Diabetes Dilemmas: Using Technology To Solve Clinical Conundrums Stephen E. Gitelman, MD UCSF A teenager with type 1 diabetes for 5 years comes into your office for a follow- up visit. You want to review how he is doing with his diabetes management. He and his parents say all is well. What is the single best way to assess things? 1. Ask to see his written logs 2. Ask to see his glucometer 3. Send him off to the lab for a HbA1C All have advantages and disadvantages Answer 2 Junior s s Glucose Log Current Glucometers Breakfast Lunch Dinner Bedtime 100 95 105 100 90 80 90 110 85 120 110 100 Have gotten smaller, use less blood, faster result Most all have memory, with time and date Can download manually or to a computer 1
HbA1C The ultimate report card Reflects the previous 3 months of glycemic control Based on irreversible nonnon-enyzmatic glycation of Hb betabeta-chain Various methods to determine Chromotography, Chromotography, HPLC, immunoagglut, immunoagglut, electrophoresis Normal range varies, according to method 4 6% is common range ~50% of HbA1C is from the preceding month Important in assessing responses to therapy, and risk for long term complications Does not assess variability Evidence this may relate to complications risk HbA1C Measurements Problem waiting for clinic lab result Need to send someone to lab 11-2 wks before visit, or will have vital data after the fact Use of DCA 2000 Measures HbA1C in minutes off fingerstick sample Highly correlated with clinic lab Home A1C kits are not as accurate What might explain a major discrepancy between the expected HbA1C from the glucometer average and the actual HbA1C measured in lab? 1. Glucometer average only reflects average of glucometer tests, and will not be a true average 2. The HbA1C can be may be falsely elevated or depressed 3. The HbA1C is more heavily weighted towards the past month 4. The log or glucometer values are fabricated 5. All of the above 6. None of the above 2
Creative Diabetes Logbooks Answer: 5. All of the above Fabricating glucose records by various methods Use of control solution Recording incorrect values in log book Testing friends glucose levels Taking batteries out of meter to lose readings Even tampering with computer files from meter downloads at home Trying to understand how the discrepancy occurred is usually not productive Managing glucose record fabrication Take away pressure about the numbers Focus on using glucoses as information, not a value judgment Give families a graceful way to start over Have parents supervise encourage patient and parents to view diabetes management as requiring teamwork from patient and parents Treat as an essential chore Insulin Dosing Basal + Bolus regimen Plasma Glucose A A A Plasma Insulin G MN 4AM 8AM Noon 4PM 8PM MN Daily insulin requirements: Food coverage, high glucose corrections Basal metabolism Each requirement consumes ~50% total daily insulin 3
You place your adolescent pt on this regimen. It works well for the first few months. However, they return and the HbA1C has risen significantly. What is the most likely reason? 1. Puberty, and increased insulin needs. 2. Missing injections 3. Lipohypertrophy at the injection site Basal + Bolus regimen Answer: 2. A A A A A A G MN 4AM 8AM Noon 4PM 8PM MN How can you help him get back on track? 1. Insist on eating just 3 large meals per day 2. Have direct adult supervision for all insulin dosing 3. Move to the pump 4. Combination of the above 4
Answer: 4. What about pumps for children? What Does The Pump Do? Continuously delivers short-acting insulin subq Program in basal delivery rates for each hour of the day can adjust for dawn phenomenon, exercise, etc. Must manually enter bolus doses for carbohydrate intake and high blood sugar correction The pump will calculate doses based on formulas The pump will calculate residual insulin, and keep the wearer from stacking doses The pump does not monitor blood glucoses (not a closed loop) Pump Considerations Benefits No more shots! Better overall control, less hypoglycemia risk Quality of life improved Potential drawbacks Risk for DKA Risk for infection at the catheter placement site Wearing a device Labor of teaching new skills to family Financial issues Who is a pump candidate? 1. A toddler with type 1 DM for 1 month 2. A middle school child with type 1 DM for 1 year, still in honeymoon, with a low HbA1C 3. A teenager with type 1 DM for 6 years with a very high HbA1C 4. A teenager with type 2 DM who fails metformin 5. All of the above 6. None of the above 5
Successful Pump Candidate Answer: 5. No real age concerns Motivated child who wants the pump, with supportive and involved family May be more than you need early in the course of DM but tighter glycemic control may preserve beta cell function Solid diabetes self-management skills monitors glucose >4 4 times per day, including school counts carbohydrates Manual dexterity, not techno-phobic HbA1C is problematic as a sole determining factor Those with higher HbA1C may benefit most from pump Bottom line anyone who requires insulin therapy Does apply to some type 2 pts Patient explanation You are seeing a teen on a pump. In reviewing the pump download, you find that there are very few boluses, and mainly basal insulin, being administered. You ask what is happening? Forget Too busy I use the insulin pen for boluses Not eating as many carbs I m m on the Atkins diet How much does one missed bolus per week raise HbA1C? A) 0.05 B) 0.10 C) 0.25 D) 0.40 E) 1.00 6
What is the best way to make sure that people remember to bolus? Answer: C. A) set a watch alarm B) set a pump alarm C) have an adult supervise and remind them D) just crank up the basal rate at the time the bolus is most likely to be missed Answer C. Use Of Pump Alarms Chase et al, Diabetes Care 29: 1012, 2006 Randomized trial for youth with A1C > 8% After 3 mos, group on alarms had missed boluses decrease from 4.9 to 2.5 / wk A1C 9.32 8.86 Control group had 4.3 to 4.2 missed boluses / wk A1C 8.93 8.67 After 6 mos,, change in A1C in treatment group from baseline no longer seen Future research is needed to explore additional techniques that may sustain the effects initially observed in this study. Chase et al, Diabetes Care 29: 1014, 2006 7
What else might you do to optimize therapy? Continuous Glucose Sensor Continuous Glucose Monitoring Which of the following should you NOT consider? 1) Increase the breakfast insulin to carb ratio 2) Change the timing of the bolus 3) Increase the AM basal 4) Add Pramlintide (Symlin) 5) Ask about snacking at school Answer 4 8
Some Considerations What s s for breakfast? Timing of bolus Bolus before meals May need to increase insulin to carb ratio Not unusual to have higher Insulin: Carb ratios at breakfast than other meals Some helped by raising basal Supervision at school to ensure patient is covering all snacks with insulin bolus Pramlintide not approved < 16 yrs Careful of effects on appetite in younger pts Sensor Considerations Helpful for trend analysis, but do not replace glucometer Still need to calibrate with glucometer Need to be willing to wear the device Often NOT covered by insurance Not a closed loop system yet! yet! Summary New technologies can assist the patient and health care provider in diabetes management Glucometers HbA1C Pumps Sensors Successful management requires on-going supervision and support by family and health care team 9