Diabetes Care Tasks: When a Student Uses Insulin, Insulin Pump and/or Glucose Monitor

Christina Trout, ACNS-BC, CDCES

This program will provide information on basic functions of insulin pump therapy. There will be a review of pumps and continuous glucose monitor options including visual screen displays for pumps and CGM devices. Hypoglycemia treatment options explored. Understanding of student/parent responsibilities and survival kits for school use when using a pump.

Transcript

1. Diabetes Care Tasks: When a Student Uses Insulin, Insulin Pump and/or Glucose Monitor 2nd Annual Virtual Diabetes Symposium February 10, 2022 Tina Trout APRN, CNS-BC, CDCES
2. Disclosures In accordance with the ACCME Standards for Integrity and Independence, the Association of Diabetes Care & Education Specialists (ADCES) requires anyone in a position to affect or control continuing education content (e.g., authors, presenters, and program planners) to disclose all financial relationships with ineligible companies. It is the responsibility of ADCES to mitigate and disclose all relevant conflicts of interest. Disclosure of a relationship is not intended to suggest or condone bias in any presentation but is made to provide participants with information that might be of potential importance to their evaluation of the presentation. Disclosure and Mitigation of Relevant Conflicts of Interest: All identified relevant conflicts of interest have been mitigated.
3. Program Objectives 1. Discuss insulin options, pump basics & continuous glucose monitors (CGM) 2. Recommended skills and knowledge of school personnel when assisting students using insulin 3. Define student and parent/guardian responsibilities when using insulin or pump therapy in school
5. Insulin Options Rapid Acting Begins Peak Duration Afrezza (Regular insulin) MannKind Inhaled 12 Minutes 30-45 Minutes 2 Hours Fiasp® (insulin aspart) Novo Nordisk Clear 16 - 20 minutes 90 - 120 minutes 5 - 6 hours NovoLog® / NovoRapid® (insulin aspart) Novo Nordisk Clear 15 - 20 minutes 60 - 180 minutes 3- 5 hours Apidra® (insulin glulisine) Sanofi Clear 15 - 20 minutes 60 - 120 minutes 4 - 5 hours Humalog® (insulin lispro) Eli Lilly Clear 20 - 45 minutes 60 - 120 minutes 4 - 5 hours Admelog® (insulin lispro) Sanofi Clear 20 - 45 minutes 45 - 150 minutes 3.5 - 4.75 hours
6. Long Acting Insulins Onset Peak Duration LANTUS® (insulin glargine U- 100) Sanofi Clear 4 - 6 hours No pronounced peak Up to 24 hours Toujeo® (insulin glargine U-300) Sanofi Clear 4 - 6 hours No pronounced peak Up to 24 hours Basaglar® (insulin glargine U-100) Eli Lilly Clear 4 - 6 hours No pronounced peak Up to 24 hours SEMGLEE™ (insulin glargine U- 100) Mylan Clear 4 - 6 hours No pronounced peak Up to 24 hours Levemir® (insulin detemir) Novo Nordisk Clear 1 - 2 hours 12-24 hours Up to 24 hours Tresiba (insulin degluec U-100 or U- 200) Novo Nordisk Clear About 1 hour About 12 hours 42+ hours U200/ U300 higher concentration. Less insulin to absorb into subcu. tissue. Childrenwithdiabetes.com/insulin options in the us as of January 2022.
7. What is an insulin pump? ► Called a Continuous Subcutaneous Insulin Infusion aka CSII ► Delivers insulin into the subcutaneous tissue replacing daily multiple injections
8. Basal insulin: ⮚ Baseline insulin for normal body functions (excluding food) ⮚ Programmed as single or multiple rates determined by Provider ⮚ Delivered in small continuous amounts over 24 hours. ⮚ Delivered with Novolog (insulin aspart), Humalog (insulin lispro) or Apidra (insulin glulisine) only ⮚ NO more Lantus (Glargine), Levemir (Detemir) or Tresiba(Decludec) insulin
9. Bolus Insulin ► Delivered in calculated amounts set by Physician: ⮲ Cover carbohydrates consumed (meal and snack) ⮲ Correct a high blood sugar (correction or “sensitivity”) ⮲ Accounts for 50-60% amount of total daily insulin ► Programmed settings: ⮲ Insulin to Carbohydrate ratios (I:C) ⮲ Correction (Sensitivity) Formula (I:S) ► Dose calculated when blood sugar &/or amount of Carbohydrate entered ► If bolus insulin not delivered basal insulin cannot reduce post meal glucose values
10. How does insulin infuse ? ► Infusion set either with tubes or in a patch delivers insulin into the fatty tissue layer below the skin. ► Set uses either a flexible plastic catheter (cannula) or a steel needle. ► Pumps with tubing can disconnect near the infusion site.
11. Where is it worn?
12. What do pumps do? Student will receive bells and whistles to alert when something is wrong. Pumps calculate bolus doses for carbohydrates consumed at meals and snacks Pumps can calculate amount of insulin needed to correct a glucose value above target range Some pumps communicate with blood glucose meters or CGM devices. Pumps can track “active” insulin on board to reduce dose and prevent hypoglycemia event Pumps can be set in a temporary basal rate for a set time to reduce risk of hypo/hyperglycemia
13. Insulin pump options ► A small device about the size of a cell phone worn externally ► Can be discreetly clipped to a belt, slipped into a pocket, or hidden under clothes ► Delivers precise doses of rapid-acting insulin to closely match the body’s needs ► Delivers both basal and bolus insulin doses Tandem T-Slim x2 Control IQ T-Slim x2 Basal IQ Omni pod Dash/ Insulet Medtronic 630G Medtronic 770
14. Responsibilities for wearing an insulin pump: ► Check blood sugar frequently ► Use results to make decisions and adjustments to insulin ► Understanding the effect of food & physical activity ► Counting Carbohydrates ► Responding quickly to hyperglycemic/ hypoglycemia events ► Monitoring pump & insertion site
15. Insulin pump limitations ► User must be able to use functions correctly ► A Pump relies on accurate input of information from humans to calculate appropriate doses. ► The user can override pump calculated dose for planned activity /food ► Unable to know if insulin given by syringe ► Unable to know if ketone levels are elevated
16. Advantages to using a pump ► Most physiologic method of insulin delivery available ► More predictable absorption of insulin: ⮚ Long acting insulin injections have a large absorption variable (In body many hours) ⮚ Rapid acting insulin absorption is more predictable (in body a short amount of time) ► A pump uses only Rapid Acting Insulin ( Novolog, Humalog, Apidra) for best absorption
17. Disadvantages to wearing an insulin pump ► Must be worn 24 hours a day ► Time and work is needed to learn how to use a pump ► If problem with delivery of rapid acting insulin still a risk of Diabetic Ketoacidosis ► Hypoglycemia still occurs ► Weight gain (teenager issues) ► Cost of co-pays
18. What is a CGM? ► A small sensor that measures interstitial glucose levels just underneath the skin ► CGM systems can provide real-time dynamic glucose information every five minutes. ► Can provide 200 readings in a 24-hour period ► Assist with hypo/hyperglycemia ► Assist with A1C reduction
19. Continuous Glucose Monitor (CGM) Devices ► A CGM has 3 parts: ► A sensor that is inserted under the skin and remains in place 10 - 14 days ► A transmitter that is attached to a sensor and transmits glucose data continuously and ► A receiver that provides a visual display of the student’s real time interstitial glucose value. ► Interstitial glucose (glucose in the fluid that surrounds the cell VERSUS the serum/plasma glucose (found in blood vessels/capillaries) ► Alarms can be set for glucose levels rising or decreasing rapidly.
20. Continuous Glucose Monitor (CGM) Devices continued ► Hypoglycemia is the most acute risk. Always set audible alarm and recommended set at 75-80mg/dl for safety. ► CGM may report an interstitial value of 70mg/dl but when checked with plasma glucose meter may be 46mg/dl. Taught when low, check plasma ► There are several devices that can be used as a receiver. Current supported devices iPhone, iPad or iPod. ► If student wearing smart device as receiver, glucose data can be shared with up to 5 mobile devices
21. CGM Glucose Monitors Free Style Libre 2 Dexcom Guardian
22. Hyperglycemia When glucose levels are high, students may: ► Have inability to concentrate, fall asleep in class ► Drinking lots of water, fluids ► Requesting use of bathroom for frequent urination Remember, Hyperglycemia can be caused by illness, injury, pain, stress or infection.
23. Very HIGH glucose Back up Plan ► Parent/guardian/ provider needs to provide school nurse with a Back up Plan if glucose values rise above 240-300mg/dl and do not come down after a correction bolus. They may even continue to climb higher. ► Ketones need to be checked by blood or urine. Ketone acids develop quickly when student does not have enough rapid acting insulin delivered by the pump ► Insulin may need to be injected with syringe or pen to assure insulin being delivered to lower glucose level. ► These interventions need to be included in school plan. Always question parent/guardian /provider for this back up plan protocol and notify them if it occurs.
24. Common pump malfunctions that can cause high glucose ► Loose connections of tubing ► Dislodged infusion set or cannula came out of skin ► Kinked or clogged cannula ► Air bubbles in tubing ► Ineffective infusion site- skin scarring, lipo-hypertrophy, poor absorption at site ► Empty insulin reservoir ► Need for new battery
25. Hypoglycemia Symptoms Mild to moderate ► Shaky, jittery, irritable, nervous ► Sweaty, pale, dizzy ► Changed personality, behavior ► Headache, lightheaded ► Confused, unable to concentrate ► Uncoordinated, weak Severe ► Inability to eat or drink ► Unresponsive ► Unconscious ► Seizure activity ► Convulsions, jerky movements
26. Hypoglycemia ► Is the most serious immediate danger to the student with Diabetes. ► Can be caused by too much insulin, too little food or delayed meal/snack, unanticipated increase in physical activity ► If student symptomatic and no meter available always treat for a low. ► The student/parent/guardian should give a list of typical hypo symptoms their student experiences or a glucose value they expect treatment given. ► Student should always have fast acting carbohydrate (about 15-30 grams rapid acting carbohydrate) with them: juice box, glucose gel/tablets, milk, hard candy, jelly beans, gum drops or honey . ► Never leave student alone, stay with them following treatment to assure they are asymptomatic and glucose rising
27. Glucagon ► Used to treat a student if unable to eat or drink, is unconscious or unresponsive or is having seizure activity or convulsions. ► We have all seen glucagon where fluid and powder are titrated into a syringe and administered either subcutaneous or IM. ► There are now 2 new formulations available. ► They both have a two year shelf life which is longer than previous option. ► When glucagon given position student on their side to prevent choking. Call 911/ parents/guardian
28. ► BAQSIMI is a dry nasal powder. It is a fast- acting form of glucagon given as a single dose for one-time use. ► BAQSIMI is puffed into the nose, and its effectiveness does not depend on whether the treated person has a cold or actively inhales. ► It is indicated for the treatment of severe low blood glucose in adults and children with diabetes ages 4 years and older. It is used when you need assistance from others by someone trained to administer it.
29. Gvoke Premixed Ready-to-use Anyone can use in 2 simple steps No visible needle No refrigeration required Available in 2 premeasured doses: 0.5 mg for children and 1.0 mg for adults Administer at multiple locations on the body (upper arm, stomach, or thigh) Gvoke Glucagon Pen
30. What should you know about an insulin pump? ► Where pump and CGM are infusing, assess skin sites ► Current blood sugar value ► How to suspend or disconnect tubing if student with very low blood sugar ► When to inject with a syringe if high glucose and ketones ► Where to store pump if removed by you or student
31. School personnel need Parents/guardian/provider to provide information on ❖ Type of insulin used ❖ Basal rate for 24 hours, insulin /carb ratio and insulin correction sensitivity information ❖ Blood sugar target range ❖ Plan for problems that may occur ❖ Manufacturers 1-800 phone number for assistance
32. Pump supplies provided by parent/ guardian ► Pump infusion set ► Pump reservoir for insulin ► Skin prep items, alcohol swabs ► Pump batteries ► Syringe/pen incase of additional external need ► Ketone blood or urine test strips ► Glucose meter strips, lancets
33. What have you learned? Which of the following can affect blood glucose levels? ►Insulin ►Food ►Physical Activity ►Illness/stress ►All of the above
34. Insulin pumps can calculate insulin dosages based on carbohydrate intake and blood glucose levels when entered into the device ► True ► False
35. Insulin pump Information ► Go to pump manufacturers web site ► All have virtual videos that you can interact with pump functions ► Review pump manuals for specifics
36. Where to get more information ► American Diabetes Association ► www.diabetes.org/safeatschool ► 1-800-Diabetes ► Annual January issue Diabetes Forecast: Diabetes Resource Guide ► National Diabetes Education Program 2016 Guide: Helping Students with Diabetes Succeed: A Guide for School Personnel ► http://www.ndep.nih.gov ► Childrenwithdiabetes.com ► Collegediabetsnetwork.org ► Diatribe.org
37. Thank you Questions?