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Diabetes 2012: Pump, Sensors, Current Medical Therapy & Future Dreams

Shannon Kelley Oates MDFebruary 2012

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Diabetes Introduction

Why we need to consider the impact

How large is the problem? How can you understand what it is

to be a person with diabetes?

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Diabetes Mellitus

Type 1 Rare—affecting only 1

in 250 (1 in 400 kids) 15,000 new cases per

year Low rates in Black and

Asian populations

Type 2 Common Probably 25 million

cases in the US. 1/3 cases undiagnosed

Projected prevalence of 11% WOW! Over age 65, 27% with DM

Cost: $ 218 billion in 2007

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Diabetes MellitusType 1 and Mortality

Mortality rates for people with DM Type 1 are 5 to 7 times the general population

More than 15% of people with DM type 1 will die by age 40

They die of DKA, of renal failure, of cardiovascular disease

Life expectancy is reduced by 15 years

Competence Questions

1.  What are the indications for an insulin pump?

        a.  desire for a pump and insulin use        b.  diabetes type 1 if on Medicare         c.  diabetes type 2 for many

commercial insurances

        d.  Insulin use  

Competence Questions

2.  Name 3 new diabetes therapies in the last few years

        a. Exenetide, bromocriptine, glimepiride

        b. Bromocriptine, linagliptin, saxagliptin

        c. Carbohydrate counting, continuous glucose monitoring, insulin

pumps

Competence Questions

3.  Continuous glucose monitoring can be used

        a. only with a pump        b. only with multidose injection insulin

therapy        c. must be used daily         d.  costs about $35 per week on-going

costs

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Take Home Goals

Think like a pancreas

Give enough insulin

Get and give loads of education

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DinnerBreakfast Lunch

Insulin Secretion- Physiology

Polonsky, N Engl J Med 1996; 334: 777-783

Serum insulin

Time of Day

Insu

lin

(m

U/L

)

70

12:00pm

3:00pm

6:00pm

9:00pm

12:00am

3:00am

6:00am

9:00am

10

30

50

0

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BiggerDinner

Breakfast SkipsLunch

Insulin Secretion- Physiology

Polonsky, N Engl J Med 1996; 334: 777-783

Serum insulin

Time of Day

Insu

lin

(m

U/L

)

70

12:00pm

3:00pm

6:00pm

9:00pm

12:00am

3:00am

6:00am

9:00am

10

30

50

0

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Intensive Therapy

Decreases risks of microvascular disease Retinopathy 75% reduction Nephropathy 50% reduction Neuropathy 60% reduction

Goal is to achieve normoglycemia Measure BS frequently Increases risk of hypoglycemia

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Insulin Time-Action Patterns

Time (hours)

Baseline

Level

Regular insulin

Premix 70/30

s.c. Injection

Normal Insulin Secretionat Meal Time

NPH Insulin

Ch

ang

e in

Ser

um

In

suli

n

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Insulin Time-Action Patterns

Time (hours)

Baseline

Level

Regular insulin

Premix 70/30

s.c. Injection

Normal Insulin Secretionat Meal Time

NPH Insulin

Ch

ang

e in

Ser

um

In

suli

n

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Insulin Aspart

Thr

Lys

AspThr

Tyr Phe Phe Gly ArgGlu

Gly

Glu

Cys

Val

Leu

Tyr

Leu

Ala

Val

Leu

His

Ser

GlyCysLeuHisGlnAsnValPheB1

Asn CysTyr

Asn

Glu

Leu

Gln

Tyr

LeuSerCysIleSerThrCys

Cys

Gln

Glu

Val

Ile

Gly

B20

A21

A1

B28B30

AspPro

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DinnerBreakfast Lunch

Normal Insulin Secretion

Polonsky, N Engl J Med 1996; 334: 777-783

Serum insulin

Time of Day

Insu

lin

(m

U/L

)

70

12:00pm

3:00pm

6:00pm

9:00pm

12:00am

3:00am

6:00am

9:00am

10

30

50

0

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Insulin Regimens

Twice a day mixed insulin Once daily long acting with lispro or

regular with each meal Twice daily intermediate or long acting

insulin with lispro or regular at each meal Once a day long acting insulin with

lispro/aspart/glulisine at each meal CSII is continuous subcutaneous insulin

infusion this is insulin pump

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‘Ventricular Tachycardia’ Sugars

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Insulin Pen or Syringe Injections with MDI can approach the Ideal

Insulin pens are very handy

Use ONLY on one person

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CSII or Insulin Pump

Programmed basal rate of insulin and calculated boluses with carbohydrate intake

Place needle or catheter subcutaneously every 3 days

Short or rapid insulin analog only Special attention to prevent DKA

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Insulin Pumps

Medtronic MiniMed

Deltec

Animas

Call 1-800 Number if ??

Accu-ChekOmnipod

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Future? Insulin Pumps

Animas

Omnipod

Tandem

Spring Zone

Old pumps

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Pump Manufacturers

MiniMed www.minimed.com Several pumps Great support

Animas www.animas.com Implantable monitor in testing phase

Omnipod No tubing www.myomnipod.com

Omnipod – no tube

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Way Cool

A 15 year old can sleep in until noon on the weekend and not get up and take an injection and eat breakfast

Indications? Desire for a pump Some understanding of

the limitations of the technology

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Need to know the glucose

Call 1-800 Number if ??

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Newer Meters

Call 1-800 Number if you have ??

Bayer USB meter Iphone add-on meter iBGStar

iPhone App- Wavesense

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Continuous Monitoring

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Patient versions of Continuous Monitoring or CGM

Dexcom 7Medtronic Real time or Guardian

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Two Versions of CGM

Professional

1. If we need more information, we can do the “Holter Monitor” of glucose

2. Several days of glucose data with meals and insulin data from the patient

Personal

1. The patient sees the glucose data as it is produced

2. Can be used continuously or intermittently

3. Cost about $35 cash per usage

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Two Versions of CGM

Professional-- called iPro

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Continuous Monitoring Software

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Continuous Monitoring Software

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CGM for Patients- Receivers

mySentry™ Remote Glucose Monitor

Up to 75% of severe hypoglycemic Up to 75% of severe hypoglycemic episodes in children occur at night* episodes in children occur at night*

*Ahmet A, Dagenais S, Barrowman NJ, et al. Prevalence of nocturnal hypoglycemia in pediatric type 1 diabetes: a pilot study using continuous glucose monitoring. J Pediatrics, 2011;159 (2): 297-302.

Glucose and Sensor Screenshots

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Transplants

Whole pancreas transplants usually along with kidney

Technical difficulties with islet only transplants

Autotransplantation of islets– only if we take out your pancreas for NON diabetes reason

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Exenatide

(GLP-1 re

ceptor agonist

)

Sitaglip

tin

(DPP-IV in

hibitor)

Liraglutid

e

(GLP-1 re

ceptor agonist

)

.

2005 2006 2007 20102008 2009

Saxagliptin

(DPP-IV in

hibitor)

Newer Classes of Antidiabetes Therapies: The Era of Incretin-based Therapies plus …

Food and Drug Administration. accessdata.fda.gov. Accessed 25 May 2010.

2012

Exe

natid

e XR

(GLP

-1 re

cept

or a

goni

st)

Brom

ocrip

tine

(dop

amin

e ag

onist

)

Cole

seve

lam

(bile

acid

bind

er)

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Best of the Web

www.diabetes.org - American Diabetes Association

www.childrenwithdiabetes.comLovely site, easy to navigate, active chat Archived expert answers Diabetes camp info

www.diabetesmonitor.com www.diabetesstation.org www.jdf.org – Juvenile Diabetes Association www.2aida.net -very cool insulin simulator

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what is it like to have diabetes?

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Real life with Diabetes Find your ice

skates Have a snack Test your blood

sugar Laugh at your

roomie Test, count, inject Study, sleep.

Test sugar Count carbs Do a shot Go to class Test sugar, count

carbs, do a shot Treat a low blood

sugar

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Real life with Diabetes

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Future ?

Artificial pancreas

Better data collection

Easier diagnosis Test genes

to see who might get disease

Your glucose sensor reminds you that you forgot to take insulin

Scan the food for auto carb calculation

Dr. Oates is on the beach with her computer and your company pays her NOT to see you

Competence Questions: Multiple right answers

1.  What are the indications for an insulin pump?

        a.  desire for a pump and insulin use        b.  diabetes type 1 if on Medicare         c.  diabetes type 2 for many

commercial insurances

        d.  Insulin use  

Competence Questions: Single Best Answer

2.  Name 3 new diabetes therapies in the last few years

        a. Exenetide, bromocriptine, glimepiride

        b. Bromocriptine, linagliptin, saxagliptin

        c. Carbohydrate counting, continuous glucose monitoring, insulin

pumps

Competence Questions -True Statements

3.  Continuous glucose monitoring can be used

        a. only with a pump        b. only with multidose injection insulin

therapy        c. must be used daily         d. can cost about $35 per week on-

going costs

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Take Home Goals

Think like a pancreas Give enough insulin Get and give loads of education Call the 800 number on the back of any technology

THANK YOU!

oatess@iuhealth.org

Cool Apps for your phone

Earn points

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Glucagon

InsulinInsulin

Glucagon

InsulinInsulin

How Incretins Work1-3

IntestineIntestine

Food triggers the release of incretin hormones (GLP-1 and GIP) by the intestines into the blood

Blood

The body makes DPP-4, an enzyme that rapidly breaks down GLP-1 and GIP

Pancreas

Blood

SugarSugar

1. Drucker DJ. Cell Metab. 2006;3:153–165. 2. Aroda VR, Henry RR. cme.medscape.com/viewarticle/474380_3. Accessed 24 June 2010. 3. Hinnen D, et al. J Am Board Fam Med. 2006;19:612-620.

GIP=glucose-dependent insulinotropic polypeptide.

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Mechanism of DPP-4 Inhibitors

DPP-4

DPP-4 inhibitorsBlock the action of DPP-4DPP-4 rapidly breaks down GLP-1 and GIP

Hinnen D, et al. J Am Board Fam Med. 2006;19:612-620.

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Mechanism of GLP-1 Receptor Agonists1,2

GLP-1 receptor agonists directly activate the GLP-1 receptor resulting in effects similar to natural GLP-1 but are resistant to breakdown by DPP-4

1. Hinnen D, et al. J Am Board Fam Med. 2006;19:612-620. 2. Drucker DJ. Cell Metab. 2006;3:153–165.

Reduce appetite

Slow down how quickly food leaves stomach and make patients feel “full”

Help the pancreas make more insulin when blood sugar is high

Help keep the liver from releasing too much sugar into the blood