Utilizing Technology for
Optimal Control
CGMS® System™ and Bolus Wizard Calculator
Bruce W Bode, MD FACE
Atlanta Diabetes Associates
Steps to Quality Care
Gather
Information
Refine
Treatment
Complete
Assessment
Limitations of Conventional Testing
• Blood glucose monitoring
– Limited data points – incomplete picture
– Fails to detect asymptomatic hypoglycemic
episodes
– Data collection and logging problems
– Susceptible to inaccurate results
• A1C blood test: 90-day averaging
– Does not identify a patient’s wide blood glucose
excursions
Daily Patient Log
400
350
Glucose (mg/dl)
300
250
200
150
Target
Range
100
Fingerstick Measurement
Insulin Bolus
50
0
Dinner
Breakfast Lunch
8:30 am 12:00 noon 6:00
p.m.
Bedtime
10:30
p.m.
Daily Patient Log and Sensor Data
400
350
Glucose (mg/dl)
300
Fingerstick Measurement
Sensor Measurement
250
200
150
Target
Range
100
50
Insulin Bolus
0
BreakfastLunch
Dinner Bedtime
8:30 a.m. 12:00 noon 6:00 p.m. 10:30 p.m.
Benefits of Continuous
Glucose Monitoring
• Supplements A1C and SMBG
information
• Can identify post prandial glucose
excursions
• Can identify undetected nocturnal
hypoglycemia
• Helpful visual patient teaching tool
GlucoWatch® Biographer
®
CGMS System
•
•
•
•
Sensor
Monitor
Sen-serter®
CGMS® system
Solutions
Software
• Com-Station
TM
TM
1-90
The Sensor
•
•
•
•
•
Tiny, flexible, sterile
Inserted just under the skin
Disposable
24 to 72-hour usable life
Sends measurement signal
to monitor every 10
seconds
• Measures glucose values
within the range of 40-400
mg/dl (2.2 mmol/l)
The Sen-serter
®
• Makes insertion virtually
painless
• Helps give insertions
consistent depth and
angle
• Design is similar to
insertion devices
available for insulin
pump disposables
The Monitor
• Connected to the sensor via a
small, flexible cable
• Worn like a pager
• Records an averaged glucose
value every 5 minutes
(up to 288 per day)
• Also records meals, exercise
or other events entered by
patient
• Holter-style monitor
The Com-Station and
®
CGMS System Solutions Software
TM
TM
• Com-Station
—
—
Downloads data
from monitor to
software
Downloads
meter data and
Medtronic
MiniMed
pump data
• Software
— Converts stored
sensor data into
easy-to-use
reports, graphs
and charts
— Saves data in
individual
patient files
— Included with
CGMS® System
GoldTM and runs
on standard PC
platforms
Calibration
Measurement Range
40-400 mg/dl
Sensor Signal
• Patient enters 3
or more blood
glucose values
per day
• Sensor glucose
data is calibrated
based on blood
glucose values
• Patient enters
event markers for
meals, insulin, …
Blood Glucose Conc.
CGMS System Reports
®
• Sensor Summary
• Sensor Daily Details
• Sensor Modal Day
• Sensor Modal Time
Periods
Sensor Modal Day Report
Glucose Excursion Statistics & Charts
• Definition:
— # and total duration of glucose values above, within and
below target glucose ranges (statistics and pie charts)
• Benefit:
— Familiar statistical means of analyzing time spent out of the
target range in a simple to understand format
Statistics: Glucose Area Above/ Below
Target Limit
• Definition:
—Area between the sensor tracing and the
target glucose line (mg/dl*day); also known
as Area Under the Curve (AUC).
• Benefit:
—More complete statistical means of
analyzing the extent and duration of
glucose excursions
Glucose Area Above Target Limit
AUC= 30 mg/dl*days
230
Modal Meal and Time Range Blocks


Definition:

Averages and ranges for pre/post meal and
other identified time periods (statistics and
graphing on separate report)
Benefits:

Clear identification of the glycemic impact of
marked events

Ability to analyze all meal periods and any
overnight and early morning time periods
separately
Modal Meal and Time Range Blocks
Modal Meal and Time Range Blocks
Patient Role in CGMS
• Attends office visit for sensor
placement and to learn sensor use
• Wears each sensor for one to three
days
• Enters at least four BG per day
• Enters event markers
• Keeps detailed diabetes care log
sheet
• Protects monitor and sensor site
Pearls for Interpretation
• What is the goal of the sensor “run”
—Lower A1C
—Lower the risk of Hypoglycemia
—Safety
• Look for trends
—Fasting state
—Postprandial
—Treatment of highs/ lows/ exercise
• Review Log
—MUST have detail of events, meals,
medication, exercise (duration, intensity, type),
Rx of highs and lows
Case Study # 1
• DC, female, age 50
• Type 1 X 40 years, A1C 7.1%
• CSII basal rate: 0.8 u/hr for 24 hours
• Insulin:Carb ratio = 1.0 u : 15 grams
• Correction Factor: BG-100 divided by 50
• History of frequent, severe hypoglycemia
• CGMS done to determine pattern of lows
and reduce/ eliminate them
Modal Day View
Sensor Daily Details- Day #3
“STRESSFUL DAY –
0.8 u
209
Bad Hair Day”
3.3 u
252
2u
109
22 toast,
jelly
toast, jelly,
97 gm
gms
Choc milk
milk 97
42 choc
5u
63
1 cup hamburger helper,
1 can Sprite, no bolus
135
Case Study #2
• MG, age 37
• Type 1 X 18 years
• History of volatile BG’s, unexplained hypoglycemia
with increasing hypo unawareness; A1C = 5.6%
• CSII basal rates: 12 am - 0.6 u/hr;
2pm - 0.5 u/hr; 7pm - 0.6 u/hr
• Insulin : Carb ratio = 1u : 20 grams
• Correction Factor: BG- 120 divided by 70
• CGMS done to determine patterns overall & gain
insight into patterns of lows
Modal Day
Sensor Daily Details- Day #2
1.5u
4oz juice
2u
Meter BG
not entered
2 toast + jelly, yogurt;
0 insulin
22 CHO
Meter BG
not entered;
stop bolus;
8 oz. OJ
40 gm, 0.5u,
1u / 2 hrs
Sensor Daily Details- Day #3
Meter BG
not entered
12 grapes+ 1
plum; o insulin
taco
salad; 1.1u
2 toast +
peanut butter
Meter BG
not entered;
1u
1u then 0.5
X 1 hour
2 .4 u
tootsie rolls 2 sl veggie pizza;
1u then 2u
12 grapes
Case Study # 3
•
•
•
•
GL, male, age 39
Type 1 X 8 years
A1C= 7%; recent increase from 6%
CSII basal rates: 12 am - 1.0 u/hr ;
4:30 am - 1.6 u/hr; 11:30 - 1.0 u/hr
• Insulin: carbohydrate ratio =1u : 10 grams
• Correction Factor: BG- 100 divided by 40
• CGMS done to assist with improving
overall glycemic control
Modal Day View
Milk choc 15g; 8u
Cheese / Crackers
20 g; 3units
6u
Ice Cream; 3 u
2u; 57 g CHO
Juice box; no insulin
80 CHO; 7u
30 gm CHO;
Heavy Exercise
Case 4: 40 year old nurse wore sensor for
CGMS Training purposes
300
200
100
October 2000
Clinical Information
 Normal A1C
 Normal lab fasting BG
 Laboratory Confirmed elevated post
prandial BG
 Family history of type 2 diabetes
 Patient with PCOS
 Mild background retinopathy on screening
ophthalmology exam
2 months later
After 10 kg weight loss
Exercise program initiated
Lower carb, higher fiber diet
Update 2002: on metformin
has regained
Some weight, but not all
CGMS Resulting Therapy Adjustments
58%
Increase Meal Bolus
Decrease Basal Insulin
49%
Change Method of Counting Carbs
49%
30%
Increase Basal Insulin
30%
Change Treatment of Hypoglycemia
24%
Change Treatment of Hyperglycemia
Change from Regular to Lispro
Decrease Meal Bolus
0%
15%
12%
20%
40%
Percent of Patients (N=33)
Sabbah H: Diabetes 49(suppl. 1):718, 2000
60%
80%
Reasons to Use CGMS
• Improve glycemic control
• Reduce risk of hypoglycemic
events
Fine-Tuning Pump Therapy
Using the Bolus Wizard
Calculator
Targeting Insulin Dosing
What must be known:
• Target BG
• Current BG
• Anticipated CHO intake
• Insulin : CHO ratio
• Correction factor
Most common bolusing errors
• Under-estimation of carbohydrates
consumed (CHO bolus)
• Over-correction of post-prandial
elevations (CF bolus)
— Remaining unused, active insulin
— Stacking of boluses
Bolus: Source of Errors
• “Inability” to count carbs correctly
— Lack of knowledge, skill
— Lack of time
— Too much work
• Incorrect use of SMBG number
• Incorrect math in calculation
• “WAG” estimations
Using the Bolus Wizard™ Calculator
with the Paradigm Link™ Monitor
Paradigm 512™
Paradigm Link™
• Monitor sends BG value to pump via radio waves
• Carbohydrate intake is entered by patient
• “Bolus Wizard” calculates a suggested insulin dose
using personal settings
The Bolus Wizard™ Calculator
• Can be customized with up to 8 different
setting per day for:
—Blood glucose targets
—Carbohydrate ratios
—Insulin-sensitivity factors
• Simplifies Diabetes Management
—May reduce math errors
—Decreases the number of correction boluses
required*
—Lowers the entry error rate when using the
Paradigm LinkTM Blood Glucose Monitor, powered
by BD LogicTM Technology
How to Utilize
The Bolus Wizard Feature
Paradigm® Pump
MiniMed
Main Menu
Press ACT
Bolus
Bolus
Bolus
• Opens Main Menu
Suspend
Suspend
Basal
Basal
Prime
Prime
Utilities
Utilities
Optional Feature
May be turned ON or OFF
How to Utilize
The Bolus Wizard Feature
Paradigm®
Pump
MiniMed
Bolus Menu
Set Bolus
Bolus History
Bolus
BolusWizard
WizardSet
SetUp
Up
Max Bolus
Dual/Square Bolus
Easy Bolus
BG Reminder
How to Utilize
The Bolus Wizard Feature
MiniMed
MiniMed
WIZARD SETUP
Edit Settings
EditSettings
Settings
Edit
ReviewSettings
Settings
Review
Wizard:
MiniMed
Carb units:
Review Settings
Carb
CarbRatios:
Ratios:
BG Units:
Carb Ratios:
12:00 A
10
11:30 A
12
6:00 P
15
Sensitivity:
BG Targets:
off
on
exchanges
grams
May set different
ratios10
for B:L:D: +
mg/dL
mmol/L
Up to 8 50
different
SF & BG Targets
100
in 24 hrs.
Example 1
Consider Robin Smith:
Parameters to enter into pump:
Target BG
Carb Ratio
Correction Factor
100
10
50
Breakfast - Step 1. Check BG
• The Paradigm system automatically
sends Blood Glucose readings from the
Link Monitor (powered by BD Logic™
Technology) to the pump
• Otherwise, the patient enters in the
Blood Glucose reading into the pump
after testing
Breakfast - Step 2. Accept BG
• Robin accepts the transferred
blood glucose value
—Requires confirmation
—Can change glucose value if necessary
• Enters CHO grams
—53 grams of carbohydrate
Breakfast - Step 3. Accept Dose
• The dose estimate is displayed
—5.3 U for 53 grams carb (CIR = 10)
—No correction dose
—Shows total 5.3 U
• Accept suggested dose
• Pump delivers dose
Late Lunch - Step 1,2
• Robin has a late lunch at 2:10 PM
— Blood glucose 160
— Accepts the transferred BG value
• Enters CHO grams
— 50 grams of carbohydrate
50
Late Lunch - Step 3. Accept Dose
• The dose estimate is displayed
—5.0 U for 50 grams carb (CIR = 10)
—Correction dose = 1.2 U
(160-100) / 50 = 60/50 = 1.2
—Shows total 6.2 U
• Accept suggested dose
• Pump delivers dose
Early Supper - Step 1,2
• Robin plans to have appetizers at 5:30 PM
— This is only 3.5 hours after lunch.
— There is still an active insulin depot
— Blood glucose is 157
— Accepts the transferred BG value
• Enters CHO grams
—50 grams of carbohydrate
50
Early Supper - Step 3. Accept Dose
• The dose estimate is displayed
— 5.0 U for 50 grams carb (CIR = 10)
— Correction dose = 1.1 U (157 -100)/50
— Remaining active insulin = 2.6 U
— Remaining active insulin > correction
dose
— No correction dose is recommended
— Total shows 5.0 U
• Accept dose
• Pump delivers dose
Summary
• Utilizing technology can help you to optimize
therapy with your patients with diabetes.
• CGMS System Gold can identify high and low
BG levels undetected by traditional methods
• New pump features like the Bolus Wizard
Calculator can help fine tune pump therapy for
better post prandial control