p umpmaster and g lucommander the far side of the diabetes world presented by paul davidson md at...
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PUMPMASTER AND
GLUCOMMANDER
THE FAR SIDE OF THE DIABETES WORLD
Presented byPaul Davidson MD
at theMiniMed Symposium
Atlanta, GADecember 13, 2003
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AIM Formulae (Accurate Insulin Management) Background
CSII dosing is related to a patient’s size
It consists of four parameters:
– Total insulin dose per day (TDD)
– Basal Insulin as percent of TDD
– Bolus insulin for meals
• Based on CHO to insulin ratio (CIR)
– Correction boluses from the correction factor (CF)
A database of 1815 records was used to find the optimal parameters for the most ideally controlled pump patients.
The interaction of the AIM formulae is portrayed as a nomogram.
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Materials and Methods
Two groups of patients:
– Target Group (TG)--183 patients with A1C <7%
– Not-to-Target Group (NTG) the remainder of the patients
– Individual's slopes determined:
• Basal versus TDD
• CF versus 1/TDD
– Median of all slopes in the TG was used as the slope for each formula
– Slignificant differences between TG and NTG
.
• TDD versus BW
• CIR versus BW/TDD
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AIM Formulaefor adults
• Carbohydrate / Insulin Ratio (CIR)
CIR = 2.8 x BodyWeight(lbs) / TDD• Correction Factor (CF)
CF = 1700 / TDD• Basal Insulin
Basal = 0.48 x TDD
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0
20
40
60
80
100
120
140
160
0 100 200 300Body Weight (lbs)
Sta
rtin
g T
DD
Starting Total Daily Insulin Dose
TDDstart = 0.24 * Wt(lb)
n = 199
File: AIM031208 199 points
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0
10
20
30
40
50
60
70
80
0 50 100 150Total Daily Insulin Dose (TDD)
Basal
Insu
lin
Basal Insulin
Basal = 0.48 * TDD
n = 199
File: AIM031208 199 points
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If HbA1c is Not to Goal i.e. 6.5%
SMBG
– frequency
– recording
– memory meter
Diet
– accurate CHO counting
– appropriate CHO/insulin bolusing
Infusion site areas Over-treatment of low BG Delayed or under-treatment
of high BG
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If HbA1c Not to Goal i.e. 6.5%
SMBG
– frequency
– recording
– memory meter
Infusion site areas Over-treatment of low BG Delayed or under-treatment
of high BG
More than 4/day
2.8 x Wt / TDD
1700 Rule
(100-BG) x 0.2
Diet
–accurate CHO counting
–appropriate CHO/insulin bolusing
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0
2
4
6
8
10
12
14
0 5 10 15 20
0
0. 5
1
1 . 5
2
2. 5
3
3. 5
0 5 1 0 1 5 20
Average2 BG’s/d
Average12 BG’s/d
24
Blo
od
Glu
co
se
Blo
od
Glu
co
se
HoursHours
Frequency of Blood Glucose MonitoringFrequency of Blood Glucose MonitoringEffect of Recurrent Adjustment for Increased BG’sEffect of Recurrent Adjustment for Increased BG’s
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5
6
7
8
9
10
0 2 4 6 8 10 12SMBG tests per day (BGpd)
A1
c %
Improvement in HbA1c with Increased BG Testing
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If HbA1c Not to Goal i.e. 6.5%
SMBG
– frequency
– recording
– memory meter
Infusion site areas Over-treatment of low BG Delayed or under-treatment
of high BG
More than 4/day
2.8 x Wt / TDD
1700 Rule
(100-BG) x 0.2Diet
–accurate CHO counting
–appropriate CHO/insulin bolusing
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450 Rule vs 2.8 Rule
Purpose of rule: Estimate the ratio: carbs / insulin. Start with:CIR = CarbsPerDay / TDD
• 2.8 Rule : says CarbsPerDay proportional to Wt(lb): CIR = 2.8 * Wt(lb) / TDD
• 450 Rule : says CarbsPerDay is the same for all people: CIR = 450 / TDD The case for 450 rule:• Advocates say it works better for children.
The case for 2.8 Rule: • Wt(lb) for CarbsPerDay makes better sense than constant.• Consistent with 1700 Rule• 450 Rule’s scatter chart data look curved.
A future study is planned for children. They were under-represented in AIM study.
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0
5
10
15
20
25
0 2 4 6 8BW# / TDD
CIR
Median slope = 2.79
Data: file: AIM031208.xls, 179 pts
CARBOHYDRATE TO INSULIN RATIOCIR = 2.8 * BW# / TDD for adults
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0
5
10
15
20
25
30
0 0.02 0.04 0.061 / TDD
CIR
Median slope = 450
Data: file: AIM031208.xls, 179 pts
CARBOHYDRATE TO INSULIN RATIOCIR = 450 / TDD
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If HbA1c Not to Goal i.e. 6.5%
SMBG
– frequency
– recording
– memory meter
Infusion site areas Over-treatment of low BG Delayed or under-treatment
of high BG
More than 4/day
2.8 x Wt / TDD
1700 Rule
(100-BG) x 0.2
Diet
–accurate CHO counting
–appropriate CHO/insulin bolusing
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20
40
60
80
100
120
140
160
Glu
cose
Correction of Hypoglycemia with Glucose100-BG X 0.2 Grams
Before After
Richardson Diabetes 1999 50:A200
100-BG X 0.15 Grams
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If HbA1c Not to Goal i.e. 6.5%
SMBG
– frequency
– recording
– memory meter
Infusion site areas Over-treatment of low BG Delayed or under-treatment
of high BG
More than 4/day
2.8 x Wt / TDD
1700 Rule
(100-BG) x 0.2
Diet
–accurate CHO counting
–appropriate CHO/insulin bolusing
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0
20
40
60
80
100
120
0 0.02 0.04 0.06 0.081 / TotalDailyInsulin
Co
rrecti
on
Facto
rCorrection Factor
The 1700 Rule
CF = 1705 / TDD
n = 199
File: AIM031208 199 points
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1700 RuleMathematical Model
Purpose of 1700 Rule: Estimate Correction Factor (CF)
• 1700 Rule: says glucose burned per day and body volume are both proportional to Wt(lb). These cancel as shown below:
CF = (glucose burned per day)/[(Body volume)*TDD] CF = K1 * Wt(lb) / [ Wt(lb) * TDD]
CF = K1 / TDD
Statistics give: CF = 1700 / TDD
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0
50
100
150
200
250
300
0 50 100 150 200
Total Daily Dose of Insulin (TDD)
Bo
dy
We
igh
t in
lbs
125
100
75
50
25
Co
r rection
Facto
r
25 20 15 12 10 8 7 6 5
Carbohydrate to Insulin Ratio
CF Curve
AIM Nomogram
( CIR = 2.8 Wt / TDD )( C
F =
17
00
/ TD
D )
Initial Dosing: Plot BW and 25 CIR for BI Plot BW and 12 CIR for TDD
Plot BW and TDD for CIRPlot TDD and CF curve for CF
4
3
2
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0
50
100
150
200
250
300
0 50 100 150 200
Total Daily Dose of Insulin (TDD)
Bo
dy
We
igh
t in
lbs
125
100
75
50
25
Co
r rection
Facto
r
25 20 15 12 10 8 7 6 5
Carbohydrate to Insulin Ratio
CF Curve
( CIR = 2.8 Wt / TDD )( C
F =
17
00
/ TD
D )
4
3
2
CIR
TDDBI
Weight
Example•210 lb.. Man Type 1 Diabetes•Starting CSII•Poorly controlled HgA1c 8.1%
•10 units lispro tid•28 units glargine hs
•Initial Dosing:•Plot BW and 25 CIR for BI•Plot BW and 12 CIR for TDD
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0
50
100
150
200
250
300
0 50 100 150 200
Total Daily Dose of Insulin (TDD)
Bo
dy
We
igh
t in
lbs
125
100
75
50
25
Co
r rection
Facto
r
25 20 15 12 10 8 7 6 5
Carbohydrate to Insulin Ratio
CF Curve
( CIR = 2.8 Wt / TDD )( C
F =
17
00
/ TD
D )
4
3
2
CF
TDD
Plot TDD and CF curve for CF
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0
50
100
150
200
250
300
0 50 100 150 200
Total Daily Dose of Insulin (TDD)
Bo
dy
We
igh
t in
lbs
125
100
75
50
25
Co
r rection
Facto
r
25 20 15 12 10 8 7 6 5
Carbohydrate to Insulin Ratio
CF Curve
( CIR = 2.8 Wt / TDD )( C
F =
17
00
/ TD
D )
4
3
2
New TDD
NewCIR
NewBI
Follow-up One Month Later•Weight 200#•4.5 BG’s per day•Average BG 172•Current basal 1.2 u/hr (28.8 u/d)•TDD from pump 64 units
NewCF
NewWeight
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AIM “N” Nomogram
80
40
30
70
40
30
100
10
40
60140
160
90
60
90
180
240
25
3550
30
80
10
40
70
100
110
100
220
4
6
8
10
3025
20
15
12
80
200
50
20
20
20
60
60
50
20
120
Carbohydrate / Insulin Ratio (CIR)
TDD
Co
rre
cti
on
Fa
cto
r (
CF
)
Kilograms(Kg)
Pounds(lb)
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Total CIR Daily Wt Wt for adults Insulin CF (kg) (lb) (gm/unit) (unit) (mg/dL/unit) 149┼329 ┼47 20┼88 142┼313 ┼43 21┼84 135┼298 ┼39 22┼80 129┼284 ┼35 23┼76 123┼270 ┼32 24┼72 117┼258 ┼29 25┼69 111┼245 ┼26 26┼65 106┼234 ┼24 28┼62 101┼222 ┼22 29┼59 96┼212 ┼20 30┼57 92┼202 ┼18 32┼54 87┼192 ┼16 33┼51 83┼183 ┼15 35┼49 79┼174 ┼13 37┼47 75┼166 ┼12 39┼44 72┼158 ┼11 41┼42 68┼151 ┼10 43┼40 65┼143 ┼9 45┼38 62┼137 ┼8 47┼36 59┼130 ┼7 49┼35 56┼124 ┼7 52┼33 54┼118 ┼6 55┼31 51┼112 ┼5 57┼30 49┼107 ┼5 60┼29 46┼102 ┼5 63┼27 44┼97 ┼4 66┼26 42┼92 ┼4 70┼25 40┼88 ┼3 73┼23 38┼84 ┼3 77┼22 36┼80 ┼3 81┼21 35┼76 ┼3 85┼20 33┼72 ┼2 89┼19 31┼69 ┼2 93┼18 30┼66 ┼2 98┼18 28┼63 ┼2 103┼17 27┼60 ┼2 108┼16 26┼57 ┼1 113┼15 25┼54 ┼1 119┼14 23┼51 ┼1 125┼14
Accurate Insulin Management
(AIM) Nomogram
1. Connect the columns with a
straight line between weight and
total daily dose of insulin (TDD).
2. Read correction factor (CF) and
carbohydrate/insulin ratio (CIR).
3. Basal insulin is one-half total daily
dose of insulin.
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AIM Study(uncontrolled)
21 Patients
HbA1c>8
Competent Self-Monitoring
Pump Veterans
Bi-Weekly Fax and Phone Follow-Up
Three Month Study
6
6.5
7
7.5
8
8.5
9
HbA1c Mean BG
Davidson et al Diabetes Technology & Therapeutics 2003
180
160
140
120
P<0.0001 P<0.0001
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PumpMaster
A Combined Database Collector
and
Patient-Treatment Advisor
for
Interactive Use by Practitioners
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Pumpmaster
Day divided into five periods
– Sleep, dawn, am, pm, evening
BG monitored initially for each period
– Mean and SD
Variation of mean from target
– Correction formula used to quantify average insulin need for each period
– Summed for day
Program suggests change in insulin for each period balancing change in basal against CIR
– Simulates best controlled patients in database
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Input Form, Screen 1
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Input Form, Screen 2
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• In development (Patent Pending)
• Has shown that it lowers A1c
• Will advise the pump therapist
• Will advise the pump-wearing diabetic
• Will encourage more pump prescribing
• Will facilitate progress to target control
• Can be programmed into PDA or pump
Overview of PumpMaster
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Future of Diabetes Management Improvements in Insulin & Delivery
Insulin analogs and inhaled insulin
Smart external pumps
Internal pumps
Real-time sensors
Closed-loop systems
Unconceived-of solutions
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QUESTIONS? For a copy or viewing of these slides
– Contact• www.adaendo.com
How can I get use of Glucommander? (Computer-directed IV insulin program)
– Available for review on internet,
• www.glucommander.com
How can I get use of Pumpmaster?
– Contact us expressing interest: