master template

1
New Insulins and Insulin Delivery Systems
Bruce W. Bode, MD, FACE Atlanta Diabetes
Associates Atlanta, Georgia
2
Prevalence of Diabetes in the US
Diagnosed Type 1 Diabetes0.5 1.0
Million
Diagnosed Type 2 Diabetes10.3 Million
Undiagnosed Diabetes5.4 Million
American Diabetes Association. Facts and Figures.
Available at http//www.diabetes.org/ada/facts.as
p. Accessed January 18, 2000.
3
Goals of Intensive Insulin Therapy

• Maintain near normal glycemia
• Avoid short-term crisis
• Minimize long-term complications
• Improve the quality of life

4
ACE / AACE Targets for Glycemic Control

• A1C (HbA1c) lt
  6.5
• Fasting/preprandial glucose lt 110 mg/dL
• Postprandial glucose lt 140 mg/dL

ACE / AACE Consensus Conference, Washington DC
August 2001
5
Specific Goals in Management of Diabetes

• Fasting or premeal BG 70 to 140 mg/dL
• Post-meal lt 140 to 160 mg/dL
• A1C lt 6.5 to 7.0
• Blood Pressure lt 130/80
• LDL lt 100 mg/dL HDL gt 45 mg/dL
• Triglycerides lt 150 mg/dL

6
Insulin

• The most powerful agent we haveto control glucose

7
The Miracle of Insulin
February 15, 1923
Patient J.L., December 15, 1922
8
Progression of Type 1 Diabetes
Precipitating Event
Antibody
Progressive loss of insulin release
Normal insulin release
Overt diabetes
Glucose normal
Beta-cell mass
C-peptide present
No C-peptide present
Age (y)
Adapted from Atkinson. Lancet. 2002358221-229.
9
Options in Insulin Therapy for Type 1 Diabetes

• Current
• Multiple injections
• Insulin pump (CSII)
• Future
• Implant (artificial pancreas)
• Transplant (pancreas islet cells)

10
Type 2 Diabetes A Progressive Disease

• Over time, most patients will need insulin to
  control glucose

11
Type 2 Diabetes Two Principal Defects
Reaven GM. Physiol Rev. 199575473-486 Reaven
GM. Diabetes/Metabol Rev. 19939(Suppl
1)5S-12S Polonsky KS. Exp Clin Endocrinol
Diabetes. 1999107 Suppl 4S124-S127.
12
A1C in the UKPDS
13
UKPDS b-Cell Function for the Patients
Remaining on Diet for 6 Years
b-Cell Function ( b)
N376
Years After Diagnosis
Adapted from UKPDS Group. Diabetes. 1995
441249-1258.
14
Multiple factors may drive progressive decline of
b-cell function
Hyperglycaemia (glucose toxicity)
Insulin resistance
b-cell (genetic background)
Protein glycation
lipotoxicity elevated FFA,TG
Amyloid deposition
15
Management of Type 2 DMStep Therapy

• Diet
• Exercise
• Sulfonylurea or Metformin
• Add Alternate Agent
• Add hs NPH vs TZD
• Switch to Mixed Insulin bid
• Switch to Multiple Dose Insulin

Utilitarian, Common Sense, Recommended
Prone to Failure from Misscheduling and
Mismanagement
16
Management of Type 2 DM Stumble Therapy

• WAG Diet
• Golf Cart Exercise
• Sample of the Week Medication
• Interrupted
• Not Combined
• Poor Understanding of Goals
• Poor Monitoring

HbA1c gt8 (If Seen)
17
Consider A New Treatment Paradigm

• Treatment designed to correct the dual
  impairments
• Vigorous effort to meet glycemic targets
• Simultaneous rather than sequential therapy
• Combination therapy from the outset
• Early step-wise titrations to meet glycemic
  targets

18
Approach to Combination Oral Therapy
19
Comparison of Human Insulins / Analogues

• Insulin Onset of Duration ofpreparations
  action Peak action

Regular 3060 min 24 h 610 h
NPH/Lente 12 h 48 h 1020 h
Ultralente 24 h Unpredictable 1620 h
Lispro/aspart 515 min 12 h 46 h
Glargine 12 h Flat 24 h
20
Dissociation Absorption of NovoLog?
21
Short-Acting Insulin AnalogsLispro and Aspart
Plasma Insulin Profiles
400
500
Regular Lispro
Regular Aspart
450
350
400
300
350
250
300
Plasma insulin (pmol/L)
200
250
Plasma insulin (pmol/L)
200
150
150
100
100
50
50
0
0
0
30
60
90
120
180
210
150
240
0
50
100
150
200
300
250
Time (min)
Time (min)
Meal SC injection
Meal SC injection
Heinemann, et al. Diabet Med. 199613625629
Mudaliar, et al. Diabetes Care. 19992215011506.
22
Pharmacokinetic Comparison Aspart vs Lispro
350
Aspart
300
Lispro
250
200
Free Insulin (pmol/L)
150
100
50
0
Time (hours)
Hedman, Diabetes Care 2001 24(6)1120-21
23
Limitations of NPH, Lente,and Ultralente

• Do not mimic basal insulin profile
• Variable absorption
• Pronounced peaks
• Less than 24-hour duration of action
• Cause unpredictable hypoglycemia
• Major factor limiting insulin adjustments

24
Insulin Glargine (Lantus)A New Long-Acting
Insulin Analog

• Modifications to human insulin chain
• Substitution of glycine at position A21
• Addition of 2 arginines at position B30
• Gradual release from injection site
• Peakless, long-lasting insulin profile

Gly
Substitution
1
Asp
5
10
15
20
1
5
10
15
20
25
30
Extension
Arg
Arg
25
Glargine vs NPH Insulin in Type 1 DiabetesAction
Profiles by Glucose Clamp
6
NPH
5
Glargine
4
Glucose utilization rate (mg/kg/h)
3
2
1
0
0
10
20
30
Time (h) after SC injection
End of observation period
Lepore, et al. Diabetes. 199948(suppl 1)A97.
26
Overall Summary Glargine

• Insulin glargine has the following clinical
  benefits
• Once-daily dosing because of its prolonged
  duration of action and smooth, peakless
  time-action profile (mean 23.5 hours)
• Comparable or better glycemic control (FBG)
• Lower risk of nocturnal hypoglycemic events
• Safety profile similar to that of human insulin

27
Primary Structure of Lys(B29)-N-?-Tetradecanoyl,
Des(B30)-Insulin
28
Insulin Detemir in Nondiabetic SubjectsPharmacoki
netics by Glucose Clamp
2.0
1.5
Glucose infusion rate(mg/kg/min)
1.0
Detemir-high
Detemir-low
0.5
Placebo
0.0
-100
100
300
500
700
900
1100
1300
1500
Elapsed time (min)
Brunner GA, et al. Exp Clin Endocrinol Diabetes.
2000108100-105.
29
ConclusionsFrom Phase 2 and 3 Studies
Insulin detemir in comparison to NPH

• Lowers A1C as effectively
• Lowers FPG significantly more
• Provides significantly lower intra-subject
  variation of fasting blood glucose (more
  predictable)
• Produces a smoother nocturnal glucose profile
• Causes a lower incidence of hypoglycaemia
• Associated with some weight loss
• Causes no safety concerns

30
Physiological Serum Insulin Secretion Profile
75
Breakfast
Lunch
Dinner
50
Plasma insulin (µU/ml)
25
400
800
1200
1600
2000
2400
400
800
Time
31
Basal/Bolus Treatment Program withRapid-acting
and Long-acting Analogs
Breakfast
Lunch
Dinner
Aspart Aspart Aspart
or
or
or
Lispro Lispro Lispro
Plasma insulin
Glargine or Detemir
400
1600
2000
2400
400
800
1200
800
Time
32
The Basal/Bolus Insulin Concept

• Basal insulin
• Suppresses glucose production between meals and
  overnight
• 40 to 50 of daily needs
• Bolus insulin (mealtime)
• Limits hyperglycemia after meals
• Immediate rise and sharp peak at 1 hour
• 10 to 20 of total daily insulin requirement at
  each meal

33
Insulin Therapy in Type 2 Diabetes Indications

• Significant hyperglycemia at presentation
• Hyperglycemia on maximal doses of oral agents
• Decompensation
• Acute injury, stress, infection, myocardial
  ischemia
• Severe hyperglycemia with ketonemia and/or
  ketonuria
• Uncontrolled weight loss
• Use of diabetogenic medications (eg,
  corticosteroids)
• Surgery
• Pregnancy
• Renal or hepatic disease

34
Starting With Basal Insulin Advantages

• 1 injection with no mixing
• Insulin pens for increased acceptance
• Slow, safe, and simple titration
• Low dosage
• Effective improvement in glycemic control
• Limited weight gain

6-37
35
Treat to Target Study Glargine vs NPH Added to
Oral Therapy of Type 2 Diabetes

• Type 2 DM on 1 or 2 oral agents (SU, MET, TZD)
• Age 30 to 70
• BMI 26 to 40
• A1C 7.5 to 10 and FPG gt 140 mg/dL
• Anti GAD negative
• Willing to enter a 24 week randomized, open
  labeled study

Riddle et al, Diabetes June 2002, Abstract 457-p
36
Treatment to Target Study NPH vs Glargine in DM2
patients on OHA

• Add 10 units Basal insulin at bedtime
  (NPH or Glargine)
• Continue current oral agents
• Titrate insulin weekly to fasting BG lt 100 mg/dL
• - if 100-120 mg/dL, increase 2 units
• - if 120-140 mg/dL, increase 4 units
• - if 140-160 mg/dL, increase 6 units
• - if 160-180 mg/dL, increase 8 units

37
Treatment to Target Study A1C
Decrease
38
Treat to Target Study Glargine vs NPH Added to
Oral Therapy of Type 2 Diabetes

• Nocturnal Hypoglycemia reduced by 40 in
  the Glargine group (532 events)
  vs NPH group (886 events)

Riddle et al, Diabetes June 2002, Abstract 457-p
39
Advancing Basal/Bolus Insulin

• Indicated when FBG acceptable but
• A1C gt 7 or gt 6.5
• and/or
• SMBG before dinner gt 140 mg/dL
• Insulin options
• To glargine or NPH, add mealtime aspart / lispro
• To suppertime 70/30, add morning 70/30
• Consider insulin pump therapy
• Oral agent options
• Usually stop sulfonylurea
• Continue metformin for weight control
• Continue glitazone for glycemic stability?

40
Novo Nordisk devices in diabetes care

• First pen (NovoPen 1) launched in 1985
• Committed to developing one new insulin
  administration system per year.

41
Lilly Insulin Pens
42
Novo FlexPen

• 3-mL prefilled disposable pen offers precise
  dosing

43
NovoLog FlexPen

• 82 of DNEs Preferred FlexPen

Source Diabetes Nurse Educators In-Depth
StudyReactions to FlexPen.
44
Novo Innolet
Large push button with low resistance
Maximum dose 50 units
Large-scale numbers
Clear uncomplicated dial, dials forward and
back
Audible clicks
1 unit increments
Contains 300 units Novolin 70/30, NPH, or R
Needle storage compartment
Support shoulder
NovoFine disposable needle
45
InDuo - Integration

• Feature
• Combined insulin doser and blood glucose monitor

46
InDuo - Doser Remembers

• Feature
• Remembers amount of insulin delivered and time
  since last dose

• Benefit
• Helps people inject the right amount of insulin
  at the right time

47
Starting MDI

• Starting insulin dose is based on weight
• 0.2 x wgt in lbs or 0.45 x wgt in kg
• Bolus dose (aspart/lispro) 20 of starting
  dose at each meal
• Basal dose (glargine/NPH) 40 of starting dose
  at bedtime

48
Starting MDI in 180 lb person

• Starting dose 0.2 x wgt. in lbs.
• 0.2 x 180 lbs. 36 units
• Bolus dose 20 of starting dose at each meal
• 20 of 36 units 7 units ac (tid)
• Basal dose 40 of starting dose at bedtime
• 40 of 36 units 14 units at HS

49
Correction Bolus

• Must determine how much glucose is lowered by 1
  unit of short- or rapid-acting insulin
• This number is known as the correction factor
  (CF)
• Use the 1700 rule to estimate the CF
• CF 1700 divided by the total daily dose (TDD)
• ex if TDD 36 units, then CF 1700/36 50
• meaning 1 unit will lower the BG 50 mg/dl

50
Correction Bolus Formula
Current BG - Ideal BG Glucose Correction factor

• Example
• Current BG 220 mg/dl
• Ideal BG 100 mg/dl
• Glucose Correction Factor 50 mg/dl

220 - 100 50
2.4u
51
Options to MDI

• A Simpler Regimen
• Insulin Pump
• Premixed BID (DM 2 only)

52
Human Insulin Time-action Patterns
Normal insulin secretion at mealtime
Change in serum insulin
Baseline level
Time (h)
SC injection
53
A More Physiologic Insulin
Normal insulin secretion at mealtime
NovoLog?
NPH insulin
NovoLog? Mix 70/30
Change in serum insulin
Baseline Level
Time (h)
54
Analog Mix 70/30 Serum Insulin Levels in Type 2
Diabetes


100
Cmax
80
60
Serum insulin (mU/L)
40
20
0
600 PM
1000 PM
800 AM
600 PM
100 PM
Breakfast
Lunch
Dinner
Time
Plt0.05.
McSorley. Clin Ther. 200224(4)530-539.
55
Aspart Mix 70/30Serum Glucose Levels in Type 2
Diabetes
Glucose excursions 0-4 h, Plt0.05. McSorley. Clin
Ther. 200224(4)530-539.
56
Analog Mix 70/30 vs 75/25 vs 70/30 Premix Serum
Insulin Levels in Type 2 Diabetes
80
Aspart Mix 70/30
Lispro Mix 75/25
60
70/30 Premix
Serum insulin (mU/L)
40
20
0
Time (h)
Hermansen. Diabetes Care. 200225(5)883-888.
57
Case 2 DM 2 on 70/30

• 60 year old black male
• DM2 age 56 Ht 69 Wgt 180
• Failed oral agents
• On 70/30 BID 10 u am and pm
• HbA1c 8.4 SMBG 144 on 0.8 tests/day
• Increased 70/30, tried 3xday, still not at goal

58
Case 2 DM 2 on 70/30

• Finally agrees to MDI
• Starting dose 0.2 x wgt in (36 u)
• Bolus 20 pre-meal (7 u ac tid)
• Basal 40 Bedtime or anytime (14 u HS)
• Correction Factor 1700 divided by TDD (50mg/dl)
• Does great - A1C 6.4
• Current dose 4 u am, 4 u noon, 10 u pm,
• 16 u Lantus HS

59
Variable Basal Rate CSII Program
Breakfast
Lunch
Dinner
Bolus
Bolus
Bolus
Plasma insulin
Basal infusion
400
1600
2000
2400
400
800
1200
800
Time
60
(No Transcript)
61
PARADIGM PUMP
Paradigm. Simple. Easy.
62
Pump Infusion Sets
63
Metabolic Advantages with CSII

• Improved glycemic control
• Better pharmacokinetic delivery of insulin
• Less hypoglycemia
• Less insulin required
• Improved quality of life

64
CSII Reduces HbA1c
10.0
Pre-pump Post-pump
9.5
.09
8.5
8.0
HbA1c
7.5
7.0
6.5
6.0
5.5
5.0
Bell Rudolph Chanteleau Bode Boland Chase
n 58 n 107 n 116 n 50 n 25 n 56
Mean dur. 36
Mean dur. 36
Mean dur. 54
Mean dur. 42
Mean dur. 12
Mean dur. 12
Adolescents
Adults
Chantelau E, et al. Diabetologia.
198932421426 Bode BW, et al. Diabetes Care.
199619324327 Boland EA, et al. Diabetes Care.
19992217791784 Bell DSH, et al. Endocrine
Practice. 20006357360 Chase HP, et al.
Pediatrics. 2001107351356.
65
Insulin Reduction Following CSII
-28 -18 -16 -17




n 389 n 389 n 298 n 246 n 187
P lt0.001
66
CSIIFactors Affecting A1C

• Monitoring
• A1C 8.3 - (0.21 x BG per day)
• Recording 7.4 vs 7.8
• Diet practiced
• CHO 7.2
• Fixed 7.5
• WAG 8.0
• Insulin type (Aspart)

Bode et al. Diabetes 199948 Suppl 1264
Bode et al. Diabetes Care 200225 439
67
Insulin aspart versus buffered R versus insulin
lispro in CSII study
Insulin aspart
Screening
Buffered regular human insulin (Velosulin)
Insulin lispro

• 146 patients in the USA 225 years with Type 1
  diabetes
• 7 ? HbA1c ? 9 previously treated with CSII
  for 3 months

Bode et al Diabetes Care, March 2002
68
Glycemic Control with CSII
Type 1 Diabetes
8.0
7.8
7.6
HbA1c ()
7.4
7.2
7.0
0
Baseline
Week 8
Week 12
Week 16
Bode, Diabetes 2001 50(S2)A106
69
Self-Monitored Blood Glucose in CSII
NovoLog
Buffered Regular
Humalog

Blood Glucose (mg/dl)


Type 1 Diabetes
Bode, Diabetes 2001 50(S2)A106
70
Symptomatic or Confirmed Hypoglycaemia
p lt 0.05
p lt 0.05
12
10
8

• Episodes/month/patient

6
4
2
0
insulin aspart
human insulin
insulin lispro
Bode et al Diabetes Care, March 2002
71
Insulin aspart versus buffered R versus insulin
lispro in CSII study pump compatibility
Insulin aspart
Buffered human insulin
50
Insulin lispro
40
30
Patients with trouble-free use ()
20
10
0
Data on file (study ANA 2024)
72
DM 1 CSII Patient Lispro to Aspart
Aspart Average 118 SD 73
Lispro Average 140 SD 118
73
Glycemic Control in Type 2 DM CSII vs MDI in
127 patients

• A1C

Baseline
End of Study (24 wks)
8.4
8.2
8.0
7.8
7.6
7.4
7.2
7.0
CSII
MDI
Raskin et al. Diabetes 200150 Suppl 2A128
74
CSII vs MDI in DM 2 Patients
Raskin et al. Diabetes 200150 Suppl 2A128
75
Case 3 DM 2 Poorly Controlled

• 58 year old female presented with a 12 year
  history of poorly controlled, insulin treated
  diabetes
• Ht 66, Wt 174, BMI 28, C-peptide 2.1
• A1C 10.4 on 165 units per day (70/30 BID)
• Added troglitazone, metformin, glimepiride to MDI
  insulin
• A1C range 7.7 to 12.6 over 3 years

76
Case 3 DM 2 Poorly Controlled

• Admitted twice for IV insulin and fasting with
  short lived success (A1C to 7.6 but back up to
  12.6)
• Tried weight watchers and appetite suppressants
  no help
• Decided to try CSII

77
Case 3 DM 2 on CSII, A1C Results
78
Case 3 DM 2 Poorly Controlled

• Patient loves the pump
• On 110 units per day consuming 2 meals only per
  day (1.4 units per kg or 0.6 units per lbs)
• Also on rosiglitazone 4 mg/day

79
Normalization of Lifestyle

• Liberalization of diet timing amount
• Increased control with exercise
• Able to work shifts through lunch
• Less hassle with travel time zones
• Weight control
• Less anxiety in trying to keep on schedule

80
Current Continuation RateContinuous Subcutaneous
Insulin Infusion (CSII)
Continued 97
Discontinued 3
N 165 Average Duration 3.6 years Average
Discontinuation lt1/yr
Bode BW, et al. Diabetes. 199847(suppl 1)392.
81
U.S. Pump Usage Total Patients Using Insulin Pumps
82
Current Pump Therapy Indications

• Diagnosed with diabetes (even new onset DM 1)
• Need to normalize blood glucose (BG)
• A1C ? 6.5
• Glycemic excursions
• Hypoglycemia

83
Poor Candidates for CSII

• Unwilling to comply with medical follow-up
• Unwilling to perform self blood glucose
  monitoring 4 times daily
• Unwilling to quantitate food intake

84
Pump Therapy

• Meal boluses
• Insulin needed pre-meal
• Pre-meal BG
• Carbohydrates in meal
• Activity level
• Correction bolus for high BG

• Basal rate
• Continuous flow of insulin
• Takes the place of NPH or glargine insulin

6
5
Meal bolus
4
Units
3
2
1
Basal rate
12 am
12 pm
12 am
Time of day
85
Initial Adult Dosage Calculations

• Starting Doses
• Based on pre-pump Total Daily Dose (TDD) Reduce
  TDD by 25-30 for Pump TDD
• Calculated based on weight
• 0.24 x wgt in pounds (0.5 x wgt in kg)

Bode BW, et al., Diabetes 1999,(Suppl 1)84. Bell
D and Ovalle F, Endocrine Practice 2000,
6357-360. Crawford, LM, Endocrine Practice 2000,
6239-43.
86
Initial Adult Dosage Calculations

• Basal Rate
• 50 of pump Total Daily Dose
• Divide total basal by 24 hours to decide on
  hourly basal
• Start with only one basal rate
• See how it goes before adding additional basals

87
Basal Dose Adjustment

• Rule of 30
• Basal Rate(s) Adjustments Overnight
• Check BG
• Bedtime
• 12 AM
• 3 AM
• 7AM
• Adjust overnight basal if readings vary gt 30
  mg/dl

88
Initial Dosage Calculations

• Meal (food) Bolus
• Usually 50 of Pump Total Daily Dose
• Marjorie C.
• Total Daily Dose 40 Units
• Basal Rate 20 Units
• Meal Bolus (total) 20 Units

89
Initial Dosage Calculations

• Meal (food) Bolus Method
• - Divide total bolus dose by 3
• - Test BG before meal
• - Give correction bolus
• - Give pre-determined insulin dose for
  pre-determined CHO content
• - Test BG after meal

90
Estimating the Carbohydrate to Insulin Ratio
(CIR)

• Individually determined
• CIR (2.8 x wgt in lbs) / TDD
• Anywhere from 5 to 25 g CHO is covered by 1 unit
  of insulin

91
What Type of Bolus Should You Give?Immediate vs
Square vs Dual Wave

• 9 DM 1 patients on CSII ate pizza and coke on
  four consecutive Saturdays
• Dual wave bolus (70 at meal, 30 as 2-h square)
• 9 mg/dl glucose rise
• Single bolus 32 mg/dl rise
• Double bolus at -10 and 90 min 66 m/dl rise
• Square wave bolus over 2 hours 79 m/dl rise

Chase et al, Diabetes June 2001 365
92
Treatment of Hyperglycemia

• If blood glucose is above 250 mg/dl
• Take a correction bolus by pump
• Check BG again in 1 hr
• If still above 250 mg/dl
• Take correction bolus by syringe
• Change infusion set and reservoir
• Check BG again in 1 hr
• If BG has not decreased
• Increase correction bolus by syringe
• CALL PHYSICIAN

93
Prevention of Hypoglycemia

• Monitor BG
• 4-6 times a day
• Set appropriate BG target range
• Set minimum BG level before sleep
• Never lt 90, unless pregnant

94
If A1C is Not to Goal
Must look at

• SMBG frequency and recording
• Diet practiced
• Do they know what they are eating?
• Do they bolus for all food and snacks?

• Infusion site areas
• Are they in areas of lipohypertrophy?
• Other factors
• Fear of low BG
• Overtreatment of low BG

95
If A1C Not to Goal and No Reason Identified

• Place on a continuous glucose monitoring system
  (CGMS by Medtronic Minimed, Glucowatch by Cygnus)
  to determine the cause

96
Cygnus GlucoWatch G2

• Watch Component
• Electrode Component
• Initial calibration takes 2 hours
• Senses glucose and gives an average every 10
  minutes up to 13 hours
• (r 0.84 home use)
• Alarm for high, low and rapidly dropping blood
  sugars

Cygnus GlucoWatch
97
GLUCOSE MONITORING SYSTEMS - EXTERNAL
98
CGMS
99
CGMS Sensor
100
Glucose Profiles

• Patient with Type 1 Diabetes
• Practicing MDI
• HbA1C of 8.5
• Complications
• of High BG
• Renal
• Retinal
• Neural

350
300
250
200
150
Glucose Concentration (mg/dl)
100
50
Meal
Meal
Meal
Meal
0
1200 Midnight
600 AM
1200 Noon
600 PM
1200 Midnight
Time
101
Glucose Profiles

• Patient with Type 1 Diabetes
• Practicing MDI
• HbA1C of 8.5
• Complications
• of High BG
• Renal
• Retinal
• Neural

350
300
250
200
150
Glucose Concentration (mg/dl)
100
50
Meal
Meal
Meal
Meal
0
1200 Midnight
600 AM
1200 Noon
600 PM
1200 Midnight
Time
102
Reasons to Use CGMS

• Improve glycemic control
• Reduce risk of hypoglycemic events
• Minimize risk of future hypoglycemia

103
GLUCOSE MONITORING SYSTEMS - Telemetry
104
Closed-loop control using an external insulin
pump and a subcutaneous glucose sensor

subcutaneous glucose sensor
Insulin infusion pump (currently MiniMed 508)
105
The Long-Term Sensor System a prototype of
implantable artificial pancreas
Sensor Tip
Inlet to Pump
Abdominal Lead Assembly (ALA)
Catheter Header with Inlet Port
Sensor Connection to the Pump
Catheter Tip for Insulin Delivery
106
Medtronic Minimed Artificial Pancreas
107
Blood Glucose Profile, Before, During and After
Closed Loop using LTSS
closed loop
108
Distribution of Blood Glucose One Week Before and
During 48H-Closed-Loop
E. Renard et al, Lapeyronie Hospital,
Montpellier, France
Average Glucose (mg/dl) 116
105 Daily Insulin Use (IU) 35 45
109
Summary

• Insulin remains the most powerful agent we have
  to control diabetes
• When used appropriately in a basal/bolus format,
  near-normal glycemia can be achieved
• Newer insulins and insulin delivery devices along
  with glucose sensors will revolutionize our care
  of diabetes

110
Billing

• Get paid for what you do
• Use your codes and negotiate for coverage
• Detailed visit 99214
• Prolonged visit with contact plus above 99354 or
  99355
• (insulin start or pump start)
• Prolonged visit w/o contact plus above
• 99358 or 59 (faxes, phone calls, emails)

111
Billing

• Bill faxes as prolong visits with out contact or
  negotiate a separate charge
• Bill meter download 99091
• Bill CGMS 95250
• Bill immediate A1C 83036

112
Questions

• For a copy or viewing of these slides, contact
• WWW.adaendo.com