Insulin-Pump Therapy: No Need to Fear It

If you are like I am (or used to be), the thought of an insulin pump injecting insulin continuously into my patients can be quite scary.

What if the patient was sick or distracted and didn't eat as much as she should have? Wouldn't she be at risk for going into a hypoglycemic coma in the middle of the night when no one would even notice? When the nurses did their early morning rounds, if there were no reason to awaken the patient for meds or blood draws, wouldn't they just document "patient resting comfortably," never realizing that the patient was teetering between life and death with a blood sugar level of 15? Wouldn't it just be easier to simply turn the pump off during an acute hospitalization?

These and many other questions have raced through my mind many times as I contemplated patients using insulin pumps. Though insulin-pump therapy was introduced over 3 decades ago, it still concerns me. As with anything, I suppose, it is a lack of familiarity with writing insulin pump orders, though my lack of experience does not negate the potential beneficial effects for my patients. Fortunately, at my institution endocrinologists write the insulin pump orders, period. So there is no chance that an inexperienced physician writes an inappropriate order (and I am most grateful for this). Nevertheless, it is important for me, and other hospitalists, to have a certain level of comfort with continuous insulin therapy for the benefit of our patients, both short term and long term.

A landmark study, the DCCT (Diabetes Control and Complications Trial), proved beyond a shadow of a doubt that the most dreaded complications of Type 1 diabetes were closely linked to blood sugar levels. Specifically, the DCCT demonstrated that intensive blood glucose control reduces the risk of diabetic retinopathy by 76%, diabetic neuropathy by 60%, and diabetic nephropathy by 50%, all very impressive reductions.

However, as practicing clinicians, we know that intensive blood glucose control comes with the potential risk of serious hypoglycemic events, especially in those patients who have hypoglycemic unawareness and may be oblivious to the fact that their blood sugar level has fallen to a dangerous level. Managing glucose levels in the hospital setting can be a particularly daunting task considering that the drugs we use, particularly steroids, can have drastic effects on blood sugar.

Nevertheless, maintaining blood glucose levels in an acceptable range during an acute illness can mean the difference between a great outcome and a horrific one. So, what can hospitalists do to improve both the acute and long-term outcomes for our patients?  

A recent article in the New England Journal of Medicine titled "Insulin-Pump Therapy for Type 1 Diabetes Mellitus," has certainly helped to assuage some of my fears. My main fear of the pump, namely, hypoglycemia, was actually shown to occur much more often with multiple daily insulin injections than with the insulin pump. As a matter of fact, "continued disabling hypoglycemia" while on multiple daily insulin injections is actually an indication to consider insulin-pump therapy (N. Engl. J. Med. 2012;366:1616-24).

In addition, several meta-analyses of randomized, controlled trials comparing insulin-pump therapy to multiple daily insulin injections found that the average glycated hemoglobin levels were not only lower with insulin-pump therapy, the amount of insulin it took to achieve these levels was 10-20% lower than that used by individuals with higher glycated hemoglobin levels who were taking multiple daily injections.  

While insulin-pump therapy is rarely, if ever, initiated in the hospital setting, we can still make recommendations for patients and their primary care physicians.
Routinely checking glycated hemoglobin levels on our diabetic patients and taking a good history regarding their home blood sugar readings may spark us to educate patients about the potential benefits of insulin-pump therapy after discharge. We may be prompted to include a brief recommendation for the primary care physician to consider referral for this modality as an outpatient. Doing so may just prevent some of our patients from presenting to the hospital years later with end-stage renal disease.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.

If you are like I am (or used to be), the thought of an insulin pump injecting insulin continuously into my patients can be quite scary.

What if the patient was sick or distracted and didn't eat as much as she should have? Wouldn't she be at risk for going into a hypoglycemic coma in the middle of the night when no one would even notice? When the nurses did their early morning rounds, if there were no reason to awaken the patient for meds or blood draws, wouldn't they just document "patient resting comfortably," never realizing that the patient was teetering between life and death with a blood sugar level of 15? Wouldn't it just be easier to simply turn the pump off during an acute hospitalization?

These and many other questions have raced through my mind many times as I contemplated patients using insulin pumps. Though insulin-pump therapy was introduced over 3 decades ago, it still concerns me. As with anything, I suppose, it is a lack of familiarity with writing insulin pump orders, though my lack of experience does not negate the potential beneficial effects for my patients. Fortunately, at my institution endocrinologists write the insulin pump orders, period. So there is no chance that an inexperienced physician writes an inappropriate order (and I am most grateful for this). Nevertheless, it is important for me, and other hospitalists, to have a certain level of comfort with continuous insulin therapy for the benefit of our patients, both short term and long term.

A landmark study, the DCCT (Diabetes Control and Complications Trial), proved beyond a shadow of a doubt that the most dreaded complications of Type 1 diabetes were closely linked to blood sugar levels. Specifically, the DCCT demonstrated that intensive blood glucose control reduces the risk of diabetic retinopathy by 76%, diabetic neuropathy by 60%, and diabetic nephropathy by 50%, all very impressive reductions.

However, as practicing clinicians, we know that intensive blood glucose control comes with the potential risk of serious hypoglycemic events, especially in those patients who have hypoglycemic unawareness and may be oblivious to the fact that their blood sugar level has fallen to a dangerous level. Managing glucose levels in the hospital setting can be a particularly daunting task considering that the drugs we use, particularly steroids, can have drastic effects on blood sugar.

Nevertheless, maintaining blood glucose levels in an acceptable range during an acute illness can mean the difference between a great outcome and a horrific one. So, what can hospitalists do to improve both the acute and long-term outcomes for our patients?  

A recent article in the New England Journal of Medicine titled "Insulin-Pump Therapy for Type 1 Diabetes Mellitus," has certainly helped to assuage some of my fears. My main fear of the pump, namely, hypoglycemia, was actually shown to occur much more often with multiple daily insulin injections than with the insulin pump. As a matter of fact, "continued disabling hypoglycemia" while on multiple daily insulin injections is actually an indication to consider insulin-pump therapy (N. Engl. J. Med. 2012;366:1616-24).

In addition, several meta-analyses of randomized, controlled trials comparing insulin-pump therapy to multiple daily insulin injections found that the average glycated hemoglobin levels were not only lower with insulin-pump therapy, the amount of insulin it took to achieve these levels was 10-20% lower than that used by individuals with higher glycated hemoglobin levels who were taking multiple daily injections.  

While insulin-pump therapy is rarely, if ever, initiated in the hospital setting, we can still make recommendations for patients and their primary care physicians.
Routinely checking glycated hemoglobin levels on our diabetic patients and taking a good history regarding their home blood sugar readings may spark us to educate patients about the potential benefits of insulin-pump therapy after discharge. We may be prompted to include a brief recommendation for the primary care physician to consider referral for this modality as an outpatient. Doing so may just prevent some of our patients from presenting to the hospital years later with end-stage renal disease.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.

If you are like I am (or used to be), the thought of an insulin pump injecting insulin continuously into my patients can be quite scary.

What if the patient was sick or distracted and didn't eat as much as she should have? Wouldn't she be at risk for going into a hypoglycemic coma in the middle of the night when no one would even notice? When the nurses did their early morning rounds, if there were no reason to awaken the patient for meds or blood draws, wouldn't they just document "patient resting comfortably," never realizing that the patient was teetering between life and death with a blood sugar level of 15? Wouldn't it just be easier to simply turn the pump off during an acute hospitalization?

These and many other questions have raced through my mind many times as I contemplated patients using insulin pumps. Though insulin-pump therapy was introduced over 3 decades ago, it still concerns me. As with anything, I suppose, it is a lack of familiarity with writing insulin pump orders, though my lack of experience does not negate the potential beneficial effects for my patients. Fortunately, at my institution endocrinologists write the insulin pump orders, period. So there is no chance that an inexperienced physician writes an inappropriate order (and I am most grateful for this). Nevertheless, it is important for me, and other hospitalists, to have a certain level of comfort with continuous insulin therapy for the benefit of our patients, both short term and long term.

A landmark study, the DCCT (Diabetes Control and Complications Trial), proved beyond a shadow of a doubt that the most dreaded complications of Type 1 diabetes were closely linked to blood sugar levels. Specifically, the DCCT demonstrated that intensive blood glucose control reduces the risk of diabetic retinopathy by 76%, diabetic neuropathy by 60%, and diabetic nephropathy by 50%, all very impressive reductions.

However, as practicing clinicians, we know that intensive blood glucose control comes with the potential risk of serious hypoglycemic events, especially in those patients who have hypoglycemic unawareness and may be oblivious to the fact that their blood sugar level has fallen to a dangerous level. Managing glucose levels in the hospital setting can be a particularly daunting task considering that the drugs we use, particularly steroids, can have drastic effects on blood sugar.

Nevertheless, maintaining blood glucose levels in an acceptable range during an acute illness can mean the difference between a great outcome and a horrific one. So, what can hospitalists do to improve both the acute and long-term outcomes for our patients?  

A recent article in the New England Journal of Medicine titled "Insulin-Pump Therapy for Type 1 Diabetes Mellitus," has certainly helped to assuage some of my fears. My main fear of the pump, namely, hypoglycemia, was actually shown to occur much more often with multiple daily insulin injections than with the insulin pump. As a matter of fact, "continued disabling hypoglycemia" while on multiple daily insulin injections is actually an indication to consider insulin-pump therapy (N. Engl. J. Med. 2012;366:1616-24).

In addition, several meta-analyses of randomized, controlled trials comparing insulin-pump therapy to multiple daily insulin injections found that the average glycated hemoglobin levels were not only lower with insulin-pump therapy, the amount of insulin it took to achieve these levels was 10-20% lower than that used by individuals with higher glycated hemoglobin levels who were taking multiple daily injections.  

While insulin-pump therapy is rarely, if ever, initiated in the hospital setting, we can still make recommendations for patients and their primary care physicians.
Routinely checking glycated hemoglobin levels on our diabetic patients and taking a good history regarding their home blood sugar readings may spark us to educate patients about the potential benefits of insulin-pump therapy after discharge. We may be prompted to include a brief recommendation for the primary care physician to consider referral for this modality as an outpatient. Doing so may just prevent some of our patients from presenting to the hospital years later with end-stage renal disease.

Dr. Hester is a hospitalist with Baltimore-Washington Medical Center who has a passion for empowering patients to partner in their health care.