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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