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

Home Glucose Monitoring

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”

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

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

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

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

“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

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

Insulin Delivery Pens, syringe or pump?

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

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

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

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”

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

Insulin Pumps

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: 0.025 units/hr – 25 units/hr

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

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

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

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”

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

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 0.05-0.1 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

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

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”

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

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

Continuous Glucose Monitoring

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

Abbott Navigator MiniMed Real Time Dexcom Seven Plus

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

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

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

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 $275-350/ month for sensors

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 amy.urbanus@providence.org