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Exercise, Pumps & Continuous Monitors. Diabetes Exercise & Sports Assoc. Colorado Springs June 29, 2007. John Walsh, P.A., C.D.E. North County Endocrine 700 West El Norte Pkwy Escondido, CA 92126 (760) 743-1431 The Diabetes Mall www diabetesnet.com

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exercise pumps continuous monitors

Exercise, Pumps & Continuous Monitors

Diabetes Exercise & Sports Assoc.

Colorado Springs June 29, 2007

John Walsh, P.A., C.D.E.

North County Endocrine

700 West El Norte Pkwy

Escondido, CA 92126

(760) 743-1431

The Diabetes Mall

www diabetesnet.com

(619) 497-0900 jwalsh@diabetesnet.com

Healthcare Across Borders - September 2003

highlights
Highlights
  • Phys Ed
  • ExCarbs
  • Pump Settings
  • DIA and BOB
  • Continuous Monitors
  • Future Devices
  • Wrap Up

Healthcare Across Borders - September 2003

polar heart monitor
Polar Heart Monitor
  • Devices like the Polar Heart Monitor provide invaluable information about cardiac function during exercise

Optimum cardiac function

Healthcare Across Borders - September 2003

glucose monitor
Glucose Monitor
  • Devices like BG meters and continuous monitors provide invaluable information about energy flow during exercise

BGs for optimum energy flow

Healthcare Across Borders - September 2003

insulin pump
Insulin Pump
  • Once BG data is available, precise insulin adjustments can be made with a pump to optimize fuel flow during exercise

BGs for Optimum energy flow

Healthcare Across Borders - September 2003

your insulin controls access to fuel
Result:

Entry to cells

Glucose release

Fat release

Your Insulin Controls Access To Fuel
  • When INSULIN is LOW
  • More stored glucose and fat is released into blood, but
  • Less glucose enters muscle cells from blood

BG

Tiredness, lack of energy

Healthcare Across Borders - September 2003

your insulin controls access to fuel1
Result:

Entry to cells

Glucose release

Fat release

Your Insulin Controls Access To Fuel
  • When INSULIN is High
  • Less stored glucose and fat is released into blood, but
  • More glucose enters muscle cells from blood

BG

Tiredness, lack of energy

Healthcare Across Borders - September 2003

your insulin controls access to fuel2
Result:

Entry to cells

Glucose release

Fat release

Your Insulin Controls Access To Fuel
  • When INSULIN is Optimum
  • Right amounts of stored glucose and fat are released
  • And glucose entry into muscle cells is appropriate

BG

Energy and performance

Healthcare Across Borders - September 2003

when your insulin levels need to change
When Your Insulin Levels Need To Change
          • The LONGER you exercise,
          • The MORE INTENSE you exercise, and
          • The LESS TRAINED you are,
  • The MORE you need to lower your insulin

Healthcare Across Borders - September 2003

what s the right starting glucose for exercise
What’s The Right Starting Glucose For Exercise?
  • The glucose you have at the time
    • Beyond that
      • < 70 glucose, Gatorade, or other fast carbs
      • 70-100 carbs
      • > 100 ? Powerbar
      • > 180 ? insulin
      • > 300 Insulin, check ketones
    • Some competitive and anaerobic sports may require insulin, no matter the starting glucose

BOB plusBG trend from cont monitor gives critical info

Healthcare Across Borders - September 2003

slide11

Fuel Type Shifts As Intensity Rises

(work, HR, or intensity)

Healthcare Across Borders - September 2003

intensity affects fuel preference
Intensity Affects Fuel Preference

Glucose Portion

As intensity rises, so too does the percentage of glucose required for exercise

Healthcare Across Borders - September 2003

muscle glycogen as glucose shock absorber
Muscle Glycogen As Glucose Shock-Absorber
  • More muscle glycogen (training) means:
    • Larger glucose stores can minimize a fall in BG during exercise
    • After large meals, more glucose is absorbed to minimize rise in BG

During exercise, stored glucose is removed from blood and glycogen.

After exercise, glucose stores must be rebuilt by removal of glucose from the blood over several hours.

Healthcare Across Borders - September 2003

excarbs
ExCarbs

Healthcare Across Borders - September 2003

how many calories you need is known
How Many Calories You Need Is Known
  • The number of calories you burn during exercise was determined decades ago.
  • To get calories, you only need to know:
    • Your weight
    • Type of exercise and intensity, such as running at 8 mph
    • How long you will exercise

Healthcare Across Borders - September 2003

exercise calories can be converted to excarbs
Exercise Calories Can Be Converted To ExCarbs
  • To determine ExCarbs, how many carbs you need for exercise, you need to know:
    • What percentage of your calories come from carbs (more intense = higher carb %)
    • And that your insulin level is appropriate

Healthcare Across Borders - September 2003

are your basals and boluses appropriate
Are Your Basals And Boluses Appropriate?
  • Is your A1c between 6% and 7%?
  • Is your meter average between 120 and 150?
  • Do you have frequent lows?
  • Does your BG go below 50?

Healthcare Across Borders - September 2003

once known excarbs can be
Once Known, ExCarbs Can Be:
  • Eaten as carbs
  • Used to lower a high BG *
  • Used to lower boluses or basal rates *
    • * If your carb and correction factors are accurate

© Pumping Insulin, 2006

Healthcare Across Borders - September 2003

excarbs the carbs you need for exercise
ExCarbs – The Carbs You Need For Exercise
  • Carla weighs 150 lbs. and will need 68 grams of carb for her 1 hour run at 5 mph

© Pumping Insulin, 2006

Healthcare Across Borders - September 2003

excarbs conversions
ExCarbs Conversions
  • Carla’s 68 grams of ExCarbs:
    • can be eaten as free carbs
    • can be converted into insulin to reduce carb boluses orbasal rates
      • 68 gr / 14 gr per u (Carla’s carb factor) = 4.9 units
    • or used to lower a high blood sugar
      • 1 u for each 65 mg/dl above 100 mg/dl (Carla’s corr factor)

© Pumping Insulin, 2006

Healthcare Across Borders - September 2003

translate intensity duration into extra carbs or bolus or basal reduction
Translate Intensity & Duration Into Extra Carbs Or Bolus Or Basal Reduction
  • Table 23.9 translates exercises with different intensity and duration into combinations of likely carb intakes and bolus or basal reductions

Carla’s run after breakfast was between moderate – so she lowered her breakfast bolus by 30%, ate an extra 12 grams of free carb before her run and 26 grams afterward

© Pumping Insulin, 2006

Healthcare Across Borders - September 2003

exfactors
ExFactors
  • Enter into pump:
    • Exercise intensity (1-7 scale)
    • Exercise duration (15-480 min)
    • Current level of fitness for that activity (1-5 scale)
  • Given this info, pump can calculate carb intake and insulin reduction you need for this activity, while accounting for any BOB

Future Pump Feature

Healthcare Across Borders - September 2003

bolus reduction
Bolus Reduction
  • Reduce bolus before short, planned exercise and during any long exercise
  • Ideal for exercise lasting less than 60 to 90 minutes and which takes place shortly after a meal
  • For premeal exercise, consider some extra carbs with a bolus reduction in the meal that follows

Healthcare Across Borders - September 2003

temporary basal reduction
Temporary Basal Reduction
  • Short, large basal reductions can be used right before short activities
    • 80% reduction for 30 min
    • or 60% for 1 hr
  • Smaller reductions for exercise lasting longer than 90 min
    • Max reduction usually 50%
    • Reduce basal an hour or so before activity starts
  • After long exercises, glucose may fall for 12 to 36 hrs
    • Temp basal reduction may be needed AFTER activity
    • More glucose needed during this time to rebuild glycogen stores

basal

basal

Healthcare Across Borders - September 2003

disconnect bolus
Disconnect Bolus
  • Disconnect for up to 2 hours for sports, sauna, etc.
  • User estimates time off pump
  • Pump offers to give up to 50% of missed basal as disconnect bolus
  • Alarm reminds user to re-connect at set time
  • On reconnecting, pump determines basal missed and offers to supply the missing basal amount

Current Feature

Healthcare Across Borders - September 2003

pump settings for improved control

Pump Settings For Improved Control

Healthcare Across Borders - September 2003

when major control problems occur adjust your tdd
When Major Control Problems Occur, Adjust Your TDD
  • Raise your TDD:
    • With a high A1c or a high average BG on your meter
  • Lower your TDD
    • For frequent lows
    • If both highs AND lows occur – which comes first?
  • Keep basals and carb boluses balanced as you adjust your TDD

TDDtoo low

or too high?

Healthcare Across Borders - September 2003

slide28

Adjust The TDD For A High Avg. BG or A1cExample: someone with a TDD of 35 units and few lows. A1c = 9%, so more insulin is needed: about 3.2 units.

© Pumping Insulin, 2006

Healthcare Across Borders - September 2003

slide29

Basal Tips

  • 50% Rule: basals usually make up 40 to 65% of an accurate TDD
  • Basal rates will be similar through the day, such as between 0.45 and 0.7, or between 1.0 and 1.4
  • Adjust basal rate in small steps – 0.05 to 0.1 u/hr
  • Change basals 3 to 8 hours before need arises

Healthcare Across Borders - September 2003

check your carb boluses
Check Your Carb Boluses
  • Does your carb factor work for large carb meals (over 80 grams)?
  • Are you counting carbs accurately?
  • Do you bolus at least 20 min before meals with a normal glucose?

Healthcare Across Borders - September 2003

most carbs much faster than rapid insulin
Most Carbs Much Faster Than “Rapid” Insulin

One hour after a meal, half of a meal’s glucose rise has occurred, but 80% of rapid insulin activity remains

Time over which most meals affect the BG

% bolus activity remaining

Take Home: Bolus 15 to 30 minutes before meals Use extended and boluses sparingly.

From Pumping Insulin

Healthcare Across Borders - September 2003

timing is everything
Timing Is Everything
  • Figure shows rapid insulin injected 0 min, 30 min, and 60 minutes before a meal
  • Normal glucose and insulin profiles are shown in the shaded areas

Healthcare Across Borders - September 2003

therapy effectiveness scorecard
Therapy Effectiveness Scorecard
  • Screen 1 :
    • Average BG
    • BG tests per day
    • BG standard deviation
  • Screen 2:
    • Carbs per day
    • TDD
      • % of TDD as correction boluses
      • % of TDD as carb boluses
      • of TDD as basal rates

Healthcare Across Borders - September 2003

exposure and variability
Exposure And Variability

One day’s BG results with usual meals and insulin. The DCCT proved that exposure to high blood glucose was damaging. New emphasis is on glucose variability.

Variability or Swing =

SD from PC or meter

Exposure or Average =

A1c or avg. BG from meter

Healthcare Across Borders - September 2003

therapy scorecard screen 1
Therapy Scorecard Screen 1

14 Day Average:

BG 146 mg/dl Tests 3.5/day Std Dev 53 mg/dl

  • Overall controlAdequate testingBG variability – aim for less than half of avg BG

Healthcare Across Borders - September 2003

therapy scorecard screen 2
Therapy Scorecard Screen 2

14 Day Average:

Carbs 206 g TDD 48.58 u Meal 38.07% Corr 4.95% Basal 56.98%

  • Boluses taken? Low carb?Guides therapy – A1c, lows, etcCarb bolus %Corrections less than 8% of TDD?Is basal at least 40-45% of TDD?

Healthcare Across Borders - September 2003

check correction bolus regularly
Check Correction Bolus % Regularly
  • When correction boluses make up over 8% of TDD
    • Raise your basal rates or carb boluses
    • Or stop skipping carb boluses
  • Move half of the excess units above 8% into basal rates or carb boluses, whichever is smaller, or into both if basals and carb boluses are balanced

Note: Paradigm pumps give correction bolus % as a % of total bolus dose, not the TDD. Do not use this percentage here!

Healthcare Across Borders - September 2003

example correction boluses over 8
Example: Correction Boluses Over 8%

10 Day Average:

Carbs 175 g TDD 54.1 u Meal 36% Corr 21% Basal 43%

  • Move 1/3 to 1/2 of the overage to basals or carb boluses:
  • 21% of 54.1 = 11.3 units, 8% of 54.1 = 4.3 units
  • 11.3 u - 4.3 u = 7 units excess
  • 1/3 to 1/2 of 7 u = 2.3 to 3.5 u to be added to basal rates or carb boluses

Over 8%

Healthcare Across Borders - September 2003

weekly schedule
Weekly Schedule
  • The user’s basal profile changes automatically for specific days of the week
  • Different basal patterns and missed meal bolus alerts for each day of the week
  • No need to remember to change basal patterns or alerts
  • Great for regular exercise, college classes, shift work, and other routine variations in schedule

Current Feature

Healthcare Across Borders - September 2003

duration of insulin action dia or how long boluses lower the blood sugar
Duration Of Insulin Action (DIA)Or how long boluses lower the blood sugar

Healthcare Across Borders - September 2003

duration of insulin action
Duration Of Insulin Action

Accurate boluses require an accurate duration of insulin action.

Glucose-lowering Activity

0

6 hrs

2 hrs

4 hrs

Current Feature

Healthcare Across Borders - September 2003

why the dia gets shorted
Why The DIA Gets Shorted
  • Pumpers and clinicians often set the DIA too short because:
  • Recommended boluses do not bring high BGs down (ie, basal rates or carb bolus are too low)
  • Shortening the DIA seems easier or safer than raising basal rates or lowering the carb factor.
  • The default DIA may be too short and never gets reset
  • A low basal rate is hiding true bolus activity

Healthcare Across Borders - September 2003

a short dia can cause problems
A Short DIA Can Cause Problems
  • A short DIA hides the true BOB and its glucose-lowering activity.
  • Hiding bolus activity makes boluses excessive and may cause basal rates to be lowered inappropriately
  • Set your DIA to your insulin’s action time.
  • Do not modify the DIA based on control problems.

Healthcare Across Borders - September 2003

recommended dia times
Recommended DIA Times
  • Set DIA to 4 hrs or more to calculate BOB and bolus doses accurately

Linear

Curvilinear

Healthcare Across Borders - September 2003

From Pumping Insulin, 4th ed., adapted fom Mudaliar et al: Diabetes Care, 22: 1501, 1999

bolus on board bob the glucose lowering activity that remains from recent boluses
Bolus On Board (BOB)The glucose-lowering activity that remains from recent boluses

An accurate BOB calculation

      • Prevents insulin stacking
      • Improves bolus accuracy
      • Reveals current carb or insulin deficit
  • Your BOB can be determined only after a BG has been entered into pump!

aka: insulin on board, active insulin, unused insulin*

* Introduced as Unused Insulin in 1st ed of Pumping Insulin (1989)

Healthcare Across Borders - September 2003

blind bolusing also hides bob
Blind Bolusing Also Hides BOB
  • Only 32.5% of 204,005 boluses from over 500 Cozmo pumps used across the US were accompanied by a BG value.
  • 2/3 of boluses are given without a BG test
  • Only 1 of every 7 boluses had both carbs and a BG

67.5% blind boluses

Data in preparation for publication

Healthcare Across Borders - September 2003

bob prevents insulin stacking
BOB Prevents Insulin Stacking
  • With a bedtime BG of 173, is there an insulin deficit or a carb deficit?

Insulin stacking is common for anyone who gives frequent boluses!

Bedtime BG

= 173 mg/dl

Correction

Dessert

Dinner

6 pm

8 pm

10 pm

12 am

Healthcare Across Borders - September 2003

hypo manager for each bg pump can show whether an insulin or a carb deficit exists
1

BG = 173 mg/dl (9.6 mmol)

Bolus on board = 0.4 u

Correction bolus: 1.2 u

Insulin deficit = - 0.8 u

Give 0.8 u now? Y or N

2

BG = 173 mg/dl (9.6 mmol)

Bolus on board = 4.6 u

Correction bolus: 1.2 u

Insulin excess = 3.4 u

You may need: 37 grams of carb later to prevent a low BG

Hypo ManagerFor each BG, pump can show whether an insulin or a carb deficit exists

Only after a BG has been entered can a pump determine whether carbs or insulin are needed

Helps prevent & treat hypoglycemia and avoid over-treatment

Current Feature

Healthcare Across Borders - September 2003

warning most pumps do not subtract bob from carb boluses
Warning: Most Pumps Do Not Subtract BOB From Carb Boluses
  • Excess BOB is subtracted from correction bolus, but NOT carb bolus
  • 3 u
  • + 1 u
      • – 3 u
  • = 1 u bolus

3.0U

45 gr

160 3.0U 1.0U3.0U

Whenever BOB is greater than correction need, recommended boluses may be excessive for Paradigm, Omnipod, Animas (for BG above target), and Cozmo (if defaults are not changed)

Healthcare Across Borders - September 2003

recommended boluses differ between pumps
Recommended Boluses Differ Between Pumps

Bolus recommendations from different pump for various BGs when BOB = 3.0 u and 30 grams of carb will be eaten

  • Carb factor = 1u / 10 gr
  • Corr. Factor = 1 u / 40 mg/dl (2.2 mmol) over 100 mg/dl (5.6 mmol)
  • Target BG = 100 mg/dl
  • TDD = ~50 u

units

BG in

mg/dl

Healthcare Across Borders - September 2003

continuous monitors
Continuous Monitors

Healthcare Across Borders - September 2003

old tools
Old Tools

Healthcare Across Borders - September 2003

continuous monitoring
Continuous Monitoring
  • Benefits
  • Lots more info
  • Alarms to prevent lows & highs
  • Security in knowing where the BG is and where it is going
  • Trends shown by graph, arrows, or predictors
  • Limitations
  • Less accuracy
  • Data gaps
  • Minimal insurance coverage in U.S.
  • Occ. cell phone, microwave, other interference

Healthcare Across Borders - September 2003

continuus monitor components
Continuus Monitor Components
  • Sensor through the skin
  • Radio transmitter on sensor
  • Display unit/controller
    • BG readings every 1-5 min
    • Trend graphs for 1, 3, 9, 24 hrs showing where BG has been and is going
    • Trend arrows
    • High and low alarms
  • Software to download & analyze data

Healthcare Across Borders - September 2003

dexcom sts
Dexcom STS
  • FDA approved 3/27/06 for 18 and older
  • Readings every 5 min.
  • 3-14 days of readings per sensor
  • One high, two low alerts
  • $475 + $60 for each 7 day sensor
  • Transmitter: ~$250 every 6 mos

Transmitter ~0.8 x 1.5”

Healthcare Across Borders - September 2003

medtronic paradigm rt
Medtronic Paradigm RT
  • FDA approved: 4/13/06, now for 7 and older
  • One high and one low alert, trend arrow
  • Readings every 5 min.
  • $1340 + $35 for each 3 day sensor
  • Transmitter: ~$900 every 6 mos

Transmitter ~1.1 x 1.4”

No closed loop

Healthcare Across Borders - September 2003

freestyle navigator
Freestyle Navigator
  • FDA approval expected soon
  • Good accuracy below 100 mg/dl
  • Calibration requires 10 hrs, then 1-2 times per day for 1st two days
  • Readings every 1-2 minutes with trend arrow (4 clicks to trend graphic)
  • 5 day use
  • High and low glucose alarms
  • Rate of change alarm
  • May be used in Deltec Cozmo and Insulet Omnipod pumps

Investigational Device.Limited by U.S. Law to Investigational Use

Healthcare Across Borders - September 2003

tru directional trend arrows

Glucose rising quickly

> 2 (mg/dL)/min

Glucose going up

1 to 2 (mg/dL)/min

Fairly stable glucose

-1 to 1 (mg/dL)/min

Glucose going down

-1 to -2 (mg/dL)/min

Glucose falling quickly

< -2 (mg/dL)/min

TRU Directional Trend Arrows

Healthcare Across Borders - September 2003

trend arrows may have little value
Trend Arrows May Have Little Value
  • No trend arrow means glucose change is less than 60 mg/dl (3.3 mmol) up or down from the current reading.
  • 1 hr later
  • 159 mg/dl (8.8 mmol)
  • Now
  • 100 mg/dl (5.6 mmol)
  • 41 mg/dl (2.3 mmol)
  • With a BG of 300 at bedtime and a level trend arrow, the breakfast reading could be 0 or 750 mg/dl!

Large changes can occur in the BG with no trend arrow

Trend arrows should not reassure a user!

Healthcare Across Borders - September 2003

line graphs provide better trend info
Line Graphs Provide Better Trend Info

Shortest Trend

1 Hr – Dexcom

2 Hr – Navigator

3 Hr – Paradigm

Longest Trend

9 Hr – Dexcom

24 Hr – Navigator & Paradigm

Target Zone – all

Event Icons – Navigator

300

250

200

150

100

50

0

2

4p

6

8p

10

12a

Healthcare Across Borders - September 2003

easier basal testing
Easier Basal Testing
  • 10 pm 2 am 8 am

Overnight basal test

120 mg/dl

Goal: green line

© Pumping Insulin, 2006

Healthcare Across Borders - September 2003

easier bolus testing
Easier Bolus Testing

Correction bolus

Carb bolus

300

200

100

60

6 pm 8 pm 10 pm

6 pm 8 pm 10 pm

Goal: green lines

© Pumping Insulin, 2006

Healthcare Across Borders - September 2003

continuous monitors and exercise
Continuous Monitors And Exercise
  • Great for optimizing control – BGs before, during, and after exercise can be seen
  • Greater confidence with variable exercise schedules
  • Can you wear one with your exercise? ie, water sports, ability to carry
  • Out of pocket cost = about a Starbucks a day
  • Helps prevent night lows or gives early warning after exercise. At night, place receiver in a glass bowl so it wakes you *

* Tip courtesy Dr. Bruce Buckingham

Healthcare Across Borders - September 2003

continuous monitor tips
Continuous Monitor Tips

Healthcare Across Borders - September 2003

no two points are created equal level of risk depends on trend
No Two Points Are Created Equal! Level of Risk Depends on Trend

Going Up

Lower Risk

Going Down

Higher Risk

Healthcare Across Borders - September 2003

going up consider action
Going Up: Consider Action!

1 hour

Healthcare Across Borders - September 2003

did not act early enough or upper alert needs to be lowered
Did Not Act Early Enough Or Upper Alert Needs To Be Lowered!

1 hour

Healthcare Across Borders - September 2003

wait and watch
Wait and Watch!

1 hour

Healthcare Across Borders - September 2003

wedge of possibilities

260

240

220

200

Glucose (mg/dl)

180

160

140

120

100

0

30

60

90

120

Minutes

Wedge of Possibilities

Red lines (wedge) show probable limits for glucose path

Healthcare Across Borders - September 2003

turnaround time an object in motion stays in motion
Turnaround Time An Object in Motion Stays in Motion

Healthcare Across Borders - September 2003

don t stack the insulin
Don’t Stack The Insulin

Healthcare Across Borders - September 2003

remember the lag time during periods of rapid change
Remember The Lag Time During Periods of Rapid Change

Healthcare Across Borders - September 2003

lots to learn
Lots To Learn
  • Breakfast bolus too small
  • Lunch bolus too small or afternoon basal too low
  • Excessive night basal or bedtime bolus

Healthcare Across Borders - September 2003

goal staying between the lines
Goal: Staying Between The Lines

As readings improve, lower the glucose for the upper alert

Healthcare Across Borders - September 2003

continuous monitoring tips
Continuous Monitoring Tips
  • Be patient, have realistic expectations
  • Don’t panic when your meter and sensor differ
  • Expect some lag time
  • Don’t react too quickly and stack your insulin
  • Look at trends, not just individual values
  • Rapid rises usually mean more insulin is needed
  • Validate your readings with a meter

Healthcare Across Borders - September 2003

future devices and pump features
Future Devices And Pump Features

Healthcare Across Borders - September 2003

animas debiotech micropump
Animas Debiotech Micropump
  • Animas is one of several companies developing very small insulin pumps from Micro-Electro-Mechanical Systems or MEMS technology.
  • Made from silicon, can be mass-produced at low cost

Healthcare Across Borders - September 2003

valeritas h patch pump
Valeritas H-Patch Pump
  • Good introduction for Type 2s to basal/bolus therapy
    • Automatic needle insertion
    • Single basal available as 20, 30, or 40 units per day
    • Button on pump delivers 2U per push

Healthcare Across Borders - September 2003

pressure pumps
Pressure Pumps
  • Pressure from small solenoid drives precise insulin delivery
  • Eliminates need for motor and solid reservoir
  • Insulin can be stored in a bladder to reduce size
  • Two bladders with independent controls allow dual delivery
  • Dual pumping for:
    • Insulin + symlin
    • Insulin + glucagon
    • Or a micro pull/push interstitial glucose monitor

Healthcare Across Borders - September 2003

temporary basal reduction for excess bob
Temporary Basal Reduction For Excess BOB

A temporary basal reduction offsets excess BOB so it is not necessary to eat at bedtime.

Future Pump Feature

Healthcare Across Borders - September 2003

super bolus for a high gi meal shift basal to bolus
Super Bolus For A High GI MealShift Basal To Bolus
  • A Super Bolus shifts part of the next 2-4 hours of basal insulin into an immediate bolus. Gives a faster insulin effect for high GI and large carb meals with less risk of a low.

Activated whenever user eats more than a selected quantity of carbs, such as 30 or 40 grams

Future Pump Feature

Healthcare Across Borders - September 2003

super bolus for a postmeal high shift basal to bolus
Super Bolus For A Postmeal HighShift Basal To Bolus

Enables a faster correction of highs with less risk of a low.

Future Pump Feature

Healthcare Across Borders - September 2003

automatic basal bolus testing
Automatic Basal/Bolus Testing
  • A pump could automatically test:
    • The TDD from
      • Average blood sugar, stand. dev., frequency of lows
      • % TDD used for corrections
      • Basal/bolus balance
    • Basal rates from
      • Daytime when a meal is skipped (accounting for BOB)
      • Overnight (accounting for BOB at bedtime)
    • The carb factor from
      • Premeal, 2 hr postmeal peak, normal in 4-5 hrs?
    • The correction factor from
      • High-to-normal in 4-5 hours?

Current And Future Pump Feature

Healthcare Across Borders - September 2003

pattern analysis
Pattern Analysis
  • Pattern shows
  • Inadequate or missed breakfast boluses or inadequate day basal rate
  • Correction or carb boluses appear to be excessive at lunch
  • Tests only when low in evenings
  • Devices
    • make sense of patterns in real time
    • analyze history accurately
    • much faster than MDs and RNs!

Future Pump Feature

Healthcare Across Borders - September 2003

insulin lookback
Insulin Lookback
  • To find out if a low or high reading was caused by basals or boluses, a pump can compare:
        • how much basal
        • and how much bolus
        • was active during the previous 5 hours
  • Lows – usually caused by the larger insulin amount
  • Highs – usually caused by the smaller insulin amount

Future Pump Feature

Healthcare Across Borders - September 2003

lookbacks
Lookbacks
  • # 1
  • BG = 47 at 1:00 am
  • 5 hr. lookback:
  • Boluses = 9.2 u
  • Basal = 4.6 u
  • # 2
  • BG = 228 at 4:30 pm
  • 5 hr. lookback:
  • Boluses = 6.5 u
  • Basal = 2.4 u

Healthcare Across Borders - September 2003

wrap up
Wrap Up
  • Pumps and continuous monitors offer technology improves control
  • More flexibility and confidence, lesshypoglycemia, less glucose exposure, less variability, and a healthier life
  • Data easily analyzed with suggested improvements that guide user toward improved control through success
  • Requires commitment, responsibility and training, but less work for everyone overall

Healthcare Across Borders - September 2003

questions discussion
Questions & Discussion

Healthcare Across Borders - September 2003