Need help navigating life with diabetes? You can always Ask D'Mine!

Welcome again to  our weekly Q&A column, hosted by veteran type 1 and diabetes author Wil Dubois. This week, Wil's addressing who can get an insulin, according to the Powers That Be, and why. 

{Got your own questions? Email us at AskDMine@diabetesmine.com }

 

Diane, D-mom from Florida, writes: The doctor said my daughter didn’t “qualify” for an insulin pump according to the standards of the hospital. Can you address that? Why would you need to “qualify” to get one (besides insurance)?

Wil@Ask D’Mine answers: Naturally, insurance—or one hell of a good job—is a major qualifier for an insulin pump. The retail price of most systems is approaching ten grand nowadays, and that’s just the price of admission. The real cost of the pump, if you haven’t choked on the $10K in the first place, is the ongoing supplies, which themselves, out of pocket, can approach a thousand bucks a month.

So having insurance that will help out with the cost is certainly a qualifier. But we both know that’s not what happened here. What the doc was saying was that he or she didn’t feel that your daughter was a good candidate for a pump, and what you’d like to know is what makes a PWD a good, or bad, pump candidate. 

I was pretty sure I knew the answer to that, but I decided to reach out to a few experts to double check. I chatted with the Barbara Davis Center’s Dr. Robert Slover; Joslin’s Dr. Michelle Katz; and Dr. Fran Kaufman, who works for both USC and insulin pump maker Medtronic. Naturally, I didn’t have them all with me in the same room at the same time.

Too bad. That would have been fun.

Anyway, I called each of them and asked them who makes a good pump candidate. Actually, I think what I really asked them was: Who makes a bad pump candidate? Not too surprisingly, Dr. Kaufman flat-out said, “Anybody with type 1 diabetes should be considered for pump therapy.” Bear in mind that in addition to being a pediatric endocrinologist, she’s also a pump saleswoman. Well, technically, her title is Chief Medical Officer and Vice President of Global Regulatory, Medical and Clinical Affairs, Diabetes Group at Medtronic, or CMOVPGRMCADGM, for short.

But Kaufman says that “no specific IQ, health literacy, or language skill” is required to run a pump, and that she didn’t feel that there was such a thing as a bad pump candidate. After talking with her for a few minutes, I pictured her standing on a mound of syringes and pens waving a flag that said, “Pumps for all!” I guess if you and your daughter had seen Dr. Kaufman, your girl would be pumping by now.

Meanwhile, Dr. Katz tells me that only about 2/3 of her patients are on pumps. But that’s not because her other 1/3 are poor candidates. It’s just that they aren’t into having a device attached to their bodies—although she feels that there are people who should not be on pumps. Who would that be? Katz says the worst possible candidate is “someone who minimally participates in diabetes management. Someone who doesn’t monitor, doesn’t understand carb counting or corrections—just really doing a minimal amount of diabetes care.” 

Her biggest concern revolves around the risks associated with what’s ironically one of an insulin pump’s greatest features: Insulin pumps do away with basal (long-acting) insulin. Instead, they deliver small drops of fast-acting insulin throughout the day. The idea is that the rate can be programmed to match the body’s needs more closely than is possible with a 24-hour basal insulin, and that’s true -- unless the pump somehow gets disconnected from a PWD who can’t be bothered to check their blood sugar. Then the spector of DKA (diabetic ketoacidosis) becomes very real, very quickly.

Dr. Slover agrees with Katz, saying he worries about minimally engaged patients, as a pump patient is “no longer living with the safety net of basal insulin,” which he feels is a good shield against DKA. Well, OK. I was being overly lyrical with that whole shield thing. He actually said basal is “likely to prevent DKA,” but that poetic “the safety net of basal” was straight from the horse’s mouth.

How engaged is engaged? For pumpers, Slover feels the lowest bar is testing four times a day, although more often would be better. But he figures that if a pumper tests before each meal and at bedtime they’ll do OK.

But Slover also says that this may be changing soon. He’s elbow-deep in clinical trials of the latest and greatest diabetes gadgets coming down the pipeline and he says, “the day may come when testing is not as important” as it is now. In fact, he says new technology may change who is a good pump candidate. As we approach the Artificial Pancreas, the PWD who is the worst pump candidate in the world today may well be the very person you’d want most to put on a future pump, as it will do for the patient what the patient won’t do for his or herself. But Slover feels that day is still 4-5 years away.

Of course, all three docs agree that there’s still the ultimate poor candidate: The person who simply doesn’t want a pump. Even pump-advocate Kaufman says she’d “never force anybody” to get one. Katz, with one-third of her patients passing on pumps says, it’s “possible to have really great control” either with or without a pump; and Slover says he excludes “kids who absolutely don’t want to do it,” regardless of what the parent wants. Slover adds, “We don’t respond to parental demands.”

So I turn it back to you, Diane. First: Who wants the pump? Is it your daughter, or is it you? Regardless of how you feel, it’s her diabetes and her body. That makes it her choice. Second: OK, let’s say she really wants a pump. How engaged is she? Does she work hard at her diabetes? Or is she a total slacker?

If she’s not going to put in the effort, then really, today’s pumps still aren’t safe enough. Even the most automatic of them, Medtronic’s 670G, requires fingerstick tests to keep working. If she’s too disengaged for fingersticks, then the pump is more dangerous for her than shots.

On the other hand, if she wants it, if she’s willing to work at it, and if she understands that today’s pumps aren’t hands-free, thought-free devices, then both the experts and I agree: She qualifies.

You just need to find a doc who’s qualified to see that.

 

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.