Normal Insulin Secretion

Transcription

1 Initiating and Adjustment of the Insulin Pump Celia Levesque RN, MSN, CNS-BC, NP-C, CDE, BC-ADM Objectives: Prescribe insulin pump therapy Initiate insulin pump therapy Calculate initial insulin pump doses Adjust insulin pump settings Prevention of acute complications Manage the insulin pump patient in special situations that affect glucose Prescribe continuous glucose monitoring Normal Insulin Secretion Prevalence of insulin pumps: 75-1 Million Worldwide? 1 st phase insulin Basal insulin 2 nd phase insulin Units of insulin Bolus Bolus Bolus Basal rate Temporary basal 0 12am 4am 8am 12pm 4pm 8pm 12am First pumps Current Insulin Pumps 1

2 Hybrid close loop Candidate Selection Auto Mode No SF needed Bolus for CHO Suspend before low Guardian sensor 3 Age 7 + May not be safe if less than 8 units/day Desires insulin pump Check BG frequently Able to operate pump Able to afford pump Able to troubleshoot Works with medical team Hypoglycemia Busy schedule Athletes Dawn phenomenon Elevated HbA1c despite best efforts Gastroparesis Pre Pump Education Carbohydrate counting Insulin to carbohydrate ratio Sensitivity factor Sick day management Prevention of DKA / ketone testing Hypoglycemia treatment BG testing / BG goals / record keeping Calculating insulin pump doses 1. Calculate the total pump total daily dose (TDD) 2. Calculate a single basal rate 3. Calculate the insulin to carb ratio 4. Calculate the correction factor 5. Choose a target BG range 6. Choose the active insulin time Calculating Total Pump Total Daily Dose (TDD) Clinical considerations Method 1 Pre-pump TDD x 0.75 Method 2 Weight: kg x 0.5 lb. x 0.23 Average values from methods 1 & 2 Frequent hypoglycemia: start at lower dose Hyperglycemia, éhba1c, preg: start higher dose Grunberger, G, Abelseth, J., Bailey, T, et. al. Consensus statement by the American Association of Clinical Endocrinologist/American College of Endocrinology Insulin Pump Management task force. Endocrine Practice. 2014;20(5): Grunberger, G, Abelseth, J., Bailey, T, et. al. Consensus statement by the American Association of Clinical Endocrinologist/American College of Endocrinology Insulin Pump Management task force. Endocrine Practice. 2014;20(5):

3 Example: Calculate Pump TDD Average total daily dose = 50 units Weight = 100 kg Method 1: 50 units x 0.75 = 37.5 Method 2: 100 x 0.5 = 50 Average: = Initial Single Basal Rate (50% TDD) Pump total daily dose x hrs = basal Or Pump total daily dose 48 = basal rate Example: TDD = 30 units 30 x 0.5 = hours = units per hour Grunberger, G, Abelseth, J., Bailey, T, et. al. Consensus state by the American Association of Clinical Endocrinologist/American College of Endocrinology Insulin Pump Management task force. Endocrine Practice. 2014;20(5): TDD before pump Carbohydrate Ratio Alternate methods: 6 x wt. in kg TDD or 2.8 x wt. in lb. TDD Fixed Meal Bolus = TDD x equal meals Continue existing CR from MDI regimen Example: Total dose before pump = 45 units = 10 1 unit for every 10 grams of carbohydrate Sensitivity/Correction Factor 1700 Pump TDD Example: Total pump dose = 85 units = 20 1 unit will decrease the BG by ~ 20 mg/dl Grunberger, G, Abelseth, J., Bailey, T, et. al. Consensus statement by the American Association of Clinical Endocrinologist/American College of Endocrinology Insulin Pump Management task force. Endocrine Practice. 2014;20(5): Grunberger, G, Abelseth, J., Bailey, T, et. al. Consensus state by the American Association of Clinical Endocrinologist/American College of Endocrinology Insulin Pump Management task force. Endocrine Practice. 2014;20(5): Continuous Glucose Monitoring Measures interstitial fluid glucose Subcutaneous catheter attached to a transmitter The receiver displays a new result every 5 minutes Pump screen Stand alone receiver Phone Interstitial Fluid Glucose Does not always match blood glucose Interstitial glucose lags behind blood glucose The faster the change in BG, the greater the difference between IFG and BG 3

4 What happens between fingersticks Benefits Reduce risk for hypoglycemia secondary to alarms Reduce risk for extreme hyperglycemia secondary to alarms Reduce risk for wide BG fluctuations Behavior modification / learning Dexcom Medtronic Enlite Guardian Connect Freestyle Libre 4

5 Eversense CGM CGM Basal Testing Select a basal period to test Plan to skip a meal during the test period Wait 4-5 hours after eating the last meal or snack before the test begins Check pump to make sure there is no active insulin on board at the start of the test Basal Testing Periods Overnight Eat early dinner Monitor BG hs, q 3 hrs., and waking Ends at breakfast Morning Skip breakfast Monitor BG q 1-2 hrs. Ends at lunch Basal Testing Periods Afternoon Skip lunch Monitor BG q 1-2 hrs. Ends at dinner Evening Skip dinner Monitor BG q 1-2 hrs. Ends at bedtime 5

6 Adjusting Basal Rates Adjust according to trends over 2-3 days Adjust to maintain a stable BG between meals and during sleep Begin new basal rate 1-2 hours before the problem Basal Testing Monitor BG at start of the test Do not start if BG < 90 or > 150 mg/dl Stop the test if BG < 70 or > 250 mg/dl Daytime tests: check BG q 1-2 hrs. Overnight test: check hs BG, 2 am, and waking Grunberger, G, Abelseth, J., Bailey, T, et. al. Consensus statement by the American Association of Clinical Endocrinologist/American College of Endocrinology Insulin Pump Management task force. Endocrine Practice. 2014;20(5): Basal Testing Repeat testing 2-3 times to ID trend Adjust basal rate if fluctuations of > 30 mg/dl Change by 5-10% Make changes before BG starts to trend up or down. It make take 2.5 to 4 hrs. for basal to change Assess effectiveness of the basal change Overnight Basal Test Start 3 hr. 6 hr. 9 hr. 12 hr. BG Time 9 pm 12 am 3 am 6 am 9 am Basal Morning Basal Test Testing CHO Ratio Start 1 hr. 2 hr. 3 hr. 4 hr. 5 hr. 6 hr. BG Time 6 am 7 am 8 am 9 am 10 am 11 pm 12 pm Basal Eat a known amt of CHO between g Eat a balance of CHO, protein, fat Wait 4-5 hrs after last food to start the test Make sure no insulin on board at start of test 6

7 Testing CHO Ratio Testing CHO Ratio Monitor BG Start of test and q 1 hr. for 5 hrs. Do not start test if BG < 90 or > 150 mg/dl Eat meal 15 minutes after bolus BG should be within 30 mg/dl from starting BG Repeat test several times Adjust CHO ratio as needed Do not eat during test Stop test if BG < 70 or > 250 Bolus Test Bolus Test Start 1 hr. 2 hr. 3 hr. 4 hr. 5 hr. BG Time 6 am 7 am 8 am 9 am 10 am 11 am Basal Start 1 hr. 2 hr. 3 hr. 4 hr. 5 hr. BG Time 12 pm 1 pm 2 pm 3 pm 4 pm 5 pm Basal Testing Correction Factor Start test when BG is > 200 mg/dl No food for 4 hours before start of test No bolus for 4 hours before start of test Monitor BG at start of test, and q 1 hr. x 5 hrs. Do not eat or bolus during test Stop test if BG < 70 or > 250 mg/dl and treat appropriately Testing Correction Factor End BG should be within 30 mg/dl of target Repeat test several times Adjust as needed 7

8 Correction Factor Test Correction Factor Test Start 1 hr. 2 hr. 3 hr. 4 hr. 5 hr. BG Time 11 am 12 pm 1 pm 2 pm 3 pm 4 pm Basal Start 1 hr. 2 hr. 3 hr. 4 hr. 5 hr. BG Time 11 am 12 pm 1 pm 2 pm 3 pm 4 pm Basal Troubleshooting Hyperglycemia BG > 250 mg/dl Insulin Loss of potency Wrong insulin in pump Infusion set Bent catheter Air in tubing Infusion site problem Insulin pump Programming error Pump malfunction Behavior Missed bolus Bloused after eating Did not correct Miscount CHO Take correction bolus Recheck BG in 1 hour If not trending down, check ketones and BG > 250 mg/dl Beta-hydroxybutyrate Negative ketones 1. Inject insulin w syringe 2. Drink SF flds 3. Recheck BG in 1 hr 4. If decreasing, change site w new insulin 5. BG not dec, inject w syringe w new insulin, ck ketones, call HCP or go to ED Positive ketones 1. Contact HCP or go to ED if urine ket mod/lg or Bld > Inject insulin w syringe do not use pump 3. Drink SF fluids 4. Continue ck BG/ket q 1 hr 5. Inject rapid acting insulin q 2-3 hrs Precision Xtra = call MD > 1.5 = go to ER NovaMax = call MD > 1.5 = go to ER 8

9 Insulin Syringes Pump supplies Monitoring supplies Hypoglycemia treatment Ketone testing: urine/blood DM identification Glucagon Supplies Needed Hypoglycemia 20% of T1DM will die from hypoglycemia UK Hypoglycemia Study Group. Diabetologia 2007; 50: % of T1DM will have severe hypo if duration of > 15 years Annual rate of severe hypoglycemia requiring emergency medical services: 7.1% Leese GP, et al. Diabetes Care 2003; 26: Mortality rate 1 year after severe hypoglycemia T1 & T2 combined = 17% Poster 389, American Diabetes Association 72 nd Scientific Sessions BG< 70 mg/dl: DM vs. Non DM Severe Hypoglycemia Treatment No Diabetes Insulin levels drop Glucagon secreted Epinephrine release Norepinepherine Cortisol release Growth hormone Neurotransmitters T1DM or low C-Peptide Insulin levels high Glucagon not secreted Epinephrine release Norepinepherine Cortisol release Growth hormone Neurotransmitters Converts glycogen to glucose 1 kit = 1 mg raises BG ~ 50 mg/dl Given SC, IM, or IV 1 mg for child > 4 ½ mg for child < 4 Mini Dose Glucagon Counting CHO: Reading Labels Pt unable to swallow CHO but is awake & alert with BG < 80 mg 2 units for 1 yo 1 unit per year of age for 2 years & older Max 15 units If not above 80 mg/dl in 30 min, double the dose (max 30) 1. Look at serving size 2. Decide how many servings will be consumed 3. Multiply the number of servings by the total grams of carbohydrate Haymond, M. W. & Schreiner, B. Mini-dose glucagon rescue for hypoglycemia in children with type 1 diabetes. Diabetes Care. 2001; 24 (4):

10 Effects of CHO, Fat & Protein on BG High GI vs Low GI on BG Glucose vs White Rice vs Apple Total Available Glucose Food Serving size GM CHO TAG Meat 1 oz. 0 4 Milk 1 cup Casserole 1 cup Cheese pizza, thin Chili with beans ¼ of cup Bean soup 1 cup University of Washington Medical Center. Carb Counting Class (2 nd ed). Downloaded May 9, 2015 from sall3_05.pdf Nutrition and Diabetes Management Apps Bolus for High Fat Meal Calorie King My Net Diary Spark People GoMeals Fooducate dlife diabetes WaveSense My Glucose Buddy BG Change from Baseline in mg/dl bolus Fast / slow 1 bolus All slow bolus Hours from Baseline Adapted from Chase et al: Diabetic Medicine 2002;19:

11 Total Available Glucose Total Available Glucose Hormel Cheezy Mac n Franks Serving Size 1 container 7.5 ounces Calories per serving 280 Total fat 18 grams Total carbohydrate 20 grams Fiber 1 gram Sugar alcohol 0 Protein 10 grams Pizza Hut Thin n Crispy Cheese Pizza 1 slice from 12 Pizza Serving Size 1 slice Calories per serving 190 Total fat 8 grams Total carbohydrate 22 grams Fiber 1 gram Sugar alcohol 0 Protein 8 grams Total Available Glucose Exercise Chick-fil-A Nuggets Serving Size 8 nuggets Calories per serving 270 Total fat 13 grams Total carbohydrate 10 grams Fiber 1 Sugar alcohol 0 Protein 28 grams Most studies show little impact on A1c for T1DM Benefits of exercise same as non DM If exercise performed within 90 min of a meal, may reduce mealtime bolus Metabolic Response to Light & Moderate Exercise Bolus Reduction if Exercise within 90 minutes after a meal Normal Insulin level decreases Glucagon increases Free fatty acid mobilization increases Restriction of glucose by non exercising skeletal muscle T1DM Insulin level fails to change at the onset of exercise Insulin excess: muscle glucose uptake exceeds liver glucose production Insulin deficiency: liver glucose production exceeds muscle uptake; FFA release and ketone body formation increase Adequate insulin: liver glucose output matches muscle glucose uptake Short duration minutes Moderate duration minutes Long duration > 60 minutes Low intensity - 10% - 20% - 30% Moderate intensity - 25% - 33% - 50% High intensity - 33% - 50% - 67% Bode, B.W Medical management of type 1 diabetes (4 th ed). Alexandria, VA: American Diabetes Association. 11

12 CHO Replacement gm/30 min of Exercise Basal Adjustment for Prolonged Activity Weight Light activity 50 lb. 23 kg 100 lb. 45 kg 150 lb. 68 kg 200 lb. 91 kg 250 lb. 114 kg Moderate Intense Exercising < 90 minutes: do not change basal Exercise > 2 hours Starting point: decrease basal by 50% If more intense activity: 70-80% reduction Start reduction 1-2 hrs. before prolonged exercise Resume full basal rate prior to stopping prolonged exercise Delayed hypoglycemia may occur after prolonged/intense activity Weight lifting Exercise Induced Hyperglycemia Intermittent bursts of activity (softball, golf, martial arts, sprints, judged events If hyperglycemia is consistent: take extra insulin in preparation: 50% of the amount expected to offset the rise in BG: give min before the expected rise Hyperglycemia Prior to Exercise Lack of insulin If explainable: hydrate, take 50% of usual correction bolus If unexplainable: Check ketones If negative: hydrate, take 50% of usual correction bolus, exercise If positive: hydrate, administer full correction dose, hyperglycemia protocol, do not exercise Kids Pregnancy Illness Menstrual cycle Sex Travel Surgery Steroids Gastroparesis Special Situations Kids & Pumps Pump therapy in kids requires commitment and motivation on the part of caregivers Children require frequent dose changes Tend to need more bolus and less basal insulin compared to adults Teens are usually insulin resistant 12

13 Kids & Pumps Common problems Missed boluses Bent catheters CHO counting is an adult concept Not finishing meal after bolus given Unpredictable, impulsive, erratic activity Kids and pumps 3-4 yo: Can deliver bolus but needs to verify amt before activating Use block feature in young kids 7-12 yo: Tend to be excited about pump Need help deciding on how much to bolus Begin to carb count can calculate insulin to carb ratio Usually can achieve good control Kids and pumps Teens: Least reliable group Learn quickly Preoccupied with many other things, Pump not priority Forget to bolus Do better on a pump than shots but not as good as younger kids NEED PARENTAL INVOLVEMENT Pumps in school Train teachers & school nurse Care plan for pump issues Phone numbers for diabetes care team Extra insulin for pump &/or insulin pen for injection Pump supplies, numbing cream if used Ketone and glucose testing supplies Pump batteries Insulin syringe and/or pen needles Pumps on the playing field If NOT going to detach: May need to reduce basal rate May consume CHO if needed If going to detach: Less than 1 hour: no adjustments Bolus q 1 hr during breaks for missing basal Small bolus with snacks during breaks Pregnancy Target BG: Premeal: mg/dl Post meal 1 hr.: < 130 mg/dl Target HbA1c: < 6% If frequent hypoglycemia, severe hypoglycemia, or hypoglycemia unawareness: customize target BG Evaluate control twice weekly and adjust 13

14 Pregnancy: BG > 200 Check ketones Give insulin via syringe or insulin pen Change infusion set Follow the hospital protocol Hourly blood glucose checks BG goal mg/dl Labor and Delivery For elective C-section: decrease basal rate by 30% 8 hours before delivery while NPO and if prone to hypoglycemia, reduce 50% Active labor: reduce basal rate 30-50% Reduced insulin requirements after delivery Illness Frequent BG and ketone testing Need basal to prevent DKA Do not reduce basal unless hypoglycemia Basal rates may need to be increased for fever, infection, surgical stress, etc. Use hyperglycemia protocol as previous outlined If prolonged fasting: sensitivity factor may need to be changed Illness Increase noncaloric fluids Need some CHO to prevent ketosis If can t eat solid food: may substitute with liquid CHO Teach pt. to call if: Fever > 100 Nausea, vomiting, diarrhea > 4 hrs. Moderate or large urine ketones, or > 0.6 on betahydroxybuterate test Effect on BG varies Menstrual Cycle Increased insulin requirements 2-3 days to 1 week before cycle due to changes in estrogen and progesterone causing insulin resistance Decreased insulin requirements the day after cycle starts May need to adjust both basal and bolus Bode, B. W. Medical management of type 1 diabetes (4th Travel If sedentary during the travel: may need temp increase in basal rate 10-20% Bring 50% more supplies than usually needed for the time away Spare pump if available Hypoglycemia treatment including glucagon Extra insulin with syringes Extra monitoring supplies including spare meter, lancing device, ketone testing products 14

15 Travel Know where the nearest pharmacy, and medical care available Extra glasses if needed Pack all medical supplies in a carry on bag Insulin stable for 28 days at room temperature Protect insulin from extreme heat Low dose x-ray screening and total body scanners: contact pump manufacturer Check with airline and TSA for any changes in rules Travel When changing time zones: Keep the pump clock the same at departure and then change it to the new time zone after arriving to the new destination If a large time zone change Change pump clock 2 hours towards the new destination daily until the correct time is achieved Surgery/Procedure What type of surgery? How long is the surgery? What time will the surgery start? How long will the patient fast? What kind of diet will the patient have after surgery? Will the patient be receiving IV dextrose? Surgery / Procedure What type of anesthesia? Can the patient skip a meal without hypoglycemia? Does the patient have a history of severe hypoglycemia? Does the patient have hypoglycemia unawareness? General Anesthesia Neuroendocrine stress response Epinephrine Glucagon Cortisol Growth hormone Inflammatory cytokines interleukin-6 tumor necrosis factor-alpha Metabolic Abnormalities from Surgery/Anesthesia Insulin resistance Decreased peripheral glucose utilization Impaired insulin secretion Increased lipolysis and protein catabolism Hyperglycemia In some cases: ketosis General anesthesia is associated with larger metabolic abnormalities as compared to epidural anesthesia 15

16 Glycemic Goals for Surgery Avoidance of marked hyperglycemia Avoidance of hypoglycemia Maintenance of fluid and electrolyte balance Prevention of ketoacidosis Options: Take pump off and replace basal insulin: 1 injection of basal prior to surgery ½ dose prior to surgery, ½ dose 12 hrs. later Patient given corrections for hyperglycemia using Regular or Rapid-acting analog insulin Leave pump on at full basal rate Patient given corrections for hyperglycemia using Regular or Rapid-acting analog insulin Leave pump on at reduced basal rate Patient given corrections for hyperglycemia using Regular or Rapid-acting analog insulin Gastroparesis Stomach emptying is variable esp. if BG levels are variable Many have gastroparesis without sx Use special bolus features as needed to match stomach emptying Generally: gastroparesis diet is low fat, low fiber Steroids Steroid Equivalent Onset Duration Betamethasone mg Rapid Cortisone 1 25 mg Slow h Dexamethasone x > than HC 5-7 x > Prednisone 0.75 mg Rapid 72 hours HC acetate 1 20 mg Slow Long HC sodium 20 mg Rapid Short phosphate 1 HC sodium 20 mg Rapid Short succinate 1 MP 5 4 mg Rapid h Prednisolone 4 5 mg Rapid h Prednisone 4 5 mg Rapid Steroids Low dose steroids: less than equivalent of Dexamethasone 40 milligrams 40% basal 60% bolus High dose steroids: equivalent of Dexamethasone 40 milligrams or higher 25% basal 75% bolus Steroids Total initial insulin dose: Low dose steroids: start at units/kg High dose steroids: start at: 0.9 units/kg if on metformin 1.2 units/kg if not on metformin 16