Insulin Pump Therapy: What You Need to Know to Mitigate Risk

With the advent of insulin pump therapy and recent funding changes, doors are opening for Manitobans with Type 1 Diabetes (T1D) to access more options for disease management.

Provincial funding, historically limited to pediatric patients and adults 18-25, now covers insulin pumps for adults of all ages with Type 1 Diabetes. However, without appropriate patient and pump selection, patients can face serious adverse consequences (e.g., Diabetic Ketoacidosis, hospitalizations), and unforeseen financial burden. 

CPSM encourages general practitioners to develop relevant knowledge and skills in this practice area to promote patient safety and timely access to care, while drawing on expert consultative supports available through the Manitoba Adult Insulin Pump Program (MAIPP) to ensure quality patient care.

Appropriate Prescription

Not all patients with Type 1 Diabetes are candidates for insulin pump therapy and not all pumps are suitable for appropriately selected patients.

The MAIPP has noted an increasing number of inappropriately prescribed insulin pumps in the community. This may be partly due to commercial vendors encouraging primary care physicians to prescribe insulin pumps to patients who have not been properly vetted for pump therapy by a clinician with the necessary clinical expertise.

Patients must have adequate functional capacity to manage the intricacies of pump therapy, including:

• Accurate carbohydrate counting and physical activity planning.
• Ability to operate the pump safely, i.e., intact cognitive and executive function, as well as fine motor skills to operate the device, including accurate carbohydrate entry.
• Awareness and ability to manage the extra patient costs of pump supplies/accessories not covered by public funding.

CPSM reminds all physicians that, prior to prescribing pump therapy, they must possess adequate knowledge, skills, and judgment to ensure the safe, effective, and appropriate prescription of insulin pumps. Prescribers must document a thorough discussion of the risks and benefits of pump therapy, ensuring their patients have adequate knowledge, skills, and financial resources to manage the technology safely.

Consult & Collaborate with MAIPP

An insulin pump is a costly device. Consultation and collaboration with the MAIPP is strongly encouraged, particularly for prescribers and patients who are new to pump therapy. Current wait times for consultation are minimal. MAIPP provides interdisciplinary assessment, education, and case management, offered in a blended model of in-person and virtual care, serving patients across Manitoba.

To consult and/or access MAIPP resources please contact the program for details:

Manitoba Adult Insulin Pump Program

AC247 En-700 Elgin Avenue – Level 2, Winnipeg, MB R3E 1B2

Fax  204-940-2193   Email  InsulinPumpProgram@sharedhealthmb.ca

Learn More About Insulin Pumps

Why Insulin Pump Therapy?

Type 1 Diabetes is a life-threatening disease affecting approximately 6,800 Manitobans. The impact of this disease on a patient’s lifestyle and health outcomes is enormous. Treatment focuses on managing blood glucose levels with insulin, diet, and lifestyle measures to prevent complications, the more serious of which can include renal disease, nerve damage, vision impairment, and cardiovascular disease. To stay alive, patients with T1D require the subcutaneous application of insulin through multiple daily injections (traditional therapy) or via insulin pump (a newer therapeutic option).

An insulin pump is a costly device that holds and delivers insulin. An infusion set or pod attaches to the skin with a subcutaneous catheter and the imbedded software controls the rate of insulin delivery. Over the last decade, this technology has become increasingly more robust, with advances that will soon become the standard of care for T1D. 

Right Patient, Right Pump

While this technology has the power to improve the chronic disease management and lifestyle of many patients, it can be wrought with risks if poorly managed. Effective therapy starts with appropriate patient assessment and selection, combined with suitable pump selection.

Patients must have adequate functional capacity to manage the intricacies of pump therapy. Insulin pumps operate within a hybrid closed loop, pairing technology with the active participation of the patient, including:

• Diet and lifestyle management, i.e., the ability to do accurate carbohydrate counting and physical activity planning.
• Functional ability to operate the pump, i.e., intact cognitive and executive function, as well as fine motor skills to operate the device, including accurate carbohydrate entry.
• Awareness and ability to manage the extra costs of pump supplies or accessories, i.e., government funding will cover the pump itself but not the monthly pump supplies or additional sensors; patients without private insurance will need to pay out-of-pocket until Pharmacare deductibles are reached. Specifically:
  • Infusion supplies for insulin pumps are minimum ~ $265/month.
  • Continuous glucose sensors can add cost, dependent on the pump chosen and which sensor is integrated (not all sensors are integrated into insulin pumps).
  • Yearly cost to use current pumps with current sensors is ~ $4500 - 7200/year.
  • Both supplies and sensors are eligible under Pharmacare once the patient’s deductible is met.

Not all pumps are suitable for insulin pump candidates. Several types of pumps are available on the market and prescribers should match patient needs with a suitable pump.

The risks, benefits, and demands of pump therapy should be explicitly discussed with the patient before selecting and prescribing a pump. This will prevent patients from purchasing a pump that ends up being unsuitable for their needs. Furthermore, prescribers are cautioned to not mistake manufacturer/vendor teaching on pump operation (device training) with medical pump education for disease management, which is essential for safe pump use. (See below for resources available through the MAIPP.)

Referral to MAIPP

The MAIPP at Health Sciences Centre has treated 620 patients since December 2022. The program serves as the hub in a hub and spoke model of insulin pump therapy and is open to referrals from community providers, including family physicians and specialists.

Patients must have an authorized prescriber while they are in the program. This is someone with demonstrated competency in this domain, who can write orders that the MAIPP diabetes educators can follow (i.e., nurses and dieticians who are pump trainers), including adjusting insulin doses and prescribing insulin pump rates/settings. 

If a referred patient does not have an authorized prescriber, there are three options:

1. An Endocrinologist will be assigned who will meet with the patient (this can be done virtually) to ensure they are appropriate for pump therapy, discuss pump selection, review glucose data to help direct the team, and supervise the process of pump initiation (this is the preferential approach),
2. The referring physician can apply to MAIPP to become an authorized prescriber if they feel they have the experience and competencies to do so, or
3. In rarer circumstances, an MAIPP-authorized physician can work with the referring physician to mentor them through the process without meeting with the patient directly.

Through education and exposure, MAIPP is committed to increasing the knowledge of insulin pump therapy and the competencies of providers throughout Manitoba. Ultimately, MAIPP wants to ensure the safety and support of those living with T1D who choose insulin pump therapy.

Physicians are strongly encouraged to draw on the resources and support available to prescribers and patients via consultation with the MAIPP. The program is growing, offering endocrinologist, nursing, dietician, and social work services.

Prior to providing an adult patient with a provincially funded pump, prescribers can review the Shared Health Prescribing Guideline for Insulin Pump Therapy for Adult Patients with Type 1 Diabetes. This clinical guideline recommends that the following clinical criteria be met:

• No more than one episode of unavoidable Diabetic Ketoacidosis (DKA) in the previous twelve months.
• Appropriate assessment and education on the following requirements for patients seeking initial and ongoing use of insulin pump therapy. Patients should:
  • Demonstrate reasonable understanding of pump technology and appropriate expectations of pump therapy,
  • Display evidence of proficiency in carbohydrate counting,
  • Provide evidence of glucose monitoring at least four times per day or appropriate use of a continuous or advanced glucose monitor,
  • Be aware of guidelines for sick day management and DKA prevention, including ketone testing and maintaining supplies for ketone testing, and
  • Commit to a program of regular clinical follow-up with a health care provider.

Adults who do not meet these clinical criteria, but who are still felt to be clinically appropriate for insulin pump therapy, may also be referred to obtain a second opinion to confirm the appropriateness of this therapy.

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Talia Carter & Dr Marina Reinecke

CPSM Prescribing Practices Program

 and

Dr Pamela Katz, MD, FRCPC

Assistant Professor of Medicine, University of Manitoba

Department of Medicine, Section of Endocrinology