Diabetes Devices Workshop Angela Aldrich, PharmD, PhC April Mott, PharmD, PhC, BCPS Presbyterian Medical Group 28 January 2018 Pumps & Sensors & Meters, Oh My! A Tale of Two Meters Technology for glucometers has advanced over recent years. These newer meters can usually be worked cold by someone who has experience handling glucometers in general, but many of the highly useful features are not immediately obvious and require a read of the manual to get the full benefit of the advances. Accu-Chek s newest general use meter. Pairs with smart phones, pads, and computers. Analyzes patterns and reminds patient to test. Easy to program. Strips are inexpensive through coupon program. Accu-Chek Guide Coupon Program 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. New Strip Case 1
Buttons Buttons and Ports Meter turns on when OK is pushed or a strip is inserted. Back arrow takes you to the previous screen. Up and down arrows allow you to scroll. OK button proceeds to new screen/selects item. Button on right side of meter ejects strip and port connects with computer to exchange data. Port is not for charging. Settings Menu Time/Date Scroll to set current time/date. Click OK to progress to next field. Beeper Wireless Settings Allows meter to beep when a reminder goes off (more to come). Flight Mode disables wireless capabilities. Default Device lists primary paired device name. Auto-Send causes readings to be synced automatically 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
Pairing Meter Pairs with Cell Phone Shows a code you then type into your cell phone to pair the devices. Up to five devices can be paired to one meter at a time. Shows Graph of BG readings, Logs, meal and insulin detail. Patient can add a picture of meal associated with a specific test. More Options Target Ranges Patterns Reminders As data is entered into the meter this allows pattern analysis to occur. Reports show patterns in high and low data. 3
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
Two Verio Flex Meters, One Log! 3 Button Model Less intuitive to program but has cheats on the back. Office based sensors Types of CGM o Collect specific time frame of data for download at set time o No real time data available to patients o Helps identify glycemic patterns to assist with a1c lowering with less hypoglycemia, helps to understand variability Patient based sensors o 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 Transmitter sensors o Have ability to transmit to insulin pumps, tablets, smartphones, watches o 288 readings per 24 hours with Dexcom o Could transmit from children at school, seniors in facilities o Typically requires calibration (2x daily shown here) On the horizon o Rumors of apple watch beta testing bloodless CGM Continuous Glucose Monitoring Case Self Monitored Results: Novolin 70/30 mix 50 units prior to breakfast and lunch, 55 units prior to dinner Case Insulin Pumps Insulin pumps approved to utilize short-acting insulin analogues o Lispro-Humalog o Aspart-Novolog o Glulisine-Apidra Relieve patients using multiple daily injections of basal/bolus insulin. For Example: o Levemir 20 units sq qam and 50 units sq qpm o Novolog tid ac and hs 5
Insulin Pumps Benefits o More precise and accurate insulin dosing can better regulate blood glucose (BG). o Customized, flexible basal and bolus dosing to meet lifestyle demands. o Less severe hypoglycemia. Challenges o Requires self-monitoring of blood glucose at least 4 times/day. o Requires thorough training. o Diabetic ketoacidosis can develop quickly if insulin delivery is interrupted for a period of time. o Blood glucose regulation is complex. 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 Insulin Pump Features Allow for variation in basal rates o Activity/sleep o Dialysis o Weekend/weekday Bolus doses can be o Flat dosing such as 20 units prior to meals o Based on carbohydrate estimation: 1 unit per 15 g CHO o Corrected for blood sugar levels: 1 unit for every 16 mg/dl >130mg/dL o Extended dosing for target meals: pizza effect where fats and protein delay carbohydrate absorption Pump Settings that Factor into Pump Therapy Basal Rate Carb Ratio (Insulin-to-Carb Ratio) Target BG (Blood glucose) Correction Factor (Insulin Sensitivity) Insulin Duration (Duration of Insulin Action) Pump Case Type 1 Diabetic, 20 year old college student Levemir 15 units sq bid Novolog roughly 10 units tid 1 unit:15gcho + 1 unit for every 50mg/dL>150mg/dL 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) How to convert? How would you set her basal rate? 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 Hyperglycemia with Pump 6
Hypoglycemia with Pump Not allowing pump to calculate bolus Carbohydrate counting error Insulin stacking (correcting too soon) Basal set too high Programming error Insulin Duration setting not accurate Behaviors/Life o Exercise or activity o Alcohol Evaluating and Adjusting Basal Rates If basal rates are set appropriately, BG s should not fluctuate more than 30 mg/dl during testing. If BG drops more than 30 mg/dl, decrease the basal rate 2-4 hours before the change occurs. If BG rises more than 30 mg/dl, increase the basal rate 2-4 hours before the change occurs. Adjustments should be no more than a 5 to 10% increase or decrease. Retest - basal rate testing is a work in progress. 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