Insulin pumps are still debatable for type 1 diabetes
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7354.46 (Published 06 July 2002) Cite this as: BMJ 2002;325:46All rapid responses
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I've had type 1 diabetes for 30 years and have been using an insulin
pump for only 1 1/2 years. For me there is no debate at all.
With MDI, I struggled daily to keep my bgs as close to normal as possible.
I worked very hard to eat properly, excercise the same amount at the same
time every day, and take appropriate doses of short acting insulin. Due
to the unpredictability of long acting insulin and my discrepant need for
basal insulin over a 24 hour period, my blood sugars often ranged from 40
to 400 on any given day. My A1c was almost always 7.1 to 7.3--that might
sound like good control, but it wasn't.
With my pump, my bgs are usually within range. I am rarely under 55 and
only occasionally over 200. My last A1c was 5.6, the one before that was
5.5 without a whole lot of very high and very low blood sugars.
My day to day life is a lot more "normal". I am not tied to a restrictive
eating schedule or diet. I can exercise when, how, and for as long as I
want. Life is easier and much more flexible and pleasant. I feel
healthier, have more energy, and am a much happier person with my pump
than I was on MDI. Debatable?? Not for me! Which way of life would you
prefer?
DEB555
Competing interests: No competing interests
I have been type 1 for 40 years. I was on a pump when they first
came out and I loved it for the six years I was on it. It made such a
huge difference in my quality of life and how I managed my diabetes. I
had to go off of it due to an allergic reaction to the metal needles.
Now with the wonders of new technology I am back on the pump. I
would not give it up for anything. I think it adds a great deal to my
quality of life and how I feel. In addition as someone who has just spent
the last nine months in and out of the hospital due to an accident I was
in, I do not believe my blood sugars would have remained relatively under
control. I had over 15 surgies and my pump went with me to each and every
one. I believe having the pump made it easier for the medical staff as
well as myself.
I also believe that until one has walked in anothers shoes that they
cannot make predications on their care or what is best for them.
Personally I wish there had been pumps out when I was diagnosed in 1963.
Thank you for your time.
Fran Baumgartner
Competing interests: No competing interests
I would like to suggest that in addition to the current standard
procedures of research used in deciding the efficacy of insulin pumps the
following process be incorporated into these studies:
Researchers themselves should be required to follow the typical type
1 diabetic's daily procedure as it regards diet, dosing and exercise on
both multiple daily injections and the insulin pump (6 mos trial for
both).
Perhaps then it would be understood how much better the quality of
life is when you don't have to live yourlife fully against the dictates of
a clock and feeding long-acting insulin when it peaks.
I have not done this personally, but am the mother of a type 1 who
has done both. I have seen the difference in the quality of life a pump
can make for a type 1 diabetic as well as his/her family and friends.
Thank you for allowing my comments in this regard.
Respectfully,
Linda Janus-Vermeersch
Competing interests: No competing interests
Greetings-
As a Type I diabetic for 37 years, Ifell into that very brittle category
many question, My last A1c before pumping was 14. I have complications of
diabetes, and some of them have reversed themselves since going on the
pump(neuropathy pain in both feet, and hands, frozen shoulders).
My current 7.2 HA1cs may not be the gold standard for many diabetics,
but being able to micromanage the different amounts of insulin I get via
basal rates during different times of the day, during different times of
the week, the month, and the year, was a godsend. Diabetes is a lot of
work, with or without a pump.
Type I's can easily develop eating disorders too, after years of
obsessing over eating when not hungry. It's not surprising that this
obsession might cause a high percentage of depression among diabetics.
It is not that you can't live without the pump, I did for years, but
the quality of that life is of no small matter to the person suffering
with this dreadful disease and its complications. Life should be more
than just staying alive.
Sincerely,
Dianne D. Mink
Competing interests: No competing interests
Successful users of pump therapy have more than a pump. They have a
significant body of knowledge and skill that allows them to use the pump
to its full advantage. This skill includes the ability to skilfully choose
the dose for foods eaten, make dose adjustments based on prevailing blood
sugar, and manage basal rates to allow flexible meal timing and variable
levels of physcial activity from day to day.
Used optimally, in my experience, the pump can offer patients a
degree of lifestyle flexibility and precision of insulin dosing
unattaintable with other forms of therapy for type 1. Furthermore, a
reduction in the risk and experience of low blood sugars is another impact
highly valued by our patients. These benefits are significant and
independent of the A1c.
We routinely encounter patients on MDI newly referred to our program
with A1c's that are at or near target levels - but their lives are far
from desirable because of extreme constraints on lifestyle and/or because
of frequent hypoglycemia. In evaluating CSII or any other therapy for
diabetes, I would like to see researchers consider a broader range of
impacts than A1c alone.
Competing interests: No competing interests
I have had Type 1 diabetes for 45 years (4/1/57). The lowest A1C I
was able to achieve on Multiple Daily Injections was 7.4. My average
total daily dose of insulin is approximately 18 units. Since being on the
Continuous Subcutaneous Insulin Infusion therapy (six years) I have been
able to take minute amounts of insulin, as little as 0.1 unit, to take
effect at the times I need it. That was an impossible feat with MDI. My
last A1c was 6.6. Without a doubt my pump is one of the main reasons I
have been able to thrive in spite of this dreadful disease.
Many people with Type 1 diabetes have this kind of insulin
sensitivity for which a pump is the best tool for control to date. Some
even have a basal of 0.0 unit for certain periods of the day as their need
requires. With Lantus or any other long-acting insulin it would be
impossible to "turn off the insulin" when it is not needed. With a pump,
control is literally at one's fingertips.
Competing interests: No competing interests
My son was diagnosed with diabetes on August 26, 1997, at the age of
11 months. Before his second birthday, we had switched from multiple
daily injections to insulin pump therapy. Before you pass judgment, you
should walk in the shoes of a parent dealing with this insidious disease.
On multiple injections, we "fed the insulin". At a typical dinner
time, we would measure out the prescribed amount of carbs, based upon an
injection hours previously. Oftentimes, he simply wasn't hungry. Or,
perhaps he was sleeping. Even if he was hungry, perhaps he wasn't
interested in what we presented. If he was interested in what was
presented, at best, some would be consumed, some would be on him and some
would end up on the floor. In otherwords, he was a typical toddler.
Invariably, given the ticking time bomb of the peaking insulin, we would
end up shoving juice or frosting into his mouth to keep him from going
low.
Also, when it came time for drawing up insulin, his body weight was
so low, we needed to be drawing up small, precise units. Please try
drawing up .25 units accurately and consistently with a commercially
available syringe (and keep in mind that at a minimum both my wife and I
would draw up the insulin, so there needed to be a consistency between us
as well - many families have three or more care givers drawing up
insulin).
An additional problem with needle therapy was dealing with a high.
Do we add another injection to his regime? When we did, it often got
"piggy backed" with long acting insulin that peaked shortly thereafter and
drove him low. Or do you tell a child that, along with all of his/her
other burdens (up to ten finger sticks per day, multiple injections, etc.)
that you cannot eat anything for another hour because you are high?
Juxtapose this lifestyle with a pump. He could eat what he wanted,
when he wanted, so long as we could accurately count the carbs and cover
them. Also, we were accurately and consistently delivering insulin in .10
units. As a scientist, please tell me how that cannot be a lot better.
When he is high, we manipulate a couple of buttons and bring him right
down. Finally, using only Humulog, we always had a very good idea of how
much insulin was in his system.
Here is my bottomline conclusion. Make no mistake about it, the pump
is NOT a cure. This disease is awful to live with. The pump takes more
work than needle therapy. We do 8 to 10 blood sugars per day. Also, the
pump and sets do have problems from time to time. However, his A1cs since
going on the pump not only improved, they have stayed very consistent.
Futher, he experiences many fewer highs and lows. Finally, his and our
lifestyle is much improved.
Why don't you do this study: survey families that have switched
their child from needle therapy to pump therapy and find out how many did
not like it better and switched back. Also, find out how many experienced
lower A1cs. In my humble opinion, it is not even close.
Also, since you now know so much about me, please anser me this
question: do any of the authors of this article have a child that is
insulin dependent? Thank you for your time. If you have any questions,
please feel free to contact me.
Competing interests: No competing interests
Do J Hans DeVries and Robert J Heine think that an A1C is the SOLE
measure of the benefit of insulin pump therapy? What about QUALITY OF
LIFE? My now 14 year old son has been on the insulin pump for over 7
years and it has made a remarkable improvement in the quality of his life
while maintaining far more manageable blood glucose values that do not
drastically fluctuate from hour to hour as they did on injection therapy.
The case has been decided for our family - CSII is far superior over
injection therapy.
Very sincerely yours,
Ellen H. Ullman
Mom, Advocate for children who have diabetes and their parents, Friend,
Webmaster...http://www.kidsrpumping.com
Please support funding a cure for diabetes: Diabetes Research Institute in
Miami, Florida: http://www.drinet.org
How wonderful it is that nobody need wait a single moment before
starting
to improve the world? -Anne Frank, Holocaust diarist (1929-1945)
Competing interests: No competing interests
Have you tried life with diabetes?
As a diabetic for seventeen years, five on MDI and twelve on an
insulin pump, I find the conclusions of this article laughable. I would
never go back to injections. I'd rather not be a prisoner of my disease.
It is all well and good that in a clinical setting, MDI and insulin
pumps seem to both do a good job controlling blood sugars. I can't say
that the pump dramatically improved my sugars compared to what they were
on MDI. But there is much, much more to the story than an A1c could EVER
tell you.
I remember being forced to eat at times when I wasn't hungry and in
fact felt sick on MDI. I also recall getting stuck in situations in which
a meal was delayed, and suffering lows or highs as a result. Real life
didn't operate as rigidly as MDI required my treatment to be. I needed
some flexibility.
On the insulin pump, I can eat when I want to and what I want. If
the meal is late, my blood sugars are usually fine. If I bolus for a
certain amount of food and decide I'm still hungry, it is easy to take
insulin to allow for it. Spur of the moment excercise is less likely to
result in lows I am constantly chasing with food, as I can immediately
adjust my basal rate (I never was able to get the long acting insulin back
out of me once injected, by comparison).
During two pregnancies, when insulin needs increased late in the
pregnancies, correction boluses required nothing more than a click of a
few buttons. I lead a normal life. I'm not imprisoned by my disease. My
pump has freed me from many of the shackles diabetes had bound me with.
I would invite the authors of this ridiculous article denying the
value of an insulin pump to live the MDI lifestyle, and then try out the
pump. After living both ways, I wonder which way they would prefer? I'll
take my pump any day, and I'll just bet the authors would, too, were they
to walk in my shoes.
Take your clinical analysis back to the laboratory and burn it. It
has no value to the diabetic trying to lead a normal life. It is only of
value to the physician who cares about nothing more than a lab test result
every three months. If he can get it either way, why does he stand in the
way of giving his patient freedom and flexibility? I'll never understand.
Competing interests: No competing interests