4/18/19 WADE 2019 Technology in Diabetes Care: Advanced Level WADE PP... · 4/18/19 2 Technology...
Transcript of 4/18/19 WADE 2019 Technology in Diabetes Care: Advanced Level WADE PP... · 4/18/19 2 Technology...
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WADE2019
TechnologyinDiabetesCare:AdvancedLevel
MeghannMoore,RD,CDE,MPH
ClinicalLead,DSMT/EProgramCoordinatorWesternWashingtonMedicalGroup
Everett,WAApril26,2019
DisclosurestoParticipantsNoticeofRequirementsforSuccessfulCompletion:Forsuccessfulcompletion,participantsarerequiredtobeinattendanceinthefullactivityandcompletetheprogramevaluationattheconclusionoftheeducationalevent.PresenterConflictsofInterest/FinancialRelationshipsDisclosures:Noconflictsexist.DisclosureofRelevantFinancialRelationshipsandMechanismtoIdentifyandResolveConflictsofInterest:Noconflictsofinterest.Non-EndorsementofProducts:AccreditedstatusdoesnotimplyendorsementbyAADE,ANCC,ACPEorCDRofanycommercialproductsdisplayedinconjunctionwiththiseducationalactivity.Off-labelUse:ParticipantswillbenotifiedbyspeakerstoanyproductusedforapurposeotherthanthatforwhichitwasapprovedbytheFoodandDrugAdministration.
TechnologyinDiabetesCare
• CGM• Insulinpumps• Otherinsulindeliverydevices• Reports• PatientProcess• DANA
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TechnologyUse:AADEMembers
• 74%-somewhat/verycomfortablew/tech• 61%-recommendtechtopatients• 59%-demotechtopatients• 53%-interpretdata• 42%-troubleshootproblems
Reference:DANAbyDivas:UsingDANAforIntegratingTechnologyIntoPractice,AADE.
CGMTherapy
• “Sensor-augmentedpumptherapymaybeconsideredforchildren,adolescents,andadultstoimproveglycemiccontrolwithoutanincreaseinhypoglycemiaorseverehypoglycemia.Benefitscorrelatewithadherencetoongoinguseofthedevice.”A
• “WhenprescribingCGM,robustdiabeteseducation,training,andsupportarerequiredforoptimalCGMimplementationandongoinguse.”E
StandardsofMedicalCareinDiabetes2019DiabetesCare2019;42(Suppl.1):S3
Real-TimeCGMUseinYouth
• “Real-timeCGMshouldbeconsideredinchildrenandadolescentswithtype1diabetes,whetherusingMDIorCSII,asanadditionaltooltohelpimproveglucosecontrolandreducetheriskofhypoglycemia.BenefitsofCGMcorrelatewithadherencetoongoinguseofthedevice”.B
StandardsofMedicalCareinDiabetes2019DiabetesCare2019;42(Suppl.1):S3
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Real-TimeCGMUseinAdults
• Whenusedproperly,…inconjunctionwithintensiveinsulinregimensisausefultooltolowerA1Cinadultswithtype1diabeteswhoarenotmeetingglycemictargets.A
• …maybeausefultoolinthosewithhypoglycemiaunawarenessand/orfrequenthypoglycemicepisodes.B
• …shouldbeusedasclosetodailyaspossibleformaximalbenefit.A
StandardsofMedicalCareinDiabetes2019DiabetesCare2019;42(Suppl.1):S3
Real-TimeCGMUseinAdults
• …maybeusedeffectivelytoimproveA1Clevelsandneonataloutcomesinpregnantwomenwithtype1diabetes.B
• Sensor-augmentedpumptherapywithautomaticlow-glucosesuspendmaybeconsideredforadultswithtype1diabetesathighriskofhypoglycemiatoprevent…hypoglycemiaandreduce…severity.B
• “Flash”CGMusemaybe…asubstituteforSMBGinadultswithdiabetesrequiringfrequent(SMBG).C
StandardsofMedicalCareinDiabetes2019DiabetesCare2019;42(Suppl.1):S3
CGMSystems
• DexcomG5orG6• Eversense• FreestyleLibre14day(Abbott)• GuardianConnect(Medtronic)
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DexcomG5orG6
• G6auto-inserter• 7-10daysensorwear• Receiver• AndroidoriOScompatible• 0-2calibrations• Low/highalerts• Clarity,Diasend,Glooko,Tidepool
Eversense
• Providerofficevisitinsertion/removal• 90-daysensorwear• Android/iOSapponly• 2/daycalibrations• Low/highalert• Predictivealerts• EversenseDMSPro
FreestyleLibre14day
• Arm• Nocalibrations• Noalerts• Mustscanq8hours• 14-daysensor/transmitterwear• ReaderorLibreLinkapp• LibreView,Tidepool
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GuardianConnect
• <=7daysensorwear• Bluetoothtransmitter• iOSapponly• 2/daycalibrations• Low/highalerts• Predictivealerts• SugarIQ• Carelink
CGMSCompare&ContrastDexcomG6 Eversense
(Senseonics)
GuardianConnect(Medtronic)
Libre14-day(Freestyle)
MARD 9% 8.5% 10% 10%
Age 2yrs 18yrs 14yrs 18yrs
Sensor 10days 90days Upto7days 14days
Trans. 3mo 1yr 1yr 14days
Calib. 0 2/day 2/day 0
Coverage All NotMedicare NotMedicare NotTricare
InsulinPumpTherapy• Mostadults,children,andadolescentswithtype1diabetesshouldbetreatedwith…eitherMDIoraninsulinpump.A
• Insulinpumptherapymaybeconsidered…forallchildrenandadolescents,especially…under7yearsofage.C
• Automatedinsulindeliverysystemsmaybeconsideredinchildren(7years)andadultswithtype1diabetestoimproveglycemiccontrol.B
• pumptherapyhasmodestadvantagesforloweringA1C…andforreducingseverehypoglycemiaratesinchildrenandadults
StandardsofMedicalCareinDiabetes2019DiabetesCare2019;42(Suppl.1):S3
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InsulinPumps
• Medtronic– 630G– 670G
• Omnipod– Aros– DASH
• Tandem– t:slimX2
Medtronic630G 670G• Colorscreen• Integratedmeter,remotecontrol
formanualbolusing• Presetbolusesandtempbasals• DownloadabletoCarelink• Sloworfastbolusdelivery• Waterproof• OptionalCGMuse• CGMdataviewedonscreen• Predictivelowglucosesuspend
• Hybridclosedloop(HCL)basaladjustmentbasedonCGMandpredictivealgorithms(Automode)
http://integrateddiabetes.com/updated-insulin-pump-comparisons-and-reviews/https://www.medtronicdiabetes.com
Omnipod
1.PurkissR,StoneS.Howinnovationmayreducethecomplexityofadministeringinsulintherapy.Whitepaper,ArgentGlobalServices.January2018.
Aros DASH
• Smallestpumpsize• Twopartsystem,pod&PDM• Canprogramthroughclothing• Notubing• Autoprime&cannulainsertion• Forcedpodchange• Watertight• Built-inBGmeter• Largestcolorscreen• NoCGMintegration• Least#userguidesteps1
• Basalrateof0.0u/hr• Displayapp–pt.pumpdata• Viewapp–12carepartners• iPhonewidgets• ContourNextOneBGmeterw/
Bluetooth• ICratio0.1increments• CalorieKing• Autoupload• Pharmacybenefit• Apidra,Admelog
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TandemX2• Softwareupdatesviaweb• Bright,full-colortouchscreen• Fastestbolusentry• Basal&bolussettingsinsameplace• 2-waybluetooth• DexcomCGMdatadisplay• Charges• NolinkedBGmeter• BasalIQw/PLGS
InsulinPumpCompare&ContrastMedtronic670G OmnipodAros Tandemt:slimX2Carelinkpersonal&professional
Diasend,Glooko,Tidepool T:connect,Diasend,Tidepool,Glooko
0.025-35u/hrbasal 0.05ubasalincrement 0.001u,q5minbasal
TempTargetupto12hr -100%-95%,30min-12htemp
0-250%,15min-72hrtemp
0.025uupto25u 0.05uupto30u 0.01ufrom0.05-25u
1uin40secor4sec 1uin40sec 1uin20sec
2-4weeksbattery 3weeksbattery 5-7dbattery
12’for24hr 25’for60min 3’for30min
Age7andoverw/T1DM Children&Adults Age6andover
OtherInsulinDeliveryDevices
• V-Go(Valeritas)• SmartDoseMonitors– InPen(CompanionMedical)– NovoPenEcho(NovoNordisk)
• EOPancreassystem• PAQMealpatchpump• iLet“bionic”pancreas
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SmartDevicePipeline2019• BigfootBiomedical– SmartapptointegratenextgenLibreCGMorBluetoothlinkedmeterresults
• Biocorp– Easylogreusablesmartpencap
• CommonSensing– Gocapreadyingforcommercialization
• Lilly– integratedinsulinmanagementsystemwithDexcomG6,smartphoneapp,smartpen(s)
• NovoNordisk– reusablesmartpen;bluetoothpenattachment
https://diatribe.org/novopen-6-and-novopen-echo-plus-connected-insulin-pens-launch-early-2019AADEcommunicationCommonSensingfieldcommunicationhttps://www.novonordisk.com/bin/getPDF.2218400.pdf
Reports:CGMSystems
• Carelink• Clarity• Diasend• Eversense• LibreView• Tidepool
AGP
AmbulatoryGlucoseProfile(AGP)
BergenstalRM,etal.Recommendationsforstandardizingglucosereportingandanalysistooptimizeclinicaldecisionmakingindiabetes:theAmbulatoryGlucoseProfile(AGP).DiabTechnolTher2013;15:198
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AmbulatoryGlucoseProfile(AGP)
CGMReport:MeaningfulMeasuresOutcome Definition
Hypoglycemia
Level1:glucose<70mg/dLand≥54mg/dLLevel2:glucose<54mg/dLLevel3:asevereeventcharacterizedbyalteredmentaland/orphysicalstatusrequiringassistance
Hyperglycemia Level1—elevated:glucose>180mg/dLand≤250mg/dLLevel2—veryelevated:glucose>250mg/dL
Timeinrange Percentageofreadingsintherangeof70–180mg/dLperunitoftime
DKAElevatedserumorurineketones(greaterthantheupperlimitofthenormalrange)andserumbicarbonate<15mmol/LorbloodpH<7.3
AgiostratidouG,etal.StandardizingClinicallyMeaningfulOutcomeMeasuresBeyondHbA1cforType1Diabetes:AConsensusReportoftheAmericanAssociationofClinicalEndocrinologists,theAmericanAssociationofDiabetesEducators,theAmericanDiabetesAssociation,theEndocrineSociety,JDRFInternational,TheLeonaM.andHarryB.HelmsleyCharitableTrust,thePediatricEndocrineSociety,andtheT1DExchange.DiabetesCare2017;40:1622-1630
InternationalConsensusPanel
• <54mg/dl–clinicallysignificanthypoglycemia• CV–correlatesbestwithhypos– <36%=stable– ≥36%=unstable
• TIR–70-180mg/dlor70-140mg/dl• 14daysconsecutivedata• 70%CGMreadings
DanneT,etal.InternationalConsensusonUseofContinuousGlucoseMonitoring.DiabetesCare2017;40:1631-1640
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UpdatedAGPReport
Adjusting Correction Boluses Based on CGM Rate of Change Arrows
Rateofchange(mg/dl/min)
JDRF/DirecNet2008
Pettus/EdelmanSurvey201519-21
ScheinerProtocol2015*22
Pettus/EdelmanProtocol2017*23
Klonoff/KerrProtocol2017
Rising1-2mg/dl/min
↑10% — Currentgluvalue(noΔ)
Currentgluvalue+50
Currentdose+1U
Rising2-3mg/dl/min
↑20% 111%higher Currentgluvalue+25
Currentgluvalue+75
Currentdose+1.5U
Rising>3mg/dl/min
↑20% 140%higher Currentgluvalue+50
Currentgluvalue+100
Currentdose+2U
Change<1mg/dl/min
NoΔ —
Falling1-2mg/dl/min
↓10% — Currentgluvalue(noΔ)
Currentgluvalue–50
Currentdose–1U
Falling2-3mg/dl/min
↓20% 40%lower Currentgluvalue–25
Currentgluvalue–75
Currentdose–1.5U
Falling>3mg/dl/min
↓20% 42%lower Currentgluvalue–50
Currentgluvalue–100
Currentdose–2U
AdaptedfromPettusetal,19PettusandEdelman,20,21,23andScheiner.22glu=glucose.Δ=change.U=units.*Glucosevaluesareallmg/dl.
ClarityReport–DexcomCGM
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ClarityReport–DexcomCGM
ClarityReport–DexcomCGM
DiasendReport-CGM
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DiasendReport-CGM
DiasendReport-CGM
EversenseReport-CGM
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EversenseReport-CGM
EversenseReport-CGM
EversenseReport-CGM
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LibreviewReport-CGM
TidepoolReport-CGM
TidepoolReport-CGM
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Reports:InsulinPumps
• Carelink• Diasend• Glooko• T:connect• Tidepool
InsulinPumpReports:whattolookfor
1. Overnightglucosetrends2. Boluspatterns3. Corrections
CarelinkReport–pumpw/CGM