learning curve May/June, 2007
Pumping Insulin: New Technology May Spur Greater Acceptance
By Daniel Trecroci and Kelly Close
The insulin pump has long been heralded as a revolutionary product in diabetes care – a brilliant delivery system that relieves patients of injections, a technology that can be programmed, manipulated, and tweaked to mimic a healthy pancreas. Pumps have their own evangelists who are mystified why any insulin-dependent patient would not use one, and in many ways their faith has been rewarded: the technology keeps getting better. Pumps are now more like powerful information-management systems than simple drug-delivery devices. They are small and discreet, they are being integrated with glucose meters and continuous glucose sensors, and they are central to the high-tech Holy Grail in diabetes management: the artificial pancreas. (Or, as some like to call it, the Artificial Pancreas.)
But for all their improvements, pumps have never become more than a niche product. In the US, only about 21 percent of type 1 patients use a pump, according to Diabetes Care, and very few insulin-dependent type 2 patients wear one. The numbers are even worse abroad: in the United Kingdom and in Denmark, for example, pumps are worn by about one to two percent of type 1 patients.
The product has never made greater inroads for several reasons. For one, many physicians are reluctant to prescribe them, let alone advocate for them. Clinicians must spend additional time to understand the pumps, additional time to train their patients, and additional time to handle the paperwork – but unbelievably, for the most part, they receive no extra compensation for their labor. What is that about?! Many patients themselves are not willing to invest the additional effort that pumps require. Money is also a factor. The pumps are expensive – about $6,000 for each device, excluding all the supplies – and some employer-sponsored health plans are cutting back on durable medical equipment coverage. No matter that pumps can improve our health dramatically over time.
Some experts blame the pump companies for not educating patients on why they should use the product and for not training their existing customers on how to take full advantage of its many features. Those are valid points.
Some observers contend that the pump companies don’t understand what they are promoting. We don’t go that far, but we definitely believe not all patients receive the right information about what pumps can do, so they are operating in the dark.
To increase the use of pump therapy (which in the medical literature is called “continuous subcutaneous insulin infusion”), patient training and reimbursement will have to improve. But so too will the technology. Like any sophisticated machine, pumps occasionally break down, and while the companies will replace them, there is nothing like a “dead pump” to throw a family vacation into turmoil. Temporary glitches require immediate troubleshooting, and serious problems can arise if the patient is unaware that – for whatever reason – the insulin is not reaching its destination. The true price of any pump is eternal vigilance that must start and end with the patient.
The Accu-Chek Spirit
Pump Technology Continues to Improve
Continued improvement in pump technology may not guarantee a surge in sales, but pumps that are easier, smarter, and safer – and those that are integrated with meters and sensors – will stand a better chance. And the companies are spending their money accordingly.
The MiniMed Paradigm REAL-Time System, for example, is the first to integrate an insulin pump with real-time continuous glucose monitoring. The new Animas 2020 has a flat-panel, high contrast color screen, the ability to store the previous 500 blood glucose values, and a food database. The Roche Accu-Chek Spirit has side-mounted tactile buttons for “no-look delivery” (you don’t have to withdraw the pump from your pocket, waistband, or bra). Deltec’s CozMore has a glucose meter attached to its back. And the one pump that does not rely on a tube – the OmniPod – consists of a lightweight device worn on the skin (like an infusion set), which delivers insulin according to signals from a handheld, wireless Personal Diabetes Manager.
How Far We’ve Come
It’s worth noting how far these pumps have come. The first models, in the 1960s, were mounted on backpacks. By the early 1980s, a pump could be attached to a belt, but it still weighed more than a pound, had flashing red lights, and was nicknamed “the blue brick” (though it was also reminiscent of a World War II-era walkie-talkie). Over the next two decades, the device became smaller, safer, more functional, more durable, and less uncomfortable.
Pumps today are about the size of a pager or even smaller, and we know size drives sales and uptake, so we can’t stress enough to the companies how critical it is to continue to reduce the size. Most pumps are composed of a reservoir that stores insulin, which is continuously delivered to the body through a tube that connects the reservoir to the cannula. The cannula is inserted underneath the skin at the site where insulin enters the body, and this “infusion set” is usually changed every three days. (Type 2 patients need more insulin so they may change the set closer to once every two days, while many type 1 patients can push the change to once every four days, which is possible with most pumps.) The battery-operated pump delivers the insulin according to how the patient programs it.
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