Insulin Pump Therapy
(A practical tool for treating people with Type I and Insulin-requiring Type II diabetes)
by Steven V. Edelman, MD.
Insulin pump therapy (CSII or Continuous Subcutaneous Insulin Infusion) is not for everybody. However, many people with Type 1 and Type 2 diabetes could improve their glucose control with an insulin pump, while enjoying a much more flexible lifestyle. Many physicians are ignorant about insulin pumps and as a result they never think to offer them to their patients. Other care givers are reluctant to prescribe insulin pumps because they do not want to create more work and 'hassles' for themselves.
The truth of the matter is that the proper use of insulin pumps allows for less work and less hassles for the care giver in the long term. There are over 18,000 people with Type 1 and Type 2 diabetes in the United States using insulin pumps. This number has grown quite dramatically since the results of the Diabetes Control and Complications trials were reported in 1993. There have been many publications documenting the benefits of insulin pump therapy since it was popularized in the early 1980's (Table 1).
From a patient's point of view insulin pump therapy has proven to be beneficial in many aspects including a much more flexible life style while simultaneously enjoying improved glucose control. Insulin pump therapy allows for increased flexibility in meal timing and amounts, increased flexibility in the time and intensity of exercise, improved glucose control while traveling across time zones or with variable working schedules, and quality of life in terms of self-reliance and control.
Because pumps use only regular insulin, there is no peaking of injected intermediate and long acting insulins, which do not provide a constant basal rate due to variable absorption and pharmacokinetics. Variable insulin absorption and pharmacokinetics are probably responsible for up to 50-60% of the day to day fluctuation in blood glucose values in individuals using insulin therapy. Insulin pump therapy allows for more regular insulin absorption and pharmacokinetic profile, resulting in reproducibility in insulin availability and reduced fluctuations in glycemic control. In addition, individuals who are extremely insulin sensitive (total daily dose less than 20 units per day), find pump therapy very beneficial and convenient since they can deliver insulin in very low doses with precision that is not possible with normal injection methods.
INSULIN PUMP THERAPY IN INSULIN REQUIRING PATIENTS WITH TYPE 2 DIABETES
Insulin pump therapy has been traditionally used mainly in people with Type 1 diabetes. However, insulin pump therapy is extremely valuable in patients with insulin requiring Type 2 diabetes who have not achieved glycemic control with subcutaneous injections and/or who are seeking for a more flexible lifestyle. All of the benefits that are enjoyed by patients with Type 1 diabetes, also apply to people with Type 2 diabetes. Many experts believe that because of the more physiologic delivery of insulin, glucose control is achieved with less insulin than was needed with the subcutaneous insulin regimen. This may be due to a reduction in glucose toxicity and improvement of insulin resistance and (-Cell secretory function as a result of improved glycemic control with pump therapy. Weight gain is less of an issue because the patient is using generally less insulin than he/she was prior to insulin pump therapy. In addition, with the reduction of hypoglycemic events there is less overeating to compensate for excessive insulin. Lastly there is no doubt that there is less strain placed on the pancreatic (-cells of these patients with Type 2 diabetes and this definitely helps with overall glycemic control, since a functioning (-cell can also autoregulate against hyper- and hypoglycemia as seen in non-diabetic individuals.
Many older patients with the diagnosis of "insulin requiring Type 2 diabetes" have true late onset Type 1 diabetes. It has been documented in the literature where large groups of patients with insulin requiring Type 2 diabetes mellitus were tested for anti-GAD antibodies (glutamic acid decarboxylase) with an approximate 5-8% positivity rate. These individuals are thinner at the time of diagnosis and generally do not respond well to oral agents and require insulin, although they do not present in severe diabetic ketoacidosis. In general, if a patient with insulin requiring Type 2 diabetes can not achieve glycemic control with an intensive insulin injection regimen, then insulin pump therapy should be considered.
IS YOUR PATIENT A CANDIDATE FOR AN INSULIN PUMP?
In general, any patient taking insulin with poor glycemic control and/or who is requesting a more flexible lifestyle should be considered for insulin pump therapy. Obviously, the patient has to be reliable and be able to perform frequent home glucose monitoring and have a fundamental understanding of diabetes and the importance of good control. The patient does not have to be a rocket scientist and there is no real age limit as patients who are between the ages of 8 and 80 can do well on pump therapy. It is also important that the patient can effectively understand, operate and maintain the insulin pump and related catheter care. In summary, a good candidate for an insulin pump is someone who is interested in his/her diabetes and is reliable and compliant. If a patient comes to you requesting an insulin pump, he/she is probably a good candidate based on that fact alone.
One of the techniques I use to determine if a patient is a good candidate for an insulin pump, is that I put the individual on an intensive insulin regimen first. I usually prescribe human Ultra Lente with Humalog at breakfast and dinner, with an extra injection of Humalog at lunch and at other times for incidental hyperglycemia. This regimen requires at least four times a day home glucose monitoring and prepares that person for an easy conversion to an insulin pump if indicated. If the patient can perform this regimen and perform frequent home glucose monitoring reliably, then he/she will do well with insulin pump therapy.
DISADVANTAGES OF INSULIN PUMP THERAPY
In older text books hypoglycemic unawareness is listed as a contraindication to insulin pump therapy because any therapeutic regimen that improves glycemic control, increases the chances for hypoglycemia. Insulin pump therapy has been proven to reduce wide fluctuations in blood glucose values, including severe hypoglycemia. It is important to set the patient's goals at a higher range to avoid severe hypoglycemia. For example, the goals of glycemic control for an individual with hypoglycemic unawareness should be between the ranges of 120 and 180 mg/dl instead of the usual 70-160mg/dl range in individuals without hypoglycemic unawareness.
In individuals who have frequent staphylococcosis skin infections, insulin pump therapy may be problematic. In my experience, patients with poor glycemic control commonly get frequent skin infections and having a catheter or needle in the subcutaneous tissue over a long period of time increases the chance of having an infection. However, with good glycemic control, many patients with a history of having frequent skin infections no longer have this problem
Another potential disadvantage of pump therapy is the risk of sudden extreme hyperglycemia and/or diabetic ketoacidosis. This is especially true if the patient is using Humalog or Lispro in the pump. Since only regular or fast acting insulin is used, and if there is a prolonged interruption of insulin delivery, one can quickly develop extreme hyperglycemia and ketoacidosis. This is easily counteracted by always carrying an extra bottle of regular or Humalog insulin, as well as being knowledgeable about sick day rules.
Financial concerns are always an issue as the cost of insulin pump therapy with the accompanying supplies may be prohibited if your patient does not have good insurance coverage. The pump itself costs 3-4 thousand dollars and the supplies which include insulin infusion lines, syringes, tape and batteries can run an additional 40-50 dollars a month. Most insurance companies will reimburse at least 80% with appropriately applied pressure by you and your patient. Representatives from the two insulin pump companies also have special staff to help you deal with the usual beaurecratical process.
Many patients who travel frequently will have hassles at the airport when they go through the airport security station. Sometimes, but not always, the insulin pump sets off the metal detector alarm and your patient will have to explain that he or she is on an insulin pump. Lastly, some individuals get tired of having something 'connected to the body' all of the time. When this occurs, I recommend a pump vacation, where the patients goes back to multiple daily injections for a few days to weeks. The disadvantages of insulin pump therapy are listed in Table 3.
There are also many misconceptions about insulin pump therapy that you and your patients need to know (Table 4). Home glucose monitoring is still important as ever with insulin pump therapy. When insulin pump therapy is initiated more glucose monitoring is required although later on, when the patient is well adjusted, the frequency of home glucose monitoring will be dependent on the variability of the patients day to day activities. Many patients think that insulin pump therapy will allow them to eat anything they want at anytime. It is important to realize that while meal times and amounts can be quite flexible with insulin pump therapy, the patient must maintain some degree of dietary discretion in order to maintain or improve glycemic control. In addition, unwanted weight gain occurs in some individuals who start to over-liberalize their diets despite good glycemic control. As mentioned above, insulin pump therapy is not contraindicated for people with hypoglycemic unawareness and insulin pumps are not only for individuals with Type 1 diabetes.
A great way to help your patient decide if he/she would be an insulin pump candidate is to talk to people with personal experience. Have your patient check with the local American Diabetes Association or Juvenile Diabetes Foundation in your area to find a support group for people who use insulin pumps. It is the individuals in these groups who will tell your patient the nitty gritty of living with a pump on a day to day basis. In addition, both insulin pump companies have information that they will send to your patient including video tapes and manuals. There are 2 insulin pump companies with excellent products (MiniMed Technologies; 1-800-933-3322 and Disetronic Medical Systems; 1-800-280-7801).
WHAT IS AN INSULIN PUMP AND HOW DOES IT WORK?
The pancreas of a non-diabetic individual secretes small amounts of insulin 24 hours a day (basal rate), even if no food is ingested. Insulin is needed for normal metabolic function and the prevention of diabetic ketoacidosis. The pancreas also normally secretes larger amounts of insulin (bolus rates) when a person ingests a meal to prevent postprandial hyperglycemia. The insulin pump was designed to mimic, as closely as possible, a normal functioning pancreas with basal and bolus rates that can be adjusted for individual needs based on prior experience and home glucose monitoring results.
Insulin pumps are now about the same size as a deck of cards or a beeper (Figure 1). They weigh approximately 4 ounces and can be put in a pocket, on a belt, in a specially designed bra, inside a sock or panty hose, and many other ingenious areas that patients have discovered. You can make an analogy between an insulin pump and an automatic, computerized and mechanical insulin syringe that delivers insulin in a more physiologic fashion. Insulin pumps have a lever that mechanically pushes down a plunger of a large insulin syringe (3.0 ml or 300 units of insulin) automatically 24 hours a day (basal rate), and on demand before meals, (bolus rate). The insulin then travels through a long infusion tube from the insulin syringe, that is housed in the insulin pump, to the subcutaneous tissue via an implanted bent needle or a soft flexible catheter. The infusion lines now have a quick release mechanism, and can be temporarily disconnected from the insertion site. (Figure 2). These quick release catheters make showering, swimming, dressing and other activities much more convenient.
Only regular or fast acting insulin is used in the insulin pumps. The basal rate of the insulin pump replaces the intermediate and longer acting insulins such as NPH, Lente or Ultra Lente. The boluses given before each meal are basically the same as with normal insulin injections of regular Humalog. Unfortunately, current insulin pumps do not have glucose sensors although this technology is being advanced at a very rapid pace and may be available in the near future. The majority of pump wearers insert the catheter or bent needle in the abdominal area, although the upper outer quadrant of the buttocks, upper thighs and triceps fat pad of the arms can be used in addition (Figure 3). It is recommended that the syringe and the infusion set be filled and changed every three days. However, many patients use their infusion sets much longer (up to six days) before changing. Prolonged use of the infusion set at a single site increases the likelihood of irritation or superficial abscess formation that may require antibiotic therapy and/or incision and drainage in the office setting. This scenario is very infrequent and most irritated sites improve on their own without the need for antibiotics or other interventions. Insulin pumps have disposable batteries which last approximately eight weeks. Both types of insulin pumps have built in alarms to prevent inadvertent insulin delivery or to warn the patient if the insulin pump is empty or if the infusion set becomes clogged or dysfunctional.
INITIATING INSULIN PUMP THERAPY
In the ideal setting, successful initiation of insulin pump therapy should be orchestrated by an educated and motivated health care team including a physician, diabetes educator, registered dietitian and a pump counselor with access to an inpatient ward. However, outpatient initiation of insulin pump therapy is a more realistic setting for integrating pump routines into an individual's lifestyle and is a necessity because of third party reimbursement plans. Before initiating insulin pump therapy, it is important to review several topics with the patient (Table 5). Both insulin companies have very knowledgeable professionals that are available to help educate your patients on these important topics before, during and after initiation of insulin pump therapy.
Initiating insulin pump therapy as an outpatient is feasible and only requires frequent contact with the patient for 2-3 days. After the patient has been educated on the workings of the insulin pump and infusion lines, bolus and basal rates are determined and set. The patient is encouraged to follow his/her routine daily schedule with frequent home glucose monitoring. Blood glucose values should be obtained before and 1-2 hours after each meal, at bedtime and at 3 AM. These values will help you adjust the pre-meal bolus rates as well as the continuos basal rates during a 24-hour period and assess if the patient needs any secondary basal rates to counteract the Dawn phenomenon for example.
The initial bolus and basal rates can be based on the patient's prior insulin regimen and/or by the 24-hour insulin requirements. As mentioned earlier in the chapter, I put most of my patients on an intensive insulin regimen using human Ultra Lente pre-breakfast and pre-dinner with Humalog or regular insulin before each meal. In this manner I simply take the total Ultra Lente dose and divide it by 24 hours to calculate the basal rate. If the patient had very good glucose control on the prior intensive insulin regimen with Ultra Lente and regular, I reduce the basal rate by 20% since many individuals need less insulin when initiating pump therapy. For the pre-meal boluses, I recommend the same Humalog or regular insulin doses.
The basal rate can also be calculated by taking 50% of the total combined insulin requirements of the patient and dividing it by 24 hours. Once again I usually reduce this rate by 20% if the patient's glucose control was fairly good prior to initiating insulin pump therapy. For example, if a patient's total daily combined insulin dose is 50 units and the degree of control is quite poor I would simply calculate the basal insulin dose as 25 units divided by 24 hours equalling 1 unit per hour.
Calculation of the basal rate can also be estimated based on the patient's body weight. A conservative starting dose for the basal rate can be calculated, by using 0.22 units per kilogram body weight per day. For example, if a patient weighs 80 kilograms then the basal rate should be 0.7 units per hour (80 kilograms X .022 units ( by 24 hours). If there is discrepancy in the estimated basal rate using these different techniques, the lower rate should be chosen for initiation of insulin pump therapy. It is also important to discontinue the patient's intermediate or long acting insulin at least 12-24 hours before initiating pump therapy.
VERIFYING THE BASAL AND BOLUS RATES
To verify the overnight basal rate, the patient should try to avoid eating food after dinner and test the glucose value 2 hours post dinner, at bedtime, 3 AM and first thing in the morning. These values are very important to determine if the patient needs an increased basal rate in the early morning hours to counteract the Dawn phenomenon (AM resistance to insulin due to circulating growth hormone levels). In my experience, many patients will experience a rise in blood glucose values between 3 and 7 in the morning requiring a .1-.4 unit per hour increase during that time period. Occasionally a patient may experience a decrease in basal insulin requirements between the hours of 12 midnight and 3 AM. The majority of pump users will achieve excellent glycemic control with three or less basal rates per day.
Evaluating the daytime and evening basal rates can be determined by having the patient fast from the morning until dinnertime. If this is inconvenient then I would suggest having the patient eat a very early breakfast, to skip lunch and monitor the blood sugars every 2-3 hours up until dinner time. An adequate basal rate will allow for ideal glucose control (between 70 and 110 mg/dl) while in the fasting state during the normal daily activities. The pre-meal bolus rates of insulin have usually been pre-determined prior to insulin pump therapy based on the patient's insulin regimen. The total daily dose of regular or Humalog insulin should be approximately 50% of the total daily insulin requirements. Some patients like to use the old dietary exchange system and others count carbohydrates and base their pre-meal regular dose on the total grams of carbohydrates. Many patients have been diabetic for several years and have a very good sense of how much insulin they need for any particular meal based on years of prior experience. In general the pre-meal insulin dose should be based on prior experience, the pre-meal glucose value and any anticipated exercise after the ingestion of the meal.
When suggesting supplemental regular or Humalog insulin to counteract an elevated blood sugar, one can use '1500' rule. The 1500 rule or sensitivity factor gives an estimation of how much the patient's blood sugar will drop when given 1 unit of regular or Humalog insulin. One simply takes the patient's total daily insulin requirements and divides that number into 1500. For example, if a patient uses 50 units of insulin per day, one unit of Humalog or regular insulin will lower the blood sugar by approximately 30 mg/dl (1500 divided by 50). This particular patient would take an additional 1 unit extra of regular or Humalog insulin for every 30mg/dl above the goal glucose value, (ie.) 120mg/ld.
Once the patient initiates pump therapy he/she should make contact with the caregiver at least once every 24 hour period in order to go over the glucose values and to have answered any questions or concerns that have arisen. The glucose values could be easily forwarded to the caregiver by facsimile or e-mail prior to phone. In most cases after 2-3 days the bolus and basal rates are fairly close to the ultimate final values and the patient can be seen in approximately 2-4 weeks.
SPECIAL PRECAUTIONS AND EVERYDAY MANAGEMENT
One of the most important precautions for people utilizing insulin pump therapy is unexplained severe hyperglycemia and sick day rules. Since there is no intermediate or long acting insulin in the patient's circulation, a disruption in regular or Humalog insulin delivery can result in a fairly rapid rise in glucose concentration and subsequent development of diabetic ketoacidosis. The patient should be well trained in trouble shooting and should always have a bottle of Humalog or regular insulin with a syringe or insulin pen. In general, I highly suggest using Humalog in the insulin pump although it is not FDA approved at the current time. The benefits of Humalog or Lispro insulin are an improved postprandial glucose value and a decreased incidence and severity of delayed hypoglycemia (ie.) 3-5 hours after a meal, especially during exercise. The disadvantages of Humalog insulin for pump therapy are that if there is an unexpected discontinuation of insulin delivery (catheter dislodged, blockage or an empty reservoir) the patient will experience a more rapid rise in the glucose value. In addition, temporary pump discontinuation for showers, exercise, etc. can only be for a very short time, no longer than 45 ñ60 minutes.
I do not recommend initiating insulin pump therapy during pregnancy since a novice pump user would be at more risk for diabetic ketoacidosis than someone who is knowledgeable, comfortable and had several months to years of experience with insulin pump therapy.
The new quick release catheters are excellent for showering, bathing and dressing although if this type of catheter is not available, the pump can simply be put into a zip lock bag and held in one hand or placed on a nearby shelf or soap dish during showering or bathing. Placement of the insulin pump during sleeping and sexual intimacy is usually not a problem, with occasional entanglement in body parts. Many patients use the quick release catheters to free themselves from the insulin pump during sexual intimacy or short periods of intensive exercise.
Traveling with an insulin pump is very convenient especially when crossing many time zones and having erratic meal amounts, types and times. The only hassle is going through the airport security with fairly ignorant personnel. Many times the insulin pump will trigger the airport security alarm and I would suggest taking all pens, coins, beepers and any other metal off before going through the security, this will help your patients avoid a hand search or a delayed passage through security.
Many patients enjoy a 'pump' vacation from insulin pump therapy when they are enjoying a water sport weekend or just want to be totally free of any mechanically device connected to their body for a few days or weeks. In this case, I recommend that the patients go back to their previous intensive insulin regimen consisting of an intermediate or long acting insulin twice a day with regular or Humalog insulin before each meal.
CASE PRESENTATION
A 28-year-old man with a 15-year history of Type 1 diabetes mellitus requests an insulin pump because of difficulty controlling his diabetes. For the prior four years, the patient has been on a multiple injection regimen consisting of human Ultra Lente insulin twice a day (8u before breakfast and 12u before dinner) and a regular insulin algorithm pre-prandially (approximately 5-10 units of regular insulin before each meal). He experiences extreme fluctuations in his daily blood glucose measurements, ranging between 40 and 400mg/dl, despite testing his blood glucose levels 4-8 times per day. Over the prior 12 months, he has had 2 severe hypoglycemic reactions that occurred in the late afternoon requiring assistance. The patient follows a fairly regular diet and exercise program, even though he is a traveling salesman and can not always eat and exercise at the same times each day. He is not prone to bacterial skin infections and is very motivated to reduce the extreme highs and lows in his blood glucose levels as well as his gycosolated hemoglobin value (most recent value of 8.5%, normal 4%-6%).
DISCUSSION
Insulin pump therapy has several advantages that would help this particular patient including; (1) a significant reduction in the extreme high and low blood glucose values; (2) a reduction in the glycosylated hemoglobin value; (3) flexibility in lifestyle regarding time and quantity of meal and exercise scheduling; (4) effective control of glucose values during the early morning hours (Dawn phenomenon). This patient has one of the most important qualities to be a pump candidate which are reliability and compliance with treatment regiments and home glucose monitoring. He is knowledgeable on sick day rules and knows how to adjust his dose of regular depending on his pre-meal blood sugar. Since he does have the propensity for hypoglycemia unawareness insulin pump therapy can be especially beneficial. The glycemic goal in patients such as this one with a history of hypoglycemia unawareness should be kept in a slightly higher and safer range to avoid unconscious reactions. The level should not be too high so that microvascular and macrovascular complications can be prevented or delayed. His glucose values should be kept in the mid 100-200mg/dl range instead of the 70-160mg/dl range that should be targeted in patients without hypoglycemic unawareness.
The hourly basal rate can be calculated by taking 50% of the total daily insulin requirements and dividing by 24 hours. In this patient, the basal rate would be initiated at 0.7 units per hour (20 Ultra Lente plus 20 regular) divided by 24 hours. His initial pre-prandial bolus rates will be the same as it was on the multiple injection regimen which were based on his pre- and post prandial home glucose monitoring results. Once this patient is comfortable using insulin pump therapy, I would convert him over to using the fast acting insulin analog Lispro or Humalog.
SUMMARY
Insulin pump therapy is a practical tool for treating people with Type 1 and insulin requiring Type 2 diabetes who have not achieved adequate glycemic control on conventional insulin injection regimens and/or are seeking an improved quality of life. Insulin pump therapy allows for improved glycemic control, thus preventing and delaying the complications of diabetes, in addition to reducing the incidence of extreme hyperglycemia and hypoglycemia. Insulin pump therapy can improve growth and development in poorly controlled adolescents with Type 1 diabetes and reduce glucose toxicity thus reducing insulin resistance and improving (-cell function in people with Type 2 diabetes. From a patient's point of view insulin pump therapy has proven to be beneficial in many aspects including a much more flexible lifestyle while simultaneously enjoying improved glucose control. Insulin pump therapy allows for increased flexibility in meal timing and amounts, increased flexibility in the time and intensity of exercise, and is invaluable for people traveling across time zones or with variable work schedules.
An appropriate insulin pump candidate should be someone who is interested in his/her diabetes and is reliable and compliant. Patients need to continue performing home glucose monitoring and be cautious about over-liberalizing their diet. Initiating insulin pump therapy as an outpatient is easily achieved, especially if the patient has already been put on a multiple daily injection regimen. In general, 50% of the total daily insulin requirements are translated into a 24-hour basal rate and the other 50% used as pre-meal boluses. Many patients need a secondary basal rate to cover the Dawn phenomenon and overall adjustment and acceptance of the insulin pump occurs quite quickly. Once a patient is instructed to adjust his/her diabetes on a day to day basis using home glucose monitoring, the work for the caregiver becomes quite minimal. More physicians and other caregivers need to become knowledgeable about insulin pump therapy so that they can at least offer them to potential candidates.
TABLE 1
PROVEN BENEFITS OF INSULIN PUMP THERAPY.
Improving glycemic control; thus preventing and delaying the complications of diabetes.
Controlling the dawn phenomenon; Early AM resistance to insulin contributing to fasting hyperglycemia.
Reducing the incidence of extreme hyperglycemia and hypoglycemia.
Improving growth and development in poorly controlled adolescents with Type 1 diabetes.
Improving insulin resistance and glucose toxicity in patients with Type 2 diabetes in poor control.
TABLE 2
ADVANTAGES OF INSULIN PUMP THERAPY FOR THE PATIENT.
Flexible lifestyle
Flexibility in meal timing and amounts
Fewer and less severe hypoglycemic reactions
Avoidance of unconsciousness in individuals with hypoglycemic unawareness
Increased flexibility in exercise intensity and times
Improved control while traveling
Improved control with a variable work schedule
Quality of life in terms of self-reliance and control
TABLE 3
DISADVANTAGES OF INSULIN PUMP THERAPY
Risk of sudden extreme hyperglycemia and diabetic ketoacidosis
Skin infections and abscesses
Financial concerns
Hassles at the airport
Always having a bodily attachment
TABLE 4
MISCONCEPTIONS ABOUT INSULIN PUMP THERAPY
Home glucose monitoring is still as important as ever
Insulin pumps are not for 'pigging out'
Not contraindicated for people with hypoglycemic unawareness
Insulin pump therapy is for Type 1 and Type 2 diabetes
TABLE 5
TOPICS TO REVIEW BEFORE INITIATING INSULIN PUMP THERAPY
Target goals for glucose control
Prevention of diabetic ketoacidosis
Prevention of hypoglycemia
Insulin pump and infusion set operation (catheter care)
Guidelines for basal rate and bolus adjustments
Sick day rules
Trouble shooting unexplained hyperglycemia
SUGGESTED READING
Brittle Diabetes, Edited by John C. Pickup. Blackwell Scientific Publications, 1985.
The Insulin Pump Therapy Book; Insights From the Experts, Edited by Linda Fredrickson, MA, RN, CDE. 1995 MiniMed Technologies.
Pumping Insulin; The Art of Using an Insulin Pump, by John Walsh, PA and Ruth Roberts, MA. Published by MiniMed Technologies in 1989.
Pumping Insulin; Everything In a Book for Successful Use of an Insulin Pump (2nd edition), by John Walsh, PA, CDE and Ruth Roberts, MA. Copyright Diabetes Inc. 1994.
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