Pharmacists Play a Growing Role in Interpreting Automated Insulin Delivery Data

Diana Isaacs, PharmD, BCACP, BC-ADM, CDCES, from the Cleveland Clinic Diabetes Center, continued her conversation with Pharmacy Times, explaining how clinicians can use pump and glucose data from automated insulin delivery systems to individualize treatment for patients with type 2 diabetes. She highlights the importance of evaluating time in range, basal-to-bolus balance, and bolus behaviors to identify opportunities for optimization. Isaacs also outlines critical safety concerns, including pump interruptions, hyperglycemia management, and hypoglycemia treatment adjustments unique to automated systems. She emphasizes the pharmacist’s role in patient education, troubleshooting, and ensuring every patient has a clear backup plan in case of pump failure.

Pharmacy Times: When using automated insulin delivery systems, how should clinicians interpret pump and glucose data to create an optimal, individualized treatment plan for type 2 diabetes?

Diana Isaacs, PharmD, BCACP, BC-ADM, CDCES: It's so important. We look at the data. The data reveals all the things happening, and we can use it to fine-tune settings. This is an area I predict that more and more pharmacists are going to get involved in because these health care teams need someone that understands the information and can make these insulin adjustments. Each pump report does look a little bit different, but they all have similar information. I think starting with the summary page and looking at whether the time in range is at the goal or not.

If it's at a goal, then you ask the person how they're doing, if they feel like things are working well. Great, your work is done. But if it's not, typically if their time in range is less than 70%, that's when we look for opportunities to optimize things. Some of the things that I'm looking at are what their breakdown of basal background insulin and bolus insulin is. Typically, people tend to do better if it's a little closer to even, 50/50. It doesn't have to exactly be even, and certain pumps might veer toward one more than the other, but generally if someone's not at goal and let's say they're only 20% bolus, I know we probably need to work on either increasing boluses or optimizing the settings.

The other area that I look at is what does the bolus behavior look like? Is a person at least bolusing for their meals, or if they have high glucose, are they going into bolus to try to help bring it down, because that's still an option with most of our systems? If I see someone is bolusing like once a day, then that may be a conversation about what we can do to get you to perhaps bolus a little bit more. Versus I've seen situations where people are bolusing like 10 times a day, and so that's usually a settings issue.

Once you kind of figure out what's maybe the issue, then you can go into the daily reports and see a little bit better what's happening. This is where you can see what the timing of the bolus is. For example, it could be that someone's bolusing, and they're going really high at their meals, but maybe they're bolusing late. Maybe they're bolusing when they've already started eating or even after. That would be more of a behavior change, as opposed to if you see that someone's glucose level is at their goal range, they bolus, and then they go up really high. That's more of a sign that maybe your carbohydrate ratio needs to be adjusted, or it could be confidence with entering in a more accurate number of carbohydrates.

Pharmacy Times: What are some of the safety concerns that pharmacists need to be aware of when starting or adjusting insulin settings for patients?

Isaacs: With insulin pumps, it is typically replacing both the background and the mealtime insulin. What that means is if there's an interruption in the insulin pump for any reason, whether someone runs out of insulin, it's leaking insulin, it stopped working, it fell off, or they didn't know, they could experience complications pretty quickly. In type 1 diabetes, that typically leads to diabetic ketoacidosis, DKA. In type 2 diabetes, it could sometimes still lead to DKA or HHS, but it can lead to an emergency much more quickly.

It's important that each person has awareness of how to troubleshoot, that they have alarms set for high glucose levels, and that they know how to take action. Typically, what that action is with most pumps would be going and giving a correction bolus for the high glucose. If it's not coming down and an hour or two passes, and it's still going up or not coming down, we have a saying called “if in doubt, change it out.” If you're not sure it's delivering insulin, go ahead and remove your pump and put on a new pump or a new site if it's a tubed pump. Sometimes, if it's gone really high, we would actually recommend that somebody give an injection outside of the pump to correct the high glucose, then wait a couple hours and put their pump back on. These are some of the troubleshooting things it's really important someone understands when they're going onto a pump.

The other thing I'll say is treating hypoglycemia is often a little bit different with these automated insulin delivery systems. That's because if someone's predicted to go low, the pump is going to back off insulin or completely suspend insulin. What that means is if someone takes in 15 grams of fast-acting carbohydrates, it could end up being too much and spike them too high. That could then lead to the pump giving more insulin, and sometimes it leads to this roller coaster of going up and down. Educating people to try to treat with five to 10 grams and be patient is important. This is also why it's really important we look at someone's settings to make sure they are optimized and not going too high or too low.

Another thing is making sure every person has a backup plan. You just never know. Sometimes people's controllers die. Recently, a lot of people are using their phones for their pumps, which is cool, but sometimes something happens to the phone. It dies, or the app disappears, and they don't know their settings anymore. Every person should have a backup plan. That backup plan is if you don't have access to your pump, you have insulin and can go back to injections temporarily until the pump situation is resolved. Each person should have a long-acting insulin and know how much to give and have a fast-acting insulin with instructions on how much to give. We can look at someone's pump data and see how much they're getting through the pump to help determine this. For example, if I see someone's getting, on average, 20 units of background insulin with their pump, I can say, "Maybe we'll give you 20 units of a long-acting insulin," and make sure they are prepared in case there ever is a safety issue.