1. WHAT’S NEW IN DIABETES Lisa Still, RN,CDE Diabetes Specialty Nurse Arkansas Children’s Hospital November 2011

2. New devices Insulin pen devices Insulin pumps Cgm

3. Insulin Pens Easier for patients to carry with them. Discreet. Looks like an ink pen Easy storage and disposal Used only for one patient ( pen devices should not be shared between patients). Less likely to break if dropped when compared to vial.

4. Rapid acting insulin pens

5. Pen cartridges

6. Long acting insulin pens

7. Pen needles

8. Insulin pumps Continuous Subcutaneous Insulin Infusion (pump therapy) Subcutaneous delivery of insulin via external electro-mechanical device. Has small plastic cannula in sub q tissue. Delivery regimen mimics the basal/bolus delivery pattern of a pancreas. Can deliver various basal rates throughout the day. Allows flexibility of dosing for snacks without having to take additional injections.

9. Delivery is extremely precise. Pump accurately delivers doses down to 0.025 unit of insulin REMEMBER.... The Insulin Pump is a computer. It can only do what the user tells it to do. Requires decisions from user. User requires Blood glucose data and carbohydrate content to make good decisions

10. Insulin pumps

11. Injection and pump site

12. Infusion sets Animas one touch ping Medtronic Omnipod

13. Un-tethered pump regimen Patient takes Lantus as basal. Connect to pump site for bolus. Allows patient to be “off pump” for extended time without extreme excursions. If patient forgets to take Lantus, will have ketones very quickly.

14. Continuous Glucose Monitoring Overview Continuous Glucose Monitoring (CGM) consists of a glucose sensor, a transmitter, and a small external monitor (may be built-in to an insulin pump or a stand- alone device) to view your glucose levels.

15. Why CGM? Continuous Glucose Monitoring (CGM) provides more complete information than finger sticks, helping you to make better decisions, which leads to better glucose control. In fact, finger sticks can miss many of the potentially dangerous highs and lows that may occur throughout the day, which can impact your glucose control. CGM can provide valuable information at crucial points during the day. This includes before and during exercise, prior to driving, prior to test/exam-taking, and in the middle of the night. It is still required to check blood glucose levels with a finger stick before administering insulin.

16. Benefits of CGM Some specific benefits of adding CGM to your diabetes therapy management include: Easily knowing your glucose levels at all times Anticipating glucose level changes Being able to avoid upcoming lows and highs Easily finding glucose patterns Also, CGM has been proven to be an effective tool to: Reduce the frequency and duration of highs and lows Reduce A1C, which can lead to reduced risk of complications Reduce A1C without increase to extreme lows

17. CGM Dexcom Partnered with Animas and omnipod In the future Medtronic

18. Type 2 Diabetes Typically seen in obese and overweight children who are physically inactive Increasing in epidemic proportions. Caused by both genetics and environmental factors. 50%-80% have a parent with a family history of type 2 diabetes. Will possibly be the next cause of morbidity and mortality in the next generation. Occurs as a result of insulin resistance and some insulin deficiency. Insulin resistance occurs when the liver and muscles are not sensitive to the insulin that is being produced.

19. Acanthosis Nigricans

20. Treatment for Type 2 diabetes Meal planning- we will give them a set meal plan with a cap on carbs. Increased activity- Need at least 30 minutes of physical activity every day. Metformin (Glucophage)- only tablet that is FDA approved for use with children over 12. None for children under 12. Insulin- Basal/Bolus with the hope of tapering off of insulin completely.

21. Research Research studies that we are doing currently for type 1 diabetes is TrialNet. Screening first and second degree relatives between the ages of 1-45 for autoantiboidies for T1DM. There are 3 clinical trials that we are participating in for T2DM. The first one is a Daiichi Sankyo study the use of colesevelam oral suspension as monotherapy or add-on to metformin in pediatric subjects. Colesevelam is marketed for adults as an adjunct to diet and exercise to reduce LDL-cholesterol in patients with hyperlipidemia. Adult studies has shown that colesevelam in addition to pre-existing anti-diabetic therapy significantly reduces A1c. The other studies we are involved with are 2 studies are Evaluating the Safety and Efficacy of Sitagliptin in Pediatric Patients with Type 2 Diabetes Mellitus with Inadequate Glycemic Control. Again Sitaglipitin is an FDA approved drug that is used in conjunction with Metromin in adults with type 2 diabetes.

22. Contact information The best way to manage diabetes is to communicate with the team. Parents/caregivers can contact us by: Phone 501-364-1430 or 1-800-495-1048 Fax 501-364-6299 Email diabetesnurse@archildrens.orgdiabetesnurse@archildrens.org web based log book www.mycareconnect.com www.mycareconnect.com

23. References www.medtronic.com www.animascorp.com www.myomnipod.com www.childrenwithdiabetes.com/clinic/unt ethered.htm www.childrenwithdiabetes.com/clinic/unt ethered.htm tcoyd.org/tcoyd-team/steven-v.- edelman-md.html