Management Tools and
CGM
Kathryn Moe, RN CDE
Medtronic Diabetes
Objectives
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Define the terms basal and bolus
Define how basal and bolus apply to
insulin pump therapy
Explain how the insulin pump can calculate
insulin doses based on ICR set up by the
dietitian
Define Continuous Glucose Monitoring
Objectives cont’d
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Explain the difference between professional
and personal cgm
Explain how cgm can be utilized by the
dietitian to assess correct ICR
Diabetes 101
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Types of Diabetes Mellitus
Pathophysiology
Treatment Modalities
Types of Diabetes Mellitus
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Type 1
Type 2
Gestational
LADA
Definition of DM
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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
Type 1
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Type 1 Diabetes Mellitus
Caused by an autoimmune disorder that
results in pancreatic beta cell destruction and
absolute insulin deficiency
Makes up ~ 5 to 10% of all DM
Must have exogenous insulin in order to
survive
Type 2
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Insulin Resistance
Increases with age, obesity, and inactivity
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
Gestational DM
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Occurs during pregnancy
Can often resolve after delivery
Can return later in life as Type 2
LADA
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Form of Type 1
Diagnosed usually after the age of 30
Non-obese individuals
Insulin dependency gradually occurs
Treatment Modalities
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Lifestyle changes
Oral agents
Insulin
Nutrition
How insulin pumps mimic
pancreatic insulin secretion
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Uses only rapid acting insulin analogs
Uses basal/bolus insulin delivery
Can quickly make adjustments up or down in
the basal rate
Bolus features that can accommodate glucose
release from high fat foods, gastroparesis,
etc…
The Pump: More like a Healthy
Pancreas
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Delivery that's customizable, flexible, adjustable
Can more closely match the natural delivery patterns
of the pancreas
Normal Insulin Secretion
Pump Delivery
Insulin
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Time
Schematic representation only
Programming the Bolus Wizard® Calculator
Setting Carbohydrate Ratios
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Grams: Carb ratio = number of
carb grams covered by 1 Unit of
insulin
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Exchanges: Carb ratio = number of
insulin Units needed to cover
1 (1.0) carb exchange
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Insulin pump allows up to 8
settings for different carb ratios at
different times of the day
Edit Settings
Wizard
Carb Units:
Carb Ratios:
Select Carb Ratios.
Press ACT.
On
Grams
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Blood Glucose (BG) Within Target Range
No Correction Insulin Calculated
TARGET RANGE 1
12:00A
mg / dL
80 – 100
Example
Estimate Details
Est
Est total:
total:
Food intake:
BG:
BG Within Programmed
Range
Food:
Food:
BG: 82 mg/dL SF = 30
Carbs: 60 g
ICR = 15
Correction:
Correction:
Active ins:
ACT to proceed,
ESC to back up
4.0U
60 gm
82
60 = 4.0 U
15 g
4.0U
– 0.0U
0.0U
BG is between
80 and 100 mg dL
No correction
calculated
Continuous Glucose Monitor
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Professional
Personal
CGM
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Analyzes interstitial glucose
Physiologic lag
Not finger stick replacement
Gold Standard is still blood glucose values
Blood glucose readings are still needed
to calibrate the sensor and keep it tracing
BG does not equal SG
Focus on the trends of the glucose
Professional CGM
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Has been used in a clinical setting since 1999
Wear for 3-5 days
Blinded study
288 glucose values in 24 hours
Clinic owned equipment
Reimburseable
Assess time periods, ICR
Patient Responsibility
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Testing four times
a day
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Fill out food log
sheet
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Bring the device
back to the office
C.A. – Lantus @ bedtime, Humalog SS
J.D. – Lantus in AM and bedtime, Humalog @ meals
K.V. – N and H in AM, H @ dinner, N @ bedtime
Sensor Modal Time Periods
It’s Not Just About A1C Anymore!
Glycemic Variability
• Very high or very
low blood glucose
levels
A1C 7
A1C 7
– Missed
with glycemic
Measuring
Fingersticks
variability in
with A1C
– combination
Missed with A1C
may be a more reliable
indicator to reduce
long term
complications
Personal CGM
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Can be used along with an insulin pump or
still on injections
288 glucose values in 24 hrs
Consumer owned
See the values in real time
FDA approved 2006
Sensor Overlay by Meal
• 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
Meal marker
Breakfast rise and fall
seen here in picture & averages
additional food markers color - coded by day
Repeating post dinner
drop in glucose
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First Insulin Pump
First Person to Take Insulin
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Leonard Thompson
Questions
Thank You