New Insulins - adaendo.com · Su + LP (n = 42) Baseline HbA1c Follow-up HbA1c Follow-up Weight 0.9...
Transcript of New Insulins - adaendo.com · Su + LP (n = 42) Baseline HbA1c Follow-up HbA1c Follow-up Weight 0.9...
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New Insulins and
Insulin Delivery Systems
Bruce W. Bode, MD, FACE
Atlanta Diabetes Associates
Atlanta, Georgia
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ADA: Clinical Practice Recommendations. 2001.
Goals of Intensive DiabetesManagement
● Near-normal glycemia– HbA1c less than 6.5 to 7.0%
● Avoid short-term crisis– Hypoglycemia– Hyperglycemia– DKA
● Minimize long-term complications
● Improve QOL
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6 7 8 9 10 11 12
Retinop
Neph
Neurop
Microalb
RE
LA
TIV
ER
ISK
HbA1cSkyler, Endo Met Cl N Am 1996
Relative Risk of Progression ofDiabetic Complications by Mean HbA1CBased on DCCT Data
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HbA1c and Plasma Glucose
● 26,056 data points (A1c and 7-point glucoseprofiles) from the DCCT
● Mean plasma glucose = (A1c x 35.6) – 77.3
● Post-lunch, pre-dinner, post-dinner, andbedtime correlated better with A1c thanfasting, post-breakfast, or pre-lunch
Rohlfing et al, Diabetes Care 25 (2) Feb 2002
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Emerging Concepts
The Importance of
Controlling Postprandial Glucose
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ACE / AACE Targets for Glycemic Control
HbA1c < 6.5 %
Fasting/preprandial glucose < 110 mg/dL
Postprandial glucose < 140 mg/dL
ACE / AACE Consensus Conference, Washington DC August 2001
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Insulin
The most powerful agent wehave
to control glucose
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Comparison of HumanInsulins / Analogues
Insulin Onset of Duration ofpreparations action Peak action
Regular 30–60 min 2–4 h 6–10 h
Lispro/aspart 5–15 min 1–2 h 4–6 h
NPH/Lente 1–2 h 4–8 h 10–20 h
Ultralente 2–4 h Unpredictable 16–20 h
Glargine 1–2 h Flat ~24 h
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Short-Acting AnalogsLispro and Aspart
● Convenient administration immediatelyprior to meals
● Faster onset of action
● Limit postprandial hyperglycemic peaks
● Shorter duration of activity
– Reduce late postprandial hypoglycemia– Frequent late postprandial hyperglycemia
● Need for basal insulin replacement revealed
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400
350
300
250
200
150
100
MealSC injection
50
00 30 60
Time (min)90 120 180 210150 240
Regular Lispro
500450400350300250
150
50
200
100
00 50 100
Time (min)150 200 300250
Pla
sm
a in
sulin
(p
mo
l/L)
Pla
sm
a in
sulin
(p
mo
l/L)
MealSC injection
Heinemann, et al. Diabet Med. 1996;13:625–629; Mudaliar, et al. Diabetes Care. 1999;22:1501–1506.
Short-Acting Insulin AnalogsLispro and Aspart Plasma Insulin Profiles
Regular Aspart
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Pharmacokinetic ComparisonNovoLog® vs Humalog®
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0
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Humalog®
Fre
e In
sulin
(p
mo
l/L)
Time (hours)Hedman, Diabetes Care 2001;24(6):1120-21
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Lispro Mix 75/25Pharmacodynamics
00 44 88 1212 1616 2020 2424
00
22
44
66
88
1010
1212
Glu
cose
infu
sio
n r
ate
mg
/kg
/min
HoursHours
Lispro
Lispro Mix 75/25
NPL
Heise T, et al. Diabetes Care. 1998;21:800–803.
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Limitations of NPH, Lente,and Ultralente
● Do not mimic basal insulin profile
– Variable absorption
– Pronounced peaks
– Less than 24-hour duration of action
● Cause unpredictable hypoglycemia
– Major factor limiting insulin adjustments
– More weight gain
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1 5 10 15 20 25 30
1 5 10 15 20Asp
Gly
ArgExtension
Substitution
Arg
Insulin GlargineA New Long-Acting Insulin Analog
● Modifications to human insulin chain
– Substitution of glycine at position A21
– Addition of 2 arginines at position B30
● Gradual release from injection site
● Peakless, long-lasting insulin profile
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Lepore, et al. Diabetes. 1999;48(suppl 1):A97.
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Time (h) after SC injection
End of observation period
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GlargineNPH
Glu
cose
uti
lizat
ion
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e(m
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)
Glargine vs NPH Insulin in Type 1 DiabetesAction Profiles by Glucose Clamp
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Glucose Infusion Raten = 20 T1DMMean ± SEM
SC insulin
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mg
/kg
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µm
ol/k
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in
Lepore M, et al. Diabetes. 2000;49:2142–2148.
NPH
Ultralente
CSII
Glargine
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Glargine
Plasma Glucose
Time (hours)
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/dL
mm
ol/
L
Lepore M, et al. Diabetes. 2000;49:2142–2148.
n = 20 T1DMMean ± SEM
SC insulin
NPH
Ultralente
CSII
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Overall Summary: Glargine
● Insulin glargine has the following
clinical benefits
– Once-daily dosing because of its prolonged
duration of action and smooth, peakless time-
action profile
– Comparable or better glycemic control (FBG)
– Lower risk of nocturnal hypoglycemic events
– Safety profile similar to that of human insulin
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Type 2 Diabetes …A Progressive Disease
Over time,most patients will need insulin
to control glucose
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Insulin Therapy in Type 2 DiabetesIndications
● Significant hyperglycemia at presentation
● Hyperglycemia on maximal doses of oral agents
● Decompensation– Acute injury, stress, infection, myocardial ischemia– Severe hyperglycemia with ketonemia and/or ketonuria– Uncontrolled weight loss– Use of diabetogenic medications (eg, corticosteroids)
● Surgery
● Pregnancy
● Renal or hepatic disease
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Mimicking NatureThe Basal/Bolus Insulin
Concept
6-16
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The Basal/Bolus Insulin Concept
● Basal insulin
– Suppresses glucose production betweenmeals and overnight
– 40% to 50% of daily needs
● Bolus insulin (mealtime)
– Limits hyperglycemia after meals
– Immediate rise and sharp peak at 1 hour
– 10% to 20% of total daily insulin requirementat each meal
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Basal vs Mealtime Hyperglycemia in Diabetes
Riddle. Diabetes Care. 1990;13:676-686.
Plas
ma
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dL)
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Time of Day1800 2400
Type 2 Diabetes
0600
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Normal
∆ AUC from normal basal >1875 mgm/dL.hr; Est HbA1c >8.7%
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When Basal Corrected
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Basal hyperglycemia Mealtime hyperglycemia
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Basal vs Mealtime Hyperglycemia in Diabetes
∆ AUC from normal basal 900 mgm/dL.hr; Est HbA1c 7.2%
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When Mealtime Hyperglycemia Corrected
Plas
ma
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dL)
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Time of Day1800 2400 0600
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Basal hyperglycemia Mealtime hyperglycemia
6-18
Normal
Basal vs Mealtime Hyperglycemia in Diabetes
∆ AUC from normal basal 1425 mgm/dL.hr; Est HbA1c 7.9
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When Both Basal & Mealtime Hyperglycemia Corrected
Plas
ma
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cose
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dL)
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100
00600 1200
Time of Day1800 2400 0600
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Basal hyperglycemia Mealtime hyperglycemia
6-18
Normal
Basal vs Mealtime Hyperglycemia in Diabetes
∆ AUC from normal basal 225 mgm/dL.hr; Est HbA1c 6.4%
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MIMICKING NATURE WITH INSULIN THERAPY
Over time,
most patients will need
both basal and mealtime insulin
to control glucose
6-19
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Starting With Basal InsulinAdvantages
● 1 injection with no mixing
● Insulin pens for increased acceptance
● Slow, safe, and simple titration
● Low dosage
● Effective improvement in glycemic control
● Limited weight gain
6-37
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Starting With Basal InsulinBedtime NPH Added to Diet
Cusi & Cunningham. Diabetes Care. 1995;18:843-851.
300
200
00800 1200 1600
Time of Day2000 2400 0400 0800
400
100
Diet onlyBedtime NPH
Plas
ma
Glu
cose
(mg/
dL)
6-38
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Treatment to Target Study: NPH vsGlargine in DM2 patients on OHA
● Type 2 DM on 1 or 2 oral agents (SU, MET, TZD)
● Age 30 to 70
● BMI 26 to 40
● A1C 7.5 to 10% and FPG > 140 mg/dL
● Anti GAD negative
● Willing to enter a 24 week randomized, openlabeled study
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Treatment to Target Study: NPH vsGlargine in DM2 patients on OHA
● Add 10 units Basal insulin at bedtime(NPH or Glargine)
● Continue current oral agents
● Titrate insulin weekly to fasting BG < 100 mg/dL
- if 100-120 mg/dL, increase 2 units
- if 120-140 mg/dL, increase 4 units
- if 140-160 mg/dL, increase 6 units
- if 160-180 mg/dL, increase 8 units
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Treatment to Target Study;A1C Decrease
8.6
7.5
7.16.9 6.9
6.5
7
7.5
8
8.5
9
0 5 10 15 20 25 30
W eeks in Study (N = 691)
Mea
n H
bA1c%
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Patients in Target (A1c < 7%)
2.5
32.3
48.8
66.2
55.3
0
10
20
30
40
50
60
70
P ercentage of P atients
W eek 0 W eek 8 W eek 12 W eek 18 W eek 24
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Treatment to Target Study: NPH vsGlargine in DM2 patients on OHA
● Nocturnal Hypoglycemia reduced by 40% inthe Glargine group
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Treatment to Target Study: NPH vsGlargine in DM2 patients on OHA
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Advancing Basal/Bolus Insulin
● Indicated when FBG acceptable but– HbA1c > 7% or > 6.5%
and/or– SMBG before dinner > 140 mg/dL
● Insulin options– To glargine or NPH, add mealtime aspart / lispro– To suppertime 70/30, add morning 70/30– Consider insulin pump therapy
● Oral agent options– Usually stop sulfonylurea– Continue metformin for weight control– Continue glitazone for glycemic stability?
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Starting With Bolus Insulin
Combination Oral Agents
+
Mealtime Insulin
6-46
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Starting With Bolus InsulinMealtime Lispro vs NPH or MetforminAdded to Sulfonylurea
Browdos, et al. Diabetes. 1999;48(suppl 1):A104.
10.0% 10.4%
−1.9%
10.2%−1.9%
−2.3%
12
10
8
6
4
2
0
12
10
8
6
4
2
0Su + Metformin
(n = 40)Su + NPH
(n = 50)Su + LP(n = 42)
Baseline HbA1c
Follow-up HbA1c
Follow-up Weight
0.9 kg2.3 kg3.4 kg
HbA
1c (%
)
Weight G
ain (kg)
6-47
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Case #1: DM 2 on SU withinfection
● 49 year old white male
● DM 2 onset age 43, wt 173 lbs, Ht 70 inches
● On glimepiride (Amaryl) 4 mg/day ,HbA1c 7.3% (intolerant to metformin)
● Infection in colostomy pouch (ulcerative colitis)glucose up to 300 mg/dL plus
● SBGM 3 times per day
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Case #1: DM 2 on SU withinfection
● Started on MDI; starting dose 0.2 x wgt. in lbs.
● Wgt. 180 lbs which = 36 units
● Bolus dose (lispro/aspart) = 20% of startingdose at each meal, which = 7 to 8 units ac (tid)
● Basal dose (glargine) = 40% of starting dose atHS, which = 14 units at HS
● Correction bolus = (BG - 100)/ SF, whereSF = 1500/total daily dose; SF = 40
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Initial Dosage Calculations
Correction Bolus
"1500 Rule"
•insulin sensitivity factor
•determines the estimated BG drop
per 1.0 unit of insulin
Davidson PC, The Insulin Pum p Therapy Book: Insights from the Experts 1995, 59-71.
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Glucose Correction Factor
1500 Rule says:
John Smith is on:
•36 units insulin/day
•1500/36= 40
•1 unit lowers BG 40 mg/dl
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Correction Bolus Formula
Example:
–Current BG: 220 mg/dl
– Ideal BG: 100 mg/dl
–Glucose Correction Factor: 40 mg/dl
Current BG - Ideal BGGlucose Correction factor
220 - 100
40=3.0u
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Case #1: DM 2 on SU withinfection
● Started on MDI
● Did well, average BG 138 mg/dL at 1month and 117 mg/dL at 2 monthspost episode with HbA1c 6.1%
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Strategies to Improve GlycemicControl: Type 2 Diabetes
● Monitor glycemic targets – Fasting andpostprandial glucose, HbA1c
● Self-monitoring of blood glucose is essential
● Nutrition and activity are cornerstones oftherapy
● Combinations of pharmacologic agents areoften necessary to achieve glycemic targets
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Intensive Therapy for Type 1 Diabetes
● Careful balance of food, activity, and insulin
● Daily self-monitoring BG
● Patient trained to vary insulin and food
● Define target BG levels (individualized)
● Frequent contact of patient and diabetes team
● Monitoring HbA1c
● Basal / Bolus insulin regimen
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Options in Insulin Therapy
● Current
– Multiple injections
– Insulin pump (CSII)
● Future
– Implant (artificial pancreas)
– Transplant (pancreas; islet cells)
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1.0
0.8
0.6
0
Insulin
Time
Multiple Injection TherapyIntermediate & Short-Acting Insulin Pre-Meal
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Injections1.0
0.8
0.6
0
Insulin
Time
Multiple Injection TherapyIntermediate & Short-Acting Insulin Pre-Meal
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Injections1.0
0.8
0.6
0
Insulin
Time
Multiple Injection Therapy Intermediate & Short-Acting Insulin Pre-Meal
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Case #2: DM 1 on MDI● 46 year old white male power line supervisor
● DM 1 age 40
● On MDI: 10 u lispro pre-meal, 20 u NPH HS
● HbA1c 7.4%
● SMBG avg 124 mg/dL based on 1.9 tests/day(fasting 171 mg/dL, noon 105 mg/dL,pm 125 mg/dL, HS 75 mg/dL)
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Case #2: DM 1 on MDI● Lantus (glargine) 20 u HS added in place of NPH
● No change in behavior (diet, SMBG frequency)
● Seen three months later (8-16-01)
● HbA1c 6.3%
● SMBG average 104 mg/dL (fasting BG 91 mg/dL,noon 126 mg/dL, pm 116 mg/dL, HS 126 mg/dL
● NO HYPOGLYCEMIA
● HAPPY
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Insulin Pens
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Introducing InDuo™
● The world’s firstcombined insulindoser and bloodglucose monitoringsystem
● A major break-through in DiabetesCare
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InDuo™ - IntegrationFeature
● Combined insulin doserand blood glucosemonitor
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InDuo™ - Compact Size
Feature
● Compact, discreet design
Benefit
● Allows discreet testing andinjecting anywhere, anytime
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InDuo™ - Doser RemembersFeature
● Remembers amount ofinsulin delivered and timesince last dose
Benefit
● Helps people inject theright amount of insulin atthe right time
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Lauritzen. Diabetologia. 1983;24:326–329.
Fast (n = 12)
Semilente (n = 9)
Intermediate (n = 36)
Fra
ctio
n a
t in
j. si
te
1.00
0.75
0.50
0.25
06 12 18 24 36 42 4830
Hours after single SC injectionsFemoral region
Variability of Insulin Absorption
CSII <2.8%
SubcutaneousInjectable10% to 52%
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Pump TherapyBasal & Bolus Short-Acting Insulin
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Pump TherapyBasal & Bolus Short-Acting Insulin
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Pump TherapyBasal & Bolus Short-Acting Insulin
● Combined withSMBG, physiologicinsulin requirementscan be achievedmore closely
● Flexibility in lifestyle
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History of Pumps
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Paradigm PumpParadigm Pump
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PARADIGM PUMP
Paradigm. Simple. Easy.
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Paradigm Pump: Advantages
● 29% smaller, water resistant
● Menu driven:
bolus, suspend, basal, prime, utilities
● Reservoir based (easier to fill)
● Silent motor
● AAA batteries
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Paradigm Pump: Advantages
● Various bolus options
normal, square, dual, and “easy bolus”
● Enhanced memory
● Enhanced safety features
(low reservoir alarm, auto off, etc.)
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Pump Infusion Sets
Softset QR Silhouette
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Lauritzen. Diabetologia. 1983;24:326–329.
Pharmacokinetic AdvantagesCSII vs MDI
● Uses only regular or very rapid insulin
– More predictable absorption than modifiedinsulins (variation 3% vs 52%)
● Uses 1 injection site
– Reduces variations in absorption dueto site rotation
● Eliminates most of the subcutaneous insulin depot
● Programmable delivery simulates normalpancreatic function
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Metabolic Advantages with CSII
● Improved glycemic control
● Better pharmacokinetic delivery of insulin
– Less hypoglycemia
– Less insulin required
● Improved quality of life
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8.18
8.58.2
8.9
6.96.977
7.6
6
7
8
9
10
Baseline 1 yr 2 yr 3 yr 4 yr
Adolescent (37) Adult (166)
Glycemic ControlH
bA
1c
Atlanta Diabetes Associates
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CSII Reduces HbA1c
5.05.56.06.57.07.58.08.5.099.5
10.0
n = 58 n = 107 n = 116 n = 50 n = 25 n = 56Mean dur. = 36
AdolescentsAdults
Mean dur. = 36 Mean dur. = 54 Mean dur. = 42 Mean dur. = 12 Mean dur. = 12
Chantelau E, et al. Diabetologia. 1989;32:421–426; Bode BW, et al. Diabetes Care. 1996;19:324–327;Boland EA, et al. Diabetes Care. 1999;22:1779–1784; Bell DSH, et al. Endocrine Practice. 2000;6:357–360;Chase HP, et al. Pediatrics. 2001;107:351–356.
Bell Rudolph Chanteleau Bode Boland Chase
Pre-pump Post-pump
Hb
A1c
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● Monitoring– HbA1c = 8.3 - (0.21 x BG per day)
● Recording 7.4 vs 7.8
● Diet practiced– CHO: 7.2– Fixed: 7.5– Other: 8.0
● Insulin type– Lispro: 7.3– R: 7.7
CSIIFactors Affecting HbA1c
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Insulin aspart versus buffered R versusinsulin lispro in CSII study:
Bode et al: Diabetes Care, March 2002
Insulin aspart
Buffered regular human insulin (Velosulin®)Screening
Insulin lispro–2 0 16
weeks weeksweeks
! 146 patients in the USA; 2–25 years with Type 1 diabetes;
7% ≤ HbA1c ≤ 9%; previously treated with CSII for 3 months
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Glycemic Control with CSIINovoLog®Human insulinHumalog®
7.0
7.2
7.8
8.0
Hb
A1c
(%
) 7.6
7.4
Baseline Week 8 Week 12 Week 160
Bode, Diabetes 2001 ; 50(S2):A106
Type 1 Diabetes
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Self-Monitored Blood Glucose in CSII
NovoLog® Buffered Regular Humalog®
80
100
120
140
160
180
200
220
Blo
od
Glu
cose
(m
g/d
l)
* **
Bedtime 2 AMBefore and90 min. after
breakfast
Before and90 min. after
lunch
Before and90 min. after
dinner
Type 1 Diabetes
Bode, Diabetes 2001 ; 50(S2):A106
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Ep
iso
des
/mo
nth
/pat
ien
t
0
2
4
6
8
10
12
insulin aspart human insulin insulin lispro
pp < 0.05 < 0.05
pp < 0.05 < 0.05
Symptomatic or ConfirmedHypoglycaemia
30% relative reduction
Bode et al: Diabetes Care, March 2002
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0
10
20
30
40
50
Insulin aspartBuffered human insulinInsulin lispro
Pat
ien
ts w
ith
tro
ub
le-f
ree
use
(%
)
Insulin aspart versus buffered R versus insulinlispro in CSII study: pump compatibility
Data on file (study ANA 2024)
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Case Study: 54 year old DM1 on CSII withLipoatrophy and Insulin Antibodies
● DM 1 onset age 21, 1968
● CSII 1998, A1C 7.8%
● Lipoatrophy with humalog 1999-2000
● Changed to Velosulin BR with still lipoatrophy
● Control suboptimal A1C 7.8%
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Case Study: 54 year old DM1 on CSII withLipoatrophy and Insulin Antibodies
● 7-10-01 A1C 7.8% on 28.8 units per day
● SMBG Avg BG 140, SD 118 based on 2.9 tests/day
● Insulin antibodies positive 1:32
● Changed to Novolog 1 to 1 transfer
● 10-16-01 A1C 6.5% on 20.8 units per day
● SMBG Avg 118, SD 73 based on 3.0 tests per day
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0
1 0 0
2 0 0
3 0 0
4 0 0
5 0 0
6 0 0
7 0 0
5 /9 /20 0 1 5 /2 9/2 0 0 1 6 /1 8/2 0 0 1 7 /8 /20 0 1 7 /2 8/2 0 0 1 8 /1 7/2 0 0 1 9 /6 /20 0 1 9 /2 6/2 0 0 1 1 0 /16 /2 0 0 1 1 1 /5/2 0 0 1
HumalogAverage = 140SD = 118
NovologAverage = 118SD = 73
DM 1 CSII Patient: Humalog to Novolog
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Case Study: 54 year old DM1 on CSII withLipoatrophy and Insulin Antibodies
● 2-5-02 A1C 6.3% on 20 units per day
● SMBG Avg BG 104, SD 74 based on 3.1tests/day
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7.197.57
9.2
5.00
6.00
7.00
8.00
9.00
10.00
Baseline 6 months 18 months
P = 0.026 P = 0.040
N = 11
CSII Usage in Type 2 PatientsAtlanta Diabetes Experience
Mean HbA1c (%)
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Glycemic Control in Type 2 DM:CSII vs MDI in 127 patients
● A1C
7.0
7.2
7.4
7.6
7.8
8.0
8.2
8.4
CSII MDI
Baseline
End of Study (24 wks)
Raskin, Diabetes 2001; 50(S2):A106
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DM 2 Study: CSII vs MDI
● Overall treatment satisfaction improved in theCSII group: 59% pre to 79% at 24 weeks
● 93% in the CSII group preferred the pump totheir prior regiment (insulin +/- OHA)
● CSII group had less hyperglycemic episodes(3 subjects, 6 episodes vs. 11 subjects, 26episodes in the MDI group)
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CSII Reduces Hypoglycemia
0
20
40
60
80
100
120
140
160
n = 55Mean age 42
n = 107Mean age 36
n = 116Mean age 29
n = 25Mean age 14
n = 56Mean age 17
Eve
nts
per
hu
nd
red
pat
ien
t ye
ars
Chantelau E, et al. Diabetologia. 1989;32:421–426; Bode BW, et al. Diabetes Care. 1996;19:324–327;Boland EA, et al. Diabetes Care. 1999;22:1779–1784; Chase HP, et al. Pediatrics. 2001;107:351–356.
Bode Rudolph Chanteleau Boland Chase
Pre-pump Post-pump
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48.1
34.539.3 40.1 39.8
0
10
20
30
40
50
60
Baseline(MDI)
15 days 6 mos 18 mos 36 mos
-28% -18% -16% -17%
* P <0.001
** * *
n = 389 n = 389 n = 298 n = 246 n = 187
Insulin Reduction Following CSII
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Normalization of Lifestyle
● Liberalization of diet — timing & amount
● Increased control with exercise
● Able to work shifts & through lunch
● Less hassle with travel — time zones
● Weight control
● Less anxiety in trying to keep on schedule
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N = 165Average Duration = 3.6 yearsAverage Discontinuation <1%/yr
Continued 97%
Discontinued 3%
Current Continuation RateContinuous Subcutaneous Insulin Infusion (CSII)
Bode BW, et al. Diabetes. 1998;47(suppl 1):392.
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6,600 8,700 11,40015,000
20,00026,500
35,00043,000
60,000
81,000
120,000
162,000
0
50,000
100,000
150,000
'90 '91 '92 '93 '94 '95 '96 '97 '98 '99 2000 2001
U.S. Pump UsageTotal Patients Using Insulin Pumps
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Pump Therapy Indications
● HbA1c >7.0%
● Frequent hypoglycemia
● Dawn phenomenon
● Exercise
● Pediatrics
● Pregnancy
● Gastroparesis
● Hectic lifestyle
● Shift work
● Type 2
Marcus. Postgrad Med. 1995.
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Poor Candidates for CSII
● Unwilling to comply with medical follow-up
● Unwilling to perform self blood glucosemonitoring 4 times daily
● Unwilling to quantitate food intake
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Current Candidate Selection
Patient Requirements
–Willing to monitor and record BG
–Motivated to take insulin
–Willing to quantify food intake
–Willing to follow-up
– Interested in extending life
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Meal bolus
1
2
3
4
5
6
12 am 12 pm 12 am
Time of day
Basal rate
Pump Therapy
Units
Meal boluses
● Insulin needed pre-meal– Pre-meal BG– Carbohydrates in meal– Activity level
● Correction bolus for high BG
Basal rate
● Continuous flow ofinsulin
● Takes the place of NPHor ultralente insulin
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What Type of Bolus Should You Give?
● 9 DM 1 patients on CSII ate pizza and coke on fourconsecutive Saturdays
● Dual wave bolus (70% at meal, 30% as 2-h square):
9 mg/dl glucose rise
● Single bolus: 33 mg/dl rise
● Double bolus at -10 and 90 min: 66 mg/dl rise
● Square wave bolus over 2 hours: 80 mg/dl rise
Chase et al, Diabetes June 2001 #365
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Treatment of Hypoglycemia
● Education
–Glucose tablets
–Glucagon
● Call healthcare team
–Any hypoglycemic events requiring assistance
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Treatment of Hyperglycemia
● If blood glucose is above 250 mg/dl
– Take a correction bolus by pump
– Check BG again in 1 hr
● If still above 250 mg/dl
– Take correction bolus by syringe
– Change infusion set and reservoir
– Check BG again in 1 hr
● If BG has not decreased
– Increase correction bolus by syringe
– CALL PHYSICIAN
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If HbA1c is Not to Goal
● SMBG frequency andrecording
● Diet practiced
– Do they know whatthey are eating?
– Do they bolus for allfood and snacks?
● Infusion site areas
– Are they in areas of lipohypertrophy?
● Other factors:
– Fear of low BG
– Overtreatment of low BG
Must look at:
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Future ofDiabetes Management
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Improvements in Insulin & Delivery
● Insulin analogs and inhaled insulin
● External pumps
● Internal pumps
● Continuous glucose sensors
● Closed-loop systems
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Pulmonary Insulin
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Oral Agents + Mealtime Inhaled InsulinEffect on HbA1c
*P < .001
Weiss, et al. Diabetes. 1999;48(suppl 1):A12.
10
9
8
7
5Baseline
(0)Follow-up
(12)
Oral Agents +Inhaled InsulinOral Agents Alone
Baseline(0)
Follow-up(12)
−2.3%*
Weeks
6
HbA
1c (%
)
6-55
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● Non-invasive
– Near Infrared Spectroscopy (NIR)
● Minimally-invasive (ISF)
– Micropore sampling
– Iontophoresis
– Subcutaneous sensors
Categories of Glucose Monitoring
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Cygnus GlucoWatch– Watch Component
– Electrode Component
– Initial calibration takes 3 hours
– Senses glucose and gives anaverage every 20 minutes up to 12hours (r = 0.80 home use)
– Alarm for high, low and rapidlydropping blood sugars
– Indicated for 18 years and older
Cygnus GlucoWatchCygnus GlucoWatch
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GLUCOSE MONITORING SYSTEMS -EXTERNAL
● Physician downloads data forretrospective analysis
● Com-Station and softwarepackages combine data from:
– Sensor
– Models 508 and 507Cinsulin pumps
– Traditional glucosemeters
Physician Product
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Patient with Type 1 Diabetes
– Practicing MDI
– HbA1C of 8.5%
– Complications
of High BG
Renal
Retinal
Neural
Glucose Profiles
0
50
100
150
200
250
300
350
12:00 Midnight 6:00 AM 12:00 Noon 6:00 PM 12:00 MidnightTim e
Meal Meal Meal MealGlu
cose
Con
cent
ratio
n (m
g/dl
)
Pre-Meal BG Tests
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Glucose Profiles
GlucoseMonitorPre-Meal BG Tests
0
50
100
150
200
250
300
350
12:00 Midnight 6:00 AM 12:00 Noon 6:00 PM 12:00 MidnightTim e
Meal Meal Meal MealGlu
cose
Con
cent
ratio
n (m
g/dl
)
Patient with Type 1 Diabetes
– Practicing MDI
– HbA1C of 8.5%
– Complicationsof High BG
Renal
Retinal
Neural
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New CGMS Software 2-26-02
● Running 24 hour calibration: no 12 am shift
● Slope 2 to 12 ok: less disconnected graphs
● Improved algorithm: less noise
● Improved analysis and printouts: easier tointerpret and provide feedback
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Other CGMS Updates 2-27-02
● Improved quality of sensors (change inmanufacturing ingredient)
● Increased reimbursement for Medicare CPTCode 95250: doubled from $52 to $109
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History
● 70 Year-old white male
● Type 2 DM, 15 years
● Current Treatment:
–Glucophage 500mg AM, 1000mg PM
–Glynase 6mg BID
–Rezulin 400mg QD
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History
● HgA1c increased to 8.0% from 6.5% 18 months earlier
● SMBG Average: 162 mg/dL
– AM = 137
– Noon = 199
– PM = 151
– HS = 188
● Ht= 73”; Wt= 180 lbs; BMI=23 kg/m2
● CGMS done to determine best course of treatment
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Modal Day
-50
0
50
100
150
200
250
300
350
400
12:00A M
4:00 A M 8:00 A M 12:00PM
4:00 PM 8:00 PM 12:00A M
Tim e
1/10/99
1/11/99
1/12/99
Glu
cose
con
cent
ratio
n (M
g/d
l)
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-50
0
50
100
150
200
250
300
350
400
12:00 A M 4:00 A M 8:00 A M 12:00 PM 4:00 PM 8:00 PM 12:00 A M
Tim e
Glucose Sensor Profile
11-30-99
Glu
cose
con
cent
ratio
n (M
g/d
l)
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Changes to be made
● Options discussed with patient:
1. Add insulin pre-meal
2. Change Glynase to Prandin
● CGMS re-done
six weeks later
-50
0
50
100
150
200
250
300
350
400
12:00A M
4:00 A M 8:00 A M 12:00PM
4:00 PM 8:00 PM 12:00A M
Tim e
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-50
0
50
100
150
200
250
300
350
400
12:00
A M
4:00
A M
8:00
A M
12:00
PM
4:00
PM
8:00
PM
12:00
A M
Tim e
3/20/00
3/21/00
3/22/00
3/23/00
Modal Day
Glu
cose
con
cent
ratio
n (M
g/d
l)
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Reasons to Use CGMS
● Improve glycemic control
● Reduce risk of hypoglycemicevents
● Minimize risk of futurehypoglycemia
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GLUCOSE MONITORING SYSTEMS -Telemetry
● “Real time” glucosereadings
● Wireless communicationfrom sensor to monitor
● High and low glucosealarms
● FDA panel pending
Consumer Product
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Closed-loop control using an external insulinpump and a subcutaneous glucose sensor
subcutaneousglucose sensor
Insulin infusion pump(currently MiniMed 508)
+
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Closed-Loop Setup for Canine Studies
Q W E R T Y U I O P { } |
A S D F G H J K L : " Enter; 'Z X C V B N M < > ?
/ Shift.,
ESC F1 F2 F3 F4 F5 F6 F7 F8 F 9 F10 F11 F12 Insert Delete Scroll Print
1 2 3 4 5 6 7 8 9 0 _ +
\][
1 2 Alt
Shift
- =
Alt
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Tab
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6 am noon 6 pm midnight 6 am noon6 am noon 6 pm midnight 6 am noon0
100
200
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400
500meals YSI GLC
Sensoradjust controlparameters
start control
GL
UC
OS
E (
mg
/dl)
6 am noon 6 pm midnight 6 am noon6 am noon 6 pm midnight 6 am noon0
2
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µU/ml(U/h)
Time (h)
Clo
sed
Lo
op
Res
on
se(U
/h)
Insu
lin ( µ
U/m
l)
24-h Closed-Loop Control (diabetic canine)
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Implantable Pump
● AverageHbA1c 7.1%
● Hypoglycemicevents reduceto 4 episodesper 100 pt-years
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MiniMed 2007 System
ImplantableInsulin PumpPlacement
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Implantable InsulinPumps Indications for Use
" Diabetes out of control (frequent, rapid ρBG)" Frequent hypoglycemic episodes" Subcutaneous insulin absorption resistance" Injection or infusion site reaction
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Long-Term Glucose Sensor
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0
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26 Thu 27 Fri 28 Sat 29 Sun 30 Mon 31 Tue 1 Nov 2 Thu 3 Fri 4 Sat 5 Sun 6 Mon 7 Tue
Glu
cose
(m
g/dL
)LONG TERM IMPLANTABLE SYSTEM
Source: Medical Research Group, Inc.
Human Clinical Trial
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Combine Pump and Sensor Technology
+
LTSS => Long Term SensorSystem (“Open Loop Control”)
Using an RF Telemetry Link…...
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Medtronic MiniMed’s ImplantableBiomechanical Beta Cell
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Today’s RealityOpen-Loop Glucose Control
Sensor # - 6347
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Source: Medical Research Group, Inc.
50
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400
16 Wed 17 Thu 18 Fri 19 Sat 20 Sun 21 Mon 22 Tue 23 WedAugust 2000
Glu
cose
(mg/
dL)
LONG TERM IMPLANTABLE SYSTEMAutomatic Glucose Regulation
in a Fully Pancreatectomized Canine
CLOSED LOOP CONTROL
ManualControl
ManualControl
Automatic ControlBegins
ControlTerminated
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Summary
● Insulin remains the most powerful agentwe have to control diabetes
● When used appropriately in a basal/bolusformat, near-normal glycemia can be achieved
● Newer insulins and insulin delivery devicesalong with glucose sensors will revolutionizeour care of diabetes
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Conclusion
Intensive therapy is
the best way to treat
patients with diabetes
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QUESTIONS
● For a copy or viewing of these slides, contact
● WWW.adaendo.com
● Email: [email protected]