Diabetes Oh My! Devices Workshop Angela Aldrich, PharmD, PhC - PDF document

1/17/2018 Pumps & Sensors & Meters, Diabetes Oh My! Devices Workshop Angela Aldrich, PharmD, PhC April Mott, PharmD, PhC, BCPS Presbyterian Medical Group 28 January 2018 • Accu- Chek’s newest general use meter. Accu-Chek A Tale of Two Meters • Pairs with smart Guide • Technology for glucometers has phones, pads, and advanced over recent years. computers. • These newer meters can usually be • Analyzes patterns and worked “cold” by someone who has reminds patient to experience handling glucometers in test. general, but many of the highly useful • Easy to program. features are not immediately obvious • Strips are inexpensive and require a read of the manual to through coupon get the full benefit of the advances. program. Coupon Program New Strip Case • Attached to the side of each box is a coupon that will allow a patient (with a prescription) to obtain from 50 strips for $19.99 up to 300 strips for $69.99 (cash price). • Coupon is to be run as insurance instead of patient’s insurance. • Meters can be obtained for free by going to Accu-Chek website. 1

1/17/2018 Buttons and Ports Buttons Meter turns on when Button on right side OK is pushed or a strip of meter ejects is inserted. strip and port Back arrow takes you connects with to the previous screen. Up and down arrows computer to allow you to scroll. exchange data. OK button proceeds Port is not for to new screen/selects charging. item. Settings Menu Time/Date Scroll to set current time/date. Click OK to progress to next field. Beeper Wireless Settings Flight Mode disables wireless Allows meter to capabilities. beep when a Default Device lists primary paired device name. reminder goes off Auto-Send causes readings to be synced automatically (more to come). with paired devices (up to 5) when meter is turned on and in close proximity. Sync Time automatically syncs meter time with primary device time. 2

1/17/2018 Pairs with Cell Pairing Meter Phone Shows a code you Shows Graph of BG readings, then type into your Logs, meal and cell phone to pair insulin detail. the devices. Patient can add Up to five devices a picture of meal can be paired to associated with a one meter at a specific test. time. More Options Target Ranges Reminders Patterns As data is entered into the meter this allows pattern analysis to occur. Reports show patterns in high and low data. 3

1/17/2018 Post Meal Reminder Last Result My Data My Data Logbook scrolls through history Averages shows for 7, 14, 30, 90 days This can be split into Overall, Before meal, After meal, Fasting, and Bedtime categories. Target % Shows same data with regard to % above, within, and below goal. Low/High Data sorts and displays all lows or all highs One Touch Verio Flex Simpler than Guide if no pairing. Can be used alone but increased functionality if paired with a smart phone. Major advantage is that 2 different meters can be paired with the same cell phone at once. The Log readings for both meters merge into one coherent log on patient’s smart phone device. 4

1/17/2018 Two Verio Flex Meters, One Log! 3 Button Model Less intuitive to program but has cheats on the back. Continuous Glucose Types of CGM Monitoring Case Office based sensors • Collect specific time frame of data for download at set time o • Self Monitored Results: Novolin 70/30 mix 50 units No real time data available to patients o Helps identify glycemic patterns to assist with a1c lowering with less o prior to breakfast and lunch, 55 units prior to dinner hypoglycemia, helps to understand variability • Patient based sensors Require readers for patient to determine glucose levels and patterns o Patients can check blood sugar frequently without sampling blood o May be helpful with neuropathic/vision impaired patients o • Transmitter sensors Have ability to transmit to insulin pumps, tablets, smartphones, watches o 288 readings per 24 hours with Dexcom o o Could transmit from children at school, seniors in facilities o Typically requires calibration (2x daily shown here) • On the horizon Rumors of apple watch beta testing bloodless CGM o Case Insulin Pumps • Insulin pumps approved to utilize short-acting insulin analogues Lispro-Humalog o Aspart-Novolog o o Glulisine-Apidra • Relieve patients using multiple daily injections of basal/bolus insulin. • For Example: Levemir 20 units sq qam and o 50 units sq qpm Novolog tid ac and hs o 5

1/17/2018 Insulin Pumps Insulin Pump Features • Benefits • Allow for variation in basal rates More precise and accurate insulin dosing can better regulate blood glucose (BG). o Activity/sleep o o Customized, flexible basal and bolus dosing to meet lifestyle demands. Dialysis Less severe hypoglycemia. o o • Challenges o Weekend/weekday Requires self-monitoring of o blood glucose at least 4 times/day. • Bolus doses can be Requires thorough training. o o Diabetic ketoacidosis can Flat dosing such as 20 units prior to meals o develop quickly if insulin Based on carbohydrate estimation: 1 unit per 15 g CHO delivery is interrupted for o a period of time. o Corrected for blood sugar levels: 1 unit for every 16 mg/dL >130mg/dL Blood glucose regulation o Extended dosing for target meals: pizza effect where fats and protein o is complex. delay carbohydrate absorption Pumps are not a cure, but a drug delivery method to treat • diabetes, they require more monitoring, record keeping and evaluation but can lead to better control • Not a license to forget that a patient has diabetes Pump Settings that Factor into Pump Therapy Pump Case • Basal Rate • Type 1 Diabetic, 20 year old college student • Carb Ratio (Insulin-to-Carb Ratio) • Levemir 15 units sq bid • Target BG (Blood glucose) • Novolog roughly 10 units tid • Correction Factor (Insulin Sensitivity) • 1 unit:15gCHO + 1 unit for every 50mg/dL>150mg/dL • Insulin Duration (Duration of Insulin Action) • Often wakes up hypoglycemic, wakes up ~11 am, doesn’t follow carb and correct dosing tightly goes to bed about midnight • A1c 11.2% (AVG Gluc: 275 mg/dL) Hyperglycemia with How to convert? • How would you set her basal rate? Pump • Currently getting 30 units basal insulin per day • Converts to 1.25 units per hour • Consider early am hypoglycemia • I used 2 basal rates 0.9 units per hour from midnight until 11 am, (10 units) then increased her rate to 1.15 units per hour from 11 am till midnight (15 units) • Decrease of 5 units basal per day, but with steady delivery, typically more insulin activity than with multiple basal injections 6

1/17/2018 Hypoglycemia with Evaluating and Adjusting Pump Basal Rates • Not allowing pump to calculate bolus • If basal rates are set appropriately, BG’s should not fluctuate more than 30 mg/dl during testing. • Carbohydrate counting error • If BG drops more than 30 mg/dl, decrease the basal • Insulin stacking (correcting too soon) rate 2-4 hours before the change occurs. • Basal set too high • If BG rises more than 30 mg/dl, increase the basal • Programming error rate 2-4 hours before the change occurs. • Insulin Duration setting not accurate • Adjustments should be no more than a 5 to 10% • Behaviors/Life increase or decrease. Exercise or activity o • Retest - basal rate testing is a “work in progress”. o Alcohol References • Accu-Chek. (2016). Accu-Chek Guide: User’s Manual for Single Patient Use Only Blood Glucose Meter. 9115 Hague Road, Indianapolis, IN 46256: Roche Diabetes Care, Inc. • One Touch. (2015-2016). One Touch Verio Flex: Owner’s Booklet Instructions for Use. Gubelstrasse 34, 6300 Zug, Switzerland. Lifescan Europe, Division of Cilag, GmbH International. 7