Management Tools and CGM

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Management Tools and CGM

• Kathryn Moe, RN CDE
• Medtronic Diabetes

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Objectives

• Define the terms basal and bolus
• Define how basal and bolus apply to
• insulin pump therapy
• Explain how the insulin pump can calculate
• insulin doses based on ICR set up by the
• dietitian
• Define Continuous Glucose Monitoring

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Objectives contd

• Explain the difference between professional
• and personal cgm
• Explain how cgm can be utilized by the dietitian
  to assess correct ICR

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Diabetes 101

• Types of Diabetes Mellitus
• Pathophysiology
• Treatment Modalities

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Types of Diabetes Mellitus

• Type 1
• Type 2
• Gestational
• LADA

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Definition of DM

• Metabolic disorder involving the beta cells of
  the pancreas
• A group of diseases marked by high levels of
  blood glucose resulting from defects in insulin
  production, insulin action, or both

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Type 1

• Type 1 Diabetes Mellitus
• Caused by an autoimmune disorder that
  results in pancreatic beta cell destruction and
  absolute insulin deficiency
• Makes up 5 to 10 of all DM
• Must have exogenous insulin in order to
  survive

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Type 2

• Insulin Resistance
• Increases with age, obesity, and inactivity
• Primary Beta Cell Dysfunction and Beta Cell Loss
• Results from loss of beta cell mass and
  the inability of the beta cells to recognize
  glucose

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Gestational DM

• Occurs during pregnancy
• Can often resolve after delivery
• Can return later in life as Type 2

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LADA

• Form of Type 1
• Diagnosed usually after the age of 30
• Non-obese individuals
• Insulin dependency gradually occurs

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Treatment Modalities

• Lifestyle changes
• Oral agents
• Insulin
• Nutrition

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How insulin pumps mimic pancreatic insulin
secretion

• Uses only rapid acting insulin analogs
• Uses basal/bolus insulin delivery
• Can quickly make adjustments up or down in the
  basal rate
• Bolus features that can accommodate glucose
  release from high fat foods, gastroparesis, etc

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The Pump More like a Healthy Pancreas

• Delivery that's customizable, flexible,
  adjustable
• Can more closely match the natural delivery
  patterns of the pancreas

• Normal Insulin Secretion
• Pump Delivery

Insulin
Time
Schematic representation only
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Programming the Bolus Wizard Calculator
Setting Carbohydrate Ratios

• Grams Carb ratio number of carb grams covered
  by 1 Unit of insulin
• Exchanges Carb ratio number of insulin Units
  needed to cover 1 (1.0) carb exchange
• Insulin pump allows up to 8 settings for
  different carb ratios at different times of the
  day

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Blood Glucose (BG) Within Target Range
No Correction Insulin Calculated
60 4.0 U 15 g
Example BG Within Programmed Range BG 82 mg/dL
SF 30 Carbs 60 g ICR 15

BG is between 80 and 100 mg dL No correction
calculated
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Continuous Glucose Monitor

• Professional
• Personal

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CGM

• Analyzes interstitial glucose
• Physiologic lag
• Not finger stick replacement
• Gold Standard is still blood glucose values
• Blood glucose readings are still needed
• to calibrate the sensor and keep it tracing
• BG does not equal SG
• Focus on the trends of the glucose

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Professional CGM

• Has been used in a clinical setting since 1999
• Wear for 3-5 days
• Blinded study
• 288 glucose values in 24 hours
• Clinic owned equipment
• Reimburseable
• Assess time periods, ICR

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Patient Responsibility

• Testing four times a day
• Fill out food log sheet
• Bring the device back to the office 6 days later

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Dex Com
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C.A. Lantus _at_ bedtime, Humalog SS
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J.D. Lantus in AM and bedtime, Humalog _at_ meals
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K.V. N and H in AM, H _at_ dinner, N _at_ bedtime
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Sensor Modal Time Periods
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Personal CGM

• Can be used along with an insulin pump or
• still on injections
• 288 glucose values in 24 hrs
• Consumer owned
• See the values in real time
• FDA approved 2006

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What is the MiniMed Paradigm REAL-Time System?
REAL-Time Continuous Glucose Monitoring
MiniLink Transmitter
MiniMed Paradigm Insulin Pump
The MiniMed Paradigm REAL-Time System
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Guardian RT
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Dex Com
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Sensor Overlay by Meal

• Meals are determined when carbs and insulin are
  first entered together in Bolus Wizard
  calculator during the selected time blocks
• View of one hour before
• individual meals and the time
• period after meals.
• Numerical and pie chart
• description of glucose before
• and after meals, during evening and overnight
  time periods.
• Use the colors to easily see
• target ranges and when in range, or above or
  below
• Up to 7 days of data

Use this report to help keep glucose in range
after eating
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Sensor Overlay by Meal
Meal marker additional food markers color -
coded by day

Breakfast rise and fall Repeating post
dinner seen here in picture averages drop in
glucose
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• First Insulin Pump

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First Person to Take Insulin

• Leonard Thompson

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Questions

• Thank You