Amy Urbanus, RD, CDEAmy Urbanus, RD, CDE

Diabetes SpecialistDiabetes Specialist

Providence Alaska Medical Providence Alaska Medical centercenter

Home Glucose MonitoringHome Glucose Monitoring

Continues to be one of the best tools for Continues to be one of the best tools for diabetes self-management 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 StripsCost/Insurance Strips AccuracyAccuracy Dexterity of patientDexterity of patient Alternate site testingAlternate site testing Lancing devicesLancing devices

Lifescan: One TouchLifescan: One Touch One Touch Ultra Mini: Consumer One Touch Ultra Mini: Consumer

Reports #1 meterReports #1 meter One Touch Ultra 2One Touch Ultra 2 One Touch Ultra LinkOne Touch Ultra Link One Touch Ultra SmartOne Touch Ultra Smart One Touch “Ping” One Touch “Ping”

All use One Touch test stripsAll use One Touch test strips Covered by insurance and MedicareCovered by insurance and Medicare Large displaysLarge displays Local customer supportLocal customer support

Accu-ChekAccu-Chek AvivaAviva

Large test strips: good for patients with difficulty Large test strips: good for patients with difficulty getting small test strips out of the bottlegetting small test strips out of the bottle

Compact Compact Bulky meter, test strips come in a “drum” (no Bulky meter, test strips come in a “drum” (no

handling of test strips), lancing device attached handling of test strips), lancing device attached to the meterto the meter

ActiveActive Cheaper meter, good for non insuredCheaper meter, good for non insured

FreestyleFreestyleSmallest sample size @ 0.3 mlSmallest sample size @ 0.3 ml

Freedom LiteFreedom Lite

Freestyle FreedomFreestyle Freedom

Freestyle meter integrated with the Freestyle meter integrated with the Navigator CGM and OmniPodNavigator CGM and OmniPod

All Freestyle meters use the same strip All Freestyle meters use the same strip that is challenging for some to use, that is challenging for some to use, very small, can not see blood on stripvery small, can not see blood on strip

““Other” Meters Other” Meters

Reli-onReli-on Wal-Mart's meter; question accuracyWal-Mart's meter; question accuracy Strips individually wrapped and difficult to get Strips individually wrapped and difficult to get

openopen TRUE TrackTRUE Track

Cheaper meter. Many pharmacies will try to Cheaper meter. Many pharmacies will try to encourage patients to “trade out” their Accu-encourage patients to “trade out” their Accu-Chek or One Touch meter for this cheaper Chek or One Touch meter for this cheaper brand claiming better reimbursement. Better brand claiming better reimbursement. Better for the pharmacy, not the patientfor the pharmacy, not the patient

Lancing DevicesLancing Devices

Most meters use similar lancing Most meters use similar lancing devicedevice

““Multiclix” by Accu-ChekMulticlix” by Accu-Chek Drum of needlesDrum of needles Sold as not being as painfulSold as not being as painful Can purchase separatelyCan purchase separately

Insulin DeliveryInsulin Delivery

Pens, syringe or pump?Pens, syringe or pump?

Insulin PensInsulin PensThe New Trend in HospitalsThe New Trend in Hospitals

Providence Alaska Providence Alaska Medical CenterMedical Center

Novolog FlexPenNovolog FlexPen Lantus syringeLantus syringe

Alaska Regional Alaska Regional HospitalHospital

Novolog Flex PenNovolog Flex Pen Lantus SoloStar PenLantus SoloStar Pen

Bartlett Bartlett Fall ’09Fall ’09

Humalog KwikPenHumalog KwikPen Lantus SoloStar Lantus SoloStar

PenPen

Alaska Native Alaska Native Medical CenterMedical Center

Novolog FlexPenNovolog FlexPen Lantus syringeLantus syringe

Types of Insulin PensTypes of Insulin Pens Rapid Acting InsulinRapid Acting Insulin

Novolog FlexPen: Prefilled 300 unitsNovolog FlexPen: Prefilled 300 units Humalog KwikPen: Prefilled 300 unitsHumalog KwikPen: Prefilled 300 units Apidra SoloStar Pen: Prefilled 300 units (new April ’09)Apidra SoloStar Pen: Prefilled 300 units (new April ’09) Humalog Memoir Pen: 300 unit cartridgeHumalog Memoir Pen: 300 unit cartridge Humalog Luxura Pen: 300 unit cartridge, can be dosed in ½ unitsHumalog Luxura Pen: 300 unit cartridge, can be dosed in ½ units

Basal InsulinBasal Insulin Lantus SoloStar Pen: prefilled 300 unitsLantus SoloStar Pen: prefilled 300 units

Opticlick pen phasing outOpticlick pen phasing out Levemir FlexPen : prefilled 300 unitsLevemir FlexPen : prefilled 300 units

Many mixed Insulins and older insulins also come in pensMany mixed Insulins and older insulins also come in pens

Pros/Cons to Insulin pensPros/Cons to Insulin pens AdvantagesAdvantages

Easy to dial up doseEasy to dial up dose Can “count” clicksCan “count” clicks Kept at room Kept at room

temperaturetemperature PortablePortable More discreteMore discrete Memoir Pen: good for Memoir Pen: good for

patients with multiple patients with multiple care givers, able to care givers, able to identify last dose identify last dose administeredadministered

DisadvantagesDisadvantages Only 300 unitsOnly 300 units Pens look similar, Pens look similar,

rapid acting and basal rapid acting and basal could get mixed upcould get mixed up

Pen is largePen is large Difficult to “plunge”Difficult to “plunge” Hold needle in for 5 Hold needle in for 5

seconds to ensure seconds to ensure administrationadministration

Supplies/Cost: Insulin PensSupplies/Cost: Insulin Pens

SuppliesSupplies Same needle Same needle

works for all pensworks for all pens Must write a Must write a

script for needlesscript for needles Many patients Many patients

end up with the end up with the pen onlypen only

CostCost Vials and pens Vials and pens

are now the same are now the same costcost

Medicaid will not Medicaid will not cover insulin pen cover insulin pen unless “medically unless “medically necessary”necessary”

Hospital Issues and Insulin Hospital Issues and Insulin PensPens

ProvidenceProvidence If patients are discharged on the same If patients are discharged on the same

insulin regimen, they will automatically insulin regimen, they will automatically be given the Novolog FlexPenbe given the Novolog FlexPen

Medicaid will not pay for thisMedicaid will not pay for this

Insulin Pen NeedlesHospital safety needles look different than the

outpatient needles

Insulin PumpsInsulin Pumps

Benefits of Insulin Pump Benefits of Insulin Pump TherapyTherapy

Improved glycemic control and Improved glycemic control and decreased variability in blood sugardecreased variability in blood sugar

Improved control of dawn Improved control of dawn phenomenonphenomenon

Decrease frequency of hypoglycemiaDecrease frequency of hypoglycemia Flexibility of lifestyleFlexibility of lifestyle Flexibility of basal rates: 0.025 units/hr Flexibility of basal rates: 0.025 units/hr

– 25 units/hr– 25 units/hr

First Things First!First Things First! Assess appropriate patientsAssess appropriate patients

Patients need to be able and willing to:Patients need to be able and willing to: Multiple daily injectionsMultiple daily injections Have andHave and use use syringes or pens as a syringes or pens as a

backupbackup Check BS 6 + x/ dayCheck BS 6 + x/ day Keep recordsKeep records

Assessment Cont.Assessment Cont.

Attend all appointments with Attend all appointments with physician and educatorsphysician and educators

Carbohydrate count and adjust meal Carbohydrate count and adjust meal planplan

Perform Insulin : CHO ratio and Perform Insulin : CHO ratio and sensitivity factor calculations without sensitivity factor calculations without use of pump calculatorsuse of pump calculators

Insulin Pump ComparisonInsulin Pump ComparisonMost Common in AlaskaMost Common in Alaska

Medtronic Minimed Medtronic Minimed Paradigm 522/722Paradigm 522/722

Animas One Touch Animas One Touch PingPing

OmniPodOmniPod

MiniMed Paradigm 522/722MiniMed Paradigm 522/722

176 or 300 unit 176 or 300 unit reservoirreservoir

Temporary basal rateTemporary basal rate Exercise Exercise Sick DaySick Day

Bolus increment of Bolus increment of 0.1 unit0.1 unit

Normal, squarewave, Normal, squarewave, audio bolus featuresaudio bolus features

Bolus “wizard”Bolus “wizard”

MiniMed Paradigm Cont.MiniMed Paradigm Cont.

AAA battery with 2-4 weeks of lifeAAA battery with 2-4 weeks of life Used in water up to 3 feet for 30 Used in water up to 3 feet for 30

minutesminutes Sensor screen on insulin pumpSensor screen on insulin pump Can be used with One Touch Ultra Can be used with One Touch Ultra

Link MeterLink Meter

OmniPod OmniPod ““Pod” is all in one: insulin, Pod” is all in one: insulin,

infusion set, and batteryinfusion set, and battery 200 unit capacity200 unit capacity Separate PDM for Separate PDM for

programmingprogramming PDM has a Freestyle BG PDM has a Freestyle BG

metermeter Temporary basal rateTemporary basal rate 0.05-0.1 unit bolus 0.05-0.1 unit bolus

incrementsincrements Normal or extended bolus Normal or extended bolus Bolus calculator on PDMBolus calculator on PDM 2 AAA batteries in PDM2 AAA batteries in PDM Pod is water tightPod is water tight Pod needs to be changed Pod needs to be changed

out every 3 daysout every 3 days

One Touch PingOne Touch Ping Meter/RemoteMeter/Remote

Programming on pump or Programming on pump or meter/remotemeter/remote

One Touch BS meterOne Touch BS meter 200 unit reservoir200 unit reservoir 0.025 bolus increment0.025 bolus increment Extended bolus featureExtended bolus feature Bolus calculatorBolus calculator BatteryBattery

1 AA alkaline with 2-4 wks 1 AA alkaline with 2-4 wks lifelife

1 AA lithium 4-6 weeks life1 AA lithium 4-6 weeks life Waterproof up to 12 feet Waterproof up to 12 feet

for 24 hrsfor 24 hrs

How Much?? Self Pay CostsHow Much?? Self Pay Costs Insurance coverage and monthly cost Insurance coverage and monthly cost

should be analyzedshould be analyzed Average Insulin Pump “start up” (MiniMed or Average Insulin Pump “start up” (MiniMed or

One Touch)One Touch) $6000-$7000$6000-$7000 Infusion sets and reservoirs: average Infusion sets and reservoirs: average

$150/month$150/month OmniPod: OmniPod:

Start up:$1750 (PDM and 2 pods)Start up:$1750 (PDM and 2 pods) Monthly expense: $450/ month for 10 podsMonthly expense: $450/ month for 10 pods

““Pay as You Go”Pay as You Go”

Don’t Forget the Insulin and Don’t Forget the Insulin and Test Strips!!Test Strips!!

Rapid Acting Insulin ~ $100/ vial in Rapid Acting Insulin ~ $100/ vial in AnchorageAnchorage

Advantage to pumpAdvantage to pump Only one co pay Only one co pay

Home Glucose Monitoring Test StripsHome Glucose Monitoring Test Strips ~ $1 per strip~ $1 per strip

InsuranceInsurance

Fairly good coverage for insulin pump Fairly good coverage for insulin pump therapy by both private insurance and therapy by both private insurance and Medicare/MedicaidMedicare/Medicaid

20% out of pocket cost per month ~ $ 30 20% out of pocket cost per month ~ $ 30 for suppliesfor supplies

Currently OmniPod does not accept Currently OmniPod does not accept MedicareMedicare

Continuous Glucose Continuous Glucose MonitoringMonitoring

Basic ConceptBasic Concept3 Parts3 Parts

1. Sensor1. Sensor Patients wear a glucose sensor that is inserted similarly to Patients wear a glucose sensor that is inserted similarly to

an insulin pump and sends data continuously to a an insulin pump and sends data continuously to a transmittertransmitter

2. Transmitter2. Transmitter Transmitter then sends the data to a “receiver”Transmitter then sends the data to a “receiver”

3. Receiver3. Receiver Hand held receivers: Navigator and Dexcom SevenHand held receivers: Navigator and Dexcom Seven Paradigm insulin pumpParadigm insulin pump

Provides glucoses value as well as graphs with a Provides glucoses value as well as graphs with a visual of BG trend visual of BG trend

Abbott Navigator MiniMed Real Time

Dexcom Seven Plus

Who Could Benefit?Who Could Benefit? Frequent nocturnal hypoglycemiaFrequent nocturnal hypoglycemia Hypoglycemia unawarenessHypoglycemia unawareness Postprandial hyperglycemiaPostprandial hyperglycemia Dawn phenomenonDawn 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 FeaturesStandard Features All need to be calibrated with All need to be calibrated with

fingerstick blood sugarfingerstick blood sugar ““Wetting time” for initiation period Wetting time” for initiation period

usually 2-12 hr (over night)usually 2-12 hr (over night)

Must be calibrated periodically during Must be calibrated periodically during wearwear

Sensor life 3-7 daysSensor life 3-7 days Patients report 2-3 weeks of wearPatients report 2-3 weeks of wear

CGM Standard Features CGM Standard Features Cont.Cont.

All have alarms to set for All have alarms to set for hyperglycemia and hypoglycemia hyperglycemia and hypoglycemia that can be customizedthat can be customized

Note: if receiver or pump is under a Note: if receiver or pump is under a pillow, most likely will not hear alarmpillow, most likely will not hear alarm

Sensor/transmitter are water resistantSensor/transmitter are water resistant

Insurance/CostInsurance/Cost

Many more patients are getting Many more patients are getting coverage for CGM by private insurerscoverage for CGM by private insurers

Currently no Medicare coverageCurrently no Medicare coverage

Start up ~ $1000 for transmitterStart up ~ $1000 for transmitter Transmitter good for ~ 1 yearTransmitter good for ~ 1 year

$275-350/ month for sensors$275-350/ month for sensors

There are many exciting tools There are many exciting tools available now, and more to available now, and more to come in the future, to help come in the future, to help

improve control and improve control and ultimately quality of life.ultimately quality of life.

Thank YouThank You

amy.urbanus@providence.orgamy.urbanus@providence.org