沈阳市糖尿教育

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1、 2 Roper-Starch Global Diabetes ReportRoper-Starch, Global Diabetes Report, 2002. 3 Roper-Starch Global Diabetes ReportRoper-Starch, Global Diabetes Report, 2002. 4中国 26 Major Countries in EU 735,000 4 ROW 138 MillionIntensive Therapy45%Pump Therapy7%Multiple Daily Injections38%Conventional55%wType

2、2: 134 millionwType 1: 4 million 2.2 million (1.2 EU) viable market 33. Viable market: EU, WP, SA/LA: Medtronic MiniMed market share 24%4. Roper Starch & IHS EU measured countries: Italy, Germany, France, Netherlands, Spain, UK (Sweden not included)2001 DIABETES PREVALENCE: 154 MILLION WORLDWIDE 1U.

3、S. 16 Million 2Conventional59%Intensive Therapy41%Pump Therapy15%Multiple Daily Injections26%Conventional59%wType 2: 15 million 3.5 - 4 million insulin usingwType 1: 1 million1. International Diabetes Federation (IDF)2. American Diabetes Association (ADA)United States: 1 million20% Other80% Medtroni

4、c MiniMed6全球糖尿病患者的人数预计将从2000年的1.51亿升至2025年3亿，增长率可达到99%。Evolution of Diabetes Management TechnologiesInsulin InjectionsUrine Test StripsGlucose SensorArtificialPancreas1999197819221900s1977Urine Tasting1776BG MetersInsulin Pump Therapy泵的发展历史9First Pump StudyYale CCRC 1979Yale University10持续皮下胰岛素输注法持续

5、皮下胰岛素输注法 ( CSII )Continuous Subcutaneous Insulin Infusion程序化界面11储液器电池12胰岛素泵输注管道系统短针快速分离器13皮下软管埋放位置14 美国选美冠军尼可尔.约翰森15 如何携带胰岛素泵16游泳与洗浴17胰岛素泵特点：胰岛素泵特点：连续微量注射短效胰岛素连续微量注射短效胰岛素18FPolonsky KS et al. N Engl J Med. 1988;318:1231-123906000600Time of day20406080100 BLDNormal Daily Insulin ProfileB=breakfast; L

6、=lunch; D=dinner060008001800120024000600 U/mL19胰岛素泵优势基础率基础率胰腺释放胰腺释放餐前剂量餐前剂量胰岛素泵采用持续微量分泌的胰岛素泵采用持续微量分泌的基础率基础率与与三餐前大剂量三餐前大剂量结合的输注方式模拟结合的输注方式模拟生理性生理性胰岛素分泌。胰岛素分泌。Pharmacokinetic Advantages:CSII vs MDIFUses only Regular insulinMore predictable absorption than with modified insulins (variation 3% vs 52%*)F

7、Uses one injection site for 2 to 3 daysReduces variations in absorption due to site rotationFEliminates most of the subcutaneous insulin depotFProgrammable insulin delivery allows closest match with physiologic needs* Lauritzen: Diabetologia 1983; 24:326-921胰岛素泵使胰岛素精确释放和良好的吸收胰岛素泵使胰岛素精确释放和良好的吸收Mainta

8、in normal or near normal glycemiaAvoid short-term crisisMinimize long-term complications01224HoursGoals of Insulin TherapyNormal PancreasFInsulin is released in response to varying blood glucose levels0.6InsulinTime24F只使用短效胰岛素只使用短效胰岛素与中长效胰岛素相比，其吸收更可预与中长效胰岛素相比，其吸收更可预测测 (变异率仅为变异率仅为 3% )F减少因为改换部位所造成的吸收

9、变异减少因为改换部位所造成的吸收变异F消除胰岛素在皮下的蓄积消除胰岛素在皮下的蓄积F根据生理需要设计胰岛素的输注根据生理需要设计胰岛素的输注* Lauritzen: Diabetologia 1983; 24:326-9F提高糖尿病控制水平提高糖尿病控制水平 HbA1c水平 低血糖的发生F改善生活质量改善生活质量F减少医疗费用支出减少医疗费用支出FIntermediate & Regular InsulinLack of consistency between insulin effect causes large variations in BG levelsFlexibility is a

10、 difficult challengeInjections2 Injections Per Day27Glucose Profile Analysis (72 hrs)0 05050100100150150200200250250300300350350400400Glucose Concentration (mg/dl)Glucose Concentration (mg/dl) 12:0012:00MidnightMidnight 12:0012:00MidnightMidnight 12:0012:00MidnightMidnight8:00AM8:00AM 4:00PM4:00PM8:

11、00AM8:00AM 4:00PM4:00PM8:00AM8:00AMMDIMDICSIICSIICSII vs. MDI28调查人NHbA1c (%)观察时间 (yrs)Bode (96)557.73.1DCCT (95)1246.84.5Wredling (93)407.64.0-5.62930UKPDS: BMJ:321:405-412降低 HbA1c水平的好处HbA1c平均值每下降1%F与糖尿病相关的死亡下降21%F心梗发生率下降14%F微血管并发症减少37%U K P D S结论结论135791113156789101112视网膜病视网膜病变变肾病肾病神经病变神经病变微血管病微血管病

12、变变风险相关性风险相关性HbA1cSkyler: Endo Met Cl N Am 1996糖尿病并发症风险与HbA1c水平的相关性数据来自DCCT Potential ChronicComplications of Elevated HbA1cCONTROL33提高糖尿病控制水平:减少低血糖的发生率13822263936050100150Pre CSII1 yr2 yr3 yr4 yr- 用泵治疗用泵治疗-Bode et al: Diabetes Care 1996; 19:324-7N=553435CSII: Less Severe Hypoglycemia0 01010202030304

13、040505060607070Usual CareUsual CareMDIMDICSII (gen)CSII (gen)CSII (study)CSII (study)White et al., Journal of Pediatric Endocrinology and Metabolism 2000; 13(suppl 4):1220.Severe hypo events in children (2-16 yrs)Severe hypo events in children (2-16 yrs)Rate per 100 pt years36CSII Reduces Hypoglycem

14、iaChantelau, E et al., Diabetologia 1989, 32:421-6.Bode, BW et al., Diabetes Care 1996, 19:324-7.Boland, EA et al., Diabetes Care 1999, 22:1779-84.Chase HP, et al., Pediatrics 2001, 107:351-6.0 02020404060608080100100120120140140Pre-PumpPre-PumpPost-PumpPost-Pumpn=55Mean age 42n=107Mean age 36n=116M

15、ean age 29n=25Mean age 14n=56Mean age 17Events per hundred patient yearsBode Rudolph Chanteleau Boland Chase37减少低血糖发生的好处F降低糖尿病脑病的风险降低糖尿病脑病的风险F降低意外事件和死亡的风险降低意外事件和死亡的风险F提高对低血糖的敏感性提高对低血糖的敏感性38采用泵治疗的患者可以证明采用泵治疗的患者可以证明:F极少的焦虑感和沮丧感极少的焦虑感和沮丧感F更强的家庭凝聚力更强的家庭凝聚力F改善人际关系改善人际关系F显著减少低血糖的不适显著减少低血糖的不适F对于青少年患者，减少了被冠

16、以对于青少年患者，减少了被冠以“糖尿病糖尿病”所带来的困难所带来的困难39泵治疗改善健康状况恶化恶化2%无变化无变化16%改善改善82%Association for Insulin Pump Therapy, Diabetes 1991:40:#1807N=886患者自我评价结果40$108,400$130,700$167,800$207,300泵治疗泵治疗MDI常规疗法常规疗法常规疗法普通人群常规疗法普通人群FHbA1c7%8%9%10%F间接支出间接支出0$21,400$44,900$61,700F直接支出直接支出$108,400$109,300$122,900$145,600Direc

17、tCostsDirectCostsDirectCostsDirectCostsAssumption: Patients follow typical scenario. Dollars are Expected Net Present ValueAssumption: Patients follow typical scenario. Dollars are Expected Net Present ValueSource: Quattro CSII Economic Analysis Model 1999Source: Quattro CSII Economic Analysis Model

18、 1999美国和加拿大美国和加拿大29个医学中心个医学中心对对1441个个1型糖尿病人的近型糖尿病人的近10年前瞻性研究。年前瞻性研究。常规治疗组常规治疗组 730例例强化治疗组强化治疗组 711例例34%长期应用胰岛素泵长期应用胰岛素泵 （ CSII ）其余每日多次胰岛素注射（其余每日多次胰岛素注射（ MDI）DCCT Pump Usageat Conclusion of StudyDCCT: Diabetes Care 1995; 18:361-376Unknown2%Pump42%MDI56%60%How Diabetes Specialists Treat Their Own Type

19、 1 DiabetesAADE Membershipn=229Industry estimates at time of survey (9/98); Graff: Diabetes Educator 2000; 46:460-4676%52%InjectionsPump TherapyColor Key:n=293ADA Membership目前进行泵治疗的比例继续继续97%中止中止3%N = 165平均持续时间平均持续时间= 3.6 years平均中止比例平均中止比例 1%/yrBode, et al.: Diabetes 1998; 47 (Suppl 1): 392.Relative

20、Risk of Progression of Diabetic Complications1DCCT Research Group. N Engl J Med. 1993;329:977986.2DCCT Research Group. Diabetes. 1995;44:968983.3Ohkubo Y, et al. Diabetes Res Clin Pract. 1995;28:103117.4UK Prospective Diabetes Study Group (UKPDS) 33: Lancet. 1998;352:837853.HbA1cRetinopathyNephropat

21、hyNeuropathyMacrovascular DiseaseDCCT1,29% to 7% 63% 54% 60% 41%*Kumamoto39% to 7% 69% 70%UKPDS48% to 7% 1721% 2433% 16%*Not statistically significant in intervention analysis.46The FactsComplicationsBlindnessAlbuminuriaEnd-stage renal disease 24% NeuropathyLower-limb amputation 7% Conventional Ther

22、apy34%46%57%Intensive Therapy20%15%7%31%4%Event Cost$53,659$26,894OBrien JA, et al., Diabetes Care 1998, 21:1122-1128.Cumulative incidence of diabetes related complications Type 1 Aged 70 yr.476,6008,70011,40015,00020,00026,50035,00043,00060,00081,000100,000010,00020,00030,00040,00050,00060,00070,00

23、080,00090,000100,000# of patients9091929394959697989900Nicole Johnson24ys,1-DM5ys.486,6008,70011,40015,00020,00026,50035,00043,00060,00081,000120,000162,000050,000100,000150,00090919293949596979899200020014950Induction of long-term glycemic control in newly diagnosed type 2 diabetic patients by tran

24、sient intensive insulin treatment Hasan Ilkova, MD1997Hebrew University Hadassah Medical Center , Jerusalem , IsraelDiabetes Care 1997;20:1353-1356515253研究设计研究设计治疗治疗: :用胰岛素泵用胰岛素泵CSIICSII治疗两周。治疗两周。 后续治疗后续治疗: :继续进行常规锻炼继续进行常规锻炼 + + 饮食控制，饮食控制，出院后的第出院后的第1 1、2 2、4 4周和每月监测餐前、餐后周和每月监测餐前、餐后2 2小小时血糖，胰岛素水平、时血糖

25、，胰岛素水平、C C肽值。同时，每月检测肽值。同时，每月检测HbA1cHbA1c。54研究设计研究设计评价标准评价标准非常好非常好 FBG 7.8mmol/l FBG 7.8mmol/l 餐后餐后2 2小时血糖小时血糖 10mmol/l 10mmol/l 较好较好 FBG 8.9mmol/l FBG 8.9mmol/l 餐后餐后2 2小时血糖小时血糖 11.1mmol/l7.0% 反复出现低血糖反复出现低血糖 预防预防/延缓慢性并发症发生延缓慢性并发症发生 黎明现象黎明现象 胃轻瘫胃轻瘫 孕前及孕妇孕前及孕妇 生活不规律生活不规律 运动量多的人运动量多的人 64泵治疗基本步骤F选择病人的标准F

26、准备工作F开始带泵F精确调整F预防急性并发症F后续工作65选择病人的标准F依从性F渴望改善血糖的控制情况F渴望过更正常的生活F有家庭成员的支持F期望值实现F视力问题，能够自己操作。Tanenberg: The Insulin Pump Book, MiniMed 1995: 21-3066准备工作F自查血糖自查血糖(SMBG)，坚持记录，坚持记录F收住院（内分泌医生、护士）收住院（内分泌医生、护士）F化验残余胰岛化验残余胰岛细胞功能，指导胰岛素泵治疗细胞功能，指导胰岛素泵治疗F化验肝功能，肾功能。化验肝功能，肾功能。F原来应用中、长效、预混胰岛素者改为四次强原来应用中、长效、预混胰岛素者改为四

27、次强化方案。化方案。67开始带泵F设置泵的参数设置泵的参数F连接泵连接泵F设定血糖控制目标设定血糖控制目标2型糖尿病血糖控制目标 良好良好 一般一般 不良不良血浆葡萄糖血浆葡萄糖mmol/L 空腹：空腹： 4.4 - 6.1 7.0 7.0 非 空 腹 ：非 空 腹 ： 4 . 4 - 8 . 0 10.0 10.0糖化血红蛋白糖化血红蛋白 7.5 亚太地区2型糖尿病治疗指南第三版首先确定血糖控制目标F为每个病人确定个人的血糖控制目标。为每个病人确定个人的血糖控制目标。F成年病人的一般控制目标：成年病人的一般控制目标： 餐前：餐前： 4.4- 6.5mmol/l4.4- 6.5mmol/l 餐

28、后餐后2 2小时：小时： 8-8.5mmol/l5mmol/l 5mmol/l F若反复出现低血糖，适当提高控制目标：若反复出现低血糖，适当提高控制目标： 餐前：餐前： 100-160mg/dl (5.6-8.9mmol/l)100-160mg/dl (5.6-8.9mmol/l)F若怀孕，适当降低目标血糖值：若怀孕，适当降低目标血糖值： 餐后：餐后： 120mg/dl (6.7mmol/l) 120mg/dl (6.7mmol/l)安装胰岛素泵的主要参数F每日胰岛素总量每日胰岛素总量F基础率基础率F三餐前大剂量三餐前大剂量71一日胰岛素总量一日胰岛素总量F根据用泵前的用量计算根据用泵前的用量

29、计算（已经注射胰岛素的病人）（已经注射胰岛素的病人）一日总量一日总量用泵前胰岛素用量用泵前胰岛素用量（707080%80%）F根据体重计算根据体重计算 (未用胰岛素的病人）未用胰岛素的病人）一日总量体重一日总量体重0.440.447250%50%BasalBasalPre-Pump DosePre-Pump DosePump Starting DosePump Starting Dose(70-75% of Pre-Pump Dose)(70-75% of Pre-Pump Dose)50%50%BolusBolus Establishing Starting Basal and Bolus

30、Doses Western ProtocolPre-PumpPre-PumpTotal Daily DoseTotal Daily DosePumpPumpStarting DoseStarting DoseTotalTotalBasal DoseBasal DoseTotalTotalBolusBolusDoseDoseReduce by 25%Reduce by 25%HourlyHourlyBasalBasalRateRateBreakfastBreakfastBolusBolusLunchLunchBolusBolusDinnerDinnerBolusBolus50%50%50%50%

31、DivideDivideDivideDividebyby24 hours24 hours20%20%10%10%20%20% Establishing Starting Basal and Bolus Doses Western Protocol40 Units30 Units15 Units15 Units0.6 u/hr6 Units3 Units6 UnitsPre-PumpPre-PumpTotal Daily DoseTotal Daily DoseTotalTotalBasal DoseBasal DoseTotalTotalBolusBolusDoseDoseHourlyHour

32、lyBasalBasalRateRateBreakfastBreakfastBolusBolusLunchLunchBolusBolusDinnerDinnerBolusBolus30- 40%30- 40%60-70%60-70%DivideDivideDivideDividebyby24 hours24 hours20%20%10%10%20%20% Establishing Starting Basal and Bolus Doses Eastern Protocol75F从单一基础率开始，将基础率总量平均分配到从单一基础率开始，将基础率总量平均分配到2424小时内小时内F根据夜间的血糖

33、监测结果判断是否要增加第二根据夜间的血糖监测结果判断是否要增加第二个基础率。个基础率。F临床一般分三至五段：临床一般分三至五段：0 0：00-400-4：00am00am； 4 4：00am-800am-8：00am00am；8 8：00am-12pm00am-12pm。根据胰岛素总量计算起始基础量起始基础量 日总量日总量 50 50根据体重计算起始基础量体重起始基础量体重 0.22 0.2276基础率的精确调整F检查三餐前、三餐后、睡前、12am和 2-4am的血糖F停用一餐，查禁食时的血糖 例：调整夜间基础率时停用晚餐；调整日间基础率时停用早餐或午餐F以 2-4am和早餐前的血糖为基础，调

34、整夜间基础率 F为避免调整过度，基础率的调整以 0.1 u/hr为幅度77BGYXX (X (胰岛素敏感系数胰岛素敏感系数) ) = 1500/= 1500/每日胰岛素用量每日胰岛素用量胰岛素敏感系数胰岛素敏感系数定义定义：注射：注射1单位胰岛素单位胰岛素25小时小时 BG降低降低mg/dl数值。数值。补充量补充量=BGBG = = 实际血糖实际血糖(mg/dl) Y Y = = 理想血糖理想血糖(mg/dl) X X = = 胰岛素敏感系数胰岛素敏感系数例：带泵后每天胰岛素例：带泵后每天胰岛素50u，餐前测血糖，餐前测血糖160mg/dl，餐前理想，餐前理想血糖血糖100 mg/dl，需要补

35、充胰岛素剂量？，需要补充胰岛素剂量？ BG = 160 Y=100 X=1500/50=30 补充胰岛素剂量补充胰岛素剂量 = （160100）/30 = 2 u78Quick-serterQuick-setSof-serterSof-setSil-serterSilhouetteADVANCED INFUSION SETS79GLUCOSE MONITORING SYSTEMS - IMPLANTABLE Inserted into the central vein leading to the heartFSensor replacement requires minor outpatie

36、nt procedureFRecords glucose every minuteFRegulatory approval requiredLong-Term SensorARTIFICIAL PANCREASi o n s i n d i a b e t e s81 TWO PATHWAYS TO THE ARTIFICIAL PANCREASFDescription Integrates external pump with sensor System displays glucose valuesExternal SystemFDescription Integrates implant

37、able pump with long-term sensorImplantable SystemAutomatically reads glucose levels and administers insulinReferred to as “Closed-Loop” SystemDescription:+MMT 2007B Modified for Sensor Connection (MIP-XS)Abdominal Lead Assembly (ALA)Catheter Tip for Insulin DeliveryCatheter Header with Inlet Port Se

38、nsor Connection to the PumpInlet to PumpSensor tip83 These results are limited to a single subject and are not necessarily indicative of future results, nor can the company provide any assurances that a product will ultimately be commercialized.5010015020025030035040016 Wed17 Thu18 Fri19 Sat20 Sun21

39、 Mon22 Tue23 WedAugust 2000Glucose (mg/dL) LONG TERM IMPLANTABLE SYSTEMAutomatic Glucose Regulationin a Fully Pancreatectomized CanineCLOSED LOOP CONTROLManualControlManualControlAutomatic ControlBeginsControlTerminatedImplantable Closed Loop System“Moon”; The First Implantable Closed Loop System86I

40、nsulin Pump Vs Insulin?87F动物胰岛素动物胰岛素F单组分动物胰岛素单组分动物胰岛素F人胰岛素人胰岛素F胰岛素类似物胰岛素类似物88F1999年年9月获得欧盟批准月获得欧盟批准F2000年年6月获得美国月获得美国FDA批准批准F2002年年8月获得中国月获得中国SDA批准批准F2002年年12月在中国上市月在中国上市新一代速效胰岛素注射液新一代速效胰岛素注射液（中国第一个胰岛素类似物）中国第一个胰岛素类似物）89ProThrglyTyrPhePheGlyArgGluGlyValLeuTyrLeuAlaGluValLeuHisSerGlyCysLeuHisGlnAsnVal

41、PheB1A21B28B30A1AsnTyrAsnGluLeuGlnTyrLeuSerLieSerThrCysGlnGluValLieCysCysCysCysThrLysPro-Asp诺和锐诺和锐90 918小时小时3-5小时小时作用持续时作用持续时间间1-3小时小时40分钟分钟达峰时间达峰时间30分钟分钟10-20分分钟钟起效时间起效时间中性可溶性中性可溶性人胰岛素人胰岛素诺和锐诺和锐92*p 0.05在胰岛素治疗中使用诺和锐或人胰岛素结晶情况的对比在胰岛素治疗中使用诺和锐或人胰岛素结晶情况的对比0.00.20.40.60.81.01.21.41.6泵池泵池导管导管Mean (+SD)结晶情

42、况结晶情况诺和锐诺和锐 n = 19人胰岛素人胰岛素 n = 10*93唯一获得唯一获得FDA批准在胰岛素泵中使批准在胰岛素泵中使用的胰岛素类似物用的胰岛素类似物94Insulin detemir ThrGluLysValPheAsnGluLeuGlnTyrLeuSerCysIleSerCysCysGlnGluValIleGlyTyrCysAsnLysProThrTyrPhePheArgGlyGluGlyCysValLeuTyrLeuAlaValLeuHisSerGlyCysAsnGlnLeuHisB1A21A1B29C14 C14 脂肪酸链脂肪酸链(Myristic acid)(Myrist

43、ic acid)Thr95HSA: HSA: 人血清白蛋白人血清白蛋白扩散扩散吸收吸收受体作用受体作用Lifetime Benefits of EffectiveIntensive Therapy (DCCT)FGain of 15.3 years of complication free living compared to conventional therapyFGain of 5.1 years of life compared to conventional therapyDCCT Study Group, JAMA 1996;276:1409-1415.Hypoglycemia T

44、reatment GuidelinesFIf BG is 70 mg/dl or belowTreat with 15 grams of carbohydrates (glucose tabs)Check BG in 15 minutes, and if not above 70 mg/dl, repeat treatmentGlucagonFCurrent emergency kit readily available and knowledgeable person trained to administer Hyperglycemia Treatment GuidelinesThe Ke

45、y to Preventing DKAFTake a correction bolus via pump, check again in 1 hourFTake correction bolus by syringe and change infusion set, review pump, check BG again in 1 hour FCall physician immediately if nausea and vomiting are presentPrevention and Treatment of Skin Irritation and InfectionsPreventi

46、onFChange infusion set every 2 to 3 daysFUse aseptic technique and cleanse skin with IV PrepFCheck site each night before bedFUse “sandwich” techniqueTreatmentFTape Irritation or Non-adhesionChange type of tapeFTubing IrritationUse “sandwich” techniqueFInfectionNotify healthcare provider ASAPFollow-

47、Up: The Patients RoleFCheck BG 4-6 times a day, and always before bedFFollow hypoglycemia guidelinesFFollow hyperglycemia guidelinesFVisit healthcare provider - even if feeling wellFReview log book and pump settings with physicianFGet an HbA1c testFReview DKA preventionFCheck BG-3am (overnight)-1 an

48、d/or 2-hour post-meal BG for all meals on a given dayInformation Revolution and the Impact on Pump TherapyFCGMS provides a true picture of glucose levels and consequent insulin requirementsFInsulin Pump Therapy provides the best tool to address those requirementsFVarying bolus type, size, and durati

49、on as well as basal profiles and patterns provides for optimal controlPump Therapy IndicationsFPoor HbA1csFFrequent hypoglycemiaFDawn phenomenonFExerciseFPediatricsFPregnancyFGastroparesisFHectic LifestyleFShift WorkFType 2103F对于胰岛素泵治疗的合理期望对于胰岛素泵治疗的合理期望F需要需要3 36 6个月的时间进行调整个月的时间进行调整F泵的使用会帮助我控制更好，而不是治

50、愈糖尿泵的使用会帮助我控制更好，而不是治愈糖尿病病F在进餐的种类和时间上有更多的自由，而不是在进餐的种类和时间上有更多的自由，而不是随意吃饭随意吃饭F会取得良好的血糖控制，减少血糖的波动，较会取得良好的血糖控制，减少血糖的波动，较少发生低血糖少发生低血糖F至少每日测定血糖至少每日测定血糖4 4次次104F不能坚持血糖自我监测者不能坚持血糖自我监测者F不愿意计算每餐食物的摄入量者不愿意计算每餐食物的摄入量者F特别害怕针、疼痛者特别害怕针、疼痛者F非常怕被别人发现自己带泵非常怕被别人发现自己带泵F对治疗计划和随访缺乏耐心对治疗计划和随访缺乏耐心F不愿让别人知道自己患有糖尿病不愿让别人知道自己患有糖

51、尿病F严重的精神异常者严重的精神异常者SummaryFPump Therapy is becoming widely recognized as the best way to treat insulin requiring diabetesFContinuous Glucose Monitoring makes pumps an even more powerful toolFBoth Pump Therapy and Continuous Glucose Monitoring are easy to implement in a medical practice106SummaryFor most patients, starting insulin pump therapy is an extremely positive life-changing experience