Management Tools and Management Tools and CGMCGM

Kathryn Moe, RN CDEKathryn Moe, RN CDE

Medtronic DiabetesMedtronic Diabetes

ObjectivesObjectives

Define the terms Define the terms basal basal andand bolus bolus Define how Define how basal basal and and bolus apply to bolus apply to

insulin pump therapyinsulin pump therapy Explain how the insulin pump can calculateExplain how the insulin pump can calculate

insulin doses based on ICR set up by the insulin doses based on ICR set up by the

dietitiandietitian Define Continuous Glucose MonitoringDefine Continuous Glucose Monitoring

Objectives cont’dObjectives cont’d

Explain the difference between Explain the difference between professionalprofessional

and and personal cgmpersonal cgm Explain how cgm can be utilized by the Explain how cgm can be utilized by the

dietitian to assess correct ICRdietitian to assess correct ICR

Diabetes 101Diabetes 101

Types of Diabetes MellitusTypes of Diabetes Mellitus PathophysiologyPathophysiology Treatment ModalitiesTreatment Modalities

Types of Diabetes MellitusTypes of Diabetes Mellitus

Type 1Type 1 Type 2Type 2 Gestational Gestational LADALADA

Definition of DMDefinition of DM

Metabolic disorder involving the beta cells of Metabolic disorder involving the beta cells of the pancreasthe pancreas

A group of diseases marked by high levels of A group of diseases marked by high levels of blood glucose resulting from defects in insulin blood glucose resulting from defects in insulin production, insulin action, or bothproduction, insulin action, or both

Type 1Type 1

Type 1 Diabetes MellitusType 1 Diabetes Mellitus

Caused by an autoimmune disorder that Caused by an autoimmune disorder that results in pancreatic beta cell destruction and results in pancreatic beta cell destruction and absolute insulin deficiencyabsolute insulin deficiency

Makes up ~ 5 to 10% of all DMMakes up ~ 5 to 10% of all DM

Must have exogenous insulin in order to Must have exogenous insulin in order to survivesurvive

Type 2Type 2

Insulin ResistanceInsulin Resistance

Increases with age, obesity, and inactivityIncreases with age, obesity, and inactivity Primary Beta Cell Dysfunction and Beta Cell Primary Beta Cell Dysfunction and Beta Cell

LossLoss

Results from loss of beta cell mass and the Results from loss of beta cell mass and the inability of the beta cells to recognize glucoseinability of the beta cells to recognize glucose

Gestational DMGestational DM

Occurs during pregnancyOccurs during pregnancy Can often resolve after deliveryCan often resolve after delivery Can return later in life as Type 2Can return later in life as Type 2

LADALADA

Form of Type 1 Form of Type 1 Diagnosed usually after the age of 30Diagnosed usually after the age of 30 Non-obese individualsNon-obese individuals Insulin dependency gradually occursInsulin dependency gradually occurs

Treatment ModalitiesTreatment Modalities

Lifestyle changesLifestyle changes Oral agentsOral agents InsulinInsulin NutritionNutrition

How insulin pumps mimic How insulin pumps mimic pancreatic insulin secretionpancreatic insulin secretion

Uses only rapid acting insulin analogsUses only rapid acting insulin analogs Uses basal/bolus insulin deliveryUses basal/bolus insulin delivery Can quickly make adjustments up or down in Can quickly make adjustments up or down in

the basal ratethe basal rate Bolus features that can accommodate glucose Bolus features that can accommodate glucose

release from high fat foods, gastroparesis, release from high fat foods, gastroparesis, etc… etc…

Time

Insu

lin

Normal Insulin Secretion

Pump Delivery

Schematic representation only

The Pump: More like a Healthy The Pump: More like a Healthy PancreasPancreas

Delivery that's customizable, flexible, adjustableDelivery that's customizable, flexible, adjustable Can more closely match the natural delivery patterns Can more closely match the natural delivery patterns

of the pancreasof the pancreas

Programming the Bolus WizardProgramming the Bolus Wizard® ® CalculatorCalculator

Grams: Carb ratio = number of Grams: Carb ratio = number of carb grams covered by 1 Unit of carb grams covered by 1 Unit of insulininsulin

Exchanges: Carb ratio = number Exchanges: Carb ratio = number of insulin Units needed to cover of insulin Units needed to cover 1 (1.0) carb exchange1 (1.0) carb exchange

Insulin pump allows up to 8 Insulin pump allows up to 8 settings for different carb ratios at settings for different carb ratios at different times of the daydifferent times of the day

Select Carb Ratios.

Press ACT.

Edit Settings

Wizard On

Carb Units: Grams

Carb Ratios: - - -Carb Ratios:

Setting Carbohydrate Ratios

Blood Glucose (BG) Within Target RangeBlood Glucose (BG) Within Target Range

–

Estimate Details

Est total: 4.0U

Food intake: 60 gm

BG: 82

Food: 4.0U

Correction: 0.0U

Active ins: 0.0U

ACT to proceed,

ESC to back up

Food:

Correction:

Est total:

Example

BG Within Programmed Range

BG: 82 mg/dL SF = 30Carbs: 60 g ICR = 15

BG is between 80 and 100 mg dL

No correction calculated

60 = 4.0 U15 g

TARGET RANGE 1

12:00A mg / dL

80 – 100

No Correction Insulin Calculated

Continuous Glucose MonitorContinuous Glucose Monitor

ProfessionalProfessional PersonalPersonal

CGMCGM

Analyzes interstitial glucoseAnalyzes interstitial glucose Physiologic lag Physiologic lag Not finger stick replacementNot finger stick replacement Gold Standard is still blood glucose valuesGold Standard is still blood glucose values Blood glucose readings are still neededBlood glucose readings are still needed

to calibrate the sensor and keep it tracingto calibrate the sensor and keep it tracing BG does not equal SGBG does not equal SG Focus on the trends of the glucoseFocus on the trends of the glucose

Professional CGMProfessional CGM

Has been used in a clinical setting since 1999Has been used in a clinical setting since 1999 Wear for 3-5 daysWear for 3-5 days Blinded studyBlinded study 288 glucose values in 24 hours288 glucose values in 24 hours Clinic owned equipmentClinic owned equipment ReimburseableReimburseable Assess time periods, ICRAssess time periods, ICR

Patient Responsibility Patient Responsibility

Testing four times a Testing four times a dayday

Fill out food log sheetFill out food log sheet

Bring the device back Bring the device back to the office 6 days to the office 6 days laterlater

C.A. – Lantus @ bedtime, Humalog SS

J.D. – Lantus in AM and bedtime, Humalog @ meals

K.V. – N and H in AM, H @ dinner, N @ bedtime

Sensor Modal Time PeriodsSensor Modal Time Periods

It’s Not Just About A1C Anymore!

• Very high or very low blood glucose levels– Missed with

Fingersticks

– Missed with A1C

Glycemic Variability

A1C 7A1C 7

A1C 7A1C 7

Measuring glycemic variability in

combination with A1C may be a more reliable

indicator to reduce long term

complications

It’s Not Just About A1C Anymore!

• Very high or very low blood glucose levels– Missed with

Fingersticks

– Missed with A1C

Glycemic Variability

A1C 7A1C 7

A1C 7A1C 7

Measuring glycemic variability in

combination with A1C may be a more reliable

indicator to reduce long term

complications

It’s Not Just About A1C Anymore!

• Very high or very low blood glucose levels– Missed with

Fingersticks

– Missed with A1C

Glycemic Variability

A1C 7A1C 7

A1C 7A1C 7

Measuring glycemic variability in

combination with A1C may be a more reliable

indicator to reduce long term

complications

Personal CGMPersonal CGM

Can be used along with an insulin pump orCan be used along with an insulin pump or

still on injectionsstill on injections 288 glucose values in 24 hrs288 glucose values in 24 hrs Consumer ownedConsumer owned See the values in real timeSee the values in real time FDA approved 2006FDA approved 2006

• Meals are determined when carbs and insulin are first entered together in Bolus Wizard® calculator during the selected time blocks

• View of one hour before individual meals and the time period after meals.

• Numerical and pie chart description of glucose before and after meals, during evening and overnight time periods.

• Use the colors to easily see target ranges and when in range, or above or below

• Up to 7 days of dataUse this report to help keep glucose in range after eating

Sensor Overlay by Meal

Breakfast rise and fall Repeating post dinnerseen here in picture & averages drop in glucose

Meal marker additional food markers color - coded by day

Sensor Overlay by Meal

First Insulin PumpFirst Insulin Pump

First Person to Take InsulinFirst Person to Take Insulin

Leonard ThompsonLeonard Thompson

QuestionsQuestions

Thank YouThank You