4/18/19 WADE 2019 Technology in Diabetes Care: Advanced Level Meghann Moore, RD, CDE, MPH Clinical Lead, DSMT/E Program Coordinator Western Washington Medical Group Everett, WA April 26, 2019 Disclosures to Participants Notice of Requirements for Successful Completion: For successful completion, participants are required to be in attendance in the full activity and complete the program evaluation at the conclusion of the educational event. Presenter Conflicts of Interest/Financial Relationships Disclosures: No conflicts exist. Disclosure of Relevant Financial Relationships and Mechanism to Identify and Resolve Conflicts of Interest: No conflicts of interest. Non-Endorsement of Products: Accredited status does not imply endorsement by AADE, ANCC, ACPE or CDR of any commercial products displayed in conjunction with this educational activity. Off-label Use: Participants will be notified by speakers to any product used for a purpose other than that for which it was approved by the Food and Drug Administration. Technology in Diabetes Care • CGM • Insulin pumps • Other insulin delivery devices • Reports • Patient Process • DANA 1
4/18/19 Technology Use: AADE Members • 74% - somewhat/very comfortable w/ tech • 61% - recommend tech to patients • 59% - demo tech to patients • 53% - interpret data • 42% - troubleshoot problems Reference: DANA by Divas: Using DANA for Integrating Technology Into Practice, AADE. CGM Therapy • “Sensor-augmented pump therapy may be considered for children, adolescents, and adults to improve glycemic control without an increase in hypoglycemia or severe hypoglycemia. Benefits correlate with adherence to ongoing use of the device.” A • “When prescribing CGM, robust diabetes education, training, and support are required for optimal CGM implementation and ongoing use.” E Standards of Medical Care in Diabetes 2019 Diabetes Care 2019;42(Suppl. 1):S3 Real-Time CGM Use in Youth • “Real-time CGM should be considered in children and adolescents with type 1 diabetes, whether using MDI or CSII, as an additional tool to help improve glucose control and reduce the risk of hypoglycemia. Benefits of CGM correlate with adherence to ongoing use of the device”. B Standards of Medical Care in Diabetes 2019 Diabetes Care 2019;42(Suppl. 1):S3 2
4/18/19 Real-Time CGM Use in Adults • When used properly,…in conjunction with intensive insulin regimens is a useful tool to lower A1C in adults with type 1 diabetes who are not meeting glycemic targets. A • … may be a useful tool in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes. B • …should be used as close to daily as possible for maximal benefit. A Standards of Medical Care in Diabetes 2019 Diabetes Care 2019;42(Suppl. 1):S3 Real-Time CGM Use in Adults • …may be used effectively to improve A1C levels and neonatal outcomes in pregnant women with type 1 diabetes. B • Sensor-augmented pump therapy with automatic low-glucose suspend may be considered for adults with type 1 diabetes at high risk of hypoglycemia to prevent…hypoglycemia and reduce… severity. B • “Flash” CGM use may be…a substitute for SMBG in adults with diabetes requiring frequent (SMBG). C Standards of Medical Care in Diabetes 2019 Diabetes Care 2019;42(Suppl. 1):S3 CGM Systems • Dexcom G5 or G6 • Eversense • Freestyle Libre 14 day (Abbott) • Guardian Connect (Medtronic) 3
4/18/19 Dexcom G5 or G6 • G6 auto-inserter • 7-10 day sensor wear • Receiver • Android or iOS compatible • 0-2 calibrations • Low/high alerts • Clarity, Diasend, Glooko, Tidepool Eversense • Provider office visit insertion/removal • 90-day sensor wear • Android/iOS app only • 2/day calibrations • Low/high alert • Predictive alerts • Eversense DMS Pro Freestyle Libre 14 day • Arm • No calibrations • No alerts • Must scan q 8 hours • 14-day sensor/transmitter wear • Reader or LibreLink app • LibreView, Tidepool 4
4/18/19 Guardian Connect • <= 7 day sensor wear • Bluetooth transmitter • iOS app only • 2/day calibrations • Low/high alerts • Predictive alerts • Sugar IQ • Carelink CGMS Compare & Contrast Dexcom G6 Eversense Guardian Libre 14-day (Senseonics) Connect (Freestyle) (Medtronic) MARD 9% 8.5% 10% 10% Age 2 yrs 18 yrs 14 yrs 18 yrs Sensor 10 days 90 days Up to 7 days 14 days Trans. 3 mo 1 yr 1 yr 14 days Calib. 0 2/day 2/day 0 Coverage All Not Medicare Not Medicare Not Tricare Insulin Pump Therapy • Most adults, children, and adolescents with type 1 diabetes should be treated with…either MDI or an insulin pump. A • Insulin pump therapy may be considered…for all children and adolescents, especially…under 7 years of age. C • Automated insulin delivery systems may be considered in children (7 years) and adults with type 1 diabetes to improve glycemic control. B • pump therapy has modest advantages for lowering A1C …and for reducing severe hypoglycemia rates in children and adults Standards of Medical Care in Diabetes 2019 Diabetes Care 2019;42(Suppl. 1):S3 5
4/18/19 Insulin Pumps • Medtronic – 630 G – 670 G • Omnipod – Aros – DASH • Tandem – t:slim X2 Medtronic 630G 670G • Color screen • Hybrid closed loop (HCL) basal • Integrated meter, remote control adjustment based on CGM and for manual bolusing predictive algorithms (Auto mode) • Preset boluses and temp basals • Downloadable to Carelink • Slow or fast bolus delivery • Waterproof • Optional CGM use • CGM data viewed on screen • Predictive low glucose suspend http://integrateddiabetes.com/updated-insulin-pump-comparisons-and-reviews/ https://www.medtronicdiabetes.com Omnipod Aros DASH • Smallest pump size • Basal rate of 0.0 u/hr • Two part system, pod & PDM • Display app – pt. pump data • Can program through clothing • View app – 12 care partners • No tubing • iPhone widgets • Auto prime & cannula insertion • Contour Next One BG meter w/ • Forced pod change Bluetooth • Watertight • IC ratio 0.1 increments • Built-in BG meter • Calorie King • Largest color screen • Auto upload • No CGM integration • Pharmacy benefit • Least # user guide steps 1 • Apidra, Admelog 1. Purkiss R, Stone S. How innovation may reduce the complexity of administering insulin therapy. Whitepaper, Argent Global Services. January 2018. 6
4/18/19 Tandem X2 • Software updates via web • Bright, full-color touch screen • Fastest bolus entry • Basal & bolus settings in same place • 2-way bluetooth • Dexcom CGM data display • Charges • No linked BG meter • Basal IQ w/ PLGS Insulin Pump Compare & Contrast Medtronic 670G Omnipod Aros Tandem t:slim X2 Carelink personal & Diasend, Glooko, Tidepool T:connect, Diasend, professional Tidepool, Glooko 0.025-35 u/hr basal 0.05 u basal increment 0.001 u, q 5 min basal Temp Target up to 12 hr -100% - 95%, 30 min-12 h 0-250%, 15 min-72 hr temp temp 0.025 u up to 25 u 0.05 u up to 30 u 0.01 u from 0.05-25 u 1 u in 40 sec or 4 sec 1 u in 40 sec 1 u in 20 sec 2-4 weeks battery 3 weeks battery 5-7 d battery 12’ for 24 hr 25’ for 60 min 3’ for 30 min Age 7 and over w/ T1DM Children & Adults Age 6 and over Other Insulin Delivery Devices • V-Go (Valeritas) • Smart Dose Monitors – InPen (Companion Medical) – NovoPen Echo (Novo Nordisk) • EOPancreas system • PAQ Meal patch pump • iLet “bionic” pancreas 7
4/18/19 Smart Device Pipeline 2019 • Bigfoot Biomedical – Smart app to integrate next gen Libre CGM or Bluetooth linked meter results • Biocorp – Easylog reusable smart pen cap • Common Sensing – Gocap readying for commercialization • Lilly – integrated insulin management system with Dexcom G6, smart phone app, smart pen(s) • Novo Nordisk – reusable smart pen; bluetooth pen attachment https://diatribe.org/novopen-6-and-novopen-echo-plus-connected-insulin-pens-launch-early-2019 AADE communication Common Sensing field communication https://www.novonordisk.com/bin/getPDF.2218400.pdf Reports: CGM Systems • Carelink • Clarity • Diasend AGP • Eversense • LibreView • Tidepool Ambulatory Glucose Profile (AGP) Bergenstal RM, et al. Recommendations for standardizing glucose reporting and analysis to optimize clinical decision making in diabetes: the Ambulatory Glucose Profile (AGP). Diab Technol Ther 2013;15:198 8
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