sarrah morris bscn, rn, mba medtronic diabetes canada [email protected] 1
TRANSCRIPT
Employed by Medtronic since 2007
Over-bearing Care Partner for 32 years!
Disclosure
Over-bearing Care Partner
Registered Nurse
Worked in acute care settings: Emerg, Congestive Heart Failure, Bone Marrow Transplant
Mount Sinai Hospital, Toronto
Medtronic Diabetes since 2007
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Excited to be here….
Growing up in a T1D household
“Thank you Caregiver!”
Today is about YOU and your FAMILY!
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Objectives
Benefits of a pump
The benefits of a pump vs MDI (multiple daily injection)
Infusion Sets
Basics of Continuous Glucose Monitoring
Education and Support
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Bruttomesso D, et al. Diabet Med. 2002;19(8):628-634. Bell DSH, et al. Endocr Pract. 2000;6(5):357-360. Rudolph DS, et al. Endocr Pract. 2002;8(6):401-405. Chantelau E, et al. Diabetologia. 1989;32(7):421-426. Boland EA, et al. Diabetes Care. 1999;22(11):1779-1784. Maniatis AK, et al. Pediatrics. 2001;107(2):351-356. Litton J, et al. J Pediatr. 2002;141(4):490-495. Weissberg—Benchell J et al. Diabetes Care. 2003.
Pumps Lower A1C Better than MDI
Published 1989 - 2003
Pu
mp
MD
I
* * *
PumpMDI
Meta-analysis 52 studies (1,547 patients) shows pump technology is significantly more effective at lowering A1C than MDI and/or conventional insulin therapy (MD 0.95)
Pumps Reduce Hypoglycemic Events
Severe Hypoglycemic Episodes: Pumps vs. MDI
PumpsMDI
Eve
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/p
er h
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Rudolph JW, Hirsch IB. Assessment of therapy with continuous subcutaneous insulin infusion in an academic diabetes clinic. Endocrine Practice.2002;8(6):401-405. Bode, BW, et al. 1996;19:324-7. Boland EA, et al. Continuous subcutaneous insulin infusion. Diabetes Care.1999;22:1779-84.
Pumps Reduce Severe Hypoglycemia
Pickup JC, Sutton AJ. Severe hypoglycaemia and glycaemic control in Type 1 diabetes: meta-analysis of multiple daily insulin injections compared with continuous subcutaneous insulin infusion. Diabet Med. 2008;25:765-774.
Results• MDI has 4.19 X more severe
hypoglycemia than pumps• Greatest hypo reduction found in
those with highest initial rates of severe hypoglycemia
Pump vs. MDI Severe Hypoglycemia Rate Ratio
Study
0.5 1 2 5 10 25
Favours CSIIFavours MDI
Study Inclusion Criteria
• Meta-analysis of 22 studies– 10 with children and
adolescents– 12 studies with adults
• Compared severe hypoglycemia
• Type 1 diabetes • Duration > 6 months on pump
Bode (poor control)Bode (good control)KadermanManiatisRizviLittonLinkeschovaBruttomessoRudolph, HirschPlotnickCohenHunger-DatheWeintrobWeinzimerMcMahonSiegel-CzarkowskiAlemzadehMack-FoggSciaffiniRodriguesLeporeHoogmaOverall (I2 = 84.2%, P = 0.00)
Published 2008
Quality of life Fewer injections More flexibility of lifestyle;eat, sleep, play Potential for better control of blood sugar Can lower A1C and reduce low blood sugars Reduced risk of diabetes complications Flexibility for picky eaters, variable activity
levels & athletes Variable daily schedules
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Is an insulin pump right for you/your child?
Intensive Insulin Therapies Comparison
Multiple Daily Injections (MDI)◦ 4-6 injections per day of rapid- and long-acting insulin◦ Basal is a fixed dose ◦ You must calculate bolus doses based on blood glucose and carbohydrates
Insulin Pump Technology◦ Rapid-acting insulin is continuously delivered by the pump◦ Most closely mimics the action of a healthy pancreas◦ Pump calculates bolus doses based on blood glucose and carbohydrates
Rapid-acting insulin
Long-actinginsulin
Intermediate-acting insulin
46%
36%
16%
Heinemann L, et al. Diabetes Care.1998;21:1910–1914; Heise T, et al. Diabetes. 2004;53:1614-1620.
Rapid-acting insulin has the lowest
intrapatient variability
Rapid-acting insulin minimizes treatment errors due to pharmacodynamic variability in insulin action*
*Percentages represent coefficients of variation for insulin action as measured by maximum glucose infusion rate in these euglycemic glucose clamp studies
Insulin Pumps Use Only Rapid-Acting Insulin
Insulin Pumps currently available in Canada
Omnipod® by Insulet
MiniMed® Paradigm® Veo™ by Medtronic MMT 554 &
MMT 754
ACCU-CHEK® Combo By Roche
OneTouch® Ping®by Animas
Vibe ® by Animas
Tubeless pump
INSULIN PUMP TECHNOLOGY AIMS TO MIMIC A HEALTHY PANCREAS
Bolus InsulinBasal Insulin
Insu
lin
Time
Aims to mimic the pancreas by delivering insulin via ◦ continuous insulin called basal insulin◦ extra insulin for food called bolus insulin
How Insulin Is Infused
Skin
Cannula
Fat
Insulin
How (Tube) Insulin Pumps Work
Fill reservoir Load reservoir into pump Insert infusion set
Infusion set attached Pump attached to infusion set
Change infusion set every 2 to 3 days
OmniPod: you are going to change the pod every 80 hours
Basal Insulin Delivers around the clock
Typically start with a single basal rate◦The basal rate can be adjusted (increased
or decreased)
You can add additional basal rates◦The pump can be programmed to deliver
higher or lower basal amounts during different periods of the day
When rates are set correctly, basal insulin
should: ◦Keep your glucose stable between meals
and through the night ◦Allows the flexibility to sleep late, eat late,
and even skip meals
Basal Rates: Deliver 24 Hours / Day
Example of single basal rate delivery @ 0.50u/hr Pump delivers 0.5 units each hour Basal insulin is divided into 0.025 unit
increments and delivered evenly throughout each hour
BASAL RATES Time
Rate1. 12 AM 0.500 u
/hr2. _____ _________3. _____ _________
0.5u
0.5u
0.5u
0.5u
0.5u
0.5u0.5u
0.5u
0.5u
0.5u
0.5u0.5u
0.5u
0.5u
0.5u
0.5u
0.5u
0.5u0.5u
0.5u
0.5u
0.5u
0.5u
0.5u
AM PM
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Food Correction
Total amount of basal insulin delivered over 24 hours
Typically ~40-50% of TDD is basal
Total amount of bolus insulin given for food & correction in 24 hours
Typically ~ 50-60% of TDD is bolus
Insulin Pump Settings
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Insulin pumps can reduce some of the burden…
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Insulin Pump Settings
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Remaining insulin: Insulin that remains from previous boluses and has the pharmacodynamic ability to lower glucose.
Active Insulin Time: Length of time pump is programmed to track remaining insulin. (example, 2, 3, 4, 5, 6, 7, 8 hrs)
• Pump subtracts active insulin before calculating a bolus dose for high BGs
• This helps to prevent insulin “stacking” and the lows that occur from over-correcting highs.
Target Range: A range of glucose values that the pump uses to determine if a correction bolus is needed.
• Can be customized and set for:- Pre-meal Target Ranges- Post-meal Target Ranges- Bedtime Target Range
Remaining insulin On board
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Advantages of today’s smart pumps
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1. Calculates bolus amounts using your child’s current:• BG • ICR • ISF • Target Range
Benefit: Determines each bolus amount based on patient’s individual pump settings & current needs (BG, carb intake, active insulin)
2. Tracks remaining insulin from previous boluses delivered:– Subtracts remaining insulin from the insulin calculated to correct highs,
before suggesting total correction amount to take.
Benefit: Helps prevent insulin “stacking” & lows that can occur from over correcting if insulin remains from previous boluses
3. Keeps accurate records:– Times and values of all BG readings– Carbohydrate intake – Type, amount, time of boluses
Benefit: Provides comprehensive records for therapy evaluation*
Infusion Sets
What is an infusion set?
The connection between the insulin pump and the body
Cannula Housing
Adhesive TapeTubing
Insertion
Device
Insulin Reservoir
Cannula
At-site disconnection
24One difference with the Pod pump, you can not remove them temporarily
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Infusion Sets for Tube Pumps: Two different types of connections available
Luer Lock infusion sets (pump specific)
Paradigm (not a luer lock connection)
90° Teflon Cannula 30-45°Teflon Cannula
90° Steel Cannula
All-in-One 90° Teflon Cannula Infusion Sets with Auto-Injector
Many options for infusion sets; your diabetes educator will help you select the best one for you.
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Benefits of Continuous Glucose Monitoring
Continuous BG monitors show trends so that problems can be avoided…….
CGM provides visual feedback to help patients and clinicians understand glucose variability
Glycemic Variability
A1c = 9 in both patients Profiles are very
different
CGM Provides Visual Feedback of Glucose Control
A1C 9
A1C 9
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MiniMed Paradigm VEOTM with Continuous Glucose Monitoring System (CGM)
• Low Glucose Suspend
• Provides time trend graph
• Alarms for high or low glucose levels
•RF Linking- Bayer Contour Next Link Meter
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Animas Vibe ® with Dexcom CGM
•Colour screen•Waterproof at 12 ft for 24 hrs•Dexcom G4 CGM technology
Consider and utilize the many available education resources for patients, parents, caregivers.
Product Technical Support• Online tools
• Product technical support 24/7
• Replacement pumps
• Training• 4 year pump
warranty• Travel/vacation
pump loaners• Therapy software
Online tools
32 | MDT Confidential
Dskate 2015: Milton and Montreal 5 day programsDskate is a unique combination of elite hockey coaching & Type 1 Diabetes Education
For 128 kids aged 7-17 with T1 Diabetes & their parents.
Families from 8 Provinces
Families from New York, Oklahoma City, California,
Alaska, Chicago. Florida, and more.
2 families from Sweden
Many diabetes experts who provide education to the kids and parents that include: Dr Mike Riddell, PhD, Exercise and Diabetes expert Dr Bruce Perkins, University of Toronto Michele Sorenson, Psychologist Chris Jarvis, Founder of I Challenge Diabetes
And Cory Conacher, Nick Boynton and more.
33 | MDT Confidential
Dskate is 2- 5 day programs of Hockey and Diabetes Experiential Learning
128 kids, 170 Parents, 28 Diabetes Educators from across Canada
My Heroes!
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Thank you
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