Transcript CSII The Insulin Pump and CGM

CSII
Continuous Subcutaneous Insulin Infusion
The Insulin Pump
and
CGM
Continuous Glucose Monitoring
Kathryn Taylor Teare, MSN, CRNP, CDE
Medtronic Diabetes
Objectives
By the end of this program, the participant will be able
to:
 Calculate the carbohydrate content of a given meal
 Understand the pharmacodynamics of rapid-acting
insulin
 Differentiate between basal and bolus insulin
 Identify a patient who would benefit from an insulin
pump
 Calculate baseline dosages for a given patient
 Identify the benefits of continuous glucose
monitoring in the clinical setting
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Carbohydrate
Counting
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What about Fiber?
• A carbohydrate that is not digested
• Fiber amounts > 5 grams can be
subtracted from the total carbohydrate
– 1/2 cup cereal
– 27 grams carbohydrate
– 6 grams fiber
– Subtract fiber grams for a total of 21 grams
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Quick Guide
to Carb Counting
Fruit / juice
½ cup
15 grams
Starchy veggies
½ cup
15 grams
Non-starchy veggies
½ cup
5 grams
Bread
1 slice
15 grams
Pasta
½ cup
15 grams
Rice
1/3 cup
15 grams
Milk
1 cup (8 oz)
12 grams
Soda
1/2 cup (4 oz)
15 grams
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How much carbohydrate for
me???
Age, Height, Weight, Sex
Activity level
Medication treatment plan
PREFERENCES
• 50 grams per meal- FEMALES (150 / day)
• 60 grams per meal- MALES (180 / day)
Insulin
INSULIN
• Stimulates the entry of glucose into cells for
use as a source of energy
• Inhibits the production of glucose from the
glycogen in liver or muscle cells
• Promotes the storage of glucose as glucogen in
muscle and liver cells
• Inhibits formation of glucose from noncarbohydrates, such as amino acids
• Stimulates the entry of amino acids into cells,
enhancing protein synthesis
• Enhances fat storage and prevents the
mobilization of fat for energy
The Basal/Bolus Insulin
Concept
• Bolus Insulin (Mealtime or Prandial)
– Limits hyperglycemia after meals
– Immediate rise and sharp peak at 1 hour
– 10% to 20% of total daily insulin requirement at each
meal
• Basal Insulin
– Suppresses glucose production between meals and
overnight
– Nearly constant levels
– 50% of daily needs
• Ideally, for insulin replacement therapy, each component
should come from a different insulin with a specific profile
Insulin Pump
• Rapid-acting insulin is given continuously
over the 24 hours
• Rates of infusion can be individualized
• Mealtime and correction bolus as needed
• Greater flexibility and glucose control for
the motivated individual
From Evolution to Revolution
1999
2003
2005
Guardian
iPro
2007
2008
Continuous Glucose Monitoring Systems
Glucose Monitoring
Insulin Delivery
1983
1985
1992
1996
1998
1999
2002
2003
MiniMed Paradigm® 511
MiniMed Paradigm® 512/712
New E-Z path menu system Introduced the Bolus Wizard®
is even easier to use.
calculator which calculates
Smaller size works on a
patient’s recommended bolus
standard AAA battery.
amount.
MiniMed, Paradigm, and Bolus Wizard, are registered trademarks of Medtronic MiniMed, Inc.
System Gold and Medtronic CareLink are trademarks of Medtronic MiniMed, Inc.
2004
MiniMed Paradigm® 515/715
Introduced the Medtronic
CareLink® Therapy Management
System for Diabetes
web-based software.
Insulin Used in Intensive Control
Rapid-Acting
• Human insulin analogues
• Approved for treatment of diabetes with
intermediate and long-acting insulins or in CSII
• Used as bolus insulin for meals / snacks and as a
basal insulin in CSII
• Begin working in 5 minutes
• Peak at 50-60 minutes
• Half-life 2-2½ hours
• Duration of action- 3-4 hours
• NovoLog- Insulin Aspart
• Humalog- Insulin Lispro
• Apidra- Insulin Glulisine
Who benefits from an Insulin
Pumps
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MDI
Flexibility
Significant fluctuations in blood glucose
Significant fluctuations in carbohydrate ingestion
Cannot achieve goal A1c on MDI
Motivated individual
Good support system
Who should NOT be on a pump
• Not willing to check blood glucose as at
least 4-6 times a day
• Altered mental status
• Not willing to count carbohydrates
• Not willing to treat hyper and
hypoglycemia
Insulin Pumps
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Medtronic MiniMed Paradigm
Animas IR-2020 / Ping
Accu-chek Spirit
Insulet Omnipod
Solo
Case Study #1
• Karen T. is an 18-year old female with Type 1
diabetes who had been on MDI for 3 years.
• Current regimen
– Lantus 25 units qhs
– Novolog 5 units with meals
• Her blood glucoses are running in the 200’s.
• She is to be started on an insulin pump
• But where to start!!!!
Calculating Insulin Needs
• Current Total Daily Dose (TDD) minus 25%
or
• 0.5-1.0 units / kg of body weight
• Adjust based on SBGM
• Basal dose is 50% of TDD
– Can vary 45%-60%
• Bolus insulin dose is 50%
– Can vary 40%-55%
Calculating Insulin Needs
• Determine TDD
Current TDD (40u) – 25% (10u) = 30 units
or
0.5-1.0 units / kg of body weight
– 60kg adult
– Estimated TDD is 30-60 units
• Adjust based on SBGM
• Basal dose is 50% of TDD (15 units)
– Can vary 45%-60%
• Bolus insulin dose is 50% (15 units)
– Can vary 40%-55%
Basal Rate
• Suppresses glucose production between
meals and overnight
• Basal dose / 24 hours
(15 units / 24 hrs = .625 or .60 units / hour)
• Adjust per SBGM
• Basal needs vary throughout the day
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Nocturnal hypoglycemia
Dawn phenomenon
Exercise / physical activity
Menstrual cycle
Illness
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Bolus dosing
• Insulin to cover the carbohydrate content
of the meal
• Insulin to return current hyperglycemia to
target blood glucose
• Adjust for current hypoglycemia
Calculating
Insulin : Carbohydrate
Ratio
Amount of carbohydrate that 1 unit of insulin will
cover, bringing the blood glucose into target range
about 3-4 hours postmeal
Rule of 500
• 500 / TDD of insulin
• Amount of carbohydrate that 1 unit of insulin will
cover, bringing the blood glucose into target
range about 3-4 hours postmeal
• Rule of 450- May be more appropriate for those
who have more insulin resistance. Often used
with insulin pump
Rule of 500
• 500 / 30 = 16.67
• Amount of carbohydrate that 1 unit of rapidacting insulin will cover, bringing the blood
glucose into target range about 3-4 hours
postmeal
– Insulin:Carbohydrate Ratio 1:17
• Rule of 450- May be more appropriate for
those having more insulin resistance Often
used with insulin pump
– 450 / 30 = 15
– Insulin:Carbohydrate Ratio is 1:15
Insulin Sensitivity Factor
Insulin Sensitivity Factor (ISF)
or
Correction Factor
• Amount of blood glucose reduction
achieved by 1 unit of sq insulin
• Used to return blood glucose to
premeal targets
• Rule of 1500
• Rule of 1700
• Rule of 1800
Rule of 1500
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Developed by an endocrinologist
Best used for those with more insulin resistance
1500 / TDD
Adjust as needed
1500/30 = 50
Insulin Sensitivity Factor is 50
1 unit of insulin will lower the blood glucose by
50mg/dL in 3-4 hours
Rule of 1800
• The Rule of 1500 was adjusted by a CDE insulin
pump specialist
• Best used with rapid-acting insulin or those with
more insulin sensitivity
• 1800 / TDD
• Adjust as needed
• 1800/30 = 60
• Insulin Sensitivity Factor is 60
• 1 unit of insulin will lower the blood glucose by
60mg/dL within about 3-4 hours
Determining the Correction or
Supplemental Dose
using the Insulin Sensitivity
Factor
Correction or Supplemental
Dose
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Current blood glucose
Target blood glucose
ISF
Current–Target = Amount above target
Amount above target / ISF
Correction dose of insulin
Correction or Supplemental
Dose
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Current blood glucose is 275
Target blood glucose is 100
ISF is 56 mg/dl
275 – 100 = 175
175 / 60 = 2.91
Correction dose of insulin is 2.9 units
Karen’s settings
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Basal rate
I:C Ratio
ISF
Target
0.60
1:15
60
90-120mg/dL
Flexibility
Basal Rates
• Suspend
• Temporary basal
• Basal patterns
Basal Rates
• Suspend
– Exercise
– Hypoglycemia
– Bathing / swimming
• Temporary basal
– Exercise
– Illness
– Unexpected rise or fall in blood glucose
Basal Rates
Basal patterns
• Shift workers
• Menstrual cycle
• Weekend pattern
• Regular change in activity
– Travel
– Exercise
Bolus
• Square / Dual Wave
– (Extended / combination)
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Bolus dose calculator
Carbohydrate data base
Bolus history
Time of day variations in bolus needs
Time of day variations in blood glucose targets
Calculation of active insulin (IOB)
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Glucose Management
Software
• Adherence- behavioral report. Are they
using the device as advised
• Meter / Sensor - blood glucose and sensor
readings
• Daily insulin use
• Blood Glucose Log
• Device Settings
• On line
CareLink
CareLink
CGMS
• Glucose sensor
• Transmitter / recorder
• Glucose readings in the interstitial fluid are
measured continuously
• Average of these measurements displayed
every 5 minutes (288/day)
• Calibrated at least twice a day
• Greater accuracy with more frequent proactive
calibration
Insulin Pump and CGMS
The Sensor Catheter
How does the sensor work:
The 3 layers of the sensor
• Semi-permeable membrane
• Glucose Oxidase
• Platinum wire
The transmitter measures electrical current caused by this
breakdown of the hydrogen peroxide (isig=current in nanoamps)
The more glucose in » the more peroxide is formed » the more
current is generated
Calibration assigns a blood glucose value to the amount of
current that is being generated
Optimal Sensor Insertion
I-PRO
• Medtronic 3 day glucose sensor
• Recorder is attached to sensor
• Patient checks FSBG qid, and keeps a
food diary.
• Recorder and glucose meter readings
downloaded into a computer program
• Reimbursed by Medicare and BC/BS
IPRO- non diabetic
I-PRO
IPRO
IPRO
IPRO
I-PRO
• CPT codes
– Continuous Glucose Monitor Study (3 days)
– 95250 Diagnostic study
– 95251 Interpretation
• Reimbursement
– Medicare- $156
– BC/BS- $130
– Allowed every 6 months
• Cost of I-PRO system
– Starter kit: Recorder plus 10 sensors- $1300
– Additional recorders- $900
– Additional sensors- $35 each
Special Populations
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Children
Blindness
Elderly
Dementia
Support System
Families / Teachers/ Caretakers
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Signs of hypoglycemia / hyperglycemia
Suspend / Disconnect
Treatment of hypoglycemia
Treatment of hyperglycemia
Use of a blood glucose monitor
Access medical assistance
Hypoglycemia
• Counting carbohydrates and bolusing correctly
• Monitoring blood glucose
• Increase the insulin : carbohydrate ratio 1 unit of
insulin covers more carbohydrate
• Decrease the basal insulin
• Instruct on calculating correction carbohydrate
intake
Calculating Correction
Carbohydrate Intake
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Target blood glucose (100)
Pre-meal blood glucose (55)
ISF (60)
Insulin:carbohydrate ratio (1:15)
Carbohydrate of I:C Ratio (Rise in blood glucose needed)
ISF
15 (45) = Amount of carbohydrate that needs to be ingested
60
= 11.25 or 12 grams
Revenue Generation with
Insulin Pumps
and CGMS
 Patient training
 Documentation of diagnostic testing
meets criteria for level 4 office visit
 I-PRO
 Procedure
 Interpretation
Putting it all Together
Case Studies
Case Study #1
• Karen T. is an 18-year old female recently
diagnosed with Type 1 diabetes.
• Karen weighs 60kg
• Her blood glucoses are running in the
200’s.
• She needs to be started on insulin
• But where to start!!!!
Karen T.
• Teach carbohydrate counting
• Encourage 60 grams of carbohydrate per meal
(3 meals a day)
• Start with TDD of 30 units
• Basal rate 0.625
• I:C
1:15
• ISF
60
• Target
90-120
Karen T’s Breakfast
• Morning fasting pre-breakfast blood glucose is
180
• Karen will be eating 60 grams of carbohydrate
• Her goal blood glucose is 120mg/dl
• She will use a rapid-acting insulin
• 60/15= 4.0 units
• 60/60=1.0 units
• Total dose = 5.0 units
Karen T’s Lunch
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Pre-lunch blood glucose is 135
Karen will be eating 60 grams of carbohydrate
Her goal blood glucose is 120mg/dl
She will use a rapid-acting insulin
60/15= 4.0 units
15/60=0.25 units
Total dose = 4.25 units
Case Study #2
David T.
• David T. is a 56-year old male who has had Type
2 diabetes for 15 years.
• He currently is taking a TZD, a sulfonylurea, and
metformin.
• David weighs 100kg.
• His blood glucoses are running in the 200’s.
• His CRNP wants to start him on insulin
• But where to start!!!!
Calculating Insulin Needs
• 0.5-1.0 units / kg of body weight
– 100 kg adult
– Estimated TDD is 50-100 units
• Adjust based on SBGM
• Determine TDD
• Basal dose is 50% of TDD (25-50 units)
– Can vary 45%-60%
• Bolus insulin dose is 50% (25-50 units)
– Can vary 40%-55%
David T.
• Teach carbohydrate counting
• Encourage 60 grams of carbohydrate per
meal (3 meals a day)
• Start with TDD of 50 units
• Basal 25units/24 hours= 1.05 u/hr
• Now for the bolus doses
David T.
• Insulin : Carbohydrate Ratio
– 450/50= units
– 1 unit insulin : 9 grams carbohydrate
• Insulin Sensitivity Factor
– 1700/50= 34
– 1 unit of insulin will lower the blood
glucose by 34mg/dl
David T’s Breakfast
• Morning fasting pre-breakfast blood glucose is
235
• David will be eating 60 grams of carbohydrate
• His goal blood glucose is 120mg/dl
• He will use a rapid-acting insulin
• 60/9= 6.7 units
• 135/34=3.4 units
• Total dose = 10.1 units
David T’s Lunch
• Pre-lunch blood glucose is 155
• David will be eating 60 grams of
carbohydrate
• His goal blood glucose is 120mg/dl
• 60/9= 6.7 units
• 35/34= 1.0 units
• Total dose = 7.7 units
Case Study #3
Jackie
• Jackie is a 58-year old female who has had
Type 2 diabetes for 20 years.
• She is currently is taking a TZD, metformin
Humulin 70/30, 20 units in the morning and
10 units in the evening.
• Her most recent HgbA1c is 8.0%
• Jackie weighs 176 lbs (80kg) and is 5’4”.
• Her blood glucoses are running in the 200’s.
• Her CRNP wants to change her insulin
regimen
• What would you do?
Calculating Insulin Needs
• Current TTD 30u - 25% = 22.5u
OR
• 0.5-1.0 units / kg of body weight
– 80 kg adult
– Estimated TDD is 40-80 units
• Adjust based on SBGM
• Determine TDD
• Basal dose is 50% of TDD (20-40 units)
– Can vary 45%-60%
• Bolus insulin dose is 50% (20-40 units)
– Can vary 40%-55%
Jackie
• Teach carbohydrate counting
• Encourage 60 grams of carbohydrate per meal
(3 meals a day)
• Start with TDD of 30 units
• Basal = 0.60u/hr
• I:C = 15
• ISF = 57
• Target 90-120
Jackie
• Insulin : Carbohydrate Ratio
– 450/30= 15 units
– 1 unit insulin : 15 grams carbohydrate
• Insulin Sensitivity Factor
– 1700/30= 56.67
– 1 unit of insulin will lower the blood
glucose by 57 mg/dl
Jackie’s Breakfast
• Morning fasting pre-breakfast blood glucose
is 240
• Jackie will be eating 60 grams of
carbohydrate
• Her goal blood glucose is 120mg/dl
• 60/15= 4.0 units rapid acting
• 120/57= 2.1 units rapid acting
• Total dose = 6.1 units rapid acting
Jackie’s Lunch
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Jackie had an small apple (15gms) around 10am.
Her pre-lunch blood glucose is 205
Jackie will be eating 75 grams of carbohydrate
Her goal blood glucose is 120mg/dl
75/15= 5.0 units
85/38= 2.3 units
Total dose = 7.3 units
Should she have taken insulin with her apple? How
much?
• 15/15=1.0 units
Questions?
Thank You !
Kathryn Taylor Teare, MSN, CRNP, CDE
Diabetes Clinical Manager
Huntsville, AL Territory
[email protected]
426-5970