9/5/20151 diabetes 2012: pump, sensors, current medical therapy & future dreams shannon kelley...
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04/19/23 1
Diabetes 2012: Pump, Sensors, Current Medical Therapy & Future Dreams
Shannon Kelley Oates MDFebruary 2012
04/19/23 2
Diabetes Introduction
Why we need to consider the impact
How large is the problem? How can you understand what it is
to be a person with diabetes?
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Diabetes Mellitus
Type 1 Rare—affecting only 1
in 250 (1 in 400 kids) 15,000 new cases per
year Low rates in Black and
Asian populations
Type 2 Common Probably 25 million
cases in the US. 1/3 cases undiagnosed
Projected prevalence of 11% WOW! Over age 65, 27% with DM
Cost: $ 218 billion in 2007
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Diabetes MellitusType 1 and Mortality
Mortality rates for people with DM Type 1 are 5 to 7 times the general population
More than 15% of people with DM type 1 will die by age 40
They die of DKA, of renal failure, of cardiovascular disease
Life expectancy is reduced by 15 years
Competence Questions
1. What are the indications for an insulin pump?
a. desire for a pump and insulin use b. diabetes type 1 if on Medicare c. diabetes type 2 for many
commercial insurances
d. Insulin use
Competence Questions
2. Name 3 new diabetes therapies in the last few years
a. Exenetide, bromocriptine, glimepiride
b. Bromocriptine, linagliptin, saxagliptin
c. Carbohydrate counting, continuous glucose monitoring, insulin
pumps
Competence Questions
3. Continuous glucose monitoring can be used
a. only with a pump b. only with multidose injection insulin
therapy c. must be used daily d. costs about $35 per week on-going
costs
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Take Home Goals
Think like a pancreas
Give enough insulin
Get and give loads of education
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DinnerBreakfast Lunch
Insulin Secretion- Physiology
Polonsky, N Engl J Med 1996; 334: 777-783
Serum insulin
Time of Day
Insu
lin
(m
U/L
)
70
12:00pm
3:00pm
6:00pm
9:00pm
12:00am
3:00am
6:00am
9:00am
10
30
50
0
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BiggerDinner
Breakfast SkipsLunch
Insulin Secretion- Physiology
Polonsky, N Engl J Med 1996; 334: 777-783
Serum insulin
Time of Day
Insu
lin
(m
U/L
)
70
12:00pm
3:00pm
6:00pm
9:00pm
12:00am
3:00am
6:00am
9:00am
10
30
50
0
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Intensive Therapy
Decreases risks of microvascular disease Retinopathy 75% reduction Nephropathy 50% reduction Neuropathy 60% reduction
Goal is to achieve normoglycemia Measure BS frequently Increases risk of hypoglycemia
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Insulin Time-Action Patterns
Time (hours)
Baseline
Level
Regular insulin
Premix 70/30
s.c. Injection
Normal Insulin Secretionat Meal Time
NPH Insulin
Ch
ang
e in
Ser
um
In
suli
n
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Insulin Time-Action Patterns
Time (hours)
Baseline
Level
Regular insulin
Premix 70/30
s.c. Injection
Normal Insulin Secretionat Meal Time
NPH Insulin
Ch
ang
e in
Ser
um
In
suli
n
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Insulin Aspart
Thr
Lys
AspThr
Tyr Phe Phe Gly ArgGlu
Gly
Glu
Cys
Val
Leu
Tyr
Leu
Ala
Val
Leu
His
Ser
GlyCysLeuHisGlnAsnValPheB1
Asn CysTyr
Asn
Glu
Leu
Gln
Tyr
LeuSerCysIleSerThrCys
Cys
Gln
Glu
Val
Ile
Gly
B20
A21
A1
B28B30
AspPro
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DinnerBreakfast Lunch
Normal Insulin Secretion
Polonsky, N Engl J Med 1996; 334: 777-783
Serum insulin
Time of Day
Insu
lin
(m
U/L
)
70
12:00pm
3:00pm
6:00pm
9:00pm
12:00am
3:00am
6:00am
9:00am
10
30
50
0
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Insulin Regimens
Twice a day mixed insulin Once daily long acting with lispro or
regular with each meal Twice daily intermediate or long acting
insulin with lispro or regular at each meal Once a day long acting insulin with
lispro/aspart/glulisine at each meal CSII is continuous subcutaneous insulin
infusion this is insulin pump
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Insulin Pen or Syringe Injections with MDI can approach the Ideal
Insulin pens are very handy
Use ONLY on one person
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CSII or Insulin Pump
Programmed basal rate of insulin and calculated boluses with carbohydrate intake
Place needle or catheter subcutaneously every 3 days
Short or rapid insulin analog only Special attention to prevent DKA
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Pump Manufacturers
MiniMed www.minimed.com Several pumps Great support
Animas www.animas.com Implantable monitor in testing phase
Omnipod No tubing www.myomnipod.com
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Way Cool
A 15 year old can sleep in until noon on the weekend and not get up and take an injection and eat breakfast
Indications? Desire for a pump Some understanding of
the limitations of the technology
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Newer Meters
Call 1-800 Number if you have ??
Bayer USB meter Iphone add-on meter iBGStar
iPhone App- Wavesense
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Patient versions of Continuous Monitoring or CGM
Dexcom 7Medtronic Real time or Guardian
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Two Versions of CGM
Professional
1. If we need more information, we can do the “Holter Monitor” of glucose
2. Several days of glucose data with meals and insulin data from the patient
Personal
1. The patient sees the glucose data as it is produced
2. Can be used continuously or intermittently
3. Cost about $35 cash per usage
Up to 75% of severe hypoglycemic Up to 75% of severe hypoglycemic episodes in children occur at night* episodes in children occur at night*
*Ahmet A, Dagenais S, Barrowman NJ, et al. Prevalence of nocturnal hypoglycemia in pediatric type 1 diabetes: a pilot study using continuous glucose monitoring. J Pediatrics, 2011;159 (2): 297-302.
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Transplants
Whole pancreas transplants usually along with kidney
Technical difficulties with islet only transplants
Autotransplantation of islets– only if we take out your pancreas for NON diabetes reason
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Exenatide
(GLP-1 re
ceptor agonist
)
Sitaglip
tin
(DPP-IV in
hibitor)
Liraglutid
e
(GLP-1 re
ceptor agonist
)
.
2005 2006 2007 20102008 2009
Saxagliptin
(DPP-IV in
hibitor)
Newer Classes of Antidiabetes Therapies: The Era of Incretin-based Therapies plus …
Food and Drug Administration. accessdata.fda.gov. Accessed 25 May 2010.
2012
Exe
natid
e XR
(GLP
-1 re
cept
or a
goni
st)
Brom
ocrip
tine
(dop
amin
e ag
onist
)
Cole
seve
lam
(bile
acid
bind
er)
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Best of the Web
www.diabetes.org - American Diabetes Association
www.childrenwithdiabetes.comLovely site, easy to navigate, active chat Archived expert answers Diabetes camp info
www.diabetesmonitor.com www.diabetesstation.org www.jdf.org – Juvenile Diabetes Association www.2aida.net -very cool insulin simulator
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Real life with Diabetes Find your ice
skates Have a snack Test your blood
sugar Laugh at your
roomie Test, count, inject Study, sleep.
Test sugar Count carbs Do a shot Go to class Test sugar, count
carbs, do a shot Treat a low blood
sugar
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Future ?
Artificial pancreas
Better data collection
Easier diagnosis Test genes
to see who might get disease
Your glucose sensor reminds you that you forgot to take insulin
Scan the food for auto carb calculation
Dr. Oates is on the beach with her computer and your company pays her NOT to see you
Competence Questions: Multiple right answers
1. What are the indications for an insulin pump?
a. desire for a pump and insulin use b. diabetes type 1 if on Medicare c. diabetes type 2 for many
commercial insurances
d. Insulin use
Competence Questions: Single Best Answer
2. Name 3 new diabetes therapies in the last few years
a. Exenetide, bromocriptine, glimepiride
b. Bromocriptine, linagliptin, saxagliptin
c. Carbohydrate counting, continuous glucose monitoring, insulin
pumps
Competence Questions -True Statements
3. Continuous glucose monitoring can be used
a. only with a pump b. only with multidose injection insulin
therapy c. must be used daily d. can cost about $35 per week on-
going costs
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Take Home Goals
Think like a pancreas Give enough insulin Get and give loads of education Call the 800 number on the back of any technology
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Glucagon
InsulinInsulin
Glucagon
InsulinInsulin
How Incretins Work1-3
IntestineIntestine
Food triggers the release of incretin hormones (GLP-1 and GIP) by the intestines into the blood
Blood
The body makes DPP-4, an enzyme that rapidly breaks down GLP-1 and GIP
Pancreas
Blood
SugarSugar
1. Drucker DJ. Cell Metab. 2006;3:153–165. 2. Aroda VR, Henry RR. cme.medscape.com/viewarticle/474380_3. Accessed 24 June 2010. 3. Hinnen D, et al. J Am Board Fam Med. 2006;19:612-620.
GIP=glucose-dependent insulinotropic polypeptide.
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Mechanism of DPP-4 Inhibitors
DPP-4
DPP-4 inhibitorsBlock the action of DPP-4DPP-4 rapidly breaks down GLP-1 and GIP
Hinnen D, et al. J Am Board Fam Med. 2006;19:612-620.
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Mechanism of GLP-1 Receptor Agonists1,2
GLP-1 receptor agonists directly activate the GLP-1 receptor resulting in effects similar to natural GLP-1 but are resistant to breakdown by DPP-4
1. Hinnen D, et al. J Am Board Fam Med. 2006;19:612-620. 2. Drucker DJ. Cell Metab. 2006;3:153–165.
Reduce appetite
Slow down how quickly food leaves stomach and make patients feel “full”
Help the pancreas make more insulin when blood sugar is high
Help keep the liver from releasing too much sugar into the blood