Sarrah Morris BScN, RN, MBA Medtronic Diabetes Canada sarrah.morris@medtronic.com 1.

transcript

Back to the Future!Sarrah Morris BScN, RN, MBA

Medtronic Diabetes Canadasarrah.morris@medtronic.com

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

Excited to be here….

Growing up in a T1D household

“Thank you Caregiver!”

Today is about YOU and your FAMILY!

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

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

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

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

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

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

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

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

Cannula

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. _____ _________

0.5u0.5u

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

Insulin pumps can reduce some of the burden…

Insulin Pump Settings

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

Advantages of today’s smart pumps

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

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.

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

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

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!

Thank you

Sarrah Morris BScN, RN, MBA Medtronic Diabetes Canada sarrah.morris@medtronic.com 1.

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