Doctors Aren’t Completely Pumped by Insulin Pumps

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‘You can be stupid and be OK on a pump, but it’s better if you’re smart.’

By Joseph Alexiou

This past July, the New England Journal of Medicine released a study showing that people with Type 1 —the metabolic disease with high levels of blood sugar caused by the body’s inability to produce insulin—were able to more effectively reduce their levels of blood sugar using insulin pumps than the traditional self-injection method.

According to the report, authored by Richard M. Bergdenstal, William V. Tamborlane, Andrew Ahmann and others, the level of glycated hemoglobin—the scientific name of the blood sugar test often called the A1C by most diabetics and endocrinologists—in
485 patients aged 7 to 70 was reduced on average from 8.3 percent to 7.5, a much more acceptable level. Twenty-seven percent of pump-therapy patients were able to reduce their A1C to under 7 percent, which is essentially the Holy Grail of acceptable sugar levels for Type 1 patients. Only 10 percent of self-injecting patients could achieve this.

So why is it, with 700,000 New Yorkers affected by diabetes, we don’t hear more about the use of insulin pumps versus traditional injection methods? Are the pumps not as effective as studies claim, or are we only now starting to benefit from the efficacy of these marvels of modern medical technology? “The technology, in general for patients with diabetes, has improved dramatically in the last 10 years,” said Dr. Joel Zonszein, a director of the Clinical Diabetes Center at the Albert Einstein College of Medicine—a division of
Montefiore Medical Center in the Bronx. “But I always say that the pump will be only as good as the person who’s using it. Patients think, ‘OK I get a pump, an automatic pilot.’ But really, they are very labor intensive.”

Insulin pumps are small electronic devices made up of a syringe and a motor-driven screwdriver. The patient attaches the pump to a catheter, which he or she has inserted into his or her skin using a needle, allowing a continuous delivery of fast-acting insulin. This plastic tubing must be changed every three days, but the constant stream of insulin allows for patients to easily adjust their level of intake for meal portions, exercise and other factors that longer-term self-injection insulin make more complicated. And the amount of needle sticks, which is usually three to five injections daily by patients who use the traditional method, are much reduced.

While diabetes experts like Dr. Zonszein and Dr. Daniel Lorber, an associate professor at the Weill-Cornell Medical and an instructor at the New York Hospital in Flushing, Queens, agree that there are advantages to using the insulin pumps, “There’s no such thing
as treatment without negatives,” said Dr. Lorber in a recent phone interview. “Pumps take work, they require logic and brain power—you can be stupid and be OK on a pump, but it’s better if you’re smart.”

According to Dr. Lorber, using the pump also requires patient training, which has more of a learning curve and can take at least a full day of training from a practice educator in the most sophisticated of diabetes medical practices. Beyond the training, there are two serious negatives for pump use: the risk of infection from improperly sanitized catheters; and mechanical pump failure—a patient who stops receiving the constant stream of fast-acting insulin can quickly develop complications of diabetic ketoacidosis, an affliction of diabetics with symptoms including falling into a coma.

Other cons of pumps include the cost—an extra $10,000 a year, which is often covered by insurance, but also the emotional and psychological weight of being attached to a machine. The size of pumps has certainly been reduced since they were introduced in the early 1990s, but “there’s an emotional response and resistance on being machine dependent,” said Dr. Lorber, who, in the face of all the negatives, sees them as minimal risks. “If I had Type 1 diabetes I’d be on a pump in a hot minute.”

Dr. Zonszein is more cautious in his view of the pump, and believes that the effectiveness of the treatment is mostly a result of the patient’s efforts, and less the technology. He sees the extra cost, no small number, to be a lot to pay for what he believes is “not such a big increase in efficiency.” Unlike the findings in the study cited above, Dr. Zonszein’s patients—80 percent of whom use a pump—are rarely able to reduce their A1C below 7 percent, regardless of the method they use for insulin delivery.

Ultimately, according to Dr. Zonszein, the best way to treat diabetes is to mimic the deficient human system as best as possible: a mechanical pancreas implanted in the pelvic region, secreting insulin directly into the central venal system. This kind of technology has been under development as long as insulin pumps, but an effective version is years away from completion.

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