Diabetes and Technology: Insulin Delivery and Monitoring

1. Diabetes and Technology:Insulin Delivery and Monitoring Amy Urbanus, RD, CDE Diabetes Specialist Providence Alaska Medical center

2. Home Glucose Monitoring

3. Home Glucose Monitoring • Continues to be one of the best tools for diabetes self-management “One is my war lance and the other is for monitoring my blood sugar”

4. Things to Consider • Cost/Insurance Strips • Accuracy • Dexterity of patient • Alternate site testing • Lancing devices

5. Lifescan: One Touch • One Touch Ultra Mini: Consumer Reports #1 meter • One Touch Ultra 2 • One Touch Ultra Link • One Touch Ultra Smart • One Touch “Ping” • All use One Touch test strips • Covered by insurance and Medicare • Large displays • Local customer support

6. Accu-Chek • Aviva • Large test strips: good for patients with difficulty getting small test strips out of the bottle • Compact • Bulky meter, test strips come in a “drum” (no handling of test strips), lancing device attached to the meter • Active • Cheaper meter, good for non insured

7. Freestyle Smallest sample size @ 0.3 ml • Freedom Lite • Freestyle Freedom • Freestyle meter integrated with the Navigator CGM and OmniPod • All Freestyle meters use the same strip that is challenging for some to use, very small, can not see blood on strip

8. “Other” Meters • Reli-on • Wal-Mart's meter; question accuracy • Strips individually wrapped and difficult to get open • TRUE Track • Cheaper meter. Many pharmacies will try to encourage patients to “trade out” their Accu-Chek or One Touch meter for this cheaper brand claiming better reimbursement. Better for the pharmacy, not the patient

9. Lancing Devices • Most meters use similar lancing device • “Multiclix” by Accu-Chek • Drum of needles • Sold as not being as painful • Can purchase separately

10. Insulin Delivery Pens, syringe or pump?

11. Providence Alaska Medical Center Novolog FlexPen Lantus syringe Alaska Regional Hospital Novolog Flex Pen Lantus SoloStar Pen Bartlett Fall ’09 Humalog KwikPen Lantus SoloStar Pen Alaska Native Medical Center Novolog FlexPen Lantus syringe Insulin PensThe New Trend in Hospitals

12. Types of Insulin Pens • Rapid Acting Insulin • Novolog FlexPen: Prefilled 300 units • Humalog KwikPen: Prefilled 300 units • Apidra SoloStar Pen: Prefilled 300 units (new April ’09) • Humalog Memoir Pen: 300 unit cartridge • Humalog Luxura Pen: 300 unit cartridge, can be dosed in ½ units • Basal Insulin • Lantus SoloStar Pen: prefilled 300 units • Opticlick pen phasing out • Levemir FlexPen : prefilled 300 units • Many mixed Insulins and older insulins also come in pens

13. Advantages Easy to dial up dose Can “count” clicks Kept at room temperature Portable More discrete Memoir Pen: good for patients with multiple care givers, able to identify last dose administered Disadvantages Only 300 units Pens look similar, rapid acting and basal could get mixed up Pen is large Difficult to “plunge” Hold needle in for 5 seconds to ensure administration Pros/Cons to Insulin pens

14. Supplies Same needle works for all pens Must write a script for needles Many patients end up with the pen only Cost Vials and pens are now the same cost Medicaid will not cover insulin pen unless “medically necessary” Supplies/Cost: Insulin Pens

15. Hospital Issues and Insulin Pens Providence • If patients are discharged on the same insulin regimen, they will automatically be given the Novolog FlexPen • Medicaid will not pay for this Insulin Pen Needles Hospital safety needles look different than the outpatient needles

16. Insulin Pumps

17. Benefits of Insulin Pump Therapy • Improved glycemic control and decreased variability in blood sugar • Improved control of dawn phenomenon • Decrease frequency of hypoglycemia • Flexibility of lifestyle • Flexibility of basal rates: 0.025 units/hr – 25 units/hr

18. First Things First!Assess appropriate patients Patients need to be able and willing to: • Multiple daily injections • Have and use syringes or pens as a backup • Check BS 6 + x/ day • Keep records

19. Assessment Cont. • Attend all appointments with physician and educators • Carbohydrate count and adjust meal plan • Perform Insulin : CHO ratio and sensitivity factor calculations without use of pump calculators

20. Insulin Pump ComparisonMost Common in Alaska • Medtronic Minimed Paradigm 522/722 • Animas One Touch Ping • OmniPod

21. MiniMed Paradigm 522/722 • 176 or 300 unit reservoir • Temporary basal rate • Exercise • Sick Day • Bolus increment of 0.1 unit • Normal, squarewave, audio bolus features • Bolus “wizard”

22. MiniMed Paradigm Cont. • AAA battery with 2-4 weeks of life • Used in water up to 3 feet for 30 minutes • Sensor screen on insulin pump • Can be used with One Touch Ultra Link Meter

23. OmniPod • “Pod” is all in one: insulin, infusion set, and battery • 200 unit capacity • Separate PDM for programming • PDM has a Freestyle BG meter • Temporary basal rate • 0.05-0.1 unit bolus increments • Normal or extended bolus • Bolus calculator on PDM • 2 AAA batteries in PDM • Pod is water tight • Pod needs to be changed out every 3 days

24. One Touch Ping • Meter/Remote • Programming on pump or meter/remote • One Touch BS meter • 200 unit reservoir • 0.025 bolus increment • Extended bolus feature • Bolus calculator • Battery • 1 AA alkaline with 2-4 wks life • 1 AA lithium 4-6 weeks life • Waterproof up to 12 feet for 24 hrs

25. How Much?? Self Pay Costs • Insurance coverage and monthly cost should be analyzed • Average Insulin Pump “start up” (MiniMed or One Touch) • $6000-$7000 • Infusion sets and reservoirs: average $150/month • OmniPod: • Start up:$1750 (PDM and 2 pods) • Monthly expense: $450/ month for 10 pods • “Pay as You Go”

26. Don’t Forget the Insulin and Test Strips!! • Rapid Acting Insulin ~ $100/ vial in Anchorage • Advantage to pump • Only one co pay • Home Glucose Monitoring Test Strips • ~ $1 per strip

27. Insurance • Fairly good coverage for insulin pump therapy by both private insurance and Medicare/Medicaid • 20% out of pocket cost per month ~ $ 30 for supplies • Currently OmniPod does not accept Medicare

28. Continuous Glucose Monitoring

29. Basic Concept3 Parts 1. Sensor • Patients wear a glucose sensor that is inserted similarly to an insulin pump and sends data continuously to a transmitter 2. Transmitter • Transmitter then sends the data to a “receiver” 3. Receiver • Hand held receivers: Navigator and Dexcom Seven • Paradigm insulin pump • Provides glucoses value as well as graphs with a visual of BG trend

30. Abbott Navigator MiniMed Real Time Dexcom Seven Plus

31. Who Could Benefit? • Frequent nocturnal hypoglycemia • Hypoglycemia unawareness • Postprandial hyperglycemia • Dawn phenomenon “Tool” to help establish patterns and trends Patients need to be able to DO something with the information Takes time to learn how to use the data

32. Standard Features • All need to be calibrated with fingerstick blood sugar • “Wetting time” for initiation period usually 2-12 hr (over night) • Must be calibrated periodically during wear • Sensor life 3-7 days • Patients report 2-3 weeks of wear

33. CGM Standard Features Cont. • All have alarms to set for hyperglycemia and hypoglycemia that can be customized • Note: if receiver or pump is under a pillow, most likely will not hear alarm • Sensor/transmitter are water resistant

34. Insurance/Cost • Many more patients are getting coverage for CGM by private insurers • Currently no Medicare coverage • Start up ~ $1000 for transmitter • Transmitter good for ~ 1 year • $275-350/ month for sensors

35. There are many exciting tools available now, and more to come in the future, to help improve control and ultimately quality of life. Thank You amy.urbanus@providence.org