Transcript Diabetes Technology Update - Friedman Diabetes Institute

Diabetes Technology
Update
By Marina Krymskaya, NP, CDE
January, 2010
Financial Disclosures
No conflict of interest to disclose.
“The past is behind, learn from it.
The future is ahead, prepare for it.
The present is here, live it.”
Thomas S. Monson
• Glucose Monitoring Systems
- Glucose Meters
- Continuous Gglucose Monitoring Systems (CGMS)
• Insulin Delivery Modes
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Syringes
Insulin Pens
Jet Injectors
Insulin Pumps
“The past is a foreign country;
they do things differently there.”
Leslie Poles Hartley
Glucose Monitoring
anTcient method
modern method
Glucose Monitoring
First Glucose Meter
Glucose Monitoring
• Home blood glucose meters
measure the glucose in whole blood,
while most lab tests measure the
glucose in plasma.
• Plasma glucose levels are generally
10%–15% higher than glucose
measurements in whole blood.
• Most of the modern meters on the
market give results as "plasma
equivalent," even though they are
measuring whole blood glucose.
• Sample sizes vary from 30 to 0.3 μl.
• Test times vary from 5 seconds to 2
minutes.
Glucose Monitoring
CGMS
Continuous Glucose Monitoring System
• test glucose in the IF
every few minutes for up
to 7 days
• alarm system warns if
glucose rapidly changes
• real time results
Glucose Monitoring - CGMS
• by analyzing the trends, the
patient or the physician can adjust
insulin
• leads to better glycemic control
Trends Better Than Points
Insight
No clue what
to do
Benefits of CGMS
• Increased security from
alarms & alerts
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Immediate feedback - look
and learn
•
BG trend provides more
information than static
readings
• Control + safety
Limitations of CGMS*
•Interference with glucose readings by sensor can
occur with certain substances
- i.e.gluthatione, ascorbic acid, uric acid, salicylates – can cause
co-oxidation, which will lead to overestimation of glucose levels
•Lag-time for up to 15 minutes when glucose changes
rapidly
•Overall percentage of error – near 15%
• Guardian REAL-Time – 17%
• DexCom 11-16%
• Navigator
12-14%
* E. Cenzic, MD and William tamboriane, MD. A Tale of Two Compartments: Interstitial Versus Blood Glucose Monitoring. DIABETES
TECHNOLOGY & THERAPEUTICS. Volume 11, September 2009.
Glucose Monitoring - CGMS
Abbott FreeStyle
Navigator®
Medtronic MiniMed
Paradigm® REAL-Time
DexCom™
SEVEN® PLUS
Insulin Delivery Modes
Syringes
Improved Technology:
• disposable
• thinner needles
• more sanitary
Insulin Delivery Modes
Insulin Pens/Devices
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Disposable
Reusable
1 Unit increments
0.5 Unit increments
Insulin Delivery Modes
Insulin Pens/Devices
•Ease of handling
•More discrete use
Insulin Delivery Modes
Jet Injectors
• sends insulin through the skin , using high pressure mechanism
• an option for people with severe needle phobia
Insulin Delivery Modes
Insulin Pumps
The prototype of the first pump that
delivered glucagon as well as insulin,
backpack style, was in the early '60s.
Omni Pod - the world’s first tubing-free insulin pump.
Insulin Delivery Modes
Insulin Pumps
•provide continues insulin delivery
•infusion site needs to be changed
only every 2-3 days
Pump Advantages
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More reliable, precise insulin action
Fewer missed doses
Less insulin stacking
Fewer lows, especially at night
Easier to exercise
Less glucose exposure and variability
Less insulin
Matches variable basal insulin need
Fewer social limitations
Better data access for providers and patients
Example
3-Step Temp Basal Reduction
For 3 hours of strenuous activity
1) 1 hr temp basal at 0%
2) 2.5 hr temp basal at 60%
3) temp basal at 85% overnight
Future
“Prediction is very difficult,
especially about the future”.
Niels Bohr
• Pump technology continues to advance
• On the horizon:
– Pumping and monitoring by cell phone
– Cooler styles
– Smaller sizes
– Improved human interface
– More helpful data analysis
– Gradual progress toward a closed loop
Closed Loop?
• Still needed:
• Faster insulins
• Better CGM accuracy
• Less sensor lag time
•
Glucose control algorithms that
won’t fail
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Closing the loop will come in small
steps over time
Injectable Continuous
Ostomotic Glucose Sensor
• LifeCare (Bergen, Norway) is working on a CGM that’s so tiny it can
be implanted without surgery.
• The company claims it’s the “new frontier in CGM!”
• Currently undergoing testing to determine reactions from the
immune system.
Non-invasive Continuous Blood
Glucose Monitor
OrSense’s NBM-200G
• A highly sensitive optical system, using an array of calibrated light sources,
measures light absorption and scattering. The desktop monitor calculates
the glucose level and displays the results.
– Exhibits comparable accuracy to invasive solutions, while providing
superior ease of use and safety
– Tested on over 450 subjects
– At this stage, the NBM 200G glucose monitor is utilized for investigation
and market awareness purpose only.
Emerging Research About
Nanomedicine and Diabetes
• nanos (Greek) – one-billionth part of something
• nanotechnology - engineering and manufacturing at the
scale of a nanometer (10 - 9 )
• Nanotechnology in Medicine:
– Nanoscale structured materials and
devices
– Genomics, proteomics and
artificial engineered microbes
– Medical nanorobots
Emerging Research About
Nanomedicine and Diabetes
Mauro Ferrari (Ohio State University) and Tejal Desai (Boston University). *, **
– implantable nanomedical device, which contains pancreatic beta cells from
animals. A tiny silicon box surrounded by a material with a very specific nanopore size. The pores are big
enough for glucose and insulin molecules, but small enough to impede the passage of much larger immune
system molecules (immunosuppressants will not be needed?)
SmartCell, which was originally developed at the Massachusetts Institute of
Technology.***
- When glucose rises in the bloodstream, the structure of the SmartCell will be eaten away. This breakdown of the
SmartCell’s protein matrix facilitates the release of insulin
Non-invasive glucose monitoring via implanted nanosensors.****
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The key techniques include fluorescence resonance energy transfer (FRET) and fluorescence lifetime sensing as
well as new nano-encapsulation technologies for sensors such as layer-by-layer (LBL) films.
*Martinac K, Metelko Z. Nanotechnology and diabetes. Diabetologia Croatica 2005; 34(4):105-110.
** Fritas RA. Current status of nanomedicine and medical nanorobotics. http://www.nanomedicine.com /Papers/NMRevMar05.pdf accessed January, 2010
***Aaron K. Outsmarting Diabetes. Cornell Engineering Magazine 2003. http://eng-2k- web.engineering.cornell.edu/engrMagazine/magazine.cfm?issu..., accessed January, 2009
**** Pickup JC, Zhi ZL, Kan F, et al. Nanomedicine and its potential in diabetes research and practice. Diabetes Metab Res Rev 2008; 24(8):604-610.
21 December 2009 University of Western Ontario
Tears of Joy for Diabetics
The non-invasive technology uses extremely small nanoparticles embedded into the
hydrogel lenses. These engineered nanoparticles react with glucose molecules found in
tears, causing a chemical reaction that changes the color of the lenses.
Diabetes Care
Enhancement Initiative
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Team: Leonid Poretsky, MD; Agustin Busta, MD; Morton Davidson, MD; Marina
Krymskaya, RN, NP; Jason Park, MD; Carmen Schmidt, RN; Daniel Steinberg, MD;
Goal: Improvement of diabetes care for both inpatients and outpatients throughout the
Beth Israel System.
Plan
Educational aspects:
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To include physicians, nurses, house staff, patients and their significant others;
The series of lectures, grand rounds, in-service events to be planned;
The “discharge kit” with general and individualized instructions to be developed and piloted;
Educational video materials for inpatient TV to be selected/created and used throughout BIMC;
Clinical aspects:
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Review of all existing diabetes protocols for general wards;
Review of current PRISM orders;
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Review of current diabetes-related protocols in CCU, MICU, CT ICU, SICU;
Quality Improvement:
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Jointly with GMA, develop program for house staff
Open for suggestions.
Diabetes Care
Enhancement Initiative
Progress so far:
Educational Sessions for:
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nurses in three psychiatric units
the hospitalists
the surgical team
cardiology NPs
KHD
In collaboration with: Carmen Schmidt, RN; Angela Babayev, RN; Dahlia Rizk, DO;
Steven Bergmann, MD; Jacqueline Lagazo-Guia, NP; Phillip Schmidt, MD
Diabetes Care
Enhancement Initiative
Progress so far:
Medical Grand Rounds:
• Successful Management of Inpatient Hyperglycemia. By Dr. Silvio E.
of Yale University. (June 16th, 2009)
Inzucchi,
• Diabetes: Diagnosis, Classification, Management. Controversies and News. *
By Dr. Leonid Poretsky, Chief, Division of Endocrinology and
Metabolism, Beth Israel Medical Center. (September 15th, 2009)
• Insulin therapy in outpatient and inpatient settings. * By Dr. Agustin Busta.
(December 1st, 2009)
• Medical Nutrition Therapy for Diabetes. Does a perfect eating plan exist? * By
Jennifer Regester, RD, CDN.
Diabetes Technology Update. * Marina Krymskaya, ANP, CDE. (January 26,
2010)
* Slides available at www.friedmandiabetesinstitute.com
Thank You!