The Growing Future of Diabetes: Insulin Pump Therapy in Type 1 and 2 Diabetes

Transcription

1 The Growing Future of Diabetes: Insulin Pump Therapy in Type 1 and 2 Diabetes Sarah Dombrowski, PharmD, BCACP Pennsylvania Pharmacists Association 10/20/18 1

2 Objectives At the completion of this activity, the participant will be able to: Discuss current insulin pump and continuous glucose monitoring options for patients and identify appropriate patients for insulin pump therapy Describe pharmacists roles in insulin pump therapy across hospital, community and ambulatory care pharmacy Utilize insulin pump reports to assess blood sugar control and adjust patient pump settings when given a patient case 2

3 Insulin Pump Basics Electromechanical device that mimics the body s natural insulin secretion More physiologic than multiple daily injections (MDI) Pump holds and delivers the insulin Patient does not require injection of any insulin via needle/syringe Insulin lispro, aspart, and glulisine preferred (regular insulin possible) Delivers rapid-acting insulin in two ways: Preset continuous basal rates Boluses at mealtimes and as needed (manual) Infusion site to be changed every 3 days 3

4 Insulin Pump Basics 4

5 Diabetes Pump Outcomes Insulin pump therapy allows for better glucose control than MDI by Breaking insulin resistance and reducing insulin dose (esp. Type 2) In general, 20% reduction in TDD of insulin for patients switching from MDI to pump Improving blood glucose control and lowering A1c Limiting excess weight gain associated with MDI Reducing the frequency of severe hypoglycemia Especially when combined with continuous glucose monitoring Improving patient engagement in their diabetes management 5

6 Type 2 Diabetes Pump Outcomes Patient Feedback So happy I made the switch to pump so convenient and not sticking myself 5 times a day 6

7 Continuous Glucose Monitoring (CGM) Basics Device worn continuously by patient Needle or canula sits under patient s skin Glucose readings are taken from interstitial fluid Sensor glucose follows blood glucose Sensor and blood glucose readings will rarely match and are expected to be different A greater difference will be seen when glucose is changing quickly Provides continuous picture of glucose levels Must more data for patient and provider than fingersticks alone 7

8 CGM + Pump - Prevention of low blood sugars 8

9 Available Products Insulin Delivery and Continuous Glucose Monitoring 9

10 Current Continuous Glucose Monitor Options Medtronic ipro 2 with Enlite Sensor Dexcom G5 Mobile Dexcom G6 Medtronic Guardian Connect Medtronic Guardian Sensor 3 Freestyle Libre 10

11 Medtronic ipro 2 with Enlite Sensor Professional GCM placed by physician practice Used by physician to gather data on patients glucose levels Does not interface in real time with any device Tests glucose every 5 minutes Records glucose for up to 6 days Must be calibrated at least 2 times per day with fingersticks No predictive alerts or alerts for caregivers Worn on abdomen 11

12 Dexcom G5 Mobile Personal CGM Interfaces with Dexcom receiver, smart device Tests glucose every 5 minutes Needs to be changed every 10 days Does not require calibration with fingersticks For use in patients with Type 1 or 2 diabetes ages 2 yo and up Alerts for high or low glucose thresholds Includes alerts for up to 5 caregivers Worn on abdomen or upper buttocks (pediatric only) 12

13 Dexcom G6 Personal CGM Interfaces with Dexcom receiver, smart device, or insulin pumps (t:slim and Omnipod) Tests glucose every 5 minutes Needs to be changed every 10 days Does not require calibration with fingersticks For use in patients with Type 1 or 2 diabetes ages 2 yo and up Alerts for high or low glucose thresholds Includes alerts for up to 5 caregivers Worn on abdomen or upper buttocks (pediatric only) 13

14 Medtronic Guardian Sensor 3 Personal CGM Interfaces with Medtronic 670G pump Tests glucose every 5 minutes Needs to be changed every 7 days Must be calibrated 2-4 times per day with fingersticks For use in patients with Type 1 or 2 diabetes ages 14 and up on 670G insulin pump Predictive alerts minutes before a low or high Does not include alerts for caregivers Worn on abdomen 14

15 Medtronic Guardian Connect Personal CGM Interfaces with Apple smart devices (Android interface in development) Tests glucose every 5 minutes Needs to be changed every 7 days Must be calibrated 2-4 times per day with fingersticks For use in patients with Type 1 or 2 diabetes ages yo on insulin Predictive alerts minutes before a low or high Includes alerts for caregivers Worn on abdomen 15

16 Freestyle Libre Personal CGM Interfaces with Freestyle Libre reader Tests glucose every 15 minutes Needs to be changed every 10 days Does not require calibrations with fingersticks For use in patients with Type 1 or 2 diabetes over 18 yo No alerts for lows/highs Does not include alerts for caregivers Worn on back of arm 16

17 Insulin pumps 17

18 Current Insulin Pump Options Omnipod Dash System Tandem t:slim X2 Medtronic 630G Medtronic 670G Hybrid Closed Loop System 18

19 Omnipod Dash 19

20 Tandem t:slim X2 20

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25 Patient-Centered Approach to Insulin Pumps and CGMs 25

26 Pump Patient Selection Motivated to achieve normoglycemia Performs self-care responsibilities associated with diabetes Technical ability to monitor glucose and operate insulin pump Intellectual ability to learn and retain information Effective coping patterns Availability of support systems Financial resources to cover cost of therapy Adapted from the American Association of Diabetes Educators Position Statement on Education for Continuous Subcutaneous Insulin Infusion Pump Users. 26

27 Factors to consider in recommending a pump or CGM Patient age Type 1 versus Type 2 diabetes Current medication regimen Dexterity Cognition Body type Activity and occupation Insurance coverage Patient goals of care 27

28 Consider Differences in Pumps and CGMs Tubing versus tubeless Insertion site location Needle versus canula Angle of insertion for infusion set User interface Open loop versus hybrid closed loop systems Special technology features and communication with other devices 28

29 Customizability for Patient Delivery settings Basal Rates Carb ratio or fixed meal bolus Sensitivity factor Active insulin time Goal blood glucose range Differences in pump supplies (depends on the pump) Type of infusion set Length of tubing Length of canula Size of reservoir 29

30 Pharmacist Roles in Insulin Pump Management Across Healthcare Continuum 30

31 Hospital Pharmacists Consider pre-op recommendations Assess patient understanding and management of pump ISMP Safe Management of Patients with an External Subcutaneous Insulin Pump During Hospitalization Keep patient connected to pump when possible AACE and the ACE encouraged not to discontinue an insulin pump, but rather to consult specialist if the patient cannot manage his/her own pump Understand how to access delivery settings on patient s pump to determine insulin rates if need to transition to subcutaneous/iv insulin Ensure patient is able to restart pump upon discharge Change in settings? 31

32 Community Pharmacists Understand basics of insulin pumps and where to refer patients Assess patient understanding and compliance Patients should only be using short- or rapid-acting insulin in insulin pump Patient may have long-acting insulin and needles/syringes on hold for emergencies Ensure patient s prescription matches actual use Patient needs enough insulin in each fill for use + filling tubing and canula (if applicable) Help patient understand treatment of high and low blood sugars Partner with pump companies to improve patient access American Diabetes Association (ADA): CSII (continuous subcutaneous insulin infusion) should be prescribed, implemented, and followed by a skilled professional team familiar with CSII therapy and capable of supporting the patient. 32

33 Ambulatory Care Pharmacists Can take primary role in management in partnership with Endocrinology/Primary Care Monitor blood glucose and continuous glucose monitoring Adjust insulin pump settings (with Collaborative practice agreements) Train new pump patients (contract with company) Online and in clinic instruction Observe 1-2 trainings with company trainer Train 1-2 patients independently with trainer observation Pass written certification exam Staff education Opportunities for payment Face to face Telephonic/telemedicine? 33

34 Sample Reports and Patient Cases 34

35 Patient 1 35

36 Patient 2 36

37 Patient 3 37

38 Patient 4 38

39 Patient 5 39

40 Patient 6 40

41 Summary Current insulin pump and continuous glucose monitoring options for patients Appropriate patients for insulin pump therapy Pharmacists roles in insulin pump therapy Hospital Community Ambulatory care pharmacy Modification of pump settings to optimize patient outcomes 41

42 Questions? Sarah Dombrowski 42

43 References Boyd LC and Boyd ST. Insulin Pump Therapy Training and Management: An Opportunity for Community Pharmacists. J Man Care Pharm. 2008;14(8): Reece SW, Hamby Williams CL. Insulin Pump Class: Back to the Basics of Pump Therapy. Diabetes Spectrum. 2014;27(2): Smetzer J (ed), Cohen M (ed), Shastay A (ed), et al. Safe Management of Patients with an External Subcutaneous Insulin Pump During Hospitalization. ISMP. Oct ;21(21):1-5. ISMP. Managing Hospitalized Patients with Ambulatory Pumps: Part 2- Recommendations for the Use of Insulin Pumps During Hospitalization. ISMP Medication Safety Alert. Oct guidelines-use-insulin-pumps Insulin Pump Therapy Resources - Educator Tools Providing Guidance on Pump and Sensor Training. American Association of Diabetes Educators. 43

44 Product Sites (for healthcare professionals)