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Insulin Pump Secrets & Settings for Great Glucose ControlJohnWalsh,PA,CDTCSaturday,March7,2015

Disclosure!Book sales – all pump companies!Advisory Boards – Companion Diabetes, Convatec, PicoLifeTechnologies!Consultant – Bayer, Roche, BD, Abbott, Tandem Diabetes,Acon Laboratories, Companion Diabetes!Speakers Bureau – Tandem Diabetes, Animas!Sub-Investigator – Glaxo Smith Kline, Animas, Lilly, Sanofi-Aventis,Bayer, Medtronic, Biodel, Dexcom, Novo Nordisk, Halozyme!Pump Trainer – Accu-Chek, Animas, Medtronic, Omnipod, Tandem!Web Advertising – Sanofi-Aventis, Sooil, Tandem DiabetesMedtronic, Animas, Accu-Chek, Abbott, etc.

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king!LimitaHonsoftheBolusCalculator

Advantages of an Insulin Pump!Average A1c reduction 0.2%1!Convenience!Software calculates dosesand tracks BOB!Easier to match varying needs!Less insulin stacking, less severe hypoglycemia, less BGvariability 2!Freedom of lifestyle!Better data (clinicians, pumpers, parents)*1Hsin- ‐ChiehY,etal:AnnInternMed.2012;157(5):336- ‐347.2PickupJC,Su onAJ:DiabetMed2008Jul;25(7):765- ‐74.

20thCenturyPumps

21stCenturyLinePumpsAccu- eSnapMedtronicRevelor530G

21stCenturyPatchPumps

RemoteControl willdothesameAnimasPingAccu- ‐ChekComboOmnipod

Advantages of a CGM!Average A1c reduction 0.7%1!Reads glucose every 5 min!Gives alarms for lows and highs!Security for wearer and family!Trend line and arrows guide bolus doses!Lower A1c, less severe hypoglycemia, less BG variability!Better data (clinicians, pumpers, parents)1YHsin- ‐Chiehetal:AnnInternMed.2012;157(5):336- ‐347.

CygnusGlucowatch(GW)" First FDA approved real timedevice (2001)" MARD 24.5%" Reverse iontophoresis" through intact skin" Significant Limitations" Poor performance" 13h duration" high hassle factor" skin irritation" discomfort limited useCygnusGlucowatchPackageinsert(2001)

CurrentCGM’s2014DexcomG4PlaHnum(505)MARD9.0%,1- ‐2weekuseMedtronicEnlightMARD13.9%,6- se,noalarms

u- ‐CheckAccu- ‐Check2016?ConnecHvityvia2015?BluetoothLowEnergy

Dexcom G4 and G5 –Animas, Asante, Omnipod, Tandem!High contrast color screens!1-2 week Dexcom G4 sensor!Internet access via Diasend,t:connect, Tidepool, iHealth!Share with Share App for iPhoneand iPod!Nightscout remote readings onAndroid!Predictive glucose suspend indevelopment

Dexcom G4AP vs Enlite AccuracyDexcomG4APwith505upgrade" MARD 9.0%1" ForBGs 70mg/dL(3.9mmol/L),MARDwas6.4mg/dL" 73%ofsensorshadMARD 10%" 92.4%ofreadingswereinClarkeerrorgridzoneAEnlite" MARD 13.6%2Bailey TS, Chang A, Mark Christiansen M: J Diabetes Sci Technol November 3, 20142. Bailey TS, Ahmann A, Mark Christiansen M, et al.: Diabetes Tech Therap. 2014, 16(5):277-2831.

PumpSetupTips16

Bolus Calculator SettingsThis SettingBasal ratesCarbF or I:C ratioCorrF or ISFTarget glucoseDIAHelpsSound sleepCover carbs wellLower highs safelyBG goal 4-5 hrs after bolusMinimize insulin occur

Which Way Do You Adjust Settings?Smaller factors larger boluses

BasalsfromTDD!SetBolusFactorsfromTDD! CarbF(carbohydratefactor)! BG!SetDIA(4.5hrsorlonger)!Repeatwhennecessary

APP Study – TDD, Basals, and arbGram/Day189.9185.2196.3187.91. 0,Vol4,#5,Sept2010

APP Study – Major Finding!Find an accurateTDD first!TDD is best guideto correct pumpsettings!Start patternmanagementAFTER the TDDand settings areoptimizedTDD controls frequency of lows and A1c/avg BG

Insulin Adjustments for GlucoseControl!If it ain’t broke, don’t fix it!!Mild – tweak pump settings or lifestyle!Moderate – For patterns, use pattern management.Otherwise calculate new TDD and retune pumpsettings!Severe – Reset TDD to an improved TDD (iTDD) andselect new settings from this iTDD to correct theproblem

UsetheTDDtoOpHmizePumpSesngs1Basalinsulin HalfoftheTDDCarbF 2.6xWt(lbs)TDDCorrF control iabetesnet.com/diabetes ence&Technology2010,Vol4,#5,Sept2010

Insulin(5thed),2012

4,TDD 80u(78- 45!DIA4hrs

UseDecisionSupportSoowareh p://www.diabetesnet.com/diabetes tools/pumpsesngs/

! Basalrate:1.7u/hr(originally1.8u/hr)! CarbF5.6(10)! CorrF23(45)! s.org

bolusStar1ngTDD 36uoRaisedbasalby0.05u/hrallday( 1.2u/day)oLoweredcarbfactorfrom1u/13gto1u/12g( 1.8u/day)EndingTDD 39u

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BasalRates30

Basal Tips – Avoid Over-Steering n0.5to0.8,or1.0to1.5u/hr beforeBGstartstoriseorfall Or5- ‐8hoursbeforeahighorlowreadingtypicallyhappens Over5basalsadayprobablyhasli esCare.2009;32(8):1437–1439.

Optimal Number of Basal Rates?Anybenefit?%Number of basal ratesused per day from selfreports of hundreds ofpumpers at insulinpumpers.orgOnce basal rate changes,it takes 3-5 hrs to have itsfull effect.*Using more than 5 basalsmay have little re.2009;32(8):1437–1439.

Check the Basals

BGdropto3hrsbeforestartshereBGdropbegins12am3am7am

Basal/Bolus BalanceIdeal Basal/Bolus Balance Differs by AgePrior to puberty30-45%High carbs, lower counter-regulatoryhormones, honeymoon phasePuberty40-55%High carbs, mid to high counterregulatory hormonesAdult45-60%Mid carbs, mid counter-regulatoryhormonesThin elderly40-50%Mid carbs, lower counter-regulatoryhormones

apumpforlows–providesnobenefitunHl60- educHon–pumprestartsonHme,fewerfollowuphighs

CarbBoluses37

CarbBolusTypesRegular! Takenimmediately–mostmealsCombo/dualwave! s,SymlinExtended/squarewave! tendedboluseswithoutaclearreason.

Get More Accurate Carb Boluses!Use carb counting resources!!Know portion sizes!!CalorieKing, MyFitnessPalMeasure portions onto plate at homeBase CarbF on TDD!CarbF (2.6 x weight) / TDD!Keepa record of doses that work!

Carb Factors Are Often Incorrect 1,2Carb Factors Found In 405 Pumps8070Number of Pumps6010CarbFsesngsfoundinpumpsCarbFs are not evenlydistributed.R2 0.403R2 0.403134 of 405 pumps (8.4%) had no carb factorPeople prefer “magic”numbers – 5, 10, 15,and 20 1516171819202122Formulas provideaccurate settings – better than WAG!Carb FactorDon’tuse“magic”numbers!1. 0,Vol4,#5,Sept20102. logyMeeHng2007

Stop Post Meal Spiking!Count carbs carefully!Bolus 15 to 30 min pre-meal!Use combo bolus with picky eaters!Delay eating until below 140 mg/dL!Eat more low GI foods, complex carbs, fewer carbs!Exercise after meals!Use a Super Bolus!Add fiber/psyllium/acarbose/Symlin/GLP-1 agonist

Clever Pump Trick –Bolus Early To Stop Meal torecommend!!!Bolus15- ‐30minearly–thebest- ‐keptsecretforbePercontrolGD Dimitriadis and JE Gerich: Importance of Timing of Preprandial SubcutaneousInsulin Administration in the Management of Diabetes Mellitus.Diabetes Care6:374-377, 1983.

Clever Pump Trick –Super Bolus – Shift Basal into s/meal Wt(lb)X0.36tostayincontrol2A Super Bolus shifts part of the next 2 to 3.5 hrs of basal insulin intothe bolus with less risk of a low later.1,21J.Walsh:h p://www.diabetesnet.com/diabetes presentaHons/super- inatedbasal- inpumptherapy.JDST,3(1),89- ‐97,2008

ses!Thesmallerthedeficit(be ses)1. 0,Vol4,#5,Sept2010

HowLongDoesaBolusLowertheGlucose?45

Duration Of Insulin ActionGlucose-lowering ActivityAccurate boluses require an accurate DIA02hrs4hrs6hrs

Insulin Action Time Duration of ActionFig. 2 Duration of Insulin ActionGlucose Infusion (mg/kg/min)Glucose Infusion (mg/kg/min)Fig. 1 Insulin Action Time3- ‐5hrsABInsulin Action TimeBasal Delivery Suppressed01234Time (hours)56IAT is measured between points A and B,and involves suppression of basal delivery.4.5- ‐6hrsCDuration of Insulin ActionADBInsulin Action TimeBasal Delivery Maintained01234Time (hours)56DIA is measured between points C and D.Once basal delivery is maintained, the PDof a bolus insulin can be directly nolJanuary2014vol.8no.1170- ‐178.

Bolus on Board / Insulin StackingBedtime BG 180 mg/dL – is there an insulin or a carb deficit?Bed1meBG 180mg/dL6pm8pm10pm12am

Insulin Stacking Is ster2007AACEMeeHng

Short DIA Times Hide BOB & Cause LowsHow much BOB a pump thinks is left 3 hours after a10 unit bolus for these DIA times:Pump’s estimate of Insulin On BoardIf DIA is set to:3 hr4.5 hr5.0 hr5.5 hrEstimated BOB is:0u2.5 u3.4 u4.0 u

Short DIA Times Cause fromthecarbbolusof4.5u.

Clever Pump Trick –How Many Carbs for a Low?1. 1 gram for each 10 lbs of weight (minimum 10 gr)2. Plus grams BOB* x CarbFExample: Amyʼs BG 52 mg/dL with 2u of BOB (CarbF 8 g/u)"At 140 lbs, she needs 14 grams of carb for the low glucose" Plus 2u BOB x 8 gram/u" 16 grams to offset BOBAmy needs 14 g 16 g 30 grams for this low*DIA1memustbeaccurate

WhenIsYourBolusCalculatorJustPlainWrong?53

Tuning and Tamingthe Bolus daHonsthatbe zinginsulinstacking

Pump Bolus Calculators OftenRecommend Excessive ds(col2),andwhatpumpsrecommend(cols3and4).CarbF 10gr/u;CorrF 50mg/dL;Target 100;DIA 5hrs

Extent of Insulin Overdose from a BCBolus Recommendations Differ between PumpsCarb Corr BolusTimeBGmg/dLCarbsEatenCarbBolusTotalIOB6:54 am11116009:52 am17403.0 u04.3 u4.3 u10:35 am140505.0 u3.3 u2.2 u5.0 u11:58 am117404.0 u3.6 u0.5 u4.0 u1:12 pm137002.3 uEat 19 gNo actionCozmoPumpOtherPumpsNo bolus hours!TDD 38 u, carb factor 10 g/u, corr factor 65 mg/dl, 65 mg/dL x 6.35 u 413 mg/dl fall in BG if Other Pump’s advice is followed

Check BC’s Recommended BolusBolusonboard(IOB) glucose- islargerthancor- begivecorrectbolusoncetheBGisbelowtarget

Case Study – Hypoglycemia From the bstocovertheirexcessiveBOB2hrs33yowoman,TDD 36units,CarbF10,DIA5hours

Case Study – Hypoglycemia From the BCBycommission: 33yowoman,TDD lbolusevenwhenexcessiveBOBispresent

Clever Pump Trick –Get an Accurate Bolus1. When BOB is smaller than correction bolus, therecommended pump bolus is CORRECT2. If BOB is larger than correction bolus, add carb andcorrection bolus, then subtract BOBExample: Carb bolus 2.9 u (Pump’s recommendation)Corr bolus 1.2 uBOB 4.3 uBOBlargerthanCorrbolusAccurate bolus 2.9 1.2 – 4.3 –0.1 unit bolus

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Life Is Better When You Know More!PI5onKindle,i- ‐Pad,andNook– 16.99Slidesatwww.diabetesnet.com/diabetes- ‐resources/diabetes- 800- ‐988- ‐4772

07!! Don'tuse! "magic"numbers! Stop Post Meal Spiking ! Count carbs carefully ! Bolus 15 to 30 min pre-meal ! Use combo bolus with picky eaters ! Delay eating until below 140 mg/dL ! Eat more low GI foods, complex carbs, fewer carbs .