1. Diabetes and Technology: Insulin Delivery and Monitoring
Amy Urbanus, RD, CDE
Diabetes Specialist
Providence Alaska Medical center

2. Home Glucose Monitoring

3. Home Glucose Monitoring
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 Accuracy Dexterity of patient
Alternate site testing
Lancing devices

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

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

7. Freestyle Smallest sample size @ 0.3 ml Freedom Lite Freestyle Freedom
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

8. “Other” Meters Reli-on TRUE Track Wal-Mart's meter; question accuracy
Strips individually wrapped and difficult to get open
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

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

10. Insulin Delivery
Pens, syringe or pump?

11. Insulin Pens The New Trend in Hospitals
Providence Alaska Medical Center
Novolog FlexPen
Lantus syringe
Alaska Regional Hospital
Novolog Flex 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 Basal Insulin
Novolog FlexPen: Prefilled 300 units
Humalog KwikPen: Prefilled 300 units
Apidra SoloStar Pen: Prefilled 300 units (new April ’09)
Humalog Memoir Pen: 300 unit cartridge
Humalog Luxura Pen: 300 unit cartridge, can be dosed in ½ units
Basal Insulin
Lantus SoloStar Pen: prefilled 300 units
Opticlick pen phasing out
Levemir FlexPen : prefilled 300 units
Many mixed Insulins and older insulins also come in pens

13. Pros/Cons to Insulin pens
Advantages
Easy to dial up dose
Can “count” clicks
Kept at room temperature
Portable
More discrete
Memoir Pen: good for patients with multiple care givers, able to identify last dose administered
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
Same needle works for all pens
Must write a script for needles
Many patients end up with the pen only
Cost
Vials and pens are now the same cost
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
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 control of dawn phenomenon
Decrease frequency of hypoglycemia
Flexibility of lifestyle
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
Have and use syringes or pens as a backup
Check BS 6 + x/ day
Keep records

19. Assessment Cont. Attend all appointments with physician and educators
Carbohydrate count and adjust meal plan
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
Animas One Touch Ping
OmniPod

21. MiniMed Paradigm 522/722 176 or 300 unit reservoir
Temporary basal rate
Exercise
Sick Day
Bolus increment of 0.1 unit
Normal, squarewave, audio bolus features
Bolus “wizard”

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

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

24. One Touch Ping Meter/Remote 200 unit reservoir 0.025 bolus increment
Programming on pump or meter/remote
One Touch BS meter
200 unit reservoir
0.025 bolus increment
Extended bolus feature
Bolus calculator
Battery
1 AA alkaline with 2-4 wks life
1 AA lithium 4-6 weeks life
Waterproof up to 12 feet for 24 hrs

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

26. Don’t Forget the Insulin and Test Strips!!
Rapid Acting Insulin ~ $100/ vial in Anchorage
Advantage to pump
Only one co pay
Home Glucose Monitoring Test Strips
~ $1 per strip

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

28. Continuous Glucose Monitoring

29. Basic Concept 3 Parts 1. Sensor 2. Transmitter 3. Receiver
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”
3. Receiver
Hand held receivers: Navigator and Dexcom Seven
Paradigm insulin pump
Provides glucoses value as well as graphs with a visual of BG trend

30. Abbott Navigator
MiniMed Real Time
Dexcom Seven Plus

31. Who Could Benefit? Frequent nocturnal hypoglycemia
Hypoglycemia unawareness
Postprandial hyperglycemia
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
“Wetting time” for initiation period usually 2-12 hr (over night)
Must be calibrated periodically during wear
Sensor life 3-7 days
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
Note: if receiver or pump is under a pillow, most likely will not hear alarm
Sensor/transmitter are water resistant

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

35. Thank You amy.urbanus@providence.org
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