CSII Continuous Subcutaneous Insulin Infusion

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CSIIContinuous Subcutaneous Insulin Infusion

• The Insulin Pump
• and
• CGM
• Continuous Glucose Monitoring
• Kathryn Taylor Teare, MSN, CRNP, CDE
• Medtronic Diabetes

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Objectives

• By the end of this program, the participant will
  be able to
• Calculate the carbohydrate content of a given
  meal
• Understand the pharmacodynamics of rapid-acting
  insulin
• Differentiate between basal and bolus insulin
• Identify a patient who would benefit from an
  insulin pump
• Calculate baseline dosages for a given patient
• Identify the benefits of continuous glucose
  monitoring in the clinical setting

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CarbohydrateCounting
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What about Fiber?

• A carbohydrate that is not digested
• Fiber amounts gt 5 grams can be subtracted from
  the total carbohydrate
• 1/2 cup cereal
• 27 grams carbohydrate
• 6 grams fiber
• Subtract fiber grams for a total of 21 grams

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Quick Guide to Carb Counting
Fruit / juice ½ cup 15 grams
Starchy veggies ½ cup 15 grams
Non-starchy veggies ½ cup 5 grams
Bread 1 slice 15 grams
Pasta ½ cup 15 grams
Rice 1/3 cup 15 grams
Milk 1 cup (8 oz) 12 grams
Soda 1/2 cup (4 oz) 15 grams
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How much carbohydrate for me???

• Age, Height, Weight, Sex
• Activity level
• Medication treatment plan
• PREFERENCES
• 50 grams per meal- FEMALES (150 / day)
• 60 grams per meal- MALES (180 / day)

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Insulin
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INSULIN

• Stimulates the entry of glucose into cells for
  use as a source of energy
• Inhibits the production of glucose from the
  glycogen in liver or muscle cells
• Promotes the storage of glucose as glucogen in
  muscle and liver cells
• Inhibits formation of glucose from
  non-carbohydrates, such as amino acids
• Stimulates the entry of amino acids into cells,
  enhancing protein synthesis
• Enhances fat storage and prevents the
  mobilization of fat for energy

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The Basal/Bolus Insulin Concept

• Bolus Insulin (Mealtime or Prandial)
• Limits hyperglycemia after meals
• Immediate rise and sharp peak at 1 hour
• 10 to 20 of total daily insulin requirement at
  each meal
• Basal Insulin
• Suppresses glucose production between meals and
  overnight
• Nearly constant levels
• 50 of daily needs
• Ideally, for insulin replacement therapy, each
  component should come from a different insulin
  with a specific profile

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Insulin Pump

• Rapid-acting insulin is given continuously over
  the 24 hours
• Rates of infusion can be individualized
• Mealtime and correction bolus as needed
• Greater flexibility and glucose control for the
  motivated individual

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From Evolution to Revolution
Guardian iPro
1999
2003
2005
2007
2008
Continuous Glucose Monitoring Systems
Glucose Monitoring
Insulin Delivery
MiniMed, Paradigm, and Bolus Wizard, are
registered trademarks of Medtronic MiniMed, Inc.
System Gold and Medtronic CareLink are
trademarks of Medtronic MiniMed, Inc.
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Insulin Used in Intensive Control Rapid-Acting

• Human insulin analogues
• Approved for treatment of diabetes with
  intermediate and long-acting insulins or in CSII
• Used as bolus insulin for meals / snacks and as a
  basal insulin in CSII
• Begin working in 5 minutes
• Peak at 50-60 minutes
• Half-life 2-2½ hours
• Duration of action- 3-4 hours
• NovoLog- Insulin Aspart
• Humalog- Insulin Lispro
• Apidra- Insulin Glulisine

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Who benefits from an Insulin Pumps

• MDI
• Flexibility
• Significant fluctuations in blood glucose
• Significant fluctuations in carbohydrate
  ingestion
• Cannot achieve goal A1c on MDI
• Motivated individual
• Good support system

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Who should NOT be on a pump

• Not willing to check blood glucose as at least
  4-6 times a day
• Altered mental status
• Not willing to count carbohydrates
• Not willing to treat hyper and hypoglycemia

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Insulin Pumps

• Medtronic MiniMed Paradigm
• Animas IR-2020 / Ping
• Accu-chek Spirit
• Insulet Omnipod
• Solo

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Case Study 1

• Karen T. is an 18-year old female with Type 1
  diabetes who had been on MDI for 3 years.
• Current regimen
• Lantus 25 units qhs
• Novolog 5 units with meals
• Her blood glucoses are running in the 200s.
• She is to be started on an insulin pump
• But where to start!!!!

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Calculating Insulin Needs

• Current Total Daily Dose (TDD) minus 25
• or
• 0.5-1.0 units / kg of body weight
• Adjust based on SBGM
• Basal dose is 50 of TDD
• Can vary 45-60
• Bolus insulin dose is 50
• Can vary 40-55

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Calculating Insulin Needs

• Determine TDD
• Current TDD (40u) 25 (10u) 30 units
• or
• 0.5-1.0 units / kg of body weight
• 60kg adult
• Estimated TDD is 30-60 units
• Adjust based on SBGM
• Basal dose is 50 of TDD (15 units)
• Can vary 45-60
• Bolus insulin dose is 50 (15 units)
• Can vary 40-55

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Basal Rate

• Suppresses glucose production between meals and
  overnight
• Basal dose / 24 hours
• (15 units / 24 hrs .625 or .60 units / hour)
• Adjust per SBGM
• Basal needs vary throughout the day
• Nocturnal hypoglycemia
• Dawn phenomenon
• Exercise / physical activity
• Menstrual cycle
• Illness

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Bolus dosing

• Insulin to cover the carbohydrate content of the
  meal
• Insulin to return current hyperglycemia to target
  blood glucose
• Adjust for current hypoglycemia

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Calculating Insulin CarbohydrateRatio
Amount of carbohydrate that 1 unit of insulin
will cover, bringing the blood glucose into
target range about 3-4 hours postmeal
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Rule of 500

• 500 / TDD of insulin
• Amount of carbohydrate that 1 unit of insulin
  will cover, bringing the blood glucose into
  target range about 3-4 hours postmeal
• Rule of 450- May be more appropriate for those
  who have more insulin resistance. Often used
  with insulin pump

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Rule of 500

• 500 / 30 16.67
• Amount of carbohydrate that 1 unit of
  rapid-acting insulin will cover, bringing the
  blood glucose into target range about 3-4 hours
  postmeal
• InsulinCarbohydrate Ratio 117
• Rule of 450- May be more appropriate for those
  having more insulin resistance Often used with
  insulin pump
• 450 / 30 15
• InsulinCarbohydrate Ratio is 115

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Insulin Sensitivity Factor
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Insulin Sensitivity Factor (ISF) orCorrection
Factor

• Amount of blood glucose reduction achieved by 1
  unit of sq insulin
• Used to return blood glucose to premeal targets
• Rule of 1500
• Rule of 1700
• Rule of 1800

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Rule of 1500

• Developed by an endocrinologist
• Best used for those with more insulin resistance
• 1500 / TDD
• Adjust as needed
• 1500/30 50
• Insulin Sensitivity Factor is 50
• 1 unit of insulin will lower the blood glucose by
  50mg/dL in 3-4 hours

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Rule of 1800

• The Rule of 1500 was adjusted by a CDE insulin
  pump specialist
• Best used with rapid-acting insulin or those with
  more insulin sensitivity
• 1800 / TDD
• Adjust as needed
• 1800/30 60
• Insulin Sensitivity Factor is 60
• 1 unit of insulin will lower the blood glucose by
  60mg/dL within about 3-4 hours

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Determining the Correction or Supplemental
Doseusing the Insulin Sensitivity Factor
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Correction or Supplemental Dose

• Current blood glucose
• Target blood glucose
• ISF
• CurrentTarget Amount above target
• Amount above target / ISF
• Correction dose of insulin

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Correction or Supplemental Dose

• Current blood glucose is 275
• Target blood glucose is 100
• ISF is 56 mg/dl
• 275 100 175
• 175 / 60 2.91
• Correction dose of insulin is 2.9 units

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Karens settings

• Basal rate 0.60
• IC Ratio 115
• ISF 60
• Target 90-120mg/dL

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Flexibility
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Basal Rates

• Suspend
• Temporary basal
• Basal patterns

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Basal Rates

• Suspend
• Exercise
• Hypoglycemia
• Bathing / swimming
• Temporary basal
• Exercise
• Illness
• Unexpected rise or fall in blood glucose

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Basal Rates

• Basal patterns
• Shift workers
• Menstrual cycle
• Weekend pattern
• Regular change in activity
• Travel
• Exercise

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Bolus

• Square / Dual Wave
• (Extended / combination)
• Bolus dose calculator
• Carbohydrate data base
• Bolus history
• Time of day variations in bolus needs
• Time of day variations in blood glucose targets
• Calculation of active insulin (IOB)

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Glucose ManagementSoftware

• Adherence- behavioral report. Are they using the
  device as advised
• Meter / Sensor - blood glucose and sensor
  readings
• Daily insulin use
• Blood Glucose Log
• Device Settings
• On line

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CareLink
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CareLink
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CGMS

• Glucose sensor
• Transmitter / recorder
• Glucose readings in the interstitial fluid are
  measured continuously
• Average of these measurements displayed every 5
  minutes (288/day)
• Calibrated at least twice a day
• Greater accuracy with more frequent proactive
  calibration

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Insulin Pump and CGMS
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The Sensor Catheter
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How does the sensor workThe 3 layers of the
sensor

• Semi-permeable membrane
• Glucose Oxidase
• Platinum wire
• The transmitter measures electrical current
  caused by this breakdown of the hydrogen peroxide
  (isigcurrent in nanoamps)
• The more glucose in the more peroxide is formed
  the more current is generated
• Calibration assigns a blood glucose value to the
  amount of current that is being generated

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Optimal Sensor Insertion
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I-PRO

• Medtronic 3 day glucose sensor
• Recorder is attached to sensor
• Patient checks FSBG qid, and keeps a food diary.
• Recorder and glucose meter readings downloaded
  into a computer program
• Reimbursed by Medicare and BC/BS

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IPRO- non diabetic
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I-PRO
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IPRO
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IPRO
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IPRO
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I-PRO

• CPT codes
• Continuous Glucose Monitor Study (3 days)
• 95250 Diagnostic study
• 95251 Interpretation
• Reimbursement
• Medicare- 156
• BC/BS- 130
• Allowed every 6 months
• Cost of I-PRO system
• Starter kit Recorder plus 10 sensors- 1300
• Additional recorders- 900
• Additional sensors- 35 each

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Special Populations

• Children
• Blindness
• Elderly
• Dementia

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Support SystemFamilies / Teachers/ Caretakers

• Signs of hypoglycemia / hyperglycemia
• Suspend / Disconnect
• Treatment of hypoglycemia
• Treatment of hyperglycemia
• Use of a blood glucose monitor
• Access medical assistance

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Hypoglycemia

• Counting carbohydrates and bolusing correctly
• Monitoring blood glucose
• Increase the insulin carbohydrate ratio 1 unit
  of insulin covers more carbohydrate
• Decrease the basal insulin
• Instruct on calculating correction carbohydrate
  intake

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Calculating Correction Carbohydrate Intake

• Target blood glucose (100)
• Pre-meal blood glucose (55)
• ISF (60)
• Insulincarbohydrate ratio (115)
• Carbohydrate of IC Ratio (Rise in blood glucose
  needed)
• ISF
• 15 (45) Amount of carbohydrate that needs to
  be ingested
• 60
• 11.25 or 12 grams

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Revenue Generation with Insulin Pumpsand CGMS

• Patient training
• Documentation of diagnostic testing meets
  criteria for level 4 office visit
• I-PRO
• Procedure
• Interpretation

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Putting it all Together

• Case Studies

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Case Study 1

• Karen T. is an 18-year old female recently
  diagnosed with Type 1 diabetes.
• Karen weighs 60kg
• Her blood glucoses are running in the 200s.
• She needs to be started on insulin
• But where to start!!!!

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Karen T.

• Teach carbohydrate counting
• Encourage 60 grams of carbohydrate per meal (3
  meals a day)
• Start with TDD of 30 units
• Basal rate 0.625
• IC 115
• ISF 60
• Target 90-120

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Karen Ts Breakfast

• Morning fasting pre-breakfast blood glucose is
  180
• Karen will be eating 60 grams of carbohydrate
• Her goal blood glucose is 120mg/dl
• She will use a rapid-acting insulin
• 60/15 4.0 units
• 60/601.0 units
• Total dose 5.0 units

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Karen Ts Lunch

• Pre-lunch blood glucose is 135
• Karen will be eating 60 grams of carbohydrate
• Her goal blood glucose is 120mg/dl
• She will use a rapid-acting insulin
• 60/15 4.0 units
• 15/600.25 units
• Total dose 4.25 units

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Case Study 2David T.

• David T. is a 56-year old male who has had Type 2
  diabetes for 15 years.
• He currently is taking a TZD, a sulfonylurea, and
  metformin.
• David weighs 100kg.
• His blood glucoses are running in the 200s.
• His CRNP wants to start him on insulin
• But where to start!!!!

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Calculating Insulin Needs

• 0.5-1.0 units / kg of body weight
• 100 kg adult
• Estimated TDD is 50-100 units
• Adjust based on SBGM
• Determine TDD
• Basal dose is 50 of TDD (25-50 units)
• Can vary 45-60
• Bolus insulin dose is 50 (25-50 units)
• Can vary 40-55

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David T.

• Teach carbohydrate counting
• Encourage 60 grams of carbohydrate per meal (3
  meals a day)
• Start with TDD of 50 units
• Basal 25units/24 hours 1.05 u/hr
• Now for the bolus doses

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David T.

• Insulin Carbohydrate Ratio
• 450/50 units
• 1 unit insulin 9 grams carbohydrate
• Insulin Sensitivity Factor
• 1700/50 34
• 1 unit of insulin will lower the blood glucose by
  34mg/dl

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David Ts Breakfast

• Morning fasting pre-breakfast blood glucose is
  235
• David will be eating 60 grams of carbohydrate
• His goal blood glucose is 120mg/dl
• He will use a rapid-acting insulin
• 60/9 6.7 units
• 135/343.4 units
• Total dose 10.1 units

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David Ts Lunch

• Pre-lunch blood glucose is 155
• David will be eating 60 grams of carbohydrate
• His goal blood glucose is 120mg/dl
• 60/9 6.7 units
• 35/34 1.0 units
• Total dose 7.7 units

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Case Study 3Jackie

• Jackie is a 58-year old female who has had Type 2
  diabetes for 20 years.
• She is currently is taking a TZD, metformin
  Humulin 70/30, 20 units in the morning and 10
  units in the evening.
• Her most recent HgbA1c is 8.0
• Jackie weighs 176 lbs (80kg) and is 54.
• Her blood glucoses are running in the 200s.
• Her CRNP wants to change her insulin regimen
• What would you do?

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Calculating Insulin Needs

• Current TTD 30u - 25 22.5u
• OR
• 0.5-1.0 units / kg of body weight
• 80 kg adult
• Estimated TDD is 40-80 units
• Adjust based on SBGM
• Determine TDD
• Basal dose is 50 of TDD (20-40 units)
• Can vary 45-60
• Bolus insulin dose is 50 (20-40 units)
• Can vary 40-55

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Jackie

• Teach carbohydrate counting
• Encourage 60 grams of carbohydrate per meal (3
  meals a day)
• Start with TDD of 30 units
• Basal 0.60u/hr
• IC 15
• ISF 57
• Target 90-120

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Jackie

• Insulin Carbohydrate Ratio
• 450/30 15 units
• 1 unit insulin 15 grams carbohydrate
• Insulin Sensitivity Factor
• 1700/30 56.67
• 1 unit of insulin will lower the blood glucose by
  57 mg/dl

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Jackies Breakfast

• Morning fasting pre-breakfast blood glucose is
  240
• Jackie will be eating 60 grams of carbohydrate
• Her goal blood glucose is 120mg/dl
• 60/15 4.0 units rapid acting
• 120/57 2.1 units rapid acting
• Total dose 6.1 units rapid acting

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Jackies Lunch

• Jackie had an small apple (15gms) around 10am.
• Her pre-lunch blood glucose is 205
• Jackie will be eating 75 grams of carbohydrate
• Her goal blood glucose is 120mg/dl
• 75/15 5.0 units
• 85/38 2.3 units
• Total dose 7.3 units
• Should she have taken insulin with her apple?
  How much?
• 15/151.0 units

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Questions?
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Thank You !

• Kathryn Taylor Teare, MSN, CRNP, CDE
• Diabetes Clinical Manager
• Huntsville, AL Territory
• Kathryn.Teare_at_Medtronic.com
• 426-5970