J Korean Diabetes 2020;21:36-40 pissn 2233-7431 eissn 2714-0547 Vol.21, No.1, 2020 구민정서울대학교어린이병원소아청소년당뇨병교실 Effective Use of Insulin Pump in Patients with Type 1 Diabetes Minjeong Gu Pediatric Diabetes Education Unit, Seoul National University Children s Hospital, Seoul, Korea Abstract In young patients with type 1 diabetes, insulin pump therapy lowers the risk of severe hypoglycemia and diabetic ketoacidosis compared to insulin injection therapy. It also increases lifestyle flexibility and improves glucose control. However, appropriate use of insulin pumps requires structured education programs to improve patient self-care. In addition, feedback and ongoing attention from diabetes educators are needed. For this purpose, a systematic education program for medical staff related to insulin pump treatment should be pursued in Korea. Keywords: Diabetes mellitus, type 1, Education, Insulin pump 서론 인슐린펌프라고불리는 continuous subcutaneous insulin infusion (CSII) 은제1형당뇨병환자에게생리적인인슐린분비에가깝게인슐린을피하에공급해줄수있는당뇨병관리기기로, 2014년기준전세계적으로 1,000,000 명이상 [1], 미국에서는 350,000~515,000명의환자가인 슐린펌프를사용중이라고한다 [2]. 그러나국내에서는고가로인한경제적부담과함께적절한교육및관리시스템의부재로인해널리사용되지못하였다. 최근에는연속혈당측정기 (continuous glucose monitoring, CGM) 를인슐린펌프에연결하면서기술적으로눈부신발전을거듭하고있다. 국내에도앱을통해인슐린펌프를연속혈당측정기와연결해서사용하거나인슐린펌프에연속혈당측정기데이 Corresponding author: Minjeong Gu Pediatric Diabetes Education Unit, Seoul National University Children s Hospital, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea, E-mail: mjgu21@snuh.org Received: Jan. 27, 2020; Accepted: Feb. 19, 2020 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. Copyright c 2020 Korean Diabetes Association 36 The Journal of Korean Diabetes
구민정 터가전송이되어저혈당한계치에도달하기전에기저인슐린주입을자동으로멈추어저혈당을예방해주는센서연동형인슐린펌프 (sensor augmented pump, SAP) 가수입되어사용중이다. 이에발맞추어 2019년 1월부터국내제1형당뇨병환자를대상으로연속혈당측정기소모품인전극이건강보험적용되었고, 2020년 1월 1일부터는연속혈당측정기의송신기와인슐린펌프까지건강보험적용이확대시행되었다. 이를계기로앞으로연속혈당측정기와함께인슐린펌프사용자가점차늘어날것으로예상되며이에제1형당뇨병에서연속혈당측정기와인슐린펌프를사용하는환자를위한자가관리교육과구조화된교육프로그램의필요성에대해논의해보고자한다. 인슐린펌프의효과및선택 젊은제1형당뇨병환자에서인슐린펌프사용은인슐린주사에비해심한저혈당및당뇨병성케톤산증발생위험을낮추고혈당조절에도움을준다 [3]. 특히센서연동형인슐린펌프사용은성인과소아모두다회주사요법과비교하여저혈당위험을증가시키지않으면서당화혈색소수치를크게개선시켰다 [4,5]. 또한삶의질측면에서도어린이와부모모두인슐린펌프치료가삶의질향상에긍정적이라고보고하였다 [6]. 대한당뇨병학회의 당뇨병진료지침 2019 에서는반복적인야간저혈당또는저혈당무감지증이있는경우지속혈당감시장치와저혈당을예측하여인슐린주입이중단되는 (threshold based sensor-agmented) 인슐린펌프치료를권고하고있다 [7]. 그러므로인슐린펌프는환자의동기부여, 비용, 보험적용범위및환자와가족에게가장유용한기능이포함되어있는지를고려하여선택해야한다 [8]. 인슐린펌프교육 인슐린펌프는가장진보된형태의인슐린전달방식이지만필요한지식과기술을제공하고동기부여를지원하기 위해서는체계적인교육이필요하다 [9]. 특히연령, 성별과상관없이구조화된인슐린펌프교육프로그램사용이인슐린펌프사용자의혈당조절개선과중증저혈당발생률을크게향상시켰다는결과도있다 [8]. 하지만현재국내에는인슐린펌프치료관련하여구조화된교육프로그램이거의없는실정이다. 이러한체계적인교육프로그램을운영하기위해서인슐린펌프시작은인슐린펌프치료에대해훈련된의사, 당뇨병교육간호사및영양사로구성된당뇨병전문팀이시작해야한다 [10]. 1. 인슐린펌프착용전교육인슐린펌프착용전환자의동기부여를높이는전략이필요하다. 또한인슐린펌프치료에대한현실적인기대를갖게하는것이중요하다. 인슐린펌프치료만으로혈당관리에대해모든것이해결될것이라는비현실적인기대를가진환자라면인슐린펌프치료의장단점에대해정확히설명해주어야한다. 또한소아를위한인슐린펌프교육을계획하는경우반드시부모및다른보호자와함께교육하도록해야한다 [11]. 1) 인슐린펌프의장단점인슐린펌프치료로인한생활패턴의유연성, 주사횟수감소등의장점뿐만아니라케톤산증발생위험증가와피부관련부작용, 착용불편감및스포츠활동장애등의일상생활방해요인, 고비용, 특히센서연동형인슐린펌프사용환자에게는센서정확도에대한만족도가낮을가능성, 알람피로도등에대해교육한다. 2) 탄수화물계산법인슐린펌프를효과적으로사용하기위해서는다회주사요법과마찬가지로탄수화물계산이필요하다. 사전에교육이제대로되어있지않은환자라면인슐린펌프착용전에탄수화물계산에대한재교육을반드시시행해야한다. www.diabetes.or.kr 37
3) 베이잘 (basal) 과볼루스 (bolus) 개념인슐린주사법을시행하던환자가인슐린펌프치료로변경하는경우초속효성인슐린만을사용하고기저인슐린을주사하지않는것에대해혼란스러워하는경우가많다. 그러므로인슐린펌프의작동원리인베이잘과볼루스의개념에대한교육이필요하다. 이와함께인슐린민감지수 (insulin sensitivity factor, ISF) 와인슐린탄수화물비 (insulin to carbohydrate ratio, ICR) 에대해서도미리확인하고점검해주어야한다 [12]. 4) 인슐린펌프와연속혈당측정기사용법메뉴와버튼조작방법및배터리장착법등인슐린펌프사용법에대해교육한다. 기기조작에대한숙련도는인슐린펌프의성공적인사용을위해매우중요하다. 만약센서연동형인슐린펌프를사용하는환자라면센서의작동원리와인슐린펌프와연결되어저혈당발생전베이잘이멈추는기능등에대해서도사전에교육한다. 2. 인슐린펌프착용교육 1) 인슐린펌프설정인슐린펌프착용당일환자를위해필요한하루총인슐린용량 (total daily dose, TDD), 베이잘용량설정, 인슐린탄수화물비와인슐린민감지수, 목표혈당등인슐린펌프세팅에필요한내용들을미리설정해둔다. 특히환자에따라적절한개별적인목표혈당설정은저혈당예방에있어중요하다 [13]. 2) 주입세트채우기주사기에 2~3일간사용할용량보다조금더넉넉히인슐린을채우고인슐린펌프에주사기를삽입한다. 3) 주입부위선택인슐린펌프주입부위는인슐린주사부위인복부, 상완부, 허벅지, 둔부등을선택할수있으나개인에따라개별 화해야한다. 주입세트변경시이전부위로부터약 5 cm 이상떨어진부위에삽입해야한다. 또한지방이상증과흉터, 발진, 감염등의피부병변을줄이기위한주입부위순환의중요성에대해인슐린펌프사용초기뿐만아니라주기적으로교육해야한다 [10]. 4) 센서삽입센서연동형인슐린펌프사용환자는센서를삽입하고인슐린펌프와센서를연결하는방법및적절한센서삽입부위선택방법에대해교육한다. 5) 경보와알람인슐린펌프사용시배터리가소진되었거나주입세트가막혀인슐린이제대로전달되지않는경우케톤산증의위험이증가하므로인슐린펌프는필요시경보와알람으로환자에게위험상황을알려준다. 환자가경보와알람에대해스트레스받지않도록경보와알람발생시대처방법교육과개별화된알람설정이필요하다. 3. Follow-up 인슐린펌프를착용한후다음방문은최소 1주일이내여야한다 [14]. 환자혹은보호자가적절한주입부위를선택하고 2~3일마다주입세트를변경하는지점검해야한다. 1) 인슐린펌프용량조절인슐린펌프착용후주기적으로센서혹은혈당측정값을확인하여베이잘주입량과볼루스계산기에대한적절한설정값변경이필요하다. 인슐린펌프및센서데이터를업로드하면 PC에서더자세한기록을검토할수있다. 의료진은이러한데이터를토대로환자와함께논의하여설정값등을변경하는것이필요하다. 환자스스로포도당패턴을인식하고인슐린용량조절에대응하는등인슐린펌프문제해결에대한철저한지식을갖추어야자가관리능력이향상되기때문이다 [15]. 특히볼루스계산기능등인슐린펌프의 38
구민정 고급기능을사용하면사용하지않은사람들과비교하여당화혈색소가크게개선되므로지속적인교육을통해이를강화해야한다 [16]. 2) Adherence 확인인슐린펌프사용자의혈당조절이불량한원인은부적절한베이잘주입량이나볼루스계산기설정값때문일수도있으나주입세트를 3일이상사용하거나식사나간식시볼루스를제때주입하지않는등환자가인슐린펌프에대한적절한수행을하지않는경우도많다. 특히청소년에서인슐린펌프사용지속기간이길어질수록인슐린펌프관련행위준수율이낮아진다고한다 [17]. 그러므로인슐린펌프의데이터를주기적으로업로드받아환자의인슐린펌프에대한 adherence를확인하고격려하는것이필요하다. 서연동형인슐린펌프는점점보편화되며기능도개선되고있다. 또한가까운미래에는인공췌장도개발될것이다. 이에발맞추어제1형당뇨병환자를돌보는의료인은빠르게변화하는당뇨병관련기술에적응하고대비해야한다. 제1 형당뇨병환자가인슐린펌프치료에대한심리사회적장벽을해결하고안전하고효율적으로인슐린펌프를사용하기위해서는인슐린펌프에특화된구조화된교육프로그램개발과지속적인교육및적절한피드백이필요하다. 이를위해국내에서는인슐린펌프치료와관련된전문의료진을위한체계적인교육프로그램시행이선행되어야한다. 당뇨병교육자뿐만아니라대한당뇨병학회와유관기관에서는이를위해노력해야할것이다. REFERENCES 3) 안전관리인슐린펌프사용시이유없이고혈당이발생하거나주입부위막힘및인슐린펌프에문제발생시케톤산증발생위험이증가하므로언제라도인슐린을직접주입할수있어야한다 [18,19]. 이를위해인슐린펌프가제대로작동하지않는경우인슐린주사용량을적절히계산하여주사기나펜형인슐린으로주사하는방법등적절한대처방법을익히도록지속적으로확인하고교육해야한다. 4) 심화교육인슐린펌프사용에익숙해지면주기적으로인슐린펌프세팅변경필요성을확인하고, 몸이아픈날이나스트레스상황등특별한경우에임시로베이잘설정을조절하는방법등환자가인슐린펌프사용시경험할수있는문제들에대해스스로해결할수있도록지속적으로교육해야한다. 결론 지난수십년간제1형당뇨병관리기술은인슐린펌프와연속혈당측정기등으로눈부신발전을이루어왔다. 특히센 1. Heinemann L, Fleming GA, Petrie JR, Holl RW, Bergenstal RM, Peters AL. Insulin pump risks and benefits: a clinical appraisal of pump safety standards, adverse event reporting, and research needs: a joint statement of the European Association for the Study of Diabetes and the American Diabetes Association Diabetes Technology Working Group. Diabetes Care 2015;38:716-22. 2. Grunberger G, Abelseth JM, Bailey TS, Bode BW, Handelsman Y, Hellman R, Jovanovič L, Lane WS, Raskin P, Tamborlane WV, Rothermel C. Consensus Statement by the American Association of Clinical Endocrinologists/American College of Endocrinology insulin pump management task force. Endocr Pract 2014;20:463-89. 3. Karges B, Schwandt A, Heidtmann B, Kordonouri O, Binder E, Schierloh U, Boettcher C, Kapellen T, Rosenbauer J, Holl RW. Association of insulin pump therapy vs insulin injection therapy with severe hypoglycemia, ketoacidosis, and glycemic control among www.diabetes.or.kr 39
children, adolescents, and young adults with type 1 diabetes. JAMA 2017;318:1358-66. 4. Bergenstal RM, Tamborlane WV, Ahmann A, Buse JB, Dailey G, Davis SN, Joyce C, Peoples T, Perkins BA, Welsh JB, Willi SM, Wood MA; STAR 3 Study Group. Effectiveness of sensor-augmented insulin-pump therapy in type 1 diabetes. N Engl J Med 2010;363:311-20. 5. Zimmerman C, Albanese-O'Neill A, Haller MJ. Advances in type 1 diabetes technology over the last decade. Eur Endocrinol 2019;15:70-6. 6. Barnard KD, Speight J, Skinner TC. Quality of life and impact of continuous subcutaneous insulin infusion for children and their parents. Pract Diabetes Int 2008;25:278-83. 7. Korean Diabetes Association. Treatment guideline for diabetes. 4th ed. Seoul: gold Planning and Development; 2019. p52-6. 8. Ehrmann D, Kulzer B, Schipfer M, Lippmann-Grob B, Haak T, Hermanns N. Efficacy of an education program for people with diabetes and insulin pump treatment (INPUT): results from a randomized controlled trial. Diabetes Care 2018;41:2453-62. 9. Pickup JC. Insulin-pump therapy for type 1 diabetes mellitus. N Engl J Med 2012;366:1616-24. 10. Evert AB, Bode BW, Buckingham BA, Nardacci E, Verderese CA, Wolff-McDonagh P, Walsh J, Hirsch IB. Improving patient experience with insulin infusion sets: practical guidelines and future directions. Diabetes Educ 2016;42:470-84. 11. American Diabetes Association. Standards of medical care in diabetes-2017-glycemic targets. Diabetes Care 2017;40 Suppl 1:S48-56. 12. Walsh J, Roberts R, Bailey T. Guidelines for insulin dosing in continuous subcutaneous insulin infusion using new formulas from a retrospective study of individuals with optimal glucose levels. J Diabetes Sci Technol 2010;4:1174-81. 13. Handelsman Y, Mechanick JI, Blonde L, Grunberger G, Bloomgarden ZT, Bray GA, Dagogo-Jack S, Davidson JA, Einhorn D, Ganda O, Garber AJ, Hirsch IB, Horton ES, Ismail-Beigi F, Jellinger PS, Jones KL, Jovanovič L, Lebovitz H, Levy P, Moghissi ES, Orzeck EA, Vinik AI, Wyne KL. American Association of Clinical Endocrinologists Medical Guidelines for Clinical Practice for developing a diabetes mellitus comprehensive care plan. Endocr Pract 2011;17 Suppl 2:1-53. 14. American Association of Diabetes Educators. Practice paper - Continuous Subcutaneous Insulin Infusion (CSII) without and with sensor integration. Available from: https://www.diabeteseducator.org/practice/practicetools/diabetes-management-tools/ipt-resources. 15. Bolderman K. Pump Start-Up in putting your patients on the pump. Alexandria, Va: American Diabetes Association; 2013. 16. Mameli C, Scaramuzza AE, Ho J, Cardona-Hernandez R, Suarez-Ortega L, Zuccotti GV. A 7-year follow-up retrospective, international, multicenter study of insulin pump therapy in children and adolescents with type 1 diabetes. Acta Diabetol 2014;51:205-10. 17. O'Connell MA, Donath S, Cameron FJ. Poor adherence to integral daily tasks limits the efficacy of CSII in youth. Pediatr Diabetes 2011;12:556-9. 18. Evert A. Insulin pump therapy troubleshooting for optimal performance. Empower 2015;7:23-4. 19. Guilhem I, Leguerrier AM, Lecordier F, Poirier JY, Maugendre D. Technical risks with subcutaneous insulin infusion. Diabetes Metab 2006;32:279-84. 40