What is the strategy to transition off an insulin pump (Insulin Pump) to alternative insulin therapies?

Strategy for Transitioning Off an Insulin Pump

The most effective strategy for transitioning off an insulin pump involves converting to multiple daily injections (MDI) by calculating the total daily basal insulin dose from the pump and replacing it with long-acting insulin in divided doses, while maintaining the same insulin-to-carbohydrate ratios for mealtime boluses. 1, 2

Initial Assessment and Planning

• Before discontinuing pump therapy, assess the patient's reason for transition, which may include issues with wearability (57%), disliking the pump or feeling anxious (44%), or problems with glycemic control (30%) 3
• Discuss alternative insulin delivery methods, focusing on multiple daily injections as the primary alternative to pump therapy 1
• Ensure the patient has all necessary supplies for MDI therapy before disconnecting the pump 2

Transition Process

Step 1: Calculate Total Daily Insulin Requirements

• Access the pump menu to determine the 24-hour total basal dose (TBD) of insulin 1, 2
• Note the patient's current insulin-to-carbohydrate ratios and correction factors from the pump settings 2

Step 2: Convert to Long-Acting Insulin

• Replace the 24-hour basal dose with an equivalent subcutaneous injection of long-acting insulin (glargine or detemir) in 2 divided doses 12 hours apart 1, 2
• For example, if the total daily basal dose is 22 units, transition to 11 units of glargine or detemir every 12 hours 1
• Administer the first injection of long-acting insulin while the pump is still active 1

Step 3: Discontinue the Pump

• Discontinue the insulin pump 2 hours after the first injection of basal insulin to ensure adequate insulin coverage 1, 2
• This overlap period prevents gaps in insulin coverage that could lead to hyperglycemia 2

Step 4: Implement Bolus Insulin Strategy

• Continue using the same insulin-to-carbohydrate ratio and correction factor for mealtime and correction boluses with rapid-acting insulin 1
• Use the same rapid-acting insulin that was in the pump (e.g., lispro, aspart) for bolus doses 4

Monitoring and Follow-up

• Check blood glucose 2 hours after transitioning and do not go to bed until blood glucose is in target range 1
• Increase blood glucose monitoring frequency during the first 48-72 hours after transition 1
• Monitor for signs of hyperglycemia (blood glucose >14 mmol/L or >250 mg/dL) and check for ketones if hyperglycemia occurs 1
• Contact healthcare provider if vomiting occurs or if persistent hyperglycemia with ketones is present 1

Special Considerations

• For patients with type 1 diabetes, the transition requires particularly careful monitoring due to absolute insulin deficiency 1
• For patients with type 2 diabetes, the transition may be more flexible as some endogenous insulin production may still be present 1
• Consider temporary use of intravenous insulin if transitioning during acute illness or hospitalization 1

Potential Challenges and Solutions

• Risk of diabetic ketoacidosis (DKA) during transition: Ensure no gaps in insulin coverage by overlapping pump and injection therapies 2
• Risk of hypoglycemia: Start with 80-90% of the calculated basal dose if concerned about hypoglycemia risk 2
• Difficulty with injection technique: Provide education on proper injection technique, including site rotation and needle selection 1
• Psychological adjustment: Acknowledge the emotional aspects of changing therapy and provide appropriate support 3

When to Seek Medical Help

• Blood glucose consistently >14 mmol/L (>250 mg/dL) despite correction boluses 1
• Presence of ketones in blood or urine 1
• Symptoms of DKA (nausea, vomiting, abdominal pain, fruity breath) 2
• Severe or recurrent hypoglycemia 2

This structured approach ensures a safe transition from insulin pump therapy to multiple daily injections while maintaining optimal glycemic control and minimizing risks of complications.