] 7:13 pm: Kelly – I wore it for about a week. It has its merits from a size & simplicity standpoint; I just wasn’t fond of having to tote around the programmer in order to program anything.

[Jon] 7:10 pm: Can you get ketones if there is insulin in your system?

[Gary Scheiner] 7:15 pm: Jon – Yes, you can become ketotic with insulin present if: 1. You are highly insulin resistant due to use of steroid medication, illness or intense stress; 2. The insulin is spoiled or has lost potency; 3. The insulin is not absorbing properly from below the skin, or 4. You are fasting for an extended time.

gInAcApS: what would you say to someone that wanted to get off the pump?

[Gary Scheiner] 7:16 pm: BTW, if anyone has more questions or would like information about my private diabetes consulting services, feel free to e-mail me at [email protected]

[Gary Scheiner] 7:18 pm: Well, glnAcApS (if that IS your real name), I’d say fine… but I’d want to know why. Multiple injection therapy is no picnic either, so the reason should make sense.

[gina] 7:19 pm: if you would like to read a review of Gary’s book and buy his book on the diabetes talkfest CLICK HEREhttp://diabetestalkfest.com/technobetes/books/thinklike.php

[Jon] 7:17 pm: Are the ketones developed with an Atkins style diet as dangerous as ketones for a diabetic?

[Gary Scheiner] 7:22 pm: No, those ketones are the result of a lack of carbohydrate available for metabolism, and higher levels of fat metabolism. The danger with diabetes is that ketosis is usually accompanied by dehydration due to hyperglycemia. The combination of ketones and dehydration is what really leads to DKA. Atkins folks don’t tend to get dehydrated.


[Kelly] 7:24 pm: Thanks Allison



[Scott] 7:25 pm: Thanks Allison, Thanks Gary … I hope you’ll come back sometime!


[Jon] 7:25 pm: Thanks a lot Gary! Come back and see us again soon!