Insulin pump therapy can be initiated in primary care
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Susan Weiner, MS, RDN, CDCES, FADCES, talks with Michael Heile, MD, FAAFP, BC-ADM, a primary care physician and person living with type 1 diabetes, about the benefits of insulin pump therapy for people with type 2 diabetes who use insulin.
Weiner: Is insulin pump therapy recommended for people with type 2 diabetes who require basal-bolus therapy?
Heile: Yes! It is quite common for health care providers to avoid intensifying therapy beyond basal insulin plus other non-insulin medications by adding mealtime insulin when needed for improved blood glucose management. As beta-cell deficiency progresses, many people with type 2 diabetes will require a proportionate amount of bolus insulin to supplement their basal insulin dose to address prandial hyperglycemia. The temptation to continue increasing basal insulin doses to avoid adding mealtime insulin is often futile and can be dangerous in terms of the hypoglycemia risk and weight gain.
In my practice, it has been easy to teach and implement intensive basal/bolus or multiple daily injections insulin therapy with people diagnosed with type 2 diabetes who are not reaching HbA1c goals with only basal insulin combined with other non-insulin therapies.
The American Diabetes Association reports that “diabetes technology, when coupled with education and follow-up, can improve the lives and health of people with diabetes; however, the complexity and rapid change of the diabetes technology landscape can also be a barrier to patient and provider implementation.” This latest consensus update also reports “the type and selection of devices should be individualized based on a person’s specific needs, desires, skill level and availability of devices.” This means that even people with type 2 diabetes can benefit from technologies for insulin delivery, such as insulin pumps and continuous glucose monitoring, from the standpoint of helping them achieve better glucose results and quality of life. My hope and passion is to help other primary care providers use these technologies more proficiently in their practices.
Weiner: Do you think an insulin pump might be a preferred method for people with type 2 diabetes on insulin? What are the benefits and challenges associated with pump therapy?
Heile: I wholeheartedly agree that people with type 2 diabetes, especially those requiring intensive or physiologic insulin therapy to achieve glycemic targets, benefit more from an insulin pump than they do from multiple daily injections. In fact, the best time to consider insulin pump therapy for a person living with type 2 diabetes is when they are not at goal on basal insulin and other therapies, and mealtime insulin is required. Many people living with type 2 diabetes who use injections frequently miss or miscalculate doses. Insulin pumps have bolus calculators that help dose more accurately for food and high blood sugars and provide information related to “insulin on board” to help manage insulin dosing more safely. Compared with insulin pump therapy, multiple daily injections likely contribute to poorer quality of life related to diabetes, which may contribute to missing injections as well. People on insulin pumps, in my practice, are more able to keep up with mealtime insulin, have more accurate insulin dosing, and seem to engage in their diabetes care and follow-up much better than those on multiple injections. I am convinced this is related to ease of dosing, which leads to better control and quality of life related to their diabetes.
Challenges associated with certain insulin pumps include navigating insurance coverage and implementing insulin pump starts.
Weiner: Are all pumps the same in terms of clinical outcomes and ease of use?
Heile: In my experience, personally using and professionally prescribing insulin pumps for both type 1 and type 2 diabetes over the years, the various insulin pumps are similar in terms of ease of use and clinical outcomes, especially when comparing those not integrated with CGM or offering automation. However, one significant difference between insulin pumps is whether they have a traditional tube or are tubeless. Many people with diabetes, including myself, feel that a tubeless insulin pump is not only more discreet and inconspicuous, but also opens up many new areas on the body to infuse insulin. Many people we see in our practice who are living with diabetes have lipodystrophy due to repeatedly using the same spot to inject or infuse insulin. This often leads to elevated blood glucose levels. The tubeless pump has the same capabilities that traditional insulin pumps offer, allows more freedom for location of insulin delivery, and is now the third insulin pump to the market that can automate with CGM.
Weiner: Do people with type 2 diabetes need to see an endocrinologist to get started on insulin pump therapy?
Heile: People with type 2 diabetes do not necessarily need to see an endocrinologist to get started on insulin pump therapy. I do understand that many primary care providers have less experience with intensive insulin therapies, which include using meal boluses with insulin-to-carbohydrate ratios, and correction boluses that use insulin sensitivity or correction factors. These concepts are germane to insulin pumps as well. However, I believe that these concepts and treatment paradigm are easy understand and learn. Once the provider’s “feet are wet,” so to speak, I believe that insulin pump therapy is a natural evolution for intensive insulin therapy with better quality of life and many other improved clinical outcomes including less hyperglycemia and hypoglycemia.
Weiner: Are there drawbacks to insulin pump therapy for people with type 2 diabetes, perhaps in terms of preauthorization paperwork?
Heile: As mentioned, there are some challenges navigating insurance coverage for people living with type 2 diabetes. This is particularly true for navigating approval for insulin pumps, especially traditional tubed pumps and especially for those on Medicare. They typically require more preauthorization paperwork than non-pump intensive insulin therapy regimens, but pump manufacturers are working to lessen this burden.
Reference:
- American Diabetes Association Professional Practice Committee. Diabetes Care. 2022;doi:10.2337/dc22-S007.
For more information:
Michael Heile, MD, FAAFP, BC-ADM, is board certified in family medicine, a fellow of the American Academy of Family Physicians, board certified in advanced diabetes management, and a person living with type 1 diabetes. He can be reached at email@mikeheile.com.
Susan Weiner, MS, RDN, CDN, CDCES, FADCES, is co-author of The Complete Diabetes Organizer and Diabetes: 365 Tips for Living Well. She is the owner of Susan Weiner Nutrition PLLC and is the Endocrine Today Diabetes in Real Life column editor. She can be reached at susan@susanweinernutrition.com; Twitter: @susangweiner.
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