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Go Ahead, Pick Your Pump

My plan is to go through life with two things at my side: My wife (‘til death do us part…) and my insulin pump, at least until there’s a cure for diabetes.

Choosing my wife was easy — she was the only woman who was willing to put up with me. Choosing an insulin pump was not nearly as simple. How could I possibly tell which features were important and which were just a bunch of sales fluff? And when I picked out my first pump 12 years ago, there were only two pumps to choose from. Today, there are seven different companies producing a variety of pump models (and one producing a disposable “patch pump”), and more are on the way!

I’m lucky enough to work in a field that allows me to sample just about everything that comes down the research pipeline, so I’ve had a chance to wear every kind of pump out there. And you know what? There is no single pump that is best for everyone. Whether you’re looking to start pump therapy for the first time or are due for an upgrade, selecting the best pump for you is very important. Anything less can impair your ability to achieve the best possible blood glucose control and may create unnecessary costs and inconvenience. So it pays to shop before you buy.

Do your research
Once you purchase a pump, plan to be “connected at the hip” for the next four years or longer. That’s how long the warranty lasts on most pumps, and insurance companies rarely pay for a new one until the warranty on the old one expires.

So before turning over insurance or payment information to any pump company representative, make sure you’ve done your homework. Contact each pump company and examine the various pumps carefully. (Click here for a list of pump companies.) Review the technical specifications for each. Check out reviews and comparisons made at some of the more reputable Web sites (For links to these reviews, click here.)

In addition, several diabetes magazines, including Diabetes Forecast, Diabetes Health, and Diabetes Positive run objective pump comparisons on an annual or semiannual basis.

Some pump companies (and company reps) will allow you to borrow a pump and wear it with a saline solution in it as a trial run. Take advantage of these opportunities! And try not to be swayed by fancy brochures, flashy videos, or smooth-talking salespeople. I would also be skeptical about comments made by other pump wearers that you meet or come across on the Internet. Very few people have an opportunity to try multiple insulin pumps, so their opinions are usually based on exposure to only one pump type.

And what if you find that you made the wrong choice after the pump has been paid for? Most pump companies offer a 30-day money-back guarantee. Ask your pump company representatives for specifics.

Common ground
All insulin pumps have certain core features in common. All are small, battery-operated devices that deliver both basal insulin (a slow, steady infusion of insulin throughout the day and night) and bolus (mealtime) insulin doses into your body by way of an infusion set — a stainless steel or flexible Teflon tube called a cannula that is placed just below the skin. In most cases, the infusion set connects to the pump by way of a thin (yet strong) strand of plastic tubing. Rapid-acting insulin analogs (aspart [brand name NovoLog], lispro [Humalog], glulisine [Apidra]) are preferred for use in pumps. Here are some of the other features that all insulin pumps have in common:

Price. Most insulin pumps cost about $5,000–$6,000. The disposable OmniPod pump costs less up front, but the long-term cost is similar to the others; the Asante Snap costs about $700.

Warranty and customer support. All pumps have a 4-year warranty and excellent 24/7 toll-free support. All pump manufacturers will replace your equipment for free, typically via overnight mail, in the event of a malfunction.

Safety features. All pumps have sensors to detect blockages in the tubing, a low battery, a low insulin level, and any internal problems with the pump itself. All can be “locked” to prevent accidental programming by young or irresponsible pump users. All have multiple systems to prevent accidental over-delivery of insulin, as well as an automatic pump shut-off and an alarm in the event that no buttons are pushed for an extended period of time.

Ease of use. All pumps use onscreen menus and are relatively simple to program. Filling the reservoir (the component of the pump that holds the insulin) and priming the infusion set tubing (filling the tubing with insulin before the infusion set is attached to the body) are tasks that are easily achievable by most people.

Training. The purchase price of all pumps includes comprehensive technical training and a limited amount of as-needed diabetes self-management education.

Small size. All pumps are small and lightweight, about the size of a modern cell phone. The disposable OmniPod pump is somewhat smaller but requires a separate, handheld programmer.

Computer connection. Data from most pumps can be uploaded to a PC for viewing settings and history. Some pumps allow two-way communication for making changes to pump settings.

Power. Most pumps use AA or AAA batteries, which last an average of two to four weeks. Some use lithium batteries, which can last two to three times as long.

Basal features. All pumps permit the user to vary the basal settings (to the nearest 20th of a unit per hour, or less) and enter multiple basal programs. Temporary basal overrides may also be used.

Prolonged bolus delivery. All pumps can deliver mealtime bolus doses all at once or over an extended period of time for foods that are digested slowly.

Backlight. All pumps have a lighted screen.

Programmable reminders. All have optional programmable reminder features to alert the user to check blood glucose at certain times of day or following each bolus dose.

Memory. All pumps store a substantial amount of data regarding boluses delivered, daily insulin totals, and alerts or error messages.

Bolus calculator. All pumps have an optional “bolus calculation” feature that helps the user determine proper bolus amounts based on carbohydrate intake, blood glucose levels, and insulin that is still working from previous boluses.

Some pump companies promote subtle differences in these common features and claim that this gives their pump a “competitive edge.” Typically, these minute differences have almost no significance at all. For example, a pump that offers up to 48 different basal time segments has no advantage over one that offers 24 or 12, since people rarely need more than four or five different basal segments in their 24-hour program. Allowing the user to set up four completely different basal programs is not a major advantage, since few people use more than one (and very few use more than two). A bolus history that holds hundreds of data points is really no better than one that holds a few dozen, since most people rarely look back more than a couple of days. In other words, not every “unique” or “special” feature provides tangible benefits to you, the user.

Deciding factors
So which features are really important? Having trained, educated, and counseled more than a thousand people on insulin pump therapy, I have learned that some pumps have attributes that make them better matches for certain individuals.

Ask the following questions when making your insulin pump selection:

Will the pump hold enough insulin to last you at least three days?
Some pumps hold as little as 176 units of insulin, while others hold as much as 315 units. Since most pump users change their infusion set every three days, it is important to have enough insulin in the reservoir to last that long. To estimate your three-day insulin requirements, take the total daily insulin you take now by injection (including short-acting and long-acting), and multiply by three. Presently, the Medtronic pumps hold either 176 or 300 units (depending on the model), the Animas OneTouch Ping and OmniPod each hold 200 units (although the OmniPod has no tubing to prime, thus saving 10–20 units), the Roche Accu-Chek Combo hold 315 units, and the Sooil Dana Diabecare IIS, Tandem t:slim, and Asante Snap hold 300 units, .

Can you see the screen reasonably well?
Unless you have somebody who can help you perform all of your daily pump programming, it is important that you be able to read the pump’s screen clearly. Check the screen contrast and the size of the characters, with and without the backlight, to make sure you can see them well enough to perform all necessary programming.

Will the bolus dose amounts work for you?
If you require very large or very small mealtime doses, be careful. Presently, the maximum bolus on the Medtronic, Roche, Tandem, and Asante pumps is 25 units, on OmniPod, it’s 30 units, on Animas, it’s 35 units, and on Sooil it’s 10 units. If you are extremely sensitive to insulin, look for a pump that delivers boluses in extremely small increments (less than a tenth of a unit).

Will the “bolus calculator” meet your needs?
One of the best features of modern pumps is the built-in bolus calculator. All of the pumps ask for your blood glucose level and the grams of carbohydrate you plan to eat in determining your dose. They then deduct insulin that is still “active” or “unused” from the last bolus given. When setting up the bolus calculator, some pumps allow you to enter your insulin-to-carbohydrate ratio in very precise proportions, while others round to whole numbers such as 1 unit of insulin per 4 grams of carbohydrate, 1 unit per 6 grams of carbohydrate, and so on. Some will not allow a ratio of less than 1 unit per 2 grams of carbohydrate or 3 grams of carbohydrate. While this is not a problem for the majority of pump users, it can be limiting for people who are on very large doses of insulin.

Likewise, the time intervals used when setting insulin-to-carbohydrate ratios are highly flexible in some pumps and less flexible in others, and when making adjustments for “active” or “unused” insulin, different pumps handle the data in different ways.

Can you hear or feel the alarms?
This is something you have to try out for yourself. The pump will alert you if there is a problem, but if you’re not aware of the alert, what good is it? All pumps, with the exception of the OmniPod, allow you to adjust the beep volume or switch to a vibrate mode.

Do you require a pump that is fully waterproof?
All pumps are “splash resistant.” Perspiration and rainwater are not typically a problem, so this is only an issue if you plan to submerge or drench your pump. And the fact is, most pump users simply disconnect at the infusion set housing before bathing or going into the water. But if you do a lot of swimming or spend a lot of time boating, rafting, or canoeing, it is a good idea to have a fully waterproof pump.

Do you desire a pump that links with a blood glucose meter or continuous glucose sensor?
This is kind of like playing the futures market. Clearly, the future of diabetes management and pump therapy involves a continuous glucose monitor feeding data about your glucose levels to a pump, which then determines how much insulin to deliver automatically. However, we are not at this point yet.

Currently, some pumps have the ability to take data directly from a blood glucose meter when performing bolus calculations (thus saving you the time of manually entering the readings). Others can display data from a continuous glucose monitor, but the data is not used to adjust insulin doses.

Is the clip or case easy and convenient?
I never thought this would be as important as it is. Given the basic similarities between pumps, I have found that many people select their pump purely based on how easy it is to wear. Again, the pump will be attached to you almost continuously for years, so you want to make sure it is going to be comfortable and convenient to have around. Although there are multiple companies that offer stylish and versatile pump pouches and cases (including Unique Accessories, Pump Wear, Inc., and Angel Bear Pump Stuff), the clip or case that is customized to fit the pump by the manufacturer is still used by most pump users. The OmniPod attaches directly to your body, so there is no need for a clip or case.

Can you use your preferred infusion set?
Infusion sets are to pumps like tires are to cars in that they make that all-important final contact. There are many varieties and styles of infusion sets, and some people have more success with certain ones. While all pumps (except for the OmniPod) connect with a variety of angled or “straight-in” infusion sets, using either a stainless steel or a flexible Teflon cannula below the skin, only pumps that utilize a universal connection called a Luer lock will work with just about every type of infusion set on the market. The Roche, Animas, and Tandem pumps use a Luer lock connection. The Medtronic and Sooil pumps, however, use a proprietary connection. The OmniPod currently has only one type of infusion system: a flexible 8-millimeter Teflon tube inserted at an angle.

Are there specific safety features that you will need?
While all pumps have basic safety features to prevent accidental over-delivery of insulin and optional nonspecific reminders (such as a daily alert at a certain time), other safety features may be desirable for enhancing your pump experience and preventing potential problems. For example, alarms can be set to detect possible missed meal or snack boluses. And since it is very important to change the pump’s infusion set on a consistent schedule, it can be very helpful to have a customizable site-change reminder.

Are the size and appearance pleasing to you?
For most people, size and image do matter. Your choice may depend on how big you are, your desire to conceal the pump, and how or where you intend to wear it. In general, smaller is usually better. The OmniPod is by far the smallest pump, and the lack of tubing makes it very discreet. However, a programmer the size of a Palm Pilot must be carried along with it.

Are loaner pumps easy to get and inexpensive?
If you plan to do a great deal of traveling, camping, etc., you may want to have access to loaner pumps to bring as backup. This is not usually an issue for those who are upgrading their pumps (because they have their old pump to use as a backup), but it can be important for first-time pump users.

Will your insurance pay for a particular model?
Given the cost of pumps, perhaps this should be the first thing you check into. Most major insurance companies will cover any pump you prefer, but some offer preferred pricing (lower copayments) for certain pumps, and some (including Medicare) will only cover pumps manufactured by companies with whom they have direct contracts. If you have difficulty getting answers on your own, each pump company has an insurance billing department that will gladly help you to determine whether their pump will be covered by your insurance.

When you still can’t decide
Of course, after listening to everything I have to say about the pros and cons of the various pumps, some of my clients just throw their hands in the air and ask me which pump I now wear (as if that magically makes it the best pump in the universe). Keep in mind that I’ve had only one wife for the past 16 years, but I’m on my 11th insulin pump! So this may not be the best way to make a decision. OK, fine, I’ll tell you anyway. After much research and deliberation, the pump I have chosen to wear at my side is none other than…

Editor’s note: The author’s printer ran out of ink just as the last sentence was printing. We apologize for any inconvenience this may cause. Please direct your questions (or complaints) to Gary Scheiner.

Statements and opinions expressed on this Web site are those of the authors and not necessarily those of the publishers or advertisers. The information provided on this Web site should not be construed as medical instruction. Consult appropriate health-care professionals before taking action based on this information.