Pump Use in Type 1.5 and Type 2 Diabetes

Many adults with Type 1.5 diabetes (LADA) or Type 2 diabetes can benefit from the delivery of insulin via an insulin pump. Insulin pumps provide convenient and precise insulin delivery, dose recommendations, reminders, and data tracking. These benefits are often as helpful for people with Type 1.5 and Type 2 diabetes as they are for Type 1 diabetes.

Pumps for Type 1.5 Diabetes

Type 1.5 diabetes is often confused with Type 2 diabetes because it also arrives during the adult years. Type 1.5 diabetes is caused by antibodies that damage beta cells rather than insulin resistance that weakens the beta cells over the years. Insulin production declines more quickly, and insulin is required sooner. On average, insulin is needed six years after the diagnosis of Type 1.5, often with smaller doses at first. A pump, with the ability to dose hundreds or even thousandths of a unit, provides added precision to doses. Early and precise insulin dosing helps preserve beta cell production. As beta cell production declines over time, Type 1.5 becomes identical to Type 1. A pump allows the small increases in basal and bolus delivery for convenient adjustments over time, especially in conjunction with a continuous glucose monitor and Automated Insulin Delivery Systems.

Pumps for Type 2 Diabetes

Type 2 diabetes differs in that it results from insulin resistance. The beta cells get overworked while producing enough insulin to keep up with greater and greater demand. This is part of the metabolic syndrome associated with insulin resistance. It also includes high blood pressure, gout, high triglycerides, low levels of HDL (protective cholesterol), and an apple shape. Many people with Type 2 eventually need insulin and benefit from pump therapy.

One way a pump can benefit a person with Type 2 diabetes is short-term intensive insulin therapy. By rapidly bringing blood sugar levels under control, beta-cell recovery is maximized. After a few weeks of tight control, beta cells recover, and insulin therapy can sometimes be stopped. In several studies, after anywhere from a week to a month of intensive insulin therapy, some individuals with a shorter duration of high glucose levels can stop insulin. Their glucose may stay in a healthy range for months afterward. The intensive insulin therapy appears to give the overworked pancreas a vacation, allowing it to produce an adequate amount of insulin again.

But short term therapy is not the only use for a pump for Type 2 diabetes.

Advantages of a pump in Type 2

Suggested treatment goals for Type 2 diabetes include:

A fasting plasma glucose of 110 mg/dl or less
A glucose of 140 mg/dl or less 2 hours after eating
An A1c of 6.5% or less

Using an insulin pump can improve control and achieve these goals. In addition to improved glucose control, other health issues that arise with the metabolic syndrome also benefit, including cholesterol levels, blood pressure, and excess inflammation and oxidation.

A pump offers convenient and flexible insulin delivery. It uses only fast insulin for both bolus (mealtime) and basal (background) insulin needs. The pump can give a bolus for every snack or meal with a few button pushes.

If you have Type 2 diabetes, using a pump can help you:

Overcome the Metabolic Syndrome

Pump use can be more effective than injections at lowering insulin resistance, reducing the amount of insulin needed, and lowering high triglycerides.

Bring Down High Morning Blood Sugar

High waking glucose is typical in Type 2 diabetes. It’s caused by the liver producing and releasing excess glucose during the night. Using a pump, which can be programmed to change basal rates throughout the day, the patient can precisely adjust the amount of insulin to reduce this effect. Research studies have found that insulin levels often need to be increased by over 40% in Type 2 diabetes during the early morning hours to prevent high morning blood sugar.

Avoid Weight Gain

Excess weight is a common problem in Type 2 diabetes, and insulin use can lead to even more weight gain. The precise dosing available with a pump usually means you use less insulin overall, which leads to less weight gain while providing better glucose control. Entering carbs into the bolus calculator each time you eat tracks carbohydrate intake and reduces mindless eating. Pump use also reduces the frequency of hypoglycemia (low blood sugar), so you won’t need to eat to raise your blood sugar. Avoiding the additional calories that go along with treating lows will reduce weight gain.

Improve Control and Lower A1c

Fasting glucose is improved by accurate overnight basal insulin delivery, and carb factors pre-programmed into the pump help the user determine the right dose for mealtimes. Post-meal glucose levels can be improved with extended and combo boluses that better match various types of carbs. All of this adds up to better control.

U-500 Insulin in a pump

Those with Type 2 diabetes may require large amounts of insulin due to high insulin resistance, sometimes 30, 50, or more units per meal. U-500 Regular insulin can be used in a pump to handle large insulin doses. U-500 is 5 times as concentrated as U-100 insulin, so the insulin dose is one fifth the volume. Even though Regular insulin has a slower onset and longer duration than Novolog, Humalog, Apidra, and other rapid-acting insulins, the ability to give less volume can make U-500 Regular more comfortable and more productive. For those who require more than 150 units of insulin per day, this can be a good option. It’s essential to work closely with a doctor familiar with U-500 insulin. Exact dose calculations are required with this more concentrated insulin.

U-200 Humalog that is twice as concentrated as U-100, is also an option. It is only available in preloaded insulin pens. Again, an experienced clinician is required for accurate pump settings and doses.

21.3 Medicare Requirements for Pump Coverage
In order for a person with Type 1.5 or Type 2 diabetes to be eligible for coverage of an insulin pump, they must have either: A low C-peptide For kidney insufficiency of creatinine clearance < 50 ml/min, a C-peptide < 200% of labs lower limit For other people, C-peptide < 110% of lab’s lower limit of normal and fasting glucose is < 225 mg/dl Or a positive beta cell autoantibody (GAD65, IA2a, etc.) Test result out of normal range documented by lab report, including the lab’s normal range Criterion A: New pump for a person currently on MDI Completed diabetes education At least 3 injections of insulin a day Documented self-adjustment of insulin doses for 6 months Documented self-testing of glucose at least 4 times a day for 2 months PLUS one of these while on MDI: – A1c > 7% – Recurring hypoglycemia – Unstable blood sugars before meals – Dawn Phenomenon with fasting blood sugar > 200 mg/dl – Severely unstable blood sugars Criterion B: On pump prior to Medicare enrollment Documented self-testing of glucose at least 4 times a day during the month prior to Medicare enrollment

21.3 Medicare Requirements for Pump Coverage

In order for a person with Type 1.5 or Type 2 diabetes to be eligible for coverage of an insulin pump, they must have either:

A low C-peptide
For kidney insufficiency of creatinine clearance < 50 ml/min, a C-peptide < 200% of labs lower limit
For other people, C-peptide < 110% of lab’s lower limit of normal and fasting glucose is < 225 mg/dl
Or a positive beta cell autoantibody (GAD65, IA2a, etc.) Test result out of normal range documented by lab report, including the lab’s normal range

Criterion A: New pump for a person currently on MDI

- Completed diabetes education
- At least 3 injections of insulin a day
- Documented self-adjustment of insulin doses for 6 months
- Documented self-testing of glucose at least 4 times a day for 2 months

PLUS one of these while on MDI:
– A1c > 7%
– Recurring hypoglycemia
– Unstable blood sugars before meals
– Dawn Phenomenon with fasting blood sugar > 200 mg/dl
– Severely unstable blood sugars

Criterion B: On pump prior to Medicare enrollment

- - Documented self-testing of glucose at least 4 times a day during the month prior to Medicare enrollment

Medicare Coverage for Pumps

People on Medicare are candidates for insulin pump coverage if they meet specific criteria.

This page was adapted from Pumping Insulin 6th edition, Chapter 21, where you can find more information about selecting, setting up, and using an insulin pump in our book.