Why Insulin Pumps Work Well With Gastroparesis

In a Facebook group for people with gastroparesis, a member with that and Type 1 Diabetes said that he'd been hospitalized a couple of times and that his doctor recommended that he should start using an insulin pump.

Gastroparesis is a complication of Diabetes where the stomach does not digest food properly. Most usually it means that the stomach does not move food along the digestive system as rapidly as a healthy stomach. Rather, for unknown reasons the food often just "sits there." One of the symptoms is excessive fullness (picture Thanksgiving afternoon but you only had a cup of yogurt). Others include pain, cramping, nausea and vomiting. The culprit is believed to be having had high blood glucose levels for an extended period of time, though other causes are being investigated.

On top of the nasty symptoms, gastroparesis makes controlling Diabetes challenging, if not impossible. I pointedly asked my Gastroenterologist what I needed to do to minimize the symptoms of gastroparesis. She said, "Get your A1C down and it will get better and possibly become unnoticeable." I passed that along to my Endocrinologist to get her advice on how to do that. She said that gastroparesis made it difficult, if not even dangerous to try and lower my A1C. Lovely.

For the uninitiated, here is how a person with diabetes normally uses insulin to control blood glucose. Before they consume a meal, they will measure their blood glucose. If it is above their target, they have to figure out how much insulin to inject to get it back to the desire range. Then, they count how many grams of carbohydrates are in the meal. Once it is eaten, those carbs convert to glucose and enter the bloodstream. To counteract that rise in glucose, an individualized formula is used to determine how much insulin will be necessary. They will add those two doses and inject the insulin about the time the meal is served.  Once injected, the insulin "peaks" at around one hour, then the amount in the person's system falls off gradually, disappearing completely after a few hours. This "rate of action" is designed to mimic how a person's blood glucose will rise shortly after a meal and then tail off. If the stomach is functioning properly and the person gets the calculations right, things often work out nicely.

Not so with Gastroparesis. Delayed or impaired stomach emptying screws up this delicate balancing act. Say a person is about to have a meal. They measure their BG, calculate the insulin correction. They count the carbohydrates in their meal, determine how much insulin to take for the meal, then add the two doses. They do the injection and have their meal. But since the food could sit for hours in their stomach, the insulin will take effect when their isn't an increase in the BG. As a result, their BG could drop to dangerously low levels. The person then would have to take some glucose to get it back to a safe level. But after wrestling with that, the food finally starts to digest and the carbs in the meal are converted to glucose and enter the bloodstream. Now the BG rises (in my case as many as 5 or 6 hours after a meal) but there isn't any of the insulin that was injected before the meal left to push the BG back down. Now the BG is too high, and the patient has to decide whether to ride it out or to inject some extra insulin to get the BG to where it ought to be.

That is how it works when using traditional shots. You could divide up the meal bolus and give yourself a couple of small shots over time, but that is unwieldy, somewhat complicated and impractical.

I use a Medtronic 530g Insulin Pump. It has  there are several features that allow me to tailor how much insulin is delivered and when. One option is to use a "square wave bolus." This delivers the insulin at a constant rate over a user selected time period. If I was eating a meal over a long duration (say a working dinner in a restaurant) and didn't need a correction, I'd use this. If a correction was needed, I would use a "dual wave bolus." With this, you get a user selected amount of insulin immediately and the remainder is delivered over time just like the "square wave bolus." You can also add some insulin to come on the front end on top of the correction bolus and the remainder later. After much trial and error, this is what I do. Most of the time it works fairly well, but not always. If a meal is particularly heavy, I might stretch out the length of the bolus from my typical one hour to an hour and a half or even two hours. If it is light and easily digested (like a can of Ensure) then I might decrease the time period, or shift more of the insulin to the beginning of the bolus.

To answer the gentleman's question of whether an insulin pump is the way to go for managing Type 1 Diabetes with gastroparesis, I'd unhesitatingly say that for many people it is. While more costly than shots, and somewhat more complicated, those drawbacks are more than offset by the flexibility it offers in dealing with a challenging and complex set of circumstances. If available to him, I'd enthusiastically encourage him to give it a try. It has made a real difference for me and given the current state of technology in diabetes management, this is the only way to go.

New NC Bill Could Get People With Diabetes Off The Road

If you have diabetes and have an accident, you could lose your drivers license if a bill being introduced in North Carolina becomes law. House Bill 653 would require reporting if a driver with diabetes had a 'diabetic coma' and was involved in an auto accident. It would mandate a temporary, and potentially permanent loss of a drivers license. It does not include similar consequences for other drivers with recognized medical conditions that could hamper safe driving.

For people with diabetes in North Carolina, getting a drivers license is no easy feat.  According to the NC DMV website, "If you suffer from a mental or physical disability that might affect driving safety, a license may not be issued. A disabled person may be issued a restricted license provided the disability does not keep him/her from driving safely" The process for getting a license requires when an applicant has a medical condition that might impact safe operation of a motor vehicle is spelled out in the DMV's "Medical Evalution Brochure." In addition to diabetes, it lists 11 other general and specific conditions that the DMV wants to know about.

If one of those conditions is reported to DMV by a physician, family member, or law enforcement official, the driver can be required to fill out a "Medical Report Form" and have their physician provide their observations. There is then a hearing to decide whether or not that person will be allowed to drive. If they don't like the answer, they can appeal. They can also put in a request to be removed from the program. Like most things DMV, it is amorphous, tedious and annoying.

But the new legislation being introduced makes keeping a license harder, is discriminatory and fatally flawed it its underlying premise. If you have a wreck and somebody figures out you have diabetes, you could be put into that program. While that process is going on (for weeks or months) you cannot drive. The proposed law is also discriminatory since it only applies to people with diabetes and epilepsy - leaving out many other conditions that could make a driver potentially unsafe. Finally, where it pertains to diabetes, it singles out drivers suspected of having an accident caused by "diabetic coma" - an inexact phrase generally referring to extremely high or low blood glucose. In most respects, many symptoms occur long before coma is experienced - most of which would make driving impossible long before an accident could happen.

To fix this bill, several possible things should happen.

• It should be killed in committee. 
• All of the other conditions that are addressed in the North Carolina Drivers Medical Evaluation Program should be included in the interest of fairness, efficacy to the intent of the bill, and to ensure consistency throughout the program. 
• Table the bill and instead create a Legislative Study Commission to ensure that the intended result is achievable, done equitably and protects both individuals with disabilities and the general public. 
• Delete the term 'diabetic coma' and instead place language that is medically justifiable, objectively determined and supports the reality that diabetes effects different people in different way.
• Delete language that arbitrarily suspends driving privileges prior to the completion of the administrative process. Such a suspension should only be allowable if there is clear and convincing evidence provided by a licensed physician that clearly states a driver cannot at any time safely operate a motor vehicle. 
• Allowance should be made for the fact that blood glucose levels may make driving unsafe at one moment and as safe as any other driver in a matter of minutes.
• Require that evaluations for driver fitness be covered by Medicaid.

On a poersonal note: I can assure you from personal experienced that having an automobile accident while in a 'diabetic coma' is next to impossible. I've been in three 'diabetic comas' and it is hard to drive a car when you are unconscious in an Intensive Care Unit.

 

CALL TO ACTION

1. Find your legislator and encourage them to NOT sign on as a co-sponsor of this bill. Doing so would indicate support of legislation that further marginalizes people with diabetes and in a way that will not accomplish the goal of safer roadways that this legislation intends.

2. Reach out to other people with diabetes in NC. Make them aware of this legislation, how it could affect them and encourage them to reach out to their legislator.

3.  Periodically check the bill status. When it is scheduled to come up before a committee, consider going to that meeting to personally express your opposition. That carries a lot of weigh with legislators, and is the easiest way to get a bill either changed or killed outright.

 LEGISLATION DETAILS

Entitled "Report/Car Accident Caused by Seizure or Coma," HB 653 would require that any automobile accident that was caused as the result of a driver suffering from a 'diabetic coma' must be reported. It further requires that the DMV "shall evaluate whether the medical condition affects the driver's ability to safely operate a motor vehicle and SUSPEND THE DRIVERS LICENSE OF THE DRIVER PENDING COMPLETION OF THE EVALUATION." (emphasis added). The proposed legislation goes of to state that, "If the Division determines that the medial condition does not affect the driver's ability to safely operate a motor vehicle, the Division shall restore the drivers license of the driver at no cost to the driver. If the Division determines that the medical condition does affect the driver's ability to safely operate a motor vehicle, the Division shall cancel the drivers license of the driver in accordance with G.S. 20-15(a)(4). Upon cancellation, the driver may appeal the decision of the Division  or seek issuance of a new restricted or unrestricted driver's license, in accordance with the process set forth in G.S. 20-9(g)." Finally, "reports under this section made by law enforcement officers and medical examiners are public records and are open to inspection by the general public at all reasonable times."