Insulin Pumps: Yay or Nay?

Often confused as a remedy for Type 1 Diabetes, Insulin pumps constitute the medical devices aimed at bettering the life of a person living with type 1 diabetes.

An insulin pump is a medical device used for the administration of insulin in the treatment of diabetes mellitus, also known as continuous subcutaneous insulin therapy.

In the current day, every person living with Type 1 Diabetes at some point might have a choice to select between being on Multiple Daily Injections (MDI) or an Insulin Pump. The entire community has remained divided on the same with a certain half of the population preferring insulin pumps and the other half vouching for MDIs.

For most of thepeople initially the only difference between the two is the fact that with insulin pumps, one doesn’t require pricking themselves multiple times a day while in reality there’s much more to an insulin pump. On having a closer look, one will realise that the very way in which the two therapies operate is different.

Insulin Pumps vs MDI

MDI regime requires one to use two different types of insulins: a short/rapid acting insulin for meals and a long/slow acting insulin for their basal or background insulin.

However a pump uses only a single type of short acting insulin. The way it mimics your background insulin is by delivering very short doses of fast acting insulin continuously throughout the day. This is in effect closely mimicking the way our own pancreas work. As a result of this one big advantage of being on pump is that it allows a person to set variable basal rates throughout the day.

Furthermore, an insulin pump provides different types of bolus deliveries you can use, depending on your insulin needs at the time. The various types are as below:

1. Normal Bolus: It provides a single and immediate dose of insulin. It can be used to cover your food intake or to correct a high BG.

2. Square Wave Bolus: It delivers a single bolus evenly over an extended period of time. The time frame to spread the dose is between 30 minutes to 8 hours. It can be used if you have delayed food digestion, if you are snacking over an extended period of time or if a normal bolus drops your BG too rapidly.

3. Dual Wave Bolus: It delivers a combination (proportion set by you) of an immediate Normal bolus followed by a Square Wave bolus. You might use this type of bolus when you eat meals that are both high in fat and carbs or when your meal bolus is combined with a correction bolus for a high BG.

Source: Medtronic

For my past 8 years of living with Type 1 Diabetes, I’ve been on MDI. There were various reasons for which I was hesitant of moving to an insulin pump:

1. Like many others out there, the idea of having another device attached to my body overwhelmed me.

2. Type 1 Diabetes management is anything but cheap. The recurring cost of insulin, glucometer strips, Libre pro sensors & medical tests already amount to a significant number. The cost of an insulin pump in India starts at around ₹1,59,000/-. To add to it, it further entails a recurring cost of insulin pump supplies.

3. The final factor for me was the fact that I was doing pretty well on MDIs. Having had a HbA1c ~5.8 for more than 2 years, it was a hard task to justify investing such a huge amount and incurring an additional recurring expense when the incremental gain wasn’t so much.

However not very long after this, a few factors finally made me consider making a switch to a pump. Being on Tresiba which gives one a flexibility of few hours w.r.t. to the dosing time daily, my dosing patterns began to slide to an extent that many days I forgot to take my basal. I hated the variability and uncertainty that it brought to my management and suddenly having to remember to take a dose at a specific time daily started to seem like a chore. Apart from this, my compulsive need of keeping a tighter control on my BG levels, very often led to late night hypos which started getting on my nerves. The idea of being on a closed loop system and the prospect of having an undisturbed sleep seemed delightful all of a sudden. Moreover, since I was already on a CGM, I was about halfway to a closed loop system already.

All these factors started to revolve around my head and fast forward to a couple of weeks later, I stood in apartment receiving the shipment of my insulin pump that I had ordered!

I opted to go with the basic Medtronic MiniMed Paradigm 715 as it supported the DIY Loop.

First observations

I’ve come across lots of others experiences with insulin pump where they took a lot of time to get used to it. This was certainly not the case for me as I got used to it from the very first day. I had some rather interesting observations after the first week of switching to an insulin pump.

• Freedom from multiple daily shots was extremely liberating. I didn’t realize how much I needed a break from the daily pricking until I got it. I hope everyone living with T1 gets to experience it some day.

• I loved the ease with which I can now bolus not only for my meals but for the smallest of the carbs as well.

• The fact that I can see an upcoming hypo and slow/avoid it by suspending my basal rate is simply superb. On MDI this could only have been treated by consuming more carbs hence switching to pump definitely decreased my carb intake to some extent? :P

• The most surprising observation was that there was a significant drop in my total daily dose (TDD) of insulin. On MDI, my average TDD was 10U(basal) + 7U+7U+7U (breakfast, lunch, dinner)+4U(snacks aggregate) = 35U. On an insulin pump however, my TDD went down to ~25U which equates to around 30% decrease.

• As a direct consequence of the last point, there was a significant decrease in the monthly cost of my insulin supplies. This definitely helped cushion the blow that the additional monthly cost of insulin pump supplies delivered.

Comparing the weekly graphs of before and after switching to an insulin pump, one can clearly see how much an insulin pump can be an enabler for better diabetes management.

Weekly graph one week before switching to an insulin pump

Weekly graph one week after switching to an insulin pump

It can be seen rather clearly from the graphs that being on an insulin pump has rather made it so much easier to keep a much tighter control on my BG levels as well as reducing the hypoglycemic occurrences by allowing me to suspend my basal.

Cost Analysis

If we are to compare the two, a cost comparison is a must to assess the long term impact of the recurring expenses of the two.

The cost of an insulin pump is rather on the extreme higher side for an average person. The starting cost of the basic insulin pump (MiniMed Paradigm 715) in India is ₹1,59,000/-. However being quite an old model, they are very limited in stock currently and might need some calls to be made to different regional Medtronic reps. The newer and more readily available models MiniMed 620G and 640G starts from ₹3,59,000/-. Without any insurance plans in India for people living with Type 1 Diabetes, the cost of an insulin pump needs to be borne out of one’s own pocket.

Below I’ve summarised and compared my own cost breakup of my monthly expenses for when I was on MDI and after transitioning to an insulin pump.

Background: While on MDI, I used to be on Fiasp and Tresiba. Now that I have transitioned to a MiniMed Paradigm 715 Insulin pump, I use Fiasp with it.

For an insulin pump, one needs to order infusion sets as well as reservoirs on a recurring basis. The cost of an infusion set (pack of 10) amounts to ₹3,797 whereas the cost of reservoir (pack of 10) amounts to ₹1,485.

• Ideally one should change their infusion site every 2–3 days, but having known people who have gone up to 6 days, I tried and was able to go up to 5 days without having any loss of sensitivity.

• Since my TDD is ~26U, a single reservoir that can hold up to 300U lasts ~11 days for me. Hence, on average I require 6 infusion sets and 3 reservoirs per month.

• Also because of my above mentioned TDD, on average I require 780U Fiasp on a monthly basis which equates to 78% of a single Fiasp vial.

While I was on MDI, my TDD comprised of ~24U of Fiasp and ~10U of Tresiba. This summed up to 720U or 2.4 x Penfills of Fiasp and 1 Penfill of Tresiba on a monthly basis. These factors might be very different for you so you’ll need to calculate them for yourself before you can do this cost analysis exercise for yourself.

Below, adding up the various components I realised that the increase in my monthly expenses was not as huge as I had initially expected it to be. While it’s common to hear in India that pump supplies add up to an extra ₹3,000-₹5,000 on a monthly basis, for me the increment was ~₹1,300 monthly!

Cost Analysis for Pens v/s Pump in MY case

Is the grass really all that green?

While it might seem like the insulin pump is really a Pandora’s box for managing diabetes, there are few things to keep in mind about it. As with any piece of technology, insulin pump malfunctions are not very rare. If you’re in any Type 1 Diabetes support group, you’ll come across stories of bad pump sites way too often where people wake up in the morning to find their BG levels raging up to 300mg/dL and beyond. These nightmarish incidents can occur due to various reasons like the cannula not being inserted properly, cannula coming out slightly due to the tubing getting tangled with door handles, while sleeping and much more. These incidents increase the chances of developing diabetic ketoacidosis if one doesn’t have the habit of monitoring their levels frequently as these pump site malfunctions would go undetected.

Also because the insulin pump works by ensuring that some amount of insulin is flowing in our bodies continuously, any pump malfunction gives us a relatively smaller time to fix it. In case of a malfunction, one has a couple of hours at max before the rising BG levels start going out of range and this can be a bit frightening to think about for some. Hence it’s always advised to keep extra infusion sets/syringes for emergencies so that in case of any such incidents, one can always use the syringe to inject insulin until one can replace the infusion set.

Afterthought

As someone who has been the carrier of the team-MDI flag in the past, I’m convinced that insulin pumps have the potential to bring a drastic improvement in our management of Type 1 Diabetes if we tap this potential carefully.

Part of the reason why pumps make it much more easier to manage is that it’s pain free. Even though the insulin pens aren’t THAT painful, it still IS painful enough to not make anyone be a fan of them. With insulin pumps, I no longer have to try and minimise the number of shots I take in a day. I can split the doses as I like, to account for the various kinds of food and their glycemic load (GL) profiles, I can bolus for the smallest of the snacks and follow carb counting more closely. On MDI, even though most pens don’t support a granularity of less than a unit for dosing, one can still split their doses for various food profiles. Still there are various factors that can be a hinderance to it like the obvious puncturing our skin yet again or being busy with other stuff.

Another factor that makes an insulin pump stand out for me in terms of delivering better care is the fact that it’s always there with me. I no longer have to wait to get my insulin pen or find a favourable environment to take my dose, which can sometimes delay my dosing. Being right there with me at all times, I can literally take my dose any time and anywhere be it in a shaking car or a crowded room. I can now bolus for the smallest carbs without thinking too much.

Having been on insulin pumps for only 2 weeks now, I cannot comment on the bad parts of it personally since I haven’t faced any bad sites or pump malfunctions yet. However I hope to revisit this piece in the future and update it based on my long term experiences with the insulin pump.

Despite of the various advantages that an insulin pump has to offer, there is a huge chunk of people who still find MDIs to be better suited to them and their lifestyle because the idea of wearing a device all the time on your body doesn’t appeal to them.

What is your preference when it comes to choosing between MDI vs Insulin Pump?