sarrah morris bscn, rn, mba medtronic diabetes canada [email protected] 1
TRANSCRIPT
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Employed by Medtronic since 2007
Over-bearing Care Partner for 32 years!
Disclosure
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Over-bearing Care Partner
Registered Nurse
Worked in acute care settings: Emerg, Congestive Heart Failure, Bone Marrow Transplant
Mount Sinai Hospital, Toronto
Medtronic Diabetes since 2007
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Excited to be here….
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Growing up in a T1D household
“Thank you Caregiver!”
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Today is about YOU and your FAMILY!
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Objectives
Benefits of a pump
The benefits of a pump vs MDI (multiple daily injection)
Infusion Sets
Basics of Continuous Glucose Monitoring
Education and Support
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Bruttomesso D, et al. Diabet Med. 2002;19(8):628-634. Bell DSH, et al. Endocr Pract. 2000;6(5):357-360. Rudolph DS, et al. Endocr Pract. 2002;8(6):401-405. Chantelau E, et al. Diabetologia. 1989;32(7):421-426. Boland EA, et al. Diabetes Care. 1999;22(11):1779-1784. Maniatis AK, et al. Pediatrics. 2001;107(2):351-356. Litton J, et al. J Pediatr. 2002;141(4):490-495. Weissberg—Benchell J et al. Diabetes Care. 2003.
Pumps Lower A1C Better than MDI
Published 1989 - 2003
Pu
mp
MD
I
* * *
PumpMDI
Meta-analysis 52 studies (1,547 patients) shows pump technology is significantly more effective at lowering A1C than MDI and/or conventional insulin therapy (MD 0.95)
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Pumps Reduce Hypoglycemic Events
Severe Hypoglycemic Episodes: Pumps vs. MDI
PumpsMDI
Eve
nts
/p
er h
un
dre
d p
atie
nt-
year
s
*
Rudolph JW, Hirsch IB. Assessment of therapy with continuous subcutaneous insulin infusion in an academic diabetes clinic. Endocrine Practice.2002;8(6):401-405. Bode, BW, et al. 1996;19:324-7. Boland EA, et al. Continuous subcutaneous insulin infusion. Diabetes Care.1999;22:1779-84.
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Pumps Reduce Severe Hypoglycemia
Pickup JC, Sutton AJ. Severe hypoglycaemia and glycaemic control in Type 1 diabetes: meta-analysis of multiple daily insulin injections compared with continuous subcutaneous insulin infusion. Diabet Med. 2008;25:765-774.
Results• MDI has 4.19 X more severe
hypoglycemia than pumps• Greatest hypo reduction found in
those with highest initial rates of severe hypoglycemia
Pump vs. MDI Severe Hypoglycemia Rate Ratio
Study
0.5 1 2 5 10 25
Favours CSIIFavours MDI
Study Inclusion Criteria
• Meta-analysis of 22 studies– 10 with children and
adolescents– 12 studies with adults
• Compared severe hypoglycemia
• Type 1 diabetes • Duration > 6 months on pump
Bode (poor control)Bode (good control)KadermanManiatisRizviLittonLinkeschovaBruttomessoRudolph, HirschPlotnickCohenHunger-DatheWeintrobWeinzimerMcMahonSiegel-CzarkowskiAlemzadehMack-FoggSciaffiniRodriguesLeporeHoogmaOverall (I2 = 84.2%, P = 0.00)
Published 2008
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Quality of life Fewer injections More flexibility of lifestyle;eat, sleep, play Potential for better control of blood sugar Can lower A1C and reduce low blood sugars Reduced risk of diabetes complications Flexibility for picky eaters, variable activity
levels & athletes Variable daily schedules
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Is an insulin pump right for you/your child?
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Intensive Insulin Therapies Comparison
Multiple Daily Injections (MDI)◦ 4-6 injections per day of rapid- and long-acting insulin◦ Basal is a fixed dose ◦ You must calculate bolus doses based on blood glucose and carbohydrates
Insulin Pump Technology◦ Rapid-acting insulin is continuously delivered by the pump◦ Most closely mimics the action of a healthy pancreas◦ Pump calculates bolus doses based on blood glucose and carbohydrates
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Rapid-acting insulin
Long-actinginsulin
Intermediate-acting insulin
46%
36%
16%
Heinemann L, et al. Diabetes Care.1998;21:1910–1914; Heise T, et al. Diabetes. 2004;53:1614-1620.
Rapid-acting insulin has the lowest
intrapatient variability
Rapid-acting insulin minimizes treatment errors due to pharmacodynamic variability in insulin action*
*Percentages represent coefficients of variation for insulin action as measured by maximum glucose infusion rate in these euglycemic glucose clamp studies
Insulin Pumps Use Only Rapid-Acting Insulin
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Insulin Pumps currently available in Canada
Omnipod® by Insulet
MiniMed® Paradigm® Veo™ by Medtronic MMT 554 &
MMT 754
ACCU-CHEK® Combo By Roche
OneTouch® Ping®by Animas
Vibe ® by Animas
Tubeless pump
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INSULIN PUMP TECHNOLOGY AIMS TO MIMIC A HEALTHY PANCREAS
Bolus InsulinBasal Insulin
Insu
lin
Time
Aims to mimic the pancreas by delivering insulin via ◦ continuous insulin called basal insulin◦ extra insulin for food called bolus insulin
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How Insulin Is Infused
Skin
Cannula
Fat
Insulin
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How (Tube) Insulin Pumps Work
Fill reservoir Load reservoir into pump Insert infusion set
Infusion set attached Pump attached to infusion set
Change infusion set every 2 to 3 days
OmniPod: you are going to change the pod every 80 hours
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Basal Insulin Delivers around the clock
Typically start with a single basal rate◦The basal rate can be adjusted (increased
or decreased)
You can add additional basal rates◦The pump can be programmed to deliver
higher or lower basal amounts during different periods of the day
When rates are set correctly, basal insulin
should: ◦Keep your glucose stable between meals
and through the night ◦Allows the flexibility to sleep late, eat late,
and even skip meals
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Basal Rates: Deliver 24 Hours / Day
Example of single basal rate delivery @ 0.50u/hr Pump delivers 0.5 units each hour Basal insulin is divided into 0.025 unit
increments and delivered evenly throughout each hour
BASAL RATES Time
Rate1. 12 AM 0.500 u
/hr2. _____ _________3. _____ _________
0.5u
0.5u
0.5u
0.5u
0.5u
0.5u0.5u
0.5u
0.5u
0.5u
0.5u0.5u
0.5u
0.5u
0.5u
0.5u
0.5u
0.5u0.5u
0.5u
0.5u
0.5u
0.5u
0.5u
AM PM
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Food Correction
Total amount of basal insulin delivered over 24 hours
Typically ~40-50% of TDD is basal
Total amount of bolus insulin given for food & correction in 24 hours
Typically ~ 50-60% of TDD is bolus
Insulin Pump Settings
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Insulin pumps can reduce some of the burden…
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Insulin Pump Settings
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Remaining insulin: Insulin that remains from previous boluses and has the pharmacodynamic ability to lower glucose.
Active Insulin Time: Length of time pump is programmed to track remaining insulin. (example, 2, 3, 4, 5, 6, 7, 8 hrs)
• Pump subtracts active insulin before calculating a bolus dose for high BGs
• This helps to prevent insulin “stacking” and the lows that occur from over-correcting highs.
Target Range: A range of glucose values that the pump uses to determine if a correction bolus is needed.
• Can be customized and set for:- Pre-meal Target Ranges- Post-meal Target Ranges- Bedtime Target Range
Remaining insulin On board
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Advantages of today’s smart pumps
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1. Calculates bolus amounts using your child’s current:• BG • ICR • ISF • Target Range
Benefit: Determines each bolus amount based on patient’s individual pump settings & current needs (BG, carb intake, active insulin)
2. Tracks remaining insulin from previous boluses delivered:– Subtracts remaining insulin from the insulin calculated to correct highs,
before suggesting total correction amount to take.
Benefit: Helps prevent insulin “stacking” & lows that can occur from over correcting if insulin remains from previous boluses
3. Keeps accurate records:– Times and values of all BG readings– Carbohydrate intake – Type, amount, time of boluses
Benefit: Provides comprehensive records for therapy evaluation*
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Infusion Sets
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What is an infusion set?
The connection between the insulin pump and the body
Cannula Housing
Adhesive TapeTubing
Insertion
Device
Insulin Reservoir
Cannula
At-site disconnection
24One difference with the Pod pump, you can not remove them temporarily
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Infusion Sets for Tube Pumps: Two different types of connections available
Luer Lock infusion sets (pump specific)
Paradigm (not a luer lock connection)
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90° Teflon Cannula 30-45°Teflon Cannula
90° Steel Cannula
All-in-One 90° Teflon Cannula Infusion Sets with Auto-Injector
Many options for infusion sets; your diabetes educator will help you select the best one for you.
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Benefits of Continuous Glucose Monitoring
Continuous BG monitors show trends so that problems can be avoided…….
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CGM provides visual feedback to help patients and clinicians understand glucose variability
Glycemic Variability
A1c = 9 in both patients Profiles are very
different
CGM Provides Visual Feedback of Glucose Control
A1C 9
A1C 9
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MiniMed Paradigm VEOTM with Continuous Glucose Monitoring System (CGM)
• Low Glucose Suspend
• Provides time trend graph
• Alarms for high or low glucose levels
•RF Linking- Bayer Contour Next Link Meter
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Animas Vibe ® with Dexcom CGM
•Colour screen•Waterproof at 12 ft for 24 hrs•Dexcom G4 CGM technology
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Consider and utilize the many available education resources for patients, parents, caregivers.
Product Technical Support• Online tools
• Product technical support 24/7
• Replacement pumps
• Training• 4 year pump
warranty• Travel/vacation
pump loaners• Therapy software
Online tools
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32 | MDT Confidential
Dskate 2015: Milton and Montreal 5 day programsDskate is a unique combination of elite hockey coaching & Type 1 Diabetes Education
For 128 kids aged 7-17 with T1 Diabetes & their parents.
Families from 8 Provinces
Families from New York, Oklahoma City, California,
Alaska, Chicago. Florida, and more.
2 families from Sweden
Many diabetes experts who provide education to the kids and parents that include: Dr Mike Riddell, PhD, Exercise and Diabetes expert Dr Bruce Perkins, University of Toronto Michele Sorenson, Psychologist Chris Jarvis, Founder of I Challenge Diabetes
And Cory Conacher, Nick Boynton and more.
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33 | MDT Confidential
Dskate is 2- 5 day programs of Hockey and Diabetes Experiential Learning
128 kids, 170 Parents, 28 Diabetes Educators from across Canada
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My Heroes!
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Thank you
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