22nd Annual Northeast Regional Nurse Practitioner Conference – May 6-8, 2015

Technological Advances in Diabetes ManagementPatti Duprey, MS, APRN

D I S C L O S U R E S

• Speakers’ Bureau for Sanofi Pasteur and Janssen.

• There has been no commercial support or sponsorship for this program.

• The program co-sponsors do not endorse any products in conjunction with any educational activity.

A C C R E D I TAT I O N

Boston College Connell School of Nursing Continuing Education Program is accredited as a provider of continuing nursing education by the American Nurses Association Massachusetts, an accredited approver by the American Nurses Credentialing Center’s Commission on Accreditation.

22nd Annual Northeast Regional Nurse Practitioner Conference – May 6-8, 2015

S E S S I O N O B J E C T I V E S

• Identify various tech devices to assist in the management of diabetes.

• Describe appropriate patient selection for different devices.

Technological Advances in Diabetes Management

Duprey Consultants, LLC Patti Duprey, MSN, APRN, CDE

Private Practice patti.duprey@gmail.com

Conway, NH 603-662-0166 Kennebunk, ME 207-467-3777

∗ Speaker Bureau ∗ Janssen ∗ Sanofi

Disclosures

∗ Review History of glucose monitoring and insulin pump therapy

∗ Describe newer technologies ∗ Select appropriate patients for use of technology ∗ Define ways to incorporate into practice

Objectives

Before and After Insulin Treatment

Discovery of insulin in 1921 changed type 1 from a death sentence to a chronic disease

7-year-old child before and 3 months after insulin therapy

Do We Need Technology?

We’ve Come a Long Way!

So….. this means my blood sugar is between something and something

This tastes sweet, it must be Diabetes Mellitus

Initial Glucose Meters

Updated Glucose Meters

http://images.google.com/imgres?imgurl=http://image.examiner.com/images/blog/wysiwyg/image/1195401227-17482_full-1.jpg&imgrefurl=http://www.examiner.com/x-798-Denver-Low-Carb-Examiner~y2009m1d17-Free-glucose-meter-a-great-way-to-fine-tune-your-diet&usg=__4pZh6teHFMJmQ7KteARcZMdrO24=&h=311&w=385&sz=24&hl=en&start=49&um=1&tbnid=NE6yt22YjRxnfM:&tbnh=99&tbnw=123&prev=/images?q=glucose+meter+image&ndsp=18&hl=en&rlz=1T4ADBR_enUS298US298&sa=N&start=36&um=1http://images.google.com/imgres?imgurl=http://www.nfb.org/images/nfb/Publications/vod/vod_24_1/meters.gif&imgrefurl=http://www.nfb.org/images/nfb/Publications/vod/vod_24_1/vodwin0910.htm&usg=__tUMU3RA30pxg4YP1iGFg1J4Z6GA=&h=313&w=288&sz=32&hl=en&start=7&um=1&tbnid=x2wIizLjZdGZ1M:&tbnh=117&tbnw=108&prev=/images?q=glucose+meters+image&hl=en&rlz=1T4ADBR_enUS298US298&sa=G&um=1http://images.google.com/imgres?imgurl=http://hoe.kgnu.net/photos/shows/99.jpg&imgrefurl=http://hippocratech.org/category/Tech/&usg=__j86TXDTcdm3IuV-teY12pu7QFMU=&h=372&w=320&sz=17&hl=en&start=18&um=1&tbnid=L4wo7D1d89fI6M:&tbnh=122&tbnw=105&prev=/images?q=glucose+meters+image&hl=en&rlz=1T4ADBR_enUS298US298&sa=G&um=1http://images.google.com/imgres?imgurl=http://www.northcoastmed.com/enlarge/meters/loBreeze2_meter_disc.jpg&imgrefurl=http://ncmed.wordpress.com/glucose-meter-comparison-chart-compare-the-latest-glucose-meters/&usg=__1ojzqZaCS6ep84NkIO9g4VeshA8=&h=535&w=500&sz=192&hl=en&start=15&um=1&tbnid=WQiM2CYoaNOaKM:&tbnh=132&tbnw=123&prev=/images?q=glucose+meters+image&hl=en&rlz=1T4ADBR_enUS298US298&sa=G&um=1http://www.google.com/imgres?imgurl=http://ecx.images-amazon.com/images/I/41lCMHGTxoL.jpg&imgrefurl=http://diabetessupplyresources.com/2009/04/24/accu-chek-compact-plus-meter-kit/&h=500&w=440&sz=29&tbnid=jJnQB5mYjy9LKM:&tbnh=130&tbnw=114&prev=/images?q=accu-chek+compact+plus+image&usg=__cwLMuse4dYQs0k8AmIH159gmJxs=&ei=nop4Spv7F5DwlAeU_oiZBQ&sa=X&oi=image_result&resnum=2&ct=imagehttp://images.google.com/imgres?imgurl=http://www.northcoastmed.com/images/stories/contour_colors_thumb.jpg&imgrefurl=http://www.northcoastmed.com/contour.htm&usg=__STmZI9xZGRF69bPczPqZcG975lM=&h=167&w=185&sz=29&hl=en&start=38&um=1&tbnid=tl-SanzS9p2veM:&tbnh=92&tbnw=102&prev=/images?q=contour+meter+image&ndsp=20&hl=en&rlz=1T4ADBR_enUS298US298&sa=N&start=20&um=1http://www.childrenwithdiabetes.com/gifs/products/Precision_Xtra_New.jpghttp://images.google.com/imgres?imgurl=http://www.healiohealth.com/images/products/Blood-Glucose-Meter-Advocate-Duo-Digital-Blood-Pressure-Monitor-b.jpg&imgrefurl=http://www.healiohealth.com/tek9.asp?pg=products&specific=jnnrjnmpm&usg=__I2bWGANllePuik9IkXfPAwjuQAM=&h=300&w=349&sz=23&hl=en&start=11&um=1&tbnid=VBxV4YwTQ47PYM:&tbnh=103&tbnw=120&prev=/images?q=glucose+meter+image&hl=en&rlz=1T4ADBR_enUS298US298&sa=X&um=1

Glucose Meters Now

Continuous Glucose Monitoring CGM

Insulin Delivery Modes

http://upload.wikimedia.org/wikipedia/en/f/f4/Standard_insulin_syringe.JPG

Insulin Delivery Modes - Pens

http://www.ideo.com/images/uploads/work/case-studies/large/KwikPen_Lilly_cd.jpghttp://images.google.com/imgres?imgurl=https://www.diaexpert.de/media/humapen-luxura.jpg&imgrefurl=https://www.diaexpert.de/de/insulininjektionen/insulinpens/diaexpert_gmbh_-_insulinpens_huma_penluxura_lilly.html&usg=__a1NRSpHANvUHNlIXP3o3P3O2cYI=&h=323&w=411&sz=20&hl=en&start=14&um=1&tbnid=Dsxl_j2zA5FUEM:&tbnh=98&tbnw=125&prev=/images?q=luxura+pen+image&hl=en&rlz=1T4ADBR_enUS298US298&sa=X&um=1http://images.google.com/imgres?imgurl=http://www.designnews.com/photo/47473-CA6436760_A.jpg&imgrefurl=http://www.designnews.com/article/9025-Luxura_HD_Insulin_Pen_Redefines_Speed_to_Market.php&usg=__boA1l3wxHGggCE7O27Er3Z1JD3A=&h=365&w=550&sz=31&hl=en&start=4&um=1&tbnid=nFNzD2a8nVcVtM:&tbnh=88&tbnw=133&prev=/images?q=luxura+pen+image&hl=en&rlz=1T4ADBR_enUS298US298&sa=X&um=1http://www.google.com/imgres?imgurl=http://www.prnewswire.com/mnr/novonordisk/37286/images/37286-hi-FlexPens.jpg&imgrefurl=http://www.prnewswire.com/mnr/novonordisk/37286/&h=1000&w=1000&sz=135&tbnid=95sIJWGQO_mk1M:&tbnh=149&tbnw=149&prev=/images?q=flexpen+image&usg=__8rWbtu9ENzhV00jKpI-ISvG3rA0=&ei=YyJJSt_MG9SEtwfWkciMCg&sa=X&oi=image_result&resnum=3&ct=imagehttp://images.google.com/imgres?imgurl=http://www.lovemarks.com/media/image/lantus-solostar_html.jpg&imgrefurl=http://www.lovemarks.com/nomination/4308&usg=__S6QekgyvuMtBPpdrhadC9JlDsL0=&h=207&w=310&sz=14&hl=en&start=8&um=1&tbnid=ORER6FLEysCx_M:&tbnh=78&tbnw=117&prev=/images?q=solo+star+pen+image&hl=en&rlz=1T4ADBR_enUS298US298&um=1http://www.google.com/imgres?imgurl=http://www.mte.cz/images/novo-pen-junior.jpg&imgrefurl=http://en.mte.cz/insulin-pen.htm&h=224&w=800&sz=51&tbnid=Uh9M11_RHXVdbM:&tbnh=40&tbnw=143&prev=/images?q=junior+insulin++pen+image&usg=__XZdCy0jZp7EZPdfERdQR9kP2t_w=&ei=_SJJSo_yDIuftgeF57WtBg&sa=X&oi=image_result&resnum=2&ct=imagehttp://images.google.com/imgres?imgurl=http://www.mte.cz/images/np4.jpg&imgrefurl=http://en.mte.cz/insulin-pen.htm&usg=__c5FW99uKanxpH5U5NWnOyUbS1XE=&h=214&w=800&sz=26&hl=en&start=36&um=1&tbnid=GjEPN2-TgwT4kM:&tbnh=38&tbnw=143&prev=/images?q=junior+insulin++pen+image&ndsp=18&hl=en&rlz=1T4ADBR_enUS298US298&sa=N&start=18&um=1

The prototype of the first pump that delivered glucagon as well as insulin, backpack style, was in the early '60s.

Omni Pod - the world’s first tubing-free insulin pump.

Insulin Delivery Modes Insulin Pumps

Newest Pumps

Recommended Goals for Therapy

A1C

∗Goals should be individualized based on ∗Duration of diabetes ∗Age/life expectancy ∗Comorbid conditions ∗Known CVD or advanced microvascular

complications ∗Hypoglycemia unawareness ∗ Individual patient considerations

Glycemic Recommendations for Adults

ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S37; Table 6.2

Glycemic Recommendations for Adults

∗More or less stringent glycemic goals may be appropriate for individual patients

∗ Postprandial glucose may be targeted if A1C goals are not met despite reaching preprandial glucose goals

ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S37; Table 6.2

Management of Hyperglycemia

ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S37. Figure 6.1; adapted with permission from Inzucchi SE, et al. Diabetes Care, 2015;38:140-149

∗ Fingerstick checks ∗ How often to check ∗ How to choose a monitor ∗ Medicare guidelines

∗ Continuous glucose monitoring (CGM) ∗ Personal CGM ∗ Medtronic, Dexcom, Navigator

∗ Continuous glucose monitoring – Diagnostic ∗ At least 3 days of data, review and written report ∗ Blinded or open view ∗ Medtronic Ipro – blinded ∗ Dexcom and Navigator - open view

Glucose Monitoring

Meter Download

Software

• Check pre and post BS readings • Make Changes

• Look at insulin or medication • CHO count • Assess food impact

Respond to the Data!

∗ Pattern assessment and Treatment Change -

∗ Basal Testing

∗ Prevention of hypoglycemia

∗ Prevention of hyperglycemia

∗ Assess the impact of food on blood glucose

∗ Assess the impact of exercise on blood glucose

∗ Behavior modification tool

∗ Alerts/Alarms: Safety, peace of mind…

Why Continuous Glucose Monitoring? Professional and Personal

• Increased security from alarms & alerts

• Immediate feedback - look and learn

• BG trend provides more information than static readings

• Control + safety

Benefits ofPersonal CGM

Glucose Monitoring - CGM

• by analyzing the trends, the patient or the physician can adjust insulin • leads to better glycemic control

http://images.google.com/imgres?imgurl=http://www.diatribe.us/images/body/photo_testdrive_5_1_large.jpg&imgrefurl=http://www.diatribe.us/issues/5/test-drive.php&usg=__t7rHWBxTraehl1yqRgVDBnnzaWw=&h=512&w=495&sz=61&hl=en&start=9&um=1&tbnid=zDg0K5oTApdhlM:&tbnh=131&tbnw=127&prev=/images?q=dexcom+image&hl=en&rlz=1T4ADBR_enUS298US298&sa=X&um=1http://images.google.com/imgres?imgurl=http://www.diabetescaregroup.info/freestylenavigator/freestyle-navigator.jpg&imgrefurl=http://www.diabetescaregroup.info/freestylenavigator/&usg=__P9Dm4jpCx2yjyInhPL5SfC003gc=&h=203&w=400&sz=24&hl=en&start=15&um=1&tbnid=mSqjM8arFJDpIM:&tbnh=63&tbnw=124&prev=/images?q=navigator+glucose+monitoring+system+image&hl=en&rlz=1T4ADBR_enUS298US298&um=1

100 mg/dl Glucose reading

OR

100 mg/dL dropping at rate of >2 mg/dL/min

Is CGM Better than FSBG?

FSBG – just a moment in time CGM adds an additional dimension, the rate of change and direction of change.

Trends Better Than Points

I have no clue

I feel fine but my

blood sugar is dropping!

Clinical Need – hypoglycemia, hypoglycemia unawareness, uncontrolled hyperglycemia

MOTIVATED patients/parents!

Willingness to learn and understand the process: it may be a rocky start

Understanding of how to use the data

Likely Candidates for CGM

Rate of Change Arrows

Gives the up-to-the-minute glucose value and a rate of change arrow

Glucose going down -1 to -2 (mg/dL)/min

Glucose going up 1 to 2 (mg/dL)/min

Glucose falling quickly >-2 (mg/dL)/min

Fairly stable glucose -1 to 1 (mg/dL)/min

Glucose rising quickly >2 (mg/dL)/min

Barbara Davis Center for Childhood Diabetes May 2008

Glucose Trends – CGM Report

Post-breakfast excursion

• There is a 10-20 minute lag time between interstitial fluid (ISF) glucose and BG

• Lag occurs with ALL subcutaneous sensors

• CGM is a trending device, NOT a treatment device

Sensor Lag Time: FSBG doesn’t always match the meter

Sensor Lag

Time (minutes) (0 = start if meal)

-40 -20 0 20 40 60 80 100 120 140

Bloo

d G

luco

se (m

g/dl

)

0

100

200

300

400

500

Freestyle Sensor

Sensor Lag Fingerstick Capillary Glucose (SMBG) Interstitial Fluid Glucose (CGM)

∗ No ~~ BG need to be done: 1. Before all treatment decisions and insulin

2. To verify symptoms of hypoglycemia

3. Before driving

4. Calibration

5. Before Activity

Does Using a CSM eliminate the need for glucose checking?

• The accuracy of all the CGM’s are dependent on the calibration phase

• Devices calibrate in 1-2 hours

• Must do a fingerstick BG to calibrate

• Do NOT calibrate when the BG is changing rapidly

When to calibrate?

1. Change behavior! • Bolus • CHO count • Assess food impact

2. Change Treatment

Respond to the Data!

Statistics

Accu-Chek Combo System

Asante Snap

Insulin Pump

System

MiniMed Paradigm Real-Time

Revel System

(523/723)

MiniMed 530G with

Enlite (551/751)

OmniPod Insulin

Manage-ment

System

OneTouch Ping

t:slim Insulin Pump

V-Go Disposable

Insulin Delivery Device

Roche Health Solutions

Asante Solutions

Medtronic MiniMed

Medtronic MiniMed

Insulet Corporation

Animas

Tandem Diabetes Care

Valeritas, Inc.

Insulin Pumps on the Market

∗ More reliable, precise insulin action ∗ Fewer missed doses ∗ Less insulin, less insulin stacking ∗ Fewer lows, especially at night ∗ Easier to exercise ∗ Less glucose exposure and variability ∗ Matches variable basal insulin need ∗ Fewer social limitations ∗ Better data access for providers and patients

Pump Advantages

∗ Improved Glycemic Control

∗ Improved pharmacokinetic delivery of insulin Less hypoglycemia Less insulin required Match insulin requirement to need

∗ Improved Quality of Life

∗ NOT NECESSARILY LESS TIME CONSUMING

Clinical Advantages of CSII

Method 1. Pre-Pump Total

Daily Dose (TDD)

Pre-Pump TDD x .75

Method 2. Patient Weight

Wt kg x .5 or lb x .23

Pump TDD

Calculations for Insulin Pump Settings

Basal Rate

(Pump TDD x .5) / 2- h

Sensitivity Factor / Correction

1700 / Pump TDD

-Start with 1 basal rate, adjust according to glucose trends over 2-3 days -Adjust to maintain stability in fasting state (between meals & during sleep) -Add additional basals according to diurnal variation (dawn phenomenon)

Carb Ratio

450 / TDD

-Adjust based on low-fat meals with known carbohydrate content -Acceptable 2-h post-prandial rise is ~60mg/dL above pre-prandial BG -Adjust carb ratio in 10%-20% increments based on post-prandial BG ALTERNATE METHODS -Carb Ratio: (6x Wt in kg / TDD) or (2.8 x Wt in lbs / TDD) -Fixed Meal Bolus = (TDD x .5) / 3 equal meals (not carb counting)

-Sensitivity Factor is correct if BG is within 30 mg/dL of target range within 2 hours after correction -Make adjustments in 10%-20% increments if 2-hr post- correction BGs are consistently above or below target

Clinical Considerations on Pump TDD -Average values from Method 1 & 2 -Hypoglycemic patients start at lower value -Hyperglycemic, elevated A1C, or pregnant start at higher value

Clinical Guidelines

TDD: total daily dose BG: blood glucose

1. Change behavior! • Bolus • CHO count • Assess food impact

2. Check basal rates

3. Use alarms

Respond to the Data!

1. Change behavior! • Bolus • CHO Count • Assess food impact

2. Check basal rates

3. Use alarms

Respond to the Data!

∗ Review History of glucose monitoring and insulin pump therapy

∗ Describe newer technologies ∗ Select appropriate patients for use of technology ∗ Define ways to incorporate into practice

Objectives

∗ Select appropriate patients for use of technology ∗ A1c not at goal ∗ Hypoglycemia, especially unawareness ∗ Changing therapy, adding insulin, MDI, pump therapy ∗ Documentation of nocturnal hypoglycemia ∗ Patient request

∗ Define ways to incorporate into practice ∗ Discuss and offer newer technologies ∗ Have Resources available ∗ Identify a CDE in an area Diabetes Education Program ∗ Partner with company based CDE programs

Objectives

Technology is only as good as the person using it! If Nothing

changes, then Nothing changes

Look for trends and ways to make appropriate

changes

And the provider evaluating it!

Boston University Associate Professor Edward Damiano

https://www.youtube.com/watch?v=xrXeAylgeTI

https://www.youtube.com/watch?v=xrXeAylgeTI

Technological Advances in Diabetes ManagementDisclosuresObjectivesSlide Number 4We’ve Come a Long Way!Initial Glucose MetersSlide Number 7Slide Number 8Slide Number 9Insulin Delivery Modes�Insulin Delivery Modes - PensInsulin Delivery Modes� Insulin PumpsNewest PumpsRecommended Goals for TherapyGlycemic Recommendations for AdultsGlycemic Recommendations for AdultsSlide Number 17Glucose MonitoringSlide Number 19Slide Number 20Slide Number 21Slide Number 22Slide Number 23Slide Number 24Meter DownloadSoftwareRespond to the Data!Why Continuous Glucose Monitoring?�Professional and PersonalSlide Number 29Benefits ofPersonal CGMGlucose Monitoring - CGMIs CGM Better than FSBG?Trends Better Than PointsLikely Candidates for CGMSlide Number 35Slide Number 36Glucose Trends – CGM ReportSensor Lag Time: �FSBG doesn’t always match the meterSensor LagDoes Using a CSM eliminate the need for glucose checking?�When to calibrate?Slide Number 42Slide Number 43Slide Number 44Respond to the Data!StatisticsSlide Number 47Pump AdvantagesClinical Advantages of CSIICalculations for Insulin Pump SettingsSlide Number 51Slide Number 52Respond to the Data!Slide Number 54Slide Number 55Slide Number 56Slide Number 57Slide Number 58Slide Number 59Respond to the Data!ObjectivesObjectivesTechnology is only as good as the person using it!Slide Number 64