Clinical Strategies for Type 1 Diabetes: Pumps, Multiple ... · Pre-diabetes Diabetes Time = months...

1Clinical Strategies for Type 1

Clinical Strategies for Type 1 Diabetes: Pumps, Multiple Daily

Injection Regimens AmylinInjection Regimens, Amylin Analogs and Continuous

Glucose Monitoring

Jeremy Pettus, MDEndocrinologist

Assistant Professor of MedicineUniversity of California, San Diego

Diabetes in the

Pre-Insulin EraEra


Risk Of Developing Type 1 Diabetes

General Population 0.3%

Sibling 4%

Mother 2 – 3%

Father 6 – 8%

Identical Twins ~50%

Edelman SV. Taking control of your diabetes: a patient oriented book on diabetes. Fourth Edition Professional Communications Inc., Greenwich, CT. 544 pages, 2013.

Natural History and Cause of Type 1 Diabetes

Autoimmune condition100% Insulin making cells

Putative Trigger

Immune System Dysfunctionof the pancreas

Immune System Dysfunction

Circulating Auto Antibodies (ICA, GAD)

Symptoms

Genetic predisposition

Damage to the cells of the pancreas

Pre-diabetes Diabetes

Time = months to a few yearsPettus J, Edelman SV. (2013) Adjunctive Therapies. In The American Diabetes Association/JDRF Type 1 Diabetes Sourcebook (319-340). VA: American Diabetes Association


Type 1 Diabetes: Important Treatment Themes

1 In addition to getting the A1c below 7% try1. In addition to getting the A1c below 7%, try to reduce the daily glucose fluctuations in your patients (hyper- and hypoglycemia)

2. The insulin regimen should mimic what happens in a non-diabetic state

3 Look out for other autoimmune conditions3. Look out for other autoimmune conditions (low thyroid levels, celiac)


Physiologic Insulin, Glucagon and Amylin Secretion

Systemic Circulation

LiverPancreas

InsulinPortal Vein

InsulinAmylin

Glucagon

Beta Cell

Alpha CellPettus J, Edelman SV. (2013) Adjunctive Therapies. In The American Diabetes

Association/JDRF Type 1 Diabetes Sourcebook (319-340). VA: American Diabetes Association


Physiologic Insulin Secretion and Glucose Levels In Healthy Subjects

50

Bolus Insulin (40 to 60% of TTD)

Insulin(µU/mL)

Glucose150

100

50

25

0 Basal Insulin: HGO(40 to 60% of TDD)

Breakfast Lunch Dinner

Glucose(mg/dL) 50

07 8 9 10 11 12 1 2 3 4 5 6 7 8 9A.M. P.M.

Basal Glucose

Time of Day

Edelman SV, Henry RR. Diagnosis and management of type 2 diabetes. 12th Edition. Professional Communications, Inc., Greenwich, CT. 288 pages, 2014.

Basal/Bolus Treatment Program With Rapid and Long-Acting Analogs Glulisine

OrInsulin AspartBreakfast Lunch Dinner

Insu

lin A

ctio

n

Insulin AspartOr

Insulin LisproOr

Inhaled InsulinU-100/300

Glargine/Levemir

4:004:00 16:0016:00 20:00 20:00 24:0024:00 4:004:00 8:008:0012:0012:008:008:00TimeTime

Glargine/Levemir

Adapted with permission from Leahy J. In: Leahy J, Cefalu W, eds. Insulin Therapy. New York: Marcel Dekker; 2002:87-112. Nathan DM. N Engl J Med 2002;347:1342-1349.


d k h l h

Lilly Pens: Memoir & Kwikpen

Convenient

Discreet

NovoNordisk: NovoPen Echo & FlexTouch

f l Protects insulin from light, heat and agitation

Sanofi-Aventis: SoloStar

First InsulinInsulin Pump

1964


2nd Generation Insulin PumpsInsulin Pumps

in the early 70s

Animas VibeT d T Sli

Insulin Pump Options

Tandem T-SlimAsante SnapMedtronic 530GOmniPod



Body

Traditional Insulin Pump Components

Body Insulin reservoir Tubing Insertion catheter

Battery compartment


Infusion sites need to be

Infusion Sites

need to be changed every two to three days

Quick release catheters

Auto inserters



Improved glycemic control◦ More precise, physiologic insulin delivery◦ Greater ability to handle dawn phenomenon, stress

and other conditions that alter insulin requirements

Insulin Pumps: Advantages

q◦ “Smart features” help to estimate insulin doses and

reduce errors, i.e. stacking insulin In some situations (but not all), freedom and

flexibility in lifestyle◦ Eliminate multiple daily injections (1 stick every 3

days). Very easy to respond to CGM results.days). Very easy to respond to CGM results.◦ Reduce restrictions on eating, exercise and sleeping

patterns: could have the same benefits with MDI◦ Greater flexibility with sports, travel, work schedule

and other activities (not with water sports)Edelman, Taking Control Of Your Diabetes 4th edition. 2013 and Walsh JA, Roberts R. Pumping Insulin 5th edition. 2011.

Bolus Options With Pump Therapy

Standard Square Wave

Dual Wave

InsulinTime

1. Standard: quickly absorbed foods2. Square Wave: gastroparesis, fatty meals, Pramlintide (symlin)3. Dual Wave: combination of rapid and slowly absorbed meals



Variable Basal Rate Capability(Total daily basal dose/24)-(10 to 20%)

Breakfast Lunch Dinnern

Basal infusion

Bolus Bolus Dual Wave Bolus

1

Plas

ma

insu

lin

3

4:004:00 16:0016:00 20:00 20:00 24:0024:00 4:004:00 8:008:0012:0012:008:008:00

TimeTime

Basal infusion

2Edelman SV. Taking control of your diabetes: a patient oriented book on diabetes. Fourth Edition ProfessionalCommunications Inc., Greenwich, CT. 544 pages, 2013.

Which patient below is NOT a good pump candidate?

A A pediatric ICU doctor with type 1 who works a 12 A p yphour graveyard shift (6pm to 6am) 10 days a month

B A US postal worker with type 1 who delivers mail primarily by foot

C A woman with type 1 who is 20 weeks pregnant with poor controlwith poor control

D An obese 68 year old male with type 2 diabetes currently on multiple daily injections


Determine the Correct Bolus Dosing (you should already have this part done on MDI)

Use what the patient was doing on MDI therapy (easiest way to start)

Carbohydrate counting (Insulin to CHO ratio) is helpful but not 100% necessary: Insulin to carbohydrate ratio: I:CHOU f ti f t i t t l Use of a correction factor is a great tool: Correction factor (CF) also called the insulin sensitivity factor (ISF)


Start with a ratio of 1:15 for insulin sensitive type 1 diabetics

Insulin to Carbohydrate Ratio Calculation: I:CHO

diabetics Start with a ratio of 1:10 for insulin resistant type 2

diabetics Formula: divide Total daily insulin dose into 500 Example: 34 year old male with type 1 diabetes

currently on 25 units of glargine (Lantus) every night and 20 to 25 units of insulin aspart (NovoLog)night and 20 to 25 units of insulin aspart (NovoLog)each day: 500/50=10 So the initial Insulin to carb ratio is 1:10

Walsh JA, Roberts R. Pumping Insulin 5th edition. 2011.


Giving your patients a correction factor is a very practical tool whether they are on a pump or not

Correction Factor (CF) or Insulin Sensitivity Factor (ISP)

The CF is an estimate of how much the BS will drop with one unit of fast acting insulinThe CF usually 1:50 for insulin sensitive (<50u) patients and 1:25 for insulin resistant patients

The CF can be estimated by taking the total daily insulin dose and dividing it into 1800 (the 1800 rule)You also need to pick a target glucose level for the patient (between 100 and 150)

Walsh JA, Roberts R. Pumping Insulin 5th edition. 2011.

Used at meal time AND for unexpected

Example of Determining the Correction Factor

Used at meal time AND for unexpected hyperglycemia in between meals

21 year old female on insulin glargine 15 units at night and taking approximately 15 –20 units a day in boluses with insulin glulisine◦ (1800/35 units = 51)~ CF 1:50


Multiple basal rates

Generic Features of Insulin Pumps

Square and dual wave bolus features Calculate a suggested bolus based on individual data input (Insulin:CHOratio and correction factor)

Insulin on-board feature (helps to Insulin on board feature (helps to avoid “stacking” insulin)

Occlusion and reservoir alarmsEdelman SV. Taking control of your diabetes: a patient oriented book on diabetes. Fourth Edition Professional Communications Inc., Greenwich, CT. 544 pages, 2013.

Ability to deliver very low basal rates (0 025 units/hour)

Advanced Features of Insulin Pumps Animas Vibe

(0.025 units/hour) for insulin sensitive patients

Easy to visualize LCD screen and very small size

Tactile bolusing/touch

Tandem T-Slim

Medtronic 530Gbolusing/touch screen

Pump acts as a billboard to display CGM results

Tubeless on body pump

Omnipod



Advanced Features of Insulin Pumps (continued)Glucose meter and pump have bidirectional communication

Animas 2020 Ping Medtronic Paradigm



Straightforward and Simple Ways to Start Insulin Pump Therapy

1. Get the patient adjusted as best as you can on a MDI1. Get the patient adjusted as best as you can on a MDI regimen with basal insulin (eg. U-100/300glargine [Lantus/Toujeo] or detemir [Levemir])2. Patient chooses a pump and the pump support people will help with insurance issues (they are good at this)

3. Determine the basal rate based on the total daily3. Determine the basal rate based on the total daily basal insulin dose (no change in boluses)

4. The pump trainer takes over and can help (0 to 100%) with the initial adjustments


74 year old female with type 1 diabetes for 10 years (LADA) on insulin glargine, 18 units qhs

Case 1: Barbara

g g , q Bolus dosing based on

carbohydrates (1 unit: 15 grams) Correction factor (1:50) with a

goal of 125mg/dL Last 3 A1c values between 7.5-

8.0% She has excessive fluctuations

with exercise She is very active and requested

an insulin pump


Her initial basal rate was calculated as 18 units (minus 10% because her A1c was

Case 1: Barbara (continued)

over 7.5%) divided by 24 = 0.675 u/hr No change with her bolus doses for now She wanted a pump without tubing Once the patient received the pump and

supplies in the mail a trainer got her upsupplies in the mail, a trainer got her up and running

What adjustment would you suggest for Barbara?

B L D HS ~3 amDay 1 227 121 143 164 142

A Increase the insulin to carbohydrate ratio at dinner time

Day 1 227 121 143 164 142Day 2 203 152 144 144 161

Day 3 198 124 132 135 133

Day 4 188

A Increase the insulin to carbohydrate ratio at dinner time

B Increase the correction factor at breakfast time

C Increase the basal rate by 20% starting at 10pm to 7am

D Increase the basal rate by 20% starting at 3am to 7am


56 year old male with type 2 diabetes for 21 years on insulin detemir 38 units qhs

Case 2: David

detemir 38 units qhs Bolus given as 10 units with each

meal and then he uses a correction dose if he is high (1:25) with a goal of 150mg/dL.

A1c has not been below 8.5%. He is tired of the multiple injections He is tired of the multiple injections

and travels frequently for his job. Centrally obese with a BMI of 30 Also treated for hypertension,

dyslipidemia

His initial basal rate was calculated as 38 units divided by 24 = 1.58 u/hr

No change with his bolus doses but was given

Case 2: David (continued)

No change with his bolus doses but was given some information on carbohydrate counting

He wanted a pump that held 300 units since his he did not want to change his syringe and tubing more than every three days

His HCP was sent Letter of Medical Necessity His HCP was sent Letter of Medical Necessity by the pump company and a pump trainer got him up and running.


What adjustment would you suggest for David?

B L D HSD 1 137 135 223 143

A Increase the pre-meal dose of fast acting insulin from 10 to 15 units before breakfast, lunch and dinner

Day 1 137 135 223 143Day 2 123 142 191 124Day 3 118 128 186 117Day 4 195 121 211

B Increase the pre-meal dose of fast acting insulin from 10 to 15 units before breakfast only

C Increase the basal rate by 20% during the day between lunch and dinner (12 noon to 6pm)

D Increase the pre-meal dose of fast acting insulin from 10 to 15 units before lunch only

A disruption in short acting insulin delivery due to a dislodged catheter, blockage, or an empty reservoir can result in a fairly rapid rise in glucose concentration

Disadvantages of Pump Therapy

rapid rise in glucose concentration◦ Severe hyperglycemia◦ Ketoacidosis

Cost of the insulin pumps◦ Pump costs approximately $3,500 to $5,000 (pay as you go

with the Omnipod)◦ Monthly cost of $30 to $40 due to batteries, infusion lines,

i d dh i tsyringes, and adhesive tape Minor skin irritation or infections at the insulin pump catheter

insertion site Very occasional abscess



T h l h k

Continuous Glucose Monitoring (CGM)

Technology that can take some of the unpredictability and frustration out of diabetes management

400

Excessive Glucose Fluctuations

Mean A1C=6.7%

9 People with Type 1 Diabetes on BLINDED CGM

400

100

200

300Glucose

Concentration (mg/dL)

12:00 AM

4:00 AM

8:00 AM

12:00 PM

4:00 PM

8:00 PM

12:00 AM

0

24-hour CGMS glucose sensor data Type 1 diabetes (N=9)

40

Impact on Pramlintide on Glucose Fluctuations and PostPrandial Glucose, Glucagon, and Triglyceride Excursions Among Patients with Type 1 Diabetes Intensively Treatedwith Insulin Pumps, Levetans et al., Diabetes, 2003, American Diabetes Association diabetesjournals.org http://care.diabetesjournals.org/content/26/1/1.short


Medtronic 530G with Enlite sensor

Dexcom G4 Platinum

N=322 with baseline A1c > 7% A significant drop in A1c @ 6 months occurred for those who

averaged > 6 days/week CGM use (p<0.001 in each age group) Also observed was a significant reduction in hypoglycemia

JDRF: Predictive Factors of CGM

Also observed was a significant reduction in hypoglycemia

0 6

-0.4

-0.2

0.0

0.2

e in

A1c

(%

)

<4 d/weekChange in A1c %

0.2

0.0

-0.2

0 4

8-14 years15-24 years

< 25 years

The Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Study Group. Continuous glucose monitoring and intensive treatment of type 1 diabetes. N Engl J Med; 359;1464-1476 2008.

-0.8

-0.6

Ch

ang

<4.0 days/week 4.0-<6.0 days/week ≥6.0 days/week

4-6 d/week6-7 d/week

in A1c % -0.4

-0.6

-0.8


Constant: Your glucose is steady (not increasing/decreasing more than 1 mg/dLeach minute)

No change in calculation

Slowly rising: Your glucose is rising 1-2 30 to 50% higher

How CGM and Trending Information Can Affect Our Decisions (CF/I:CHO)

Slowly rising: Your glucose is rising 1 2 mg/dL each minute

30 to 50% higher

Rising: Your glucose is rising 2-3 mg/dLeach minute

50 to 150% higher

Rapidly Rising: Your glucose is rising more than 3mg/dL each minute

100 to 200% higher

Slowly Falling: Your glucose is falling 1-2 mg/dL each minute VariablesFalling: Your glucose is falling 2 3 mg/dL BS Level

Meal Type/SizeExercise Duration

& Intensity

Falling: Your glucose is falling 2-3 mg/dLeach minuteRapidly Falling: Your glucose is falling more than 3 mg/dL each minute

No Arrow

No Rate of Change Information: The receivercannot always calculate how fast your glucose is rising or falling

Herrmann K, Frias JP, Edelman SV, Lutz K, Shan K, Chen S, Maggs D, Kolterman OG. Pramlintide improved measures of glycemic control and body weight in patients with type 1 diabetes mellitus undergoing continuous subcutaneous insulin infusion therapy. Postgraduate Medicine. 123(3), 2013.


35 year old male with type 1 diabetes for 20 years CHO to insulin ratio 10:1 CF 1:30 gosl 120 mg/dl

Case 3: Jeremy

Post “Snack” BS of 220mg/dL at 4:00 p.m. (snack at 3:30 p.m., no insulin given with snack)

Jeremy’s CGM Guidelines◦ Correction factor 1:30

Case 3: Jeremy (continued)

◦ Correction factor 1:30◦ Target glucose 120 mg/dL◦ 220-120/30 = 3.3 units

N t A bl d f 220 d tNote: A blood sugar of 220 does not lead to any symptoms


Which option below is the best suggestion for Jeremy to follow at 4:00 pm?

A Watch and wait (give no additional insulin)B Walk for an hour at a brisk paceC Give a correction dose of 3.3 unitsD Give a correction dose greater than 3.3 units

Change in mean Insulin Dose Based on 2 ARROWS UP: Survey of 300 CGM users

3.2 units 7.2 units7.2 units

J. Pettus, D.A. Price, K.J. Hill, S. Edelman (2014), Diabetes Technology & Therapeutics. February 2014, 16(S1): A-76 page 198

Need to confirm BS value with a glucose meter before giving insulin


How CGM and Trending Information Can Affect Dosing Decisions

3.2 units

140% Mean Increase

7.2 units

48% Mean Decrease1.5 units

J. Pettus, D.A. Price, K.J. Hill, S. Edelman (2014), Diabetes Technology & Therapeutics. February 2014, 16(S1): A-76 page 198

Robyn is a 24 year old type 1 diabetic for 5 years on insulin glargine

She eats pizza at 12:00 MN and takes 5 units of fast acting insulin

Case 4: Robyn

Her high glucose alert goes off at 2:15am and her BS is275mg/dl.

Her CF is 1:40 with a goal of 120mg/dLRobyn gave a correction bolus of 325-120/40= 5.1 units


Robyn looks at her Dexcom (CGM) at 3am and her BS was now over 350mg/dl and she gave herself another “Rage Bolus” 5.0 units.

At 8:00 am she had a hypoglycemic reaction and needed

Case 4: Robyn

yp g yto ingest glucose tabs

First bolus 12 Midnight: 5 units for pizza Second bolus 2:15 a.m.: 5 unit correction

“Stacking The Dose”

dose Third bolus 3:00 a.m.: 5 more units


No safety concerns as more information is better than no

Concerns To Address With CGM

information is better than no information

Alarm fatigueAlert high and low settingsHigh and low snooze alarmsHigh and low snooze alarms Take advantage of the Share system

Stacking

Wait at least 90 minutes before a second dose We need a faster on/off insulin (technosphere

An Object in Motion Stays in Motion: Turnaround Time

/ ( p[Afrezza])

SubQinsulin isinsulin is not physiologic


Inhaled Insulin, Afrezza

Pk h hPk

Pd

Technosphere/Inhaled Insulin

(Afrezza)VS

Rapid ActingAnaloguePd

Santos Cavaiola T, Edelman SV. Inhaled insulin: A breath of fresh air? A review of inhaled insulin. Clinical Therapeutics. 2014. 36(8)

(Insulin Human) Inhalation Powder Black Box Warning

(Spirometry at baseline, 6 months, then yearly)

WARNING: RISK OF ACUTE BRONCHOSPASM IN S C O C G S SPATIENTS WITH CHRONIC LUNG DISEASE

• Acute bronchospasm has been observed in patients with asthma and COPD using Afrezza

• Afrezza is contraindicated in patients with chronic lung disease such as asthma or COPDlung disease such as asthma or COPD

• Before initiating Afrezza, perform a detailed medical history, physical examination, and spirometry (FEV1) to identify potential lung disease in all patients

Afrezza full prescribing information: http://www.accessdata.fda.gov/drugsatfda_docs/label/2014/022472lbl.pdf


Who would benefit the most from a CGM device?

A A person with type 2 diabetes and hypoglycemia unawarenesshypoglycemia unawareness

B A person with type 1 diabetes (A1C 6.9%) and with widely fluctuating and unpredictable glucose values

C A person with type 2 diabetes on orals and basal insulin at night

D A two year old child with type 1 diabetes

E A, B and D

Total daily basal and bolus doses Ins to carb ratio

Important Questions To Ask

s to ca b at o Correction factor (Insulin sensitivity ratio) If on a pump….do you disconnect and for

how long, basal rates, how often do you change out your infusion sets, and do you use the square wave or dual bolus features

CGM issues: check upper and lower alert limits as well as checking the snooze alarm


Snooze Alert: very important

Statistical Summary• Glucose exposure (mean and eA1C) • Variability (SD & IQR)• % in target, above and below

Ambulatory Glucose Profile (AGP)

Visual Display• Modal day (14 if possible)• 5 glucose curves

Median (orange line),25th & 75th % (solid lines)10th a& 90th %(dotted lines)

75th

25th

10th

90th

50th

Daily View• Thumbnail view - Calendar format

Work vs. non-workWeekend vs. weekday

• Target range

10th

Diabetes Technology and TherapeuticsVol 15:2 2013


AGP Statistics

Bergenstal, et. al, Diabetes Technology and TherapeuticsVol. 15:2 2013

What is Normal?

32 subjects with32 subjects with normal glucose

metabolism

(confirmed by OGTT and HOMA) monitored for 30

days.

Bergenstal, et. al, DiabetesTechnology and Therapeutics Vol. 15:2 2013


AGP Uncontrolled Type 1 Diabetes

Bergenstal, et. al, Diabetes Technology and Therapeutics Vol. 15:2 2013

Identifying Glycemic Trouble SpotsAmbulatory Glucose Profile (AGP)

Where am2

75th

25th

10th

90th

50th

1

Where am I high?

2

Where is there3Where am I Low?

Where is there a lot of variability?

3

Bergenstal, et. al, Diabetes Technology and Therapeutics Vol. 15:2 2013


Physiologic Insulin and Amylin Secretion After Meals

l

Meal Meal Meal

Amylin

Insulin

Plasma insulin (pM)

Plasma amylin(pM)

30

25

20

15

600

400

20010

5

7 am Midnight5 pm12 noon

Time

200

0

Koda et al, Diabetes. 1995; 44 (s1): 23BA.Weyer et al. Curr Pharm Des. 2001;7:1353-1373

Regulation of Blood Glucose Levels After Meals By Amylin (Symlin) Reduces the appetite

and leads to weight lossloss

The reduced

Suppression of glucagon levels from the alpha cells of the pancreas

Amylin is co-released with insulin after

ingestion of food

Stomach motility is normalized

glucagon levels help to control excessive glucose production by the liver

Edelman SV, Henry RR. Diagnosis and management of type 2 diabetes. Eleventh Edition. Professional Communications, Inc., Greenwich, CT. 288 pages, 2011.


Pramlintide Reduces FBG, PPG and Glucose Fluctuations

220

140

160

180

200

Glu

cose

(m

g/dL

)

*

*

*

*

** *

insulin alone

insulin plus pramlitide120

pre-bf post-bf pre-lu post-lu pre-di post-di bedtime

Clinical Practice Study, 120 g SYMLINbf, breakfast; lu, lunch; di, dinnerN=166; *p-values for all data points <0.05Data on file, Amylin Pharmaceuticals, Inc.

* insulin plus pramlitide

Edelman, S, Lush, C, Kesty, N, Burns, C, Weyer, C, Frias, J. Progressive Reduction in Body Weight with Pramlintide Therapy in Obese Subjects with Type 2 Diabetes Treated with Diet and Exercise and/or Metformin. Diabetes. 56 (Suppl 1):1826-P.

4.0

5.0

Pramlintide + Insulin: Effect on Sustained Weight Loss

Insulin alone: weight gain

-3.0

-2.0

-1.0

0.0

1.0

2.0

3.0

Weightchange

(lbs)insulin plus pramlintide: weight loss

* **

**

-5.0

-4.0

0 13 26 39 52

Week

Edelman, S, Lush, C, Kesty, N, Burns, C, Weyer, C, Frias, J. Progressive Reduction in Body Weight with PramlintideTherapy in Obese Subjects with Type 2 Diabetes Treated with Diet and Exercise and/or Metformin. Diabetes. 56 (Suppl1):1826-P.

P<0.001 Between Groups


Practical Clinical and Safety Tips for Patients Initiating Pramlintide in Type 1 and Type 2 Diabetes

Start with a low dose and titrate slowly to avoid nausea, which is the only side effect directly related towhich is the only side effect directly related to pramlintide

Take pramlintide with the main part of the meal Decrease the amount of fast-acting insulin by 30% to

50% when initiating pramlintide to avoid an insulin induced hypoglycemic reaction.

Use the extended bolus if on pump therapy Use the extended bolus if on pump therapy Be prepared to go through some interesting

psychological changes with regard to eating when initiating pramlintide

Edelman, Steven, Hirsch, Irl, Pettus, Jeremy; Practical Management of Type 1 Diabetes Second Edition, Professional Communications, Inc; 2014 Chapter 12 Pages 239-264

Physiologic insulin delivery: MDI or h

Components of a Complete Therapeutic Regimen

pump therapy Amylin replacement with pramlintide(Symlin) if appropriate

Home and continuous glucose monitoring (HGM and CGM)monitoring (HGM and CGM)

Self management: education, carb counting, correction factor, sick day rules, ect.

Edelman SV, Henry RR. Diagnosis and management of type 2 diabetes. 12th

Edition. Professional Communications, Inc., Greenwich, CT. 288 pages, 2014.


Diagnosis and Treatment Of Type 1 Diabetes by Steven Edelman, Irl Hirsch and Jeremy Pettus , Professional Communications www.pcibooks.com

Additional Information

Edelman SV. Taking control of your diabetes: a patient oriented book on diabetes. Fourth Edition Professional Communications Inc., Greenwich, CT. 544 pages, 2013.◦ Physiologic insulin delivery: Chapter 8*◦ Pump therapy: Chapter 9*

C i l i i Ch 12*◦ Continuous glucose monitoring: Chapter 12*◦ Home glucose monitoring: Chapter 10*◦ Carbohydrate counting: Chapter 5*◦ Pramlilntide (Symlin) Chapter 8*

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Clinical Strategies for Type 1 Diabetes: Pumps, Multiple ... · Pre-diabetes Diabetes Time = months...

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