7/18/2017. An Educator s Use of Outpatient Insulin Dosing Decision Support Software. Disclosure to Participants. Bruce Bode MD.

Transcription

1 An Educator s Use of Outpatient Insulin Dosing Decision Support Software Bruce Bode MD Diabetologist, Internist Atlanta Diabetes Associates Atlanta, GA Disclosure to Participants o Notice of Requirements For Successful Completion o Please refer to learning goals and objectives o Learners must attend the full activity and complete the evaluation in order to claim continuing education credit/hours o Conflict of Interest (COI) and Financial Relationship Disclosures: o Bruce Bode, MD: Presenter: Astra Zeneca, BI, Janssen, Mannkind, Medtronic, Novo Nordisk, Sanofi Consultant: Becton Dickinson, Intarcia, Janssen, Medtronic, Novo Nordisk, Sanofi Stock: Aseko o Lisa Kiblinger, NP, CDE: Presenter/Consultant: none Stock: Sanofi o Atlanta Diabetes Associates: Research/Grants Abbott, BD, DexCom, Diasome, GSK, Janssen, JDRF, Lexicon, Lilly/BI, MannKind, Medtronic, NIH, Novo Nordisk, Pfizer, Sanofi, Sensonics o Non-Endorsement of Products: o Accredited status does not imply endorsement by AADE, ANCC, ACPE or CDR of any commercial products displayed in conjunction with this educational activity o Off-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. Lisa Kiblinger NP-c, RN, CDE Nurse Practitioner/Researcher Atlanta Diabetes Associates Atlanta, GA Objectives Following the program the participant will be able to o Identify the need for basal, bolus or basal/bolus titrations in specific patients o Discuss options for outpatient insulin dose titration technology o Describe the possible roles of the educator in insulin titration 1

2 (1) Data on file Real-World Data on Hypos Following Basal Insulin Initiation (2) Peyrot M et al. Diabet Med 2012;29: (3) Leiter LA et al. Can J Diabetes 2005;29: /18/2017 WHO Diabetes can be treated and its consequences avoided or delayed with diet, physical activity, medication and regular screening and treatment for complications. Diabetes Control 30 million Americans and 400 million people worldwide have diabetes Diabetes Stats o the number of people with diabetes increased from 108 to 444 million in the past 35 years o direct and indirect U.S. medical costs $245 billion o diabetes control continues to be a significant problems in the U.S. o encounter frequency (q 2 weeks) improves A1c, B/P and Cholesterol levels Medication Adherence o This is a national issue o 31% of patients don t fill their prescriptions o patient adherence and persistence determines medication effectiveness McGovern et al It s a Dosing Problem, Not an Insulin Problem Fear of, or experience with, hypoglycemia is the #1 cause of adherence issues in the home setting 31% Never fill their insulin script 50% Modify their insulin dose after a hypo episode 40-60% Experience hypoglycemia 40% Experience hypoglycemia in the FIRST month 50% Of patients taking basal insulin are not at A1c goal 77% Discontinue insulin within 12 months if experienced hypo in the first 6 months Downloading Devices o Prior to each visit o Time commitment o Benefit to the providers o Benefit to the patient o Provides a basis for making changes U.S. Cost Savings for insulin adherence $4,690 per patient per year 2

3 When to Move to Insulin o the person has type 1 diabetes o the person has new onset diabetes with an A1c above 9.0% with symptoms o the person is above their goal after 3 months of triple oral therapy o If fasting glucose is elevated try a basal dose o If fasting is at goal and post meal blood sugars are elevated try prandial dosing at 1, 2 or 3 meals The Ultimate Goals of Insulin Therapy o Optimize insulin doses to prevent complications o Blood glucose in range for the longest period of time o Minimal low blood sugars o No unwanted weight gain o A1c in range for this person How to Move to Insulin Start Basal o A1c < 8% o TDD units/kg o A1c> 8% o TDD units/kg o Fasting Goal o FBG mg/dl Intensify o Basal plus o Add 5 units at one meal, then 2 and then 3 meals and titrate based on 2h post prandial dose o Add Bolus insulin 50% TDD divided into # meals per day o Post Prandial Goal o mg/dl Go Dose (Eli Lilly) o Dosing prandial Humalog insulin one meal at a time o Type 2 DM o Requires a prescription o FDA Cleared, Patient facing app and Professional version for office/clinic use AACE Algorithm for adding/intensifying insulin Insulia makes a Diabetes Management product that o Helps patients make evidenced-based basal insulin adjustments o Is a prescription-only medical device o Provides educational coaching messages in response to glucose values o FDA cleared app Sanofi makes a Diabetes Management product that o Helps patients make evidenced-based insulin adjustments o Is a prescription-only medical device o Provides educational coaching messages in response to glucose values o FDA cleared, adjusts basal insulin. Motivational app 3

4 isage Rx is a Diabetes Management product that o Helps patients basal insulin titration o Is a prescription-only medical device o Provides feedback on current blood sugars o FDA cleared, adjusts basal insulin Accu-Chek Guide o Prescription meter o Pump program technology o FDA Approved Glytec o Helps make insulin adjustments o Is a prescription-only medical device o FDA cleared, adjusts basal and bolus insulin o Educate the Patient o Coordinate the team o Monitor the Patient Educate the Patient o Initial training on when and why to check blood sugars, how to use the system, what to expect o Importance of when to eat in relation to BG checks o AADE 7 o Educational component to get them to wean off o When to come back or initiate the system again Coordinate the team o Dosing and titrating is prescribing o Working under the auspices of a provider s order to titrate o Need standing orders (Educator and Patient/Supporter) o Naturally extension to DSME & Support o Our CDEs receive the downloads and start adjustments o Virtual insulin dosing clinic 4

5 Standing Orders Example Monitoring the Patient o Monitor for safety (hypo, hyper, DKA, poor practices) o Set the frequency of communication o Pregnancy patients may be weekly downloads o New to insulin patients may be daily o High risk patients may be every few days to every few weeks o Non-adherent patients may be ever 2 to 4 weeks Continuum of Care EMERGENCY DEPARTMENT ICU STEPDOWN/FLOOR LTAC SNF Glucommander IV Glucommander IV Glucommander Transition Glucommander Transition Glucommander SubQ Glucommander SubQ HOME PROVIDER OFFICE DISCHARGE Glucommander OutpatientGlucommander H2H HCP Monitored Self Titration < Monitoring the Patient o Medication adherence and troubleshooting o Remind the patient that this is a process and needs to be re-addressed with any major changes (change in wt., pregnancy, illness) o People who write a narrative need reinforcement and encouragement within teachable moments Insulin Adjustment Example 1 Insulin Adjustment Example 1 Initial A1c 9.0 on 60 glargine/62 lispro Final A1c 7.1 on 72 glargine/84 lispro 5

6 Insulin Adjustment Example 2 Insulin Adjustment Example 2 Final A1c 6.3 on 106 glargine/85 aspart Glucommander Outpatient, a Cloud-Based Insulin Management Solution Titrated Patients to Goal in 11 Days and Sustained a 2.6% Drop in HbA1c Over 6 Months Bruce Bode, MD; John Clarke, RN, CDE Sam Type 2 Diabetes, newly diagnosed When I saw an A1c of 14%, I fell out of my chair. I am very pleased with my progress in this program. 16.0% 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 14.0% Baseline Hypo < 70 mg/dl: 0.5% 6.4% 3 Months Team Work Patient s Benefit from o Having someone look at their logbook periodically between visits o Having the providers and the CDEs work together on making changes o Getting education when the CDEs notice problems with the diary o Downloading every visit Bode et al.; ATTD 2017, Paris, France. References Diabetes in America, 3rd ed. Cowie CC, Casagrande SS, Menke A, Cissell MA, Eberhardt MS, Meigs JB, Gregg EW, Knowler WC, Barrett-Connor E, Becker DJ, Brancati FL, Boyko EJ, Herman WH, Howard BV, Narayan KMV, Rewers M, Fradkin JE, Eds. Bethesda, MD, National Institutes of Health, NIH Pub No , 2017 accessed at McGovern A, Tippu Z, Hinton W, et al. Systematic review of adherence rates by medication class in type 2 diabetes: a study protocol. MJ Open 2016;6:e doi: /bmjopen Glucommander Hospital to Home (H2H) Transition Nursing Workflow Nursing and Provider Workflow H2H is a seamless transition from inpatient Glucommander SubQ insulin dosing to an outpatient basal/bolus regimen Provider can request Glucommander s hospital to home medication considerations at any time Glucommander provides medication considerations for basal insulin, bolus insulin, and other medications Provider writes discharge orders based on their clinical judgement and Glucommander s medication considerations Hospital to Home Workflow 6