Clinical Case Studies (Insulin Delivery)
Donna Tomky, MSN, RN, C-NP, CDE, FAADE, CDTCABQ Health Partners, Albuquerque, New Mexico
InsulinDelivery:Pumps,Pens&More
ClinicalCaseStudiesBy
DonnaTomky,MSN,RN,BC-ANP,CDE,FAADE,CDTCABQHealthPartners
DeptofEndocrinology&DiabetesAlbuquerque,NM
Disclosures
• Consultant:BectonDickinson,Voluntis
• Speaker: ProgramManagementServices,Inc.
CaseStudyforInsulinPens• 71yo NativeAmericanfemalewithT2DMx8yrs.Lives
withdaughter&9yo grandson• Novolog(flexpen)5-10unitsbeforemeals,Lantus 25
unitsatbedtime• A1Cof9.3%,Wt147lbs,BMI28• DifficultydrawingupLantuswithoutglasses&gives
insulininjectionat45degreeanglewithinsulinsyringe(doesn’tknowaboutLantuspen-likesNovologpen)
• Localizedfibrosis&ecchymosis bilaterallowerabdomen
• Checkingbloodsugar1-2timesaday– glucoserangefrom86-465mg/dl
Whatisyourassessmentofproblems?(Groupactivity)
• Diabetesuncontrolled• PossiblynotalwaysgettingprescribedLantusdosebecauseofpoorvision(20-80%ptsmakeerrors1)
• Notrotatinginjectionsites• Possiblygettingintra-dermalinjections• Non-adherence(estimates30-60%)1-3
1.Meichenbaum D,TurkDC.FacilitatingTreatmentAdherence:APractitioner'sGuidebook. NewYork:PlenumPublishingCorp;1987.2.Buckalew LW,Sallos RE.Patientcomplianceandmedicationperception.JClin Psychol. 1986;42:49-53.Sackett DL,SnowJC.Themagnitudeofcomplianceandnoncompliance.In:HaynesNRB,TaylorDW,Sackett DL,eds.3.ComplianceinHealthcare. Baltimore:JohnsHopkinsUniversityPress;1979:11-22.
PossibleSolutions(GroupActivity)• SwitchtoLantus solostar
pen• Reviewproperinjection
techniqueandrotationofsites– “Airshot”orprimingofpen– Dialingupdose– Adequatestrength&
dexterityforoperatingdosingbutton
– Pushdosingbuttondown(Notdialingdown)
– Assessforfibrosis• StepupSBMGac&hs• Use4or5mmpenneedle
Applications-PumpCaseStudy
1. Choosingtherightpumpforeachpatient
2. Determiningtotaldailyinsulindoses3. Determiningandadjustingbasaldoses
4. Determiningbolusdoses
5. Calculatingtheinsulin–carbohydrateratio(ICR)6. Calculatingtheinsulinsensitivityfactor(ISF)
7. Calculatinginsulinonboard(IOB)andavoidingstacking
Application– PumpCaseStudy
• Janetis36-yofemalew/T1DMx3yrs
• Patienthascollegedegree,stayathomemom&extremelybusylifewith4children– 5yo son&with3yotriplets.Patientstruggleswithweight
Janet– PumpCaseStudy• Currentinsulindoses:– Lantusinsulin- 12unitsBID,HumalogKwikpenadjusteddoses1unitforevery12gofcarbohydrateandcorrectionfactorIunitforevery25above150
• MonitoringglucosewithaOneTouchmeter5-8timesaday.Averageglucose158mg/dl,rangingfrom55-398mg/dL
• A1C- 7.1%-8.6%;Wt-161,Ht-59”(4’11”)BMI-31.8
WhichpumpisbestforJanet?
1. Medtronic530G2. Omni-Pod3. TandemT-SlimG44. AnimasVibe5. Accuchek Combo
•
ConsumerGuide2015.DiabetesForecast,Mar/Apr2015
WhichpumpisbestforJanet?
PUMPBRAND1. Medtronic530G
2. Omni-Pod
3. TandemT-SlimG4
4. AnimasVibe
5. Accuchek Combo
ONEUNIQUEFEATURE• LinkstoEnlite CGMsensor
• Patchpump– notubing
• ColortouchscreenandlinkstoDexCom G4CGM
• OnetouchmeterremotecontrolLinkstoDexCom G4CGM
• Accuchek meterremotecontrol
WhichpumpisbestforJanet?
PUMPBRAND1. Medtronic530G2. Omni-Pod3. TandemT-Slim4. Animas5. AsanteSnap6. Accuchek Combo
ONEUNIQUEFEATURE• LinkstoEnlite CGMsensor• Patchpump– notubing• Colortouchscreen• LinkstoDexCom G4CGMsensor• 300unitprefilledcartridge• Accuchek meterremotecontrol
ANSWER:TheonethatfitsJanet’slifestyleandneeds
StartbydeterminingJanet’sTotalDailyDose(TDD)?
• TDDissumofbasal,bolus&correctioninsulin• Majorfactorforcontrollingglucose-A1c• CloselyestimatesBolusCalculatorsettings• Methodsforcalculating:
1. UseReducedInjectionDoseapproach
2. UseWeightBaseapproach
3. Combinationofboth
4. ConversionfromMDIDoses
DeterminingJanet’sPumpTotalDailyDose(TDD)?
Reduce Injection Dose (RD)• Based on daily Injection Doses
(basal, bolus, CF)• Injection Dose x 0.75 (75-80%)
=RD
Weight Dose (WD)• Based on Weight• Lb x 0.23 units =Wt Dose • or kg x 0.50 u= Wt Dose
Initial Pump TDD
Take average of Reduced and Weight Dose
(Reduced Dose + Weight Dose) ÷2 = Pump TDD
BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulin PumpTherapyInitiation
WhatisJanet’sTotalDailyDose(TDD)?
ReduceInjectionDose(RD)• InjectionDosex0.75=RD• Janet’sTDD=24uLantus +
7uTIDofHumalog=45ux0.75=33.75u/day(TDD)
WeightDose(WD)• Lbx0.23u=WDorkgx0.50
u=WD• 161(wt-lbs)x0.23u=37• (161/2.2)=73kgx0.5u=36.5
Initial Pump TDD (33.75 u/day +37 u/day)÷2 = 35 u/day
BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation
ConsiderationsforBasalInsulin
• TotalBasalDose(TBD)=U/dachievestargetBGforfasting(>4hrpp),controlsearlyam,dawnphenomenon,w/ohypoglycemiaifmealmissed
• SingleorMultipleBasals– Besttostartwithsinglebasal– Considermultiplebasals fordawnphenomenonor
physicallyactiveduringdayorifuniquepatternidentified• Basalinsulinaccounts~50%ofTDD
– Adults– 40-50%– PubertytoAdult—30-40%– Pre-pubertytoPuberty—20-40%
Determining&AdjustingBasalDoses
• Method1:Basalrate=TDDx40-50%– DailyBasalDose÷24=u/h(1conventional)
• Method2:Basalrate=TDDx0.48÷24(2APP)• AdjustbasalratesbasedonSMBGorCGMpatterns
• Nighttimebasalratesshouldbefine-tunedbeforedaytimebasalrates
2WalshJetal.GuidelinesforOptimalBolusCalculatorSettingsinAdults.JofDiab Science&Technology.Vol 5,1,Jan2011.
1 BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation
WhatisJanet’sBasalRate• Method1:Basalrate/hr=(TDDx
0.5)÷24hrs (1conventional)– 35unitsx0.5÷ 24hrs– 17.5units÷ 24hrs =0.729or0.75u/h
• Method2:Basalrate=TDDx0.48÷24 (2APP)– 35unitsx0.48÷ 24hrs– 16.8÷ 24hrs =0.7u/h
1 BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation2WalshJetal.GuidelinesforOptimalBolusCalculatorSettingsinAdults.JofDiab Science&Technology.Vol 5,1,Jan2011.
DeterminingBolusI:CDoses
• Insulin-to-CarbohydrateRatio(ICR)– #ofunitsthatreturns
theBG+/-20%ofpre-mealBGin2-4hrs
– 1unitofinsulincovers#gramsofcarbohydrates
– Patientsmayneeddifferentratiosthroughouttheday
DeterminingBolusI:CDoses
• Methodsforcalculating– ConvertfromMDIregime(if
wellcontrolled)– EstimateDailyCarbIntake1
• TotalCarbGrams÷ TotalDailyBolus(~50%TDD)=ICR
– 450(500)Rule(Conventional)1• 450(500)÷ PumpTDD=ICR
– ICR=[2.6xWt(lb)]÷ TDD(APP)2
1BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation2WalshJetal.GuidelinesforInsulinDosinginCSIIusingnewformulasfromretrospectivestudyofindividualsw/optimalglucoselevels.JofDiab Sci &Tech.Vol 4,Sept2010
WhatisJanet’sICR• Method1:
450(500)Rule(Conventional)1
– 450(500)÷ PumpTDD=ICR• 450÷ 35(TDD)=12.8=1:13• 500÷ 35(TDD)=14.3=1:14
• Method2:ICR=[2.6xWt(lb)]÷ TDD(APP)2- ICR=[2.6x161lbs]÷ 35- ICR=418.6÷ 35- ICR=11.96=1:12
• Janet’sPreviousICR=1:121BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation2WalshJetal.GuidelinesforInsulinDosinginCSIIusingnewformulasfromretrospectivestudyofindividualsw/optimalglucoselevels.JofDiab Sci &Tech.Vol 4,Sept2010
CarbohydrateCountingApproaches
• Basic Carb Counting– Consistent amounts of carb at meals &
snacks– Some find it difficult to be consistent
• Advanced Carb Counting– Insulin dose is adjusted to match carb intake– Accuracy of insulin dose depends on ability to
estimate/measure food portions and knowledge of amount of carbs/portion
• WAG Carb Counting –commonly used
Notasimpletask…
CarbCountingTools
“PumpingInsulin”byWalshJ&RobertsR
ThreeTypeofBolusInsulin
RegularorNow§ Takeimmediately—formostmeals
Combo/Dualwave§ Somenow,somelater–beanburrito,
somepastas,pizza,Symlin
Extended/Squarewave§ Extendedovertime-- gastroparesis
%In
sulin
Time(hours)012345678
01
0203
04
05
06070
809
01
00%
DeterminingBolusCorrectionFactor(CorrF)orInsulinSensitivityFactor(ISF)
• CorrectionFactor(CorrF)orInsulinSensitivityFactor(ISF)– Usedtocalculate
correctionbolusamountstoreturnBG+/-20%oftargetBGin2-4hrs
– Thenumberofmg/dlthat1unitofinsulinlowersBG
– InsulinsubtractedfromfoodboluswhenBG<target
DeterminingBolusCorrF Doses
• Methods– 1700Rule1
• 1700÷PumpTDD=ISF
– 2000Rule(frequenthypoglycemia) 2• 2000÷ PumpTDD=ISF
– 1960Rule(nearnormal-144mg/dl~BG)3• 1960÷ PumpTDD=ISF
1DavidsonPetal.AnalysisofGuidelinesforBasal-Bolusinsulindosing.EndocrinePractice.Dec20082BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation3WalshJetal.GuidelinesforInsulinDosinginCSIIusingnewformulasfromretrospectivestudyofindividualsw/optimalglucoselevels.JofDiab Sci &Tech.Sept2010
WhatisJanet’sCorrF orISF?• Method1:1700Rule1
– ISF=1700÷35àISF=49
• Method2:2000Rule(frequenthypoglycemia) 2– ISF=2000÷ 35àISF=57
• Method3:1960Rule(nearnormal-144mg/dl~BG)3
• ISF=1960÷ 35à ISF=56
• Janet’sPreviousISF=251BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation2WalshJetal.GuidelinesforInsulinDosinginCSIIusingnewformulasfromretropective studyofindividualsw/optimalglucoselevels.JofDiab Sci &Tech.Vol 4,Sept2010
DeterminingTargetBloodGlucose• CorrectionBolusandTargetBloodGlucoseorRange– TheBGorrangeofglucosevaluestheboluscalculatorusestodetermineifcorrectiondoseisneeded
BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation
DeterminingBolusActiveInsulin• ActiveInsulinTime– Thelengthoftimethecalculatortracksactiveinsulinafterbolusisgiven
– Avoidsstackingofinsulin– Considerinsulinaction
• ClinicalConsiderations– Adults:4-5hours– Children:3-4hours– Pregnancy:3-4hours
BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation
WhatshouldJanet’sTargetBG&ActiveInsulin?
• Historyofhypoglycemiaunawareness• Consider110-130mg/dl–night
time
• Consider100-120mg/dl– daytime
• Janet’sPreviousISF=25• NewISForCF=49-57=50
• ActiveInsulinTime=4hrs1BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation2WalshJetal.GuidelinesforInsulinDosinginCSIIusingnewformulasfromretropective studyofindividualsw/optimalglucoselevels.JofDiab Sci &Tech.Vol 4,Sept2010
BasalRateAdjustments
• Overnightvs DaytimeBasalRates– Lastdoseofbolusinsulin4hrspriortotest– Assessovernightcontrolrise/fallpatterns– Assessdaytimecontrolbyskippingmeal-time– Goal- BGstablewithintarget(+/-30mg/dl)– IfBGrise/fall>30mg/dlà adjustrateá 10-20%~2-3hrsbefore
– IfBGdropsbelow70mg/dlà treatàâ 10-20%
BolusAdjustments
• Insulin-to-CarbRatios(ICR)– Goal:2hppBGisbetween30-60mg/dlhigherthanpre-mealBG• Bolusesmissedorlate?• Accuratecarb counting?• Adheretopumpcalculatoradvise?
• InsulinSensitivityFactororCorrectionBolus– Goal:Post-correction,2-hrBG~halfwaytotarget&attargetby4hrs
TwoWeekGlucoseMeterSummary
FollowupData– Meter
StatisticsAverage Glucose 146 mg/dL
Sensor Usage 7 of 7 DaysCalibrations / day 3.3Standard Deviation ± 43 mg/dL
61 % High
39 % Target
1 % Low
Target Range 80 - 130 mg/dLNighttime 10:00 PM - 6:00 AM
CGMData– Refinement&Safety
ConsiderPumpSafety&EnhancementFeatures
• MaximumBolusdose• MaximumBasalrate• Lowreservoiralert• Sitechangealert• Settingalert2hrs aftersitechangetocheckBG• Auto-Off• CGMalerts• Customreminders
Onemorethought&casestudy…
• ReferredforFrequentseverehypoglycemicevents(>1x/wk duringday)
• SMBG5-6xperday• A1Crange7.3-9.0%• Insulinregime:Lantus10
unitsqam;NovologonlyCF- 1unitforBG>300
• Wt - 100lbs;Ht – 5’1”• Cr-0.83mg/dl;GFR-83• Nonephropathy
• Smokerw/frequentURI&pneumonias
• Significantstresswithworkandfamily– onantidepressant
• Endocrinologyworkupforadrenalinsufficiency,&celiacisnegative
• Hypothyroidismstable
MeetTJ… 48yo Fw/T1DMx45yrs
TJ…continued• Endocrinologistchangedinsulinregime– SplitLantusto6unitsqAMand2unitsqPM– TriedToujeobuthypoglycemiawasworse– PatientrestartedLantus7unitsqAM
• StartedCGMwhichhelpedreduceseverehypoglycemicepisodes
• HadaseverehypoglycemicepisodewhilewearingCGM,butalsodiagnosedwithpneumoniaintheER
• ReferredtoNP/CDEforpumppreparation
TJsCGMRecordsHighBGs
• What does the A1c level tell you? 7.3% indicates reasonable control
• What does the history tell you? Erratic BGs and multiple severe hypoglycemic episodes. Work up for other endocrinopathies negative, except for hypothyroidism which is stable. Has tried several basal insulin adjustments and uses bolus insulin sparingly
• What do the glucose records tell you?– Identify the problem – Severe hypoglycemia disabling
patient, on medical leave from work and not driving.– Determine the pattern/trend – Day time low blood
glucose and night time high blood glucose; not checking BG before dosing insulin.
– Identify the cause(s) – Not enough information based on above
• What’s your approach? Ask more questions about behaviors and do focused exam
Putting it all together?
BGResults
WhatEffectsBloodGlucoseResults?
Physical Activity•Change in type,
frequency, duration, or intensity
Eating· Effect of type, amount, frequency, timing of food and alcohol on glucose,
special situations
MedicationChange in timing, amount, delivery, dose accuracy, lipodystrophy, polypharmacy
Acute Problems Illness, stress or acute
complications, co-morbid conditions
Complications or RisksPhysical infirmities, gastroparesis, visual
impairment, renal function, pregnancy
Coping SkillsStress, change in
coping skills, depression, cognition,
social isolation Self-CareBehaviorsAre
Important!
WhataboutTJ’sSelf-Care?
• Lipohypertrophy—usingforallinjections(48-65%prevalence)1,2
• Using8mmpenneedle• Usinginsulinpenbuthasneverknownaboutgivingan“airshot”
• FocusedExam…
1.BlancoMetal.Prevalence&riskfactorsoflipohypertrophy ininsulin injectingpts w/dm.DiabetesMetab.2013.2.Ji Letal.Lipohypertrophy –prevalence,&riskfactors&clinical characteristics ofinsulin-requiringpatientsinChina.AbstractEASDVienna2014.
NextStepsforTJ…• Identify the cause(s)—
– Lipodystrophy injection sites causes insulin absorption variability
– Possible IM injections with 8 mm needles– Incorrect Injection technique maybe causing dosing
errors– Dosing insulin and treating low BG without verifying
CBG• What’s your approach?
– Options: 1)Avoidlipohypertrophy areas;2)Changeto4mmpenneedle;3)Correctinjectiontechnique;4)Trydegludec insulin;5)Use½unitdosingpenforNovolog;5)PrepareforCSII
– Shared Decision: Action Plan: All of the above agreed upon
InSummary• Patientselectionandadherenceiscritical• Initiationandtraining• PatientcenteredàIndividualizesettings• Problemsolvingskills/behaviorscriticalforsuccessfulpumpexperience
• Accuratedataiscriticalformakingdecisions• Focusedexamofsitesateveryvisitoratleastannually
• Planandprovideongoingevaluationandsupportbyentireteam
Muchas Gracias– Questions?