Integrated insulin pump therapy with continuous glucose monitoring for improved adherence: technology update

Figures & data

Figure 1 Sensor-augmented pump therapy.

Notes: (A) Real-time glucose sensor, sitting on the skin surface with its tip inserted in the tissue interstitial fluid, measures glucose levels. The glucose value is transmitted to the insulin pump by radio frequency. (B) Current available devices for sensor-augmented insulin pump therapy: Medtronic Paradigm VEO (Northridge, CA, USA) (top); Animas VIBE (West Chester, PA, USA) (bottom).

Table 1 Factors involved in the success (or failure) of SAP therapy

Patient-related	Health care giver-related
• Motivation to change previous behaviors regarding diabetes management.	• Proper patient selection.
• Frequency of sensor use (at least 60%–70% of the total time).	• Training on diabetes management (eg, self-management of blood glucose monitoring, dietary education, carbohydrate counting, etc).
• Right interpretation of trends on RT-CGM receiver (glucose trend arrows).	• Training on technical devices (glucometer, insulin pump, RT-CGM system).
• Awareness of the lag-time period (RT-CGM devices measuring interstitial fluid glucose concentration, exhibit 3–12 minutes time delay when compared to capillary blood glucose).	• Instruction to patients regarding the use of specific algorithms to adjust their insulin regimen based on glucose trends.
	• Involvement of parents in the educational program (children and adolescents).

Abbreviations: RT-CGM, real-time continuous glucose monitoring; SAP, sensor-augmented insulin pump.

Figure 2 Glucose trend arrows.

Notes: Real- time continuous glucose monitoring data include “trend arrows” which indicate when the blood glucose is rapidly falling or rising, thus enabling the pump user to make immediate adjustments in insulin delivery to prevent subsequent hypo- or hyperglycemia.

Table 2 Common barriers to SAP therapy and potential solutions

Barriers	Solutions
• Wrong expectations about SAP therapy (usually believed to be an “artificial pancreas” by the patient).	• Provide the proper training and education before starting SAP therapy (eg, continued requirement of finger stick testing, possible discordances between RT-CGM and meter readings, etc).
• Discomfort from the sensor needle insertion.	• Use appropriate insertion techniques: insert the sensor in a “pinchable” area and spread the skin before insertion. Lidocaine-based cream or a cool pack can serve to numb the area just prior to sensor placement.
• Low accuracy of glucose calibrations.	• Clean hands; calibrate during periods when blood glucose levels are not changing rapidly; calibrate routinely (fasting, premeal, and pre-bedtime).
• RT-CGM alerts nuisance.	• Stepwise introduction of alarms. Initial threshold values of 70 and 250 mg/dL. In the beginning, do not use any alerts for an initial period of 1–2 weeks unless the user frequently experiences hypoglycemia; in such cases, a low alert may be indicated from the beginning.

Abbreviations: RT-CGM, real-time continuous glucose monitoring; SAP, sensor-augmented insulin pump.

Figure 3 Software reports.

Notes: Software report of a patient on sensor-augmented insulin pump therapy. All the available devices are linked to specific software, which provides the following information about the patient: (a) glucose trend graph, (b) basal and bolus insulin, (c) carbohydrate intake.