Insulin Pumps and Paediatrics

Transcription

1 Insulin Pumps and Paediatrics RURAL MATTERS Gippsland Acute Care Symposium Friday 27 th November 2015 Andrea Curtis, BN, Grad Cert Diabetes Education, CDE, CPT

2 I wish (my friends) knew what it felt like every single day and I wish they thoroughly understood how difficult this disease is to manage and it s not just the two finger pricks you see me doing at recess or lunch. I wish they knew I didn t get a holiday on my holiday Male, age 14

3 This Session 1. What do the Paediatric Diabetes guidelines recommend? 2. Targets How are we going? 3. What are the challenges facing families & clinicians? 4. What is an insulin pump & how does it work? 5. What lies ahead in the future? No conflict of interest to declare

4 Clinical Care Guidelines Type I Diabetes in Children Paediatric F.BGL 4-7.0mmol/L 2 hrs 5-10mmol/L Bedtime 6 10mmol/L Overnight 5 8mmol/L Infant F.BGL 5 10mmol/L 2hr 6 10mmol/L Bedtime 6 12mmol/L Targets Individualised

5 Clinical Care Guidelines Type I Diabetes in Children HbA1C 7.5%

6 How are we measuring up? 27% achieving HbA1C <7.5% Treatment improvements since 1990 s but funding not increased Australia in top 10 countries for incidence T1DM annual rise 3% & remains stable Mean age of Dx 8yr Increased proportion Dx with low risk human leukacyte antigen (HLA) indicating increased environmental role in pathogenisis

7 Figure 4: Trends in incidence of Type 1 Diabetes, by age,

8 Diabetes Control and Complications Trial (DCCT) Multi-center, randomized 10 year clinical trial 1441 participants Ended early in 1993 Eye disease: 76% Kidney disease: 54% Nerve disease: 60% Heart disease: 42%

9 Relative risk A1c and relative risk of microvascular complications DCCT A1c (%) DCCT, Diabetes Control and Complications Trial. 1. Adapted from Skyler JS. Endocrinol Metab Clin North Am 1996;25: DCCT. NEnglJ Med 1993;329: DCCT. Diabetes 1995;44: Retinopathy Nephropathy Neuropathy Microalbuminuria

10 What are the challenges? Metabolic Memory: Early tight control blood glucose = lower long term HbA1C Improvement in glycaemic control following periods of poor control doesn t provide the complication protection originally thought.

11 Mental health Type I Diabetes is associated with a higher incidence of Depression, Anxiety & Bulimia Nervosa compared with population Greater number referrals made to mental health team

12 Hypo Avoidance Hypoglycaemia reported to be the greatest concern for parents & children with diabetes Intentionally elevated BGL s to avoid hypo No strong evidence that cerebral function is effected by hypo & hypo seizures having negligible effect on cognition

13 I worry about going low during activities, and when I sometimes don t give myself as much insulin as I know I should just so I can protect myself. I m scared I will never wake up. Mum and Dad say they will check me that doesn t help with the fear of never waking up!!!!!! (Citation Diabetes MILES Youth study 2014)

14 Hyperglycaemia Elevated HbA1c is associated with a modest decline in psychomotor & mental efficiency Magnitude greater for early onset T1DM Only 50% adolescents with T1DM completing year 12 study in comparison with their nondiabetic peers.

15 Young Children with Diabetes Toddlers are highly sensitive to insulin making regulation of doses complex Marked increase in GAD antibodies at Dx indicating aggressive autoimmune insult 50-80% present with DKA & cerebral odema Shorter honeymoon period Toddlers have blunted counter regulatory response to hypo Early childhood insulin regimes attribute to eating disorders in up to 30% children

16 My parents think I m just being a typical teen not wanting to look after myself because I think I m invincible but I m not I m just trying to fit in and have a normal life Female, age 16

17 Adolescents Normal behaviour = risk taking behaviour in Type I Diabetes Sleeping in, delayed mealtime, omission of carbohydrate foods, driving, alcohol Adolescents learn by trial & error Working with this behaviour = success Support controlled experimentation. Most successful people are trailblazers Secret weapon is technology!

18 What is an Insulin Pump? How does it work?

19 Discovery of Insulin 1921 Sir Frederick Banting Canadian & Medical Scientist Leonard Thompson Aged 14yrs First person to receive beef insulin in 1922 Charles Herbert Best American Canadian Scientist

20 Evolution of Insulin 1950 s Porcine Insulin available (NPH) 1980 s Synthetic Human Insulin 1996 Lispro (Humalog) & Aspart (Novorapid) 2000 Glargine (Lantus) & Determir (Levermir)

21 Insulin Delivery Insulin pens 1990 s Enhanced independence & glycaemic control

22 The first insulin pump Dr Arnold Kadish 1963 Dual delivery insulin & glucagon

23 Big Blue Brick released early 70 s

24 Pumps in 2015

25 3 Key Elements of Diabetes Management

26 Components and their functions A small computerised, battery operated pump Allows the user to control exactly how much insulin is delivered A pump reservoir Similar to a regular syringe, holds 2 to 3 days worth of insulin A thin plastic tube called an infusion set Has a soft cannula or needle at the end inserted just under the skin, usually in the abdomen

27 Keeping HbA1c in target is a challenge 16.7 Uncontrolled A1C ~9% BG mmol/l 11.1 Controlled A1C <7% A1C ~6% 5.5 Normal A1C 4% 6% Time of Day for this you need ADVANCED therapy Acknowledgement Kim Henshaw, DAV

28 Normal insulin secretion Intensive insulin therapy Bolus insulin Basal insulin

29 An insulin pump provides: Basal or background insulin Constant pre-programmed delivery of insulin to meet daily needs Rates (unit/hr) may vary during the day Rates may change at times according to need eg. sick day, sport, adolescence

30 An insulin pump provides: Bolus insulin To cover carbohydrate containing food/drink (carb bolus) To reduce high blood glucose levels (correction bolus) Smart pumps use formulas to calculate dose required, known as Bolus Wizard

31 Pumps are also smart Smart pumps Calculate the insulin dose to the amount of carbohydrate eaten Calculate the dose required to correct a high blood glucose Track the amount of insulin on board to prevent insulin stacking Have bolus & blood glucose reminders

32 Continuous Glucose Monitoring Linked glucose monitoring Does not initiate insulin delivery Requires finger pricks for calibration Predicts trends in glucose levels Predictive alerts & Low Glucose suspend First step in Closing the Loop

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34 Why consider a pump? Improved glycaemic control 75% reduction in severe hypoglycaemia 1 Reduced glycaemic excursions Possible reduced HbA1c depending on baseline 2 1. Pickup JC, Renard E: Long-Acting Insulin Analogs Versus Insulin Pump Therapy for the Treatment of Type 1 and Type 2 Diabetes Diabetes Care 31 (Suppl. 2):S140 S145, Doyle (Boland) EA, et al: Diabetes Care 27: , 2004

35 Why consider a pump? Flexibility & quality of life Pump mimics normal insulin secretion Small precise doses possible, delivered as/when required More predictable insulin absorption & action Dose calculation tools e.g. bolus wizard Eat when hungry Exercise without hypos Acknowledgement Kim Henshaw, DAV 2013

36 Pumps are also great for: Nocturnal hypos & hypo unawareness Varied or intense exercise/activity Child & toddler eating routines Dawn phenomenon, gastroparesis, Preparation for pregnancy Varied work or school schedule Travel Sleeping in Acknowledgement Kim Henshaw, DAV 2013

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40 Insulin pump therapy things to consider SMBG are needed 4-6 times per day Carbohydrate counting is required Wearing a device on your body Must carry a back-up insulin delivery system Follow-up Healthcare Team Approach Cost

41 Reverting to Injections Short term Quick acting insulin used at regular intervals ie divide pump total daily dose (TDD) by 6 & give 4 hourly Long term (more then 24hrs) Use both quick & long acting insulin Quick Acting = 20% TDD (x3 meals) Long Acting = 40% of TDD Titrate doses according to BGL s, food & exercise

42 How to get started with a pump? Discussion with Healthcare team the suitability of pumping for individual Research Private Health Insurance Providers or grants available Talk with other Pumpers Get informed

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44 For the first time in my life I feel normal One week after commencing on her insulin pump, Age 14

45 What lies ahead in the future? New Insulin s New Technology New Devices

46 New Insulin Trials Ultrarapid very fast acting insulin closer to endogenous insulin response. Game changer for pump therapy Trial delivery devices - Patches, inhaled, insulin spray (mucosa), intradermal & subcutaneous jet infusion. Tesila (new Degludec) 25 hour half life with 42 hour duration. Less hypo potential than Lantus SMART Insulin on/off switch auto-adjusting according to BGL. Glucose mediated degradation

47 640G hybrid trail 2014 Suspend delivery when low, initiate delivery when high. Consumer enters the data.

48 The Islet glucogon & insulin delivery Bionic Pancreas Insulin & Glucogon delivery in response to CGM & managed by phone app Overnight closed loop Trial in WA effective overnight but during day not feasible due to sensor accuracy, sensor lag, insulin onset Insulin or insulin & glucagon delivery results comparable Bluetooth enabled sensor linking CGM data to phone App, text hypo events to several phones What will Success look like? Improved algorithms Calibrated sensors No carbohydrate counting!

49 Success is.. Having a clear plan developed with the family & ensuring that all of the team is on same page Enabling a person with diabetes to live their best life through increased knowledge, support & confidence Take a walk in their shoes

50 Resources Cameron, F. et al. Care of children & adolescents with diabetes in Australia & New Zealand: Have we achieved the defined goals? Journal of Paediatrics & Child Health, 2013,Pg 1-5. Cody, D., The Medical Management of Infant & Toddler Diabetes, Our Lady s Children s Hospital, Crulin, Dublin, Ireland, ISPAD & APEG conference 2015 Cohen, N. Baker IDI, Melbourne, Australia, ISPAD & APEG Conference 2015 DCCT and EDIC: The Diabetes Control & complications Trial and Follow up study, NIDDK, Diabetes MILES Youth Study 2014 Survey Report, The Australian Centre for Research in Diabetes Incidence Type I diabetes in Australia, Australian Institute Health & Welfare 2015 National Evidence Based Clinical Care Guidelines for Type I Diabetes in Children & Adolescence & Adults, APEG & APS 2011 Stupianski, N., Diabetes & Adolescence Don t Mix? USA, ISPAD & APEG Conference 2015

51 Living with diabetes is definitely a difficult and stressful task but as long as you manage it well you can do and be whatever you aspire to be Female, age 13