Technological Advances in Diabetes Management. Patti Duprey, MS, APRN

Transcription

1 Technological Advances in Diabetes Management Patti Duprey, MS, APRN 22nd Annual Northeast Regional Nurse Practitioner Conference May 6-8, 2015

2 DISCLOSURES 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.

3 ACCREDITATION 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.

4 SESSION OBJECTIVES Identify various tech devices to assist in the management of diabetes. Describe appropriate patient selection for different devices. 22nd Annual Northeast Regional Nurse Practitioner Conference May 6-8, 2015

5 Technological Advances in Diabetes Management Duprey Consultants, LLC Patti Duprey, MSN, APRN, CDE Private Practice Conway, NH Kennebunk, ME

6 Disclosures Speaker Bureau Janssen Sanofi

7 Objectives 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

8 Do We Need Technology? 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

9 We ve Come a Long Way! This tastes sweet, it must be Diabetes Mellitus So.. this means my blood sugar is between something and something

10 Initial Glucose Meters

11 Updated Glucose Meters

12 Glucose Meters Now

13 Continuous Glucose Monitoring CGM

14 Insulin Delivery Modes

15 Insulin Delivery Modes - Pens

16 Insulin Delivery Modes Insulin Pumps 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.

17 Newest Pumps

18 Recommended Goals for Therapy A1C <7.0% * Preprandial capillary plasma glucose mg/dl * ( 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

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

20 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

21 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:

22 Glucose Monitoring 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

23

24

25

26

27

28

29 Meter Download

30 Software

31 Respond to the Data! Check pre and post BS readings Make Changes Look at insulin or medication CHO count Assess food impact

32 Why Continuous Glucose Monitoring? Professional and Personal 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

33

34 Benefits ofpersonal CGM Increased security from alarms & alerts Immediate feedback - look and learn BG trend provides more information than static readings Control + safety

35 Glucose Monitoring - CGM by analyzing the trends, the patient or the physician can adjust insulin leads to better glycemic control

36 Is CGM Better than FSBG? FSBG just a moment in time CGM adds an additional dimension, the rate of change and direction of change. 100 mg/dl Glucose reading OR 100 mg/dl dropping at rate of >2 mg/dl/min

37 Trends Better Than Points I feel fine but my blood sugar is dropping! I have no clue

38 Likely Candidates for CGM 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

39 Rate of Change Arrows Gives the up-to-the-minute glucose value and a rate of change arrow Glucose rising quickly >2 (mg/dl)/min Glucose going up 1 to 2 (mg/dl)/min Fairly stable glucose -1 to 1 (mg/dl)/min Glucose going down -1 to -2 (mg/dl)/min Glucose falling quickly >-2 (mg/dl)/min Barbara Davis Center for Childhood Diabetes May 2008

40

41 Glucose Trends CGM Report Post-breakfast excursion

42 Sensor Lag Time: FSBG doesn t always match the meter There is a 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

43 Sensor Lag Sensor Lag Freestyle Sensor Fingerstick Capillary Glucose (SMBG) Interstitial Fluid Glucose (CGM) Blood Glucose (mg/dl) Time (minutes) (0 = start if meal)

44 Does Using a CSM eliminate the need for glucose checking? 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

45 When to calibrate? 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

46

47

48

49 Respond to the Data! 1. Change behavior! Bolus CHO count Assess food impact 2. Change Treatment

50 Statistics

51 Insulin Pumps on the Market 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 Management 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.

52 Pump Advantages 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

53 Clinical Advantages of CSII 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

54 Calculations for Insulin Pump Settings Clinical Guidelines Method 1. Pre-Pump Total Daily Dose (TDD) Pre-Pump TDD x.75 Basal Rate (Pump TDD x.5) / 2- h -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) Method 2. Patient Weight Wt kg x.5 or lb x.23 Pump TDD 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 Carb Ratio 450 / TDD Sensitivity Factor / Correction 1700 / Pump 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 postcorrection BGs are consistently above or below target TDD: total daily dose BG: blood glucose

55

56

57 Respond to the Data! 1. Change behavior! Bolus CHO count Assess food impact 2. Check basal rates 3. Use alarms

58

59

60

61

62

63

64 Respond to the Data! 1. Change behavior! Bolus CHO Count Assess food impact 2. Check basal rates 3. Use alarms

65 Objectives 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

66 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

67 Technology is only as good as the person using it! Look for trends and ways to make appropriate changes If Nothing changes, then Nothing changes And the provider evaluating it!

68 Boston University Associate Professor Edward Damiano