WHEN AND HOW TO HAVE 'THE TALK' ABOUT INITIATING PUMP/CGM THERAPY Starting a discussion with a patient about insulin pump therapy and continuous glucose monitoring (CGM) is as much an art as it is a science.

First, you need to determine, along with the MDs/other providers in your office as appropriate, who is a good potential candidate for this therapy:

  • TYPE 1 DIABETES (T1D): We begin discussing insulin pump therapy (CSII) with all patients with T1D who have insurance coverage. The scientific evidence is clear that CSII is the most effective treatment for T1D, and that is consistent with our experience.
  • TYPE 2 DIABETES (T2D): Once a patient with T2D is on multiple daily injections (MDI), it can become more and more difficult to control blood sugar levels. Patients with T2D can have low C-peptide levels from gradual depletion of pancreatic beta cells, and CSII can be very helpful in achieving better blood glucose (BG) control.

In our experience, these patients are thrilled to finally achieve good BG levels without the burden of MDI. Their lives become more flexible, with fewer highs and lows. It is important that you have a good understanding of insurance coverage for CSII for T2D. We always utilize Medtronic Diabetes’ Therapy Associates to provide a thorough benefit investigation before we move forward.

PRIOR TO DEVICE INITIATION: To prepare for integrated pump therapy with CGM, patients need to show evidence that they can accurately count carbohydrates by completing a 3-day food record, which is reviewed by an RD or an RD/CDE. If patients cannot do this successfully, they need to work on their carb-counting skills and will see an RD for additional training. There are other simplified methods of estimating carbohydrates that can be used if needed.

Patients also must demonstrate that they consistently test blood sugars 3 to 4 times daily.We also require that they show up for appointments consistently—they cannot be a chronic “no show.”

COST CONSIDERATIONS: Patients who are interested in pump therapy with or without CGM need to have insurance or another means of paying for the insulin pump system and ongoing pump/CGM supplies and BG test strips. Patients who have insurance coverage for CSII and CGM get both ordered.

EASING THE TRANSITION: Occasionally, patients on MDI do not want to pursue insulin pump therapy. In our experience, the most common reason is that they don’t want to be attached to an insulin pump 24/7. Wearing an insulin pump is a step that some patients are not ready to take. You must be patient with them and not apply too much pressure, while also sharing with them the benefits they could see in their diabetes control and lifestyle if they initiate the therapy. It is a decision that individuals must make for themselves.

‘WHY DID I WAIT SO LONG?’: When patients have concerns, I talk with them about the benefits of CSII and CGM and answer their questions. I also let them know that we will help them in their diabetes journey no matter what they decide. We often offer patients a “test drive” with an insulin pump with saline so that they can have a better idea of what the experience will be like. Once they do initiate the therapy, most of our patients say, “Why did I wait so long?”

PERSONAL EXPERIENCE: On a personal level, I have experienced for myself MDI therapy with and without CGM as well as CSII with and without CGM, and I have had the best blood sugar control with CSII and CGM (specifically, the MiniMed® 530G with Enlite®, and the Bayer CONTOUR® NEXT LINK meter).

What I have learned along the way is that knowledge is power—and peace of mind. I have learned how various meals affect my blood sugar levels, as well as other factors that I need to be aware of—travel, illness, emotions, activity (or lack thereof).

I do not feel low sugars at night, and the Threshold Suspend feature on the pump system has alerted me so that I can intervene hypoglycemic events. I also do not feel high sugars unless they are very high. Now I am warned when my sugars get too high or too low, so that I can take corrective action right away.

THE REWARDS: These first-hand insights have been very helpful in counseling my patients. My insight and knowledge has increased greatly since being on this remarkable technology. I feel that my personal experience has enhanced my ability to assist patients with diabetes to achieve the best control possible while being able to live more normal and fulfilling lives.

I feel lost when I go even one day without wearing my sensor. When I am wearing my pump and sensor system, I feel like I have my diabetes rather than it having me. When my patients have that same experience, I know that I’ve done my job—and there’s nothing more rewarding.

Heather Leclerc, MS, RD, CDE, is a clinical supervisor of The Diabetes and Endocrine Specialists of Maine, an outpatient practice of Eastern Maine Medical Center where she has worked for the past 28 years. Along with the office’s 5 other CDEs, Heather provides education for patients with diabetes of all ages and assists the 5 providers in the office with day-to-day medical management. Approximately 8 years ago, Heather developed LADA (Latent Autoimmune Diabetes in Adults) and is treating it with the MiniMed 530G with Enlite.