How do you initiate and set up insulin pump therapy in a 16-year-old patient with type 1 diabetes?

Initiating Insulin Pump Therapy in a 16-Year-Old with Type 1 Diabetes

Insulin pump therapy should be offered immediately to this adolescent with type 1 diabetes, as it can be safely started at diagnosis and provides superior glycemic control with reduced hypoglycemia risk compared to multiple daily injections. 1

Patient Readiness Assessment

Before initiating pump therapy, assess the following factors:

• Cognitive ability to understand pump operation and troubleshoot basic problems 1
• Manual dexterity to operate the device and change infusion sets 1
• Willingness of both the adolescent and family to engage with the technology 1
• Financial coverage and insurance approval for the device 1
• Psychosocial factors including anxiety or depression that may affect adherence 1

Note: There is no requirement for a trial period on multiple daily injections before starting pump therapy—pumps can be initiated at diagnosis. 1

Initial Pump Settings

Total Daily Dose Calculation

• Start with 0.5-1.0 units/kg/day as the total daily insulin dose 2, 3
• Adolescents typically require doses toward the higher end (closer to 1.0 units/kg/day) due to pubertal insulin resistance 2
• Split approximately 50% as basal insulin and 50% as bolus insulin 1, 2

Basal Rate Programming

• Divide the total basal dose by 24 hours to establish the initial hourly basal rate 1
• Program multiple basal rates to account for dawn phenomenon (typically higher rates from 4-8 AM) and nocturnal insulin sensitivity 1
• Adjust basal rates in 0.05-0.1 unit/hour increments based on fasting glucose patterns 1

Bolus Settings

• Use rapid-acting insulin analogs (aspart/Novolog, lispro/Humalog, or glulisine/Apidra) exclusively in the pump 2, 4
• Calculate insulin-to-carbohydrate ratio (ICR) using the "500 rule": divide 500 by total daily dose 1
• Calculate correction factor using the "1800 rule": divide 1800 by total daily dose 1
• Set active insulin time (duration of insulin action) to 3-4 hours for rapid-acting analogs 1

Essential Patient and Family Education

Core Competencies Required

• Carbohydrate counting as the foundation for bolus dosing 1, 4
• Matching prandial insulin to carbohydrate intake, premeal blood glucose, and anticipated activity 1
• Infusion set changes every 2-3 days to prevent site infections and lipohypertrophy 1
• Site rotation across abdomen, thighs, buttocks, and upper arms 1
• Recognition and management of pump malfunctions including occlusions and disconnections 1

Critical Safety Education

• DKA risk with pump failure: Unlike long-acting insulin that provides basal coverage for 24+ hours, pumps use only rapid-acting insulin, so any interruption in delivery can lead to ketosis within 4-6 hours 1
• Always have backup insulin available: Keep rapid-acting insulin pens and long-acting insulin for emergencies 1
• Check blood glucose or CGM frequently during the first weeks to identify patterns and adjust settings 1
• Glucagon prescription and training for severe hypoglycemia management 2, 4

Technology Integration

Continuous Glucose Monitoring

Real-time CGM should be offered at pump initiation or as soon as possible to optimize outcomes 1

• CGM integration with pumps improves glycemic control and reduces hypoglycemia 1
• Sensor-augmented pumps with low-glucose suspend features significantly reduce nocturnal hypoglycemia 1

Automated Insulin Delivery Systems

Automated insulin delivery (AID) systems should be offered as first-line therapy if available and covered by insurance 1

• AID systems (hybrid closed-loop) are superior to standard pump therapy for achieving time in range and reducing hypoglycemia 1
• These systems automatically adjust basal insulin delivery based on CGM readings 1

Glycemic Targets for Adolescents

• A1C goal: <7.0% for most adolescents, though <7.5% is acceptable if hypoglycemia risk is high 1
• Time in range (70-180 mg/dL): >70% of the time 1
• Time below range (<70 mg/dL): <4% and (<54 mg/dL: <1%) 1
• Time above range (>180 mg/dL): <25% 1

School Accommodation

The student must be supported at school in using all diabetes technology including the insulin pump, CGM, and any connected devices as prescribed 1

• Provide a 504 Plan or Individualized Healthcare Plan documenting pump use permissions 1
• Allow pump bolusing during class without requiring nurse visits for routine dosing 1
• Ensure backup supplies are available at school 1

Follow-Up Schedule

• Initial follow-up within 1-2 weeks after pump start to review downloaded data and adjust settings 1
• Subsequent visits every 3 months with A1C measurement 2, 3
• Download pump and CGM data at each visit to assess basal rates, bolus patterns, and glycemic trends 1
• Reassess insulin regimen every 3-6 months and adjust for growth, puberty, and activity changes 3, 4

Common Pitfalls to Avoid

• Do not use NPH or regular human insulin in pumps—only rapid-acting analogs are appropriate 2, 5
• Do not delay pump initiation waiting for "better control" on injections—pumps can be started at diagnosis 1, 6
• Do not neglect site rotation—lipohypertrophy and lipoatrophy impair insulin absorption 1
• Do not assume the pump eliminates the need for frequent monitoring—blood glucose or CGM checks remain essential 1
• Do not forget to address psychosocial factors—anxiety, depression, and diabetes-specific family conflict significantly impact pump success 1

Advantages of Early Pump Initiation

Evidence demonstrates that starting pump therapy within the first 6 months after diagnosis compared to delaying 2-3 years results in:

• Lower A1C values (7.9% vs 8.0%) 6
• Reduced rates of severe hypoglycemia (56% reduction in hypoglycemic coma) 6
• Fewer diabetes-related hospitalizations 6
• Better cardiovascular risk profile including lower systolic blood pressure and higher HDL cholesterol 6
• Improved quality of life and treatment satisfaction 1