Using the Accu-Chek Aviva Expert
Bolus Advisor
Diabetes Education Network
May, 2012
Dr K Barnard CPsychol AFBPsS
Overview
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Diabetes and personal motivation
Hidden challenges facing people with diabetes
Accu-Chek Aviva Expert Bolus Advisor
How can we use the bolus advisor to support
patient self-management
The Here and Now – Diabetes is Tough
• Sustained daily effort to maintain ‘good’
diabetes control
• Lots of new rules ….. BUT no cure
• Abundant and sometimes competing medical
advice from HCPs and family/friends
• No obvious immediate benefit
• No guarantees
What Does Motivation Look Like?
What Does Motivation Look Like?
Does You Feel Like This Sometimes?
Ignorance?
• Assumption: simply increasing patients'
knowledge of treatment would be an effective
means of reducing non-compliance (Ley 1988)
• We know that this is not true. One of the
biggest barriers to optimal self management is
the ability to calculate bolus doses
Hidden Difficulties
• Complex mathematical calculations required
to work out bolus insulin requirements
• 45% of UK adults have only primary school
maths ability i.e. aged 7-10 years
• GCSE maths or above is required for effective
bolus calculations
• Approx 80% of people struggle with the maths
a/w bolus dosing
Barriers to Intensification
• Many patients do not intensify their insulin
regimens because of fear of hypoglycemia.
• One severe hypo can be a strong deterrent from
having another one
• A significant percentage of patients with diabetes
remain well above their glycemic goals
• Intensification of therapy can improve glycaemic
control and reduce risk of complications
Sub-optimal Self-Management
• Despite the proven benefits of effective
diabetes management, many people with
diabetes are reluctant or unable to follow
and/or adjust their insulin regimens as needed
• Many people with T1DM perform selfmonitoring of blood glucose (SMBG) at
suboptimal levels
Support for Self Management
• Structured education e.g. DESMOND, EXPERT,
DAFNE, BERTIE
• Individualised treatment plans in collaboration
with patient
• Carbohydrate counting tools e.g. carbs and
cals
• Bolus advisor
Bolus Calculation Requirements
Calculation of an insulin dose is a complex
process requiring knowledge of:
– Pre-prandial glucose level
– grams of carbohydrate
– insulin sensitivity
– insulin-to-CHO ratio
– active insulin on board
Why So Hard?
• Maths: 1 unit of insulin for 10g carbs. Eating
100g carbs. BG 4.8; no exercise planned.
BUT:
how often in reality is it that straightforward?
More Typically …
• 1 unit of insulin for 13g carbs. Eating 68g
carbs. BG 9.4; (ISF 1.5 units to lower bg by 3)
no exercise planned.
• OR: 1 unit of insulin for 8g carbs. Eating 115g
carbs. BG 12.3; (ISF 1.2 units to lower bg by
2); stressful meeting planned
Bolus Calculations
Based on 3 meals a day, no snacks:
– 21 calculations a week
– 84 calculations a month
– 1095 calculations a year
Bolus Calculations
So if you throw in a biscuit with your morning
coffee and a bit of supper:
Based on 3 meals a day, plus 2 snacks:
– 35 calculations a week
– 150 calculations a month
– 1,825 calculations a year
Accu-Chek Avia EXPERT Meter
• An insulin bolus advisor (BA) can help reduce the
burden of diabetes self management
– The BA recommends the appropriate
insulin dose according to the carbohydrate
content of meals, current blood glucose
level and patient target range
– Difficult calculations can be avoided;
greater accuracy in insulin boluses;
reduced risk of long term complications
contf
enabling
and
• BA use is safe and effective in managing postprandial
glucose excursions
Gross et al, 2003; Zisser et al, 2010.
Existing Use of Bolus Advisors
• bolus advisors have been very effective in
insulin pump therapy to help people
accurately calculate their insulin doses
• Once a person’s individual parameters have
been set into the device, in association with
clinical team, the only requirement is to tell
the device how many carbs are in a meal and
what the current b.g. level is
Pilot Data
• Survey of 1,412 T1DM patients treated with MDI
at 270 hospitals in the UK and Republic of Ireland
• Aim: to assess attitudes and behaviors regarding
insulin therapy after use of a bolus advisor
• Participants: 588 respondents; age 0-70 years,
diabetes duration of 0 - >15 years.
• Respondents had 4-12 weeks prior experience
using the bolus advisor.
Pilot Data
• Results:
– 52.0% of respondents indicated that fear of hypoglycemia
was reduced (39.0%) or significantly reduced (13.0%)
– 78.8% indicated that confidence in the insulin dose
calculation improved (50.8%) or significantly improved
(28.0%)
– 89.3% indicated that the bolus advisor made bolus
calculation easy or very easy compared with manual
calculation
Barnard et al. J Diab Sci Tech, 2012
What Does That Mean?
• No more difficult and complicated
mathematical equations to work out every
time you eat
• Less stress a/w meal times
• Parents report reduced anxiety and increased
confidence in their children’s ability to selfmanage at school
What Participants Said
• “It has changed my life, HbA1c is 8 from 12.”
• “It has made me a healthier person and made
living with diabetes a lot easier”
• “Makes me feel more secure in my control.”
• “HbA1c is down from 10.9 to 8.3 mmol/l and is
a great tool for my driving ability and
convenience.”
What Participants Said
• “I have much more confidence now and don’t
fear hypos because of it.”
• “I feel more confident about the insulin dose I
have to take when eating.”
• “It has given us the confidence to move to MDI
and made the transition an awful lot easier.”
Conclusions
• Using the bolus advisor was easier than
manual bolus calculation
• Reduced fear of hypoglycemia
• Increased confidence in bolus calculation
• Improved ability to control bG levels and
achieve glycemic goals,
• Sense of increased flexibility in lifestyle, and
improvement in overall well being
Hvidovre Hospital Data
The BolusCal Study Use of Flexible Intensive
Insulin Therapy and an Automated Bolus
Calculator in MDI Treated Type 1 Diabetes
A study of the effects of carbohydrate counting and
and automated bolus calculator in patients with
poorly controlled type 1 diabetes treated with
multiple daily injections
PI: Signe Schmidt, Dept of Endocrinology
Hypotheses
• Non-optimally treated, carbohydrate countingnaïve patients with type 1 diabetes can achieve
better metabolic control, treatment satisfaction
and quality of life by counting carbohydrates
• The benefits can be further improved by
concurrent use of an automated bolus calculator
• HbA1c primary outcome
• Secondary psychosocial outcomes and change in
distribution of bg values
Design
• A 16-week randomized controlled study
• Inclusion criteria : Age 18-65 years; Diabetes duration ≥
12 months; HbA1c 8-10.5%; MDI therapy (rapid-acting
analog for meals; long-acting analog as basal)
• Exclusion: Current or former practice of carbohydrate
counting; Gastroparesis; Pregnancy or nursing
• 3 parallel study arms:
- Control (MDI)
- CarbCount (MDI and carb count)
- CarbCountABC (MDI, carb count, bolus advisor)
Method
Results
Baseline
16 weeks
Change
Change Adjusted
for Baseline
HbA1c
Control
9,1 ± 0,7%
8,9 ± 1,1%
-0,1%
(-1,0 – 0,7%)
0,0%
[Reference]
Carb
Count
9,2 ± 0,6%
8,4 ± 0,9%
-0,8%
-0,6%
(-1,3 – -0,3%) (-1,2 – 0,1%)
Carb
Count
ABC
8,8 ± 0,7%
8,1 ± 0,4%
-0,7%
-0,8%
(-1,0 – -0,4%) (-1,4 – -0,1%)
p = 0.056
Conclusions
• Non-optimally treated, carbohydrate
counting-naïve patients with type 1 diabetes
can achieve better metabolic control,
treatment satisfaction and quality of life by
counting carbohydrates
• The benefits can be further improved by
concurrent use of an automated bolus
calculator
UK/Germany Next Steps
Design:
• Prospective, randomized, multi-centre study (17 German centres;
16 UK centres)
Duration:
• 26 weeks from November 2011
Sample Size:
• 285 – assuming a drop-out rate of 20%
• Sample size of 228 (114 per study group) results in ≈80% power to
detect a mean difference of 0.5%, with SD of 0.9% presuming a
one-sided 5% significance level, by taking two age strata (18-30
years & >30 years) into account
RCT Primary Outcome
• Determine whether use of a BA improves
glycemic control in people treated with
multiple daily insulin injections (MDI)
Secondary Outcomes
• Change in time spent within blood glucose (bG) target range
• Frequency and severity of hypoglycaemia
• Change in glycaemic variability parameters
• Change in magnitude of postprandial glucose excursions
• Frequency of bolus advisor use
• Frequency of participant adjustments to proposed bolus
amounts
• Self Monitoring of Blood Glucose test frequency
• Change in participants’ therapy adherence and use of rule sets
Results
The BA has the potential to:
• Help patients on MDI therapy safely and more
effectively manage their diabetes, thus
reducing both acute and long-term
complications
• Reduce the burden of diabetes selfmanagement, contributing to improved
diabetes control and quality of life
So What Difference Will It Make?
• Using the bolus advisor removes a major
barrier to effective self-management
• Helping patients to overcome a major hurdle
increases self-efficacy
• Increased self-efficacy is associated with
improved diabetes control (both biological
and psychosocial)
Goals – Who Knows Best?
• We may (and often do) know the best medical
advice to achieve optimal diabetes control
BUT
• Only our patients know whether they are
willing or able to achieve it
Diabetes
• Well controlled diabetes is the leading cause
of ……. NOTHING
• Optimising biomedical control alongside
psychosocial management is crucial
• Removing a major barrier to optimal diabetes
control is a massive step forward
Thank you
Any
questions?
For further information, please contact:
K.barnard@soton.ac.uk