22nd Annual Northeast Regional Nurse Practitioner Conference – May 6-8, 2015 Technological Advances in Diabetes Management Patti Duprey, MS, APRN
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 [email protected]
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
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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