Clinical Case Studies (Insulin Delivery)

Donna Tomky, MSN, RN, C-NP, CDE, FAADE, CDTCABQ Health Partners, Albuquerque, New Mexico

InsulinDelivery:Pumps,Pens&More

ClinicalCaseStudiesBy

DonnaTomky,MSN,RN,BC-ANP,CDE,FAADE,CDTCABQHealthPartners

DeptofEndocrinology&DiabetesAlbuquerque,NM

Disclosures

• Consultant:BectonDickinson,Voluntis

• Speaker: ProgramManagementServices,Inc.

CaseStudyforInsulinPens• 71yo NativeAmericanfemalewithT2DMx8yrs.Lives

withdaughter&9yo grandson• Novolog(flexpen)5-10unitsbeforemeals,Lantus 25

unitsatbedtime• A1Cof9.3%,Wt147lbs,BMI28• DifficultydrawingupLantuswithoutglasses&gives

insulininjectionat45degreeanglewithinsulinsyringe(doesn’tknowaboutLantuspen-likesNovologpen)

• Localizedfibrosis&ecchymosis bilaterallowerabdomen

• Checkingbloodsugar1-2timesaday– glucoserangefrom86-465mg/dl

Whatisyourassessmentofproblems?(Groupactivity)

• Diabetesuncontrolled• PossiblynotalwaysgettingprescribedLantusdosebecauseofpoorvision(20-80%ptsmakeerrors1)

• Notrotatinginjectionsites• Possiblygettingintra-dermalinjections• Non-adherence(estimates30-60%)1-3

1.Meichenbaum D,TurkDC.FacilitatingTreatmentAdherence:APractitioner'sGuidebook. NewYork:PlenumPublishingCorp;1987.2.Buckalew LW,Sallos RE.Patientcomplianceandmedicationperception.JClin Psychol. 1986;42:49-53.Sackett DL,SnowJC.Themagnitudeofcomplianceandnoncompliance.In:HaynesNRB,TaylorDW,Sackett DL,eds.3.ComplianceinHealthcare. Baltimore:JohnsHopkinsUniversityPress;1979:11-22.

PossibleSolutions(GroupActivity)• SwitchtoLantus solostar

pen• Reviewproperinjection

techniqueandrotationofsites– “Airshot”orprimingofpen– Dialingupdose– Adequatestrength&

dexterityforoperatingdosingbutton

– Pushdosingbuttondown(Notdialingdown)

– Assessforfibrosis• StepupSBMGac&hs• Use4or5mmpenneedle

Applications-PumpCaseStudy

1. Choosingtherightpumpforeachpatient

2. Determiningtotaldailyinsulindoses3. Determiningandadjustingbasaldoses

4. Determiningbolusdoses

5. Calculatingtheinsulin–carbohydrateratio(ICR)6. Calculatingtheinsulinsensitivityfactor(ISF)

7. Calculatinginsulinonboard(IOB)andavoidingstacking

Application– PumpCaseStudy

• Janetis36-yofemalew/T1DMx3yrs

• Patienthascollegedegree,stayathomemom&extremelybusylifewith4children– 5yo son&with3yotriplets.Patientstruggleswithweight

Janet– PumpCaseStudy• Currentinsulindoses:– Lantusinsulin- 12unitsBID,HumalogKwikpenadjusteddoses1unitforevery12gofcarbohydrateandcorrectionfactorIunitforevery25above150

• MonitoringglucosewithaOneTouchmeter5-8timesaday.Averageglucose158mg/dl,rangingfrom55-398mg/dL

• A1C- 7.1%-8.6%;Wt-161,Ht-59”(4’11”)BMI-31.8

WhichpumpisbestforJanet?

1. Medtronic530G2. Omni-Pod3. TandemT-SlimG44. AnimasVibe5. Accuchek Combo

•

ConsumerGuide2015.DiabetesForecast,Mar/Apr2015

WhichpumpisbestforJanet?

PUMPBRAND1. Medtronic530G

2. Omni-Pod

3. TandemT-SlimG4

4. AnimasVibe

5. Accuchek Combo

ONEUNIQUEFEATURE• LinkstoEnlite CGMsensor

• Patchpump– notubing

• ColortouchscreenandlinkstoDexCom G4CGM

• OnetouchmeterremotecontrolLinkstoDexCom G4CGM

• Accuchek meterremotecontrol

WhichpumpisbestforJanet?

PUMPBRAND1. Medtronic530G2. Omni-Pod3. TandemT-Slim4. Animas5. AsanteSnap6. Accuchek Combo

ONEUNIQUEFEATURE• LinkstoEnlite CGMsensor• Patchpump– notubing• Colortouchscreen• LinkstoDexCom G4CGMsensor• 300unitprefilledcartridge• Accuchek meterremotecontrol

ANSWER:TheonethatfitsJanet’slifestyleandneeds

StartbydeterminingJanet’sTotalDailyDose(TDD)?

• TDDissumofbasal,bolus&correctioninsulin• Majorfactorforcontrollingglucose-A1c• CloselyestimatesBolusCalculatorsettings• Methodsforcalculating:

1. UseReducedInjectionDoseapproach

2. UseWeightBaseapproach

3. Combinationofboth

4. ConversionfromMDIDoses

DeterminingJanet’sPumpTotalDailyDose(TDD)?

Reduce Injection Dose (RD)• Based on daily Injection Doses

(basal, bolus, CF)• Injection Dose x 0.75 (75-80%)

=RD

Weight Dose (WD)• Based on Weight• Lb x 0.23 units =Wt Dose • or kg x 0.50 u= Wt Dose

Initial Pump TDD

Take average of Reduced and Weight Dose

(Reduced Dose + Weight Dose) ÷2 = Pump TDD

BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulin PumpTherapyInitiation

WhatisJanet’sTotalDailyDose(TDD)?

ReduceInjectionDose(RD)• InjectionDosex0.75=RD• Janet’sTDD=24uLantus +

7uTIDofHumalog=45ux0.75=33.75u/day(TDD)

WeightDose(WD)• Lbx0.23u=WDorkgx0.50

u=WD• 161(wt-lbs)x0.23u=37• (161/2.2)=73kgx0.5u=36.5

Initial Pump TDD (33.75 u/day +37 u/day)÷2 = 35 u/day

BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation

ConsiderationsforBasalInsulin

• TotalBasalDose(TBD)=U/dachievestargetBGforfasting(>4hrpp),controlsearlyam,dawnphenomenon,w/ohypoglycemiaifmealmissed

• SingleorMultipleBasals– Besttostartwithsinglebasal– Considermultiplebasals fordawnphenomenonor

physicallyactiveduringdayorifuniquepatternidentified• Basalinsulinaccounts~50%ofTDD

– Adults– 40-50%– PubertytoAdult—30-40%– Pre-pubertytoPuberty—20-40%

Determining&AdjustingBasalDoses

• Method1:Basalrate=TDDx40-50%– DailyBasalDose÷24=u/h(1conventional)

• Method2:Basalrate=TDDx0.48÷24(2APP)• AdjustbasalratesbasedonSMBGorCGMpatterns

• Nighttimebasalratesshouldbefine-tunedbeforedaytimebasalrates

2WalshJetal.GuidelinesforOptimalBolusCalculatorSettingsinAdults.JofDiab Science&Technology.Vol 5,1,Jan2011.

1 BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation

WhatisJanet’sBasalRate• Method1:Basalrate/hr=(TDDx

0.5)÷24hrs (1conventional)– 35unitsx0.5÷ 24hrs– 17.5units÷ 24hrs =0.729or0.75u/h

• Method2:Basalrate=TDDx0.48÷24 (2APP)– 35unitsx0.48÷ 24hrs– 16.8÷ 24hrs =0.7u/h

1 BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation2WalshJetal.GuidelinesforOptimalBolusCalculatorSettingsinAdults.JofDiab Science&Technology.Vol 5,1,Jan2011.

DeterminingBolusI:CDoses

• Insulin-to-CarbohydrateRatio(ICR)– #ofunitsthatreturns

theBG+/-20%ofpre-mealBGin2-4hrs

– 1unitofinsulincovers#gramsofcarbohydrates

– Patientsmayneeddifferentratiosthroughouttheday

DeterminingBolusI:CDoses

• Methodsforcalculating– ConvertfromMDIregime(if

wellcontrolled)– EstimateDailyCarbIntake1

• TotalCarbGrams÷ TotalDailyBolus(~50%TDD)=ICR

– 450(500)Rule(Conventional)1• 450(500)÷ PumpTDD=ICR

– ICR=[2.6xWt(lb)]÷ TDD(APP)2

1BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation2WalshJetal.GuidelinesforInsulinDosinginCSIIusingnewformulasfromretrospectivestudyofindividualsw/optimalglucoselevels.JofDiab Sci &Tech.Vol 4,Sept2010

WhatisJanet’sICR• Method1:

450(500)Rule(Conventional)1

– 450(500)÷ PumpTDD=ICR• 450÷ 35(TDD)=12.8=1:13• 500÷ 35(TDD)=14.3=1:14

• Method2:ICR=[2.6xWt(lb)]÷ TDD(APP)2- ICR=[2.6x161lbs]÷ 35- ICR=418.6÷ 35- ICR=11.96=1:12

• Janet’sPreviousICR=1:121BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation2WalshJetal.GuidelinesforInsulinDosinginCSIIusingnewformulasfromretrospectivestudyofindividualsw/optimalglucoselevels.JofDiab Sci &Tech.Vol 4,Sept2010

CarbohydrateCountingApproaches

• Basic Carb Counting– Consistent amounts of carb at meals &

snacks– Some find it difficult to be consistent

• Advanced Carb Counting– Insulin dose is adjusted to match carb intake– Accuracy of insulin dose depends on ability to

estimate/measure food portions and knowledge of amount of carbs/portion

• WAG Carb Counting –commonly used

Notasimpletask…

CarbCountingTools

“PumpingInsulin”byWalshJ&RobertsR

ThreeTypeofBolusInsulin

RegularorNow§ Takeimmediately—formostmeals

Combo/Dualwave§ Somenow,somelater–beanburrito,

somepastas,pizza,Symlin

Extended/Squarewave§ Extendedovertime-- gastroparesis

%In

sulin

Time(hours)012345678

01

0203

04

05

06070

809

01

00%

DeterminingBolusCorrectionFactor(CorrF)orInsulinSensitivityFactor(ISF)

• CorrectionFactor(CorrF)orInsulinSensitivityFactor(ISF)– Usedtocalculate

correctionbolusamountstoreturnBG+/-20%oftargetBGin2-4hrs

– Thenumberofmg/dlthat1unitofinsulinlowersBG

– InsulinsubtractedfromfoodboluswhenBG<target

DeterminingBolusCorrF Doses

• Methods– 1700Rule1

• 1700÷PumpTDD=ISF

– 2000Rule(frequenthypoglycemia) 2• 2000÷ PumpTDD=ISF

– 1960Rule(nearnormal-144mg/dl~BG)3• 1960÷ PumpTDD=ISF

1DavidsonPetal.AnalysisofGuidelinesforBasal-Bolusinsulindosing.EndocrinePractice.Dec20082BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation3WalshJetal.GuidelinesforInsulinDosinginCSIIusingnewformulasfromretrospectivestudyofindividualsw/optimalglucoselevels.JofDiab Sci &Tech.Sept2010

WhatisJanet’sCorrF orISF?• Method1:1700Rule1

– ISF=1700÷35àISF=49

• Method2:2000Rule(frequenthypoglycemia) 2– ISF=2000÷ 35àISF=57

• Method3:1960Rule(nearnormal-144mg/dl~BG)3

• ISF=1960÷ 35à ISF=56

• Janet’sPreviousISF=251BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation2WalshJetal.GuidelinesforInsulinDosinginCSIIusingnewformulasfromretropective studyofindividualsw/optimalglucoselevels.JofDiab Sci &Tech.Vol 4,Sept2010

DeterminingTargetBloodGlucose• CorrectionBolusandTargetBloodGlucoseorRange– TheBGorrangeofglucosevaluestheboluscalculatorusestodetermineifcorrectiondoseisneeded

BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation

DeterminingBolusActiveInsulin• ActiveInsulinTime– Thelengthoftimethecalculatortracksactiveinsulinafterbolusisgiven

– Avoidsstackingofinsulin– Considerinsulinaction

• ClinicalConsiderations– Adults:4-5hours– Children:3-4hours– Pregnancy:3-4hours

BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation

WhatshouldJanet’sTargetBG&ActiveInsulin?

• Historyofhypoglycemiaunawareness• Consider110-130mg/dl–night

time

• Consider100-120mg/dl– daytime

• Janet’sPreviousISF=25• NewISForCF=49-57=50

• ActiveInsulinTime=4hrs1BodeB,Kyllo J,KaufmanK.MedtronicPumpProtocol:AGuidetoInsulinPumpTherapyInitiation2WalshJetal.GuidelinesforInsulinDosinginCSIIusingnewformulasfromretropective studyofindividualsw/optimalglucoselevels.JofDiab Sci &Tech.Vol 4,Sept2010

BasalRateAdjustments

• Overnightvs DaytimeBasalRates– Lastdoseofbolusinsulin4hrspriortotest– Assessovernightcontrolrise/fallpatterns– Assessdaytimecontrolbyskippingmeal-time– Goal- BGstablewithintarget(+/-30mg/dl)– IfBGrise/fall>30mg/dlà adjustrateá 10-20%~2-3hrsbefore

– IfBGdropsbelow70mg/dlà treatàâ 10-20%

BolusAdjustments

• Insulin-to-CarbRatios(ICR)– Goal:2hppBGisbetween30-60mg/dlhigherthanpre-mealBG• Bolusesmissedorlate?• Accuratecarb counting?• Adheretopumpcalculatoradvise?

• InsulinSensitivityFactororCorrectionBolus– Goal:Post-correction,2-hrBG~halfwaytotarget&attargetby4hrs

TwoWeekGlucoseMeterSummary

FollowupData– Meter

StatisticsAverage Glucose 146 mg/dL

Sensor Usage 7 of 7 DaysCalibrations / day 3.3Standard Deviation ± 43 mg/dL

61 % High

39 % Target

1 % Low

Target Range 80 - 130 mg/dLNighttime 10:00 PM - 6:00 AM

CGMData– Refinement&Safety

ConsiderPumpSafety&EnhancementFeatures

• MaximumBolusdose• MaximumBasalrate• Lowreservoiralert• Sitechangealert• Settingalert2hrs aftersitechangetocheckBG• Auto-Off• CGMalerts• Customreminders

Onemorethought&casestudy…

• ReferredforFrequentseverehypoglycemicevents(>1x/wk duringday)

• SMBG5-6xperday• A1Crange7.3-9.0%• Insulinregime:Lantus10

unitsqam;NovologonlyCF- 1unitforBG>300

• Wt - 100lbs;Ht – 5’1”• Cr-0.83mg/dl;GFR-83• Nonephropathy

• Smokerw/frequentURI&pneumonias

• Significantstresswithworkandfamily– onantidepressant

• Endocrinologyworkupforadrenalinsufficiency,&celiacisnegative

• Hypothyroidismstable

MeetTJ… 48yo Fw/T1DMx45yrs

TJ…continued• Endocrinologistchangedinsulinregime– SplitLantusto6unitsqAMand2unitsqPM– TriedToujeobuthypoglycemiawasworse– PatientrestartedLantus7unitsqAM

• StartedCGMwhichhelpedreduceseverehypoglycemicepisodes

• HadaseverehypoglycemicepisodewhilewearingCGM,butalsodiagnosedwithpneumoniaintheER

• ReferredtoNP/CDEforpumppreparation

TJsCGMRecordsHighBGs

• What does the A1c level tell you? 7.3% indicates reasonable control

• What does the history tell you? Erratic BGs and multiple severe hypoglycemic episodes. Work up for other endocrinopathies negative, except for hypothyroidism which is stable. Has tried several basal insulin adjustments and uses bolus insulin sparingly

• What do the glucose records tell you?– Identify the problem – Severe hypoglycemia disabling

patient, on medical leave from work and not driving.– Determine the pattern/trend – Day time low blood

glucose and night time high blood glucose; not checking BG before dosing insulin.

– Identify the cause(s) – Not enough information based on above

• What’s your approach? Ask more questions about behaviors and do focused exam

Putting it all together?

BGResults

WhatEffectsBloodGlucoseResults?

Physical Activity•Change in type,

frequency, duration, or intensity

Eating· Effect of type, amount, frequency, timing of food and alcohol on glucose,

special situations

MedicationChange in timing, amount, delivery, dose accuracy, lipodystrophy, polypharmacy

Acute Problems Illness, stress or acute

complications, co-morbid conditions

Complications or RisksPhysical infirmities, gastroparesis, visual

impairment, renal function, pregnancy

Coping SkillsStress, change in

coping skills, depression, cognition,

social isolation Self-CareBehaviorsAre

Important!

WhataboutTJ’sSelf-Care?

• Lipohypertrophy—usingforallinjections(48-65%prevalence)1,2

• Using8mmpenneedle• Usinginsulinpenbuthasneverknownaboutgivingan“airshot”

• FocusedExam…

1.BlancoMetal.Prevalence&riskfactorsoflipohypertrophy ininsulin injectingpts w/dm.DiabetesMetab.2013.2.Ji Letal.Lipohypertrophy –prevalence,&riskfactors&clinical characteristics ofinsulin-requiringpatientsinChina.AbstractEASDVienna2014.

NextStepsforTJ…• Identify the cause(s)—

– Lipodystrophy injection sites causes insulin absorption variability

– Possible IM injections with 8 mm needles– Incorrect Injection technique maybe causing dosing

errors– Dosing insulin and treating low BG without verifying

CBG• What’s your approach?

– Options: 1)Avoidlipohypertrophy areas;2)Changeto4mmpenneedle;3)Correctinjectiontechnique;4)Trydegludec insulin;5)Use½unitdosingpenforNovolog;5)PrepareforCSII

– Shared Decision: Action Plan: All of the above agreed upon

InSummary• Patientselectionandadherenceiscritical• Initiationandtraining• PatientcenteredàIndividualizesettings• Problemsolvingskills/behaviorscriticalforsuccessfulpumpexperience

• Accuratedataiscriticalformakingdecisions• Focusedexamofsitesateveryvisitoratleastannually

• Planandprovideongoingevaluationandsupportbyentireteam

Muchas Gracias– Questions?