Mindy Saenz RDN, LDN, CDE - PowerPoint Presentation

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2. Mindy SaenzRDN, LDN, CDEI Wear My Pancreas on the Outside: Insulin Pump and CGM BasicsClinical Dietitian/Certified Diabetes EducatorBrody School of Medicine at East Carolina University. Pediatric Specialty Care Greenville, NC

3. ObjectivesReview basal/bolus conceptDescribe how insulin pumps workDiscuss advantages and disadvantages of insulin pump therapyDiscuss day to day living with a pumpDiscuss how continuous glucose monitoring worksDescribe benefits and limitations of continuous glucose monitoringDescribe hybrid closed loops systemsDescribe the currently available insulin pump and continuous monitoring systems.

4. Insulin Pump Therapy

5. Mixing of short and intermediate insulin led to thinking of insulin action in blocks of time i.e. AM NPH covers lunch and afternoon, PM Regular covers time after dinner, etc.One part of the insulin acts as a basal component, the other as a bolusInsulin analogs permit thinking of the insulin based on it’s action. Long lasting or basal insulins are relatively flat and last 24 hours or longer and provide insulin overnight and between meals. Rapid acting or bolus insulins give coverage for meals and for correcting high blood glucose levels.Pumps use only rapid acting insulin for both basal and bolus requirements.Basal/bolus concept

6. BID NPH and Regular(Or 70/30 bid) _______________________ B L S HS

7. 4 Shots with Basal and Rapid-Acting Insulin ________________________ B L S HS Rapid-actingRapid-actingRapid-actingBasal

8. Insulin pump________________________ B L S HS

9. All pumps have the same basic components and deliver a pre-programmed basal rate and then are programmed to give bolus insulin on demand for food or high blood glucose levelsThe differences are the additional features such as no tubing, color screen, built in CHO database, ability to bolus from the meter, integrated CGM, waterproof, etc.Components of insulin pumps:Reservoir to hold 3 days worth of insulinMotor to push the insulin into the patientMenu-driven operating systemBattery and casingAll but OmniPod also have an infusion set (tubing) to get the insulin from the reservoir to the patient.Insulin pumps

10. Advantages of pumpsImproved glucose levels and reduced A1cLifestyle flexibility-shift work, travel, etc.Fewer injections/needlesYou have the tools you need on your body all the timeDecreased hypoglycemiaLess anxiety trying to keep on scheduleIncreased control with exerciseChild safety featuresImproved quality of lifeMultiple basal ratesTemporary basal ratesMultiple basal patternsAvoidance of long/intermediate-acting insulinMore precision in insulin deliveryMore accurate dosing for food intake-fractions of a unitBolus calculatorsEasier correction of high BGsWeight management

11. Risk of DKA if insulin delivery is interruptedBeing attached-constant reminder of diabetesPrivacy-visible in public and may promote unwanted questions.Skin issuesInfusion set issuesMissing bolusesWeight gainMachines can fail and breakCostDisadvantages of pumps

12. Inadequate BG controlFrequent hypoglycemiaDawn phenomenonExercisePediatricPre-conception/pregnancyHectic lifestyleShift workGastroparesis? Anyone with diabetesPump therapy indications

13. Patient Selection CriteriaWants to improve glucose controlDesires to live a more normal lifeHas family supportAbility to problem solveHas realistic expectationsMotivated to take insulinWilling to monitor and record BG-minimum of 4 per day (can be less if wearing CGM)Willing to quantify food intakeWilling to follow-up

14. Provide the names of the companies and their brochures to the patientExplain the similarities and differencesLet the patient choose!Which pump?

15. Living with a pump-where to wearClipped to beltIn a pocketTucked in braSpecial pump clothing with pockets sewn insidePump accessories such as a “thigh thing”, zipper bag or back harness are sold by the companies

16. Living with a pump-sleepClip to pajamas or underwearPut it under a pillowBuy special pump clothing with pocketsLeave it loose next to you

17. Living with a pump-bathingMost pumps are watertight, but usually patients simply disconnect and leave it on the counter

18. Living with a pump-intimacyCan disconnect—have to make sure to reconnect prior to falling asleepLeave it connected and just move it if it gets in the way

19. Living with a pump-exercise/sportsMost people just wear it and use a lower temporary basal rateFor intense activity they can disconnect-check BG every hour and reconnect and take a small bolus if neededMost kids choose to disconnect and may even need extra food in addition to disconnecting.

20. Continuous Glucose Monitoring(CGM)

21. Self-monitoring of BG provides only a “snapshot”- and many patients don’t reach targetsCGM providesReal time information about current glucose concentrationFeedback about the effectiveness of interventionWarnings when glucose concentrations become dangerously high or low (except Libre)Alerts can be used preemptively to avoid hypo-and hyperglycemiaCGM changes the way we interpret glucose data

22. 4 checks/day are good but what do we miss?

23. Sensor-thin flexible wire inserted beneath the skin into the interstitial fluid space using an introducer needle (26 gauge to 22 gauge)Transmitter- seated into a plastic pod or clicked into the side of the sensor, Libre is all one pieceReceiver- either pump, phone or separateCGM components

24. Display and record glucose levels throughout the day and night (Libre only when scanned)Provide direction and rate of change of glucose information to help maintain euglycemiaProvide alerts if glucose is traveling outside of targets (not Libre)Measure glucose in the Interstitial Fluid spaceUse an electrochemical process for sensing glucoseCurrently 4 companies with FDA approved patient systems.CGM systems

25. CGMBenefitsAlerts for lows & highs (not on Libre)Rate of change alarms help prevent lows and highsIdentify trends for dose adjustmentsImmediate feedback on how changes in diet, exercise and insulin affect BGDecreased variability-less hypo-/ hyperglycemiaLimitationsAlarmsAnnoying and disruptiveCannot always be heardExpensiveTime consumingMust be worn frequently to get benefits***Patients/Parents need to have reasonable expectations

26. Better glucose managementAvoiding frequent hypoglycemiaPreventing hypoglycemia unawarenessUnderstanding the effects of particular foods on post meal BGOvernight safetyLiving aloneFrequent driving, travel, high-risk professionsYoung children unable to report hypoglycemiaTight control before and during pregnancyAvoiding complicationsPeople choose cgm for:

27. Person and family are interested in itPerson is willing to wear a sensorStable and adequate diabetes care team to help manage the infoWillingness to change the way they think about BG and insulin dosingEnough body fat to wear the sensorAble to afford itWho should use CGM

28. Artificial Pancreas(Closed Loop System/hybrid closed loop)

29. The currently FDA approved system and those looking to be approved over the next year are hybrid closed loop systems. This means that they can deliver insulin based on sensor readings using an algorithm to either increase or decrease the persons insulin as long as certain conditions are met.They all require input when the person eats carbohydrate. They still require site and sensor changes and fingersticks may still be required for calibration and algorithm updates. Require more training and work on the part of the patient and the healthcare team.Patients and families need to have realistic expectations.Hybrid closed loop

30. What’s currently available?

31. VGO

32. Insulet OmniPod

33. Omnipod DASH™ Mobile AppsOmnipod DISPLAY™ AppSecondary PDM display on personal SmartphoneOmnipod VIEW™ App12 Caregivers can view Pod info on personal SmartphoneToday View WidgetCGM and Pod single screen view on iOS devicesThe Dexcom System does not have integrated functionality with the Omnipod DASH™ System

34. Medtronic MiniMed Revel

35. Freestyle Libre Flash

36. Dexcom G5 and G6

37. Medtronic MiniMed Guardian Connect

38. Eversense CGM

39. Tandem t:slim X2 and X2 with Basal-IQ

40. Medtronic MiniMed 530g

41. Medtronic Minimed 630g with enlite

42. Medtronic Minimed 670g with guardian

43. Faster rapid-acting insulin Better sensors with improved accuracy and less lag timeConsideration of the use of other hormones (glucagon, amlyin, leptin)Algorithms to integrate all of the above that can account for acute changes in activity levels and/or hormonal changesWhat we need for fully closed loop?

44. Insulin Pumps and Continuous Glucose Monitoring: A User’s guide to Effective Diabetes Management. Francine R. Kaufman, MD with Emily Westfall 2012Pumping Insulin. John Walsh, PA, CDTC and Ruth Roberts, MA. 5th edition 2013Think Like a Pancreas. Gary Scheiner, MS, CDE. Revised edition 2011Tanenberg: The Insulin Pump Book, MiniMed 1995: 21-30www.medtronicdiabetes.comwww.myomnipod.comwww.tandemdiabetes.comwww.dexcom.comwww.bionicpancreas.orgwww.eversensediabetes.comhttp://integrateddiabetes.com/2018-new-insulin-pump-comparisons-and-reviews/Resources/references

45. Disclosure to ParticipantsNotice of Requirements For Successful CompletionPlease refer to learning goals and objectivesLearners must attend the full activity and complete the evaluation in order to claim continuing education credit/hoursConflict of Interest (COI) and Financial Relationship Disclosures:Mindy Saenz, RDN, LDN, CDE has no COI or financial disclosures.Non-Endorsement of Products:Accredited status does not imply endorsement by AADE, ANCC, ACPE or CDR of any commercial products displayed in conjunction with this educational activityOff-Label Use:Participants will be notified by speakers to any product used for a purpose other than for which it was approved by the Food and Drug Administration.