1.Why We Pump Henry Anhalt, DO, CDE Director, Pediatric Endocrinology and Diabetes Saint Barnabas Medical Center Livingston, NJ

2. Pump Gasoline? 3. Pump Iron? 4. Pump Breast Milk? 5. THE PANCREAS THROUGHOUT HISTORY

1550 BCE-Papyrus describes polyuria and its treatment

4 thcentury BCE-Ayur Veda of Susruta (India) describedsugarcreamurine which attracted ants.

7 thcentury CE-Chinese physician Chen Chuan recorded sweet urine in diabetes

1869-Langerhans describes islets

1909-the name insuline is suggested by Jean de Meyer (Brussels)

1921-Banting and Best-report discovering Insulin used in 1922

6. BANTING-1891-1941 & BEST-1899-1978 Orthopod who became a physiologist and died in air crash in Newfoundland while on wartime mission Together they isolated insulin and Banting won the Nobel Prize in 1923 knighted in 1934 7. First commercial insulin 8. Prevalence of Diabetes in the US DiagnosedType 1 Diabetes 1.5 Million(1:400-600 children) DiagnosedType 2 Diabetes 14 million Undiagnosed Diabetes 6 Million 1.5 million new cases of diabetes were diagnosed in people aged 20 years or older in 2005 9. Good Glycemic Control (Lower HbA 1c )Reduces Incidence of Complications DCCT Research Group.N Engl J Med . 1993;329:977-986. Ohkubo Y et al.Diabetes Res Clin Pract . 1995;28:103-117. UKPDS 33:Lancet . 1998;352:837-853. HbA 1c Retinopathy Nephropathy Neuropathy Macrovascular disease DCCT 97% 63% 54%60% 41%* Kumamoto 97% 69% 70% UKPDS 87% 17-21% 24-33% 16%* * not statistically significant 10. HbA 1cand Microvascular Complications Relative Risk 15 13 11 9 7 5 3 1 HbA 1c ,% 7 8 9 10 11 12 Neuropathy Nephropathy Retinopathy 11. Every 1% HbA 1cIncrease Above Goal Elevates the Risk of Diabetic Complications Increase in Any Diabetes-RelatedEndpoint Increase in Risk of Myocardial Infarction (MI) Increase in Risk of Stroke Increase in Risk of Microvascular Complications Incidence of Diabetes- Related Complications (%) +21% +37% +12% +14% Adapted from Stratton et al.BMJ . 2000;321:405-412. 12. Physiology of Insulin and blood glucose BreakfastLunchDinner Basal Insulin Insulin secretion Basal blood glucose Blood glucose 13. Insulin Preparations Onset of Duration of Action PeakAction Humalog/Novalog 5 to 15 min 1 to 2 hr 4 to 6 hr Human Regular 30 to 60 min 2 to 4 hr 6 to 10 hr Human NPH 1 to 2 hr 4 to 6 hr 10 to 16 hr Human Lente 1 to 2 hr 4 to 6 hr 10 to 16 hr Human Ultralente 2 to 4 hr Unpredictable 6y old

My Criteria

Any patient who is willing to start and has abilities to learn

May improve compliance

Any age adults and children of any age (independent users 7-80 y old)

Particularly non-compliant patients

50. ADVERSE EVENTS 51. PSYCHOSOCIAL OUTCOMES 52. The Yale Experience

>200 children started on pumps over last 5 yrs

No difference in severe hypoglycemia

Parents report less mild hypoglycemia

Ahern et al.,Journal of Pediatric Endocrinology and Metabolism2000, 13(suppl 4):1220. 7.5 7.9 13-18 7.3 7.8 7-12 6.7 7.6 < 7 3 mos post pre Age (yr) HbA 1c 53. Additional Evidence From Yale Ahern, JAH, et.al. Pediatric Diabetes 2002;3:10-15.

Decreased hypoglycemia

No change in BMI or TDD

98% remained on CSII

54. CSII vs. MDI With Glargine in Children Boland et al., Diabetes 2003, 52:S1, A45, 192-OR CSII (aspart) n=12 MDI (aspart/glargine) n=14 Injection therapy Randomized, Parallel-group, 16 week study Subjects at baseline Age: 8-19 yr (mean 12.7 2.7) Type 1 DM > 1 yr durationStandard insulin therapy (2-3 injections/day) 55. Pump Group Achieved Better Control Overall Changes in HbA1c Levels 6.5 7 7.5 8 8.5 Baseline 4 wks 8 wks 12 wks 16 wks Pump MDIBoland, E. Diabetes 52,(Suppl 1), 2003 Abstract 192. p = .03 p=.30(NS) p=.15 (NS) p=.001 56. More Pump Wearers Achieved HbA1c6.9% % Patients AchievingHbA1c< 6.9% PumpGlargine Boland, E. Diabetes 52,(Suppl 1), 2003 Abstract 192. < _ 0 10 20 30 40 50 57. Swedens Experience

89 children 3-21 y.o

Diabetes duration 6.1 years

30% using CSII

HbA 1cdecreased from 9.2% to 8.4% after CSII start

Severe hypos

• Pump: 11.1/100 pt years

• MDI: 40.3/100 pt years

. Hanas, Diabetes, 2000, 49 (Suppl 1):A133 . 58. Patient Characteristics of Successful Pediatric Pumpers

Able to maintain follow up appointments with health care provider

Willing to record blood glucose values

Able to count carbohydrates

Good family/social support system

59. Pump therapy benefits

Improved control - more physiological basal rates (dawn phenomenon match), different boluses for food, less absorption variability

Less hypoglycemia

More flexible lifestyle and possibility to exercise

Precise dosing -0.1u - 0.025u increments for basal rate and boluses

Less injections - improved quality of life

Less possibility of overdose

Adapted from Plotnick L et al;Diabetes Care2003; 26(4):1142-1146. 60. Pump Use in Children Is Increasing

200,000 users (adults and kids in the US). 10,000 are adults with type 2 diabetes

~ 20,000 children using pump therapy

• 10% of all children with diabetes

Penetration as high as 90% in some pediatric clinics (ours)

Increasing use in younger children (as young as 10 months)

Current outcomes indicate CSII is safe and effective in children

Increasing acceptance likely due to DCCT findings as well as the introduction of smaller, safer insulin pumps

There are approximately 400,000 insulin pump users worldwide

61. Avoiding DKA

Give a pen with the pump

Instruct that any time the patient feels nauseated or has abdominal pain -- change the site

Blood sugar is greater than 250 mg/dl

• Take correction dose

• Check for ketones

• Recheck in 60 minutes

• • If coming down, leave alone

• • If not, take a shot and change the site

62. Summary

Pump therapy is an intensive process for pediatric patients and their families and the diabetes education team.

Successful pumpers are motivated and willing to maintain follow-up, carbohydrate count, and check blood glucose frequently.

Benefits of pump therapy for pediatric patients include:improved lifestyle, decrease in hypoglycemia, accurate dosing , ability to review history to see if doses were actually given.

63. Summary

Children with diabetes should be intensively treated to avoid short and long term complications

Insulin pumps can provide better control and less hypoglycemia than MDI

With good support and a standardized process, insulin pump therapy can help to improve diabetes management in children

Insulin pump therapy should be the only form of therapy offered to children with diabetes

64. When meditating over a disease, I never think of finding a remedy for it, but rather, a means of preventing it. Louis Pasteur, 1884 65.