How I use the latest technology to investigate and treat a person with Type 1 Diabetes Dr Pratik Choudhary
Disclosures Advisory board and speaker fees from Medtronic, Roche, Abbott and Johnson and Johnson, Sanofi, Lilly, Novo Nordisk, MSD, BI Research support - Medtronic, Beta O2, Diabetes UK, JDRF, Keen to try any new technology Dr Pratik Choudhary
Control Hypoglycaemia
Case vignette Sarah aged 43yrs, T1D 24 years HbA1c 8.8% Rapid insulin 10 10 12 Background 18 Measures BG 2 3 / day From memory BG 5-15 variable Hypo 2-3 / week Guestimates doses.
Levels of Care Fixed Doses OD Basal CHO Counting BD Basal CHO Counting BD Basal OR CSII 6 + 6 + 6 20 2-3 tests/day Visual estimation Guessed corrections 1:1 + 1:1+ 1:1 12 12 ISQ = 3 4 tests/day Pre-meal boluses 1:1 + 1:1+ 1:1 12 12 ISQ = 3 6-8 tests/day OR CGM Adjustments for ex Adjust for Fat/prot Pattern recognition P Choudhary.
Why do you think she is not at target? Education Skills Tools Support Confidence Motivation Presentation title 6
The Building Blocks Structural Behavioural Basal Day / Night Carb Counting N of BG / day Bolus Insulin: Carb Ratios Correction Ratios Adjusting basal for exercise / illness Over-correcting highs and lows Presentation title 7
Mimicking physiology Basal Basal secretion represented 50.1±3.1% of the total 24-h insulin secretion in normal subjects and 45.2±2.2% in obese patients (P < 0.2). polonsky et al, JCI, 1998 8
Mean HbA 1c 11.0 % 10.5 % 10.0 % 9.5% 9.0% 8.5% 8.0% 7.5% 7.0% Relationship between CBG frequency and HbA 1c SMBG per day 1 HbA 1c (%) 11 10 9 8 7 Frequency of daily SMBG 2 6.5% 0-2 3-4 5-6 7-8 9-10 11-12 13 0 0 1 2 3 4 5 6 7 8 9 10 SMPG per day 1. Miller KM et al., Diabetes Care 2013; 36:2009-14 2. Ziegler R et al. Ped Diabetes 2011; 12: 11-17. Frequency of daily SMPG MDI CSII
Dose adjustment Carb Food content insulin Insulin: Carb BG Correction - target glucose insulin Insulin sensitivity factor Insulin on board 65 [ 6.5] 10 12-6 3 [ 2 ] Insulin : Carb ratio 1 : 10 gms Correction factor = 3 Current glucose = 12 mmol/l Insulin on board Rules ICR = 350 / TDD ISF = 120 / TDD Pratik Choudhary
SMART METERS Bolus calculators average glucose [ HbA1c] Data analysis - real time Real time data upload
Timing is everything Bolus 20 minutes before meals Blood glucose (mmol/l) 13.9 12.5 11.1 9. 7 8. 3 Bolus 20 min after meal Bolus 20 min before Bolus at meal start Pre (-20) Start (0) Post (+20) 6. 9 5. 6 0 30 60 90 12 0 15 0 18 0 21 0 24 0 Time post meal (min) Cobry et al Diabetes Technol Ther 2010; 12: 173-177
What education can deliver 20-50% achieve A1c < 7.5% depending on centre For the majority, not enough to achieve < 7.0%
Proportion in range 100 80 60 28.9% 40.6% 55.6% % Above Target % In Target % Below Target 40 20 57.3% 50.6% 39.9% Figure 1: Proportion of daily CBG results above, below and within the target range amongst the varying HbA1c groups. 0 HbA1c <7.5 HbA1c 7.5 8.9 HbA1c 9 Sivasubramaniyam S et al., Diabet Med 2017; 34 (10): 1456-1460. Dr Pratik Choudhary
6 months later Done DAFNE HBA1c dropped to 8% BUT Had a few night time hypos So Overnight insulin reduced But HBA1c is now 8.4%
P Choudhary Using blinded Continuous glucose monitoring
Overnight and fasting glucose High x 2 nights OK x 2 nights Low x 3 nights A typical week in the life of T1D How do you adjust overnight basal?
Variability in overnight insulin requirements Ruan et al., Diabetes Care 2016; 39(5): 830-832.
Continuous glucose monitoring 10% IN CONTROL 9% JDRF(age 8-24) HbA1C 8% RealTrend JDRF<7 IMPACT Danne et al Ly et al. 7% ASPIRE IN HOME Choudhary et al. 6% Low Hypoglycaemia High Dr Pratik Choudhary Slattery et al, Diabetes Tech Ther; 2017 19
CGM can help reduce HbA1c Lind M, et al JAMA. 2017;317(4):363-364.
Alarms are not enough Patients sleep through up to 71% of nocturnal alarms Buckingham et al Diabetes Technol Ther. 2005 Dr Pratik Choudhary 21
Case study for CGM Life changing Able to travel independently Husband able to leave her alone with her children NO further severe hypos Able to get driving license back
Other technology to support people with type 1 diabetes 23
T1 resources.uk
Virtual clinics HCP: HCP PWD: HCP
Dr Pratik Choudhary, KCL
Basic principles Delay in glucose sensing Algorithmic delays Delay in insulin action
Patients pushing the boundries #wearenotwaiting #OpenAPS #nightscout Page 28
Cellular therapies Recurrent severe hypoglycemia despite optimised medical therapy 70% graft survival at 5 years 30% insulin independence
Summary Get the data Teach the patient how to use the data Think of the split between background and rapid acting insulin Timing of the rapid acting is key Better monitoring and better delivery can help Frequent virtual contact helps Presentation title 30