CGMs and Insulin Pumps 2013
Is this dynamic duo the right choice for you?
Tech geeks aren't the only ones who benefit from advancements in diabetes devices. Even people who haven't yet upgraded to a smartphone can appreciate the precision that insulin pumps and continuous glucose monitors (CGMs) bring to diabetes care.
Insulin pumps are almost as ubiquitous as blood glucose meters. In fact, they're more popular than insulin pens for type 1 diabetes in the United States, according to a 2010 study in the Journal of Diabetes Science and Technology. About 20 percent of Americans with type 1 diabetes use one. And though they're hardly new (the first pump was created in the '70s), they're one part of a duo of diabetes devices that can make for the most comprehensive diabetes management. But as useful as pumps and CGMs are, they're not for everyone.
How do you know if a pump or CGM is right for you? Here, we talk to a pump and CGM user and his doctor to find out some of the considerations and conversations that are part of the decision-making process.
One Man's Device Journey
Paul Penta was no stranger to insulin pumps when he started using one in earnest about eight years ago. He had used a pump as a teen but hadn't quite been ready for the responsibility. "It's certainly more effort to be on a pump than not," says Penta, now 31. "I was hanging out with friends, playing sports. I couldn't be bothered with all of the things that go along with it." That included carting around supplies, changing his pump's reservoir and batteries, and finding the right infusion set. In his late teens, Penta wanted a break. "You're always tethered to something. You're always connected," he says, while admitting that another reason he returned to daily injections was because he wasn't emotionally ready to handle a pump.
The Right Time
Penta's doctor, Howard Wolpert, MD, is director of the Joslin Diabetes Center's insulin pump program. Although he knows the ability of pumps and CGMs to transform diabetes care, he understands that the technology isn't for everyone. Much of prescribing a pump or CGM is about timing. He didn't object when, as a teenager, Penta returned to injections after years of pumping. "There are a number of patients who are college age and don't want to wear a pump. They feel a pump is more stigmatizing," Wolpert says. "There's no right or wrong to that. Any one individual's choices will vary over their lives."
Still, Penta knew he'd return to the technology—the blood glucose improvements were worth it. So after college, when he was taking control of his post-academic life, he decided to better control his diabetes, too. "I was ready to take ownership of my disease, and I was willing to make the trade-off," he says, referring to the extra supplies and attention his pump required. "Before I went on a pump, I was on multiple daily injections. … And my control was abysmal." He brought the issue up with Wolpert, who backed the decision wholeheartedly.
Part of the reason the second time was a charm for Penta was his altered expectations for the device. He'd gotten a feel for the downsides of pumping when he was younger, so by the time he was ready to give it another go, he knew exactly how much work it entailed. Current pumps offer precise dosing that you can program for your 24-hour insulin needs and take some of the math work out of insulin-to-carb calculations; CGMs show trends and patterns in glucose levels and offer helpful high-low alarms. But you can't just set them and forget them. "If people go into it with realistic expectations of what the technology's benefits are and what its limitations are, they don't end up disappointed," Wolpert says.
|Try Before You Buy|
|Professional CGMs, which your doctor can prescribe for three- or seven-day sessions and use to assess and adjust your treatment, can show you what it would be like to have your own CGM. Insurance plans including Medicare and Medicaid may provide this benefit for people with diabetes when it's medically necessary (such as during medication changes or to help solve hypoglycemia unawareness). Also, ask your health care provider or the device company about "test driving" a CGM or pump (with saline solution instead of insulin).|
As for continuous glucose monitoring, Penta was slow to embrace the technology. "For a long time, I refused to go on a CGM," he says. While Wolpert is a believer in the ability of a CGM to improve blood glucose control, he didn't force the issue with Penta. "Howard's great about not pushing things on you if you're not ready," Penta says.
Three years ago, Penta's A1C hovered in the high 8 percent range, and while he wanted to lower the number, that's not what made him finally buy a CGM. Frustration with frequent swings in blood glucose persuaded him to try the technology. He made the decision while halfway up a mountain when his blood glucose plummeted to 35 mg/dl. His friends waited 25 minutes as Penta's blood glucose rose before they could continue their hike. "That, for me, was the last straw. I was tired of the low blood sugar," he says. "I think a CGM can be an even more valuable technology than a pump for some people."
When Penta was ready for continuous monitoring of his glucose, Wolpert guided him through the pros and cons. In assessing whether a patient will benefit from a CGM, one of Wolpert's main concerns is safe blood glucose control—regardless of A1C. "The issue comes down to hypoglycemia," he says. "[Continuous monitoring] will minimize the fluctuations and minimize the risk for hypoglycemia."
But for Penta, it wasn't love at first sensor insertion. He was miserable with the constant "noise" of the CGM and the ever present blood glucose level that shows on the screen. "The alarms go off all the time, and it took an emotional toll, always seeing that number," he says. "As a person with diabetes, you're going to have good days and bad days, and seeing that number, there's an added element of stress."
Wolpert admits the device takes some getting used to—it's part of the reason he never suggests a patient start insulin pump and CGM therapy at the same time. It can be overwhelming at first. Take, for instance, the alarms for the low and high blood glucose levels, which Penta found particularly irritating. "What [many people] want to do is set [the glucose ranges of the alarms] pretty wide because what happens is they start on a CGM and they get really frustrated," Wolpert says. "They can get burned out."
Because anxiety over seeing a "bad" number happened only a fraction of the time, Penta kept with it. And soon, as he familiarized himself with the device, his unease lessened. The CGM provided valuable insight into his body's response to food, medication, and activity. Penta used insulin before dinner to monitor how long it took for his blood glucose to fall (the answer: longer than he thought). He studied his body's response to exercise and found that he absorbed insulin more quickly when he exercised daily than when he didn't.
If a person sticks with it, learning the device and, as Penta did, learning how the body responds to various day-to-day activities, blood glucose levels can improve significantly, Wolpert says. "It's like learning to drive," he says. "Over time, it becomes more automatic."
The Rest of the Story
Three years later, with a better understanding of how his body works and an A1C at 6.8 percent (with fewer lows and blood glucose fluctuations), Penta says he can't imagine managing his diabetes without his CGM. When he feels burned out on the technology, he takes a short break from the device. Most recently, he left his CGM behind on his honeymoon when he wanted one less device attached to his body at the beach. "The lifestyle impact is even greater than with a pump. It's another thing to carry around," he says. "If you're on injections and want to forget you have diabetes, you can do it. With a pump, it's harder to do. With a CGM, it's nearly impossible."
That said, Penta wouldn't think of going back to injections alone. "Even though I will complain all day long about pumps and CGMs, I would never live without them," he says. "The benefit far outweighs the cost."