technological advances in diabetes management · the management of diabetes. ... technological...
TRANSCRIPT
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22nd Annual Northeast Regional Nurse Practitioner Conference – May 6-8, 2015
Technological Advances in Diabetes ManagementPatti Duprey, MS, APRN
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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.
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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.
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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.
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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
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∗ Speaker Bureau ∗ Janssen ∗ Sanofi
Disclosures
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∗ 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
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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?
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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
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Initial Glucose Meters
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Updated Glucose Meters
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Glucose Meters Now
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Continuous Glucose Monitoring CGM
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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
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Newest Pumps
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Recommended Goals for Therapy
A1C
<7.0%*
Preprandial capillary plasma glucose
80–130 mg/dL* (4.4–7.2 mmol/L)
Peak postprandial capillary plasma glucose†
<180 mg/dL* (<10.0 mmol/L)
*Goals should be individualized. †Postprandial glucose measurements should be made 1–2 h after the beginning of the meal, generally peak levels in patients with diabetes.
ADA. 6. Glycemic Targets. Diabetes Care 2015;38(suppl 1):S37; Table 6.2
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∗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
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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
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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
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∗ 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
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Meter Download
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Software
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• Check pre and post BS readings • Make Changes
• Look at insulin or medication
• CHO count
• Assess food impact
Respond to the Data!
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∗ 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
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• Increased security from alarms & alerts
• Immediate feedback - look and learn
• BG trend provides more information than static readings
• Control + safety
Benefits ofPersonal CGM
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Glucose Monitoring - CGM
• by analyzing the trends, the patient or the physician can adjust insulin • leads to better glycemic control
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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.
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Trends Better Than Points
I have no clue
I feel fine but my
blood sugar is dropping!
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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
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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
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Glucose Trends – CGM Report
Post-breakfast excursion
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• 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
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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)
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∗ 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?
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• 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?
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1. Change behavior! • Bolus • CHO count • Assess food impact
2. Change Treatment
Respond to the Data!
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Statistics
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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
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∗ 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
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∗ 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
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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
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1. Change behavior! • Bolus • CHO count • Assess food impact
2. Check basal rates
3. Use alarms
Respond to the Data!
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1. Change behavior! • Bolus • CHO Count • Assess food impact
2. Check basal rates
3. Use alarms
Respond to the Data!
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∗ 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
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∗ 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
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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!
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Boston University Associate Professor Edward Damiano
https://www.youtube.com/watch?v=xrXeAylgeTI