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Diabetes 2012: Pump, Sensors, Current Medical Therapy & Future Dreams

Diabetes 2012: Pump, Sensors, Current Medical Therapy & Future Dreams. Shannon Kelley Oates MD February 2012. Diabetes Introduction. Why we need to consider the impact How large is the problem? How can you understand what it is to be a person with diabetes?. Diabetes Mellitus. Type 1

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Diabetes 2012: Pump, Sensors, Current Medical Therapy & Future Dreams

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  1. Diabetes 2012: Pump, Sensors, Current Medical Therapy & Future Dreams Shannon Kelley Oates MD February 2012

  2. Diabetes Introduction Why we need to consider the impact How large is the problem? How can you understand what it is to be a person with diabetes?

  3. Diabetes Mellitus Type 1 Rare—affecting only 1 in 250 (1 in 400 kids) 15,000 new cases per year Low rates in Black and Asian populations Type 2 Common Probably 25 million cases in the US. 1/3 cases undiagnosed Projected prevalence of 11% WOW! Over age 65, 27% with DM Cost: $ 218 billion in 2007

  4. Diabetes MellitusType 1 and Mortality Mortality rates for people with DM Type 1 are 5 to 7 times the general population More than 15% of people with DM type 1 will die by age 40 They die of DKA, of renal failure, of cardiovascular disease Life expectancy is reduced by 15 years

  5. Competence Questions 1.  What are the indications for an insulin pump?         a.  desire for a pump and insulin use         b.  diabetes type 1 if on Medicare         c.  diabetes type 2 for many commercial insurances         d.  Insulin use

  6. Competence Questions 2.  Name 3 new diabetes therapies in the last few years         a. Exenetide, bromocriptine, glimepiride         b. Bromocriptine, linagliptin, saxagliptin         c. Carbohydrate counting, continuous glucose monitoring, insulin pumps

  7. Competence Questions 3.  Continuous glucose monitoring can be used         a. only with a pump         b. only with multidose injection insulin therapy         c. must be used daily         d.  costs about $35 per week on-going costs

  8. Take Home Goals Think like a pancreas Give enough insulin Get and give loads of education

  9. Insulin Secretion- Physiology 70 Serum insulin 50 Insulin (mU/L) 30 10 0 9:00 am 9:00 pm 12:00 am 3:00 am 6:00 am 12:00 pm 3:00 pm 6:00 pm Time of Day Lunch Dinner Breakfast Polonsky, N Engl J Med 1996; 334: 777-783

  10. Insulin Secretion- Physiology 70 Serum insulin 50 Insulin (mU/L) 30 10 0 9:00 am 9:00 pm 12:00 am 3:00 am 6:00 am 12:00 pm 3:00 pm 6:00 pm Time of Day Skips Lunch BiggerDinner Breakfast Polonsky, N Engl J Med 1996; 334: 777-783

  11. Intensive Therapy Decreases risks of microvascular disease Retinopathy 75% reduction Nephropathy 50% reduction Neuropathy 60% reduction Goal is to achieve normoglycemia Measure BS frequently Increases risk of hypoglycemia

  12. Insulin Time-Action Patterns Normal Insulin Secretion at Meal Time Regular insulin NPH Insulin Premix 70/30 Change in Serum Insulin Baseline Level Time (hours) s.c. Injection

  13. Insulin Time-Action Patterns Normal Insulin Secretion at Meal Time Regular insulin NPH Insulin Premix 70/30 Change in Serum Insulin Baseline Level Time (hours) s.c. Injection

  14. Insulin Aspart Pro Asp Phe Gly Arg Phe Tyr Glu B20 Thr Gly Asp Cys Lys B28 B30 Thr A21 Asn Cys Val Tyr Leu Gly A1 Asn Tyr Ile Glu Leu Val Leu Ala Glu Gln Glu Gln Tyr Val Cys Leu Cys Ser Thr Ser Ile Leu Cys His Ser Gly Cys Leu B1 Phe Val Asn Gln His

  15. Normal Insulin Secretion 70 Serum insulin 50 Insulin (mU/L) 30 How can we approach this ideal? 10 0 9:00 am 9:00 pm 12:00 am 3:00 am 6:00 am 12:00 pm 3:00 pm 6:00 pm Time of Day Lunch Dinner Breakfast Polonsky, N Engl J Med 1996; 334: 777-783

  16. Insulin Regimens Twice a day mixed insulin Once daily long acting with lispro or regular with each meal Twice daily intermediate or long acting insulin with lispro or regular at each meal Once a day long acting insulin with lispro/aspart/glulisine at each meal CSII is continuous subcutaneous insulin infusion this is insulin pump

  17. ‘Ventricular Tachycardia’ Sugars

  18. Insulin Pen or Syringe Injections with MDI can approach the Ideal Insulin pens are very handy Use ONLY on one person

  19. CSII or Insulin Pump Programmed basal rate of insulin and calculated boluses with carbohydrate intake Place needle or catheter subcutaneously every 3 days Short or rapid insulin analog only Special attention to prevent DKA

  20. Insulin Pumps Call 1-800 Number if ?? Accu-Chek Omnipod Medtronic MiniMed Animas Deltec

  21. Future? Insulin Pumps Old pumps Animas Accu-Chek Omnipod Deltec Tandem Spring Zone

  22. Pump Manufacturers MiniMed www.minimed.com Several pumps Great support Animas www.animas.com Implantable monitor in testing phase Omnipod No tubing www.myomnipod.com

  23. Omnipod – no tube

  24. Way Cool A 15 year old can sleep in until noon on the weekend and not get up and take an injection and eat breakfast Indications? Desire for a pump Some understanding of the limitations of the technology

  25. Need to know the glucose Call 1-800 Number if ??

  26. Newer Meters iPhone App- Wavesense Iphone add-on meter iBGStar Bayer USB meter Call 1-800 Number if you have ?? 4/2/2014 28

  27. Continuous Monitoring 4/2/2014 29

  28. Patient versions of Continuous Monitoring or CGM Dexcom 7 Medtronic Real time or Guardian

  29. Two Versions of CGM • Professional • If we need more information, we can do the “Holter Monitor” of glucose • Several days of glucose data with meals and insulin data from the patient • Personal • The patient sees the glucose data as it is produced • Can be used continuously or intermittently • Cost about $35 cash per usage 4/2/2014 31

  30. Two Versions of CGM Professional-- called iPro 4/2/2014 32

  31. Continuous Monitoring Software

  32. Continuous Monitoring Software 4/2/2014 34

  33. CGM for Patients- Receivers 4/2/2014 35

  34. mySentry™ Remote Glucose Monitor

  35. Up to 75% of severe hypoglycemic episodes in children occur at night* *Ahmet A, Dagenais S, Barrowman NJ, et al. Prevalence of nocturnal hypoglycemia in pediatric type 1 diabetes: a pilot study using continuous glucose monitoring. J Pediatrics, 2011;159 (2): 297-302.

  36. Glucose and Sensor Screenshots

  37. Transplants Whole pancreas transplants usually along with kidney Technical difficulties with islet only transplants Autotransplantation of islets– only if we take out your pancreas for NON diabetes reason

  38. Newer Classes of Antidiabetes Therapies: The Era of Incretin-based Therapies plus … Exenatide (GLP-1 receptor agonist) Liraglutide (GLP-1 receptor agonist) Sitagliptin (DPP-IV inhibitor) Saxagliptin (DPP-IV inhibitor) 2005 2006 2007 2008 2009 2010 Colesevelam (bile acid binder) Bromocriptine (dopamine agonist) 2012 Exenatide XR (GLP-1 receptor agonist) . Food and Drug Administration. accessdata.fda.gov. Accessed 25 May 2010.

  39. Best of the Web www.diabetes.org - American Diabetes Association www.childrenwithdiabetes.com Lovely site, easy to navigate, active chat Archived expert answers Diabetes camp info www.diabetesmonitor.com www.diabetesstation.org www.jdf.org – Juvenile Diabetes Association www.2aida.net -very cool insulin simulator

  40. what is it like to have diabetes?

  41. Real life with Diabetes Find your ice skates Have a snack Test your blood sugar Laugh at your roomie Test, count, inject Study, sleep. Test sugar Count carbs Do a shot Go to class Test sugar, count carbs, do a shot Treat a low blood sugar

  42. Real life with Diabetes

  43. Future ? Artificial pancreas Better data collection Easier diagnosis Test genes to see who might get disease Your glucose sensor reminds you that you forgot to take insulin Scan the food for auto carb calculation Dr. Oates is on the beach with her computer and your company pays her NOT to see you

  44. The Provider is always in

  45. Competence Questions: Multiple right answers 1.  What are the indications for an insulin pump? a.  desire for a pump and insulin use         b.  diabetes type 1 if on Medicare         c.  diabetes type 2 for many commercial insurances         d.  Insulin use

  46. Competence Questions: Single Best Answer 2.  Name 3 new diabetes therapies in the last few years         a. Exenetide, bromocriptine, glimepiride         b. Bromocriptine, linagliptin, saxagliptin         c. Carbohydrate counting, continuous glucose monitoring, insulin pumps

  47. Competence Questions -True Statements 3.  Continuous glucose monitoring can be used         a. only with a pump         b. only with multidose injection insulin therapy         c. must be used daily d. can cost about $35 per week on-going costs

  48. Take Home Goals Think like a pancreas Give enough insulin Get and give loads of education Call the 800 number on the back of any technology

  49. THANK YOU! • oatess@iuhealth.org

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