Pillars of Diabetes Care Technology - Episode 3
Robert Busch, MD, and Diana Issacs, PharmD, BCPS, BCACP, BC-ADM, CDCES, provide insight into the use of insulin pumps in type 2 diabetes and describe currently available smart pumps.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Diana, I know you do a lot of the nitty-gritty with the pumps. Dr Busch, you recommend it and you have a team that helps you make sure all the settings are correct on it. If each of you could talk to me about when you recommend an insulin pump, some of the benefits that you’ve seen, and how you work through that process as you see a patient. Dr Busch, we’ll start with you, then we’ll go to Dr Isaacs.
Robert Busch, MD: Yes. [For example, say] my patient is on basal insulin and they tune up the basal to the fasting sugar. If they’re bottoming out before lunch or dinner and you see that’s not their rapid acting that they’re taking at mealtime, but the basal is too much during the day because of their activity, even though it was fine overnight—that’s someone who wants a variable basal and that’s where I’d recommend the pump. For someone who’s on multiple bolus doses and forgets to take their insulin with them to work, there’s the convenience of having the pump. Of course, you must get over that you’re wearing something, and some people don’t want to do that. But [this is] where you need a variable basal, [and to make sure] that your basal isn’t fixed to the morning reading. Also, if you’re bottoming out at lunch or dinner, or high pre-lunch to high pre-dinner and you need higher basal, how do you do that if you’re tuning up your basal to the fasting sugar?
Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: Unfortunately,the reality is a lot of people with type 2 diabetes end up progressing to multiple daily injections. Of course, we try to optimize their SGLT-2 [sodium-glucose cotransporter-2] inhibitors and GLP-1 [glucagonlike peptide-1] agonists, but people are developing type 2 diabetes earlier in life. When you’ve had it for 40 years or 50 years, it’s not surprising that eventually insulin may be needed to achieve those glucose targets. For me, any person that is requiring multiple injections a day can be a candidate for insulin pump therapy. I find there’s a lot of misconceptions about a pump. People think, “Oh, that means you have the bad kind of diabetes,” or, “It must be serious,” and, “I failed at my diabetes management.” None of those things are true. It is just another method to deliver insulin, and often a much more convenient method. We’ve got pumps that have tubing. We also have pumps that don’t have tubing. It’s a convenient way to deliver insulin, so it’s something I share with my patients, and many people with type 2 diabetes are eligible through insurance coverage to be able to utilize [a] pump.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: Absolutely. Sometimes we paint everything with a broad stroke when we think about who those candidates are, but also when we talk about the category of insulin pumps. Dr Isaacs, while you have the mic, can you walk us through some of the options that are available from the more common manufacturers and how you filter through them for your patients?
Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES: Yes. We currently have 3 companies that have FDA-approved products, starting with Omnipod, which is a tubeless pump. A lot of people like that feature. It does hold a bit less insulin than the other 2 options, it holds 200 units instead of 300 [units], so that can sometimes be an issue for people who are on higher doses, but the tubeless feature makes it convenient. What’s exciting is that the Omnipod 5 is in the pipeline, which will have integration with Dexcom G6 to automate insulin delivery. We’re expecting that to become available in the second half of 2021.
We also have Medtronic. With Medtronic, the 630G is FDA approved for type 2 diabetes and that does integrate with their Medtronic Guardian Sensor to be able to suspend insulin delivery if someone is predicted to go below their low threshold. We also have other hybrid closed loop pump options with Medtronic, the 670G and the 770G, and those are FDA approved for type 1 diabetes. However, we know many times, in the real world, these are used off-label in people with type 2 diabetes that still experience a lot of benefit. And what’s in the pipeline for Medtronic is the 780G, which is approved in Europe and is a more sophisticated algorithm. It’s going to have an updated sensor, the Guardian 4, which will be more efficient and not have all those calibration requirements, so that’s exciting.
The final player we have is Tandem. The Tandem [t:slim] X2 [insulin pump] integrates with Dexcom G6. There is Basal-IQ [technology] where insulin is suspended if it’s predicted to go below 80, and then Control-IQ [technology], which is a hybrid closed loop that regulates insulin delivery and gives automatic correction doses every hour as needed to achieve the glucose targets. This is an exciting area and it’s continuing to rapidly evolve, but those are our current options and things that I like to share and go through with my patients.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: That’s excellent. Dr Busch, Diana just did a fabulous job of [describing] what our options are. When you step back and look at the big picture as we talk about automated insulin delivery and some other things, what excites you the most? What’s possible here for your patients as we think about this connectivity? Yes, you’ve been using insulin pumps for quite some time, but you’re now starting to see some of these integrations and interconnectivity that Diana mentioned. How does that affect the care that you provide?
Robert Busch, MD: It’s customizing the care so the patient can own their diabetes. I know Diana and others are doing basal bolus pumps and connective pumps—that’s the term they tend to use—and I like that you can customize it or do precision diabetes management. I’m spoiled, so I get to work with someone like Diana, but she knows all that stuff while I’m busy with the cardiovascular outcome studies, the renal outcome studies, and that kind of stuff. I’m doing the rest of their diabetes, but my pump specialist keeps track of all those options, and we share the patients. I might see the patients every 6 months, she sees the patients every 6 months, so they’re being seen every 3 months, but they have the expertise of the pump [specialist] who knows all that [information], and then I’m doing their lipids, their blood pressure, and [handling] the other noninsulin drugs on top of what they’re on. It works out.
Dhiren Patel, PharmD, CDE, BC-ADM, BCACP: We’re all fortunate to be in multidisciplinary practices where we have resources and we can share some of the work because it’s not easy. I always say it takes a village to take care of a patient with diabetes, so we’re all fortunate that we have a lot of different folks that can help on the care team.
Transcript edited for clarity.