1. Management Tools and CGM Kathryn Moe, RN CDE Medtronic Diabetes

2. Objectives Define the terms basal and bolus Define the terms basal and bolus Define how basal and bolus apply to Define how basal and bolus apply to insulin pump therapy Explain how the insulin pump can calculate Explain how the insulin pump can calculate insulin doses based on ICR set up by the dietitian Define Continuous Glucose Monitoring Define Continuous Glucose Monitoring

3. Objectives cont’d Explain the difference between professional Explain the difference between professional and personal cgm Explain how cgm can be utilized by the dietitian to assess correct ICR Explain how cgm can be utilized by the dietitian to assess correct ICR

4. Diabetes 101 Types of Diabetes Mellitus Types of Diabetes Mellitus Pathophysiology Pathophysiology Treatment Modalities Treatment Modalities

5. Types of Diabetes Mellitus Type 1 Type 1 Type 2 Type 2 Gestational Gestational LADA LADA

6. Definition of DM Metabolic disorder involving the beta cells of the pancreas Metabolic disorder involving the beta cells of the pancreas A group of diseases marked by high levels of blood glucose resulting from defects in insulin production, insulin action, or both A group of diseases marked by high levels of blood glucose resulting from defects in insulin production, insulin action, or both

7. Type 1 Type 1 Diabetes Mellitus Type 1 Diabetes Mellitus Caused by an autoimmune disorder that results in pancreatic beta cell destruction and absolute insulin deficiency Caused by an autoimmune disorder that results in pancreatic beta cell destruction and absolute insulin deficiency Makes up ~ 5 to 10% of all DM Makes up ~ 5 to 10% of all DM Must have exogenous insulin in order to survive Must have exogenous insulin in order to survive

8. Type 2 Insulin Resistance Insulin Resistance Increases with age, obesity, and inactivity Increases with age, obesity, and inactivity Primary Beta Cell Dysfunction and Beta Cell Loss Primary Beta Cell Dysfunction and Beta Cell Loss Results from loss of beta cell mass and the inability of the beta cells to recognize glucose Results from loss of beta cell mass and the inability of the beta cells to recognize glucose

9. Gestational DM Occurs during pregnancy Occurs during pregnancy Can often resolve after delivery Can often resolve after delivery Can return later in life as Type 2 Can return later in life as Type 2

10. LADA Form of Type 1 Form of Type 1 Diagnosed usually after the age of 30 Diagnosed usually after the age of 30 Non-obese individuals Non-obese individuals Insulin dependency gradually occurs Insulin dependency gradually occurs

11. Treatment Modalities Lifestyle changes Lifestyle changes Oral agents Oral agents Insulin Insulin Nutrition Nutrition

12. How insulin pumps mimic pancreatic insulin secretion Uses only rapid acting insulin analogs Uses only rapid acting insulin analogs Uses basal/bolus insulin delivery Uses basal/bolus insulin delivery Can quickly make adjustments up or down in the basal rate Can quickly make adjustments up or down in the basal rate Bolus features that can accommodate glucose release from high fat foods, gastroparesis, etc… Bolus features that can accommodate glucose release from high fat foods, gastroparesis, etc…

13. Time Insulin  Normal Insulin Secretion  Pump Delivery Schematic representation only The Pump: More like a Healthy Pancreas Delivery that's customizable, flexible, adjustable Delivery that's customizable, flexible, adjustable Can more closely match the natural delivery patterns of the pancreas Can more closely match the natural delivery patterns of the pancreas

14. Programming the Bolus Wizard ® Calculator Grams: Carb ratio = number of carb grams covered by 1 Unit of insulin Grams: Carb ratio = number of carb grams covered by 1 Unit of insulin Exchanges: Carb ratio = number of insulin Units needed to cover 1 (1.0) carb exchange Exchanges: Carb ratio = number of insulin Units needed to cover 1 (1.0) carb exchange Insulin pump allows up to 8 settings for different carb ratios at different times of the day Insulin pump allows up to 8 settings for different carb ratios at different times of the day Select Carb Ratios. Press ACT. Edit Settings WizardOn Carb Units: Grams Carb Ratios:- - - Carb Ratios: Setting Carbohydrate Ratios

15. Blood Glucose (BG) Within Target Range – Estimate Details Est total:4.0U Food intake:60 gm BG:82 Food:4.0U Correction:0.0U Active ins:0.0U ACT to proceed, ESC to back up Food: Correction: Est total: Example BG Within Programmed Range BG: 82 mg/dL SF = 30 Carbs: 60 g ICR = 15 BG is between 80 and 100 mg dL No correction calculated 60 = 4.0 U 15g TARGET RANGE 1 12:00A mg / dL 80 – 100 No Correction Insulin Calculated

16. Continuous Glucose Monitor Professional Professional Personal Personal

17. CGM Analyzes interstitial glucose Analyzes interstitial glucose Physiologic lag Physiologic lag Not finger stick replacement Not finger stick replacement Gold Standard is still blood glucose values Gold Standard is still blood glucose values Blood glucose readings are still needed Blood glucose readings are still needed to calibrate the sensor and keep it tracing BG does not equal SG BG does not equal SG Focus on the trends of the glucose Focus on the trends of the glucose

18. Professional CGM Has been used in a clinical setting since 1999 Has been used in a clinical setting since 1999 Wear for 3-5 days Wear for 3-5 days Blinded study Blinded study 288 glucose values in 24 hours 288 glucose values in 24 hours Clinic owned equipment Clinic owned equipment Reimburseable Reimburseable Assess time periods, ICR Assess time periods, ICR

20. Patient Responsibility Testing four times a day Testing four times a day Fill out food log sheet Fill out food log sheet Bring the device back to the office 6 days later Bring the device back to the office 6 days later

21. Dex Com

22. C.A. – Lantus @ bedtime, Humalog SS

23. J.D. – Lantus in AM and bedtime, Humalog @ meals

24. K.V. – N and H in AM, H @ dinner, N @ bedtime

26. Sensor Modal Time Periods

28. Personal CGM Can be used along with an insulin pump or Can be used along with an insulin pump or still on injections 288 glucose values in 24 hrs 288 glucose values in 24 hrs Consumer owned Consumer owned See the values in real time See the values in real time FDA approved 2006 FDA approved 2006

29. MiniMed Paradigm Insulin Pump REAL-Time Continuous Glucose Monitoring; MiniLink® Transmitter The MiniMed Paradigm REAL- Time System What is the MiniMed Paradigm ® REAL-Time System?

30. Guardian RT

31. Dex Com

32. Meals are determined when carbs and insulin are first entered together in Bolus Wizard® calculator during the selected time blocks View of one hour before individual meals and the time period after meals. Numerical and pie chart description of glucose before and after meals, during evening and overnight time periods. Use the colors to easily see target ranges and when in range, or above or below Up to 7 days of data Use this report to help keep glucose in range after eating Sensor Overlay by Meal

33. Breakfast rise and fallRepeating post dinner seen here in picture & averagesdrop in glucose Meal marker additional food markers color - coded by day Sensor Overlay by Meal

34. First Insulin Pump First Insulin Pump

35. First Person to Take Insulin Leonard Thompson Leonard Thompson

36. Questions Thank You