Best Practices … Or Suggestions on Diabetes Care What You Should Know Jeff Hitchcock Children with Diabetes October 2007

Goals for Today Background … or Why This Matters Overview of current tools and techniques Its more than type 1 diabetes Some science Hints at the future Mostly, reassurance

Knowledge is … "...you shall know the truth, and the truth shall make you free." -- John 8:32 Power -- Sir Francis Bacon Life: The person with diabetes who knows the most lives the longest. -- Elliott Joslin, M.D.

That was Then … Prior to 1980, 50% of people with type 1 diabetes would develop renal failure years after onset of diabetes

This is Now Age at Onset of Childhood-Onset Type 1 Diabetes and the Development of End-Stage Renal Disease Svensson, Diabetes Care 29:538–542, 2006

So, Whats Different? Home glucose monitoring Insulin analogs Insulin pumps Blood ketone measurement Continuous sensors And more importantly … … a realization that complications are not inevitable and you can do something about it

Tools … or Diabetes Technology Glucose Meters Other Meters LancingWhere the metal meets the skin Insulin delivery Other drugs Continuous sensors

What to Look for in a Glucose Meter Accuracy –Major brands make a difference –But technique matters Memory with PC download –Pattern analysis to reduce variability Intangibles –Lighting –Ease of use –On board data analysis

FreeStyle Flash / Lite Smallest meter 0.3 microliter sample 7+ second test time 250 test memory 14 day average 4 built in alarms for test reminders Built in backlight and test strip light Interfaces with a PC Most popular at CWD: 20% (Flash + Lite) Last poll:

ACCU-CHEK Compact Plus 17-test strip drum 1.5 microliter blood volume 5 second test time One handed testing Could attach to car dashboard and check while driving

OneTouch UltraSmart On board analysis and graphing 1 microliter sample 5 second test time 3,000 test memory Tracks glucose, insulin, food, and exercise Interfaces with a PC Clinical trial shows use can lower A1c

GlucoMON How do I know my child checked at … ? Wireless interface to a OneTouch Ultra Remote oversight of glucose testing Available in limited markets in the US

What we really need is … Biodegradable test strips

Other Meters: Ketone Testing Old Way: Urine –Yucky –15 seconds –As low as 10¢ per test –Accuracy issues –Force a child to pee? New Way: Blood –Familiar, easy –10 seconds –1.5 microliters –About $4 per test –Clinical benefits Diabetic Medicine 23 (3),

Lets save urine testing for … Proving that beer is in fact just rented … … and as a truth detector for athletes.

Other Meters: A1c Measurement Old way: venous blood draw, results long after the clinic visit Can be very stressful, sometimes painful In 1999, study showed that discussing A1c at clinic visit improved control Enter the DCA2000 and A1cNow+ Immediate feedback of HbA1c levels improves glycemic control in type 1 and insulin- treated type 2 diabetic patients (Diabetes Care Nov;22(11):1785-9) New A1cNow+ has variance of around 3% and a blood volume of 5 microliters. About $10 per test. Available for home use. DCA2000 is for office use. Finger stick sample, results in minutes.

Lancing Lancing is often overlooked, yet its a major reason people dont check because it hurts Many people rarely change lancets –25% report changing only when painful or bounces MultiClix is the best lancing device for kids –No exposed sharp ever –6 lancets on board –Very easy to use

How often … Number of blood glucose checks per day is increasing … … but changing lancets remains about the same – not often enough –24% said change due to excessive pain or when lancet bounces –23% change every time

Insulin Delivery – Some Science 65% of kids on pumps missed more than 1 meal bolus/week 2 missed meal bolus/week caused A1c to increase ½% Insulins a great drug if you take it -- Dr. Darrell Wilson, Stanford Burdick, Chase, Pediatrics 113: e221, 2004

Insulin Delivery – Injection Devices Pens and pen-like devices becoming more common in the US; the norm elsewhere Dosing convenience the issue Allows for very precise dosing that cannot be matched with syringes Downside is no mixing

Insulin Delivery – Insulin Pumps Studies show better A1c with lower risk of hypoglycemia, especially in grade school kids Studies show efficacy even in infants Untethered Regimen allows for pump breaks Pumps not shown to scale

But how do kids choose a pump? Color

SymlinAnother Drug Slows gastric emptying Suppresses postprandial glucagon secretion Makes you feel full sooner Can help you lose weight But … –Nausea at first –Must decrease insulin because of delayed absorption of food –Severe lows if not attentive Use in <18 off label

Diabetes Mixology Lantus –No change in A1c when mixed and immediately injected Glucagon –Glucagon is effective for at least 7 days once mixed and stored at room temperature Symlin –Anecdotal evidence shows no difference via syringe –Some reports of mixing in pumps This is all very off label J Pediatr Apr;148(4):481-4

Continuous Glucose Sensors Promises a revolution in diabetes care Minute-by-minute glucose data has dramatic clinical implications Predictive alarming for impending lows and highs Near Future: Sensor + Pump = Closed Loop (& sleep) MiniMed Paradigm® REAL-Time System DexCom Abbott Freestyle Navigator

Pumps and Sensors Today, one company has insulin pump and sensor data integrated –Integrated display of insulin delivery and glucose data –Insulin delivery separate from sensing (two probes) –No control of insulin delivery based on glucose data

Its Not About Blood Anymore Continuous sensors look at interstitial fluid, not blood Blood has been easy to access, but … … interstitial might be the better compartment We really care about the brain, not the fingertip Danish pot belly pig study

CGMS Performance From Use of Continuous Glucose Monitoring in the Detection and Prevention of Hypoglycemia by Howard A. Wolpert, M.D. (J Diabetes Sci Technol 2007; 1: ). Original from Evaluating the Clinical Accuracy of Two Continuous Glucose Sensors Using Continuous Glucose–Error Grid Analysis by William Clarke, et al (Diabetes Care : ) Performance of two sensors during induced moderate hypoglycemia.

CGMS Accuracy % MAD of HGM Diabetes Care 26:1176, 2003 From Bruce Buckingham, CWD FFL 2005

Sensor Summary Point accuracy not the same as finger stick glucose monitors, but … … interstitial fluid might be more relevant than finger stick blood Current point accuracy essentially the same as first generation blood glucose monitors Trend data has potential to improve care dramatically Low alarms

More than DiabetesCeliac Allergy to gluten (wheat, barley, rye) Autoimmune disease About 10% of people with type 1 have celiac Can explain erratic control Testing is easy … … Living with getting easier

The Effects of Celiac Left: Healthy villi – increases the absorption area of the intestinal mucosa to ~ 250 square yards Right: Villi that have been destroyed by celiac antibodies – absorption area just ~ 2 square yards Enormous variability in nutrient absorption negatively impacts predictability of food and therefore diabetes control From Ragnar Hanas, CWD FFL 2006

Some Science– Risk for Retinopathy Conventional Adapted from Diabetes 44: , 1995 From Irl Hirsch, DTM % Rate Per Patient Year 10% 9% 8% 7% Time During Study (Years) Mean HbA1c Intensive Rate Per Patient Year 9% 8% 7% Time During Study (Years) Mean HbA1c Tight Control Matters More Than We Thought

Could it be Glucose Variability? Cell death of human umbilical vein endothelial cells Variability in glycemic control may be more deleterious than a constant high concentration of glucose Am J Physiol Endocrinol Metab 281: E924-E930, 2001 From Irl Hirsch DTM2006

OK, So Give Me a Goal What makes this hard to achieve? –Not taking enough insulin (check fasting) –Miscounting carbs (under or over bolusing) –Gastroparesis or celiac –Not pre-bolusing or missing meal boluses –Erratic snacking and not covering with insulin –Absorption variability Youre not still using NPH are you? SD X 2 < MEAN From Irl Hirsch DTM2006

Hints at the FutureClosing the Loop Sensor + Pump = Set it and forget it? Semi closed loop –Pre-meal bolus, or at least partial pre-meal bolus –Even semi closed loop can provide essentially normal blood sugars for at least 1/3 rd of the day – at night Fully closed loop –Set it and forget it –Sensor lag (?) and kinetics of insulin action remain a major challenge Is glucagon also needed? –At recent Diabetes Technology Meeting, 60% of attendees decided yes after one presentation (vs. 47% pre)

Why Even Semi-Closed Loop Matters Artificial External Insulin Pump GARRY M. STEIL, Diabetes 53:A3, 2004 SLEEP! This is relatively old data using older sensor technology

Sensor glucose levels during CL control vs. home open-loop pump therapy From Stu Weinzimer, DTM 2006

Comparing Closed vs. Semi Closed Loop: Single Meal Example From Stu Weinzimer, DTM 2006

Reference Glucose Levels in Closed Loop Versus Hybrid (Semi Closed) MeanDaytimePeak PP Full CL Hybrid From Stu Weinzimer, DTM 2006

We Proudly Wear our Technology Monica with Navigator (yes, in a study) Kenny with DexCom (yes, off label) Hugh of Borg with Borg Drone Suit (not FDA approved)

In Closing … The tools are good and getting better Pump therapy has decided advantages Dont be afraid to mix More data means better decision making –Continuous sensing is real and makes a difference Variability might be as important as A1c Get checked for celiac The future looks very bright The tools have made a dramatic impact on reducing the risk of complications