Mealtime insulin doses are determined by the amount of carbohydrate in the meal, as well as premeal blood glucose level and anticipated physical activity. The doses can be highly precise: Insulin can be administered in half units or even tenths or twentieths of a unit, depending on the pump model. In addition, most pumps offer the option of delivering mealtime insulin steadily over an extended period of time (rather than all at once) if you are eating an extra-large or high-fat meal that may take a while to digest.
Despite the fact that pump users tend to have improved blood glucose control, fewer hypoglycemic episodes, and almost unlimited lifestyle flexibility, pump use does have its drawbacks. To begin with, it takes extra training and frequent blood glucose monitoring to fine-tune your basal rates and bolus formulas and learn to make insulin adjustments on your own. It usually takes at least a month before decent blood glucose control can be achieved. In addition, because no long-acting insulin is used, pump users are at high risk of developing ketoacidosis in the event of a programming mistake or a mechanical problem, such as a kink in the tubing that blocks insulin delivery. Wearing the pump can be an inconvenience at times, and some people may find it embarrassing. Inserting the infusion set beneath the skin requires a relatively long introducer needle, which can be painful and intimidating at first (although there are special insertion devices that can make this easier and less painful). The tape that holds the infusion set in place can come loose or cause irritation at the insertion site. Finally, the cost of the pump ($4,000–$6,500, plus hundreds of dollars a month in pump supplies) makes it prohibitive for those who do not have adequate health insurance.
Give it a test drive
Choosing the right insulin program — like choosing a car — means finding something that fits your budget, your lifestyle, and your needs. Who wouldn’t love to tool around town in a Corvette Stingray convertible? The trouble is, it’s a bit pricey, and it isn’t all that practical for some (it couldn’t fit, for instance, four kids, two booster seats, two infant car seats, plus diaper bags and coloring books). Similarly, a low-price beater isn’t a deal if it spends half its time in the shop.
When it comes to your insulin therapy, you want a program that provides the greatest overall blood glucose control with the least inconvenience. Carefully considering your options can lessen the impact of diabetes on your lifestyle and greatly improve your long-term health and quality of life.
If you think your current regimen could use an upgrade, consider what you like and dislike about it, and share this information with your health-care team. Be as honest and detailed as possible about your schedule, your habits, and your frustrations. Are you experiencing frequent highs or lows at certain times of day? Are you having a hard time handling so many injections? Are you tired of having to eat snacks when you’re not hungry? Often, you can “test drive” a new insulin or a different insulin regimen for a month or two to see how well it works for you. (Click here to see a chart comparing insulin regimens.)
And what if your health-care team doesn’t agree with your decision to change your program? Ask them why. Perhaps they have some good arguments that will sway your decision. If not, you might want to look for a second opinion. After all, it’s your diabetes, and you have the right to manage it in the manner that suits you best.