Diabetes 2012: Pump, Sensors,
Current Medical Therapy &
Future Dreams
Shannon Kelley Oates MD
February 2012
4/13/2015
1
Diabetes Introduction
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Why we need to consider the impact
How large is the problem?
How can you understand what it is
to be a person with diabetes?
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2
Diabetes Mellitus
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Type 1
Rare—affecting only 1
in 250 (1 in 400 kids)
15,000 new cases per
year
Low rates in Black and
Asian populations
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Type 2
Common
Probably 25 million
cases in the US. 1/3
cases undiagnosed
Projected prevalence
of 11% WOW! Over
age 65, 27% with DM
Cost: $ 218 billion in 2007
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Diabetes MellitusType 1 and
Mortality
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Mortality rates for people with DM
Type 1 are 5 to 7 times the general
population
More than 15% of people with DM
type 1 will die by age 40
They die of DKA, of renal failure, of
cardiovascular disease
Life expectancy is reduced by 15
years
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Competence Questions
1. What are the indications for an insulin
pump?
a. desire for a pump and insulin use
b. diabetes type 1 if on Medicare
c. diabetes type 2 for many
commercial
insurances
d. Insulin use
Competence Questions
2. Name 3 new diabetes therapies in the
last few years
a. Exenetide, bromocriptine,
glimepiride
b. Bromocriptine, linagliptin,
saxagliptin
c. Carbohydrate counting, continuous
glucose monitoring, insulin
pumps
Competence Questions
3. Continuous glucose monitoring can be
used
a. only with a pump
b. only with multidose injection insulin
therapy
c. must be used daily
d. costs about $35 per week on-going
costs
Take Home Goals
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Think like a
pancreas
Give enough
insulin
Get and give
loads of
education
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9
Insulin Secretion- Physiology
Insulin (mU/L)
70
Serum insulin
50
30
10
0
9:00
am
12:00
pm
3:00
pm
6:00
pm
9:00
pm
12:00
am
3:00
am
6:00
am
Time of Day
Breakfast
Lunch
Dinner
Polonsky, N Engl J Med 1996; 334: 777-783
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10
Insulin Secretion- Physiology
Insulin (mU/L)
70
Serum insulin
50
30
10
0
9:00
am
12:00
pm
3:00
pm
6:00
pm
9:00
pm
12:00
am
3:00
am
6:00
am
Time of Day
Breakfast
Skips
Lunch
Bigger
Dinner
Polonsky, N Engl J Med 1996; 334: 777-783
4/13/2015
11
Intensive Therapy
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Decreases risks of microvascular
disease
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Retinopathy 75% reduction
Nephropathy 50% reduction
Neuropathy 60% reduction
Goal is to achieve normoglycemia
Measure BS frequently
Increases risk of hypoglycemia
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Insulin Time-Action Patterns
Change in Serum Insulin
Normal Insulin Secretion
at Meal Time
Regular insulin
NPH Insulin
Premix 70/30
Baseline
Level
Time (hours)
s.c. Injection
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Insulin Time-Action Patterns
Change in Serum Insulin
Normal Insulin Secretion
at Meal Time
Regular insulin
NPH Insulin
Premix 70/30
Baseline
Level
Time (hours)
s.c. Injection
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Insulin Aspart
Pro
Asp
Phe
Tyr
Phe
Gly
Arg
Thr
Glu
Gly
Asp
B30
A1
Lys
B20
Cys
B28
Thr
Asn
A21
Cys
Val
Tyr
Gly
Leu
Asn
Tyr
Ile
Glu
Val
Leu
Glu
Gln
Leu
Ala
Glu
Gln
Tyr
Cys
Val
Leu
Cys
Thr
Ser
Ile
Cys
Ser
Leu
His
Ser
Gly
B1
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Phe
Val
Asn
Gln
His
Leu
Cys
16
Normal Insulin Secretion
Insulin (mU/L)
70
Serum insulin
50
30
10
0
9:00
am
12:00
pm
3:00
pm
6:00
pm
9:00
pm
12:00
am
3:00
am
6:00
am
Time of Day
Breakfast
Lunch
Dinner
Polonsky, N Engl J Med 1996; 334: 777-783
4/13/2015
17
Insulin Regimens
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Twice a day mixed insulin
Once daily long acting with lispro or
regular with each meal
Twice daily intermediate or long acting
insulin with lispro or regular at each meal
Once a day long acting insulin with
lispro/aspart/glulisine at each meal
CSII is continuous subcutaneous insulin
infusion this is insulin pump
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‘Ventricular Tachycardia’ Sugars
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Insulin Pen or Syringe Injections with
MDI can approach the Ideal
Insulin pens are very handy
Use ONLY on one person
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20
CSII or Insulin Pump
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Programmed basal rate of insulin
and calculated boluses with
carbohydrate intake
Place needle or catheter
subcutaneously every 3 days
Short or rapid insulin analog only
Special attention to prevent DKA
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Insulin Pumps
Medtronic MiniMed
Call 1-800 Number if ??
Omnipod
Accu-Chek
Animas
Deltec
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Future? Insulin Pumps
Animas
Omnipod
Old
pumps
Tandem
Spring Zone
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Pump Manufacturers
MiniMed
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www.minimed.com
Several pumps
Great support
Animas
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www.animas.com
Implantable monitor in testing phase
Omnipod
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No tubing
www.myomnipod.com
24
Omnipod – no tube
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25
Way Cool
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A 15 year old can sleep
in until noon on the
weekend and not get
up and take an
injection and eat
breakfast
Indications?
Desire for a pump
Some understanding of
the limitations of the
technology
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Need to know the glucose
Call 1-800 Number if ??
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Newer Meters
iPhone AppWavesense
Bayer USB meter
Iphone addon meter
iBGStar
Call 1-800 Number if you have ??
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Continuous Monitoring
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Patient versions of Continuous
Monitoring or CGM
Dexcom 7
Medtronic Real time or
Guardian
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Two Versions of CGM
Professional
Personal
1. If we need more
information, we can
do the “Holter
Monitor” of glucose
1. The patient sees
the glucose data as
it is produced
2. Several days of
glucose data with
meals and insulin
data from the patient
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2. Can be used
continuously or
intermittently
3. Cost about $35
cash per usage
31
Two Versions of CGM
Professional-- called iPro
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Continuous Monitoring Software
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Continuous Monitoring Software
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CGM for Patients- Receivers
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mySentry™ Remote Glucose Monitor
Up to 75% of severe hypoglycemic
episodes in children occur at night*
*Ahmet A, Dagenais S, Barrowman NJ, et al. Prevalence of nocturnal hypoglycemia in pediatric type 1 diabetes: a pilot study
using continuous glucose monitoring. J Pediatrics, 2011;159 (2): 297-302.
Glucose and Sensor Screenshots
Transplants
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Whole pancreas transplants usually
along with kidney
Technical difficulties with islet only
transplants
Autotransplantation of islets– only if
we take out your pancreas for NON
diabetes reason
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Newer Classes of Antidiabetes Therapies:
The Era of Incretin-based Therapies plus …
2005
2006
2007
2008
2009
2010
.
Food and Drug Administration. accessdata.fda.gov. Accessed 25 May 2010.
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Best of the Web
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www.diabetes.org - American Diabetes
Association
www.childrenwithdiabetes.com
Lovely site, easy to navigate, active chat
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Archived expert answers
Diabetes camp info
www.diabetesmonitor.com
www.diabetesstation.org
www.jdf.org – Juvenile Diabetes Association
www.2aida.net -very cool insulin simulator
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what is it like to have diabetes?
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Real life with Diabetes
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Test sugar
Count carbs
Do a shot
Go to class
Test sugar, count
carbs, do a shot
Treat a low blood
sugar
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Find your ice
skates
Have a snack
Test your blood
sugar
Laugh at your
roomie
Test, count, inject
Study, sleep.
45
Real life with Diabetes
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Future ?
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Artificial
pancreas
Better data
collection
Easier diagnosis
Test genes
to see who might
get disease
4/13/2015
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Your glucose sensor
reminds you that you
forgot to take insulin
Scan the food for
auto carb calculation
Dr. Oates is on the
beach with her
computer and your
company pays her
NOT to see you
48
vid-clinic
Web cam
digital
stethoscop
e
Transmit
eRx
Pick up the
med at
clinic
Pay by
phone
Update
record
Competence Questions: Multiple right
answers
1. What are the indications for an insulin
pump?
a. desire for a pump and insulin use
b. diabetes type 1 if on Medicare
c. diabetes type 2 for many
commercial
insurances
d. Insulin use
Competence Questions: Single Best
Answer
2. Name 3 new diabetes therapies in the
last few years
a. Exenetide, bromocriptine,
glimepiride
b. Bromocriptine, linagliptin,
saxagliptin
c. Carbohydrate counting, continuous
glucose monitoring, insulin
pumps
Competence Questions -True
Statements
3. Continuous glucose monitoring can be
used
a. only with a pump
b. only with multidose injection insulin
therapy
c. must be used daily
d. can cost about $35 per week ongoing
costs
Take Home Goals




Think like a pancreas
Give enough insulin
Get and give loads
of education
Call the 800 number on
the back of any technology
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53
THANK YOU!

oatess@iuhealth.org
Cool Apps for your phone

Earn points
How Incretins Work1-3
Food triggers the release of
into the blood
incretin hormones (GLP-1 and GIP) by the intestines
Pancreas
Blood
Blood
 Glucagon
Intestine
 Sugar
 Insulin
The body makes DPP-4,
an enzyme that rapidly
breaks down GLP-1 and GIP
GIP=glucose-dependent insulinotropic polypeptide.
1. Drucker DJ. Cell Metab. 2006;3:153–165. 2. Aroda VR, Henry RR. cme.medscape.com/viewarticle/474380_3.
Accessed 24 June 2010. 3. Hinnen D, et al. J Am Board Fam Med. 2006;19:612-620.
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Mechanism of DPP-4 Inhibitors
DPP-4 inhibitors
Block the action of DPP-4
DPP-4 rapidly breaks down GLP-1 and GIP
DPP-4
Hinnen D, et al. J Am Board Fam Med. 2006;19:612-620.
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Mechanism of GLP-1 Receptor Agonists1,2
directly activate the GLP-1 receptor resulting in effects similar to natural GLP-1 but
wn by DPP-4
Reduce appetite
Slow down how quickly food leaves stomach and make
patients feel “full”
Help the pancreas make more insulin when blood sugar is
high
Help keep the liver from releasing too much sugar into the
blood
1. Hinnen D, et al.
J Am Board Fam Med. 2006;19:612-620. 2. Drucker DJ. Cell Metab. 2006;3:153–165.
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