Insulin Pumps: Free to sleep in, miss meals . . .

Understanding Basal Insulin

Insulin pumps offer unique flexibility and quality of life options. Options that aren't available with injections or insulin pens. How do they do that?  It's all in the electronics and the BASAL and BOLUS insulins.  Nothing speaks like real -life examples. You'll find some below. 

As you read through this, keep in mind  that insulin pumps are not for everyone, no matter how tempting they might seem at first glance.  Discuss your interest in pumps with your diabetes team. They'll help you decide if it's right for you.

Just a reminder that this site if for information only and not to be used as medical advice. Please read the disclaimer.  

When You Didn't Have Diabetes

First, a bit of a necessary information.

BASAL INSULIN: 

Your body makes a small amount of sugar every hour whether you're eating or not. That's normal and necessary for everyone. In response to this sugar being made, the pancreas releases a smidge of insulin every hour to hold those blood sugars in perfect range.  This means you could go all day without eating and still have great sugars. At least you did. Before you got type 1 diabetes. Now you no longer make this "BASAL" insulin.

 Basal rates are what cause the most problems in diabetes. Everyone's basal needs are different. Much like everyone's signature is different. Below are examples of basal rates for  3 people - one of which is me. (You determine your basal rate when going through insulin pumps program. In hindsight,  many folks say "Oh, that's why I was having so much trouble with that time of the day." ) 

BOLUS INSULIN: 

You  make a "blob" (very technical term) of insulin whenever you eat carb food.  We call this  "BOLUS" insulin. Of course, if you have type 1 diabetes you don't make BOLUS or BASAL  insulin anymore.  Sorry.

Now That You Have Diabetes

The BASAL and BOLUS insulins need to be replaced now that you have diabetes - particularly type 1 diabetes.  The problem is that basal rates are as individual as their owner's signatures. They are rarely flat and peakless despite what you hear.  And they are hard to copy.  But that's just what NPH or Glargine (lente, ultralente in the past) are attempting to do.  Sometimes they're successful, but many times not.  This may explain some of the wonky things you've seen in your blood sugars and why pumps are often able to help them. 

Let's work through me as an example so you can see what I mean. 

When I first went on to multiple daily injections with Humalog I tried going with NPH only once a day - in the evenings. I got great blood sugars after lunch thanks to the Humalog, but was sky high  by supper because the Humalog ran out. There was no basal insulin to work with the sugar that my liver leaked out. So I had to look for options. Remember, I didn't know my basal rate at the time. This is all hindsight. But it is how we as diabetes educators - and you - reason through your basal needs. 

Basal Insulin: Unlucky with NPH

I started with NPH twice a day as my basal and humalog at meals. Forget the meal insulin for now and just look a the "basal" insulin. (I didn't plot the meal insulin anyway).  My real basal rate is the solid line. The red line is the NPH. Any splotches of red or blue are not good - signifying either too much or too little background basal insulin on board.  (Sometimes the NPH overlaps itself -eg. in the morning.  It looks like there should be too little NPH on board, until you add up the two overlapping insulins).

 You can see that I had too much NPH insulin in the afternoon (red patch) compared to what my body really wanted (black line).  I had to run my sugars around 15 mmol (270 mg/dl) after lunch until 3pm to prevent going low by supper. If I exercised in the afternoon or just ran a flight of stairs, I was suffering with more lows. 

I had the reverse problem at supper.  My sugars skyrocketed if supper was quite late. You can see from the blue patch that I didn't have enough basal insulin on board from 6 pm to 3 am to match what my body  wanted.  I was relying on eating supper at a reasonable time so my body could use some of the supper humalog to supplement my basal insulin needs. That explains why my insulin to carb ratio only allowed for 1 unit per 5 g carb.

 Needless to say, I wasn't happy with this regime so I moved on to the next option available at the time.  It wasn't pump, although  Insulin pumps were available - and I was offered one for free-  but I wasn't yet ready to be "hooked up." And to be honest, I didn't believe at the time that insulin pumps were any better than injections. (course, that was then).

Unlucky with Ultralente (would be with Glargine too!)

I added in Ultralente in the morning but kept the NPH at night.  The ultra-lente gave me somewhat less insulin at my low period of the day - 3 pm.  I still got high sugars later if I didn't eat supper on time (as you can see by the blue patch signifying not enough insulin). Of note, some people's basal needs don't rise by the evening. This explains why some folks' blood sugars are fine ( or low) if they have a delayed supper.  It really depends on what background injected insulin is on board and what their bodies really need at the time. 

Clearly I needed more insulin at 1800 hr to hold my blood sugar stable than I did at 1500 hr . Even if I went on to Glargine - which is a flat line 24 hr basal (almost) - my needs wouldn't be met.  

This  ultra-lente was not ideal but I stayed with it for many years until I seriously considered insulin pumps as a solution.  (Truth be told, a 12 year old convinced me to try the pump). 

Basal Insulin : Lucky with  Insulin Pumps

My final choice and the one I currently use now, is the insulin pump. I have programmed it to give me a fraction of rapid insulin every hour to match my BASAL needs. (after completing a pump program to teach me how to find my "basal profile").  The pump gives me less insulin at my low time of the day - the afternoon. And more insulin for the other times of the day . I take no intermediate or long acting insulin.  It's actually worked out in units per hour. Eg. 0.8 units per hour now, 0.5 units per hour at 14:00 hr etc.  For my needs, the insulin pump is the ideal individualized basal insulin. But there's more  . . . 

The real benefit of being on the insulin pump, besides better blood sugar control, has been a much improved quality of life. So much so that I, like many of other pumpers, would not voluntarily give up my pump.

Being Realistic with Diabetes Pumps

Okay, I have my basal profile programmed into my pump. Does that mean that I am always in target according blood sugar guidelines?  No. It doesn't. Remember that many things can change your basal rate up or down from it's normal.  For example, being sick. I've got my basal rate turned up right now because I am sick. Other things might mean I need to turn it down. But, I still have my "normal" days basal rates programmed in to run automatically.  Read below to see the other benefits to using  insulin pumps for your basal insulin needs. Or skip right to learning about how an insulin pump can help you with your meal bolus insulin. 

The "Bonus" with Insulin Pumps

As a bonus, if I exercise at 3 pm, I program my insulin pump (in less than 12 seconds - I just timed it) to give me 50% less of my usual BASAL insulin so I don't get a low glucose.  When I'm done exercising I can leave it at 50% for as long as I want or I can put it right back to the normal BASAL need immediately (Okay, in another 12 seconds).  On NPH or any other long acting insulin,  I simply could not reach into my body and yank out some of the insulin that was already given that morning.  Insulin pumps revolutionize how basal is delivered - as it is needed and not in advance.

This flexible programming is what allows insulin pumps to reduce the risk for hypoglycemia. Yes, folks on insulin pumps get less low sugars than those not on insulin pumps (as a whole, remember individuals differ). You can see why that is though:

1. Program individual basal insulin needs (basal profile)on the insulin pump to avoid extra insulin when not needed and to get more insulin when needed. 
   - have a basal profile for workdays
   - have a basal profile for days off
   
2. Sleep in, Stay up late, miss meals - the insulin pump lets you.
   -If you've worked with your educator to figure out your basal rate (or close to) then you can sleep in, stay up late or miss meals without ANY extra programming of the insulin pump. The basal profile that you put into the pump will keep working AUTOMATICALLY to keep your sugars stable  until you either change it  or ask it for a temporary change. But yes, check your glucose levels.  The body can throw in some curve-balls.
    
3. Temporarily change basal up or down at any time 
   -for busy mornings 
   -for sedentary afternoons
   -for exercise
   -for . . . etc. 
   I have programmed my insulin pump to give my less insulin even while teaching a busy diabetes class to avoid going low. (Mine can do everything by buttons/sound if I choose.)
   
4. Turn BASAL insulin off at any time.
   -Eg. Suppose you're having a bad low and want to stop any insulin from getting in. Or suppose you gave a tad too much insulin at a meal. You can't reach in to take it back but you can tell insulin pumps  to stop giving you background or BASAL insulin for a few hours or longer (your choice). 
   
5. Change basal profile when life changes
   Interesting point here. We don't stay the same over time. Certainly the wrinkles that have popped up on my face tell me this.  Our BASAL insulin needs do not stay the same either. At some point in time they will change.  An example: a few years ago I seemed to need a lot more insulin at 0300-0600 hrs in the morning than I do now. Go figure. Luckily you can reprogram your insulin pump at home in minutes. So I did.  I'd have had a hard time adjusting to that change with NPH or Glargine. 

BASAL insulin is only one flexible component of insulin pumps.  BOLUS insulin, or meal dose insulin, can also be given in flexible ways on pumps. Curious about how easy it is to give bolus doses on insulin pumps? How about the different types of bolus doses that can be given using insulin pumps? Read on.

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Leaving Insulin Pumps : Sleep in, miss meals to go Home: How to to Lower Blood Glucose Levels