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  • Introduction

    Welcome to Beginner’s Training Module for the Accu-Chek Combo insulin delivery system. The lessons in this Module cover the basics of insulin pump therapy. None of us live rigid lives. We may skip meals, sleep in late and exercise more or less depending on the day.

    The Accu-Chek Combo insulin delivery system supports a more flexible lifestyle than multiple daily injections (MDI).

    You can adjust insulin delivery to changing needs when you get up at different times in the morning, when you exercise, or when you eat different types of meals. The content of this module covers the basics of insulin pump therapy so that you can understand how it works and take full advantage of its use.

    In this lesson, you will be introduced to the general principles of insulin pump therapy. Before opting for insulin pump therapy, it is recommended that you seek advice from a doctor or healthcare team with experience in this form of diabetes management.

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  • Goals

    At the end of this lesson, you will know:

    • What an insulin pump is
    • How insulin pump therapy mimics the (physiologic) insulin secretion from the pancreas
    • Goals of insulin pump therapy
    • Benefits and drawbacks of insulin pump therapy
    • Whether or not an insulin pump is right for you

    To meet these goals, let’s review some basics about diabetes.

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  • Diabetes: a quick review

    The beta cells of the pancreas, a small organ in the abdomen, produce insulin (1). Insulin regulates the use and storage of sugar (glucose 2), the body’s main fuel. Insulin acts like a key. It binds to the receptors (3) and opens the doors (4) of the body cells (5) to let glucose enter (6).

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  • Diabetes: a quick review

    In type 1 diabetes, the beta cells in the pancreas are destroyed and therefore they can no longer make insulin or produce enough insulin to sustain normal daily living. In type 2 diabetes, the body is not able to respond to insulin properly, thus, more is required to absorb glucose from the bloodstream. This is called insulin resistance. Over time, insulin secretion is declining in type 2 diabetes.

    Unless lowered through appropriate therapy, glucose levels remain elevated (high) in both type 1 and type 2 diabetes. To shorten the time spent in hyperglycaemia is one of the goals of diabetes therapy. Elevated blood glucose levels can over time lead to serious problems with your blood vessels, heart, nerves, kidneys, eyes, and feet.

    A high level of glucose in the blood is called hyperglycaemia. If not taken care of, it can cause ketones to build up in the body. In turn, this can cause a very serious condition called diabetic ketoacidosis (DKA).

    Legend: (1) insulin (2) glucose (3) receptor (4) door (5) body cell (6) glucose entering the cell

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  • Importance of intensive insulin therapy

    Intensive insulin therapy reduces the risk of serious problems developing over time with your blood vessels, heart, nerves, kidneys, eyes, and feet.

    Intensive insulin therapy can be implemented with a basal-bolus regime using multiple daily injections with insulin pens, syringes, injection device, or with insulin pump therapy. Insulin pump therapy is often referred to as continuous subcutaneous insulin infusion (CSII).

    Hyperglycaemia (high blood glucose) and hypoglycaemia (low blood glucose) can occur when glucose levels are out of control. Insulin pump therapy can help to reduce glucose fluctuations as compared to multiple daily injections.

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  • Continuous subcutaneous insulin infusion aims to mimic insulin secretion by the pancreas

    Insulin pump therapy mimics the pattern of insulin secretion of the pancreas of people without diabetes. Insulin pumps continuously deliver insulin over each hour of the day in small bursts every few minutes, the so-called basal insulin. Basal insulin needs over the 24 hours differ between individuals. Additional doses of insulin are programmed either on your insulin pump or diabetes manager as needed to cover carbohydrate intake (meal bolus) or to lower / correct elevated BG levels (correction bolus).

    What the pancreas does What an insulin pump system with a bolus advisor does
    Continuously adjusts insulin secretion to physiologic needs Delivers basal insulin to cover background insulin needs
    Recommends bolus doses required to cover carbohydrates included in meals
    Calculates the appropriate bolus dose (according to input from the user) to reduce elevated BG levels back into the target range
    In addition to the above, the Accu-Chek Bolus Advisor can also recommend the necessary amount of carbohydrates (according to input from the user) to correct a hypoglycaemic event to bring low BG levels back into the target range
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  • How does a pump work?

    An insulin pump is a small motorized medical device that delivers insulin. The insulin passes from a cartridge inside the insulin pump, through an infusion set into the subcutaneous tissue. You will learn more about infusion sets later in this module. The insulin pump is programmed and operated by the user according to his or her needs.

    An insulin pump does not automatically keep the blood glucose within normal range. The user must continue to measure blood glucose levels and program insulin boluses as necessary. As you will see, the Accu-Chek Combo insulin delivery system has many functions that make this task easier.

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  • Benefits of using continuous subcutaneous insulin infusion and a "Bolus Advice" calculator

    With an insulin pump, insulin doses can be adjusted in smaller increments to individual requirements than with multiple daily injections.

    With an insulin pump, insulin delivery is precise and predictable.

    Your basal rate is set to match your meal-independent insulin needs over the course of the day. And, with your Accu-Chek Combo insulin delivery system, you have the opportunity to adjust your basal rate and calculate boluses to cover carbohydrates in foods and to correct high blood glucose levels. It also provides information of how many carbohydrates you need to treat a hypo based on information pre-programmed together with your Healthcare professional.

    For example, when you exercise, you can lower the basal rate. You will learn more about the basal rate and boluses later in this module.

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  • Benefits of insulin pump therapy over MDI therapy

    • Improved glycaemic control 1,2
    • Lower rates of severe hypoglycaemia 3
    • Fewer episodes of hypoglycaemia during the night 1
    • Better quality of life and treatment satisfaction 4
    • It may assist to achieve better glycaemic control in pregnancy 5,6
    • Due to improved glycaemic control, there may be fewer long-term diabetes complications, such as retinopathy, nephropathy, neuropathy 7,8, or heart problems 8

    retinopathy, nephropathy neuropathy, heart problems.

    Potential advantages of the Accu-Chek Combo insulin delivery system

    • Discreet bolus dosing via remote control option of the Accu-Chek Combo diabetes manager may assist to not miss bolus doses 8 The Accu-Chek Bolus Advisor can also recommend the necessary amount of carbohydrates (according to input from the user) to correct a hypoglycaemic event to bring "low BG levels" back into the target range.

    References

    1. Benkhadra K, Alahdab F, Tamhane SU, McCoy RG, Prokop LJ, Murad MH. Continuous subcutaneous insulin infusion versus multiple daily injections in individuals with type 1 diabetes: a systematic review and meta-analysis. Endocrine 2016; 10.1007/s12020-016-1039-x.

    2. Pickup J, Mattock M, Kerry S. Glycaemic control with continuous subcutaneous insulin infusion compared with intensive insulin injections in patients with type 1 diabetes: meta-analysis of randomised controlled trials. BMJ 2002; 324(7339): 705.

    3. Pickup JC, Sutton AJ. Severe hypoglycaemia and glycaemic control in Type 1 diabetes: meta-analysis of multiple daily insulin injections compared with continuous subcutaneous insulin infusion. Diabet Med 2008; 25(7): 765-74.

    4. Misso ML, Egberts KJ, Page M, O'Connor D, Shaw J. Continuous subcutaneous insulin infusion (CSII) versus multiple insulin injections for type 1 diabetes mellitus. Cochrane Database Syst Rev 2010; (1): CD005103. DOI: 10.1002/14651858.CD005103.pub2.

    5. Kallas-Koeman MM, Kong JM, Klinke JA, Butalia S, Lodha AK, Lim KI, et al. Insulin pump use in pregnancy is associated with lower HbA1c without increasing the rate of severe hypoglycaemia or diabetic ketoacidosis in women with type 1 diabetes. Diabetologia 2014; 57(4): 681-9.

    6. Kekalainen P, Juuti M, Walle T, Laatikainen T. Continuous Subcutaneous Insulin Infusion During Pregnancy in Women with Complicated Type 1 Diabetes Is Associated with Better Glycemic Control but Not with Improvement in Pregnancy Outcomes. Diabetes Technol Ther 2016; 18(3): 144-50.

    7. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993; 329(14): 977-86.

    8. Diabetes Control and Complications Trial Research Group/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group, Nathan DM, Cleary PA, Backlund JY, Genuth SM, Lachin JM, et al. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med 2005; 353(25): 2643-53.

    9. Weis N, Caruso A, Woll B, Weissmann J. [Discreet Remote Control of the Insulin pump Facilitates the Therapy Self-Management of Patients with Type 1 Diabetes]. Poster presented at the 48th Annual Meeting of the German Diabetes Association (DDG); Leipzig, Germany; May 8-11, 2013. Diabetologie und Stoffwechsel 2013; 8(S01).
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  • Drawbacks of insulin pump therapy

    Although there are many benefits, insulin pump therapy is not for everyone:

    • A pump can be a visible sign that someone has diabetes
    • The insulin pump can get in the way during sports or intimate activities
    • Insulin pump users need to have a backup plan in place should the system fail and be able to respond to any technical problems if they arise
    • Blood glucose tests need to be done often and regularly, at least 4 times a day
    • Insulin pump users need to commit to replacing the infusion set on a regular basis
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  • Is insulin pump therapy right for me?

    Any of the following may indicate to a healthcare professional that you are a good candidate for insulin pump therapy:

    • Blood glucose control is not optimal
    • Noticeable variability of day-to-day blood glucose levels
    • Frequent hypoglycaemia, especially if requiring emergency treatment
    • Presence of diabetes complications
    • Need for more flexibility (a shift worker or a person who needs to travel on business, children, those with active lifestyles)
    • Women wishing to gain tighter/improved glycaemic control before, during or after pregnancy
    • Person who has very low insulin needs
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  • Is insulin pump therapy right for me?

    The following may indicate to a healthcare professional that a person is not a good candidate for insulin pump therapy:

    • Not motivated to use and carry a pump all day long
    • Not motivated to perform the tasks, such as regular glucose measurement, required to use a pump safely
    • Not reliable because of psychiatric disorders, drug or alcohol abuse
    • Regularly exposed to high temperatures due to the nature of their work
    • Have poor body hygiene or regular skin infections

    Discuss with your healthcare team whether insulin pump therapy is right for you.

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  • What about reimbursement?

    Reimbursement for the device depends on your country’s health system and other private insurance policies. Discuss your options with your doctor or healthcare team.

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  • Quiz

    Before opting for insulin pump therapy, it is recommended that you seek advice from a doctor or healthcare team with experience in this form of diabetes management.

  • Quiz

    Which of the following criteria describe a person who is a good candidate for insulin pump therapy?

    Check all that apply.

  • Congratulations!

    You have completed this section.

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