Pumps and Sensors In the School Setting

2 Agenda Comparison of available insulin pumps Continuous glucose monitors Pump therapy & CGM in the school setting

3 Advantages of Insulin Pump Therapy  Improved glucose control  Decreased total daily insulin dose  More flexibility  Less injections  More independence  More ways to fix issues  Easy insulin delivery  “Smart Pumps” calculate insulin doses for you  “Insulin On Board” prevents insulin dose stacking  “Custom Fit” basal rates  Can use pump software to download the pump

4 Disadvantages of Insulin Pump Therapy  Expense and insurance issues  Possibility of skin infections at infusion site  Increased risk of ketones/DKA  24 hour attachment  Labor intensive process “feels like starting over”  Different troubleshooting protocols than before  Technical problems

5 How Pumps Are Similar Multiple ratios for carbs and correction factors can be entered for different times of day. Various bolus types are available (normal, extended, combo). Reminders and alerts can be activated Active insulin time: the pump will recommend a reduced bolus amount if insulin has been given in the recent past to prevent stacking doses. Temporary basal rates: can be adjusted up or down depending on circumstances (illness, travel, exercise). Memory: the pump will not lose its settings if the battery is changed or goes dead.

Accu-CHEK Spirit Combo Quick Facts: The Accu-CHEK Aviva Combo is a meter/remote. After a BG check, the remote can be used to bolus. If the remote isn’t available, a bolus can still be delivered via the pump, but the dose must be manually calculated. This system doesn’t offer a food database. Only correction insulin is counted toward insulin on board-insulin for carbs isn’t included. 6

Animas OneTouch Ping Quick Facts: The OneTouch Ping has a meter/remote. After a BG check, the remote can be used to bolus. If the remote isn’t available, a bolus can still be delivered via the pump. The blood sugar and carbohydrate grams can be entered in and the pump will calculate the insulin dose required. A food library is located in the remote only. Both carbs and correction are counted towards insulin on board. 7

Insulet OmniPod Quick Facts: The PDM device is a meter/remote. After a BG check, the remote can be used to bolus. If the PDM device is not available, a bolus cannot be delivered via the pod. The dose must be manually calculated and delivered via syringe or insulin pen. The pod will continue to deliver the basal insulin. A food database is located in the PDM. Both carbs and correction are counted towards insulin on board. 8

Medtronic MiniMed Paradigm Revel Quick Facts: When utilized, the Bayer Contour Next Link meter will transmit blood sugars automatically to the pump, but bolusing must be accomplished using the pump buttons. The Bayer meter is not a remote. This pump does not offer a food database. Both carbs and correction are counted towards insulin on board. 9

Medtronic MiniMed 530G with Enlite Quick Facts: When utilized, the Bayer Contour Next Link meter will transmit blood sugars automatically to the pump, but bolusing must be accomplished using the pump buttons. The Bayer meter is not a remote. The MiniMed 530G works in conjunction with the Enlite sensor. It automatically stops insulin delivery if the sensor glucose values reach a preset low threshold and there is no response to the sensor’s low BG alarm. This pump does not offer a food database. Both carbs and correction are counted towards insulin on board. 10

Tandem t:slim Quick Facts: This pump has a touch screen, much like a smart phone. Users do not have to use a specific BG meter with this pump. A bolus is delivered by typing in the carbs and BG using a touch screen keypad. This pump does not offer a food database. Both carbs and correction are counted towards insulin on board. This pump does not have a “reverse” correction if the tested BG is under the target. 11

Continuous Glucose Monitoring How it works: The sensor is placed into the subcutaneous fat tissue with an introducer needle. After a “wetting” period during which the sensor “soaks” in the interstitial fluid, the receiver asks the user to do a blood sugar calibration test. Results then start appearing on the receiver. The Medtronic sensor takes a reading of the glucose in the interstitial fluid every 10 seconds and sends an average of those readings to the receiver every five minutes, translating it into an equivalent blood sugar. The Dexcom continuously monitors the glucose and sends a real-time reading to the receiver every 5 minutes. This gives the user 288 “blood sugar checks” in a 24 hour period! 12

Why Use CGM? Hypoglycemia unawareness Young children who cannot verbalize their low blood sugars History of severe hypoglycemia History of DKA episode(s), post diagnosis Extreme glycemic excursions 13

Benefits of CGM Alerts when blood sugar passes high and low thresholds Pattern management – adjusting insulin therapy for tighter BG control Learning how to treat hypoglycemia more effectively: how much fast-acting carb and/or snack is really needed? Clarifies how everyday habits affect blood sugar levels Hypoglycemia and hyperglycemia prevention. Because one knows how the blood sugar is trending, intervention can be applied sooner. Feeling safer and more in control of diabetes 14

15 Pumps in the School Setting  Embrace insulin pumps – they can make diabetes management easier!  Pumps calculate the doses using formulas based on the blood sugar result and carbohydrate amount that is entered: no need to worry about math errors or delegating dose calculations to non-clinical support staff.  Because the pump keeps track of how much insulin is active in the body, children can be dosed as often as needed. They are not limited to the “three hour rule” of keeping insulin doses apart.  Don’t concern yourself with the programming of the pump. That is up to the parents, physicians and educators.

What You Need To Know  How to give a bolus  How to troubleshoot high blood sugars and/or ketones  How to treat hypoglycemia  How to manage exercise 16

17 Bolusing  A “bolus” is insulin given for carbohydrates and/or to correct a high blood sugar.  Bolusing can be done at anytime during the day, in consultation with the parents/caregivers and physician/educator.  How to give a bolus – Simple!  Enter blood sugar  Enter carbs (if eating)  Deliver the dose recommended by the pump

Hyperglycemia (>300 mg/dL)  Check for ketones, if possible. If ketone strips are not readily available, contact the parent to provide them. If not possible, follow the directions for negative ketones and proceed from there.  If ketones are negative, give a bolus with the pump and recheck the blood sugar in one to two hours. Push carb-free fluids.  If the blood sugar comes down, all is well. Back to class and normal activities!  If the blood sugar doesn’t come down… Give a high sugar correction with a syringe or insulin pen Change the infusion set/pod Push fluids and recheck the blood sugar and ketones in one to two hours 18

Ketones If the ketones are positive – call the parent or our clinic if not available. The student will need the following: Insulin via syringe or insulin pen A new infusion set/pod Fluids Exercise Avoidance 19

Hypoglycemia Troubleshooting Hypoglycemia For blood sugars <80 mg/dL use the 15/15 rule (15g fast-acting carb followed by a 15 minute blood sugar recheck) If the blood sugar is still 100 mg/dL. Snacks are per parent discretion. However, a snack is usually only needed if they have bolused within the past two to three hours. For severe hypoglycemia (loss of consciousness/seizure activity), use Glucagon as directed and suspend the pump or disconnect the infusion set. Don’t cut the tubing! Cutting the tubing will require the student to get new tubing. If it’s not readily available – how will they get insulin?! 20

21 Exercise  Confer with the parent to get specific directions about how they want exercise handled.  How to manage exercise – so many options!!!  Give extra carbs  Decrease the meal bolus if the exercise is following the meal  Set a temporary basal rate  Disconnect the pump from the infusion site (not for more than one hour)  Be sure to communicate with the PE teacher and/or coach the student’s plan for managing exercise.

CGM in the School Setting School staff shouldn’t worry about troubleshooting or placing the sensor. If it comes off or gives error messages – contact the parents. Work with the parents on how they want school staff to respond to sensor alerts. If too many alerts are disrupting the school day Obviously, the student’s insulin doses probably need to be adjusted! Contact the parents with your concerns. If needed, the parents can contact the doctor’s office for advice on dosing changes. Also, the setting for alerts can be changed to a wider window to decrease the amount of alerts. For example, the setting for a high alert can be changed from 200 mg/dL to 300 mg/dL instead. 22

THANK YOU!!! Questions or Comments? 23