1. Diabetes Devices Workshop
Angela Aldrich, PharmD, PhC
April Mott, PharmD, PhC, BCPS
Presbyterian Medical Group
28 January 2018

2. Pumps & Sensors & Meters, Oh My!

3. A Tale of Two Meters
Technology for glucometers has advanced over recent years.
These newer meters can usually be worked “cold” by someone who has experience handling glucometers in general, but many of the highly useful features are not immediately obvious and require a read of the manual to get the full benefit of the advances.

4. Accu-Chek Guide Accu-Chek’s newest general use meter.
Pairs with smart phones, pads, and computers.
Analyzes patterns and reminds patient to test.
Easy to program.
Strips are inexpensive through coupon program.
Accu-Chek Guide

5. Coupon Program
Attached to the side of each box is a coupon that will allow a patient (with a prescription) to obtain from 50 strips for $19.99 up to 300 strips for $69.99 (cash price).
Coupon is to be run as insurance instead of patient’s insurance.
Meters can be obtained for free by going to Accu-Chek website.

6. New Strip Case

7. Buttons Meter turns on when OK is pushed or a strip is inserted.
Back arrow takes you to the previous screen.
Up and down arrows allow you to scroll.
OK button proceeds to new screen/selects item.

8. Buttons and Ports
Button on right side of meter ejects strip and port connects with computer to exchange data. Port is not for charging.

9. Settings Menu

10. Time/Date Scroll to set current time/date.
Click OK to progress to next field.

11. Allows meter to beep when a reminder goes off (more to come).
Beeper
Allows meter to beep when a reminder goes off (more to come).

12. Wireless Settings Flight Mode disables wireless capabilities.
Default Device lists primary paired device name.
Auto-Send causes readings to be synced automatically with paired devices (up to 5) when meter is turned on and in close proximity.
Sync Time automatically syncs meter time with primary device time.

13. Pairing Meter
Shows a code you then type into your cell phone to pair the devices.
Up to five devices can be paired to one meter at a time.

14. Pairs with Cell Phone
Shows Graph of BG readings, Logs, meal and insulin detail. Patient can add a picture of meal associated with a specific test.

15. More Options

16. Target Ranges

17. Patterns
As data is entered into the meter this allows pattern analysis to occur. Reports show patterns in high and low data.

18. Reminders

19. Post Meal Reminder

20. Last Result

21. My Data

22. My Data Logbook scrolls through history
Averages shows for 7, 14, 30, 90 days
This can be split into Overall, Before meal, After meal, Fasting, and Bedtime categories.
Target % Shows same data with regard to % above, within, and below goal.
Low/High Data sorts and displays all lows or all highs

24. Simpler than Guide if no pairing.
One Touch Verio Flex
Simpler than Guide if no pairing.
Can be used alone but increased functionality if paired with a smart phone.
Major advantage is that 2 different meters can be paired with the same cell phone at once. The Log readings for both meters merge into one coherent log on patient’s smart phone device.

25. Two Verio Flex Meters, One Log!
Add picture of graphs in next inserted slide

26. Less intuitive to program but has cheats on the back.
3 Button Model
Less intuitive to program but has cheats on the back.

27. Types of CGM Office based sensors Patient based sensors
Collect specific time frame of data for download at set time
No real time data available to patients
Helps identify glycemic patterns to assist with a1c lowering with less hypoglycemia, helps to understand variability
Patient based sensors
Require readers for patient to determine glucose levels and patterns
Patients can check blood sugar frequently without sampling blood
May be helpful with neuropathic/vision impaired patients
Transmitter sensors
Have ability to transmit to insulin pumps, tablets, smartphones, watches
288 readings per 24 hours with Dexcom
Could transmit from children at school, seniors in facilities
Typically requires calibration (2x daily shown here)
On the horizon
Rumors of apple watch beta testing bloodless CGM

28. Continuous Glucose Monitoring Case
Self Monitored Results: Novolin 70/30 mix 50 units prior to breakfast and lunch, 55 units prior to dinner

29. Case

30. Insulin Pumps
Insulin pumps approved to utilize short-acting insulin analogues
Lispro-Humalog
Aspart-Novolog
Glulisine-Apidra
Relieve patients using multiple daily injections of basal/bolus insulin.
For Example:
Levemir 20 units sq qam and
50 units sq qpm
Novolog tid ac and hs

31. Insulin Pumps Benefits Challenges
More precise and accurate insulin dosing can better regulate blood glucose (BG).
Customized, flexible basal and bolus dosing to meet lifestyle demands.
Less severe hypoglycemia.
Challenges
Requires self-monitoring of blood glucose at least 4 times/day.
Requires thorough training.
Diabetic ketoacidosis can develop quickly if insulin delivery is interrupted for a period of time.
Blood glucose regulation is complex.
Pumps are not a cure, but a drug delivery method to treat diabetes, they require more monitoring, record keeping and evaluation but can lead to better control
Not a license to forget that a patient has diabetes

32. Insulin Pump Features Allow for variation in basal rates
Activity/sleep
Dialysis
Weekend/weekday
Bolus doses can be
Flat dosing such as 20 units prior to meals
Based on carbohydrate estimation: 1 unit per 15 g CHO
Corrected for blood sugar levels: 1 unit for every 16 mg/dL >130mg/dL
Extended dosing for target meals: pizza effect where fats and protein delay carbohydrate absorption

33. Pump Settings that Factor into Pump Therapy
Basal Rate
Carb Ratio (Insulin-to-Carb Ratio)
Target BG (Blood glucose)
Correction Factor (Insulin Sensitivity)
Insulin Duration (Duration of Insulin Action)

34. Pump Case Type 1 Diabetic, 20 year old college student
Levemir 15 units sq bid
Novolog roughly 10 units tid
1 unit:15gCHO + 1 unit for every 50mg/dL>150mg/dL
Often wakes up hypoglycemic, wakes up ~11 am, doesn’t follow carb and correct dosing tightly goes to bed about midnight
A1c 11.2% (AVG Gluc: 275 mg/dL)

35. How to convert? How would you set her basal rate?
Currently getting 30 units basal insulin per day
Converts to 1.25 units per hour
Consider early am hypoglycemia
I used 2 basal rates 0.9 units per hour from midnight until 11 am, (10 units) then increased her rate to 1.15 units per hour from 11 am till midnight (15 units)
Decrease of 5 units basal per day, but with steady delivery, typically more insulin activity than with multiple basal injections

36. Hyperglycemia with Pump

37. Hypoglycemia with Pump
Not allowing pump to calculate bolus
Carbohydrate counting error
Insulin stacking (correcting too soon)
Basal set too high
Programming error
Insulin Duration setting not accurate
Behaviors/Life
Exercise or activity
Alcohol

38. Evaluating and Adjusting Basal Rates
If basal rates are set appropriately, BG’s should not fluctuate more than 30 mg/dl during testing.
If BG drops more than 30 mg/dl, decrease the basal rate 2-4 hours before the change occurs.
If BG rises more than 30 mg/dl, increase the basal rate 2-4 hours before the change occurs.
Adjustments should be no more than a 5 to 10% increase or decrease.
Retest - basal rate testing is a “work in progress”.
Let’s see if Jessica can provide a screen shot of the computer program she uses to adjust basal dosing on pumps from a read of a pump paired with a Dexcom.

39. References
Accu-Chek. (2016). Accu-Chek Guide: User’s Manual for Single Patient Use Only Blood Glucose Meter Hague Road, Indianapolis, IN 46256: Roche Diabetes Care, Inc.
One Touch. ( ). One Touch Verio Flex: Owner’s Booklet Instructions for Use. Gubelstrasse 34, 6300 Zug, Switzerland. Lifescan Europe, Division of Cilag, GmbH International.