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Diabetes and Technology: Insulin Delivery and Monitoring. Amy Urbanus, RD, CDE Diabetes Specialist Providence Alaska Medical center. Home Glucose Monitoring. Home Glucose Monitoring. Continues to be one of the best tools for diabetes self-management .

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diabetes and technology insulin delivery and monitoring

Diabetes and Technology:Insulin Delivery and Monitoring

Amy Urbanus, RD, CDE

Diabetes Specialist

Providence Alaska Medical center

home glucose monitoring3
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”

things to consider
Things to Consider
  • Cost/Insurance Strips
  • Accuracy
  • Dexterity of patient
  • Alternate site testing
  • Lancing devices
lifescan one touch
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
accu chek
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
freestyle
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
other meters
“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
lancing devices
Lancing Devices
  • Most meters use similar lancing device
  • “Multiclix” by Accu-Chek
    • Drum of needles
    • Sold as not being as painful
    • Can purchase separately
insulin delivery

Insulin Delivery

Pens, syringe or pump?

insulin pens the new trend in hospitals
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
types of insulin pens
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
pros cons to insulin pens
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
supplies cost insulin pens
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
hospital issues and insulin pens
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

benefits of insulin pump therapy
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
first things first assess appropriate patients
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
assessment cont
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
insulin pump comparison most common in alaska
Insulin Pump ComparisonMost Common in Alaska
  • Medtronic Minimed Paradigm 522/722
  • Animas One Touch Ping
  • OmniPod
minimed paradigm 522 722
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”
minimed paradigm cont
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
omnipod
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
one touch ping
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
how much self pay costs
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”
don t forget the insulin and test strips
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
insurance
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
basic concept 3 parts
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
slide30

Abbott Navigator

MiniMed Real Time

Dexcom Seven Plus

who could benefit
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

standard features
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
cgm standard features cont
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
insurance cost
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
slide35

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