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Amy Urbanus, RD, CDE Diabetes Specialist Providence Alaska Medical center.

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Presentation on theme: "Amy Urbanus, RD, CDE Diabetes Specialist Providence Alaska Medical center."— Presentation transcript:

1 Amy Urbanus, RD, CDE Diabetes Specialist Providence Alaska Medical center

2

3 Home Glucose Monitoring Continues to be one of the best tools for diabetes self-management Continues to be one of the best tools for diabetes self-management One is my war lance and the other is for monitoring my blood sugar

4 Things to Consider Cost/Insurance Strips Cost/Insurance Strips Accuracy Accuracy Dexterity of patient Dexterity of patient Alternate site testing Alternate site testing Lancing devices Lancing devices

5 Lifescan: One Touch One Touch Ultra Mini: Consumer Reports #1 meter One Touch Ultra Mini: Consumer Reports #1 meter One Touch Ultra 2 One Touch Ultra 2 One Touch Ultra Link One Touch Ultra Link One Touch Ultra Smart One Touch Ultra Smart One Touch Ping One Touch Ping All use One Touch test strips All use One Touch test strips Covered by insurance and Medicare Covered by insurance and Medicare Large displays Large displays Local customer support Local customer support

6 Accu-Chek Aviva Aviva Large test strips: good for patients with difficulty getting small test strips out of the bottle Large test strips: good for patients with difficulty getting small test strips out of the bottle Compact Compact Bulky meter, test strips come in a drum (no handling of test strips), lancing device attached to the meter Bulky meter, test strips come in a drum (no handling of test strips), lancing device attached to the meter Active Active Cheaper meter, good for non insured Cheaper meter, good for non insured

7 Freestyle Smallest sample 0.3 ml Freedom Lite Freedom Lite Freestyle Freedom Freestyle Freedom Freestyle meter integrated with the Navigator CGM and OmniPod Freestyle meter integrated with the Navigator CGM and OmniPod All Freestyle meters use the same strip that is challenging for some to use, very small, can not see blood on strip All Freestyle meters use the same strip that is challenging for some to use, very small, can not see blood on strip

8 Other Meters Reli-on Reli-on Wal-Mart's meter; question accuracy Wal-Mart's meter; question accuracy Strips individually wrapped and difficult to get open Strips individually wrapped and difficult to get open TRUE Track TRUE Track Cheaper meter. Many pharmacies will try to encourage patients to trade out their Accu- Chek or One Touch meter for this cheaper brand claiming better reimbursement. Better for the pharmacy, not the patient Cheaper meter. Many pharmacies will try to encourage patients to trade out their Accu- Chek or One Touch meter for this cheaper brand claiming better reimbursement. Better for the pharmacy, not the patient

9 Lancing Devices Most meters use similar lancing device Most meters use similar lancing device Multiclix by Accu-Chek Multiclix by Accu-Chek Drum of needles Drum of needles Sold as not being as painful Sold as not being as painful Can purchase separately Can purchase separately

10 Insulin Delivery Pens, syringe or pump?

11 Insulin Pens The New Trend in Hospitals Providence Alaska Medical Center Providence Alaska Medical Center Novolog FlexPen Novolog FlexPen Lantus syringe Lantus syringe Alaska Regional Hospital Alaska Regional Hospital Novolog Flex Pen Novolog Flex Pen Lantus SoloStar Pen Lantus SoloStar Pen Bartlett Fall 09 Humalog KwikPen Lantus SoloStar Pen Alaska Native Medical Center Novolog FlexPen Lantus syringe

12 Types of Insulin Pens Rapid Acting Insulin Rapid Acting Insulin Novolog FlexPen: Prefilled 300 units Novolog FlexPen: Prefilled 300 units Humalog KwikPen: Prefilled 300 units Humalog 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 cartridge Humalog Memoir Pen: 300 unit cartridge Humalog Luxura Pen: 300 unit cartridge, can be dosed in ½ units Humalog Luxura Pen: 300 unit cartridge, can be dosed in ½ units Basal Insulin Basal Insulin Lantus SoloStar Pen: prefilled 300 units Lantus SoloStar Pen: prefilled 300 units Opticlick pen phasing out Opticlick pen phasing out Levemir FlexPen : prefilled 300 units Levemir FlexPen : prefilled 300 units Many mixed Insulins and older insulins also come in pens Many mixed Insulins and older insulins also come in pens

13 Pros/Cons to Insulin pens Advantages Advantages Easy to dial up dose Easy to dial up dose Can count clicks Can count clicks Kept at room temperature Kept at room temperature Portable Portable More discrete More discrete Memoir Pen: good for patients with multiple care givers, able to identify last dose administered Memoir Pen: good for patients with multiple care givers, able to identify last dose administered Disadvantages Disadvantages Only 300 units Pens look similar, rapid acting and basal could get mixed up Pen is large Difficult to plunge Hold needle in for 5 seconds to ensure administration

14 Supplies/Cost: Insulin Pens Supplies Same needle works for all pens Same needle works for all pens Must write a script for needles Must write a script for needles Many patients end up with the pen only Many patients end up with the pen onlyCost Vials and pens are now the same cost Vials and pens are now the same cost Medicaid will not cover insulin pen unless medically necessary Medicaid will not cover insulin pen unless medically necessary

15 Hospital Issues and Insulin Pens Providence If patients are discharged on the same insulin regimen, they will automatically be given the Novolog FlexPen If patients are discharged on the same insulin regimen, they will automatically be given the Novolog FlexPen Medicaid will not pay for this Medicaid will not pay for this Insulin Pen Needles Hospital safety needles look different than the outpatient needles

16 Insulin Pumps

17 Benefits of Insulin Pump Therapy Improved glycemic control and decreased variability in blood sugar Improved glycemic control and decreased variability in blood sugar Improved control of dawn phenomenon Improved control of dawn phenomenon Decrease frequency of hypoglycemia Decrease frequency of hypoglycemia Flexibility of lifestyle Flexibility of lifestyle Flexibility of basal rates: units/hr – 25 units/hr Flexibility of basal rates: units/hr – 25 units/hr

18 First Things First! Assess appropriate patients Patients need to be able and willing to: Multiple daily injections Multiple daily injections Have and use syringes or pens as a backup Have and use syringes or pens as a backup Check BS 6 + x/ day Check BS 6 + x/ day Keep records Keep records

19 Assessment Cont. Attend all appointments with physician and educators Attend all appointments with physician and educators Carbohydrate count and adjust meal plan Carbohydrate count and adjust meal plan Perform Insulin : CHO ratio and sensitivity factor calculations without use of pump calculators Perform Insulin : CHO ratio and sensitivity factor calculations without use of pump calculators

20 Insulin Pump Comparison Most Common in Alaska Medtronic Minimed Paradigm 522/722 Medtronic Minimed Paradigm 522/722 Animas One Touch Ping Animas One Touch Ping OmniPod OmniPod

21 MiniMed Paradigm 522/ or 300 unit reservoir 176 or 300 unit reservoir Temporary basal rate Temporary basal rate Exercise Exercise Sick Day Sick Day Bolus increment of 0.1 unit Bolus increment of 0.1 unit Normal, squarewave, audio bolus features Normal, squarewave, audio bolus features Bolus wizard Bolus wizard

22 MiniMed Paradigm Cont. AAA battery with 2-4 weeks of life AAA battery with 2-4 weeks of life Used in water up to 3 feet for 30 minutes Used in water up to 3 feet for 30 minutes Sensor screen on insulin pump Sensor screen on insulin pump Can be used with One Touch Ultra Link Meter Can be used with One Touch Ultra Link Meter

23 OmniPod Pod is all in one: insulin, infusion set, and battery Pod is all in one: insulin, infusion set, and battery 200 unit capacity 200 unit capacity Separate PDM for programming Separate PDM for programming PDM has a Freestyle BG meter PDM has a Freestyle BG meter Temporary basal rate Temporary basal rate unit bolus increments unit bolus increments Normal or extended bolus Normal or extended bolus Bolus calculator on PDM Bolus calculator on PDM 2 AAA batteries in PDM 2 AAA batteries in PDM Pod is water tight Pod is water tight Pod needs to be changed out every 3 days Pod needs to be changed out every 3 days

24 One Touch Ping Meter/Remote Meter/Remote Programming on pump or meter/remote Programming on pump or meter/remote One Touch BS meter One Touch BS meter 200 unit reservoir 200 unit reservoir bolus increment bolus increment Extended bolus feature Extended bolus feature Bolus calculator Bolus calculator Battery Battery 1 AA alkaline with 2-4 wks life 1 AA alkaline with 2-4 wks life 1 AA lithium 4-6 weeks life 1 AA lithium 4-6 weeks life Waterproof up to 12 feet for 24 hrs Waterproof up to 12 feet for 24 hrs

25 How Much?? Self Pay Costs Insurance coverage and monthly cost should be analyzed Insurance coverage and monthly cost should be analyzed Average Insulin Pump start up (MiniMed or One Touch) Average Insulin Pump start up (MiniMed or One Touch) $6000-$7000 $6000-$7000 Infusion sets and reservoirs: average $150/month Infusion sets and reservoirs: average $150/month OmniPod: OmniPod: Start up:$1750 (PDM and 2 pods) Start up:$1750 (PDM and 2 pods) Monthly expense: $450/ month for 10 pods Monthly expense: $450/ month for 10 pods Pay as You Go Pay as You Go

26 Dont Forget the Insulin and Test Strips!! Rapid Acting Insulin ~ $100/ vial in Anchorage Rapid Acting Insulin ~ $100/ vial in Anchorage Advantage to pump Advantage to pump Only one co pay Only one co pay Home Glucose Monitoring Test Strips Home Glucose Monitoring Test Strips ~ $1 per strip ~ $1 per strip

27 Insurance Fairly good coverage for insulin pump therapy by both private insurance and Medicare/Medicaid Fairly good coverage for insulin pump therapy by both private insurance and Medicare/Medicaid 20% out of pocket cost per month ~ $ 30 for supplies 20% out of pocket cost per month ~ $ 30 for supplies Currently OmniPod does not accept Medicare Currently OmniPod does not accept Medicare

28 Continuous Glucose Monitoring

29 Basic Concept 3 Parts 1. Sensor Patients wear a glucose sensor that is inserted similarly to an insulin pump and sends data continuously to a transmitter Patients wear a glucose sensor that is inserted similarly to an insulin pump and sends data continuously to a transmitter 2. Transmitter Transmitter then sends the data to a receiver Transmitter then sends the data to a receiver 3. Receiver Hand held receivers: Navigator and Dexcom Seven Hand held receivers: Navigator and Dexcom Seven Paradigm insulin pump Paradigm insulin pump Provides glucoses value as well as graphs with a visual of BG trend Provides glucoses value as well as graphs with a visual of BG trend

30 Abbott NavigatorMiniMed Real Time Dexcom Seven Plus

31 Who Could Benefit? Frequent nocturnal hypoglycemia Frequent nocturnal hypoglycemia Hypoglycemia unawareness Hypoglycemia unawareness Postprandial hyperglycemia Postprandial hyperglycemia Dawn phenomenon Dawn 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

32 Standard Features All need to be calibrated with fingerstick blood sugar All need to be calibrated with fingerstick blood sugar Wetting time for initiation period usually hr (over night) Wetting time for initiation period usually hr (over night) Must be calibrated periodically during wear Must be calibrated periodically during wear Sensor life 3-7 days Sensor life 3-7 days Patients report 2-3 weeks of wear Patients report 2-3 weeks of wear

33 CGM Standard Features Cont. All have alarms to set for hyperglycemia and hypoglycemia that can be customized All have alarms to set for hyperglycemia and hypoglycemia that can be customized Note: if receiver or pump is under a pillow, most likely will not hear alarm Note: if receiver or pump is under a pillow, most likely will not hear alarm Sensor/transmitter are water resistant Sensor/transmitter are water resistant

34 Insurance/Cost Many more patients are getting coverage for CGM by private insurers Many more patients are getting coverage for CGM by private insurers Currently no Medicare coverage Currently no Medicare coverage Start up ~ $1000 for transmitter Start up ~ $1000 for transmitter Transmitter good for ~ 1 year Transmitter good for ~ 1 year $ / month for sensors $ / month for sensors

35 There are many exciting tools available now, and more to come in the future, to help improve control and ultimately quality of life. Thank You


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