4. Basal/Bolus Treatment Program with
Rapid-acting and Long-acting Analogs
Breakfast
Lunch
Plasma insulin
Aspart
or
Lispro
Dinner
Aspart
or
Lispro
Aspart
or
Lispro
Glargine
4:00
8:00
12:00
16:00
Time
20:00
24:00
4:00
8:00
6. Metabolic Advantages with CSII
• Improved glycemic control
• Better pharmacokinetic delivery of
insulin
— Less hypoglycemia
— Less insulin required
• Improved quality of life
9. Current Pump Therapy
Indications
•
Diagnosed with diabetes
(even new-onset type 1 diabetes)
•
Need to normalize blood glucose
— A1C > 6.5%
— Glycemic excursions
— Hypoglycemia
•
Need for flexible insulin program
10. CSII
Factors 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 1999;48 Suppl 1:264
Bode et al. Diabetes Care 2002;25 439
11. Initial Adult Dosage: Calculations
Starting doses
• Based on pre-pump total daily dose (TDD)
reduce TDD by 25% to 30% for pump TDD
• Calculated based on weight
0.24 x weight in lb (0.53 x weight in kg)
Bode BW, et al. Diabetes. 1999;48(suppl 1):84.
Bell D, Ovalle F. Endocr Pract. 2000;6:357-360.
Crawford LM. Endocr Pract. 2000;6:239-243.
12. Target BG Ranges for CSII
• Normal
—Preprandial:
—1 hr postprandial:
70 - 140 mg/dl
<160 mg/dl
• Hypoglycemic unawareness
—Preprandial:
100 - 160 mg/dl
• Pregnant
—Preprandial:
—1 hr postprandial:
60 - 90 mg/dl
<120 mg/dl
Individually set for each patient
Fanelli CG et al., Diabetologia 1994, 37:1265-76.
Jovanovich L, AMJObGynec 1991, 164:103-11.
13. Initial Adult Dosage: Calculations
Basal rate
• 45% to 50% of pump TDD
• Divide total basal by 24 hours to
decide on hourly basal
• Start with only 1 basal rate
• See how it goes before adding basals
14. Basal Dose Adjustment Overnight
Rule of 30:
Check BG
Bedtime
12 AM
3 AM
6AM
Adjust overnight basal if readings
vary > 30 mg/dl
15. Basal Dose Adjustment Overnight
• Adults often need an increase in basal rate
in the “Dawn” hours (4 am to 9 am)
• Children often need an increase in basal
rate earlier starting at 10 pm to 2 am
18. Bolus Dose Calculations
Meal (food) Bolus Method 1
• Test BG before meal
• Give pre-determined insulin dose for
pre-determined CHO content
• Test BG after meal
• Goal < 60 mg/dl rise post meal or
< 160 mg/dl
19. 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
Davidson et al: Diabetes Tech & Therap. April 2003
20. Correction Bolus
• Must determine how much glucose is
lowered by 1 U of rapid-acting insulin
• This number is known as the
correction factor (CF)
• Use the 1700 rule to estimate the CF
• CF=1700 divided by TDD
example: if TDD=36 U, then
CF=1700/36=≈50, meaning
1 U will lower the BG ≈50 mg/dL
22. 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
23. Case Study # 1
•
•
•
•
GL, male, age 39
Type 1 X 8 years
A1C= 7%; recent increase from 6%
CSII basal rates: 12 am 1.0 u/h;
4:30 am 1.6 u/h; 11:30 am 1.0 u/h
• Insulin: carbohydrate ratio =1u : 10 grams
• Correction Factor: BG - 100 divided by 40
• CGMS done to assist with improving
overall glycemic control
25. 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
26. 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
27. 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
28. The Major Problems
♦ Up until now we have not taken the
active insulin issue into
consideration
♦ The math involved with this has
become too complicated, and it
would be impossible to accurately
calculate the active insulin without
assistance
30. Bolus Wizard Calculator : meterentered
)))
)
)))))
)))
)
Paradigm 512™
Paradigm Link™
• Monitor sends BG value to pump via radio
waves : No transcribing error
• Enter carbohydrate intake into pump
• “Bolus Wizard” calculates suggested dose
31. Insulin Activity Over Time
Insulin Activity (GIR)
700
Rapid Acting
Regular
600
500
400
300
200
100
0
0
1
2
3
4
5
6
Time (hrs)
Insulin Pharmacodynamic Data
Adapted from Henry R: Diabetes Care 1999
7
8
32. Adjusting for Active Insulin:
How smart pumps do it
Percent Remaining
100
Rapid Acting
Regular
80
60
40
20
0
0
1
2
3
4
Time (hrs)
5
6
7
8
33. Bolus Wizard Set Up Screen
Wizard:
Wizard:
Carb Units:
Carb Units:
Carb Ratios:
Carb Ratios:
BG Units:
BG Units:
Sensitivity:
Sensitivity:
BG Target:
BG Target:
On
On
grams
grams
10
10
mg/dl
mg/dl
50
50
100
100
34. For This System To Work
♦ It is critical the target, basal doses,
the correction doses, and the
carbohydrate ratios are accurate
♦ Understanding how to match
carbohydrate amounts with insulin
is critical
35. Do Smart Pumps Enable Others To
Go To CSII?
• YES
• All patients with diabetes not at goal
are candidates for Insulin Pump
Therapy
- Type 1 any age
- Type 2
- Diabetes in Pregnancy
36. Summary
• Insulin pump therapy offers improved
glucose control with less risk of
hypoglycemia and an improvement in
quality of life
• Appropriate candidate selection, training,
and follow-up ensures safe and effective
therapy
37. Questions
• For a copy or viewing of these
slides, contact
• WWW.adaendo.com
Editor's Notes
Patient must have last meal 4 hours prior
Patient must have last meal 4 hours prior
Figuring out how to dose correctly for food and/or correction is one of the key challenges in the intensive management of diabetes.
These common bolusing errors can occur with either MDI therapy or pump therapy.
The first obvious opportunity for error occurs because many people under-estimate the amount of carbohydrate they plan to consume, which leads to the next problem…..
When a post-meal blood glucose is elevated, people may take too much correction insulin and inadvertently end up later with hypoglycemia. This over-correction can happen when the correction dose “stacks” on the insulin that is still active in the body from a previous dose.
Unfortunately, the traditional methods used to avoid “insulin stacking” rely upon crude formulae designed to be as simple and practical as possible.
Because pump therapy offers the benefit of delivering insulin without the discomfort and hassle of shots, pump wearers may administer more frequent doses of insulin than those using injection therapy. As a result, that in order avoid hypoglycemia caused by over-correcting for high blood glucoses, pump users may need to keep track of active insulin from multiple boluses.
WAG, very simlilar to “seat of the pants”, it’s Wild Ass Guess
Bruce Bode uses this quite a bit
By looking at a number of published studies, including data from insulin manufacturers, two consensus insulin action curves were established.
The red line shows rapid-acting analog insulin. The blue line shows regular human recombinant insulin.
To determine insulin action over time, the “area under the curve” for each of these lines are used in a mathematical calculation.
Slide appears with just the 2 insulin action lines
What you see here is 100% of the insulin is remaining when the dose is administered. We can also see how the “percent remaining” declines over time. Because insulin action is not linear, these are not straight lines.
Click once: The green line to 4 hours appears
If a straight-line 25% per hour assumption is used as shown here, which would presum all the insulin is completely gone in 4 hours, it may look relatively close …..
Click again: The first orange oval appears
However, you can identify the opportunity for unintended insulin stacking which can occur when the patient is taking multiple boluses within a short period of time.
Click again: The green line to 3 hours appears
Now, if you assume the complete insulin dose is gone in 3 hours as shown in this green line…..
Click again: The second orange oval appears
Then, you can immediately identify that a correction dose for an elevated blood glucose would not consider all this insulin that is still active in the body, according to the published on insulin dynamics represented in these red and blue curves. A correction dose based on this 3-hour formula risks over-correcting, which can cause hypoglycemia. (A 5 unit dose after 3 hours would still have 2 units active remaining.
I need it, hopefully you will ok this, I won’t spend much time