1	Best Practices … Or Suggestions on Diabetes Care What You Should Know Jeff Hitchcock Children with Diabetes October 2007
2	Goals for Today Background … or Why This Matters Overview of current tools and techniques It’s more than type 1 diabetes Some science Hints at the future Mostly, reassurance
3	Knowledge is …
4	That was Then … Prior to 1980, 50% of people with type 1 diabetes would develop renal failure 10-20 years after onset of diabetes
5	This is Now
6	So, What’s Different? Home glucose monitoring Insulin analogs Insulin pumps Blood ketone measurement Continuous sensors And more importantly … … a realization that complications are not inevitable and you can do something about it
7	Tools … or Diabetes Technology Glucose Meters Other “Meters” Lancing—Where the metal meets the skin Insulin delivery Other drugs Continuous sensors
8	What to Look for in a Glucose Meter Accuracy Major brands make a difference But technique matters Memory with PC download Pattern analysis to reduce variability Intangibles Lighting Ease of use On board data analysis
9	FreeStyle Flash / Lite Smallest meter 0.3 microliter sample 7+ second test time 250 test memory 14 day average 4 built in alarms for test reminders Built in backlight and test strip light Interfaces with a PC Most popular at CWD: 20% (Flash + Lite)
10	ACCU-CHEK Compact Plus 17-test strip drum 1.5 microliter blood volume 5 second test time One handed testing Could attach to car dashboard and check while driving
11	OneTouch UltraSmart On board analysis and graphing 1 microliter sample 5 second test time 3,000 test memory Tracks glucose, insulin, food, and exercise Interfaces with a PC Clinical trial shows use can lower A1c
12	GlucoMON How do I know my child checked at … ? Wireless interface to a OneTouch Ultra Remote oversight of glucose testing Available in limited markets in the US
13	What we really need is … Biodegradable test strips
14	Other Meters: Ketone Testing Old Way: Urine “Yucky” 15 seconds As low as 10¢ per test Accuracy issues Force a child to pee? New Way: Blood Familiar, easy 10 seconds 1.5 microliters About $4 per test Clinical benefits
15	Let’s save urine testing for …
16	Other Meters: A1c Measurement Old way: venous blood draw, results long after the clinic visit Can be very stressful, sometimes painful In 1999, study showed that discussing A1c at clinic visit improved control Enter the DCA2000 and A1cNow+
17	Lancing Lancing is often overlooked, yet it’s a major reason people don’t check because it hurts Many people rarely change lancets 25% report changing only when painful or “bounces” MultiClix is the best lancing device for kids No exposed sharp ever 6 lancets on board Very easy to use
18	How often … Number of blood glucose checks per day is increasing … … but changing lancets remains about the same – not often enough 24% said change due to excessive pain or when lancet “bounces” 23% change every time
19	Insulin Delivery – Some Science 65% of kids on pumps missed more than 1 meal bolus/week 2 missed meal bolus/week caused A1c to increase ½%
20	Insulin Delivery – Injection Devices Pens and pen-like devices becoming more common in the US; the norm elsewhere Dosing convenience the issue Allows for very precise dosing that cannot be matched with syringes Downside is no mixing
21	Insulin Delivery – Insulin Pumps Studies show better A1c with lower risk of hypoglycemia, especially in grade school kids Studies show efficacy even in infants “Untethered Regimen” allows for pump breaks
22	But how do kids choose a pump?
23	Symlin—Another Drug Slows gastric emptying Suppresses postprandial glucagon secretion Makes you feel full sooner Can help you lose weight But … Nausea at first Must decrease insulin because of delayed absorption of food Severe lows if not attentive Use in <18 off label
24	Diabetes Mixology Lantus No change in A1c when mixed and immediately injected Glucagon Glucagon is effective for at least 7 days once mixed and stored at room temperature Symlin Anecdotal evidence shows no difference via syringe Some reports of mixing in pumps This is all very off label
25	Continuous Glucose Sensors Promises a revolution in diabetes care Minute-by-minute glucose data has dramatic clinical implications Predictive alarming for impending lows and highs Near Future: Sensor + Pump = Closed Loop (& sleep)
26	It’s Not About Blood Anymore Continuous sensors look at interstitial fluid, not blood Blood has been easy to access, but … … interstitial might be the better compartment We really care about the brain, not the fingertip Danish pot belly pig study
27	CGMS Performance
28	CGMS Accuracy
29	Sensor Summary Point accuracy not the same as finger stick glucose monitors, but … … interstitial fluid might be more relevant than finger stick blood Current point accuracy essentially the same as first generation blood glucose monitors Trend data has potential to improve care dramatically Low alarms
30	More than Diabetes—Celiac Allergy to gluten (wheat, barley, rye) Autoimmune disease About 10% of people with type 1 have celiac Can explain erratic control Testing is easy … … Living with getting easier
31	The Effects of Celiac Left: Healthy villi – increases the absorption area of the intestinal mucosa to ~ 250 square yards Right: Villi that have been destroyed by celiac antibodies – absorption area just ~ 2 square yards Enormous variability in nutrient absorption negatively impacts predictability of food and therefore diabetes control
32	Some Science– Risk for Retinopathy
33	Could it be Glucose Variability?
34	OK, So Give Me a Goal What makes this hard to achieve? Not taking enough insulin (check fasting) Miscounting carbs (under or over bolusing) Gastroparesis or celiac Not pre-bolusing or missing meal boluses Erratic snacking and not covering with insulin Absorption variability You’re not still using NPH are you?
35	Hints at the Future—Closing the Loop Sensor + Pump = “Set it and forget it?” Semi closed loop Pre-meal bolus, or at least partial pre-meal bolus Even semi closed loop can provide essentially normal blood sugars for at least 1/3^rd of the day – at night Fully closed loop Set it and forget it Sensor lag (?) and kinetics of insulin action remain a major challenge Is glucagon also needed? At recent Diabetes Technology Meeting, 60% of attendees decided yes after one presentation (vs. 47% pre)
36	Why Even Semi-Closed Loop Matters
37	Sensor glucose levels during CL control vs. home open-loop pump therapy
38	Comparing Closed vs. Semi Closed Loop: Single Meal Example
39	Reference Glucose Levels in Closed Loop Versus Hybrid (Semi Closed)
40	We Proudly Wear our Technology
41	In Closing … The tools are good and getting better Pump therapy has decided advantages Don’t be afraid to mix More data means better decision making Continuous sensing is real and makes a difference Variability might be as important as A1c Get checked for celiac The future looks very bright The tools have made a dramatic impact on reducing the risk of complications