Transcript Diabetes_Summit_Presentation_Day_1x

Welcome to the
2016 Diabetes Summit!
Before we get started…
Folders
Handouts
CME Forms
Pre-Test
Reimbursement Forms
-Submit to Janet Lucas by Friday
Bathroom Location
Wi-Fi Password:
Agenda Day 1
10:30 – 12:00
Motivational Interviewing For Health Behavior Change in
Diabetes
12:00 - 1:-00
Lunch Break
1:00 - 2:30
Motivational Interviewing For Health Behavior Change in
Diabetes
2:30 – 2:45
Break
2:45 – 3:45
Diabetes Guideline Based Intensification
3:45 – 4:00
Stretch Break
4:00 – 5:00
Technology: What Every Provider Show Know”
5:00 – 6:30
Social
Ellen Glovsky, PhD, RDN
Ellen Glovsky, PhD, RDN
Dr. Eric Johnson, MD
Dr. Eric Johnson MD
Motivational Interviewing
for Health Behavior
Change in Diabetes
Ellen R. Glovsky, PhD, RD, LDN
Training with Dr. Ellen
and
Northeastern University
Diabetes Summit
April 21, 2016
4
• Try to be here today with a “beginner’s mind”.
• Put aside what you think you already know.
• Start fresh, assume there are millions of
possibilities.
5
Motivational Interviewing
Definition: A directive, person-centered
counseling style for increasing intrinsic
motivation by helping clients explore and resolve
ambivalence.
(Miller & Rollnick, 2002)
MI is a collaborative approach to helping people change
their behavior regarding their health.
MI is what you already know.
*Page 3-5 of handouts
6
Primary Belief
(Michelangelo Belief):
• The capacity and potential for change
and adherence is within every person!
“People possess substantial personal expertise and
wisdom regarding themselves, and tend to develop in a
positive direction, given the proper conditions and
support…”
- Miller & Moyers, ‘06
7
The MI Shift in Clinician
Thinking
• From feeling responsible for changing
client behavior to….
• Supporting them in thinking and talking
about their own reasons and means of
making changes.
8
We motivate by our presence….
• Calm, focused, listening presence
•
Begin with RESPECT
 Honor each client as if they are an honored guest in my living room.
•
EMPATHY
 My ability to step into another’s shoes
• What most stimulates change is the interpersonal style
 Style is everything!
• Empathic
•
•
•
•
Collaborative
Respectful
Eliciting and listening
No Fixin’!
Warm and friendly
Accepting
Optimistic
Honoring
9
What is MI?
• Primary Goals:




Minimize resistance
Evoke change talk
Explore and resolve ambivalence
Create and amplify, from the client’s perspective,
a discrepancy between present behavior and his
or her broader goals and values!
 Nurture hope and confidence
*Pages 3-5, handouts
10
What is MI?
• Clinician has no agenda to start with
• Remember MI is directional
• Give people a chance to explore ambivalence in a nonjudgmental way
• GUIDING
• Particularly good w people who are ambivalent, also when
added to another treatment
• Evidence based
• Deceptively simple!
*Page 3-5 Handouts
11
The Stages of Change
Prochaska & DiClemente
Permanent
Exit?
Precontemplation
Relapse to
Previous
Behavior
Maintenance
Action
Contemplation
Preparation
12
The Spirit of MI
• Collaboration
 You don’t have to make change happen; you can’t
 You don’t have all the answers
 Message to your client is “you have everything you need, and
we’ll find it together”
• Evocation
 Calling forth that which the client already has
 Not “installation therapy”
 Doesn’t come from a deficit model
13
The Spirit of MI
• Acceptance
 Not necessarily that you approve of the
other’s actions
 No judgment
 Express Accurate Empathy
• Empathy is


The ability to accurately understand the client’s meaning, and
The ability to reflect that understanding back to the client
• The most powerful predictor of change
• NOT “let me tell you my story”.
14
The Spirit of MI
• Compassion
 Actively promote the other’s welfare, give priority to the
other’s needs
• Affirm Autonomy
 Counselor is willing to let the patient decide if, when and
how they will go about changing.
 Seek and acknowledge the other’s strengths and efforts
15
The Four Processes of MI
• Form the flow of MI
 Overlap, flow into each other, recur
 Each process builds on the one before it
and remains as a foundation
Planning
Evoking
Focusing
Engaging
Engaging, Focusing and Evoking are
the “Prep Steps”
16
The Four Processes of MI
Engaging: the process of establishing a helpful working
relationship, forming an alliance.
• A prerequisite for everything that will follow.
• Resist the urge to ask questions and give advice.
Focusing: creating the agenda
• Reason client is talking to you
• Agenda of clinician and client may differ
• Process by which you develop and maintain a specific direction in the
conversation about change
Planning
Evoking
Focusing
Engaging
17
The Four Processes of MI
• Evoking: eliciting the client’s own motivations for
change
• Mirror opposite of expert-didactic approach
• Having the client voice the argument for change
• Help resolve ambivalence in the direction of change
• Planning: taking action
 When patient reaches threshold of readiness, balance tips
 Making a plan for change
Planning
Evoking
Focusing
Engaging
18
A “Taste” of MI
*Page 7, Handouts
19
Ambivalence
• Not pathology!
• A defining state of human experience
• A normal part of the process of change




I need to but I don’t want to
I’d like to, but don’t think I can
I will one day, but not today
Smoking helps me concentrate and calm down,
but I really don’t like this cough
 I mean to test my sugars, but just forget.
20
Ambivalence
• Think of a time when you were asked to
change something about yourself.
 Were you sure you wanted to do it?
 Were you sure you were able to do it?
MI helps people to keep
moving forward through the
natural process of resolving
ambivalence.*
* Miller and Rollnick, 2013
21
MI: The Guiding Style
GUIDE
Instruct
Listen
....*….....….…....….......*..............................*…...
22
The Guiding Style in
Motivational Interviewing
Direct
Guide
Follow
Manage
Prescribe
Lead
“I can help
you solve
this for
yourself”
Permit
Let be
Allow
Instead of Persuasion…
Collaboration
• Your client is the expert on how s/he will
change
• Share the power!
Ask Permission First!
24
Avoid the Righting Reflex:
The “Taking Sides” Trap
Counselor
Client
• “You must change”
• “I don’t want to change”
• “You’ll be better off”
• “Things aren’t half bad.”
• “You can do it!!”
• “No I can’t!!”
• “You’ll die…”
• “Uncle Fred is 89 and
healthy as can be.”
25
The Righting Reflex
•
•
•
•
•
The clinician’s urge/need to FIX
Making someone “right”
Making the client “face up to reality”
Breaking down “denial”
Comes from clinician’s need, not what
the client needs
https://www.youtube.com/watch?v=_KNIPGV7Xyg
1:21 and 13:39
Effective/Ineffective video
26
Two Broad Sets of
Skills in MI
• Listening skills
 What did h/she say?
 What did h/she mean?
 Listening for CHANGE TALK
• What-do-I-say-in-response skills
 OARS
27
Listening Skills
Reinforce Change Talk
Change Talk is any selfexpressed language that is
an argument for change.
It REALLY Matters
Who Said What!
28
Types of Change Talk
• Preparatory Change Talk




Desire: I want to…
Ability: I could, I can…
Reason: There are good reasons to…
Need: I really need to….
DARN-CAT
Commitment Talk
I’m going to…
I intend to…
I will…
I plan to…
Commitment, Action,
Taking Steps
When you hear change talk, don’t
just sit there!
 Reflect
*Page 8-10
 Reinforce
Handouts
 Ask for more
29
Listening Skills
DARN-C Questions
D:
A:
R:
N:
C:
Why would you want to make this change?
How would you do it if you decided?
What are the three best reasons?
How important is it? and why?
What do you think you’ll do?
30
Evoking “Change Talk”
Decisional Balance/Matrix
Technique
• Works best with people who are in
contemplation, preparation or action
stages
• If there’s little or no change talk, no
ambivalence, it’s not so effective
Miller, W. From the Desert: Reflections of a
Recovering Trainer. MITRIP, January 2013.
31
Decisional Matrix: Diet
Eat Whatever
I Desire
Healthier
Eating Habits
BENEFITS
OF:
•
•
•
•
COSTS OF:
• My dietitian lectures
• Too much $$
• I’ve gained another 20
• Hard to prepare
• I can’t control my sugars • I hate veggies and
other “healthy stuff”
I like the tastes.
It’s cheaper.
It’s faster and easier.
It’s what everyone else
is eating
•
•
•
•
•
Stay healthy.
Fewer meds.
Control sugars
Take charge!
Everyone would stop
nagging
32
Decisional Matrix: Exercise
No Change, No
Exercise
Exercising
BENEFITS/Pros
OF:
• I’m tired at the end of
the day
• Want to go home and
watch TV
• More time online with
friends
• Stay healthy
• Fewer meds
• My doctor won’t nag
me anymore
• Probably have more
energy
COSTS/Cons OF:
• My doctor and dietitian
lecture
• I’ve gained another 20
• My BS is too high
• My joints hurt
• Takes too much time
• I hate exercising and
getting sweaty
• I’m not convinced it
will give me more
energy
• Can’t stand people
watching me exercise
33
Listening Skills
Looking for Change Talk
No Change
Benefits
Costs
Change in Behavior
Life could be
better
I have
problems
34
Listening Skills
Sustain Talk
No Change
Benefits
Costs
Change in Behavior
I like my life
Your plan
doesn’t work for
me
35
STAYING THE
SAME:
BENEFITS
OF:
CHANGING:
GOOD
PROS
NOT SO
GOOD
CONS
COSTS OF:
36
Or, keep it really
simple….
No Change
What’s not-so-good about
the way you are doing
things?
Change
What would be good about
change?
37
Listening Skills
Good and Not So Good
• Develop a discrepancy
• Help the client discover their
ambivalence
• Discrepancy is the ENGINE of change
38
Decisional Balance Practice
“Good Not-So-Good”
Work in groups of 2
1) Speaker:
Something about yourself that you
want to change
need to change
should change
have been thinking about changing
but you haven’t changed yet
i.e. – something you’re ambivalent about
2) Listener:
Let speaker tell you about his/her concerns
Follow instructions on Good – Not-So- Good handout
*Pages 11-13
39
Drumming for Change…
…and pearls of
Commitment…
40
Good listening is more than
being silent and paying
attention
So what do you say?
Build A Foundation of Listening:
Get Your “OARS” in the Water
• O: Open-ended questions
• How you ask questions is critical!
• Questions used sparingly
• A: Affirm
• Rapport building
• Things that are positive or complimentary
• R: Reflect
• Helps to let your listener know you heard and helps to clarify
what you heard
• S: Summarize
• Link material client has offered; ask if it’s accurate
• Allows clinician a chance to build “argument” for change
*Page 14, Handouts
42
Open Questions
• Can not be answered with a “yes” or “no”
• Patient will often provide more information when
questions are open rather than closed
• Like an open door
• Examples
 What concerns do you have about your diabetes?
 What would it be like to _______________?
 How does this work for you?
43
Affirmations
• Something positive you have heard the client say
 You’re a really caring friend and a good listener.
 This is really important to you!
• A statement of appreciation
 I really appreciate your honesty with me
• Catch the person doing something right
 Thanks for coming in today!
• An expression of hope, caring or support
 I hope this week goes well for you; I’ll be thinking about
you.
Page 15, handouts
44
Three Places Communication Can Go
Wrong
Speaker
Listener
Words
Words
2
1
Meaning
3
Meaning
45
The Function of Reflection
Speaker
Listener
Words
Words
2
1
Meaning
Reflection
3
Meaning
46
Reflective Listening
Content reflections are short summaries
“What did she say”
Meaning reflections add the next sentence to
the story
“What did he mean?”
A forward moving reflection; focus on the hope,
and how it will work in making change
*If it feels like you are going around in circles with
your client, your reflections may be too simple
*Page 16, handouts
47
“I know I should be taking my medicine for
diabetes, but I just forget. Besides, I feel fine so
maybe I don’t need it? Still, my husband is always
nagging me about it and maybe he’s right. I do
worry sometimes.”
• Content Reflection:
• “It seems like taking your medicine would be a good idea,
but you’re not so sure you really need it.”
• Meaning Reflection:
• “You’ve been thinking about taking your medicine, your
husband thinks you should, and you worry about it. But
you’re not so sure it’s necessary.”
48
“I want to lose weight because I
don't want another heart attack; I
want to see my grandkids grow up.”
Content reflection
“You see a connection between your weight and the
way you eat and the possibility of having another
heart attack.”
Meaning reflection
“Your children are important to you and you’ll go to
great lengths to be there for them”
*It’s OK to guess and be wrong!
Modern Family Video
49
3 key moments when you
want to reflect
• 1) when you hear change talk
• 2) when you hear ambivalence
• 3) when you hear resistance
A question takes a person to their head,
while a reflection takes them to their heart.
-Steven Berg-Smith
50
Summaries can:
• Collect material that has been offered
 So far you’ve expressed concern about your child’s weight, his
watching video games, and not being able to afford healthy
food.
• Link something just said with something discussed
earlier.
 That sounds a bit like the problems you have with eating
chocolate when you’ve decided you won’t.
 Draw together what has happened and transition to
a new task
 Let’s me summarize what you’ve told me so far, and see if I’ve
missed anything important.
Invite resistance into the
room…
• Don’t try to stop resistance or anger; listen, listen,
listen
• Let client know you heard and understand
• When client feels validated, anger decreases
• You may learn something very important about your
client
• Shift gears, ask what they would like to talk about
*Page 18-20, Handouts
52
Roll with Resistance, Dance
with Discord
Dancing, Not Wrestling :
 Content reflection
 Meaning reflection
 Double-sided reflection
When you meet resistance, try a
different approach!
Rounder
Counting Sheet,
**Pages 17, Handouts
53
Resistance and Discord
• Recognize resistant behaviors as a
signal to change your behavior
• The clinician can generate resistance by
his/her behavior
• The clinician can prevent or minimize
resistance by his/her behavior
54
Batting Practice
Skill: Responding to Resistance
• One person at a time is “at bat”
• The others are pitchers, who throw out resistance
statements typical of their setting
• The batter replies with one response
• Another pitcher throws out resistance, until there
have been four pitches
• Then the next person is at bat
• ** Use “Sentence Stems” handout, page 18
Assess Readiness and Set an
Agenda
•2 Important keys:
Be alert for Readiness to
Change
Shift between
Instructing and Listening
Overuse of Instruction
gets in the way of
“natural change”
56
Recognizing Readiness
•
•
•
•
•
•
•
Diminished resistance
Decreased discussion about the problem
Resolve
Change talk
Questions about change
Envisioning
Taking steps
Page 20, Handouts
Importance/Confidence
1. How important is it for you right now to change?
On a scale of 0 to 10, what number would you give yourself?
0 ………………………………………………………………….. 10
not at all
extremely important
A. Why are you there and not at 0?
B. What would need to happen for you to raise your
score a couple of points?
58
Importance/Confidence
2. If you did decide to change, how confident are you that you
could do it?
0 ………………………………………………………….. …..10
not at all
confident
extremely
confident
A. Why are you there and not at 0?
B. What would need to happen for you to raise your score a
couple of points?
Listening and Responding Skills
59
Offer a “Transitional
Summary”
 We’ve talked a lot so far about why you would want to
make changes, and it sounds like you’re ready. What do
you think? *Which of these areas are you ready to
tackle?
 So, what you’re telling me is that you want to eat more fruit,
but you often can’t get it. *Do you have any ideas to
solve this problem?
*Followed by a Key
Question
*Page 21, handouts
60
Giving Information and Advice:
3 Kinds of Permission
1. The person asks for advice
2. You ask permission to give advice
3. You qualify your advice to emphasize
autonomy
**Pages 22-24
Giving Information and Advice:
3 Kinds of Permission
1.
The person asks for advice
I’d be happy to share some ideas with you, but I’m wondering if there are
any thoughts you’ve got about what might work for you.
2.
You ask permission to give advice
Would it be OK with you if I make a suggestion about that?
3.
You qualify your advice to emphasize autonomy
I don’t know if this will work for you; you are the best judge.
Motivational Interviewing
Client-Centered Advice
Explore-Offer-Explore
1) Explore
client’s ideas, needs
2) Offer relevant advice, information
3) Explore
client’s reactions & commitment to change
*Pages 22-24, Handouts
63
Explore Readiness and
Interest/Offer Information
• Readiness:
 What would you most like to know about how what you eat affects
your blood sugar? What do you know about diet and diabetes?
 Provide Information and Feedback
 When you eat regularly, your blood sugar might be more stable,
allowing you to have the energy you need for your everyday
activities. (Here you might mention things the client wants to do, but
has been unable to do recently.)
 We know that spreading out the carbohydrate you eat over the day,
instead of having a lot at once, can help to stabilize your blood
sugar.
64
A Summary of “MI-Consistent”
Clinician Behaviors
• Talk less than your client does
• On average, reflect twice for each question you ask
• When you reflect, use complex reflections more than half
the time
• When you do ask questions, ask mostly open questions
• Avoid getting ahead of your client’s level of readiness
(warning, confronting, giving unwelcomed advice or
direction, taking the "good" side of the argument)
65
How to Learn MI
1.
2.
3.
4.
Attend a workshop
Read & learn
Practice & listen
Get feedback and supervision
66
www.trainingwithdrellen.com
http://bit.ly/WellnessNotWeight
67
Guilford Press,
2011,2012, 2013
www.guilford.com
Use Promo Code: MINT
68
www.changecompanies.net/motivational
_interviewing.php
http://www.motivationalinterviewing
online.com/ebook.html
69
Ellen Glovsky:
[email protected]
www.nutrition-coach.com
www.trainingwithdrellen.com
Resources for Motivational Interviewing
www.motivationalinterviewing.org
70
Questions?
BREAK TIME!
Reminder: For those of you submitting
reimbursement forms you can begin filling these
out. Please submit to Janet Lucas once complete.
These are due before you leave on Friday.
Thank you!
Diabetes Guideline Based
Intensification
Eric L. Johnson, M.D.
Associate Professor
Department of Family and Community Medicine
University of North Dakota
School of Medicine and Health Sciences
Assistant Medical Director
Altru Diabetes Center
Grand Forks, North Dakota
Disclosures
• PI/SubPI on many clinical trials at
Altru Health System, Grand Forks, ND
• Speakers Bureau Novo Nordisk
• Advisory Board Sanofi
• American Diabetes Association speaker
• I have type 1 diabetes and use insulin
Objectives
• Review current use of diabetes medication
guideline based management
• Assess patients with type 2 diabetes
requiring more intensive management
• Describe the use of more intensive insulin
management in patients with type 2
diabetes in a clinical setting
Brief Review of
Medication Algorithms
Antihyperglycemic Therapy in Type 2 diabetes:
General Recommendations
Copyright © 2014 American Diabetes Association, Inc.
Ominous Octet
AACE 2015
Goals of Glucose
Management
Targets for glycemic control for
many patients:
ADA
AACE
<7
≤6.5
Fasting (preprandial)
plasma glucose
70-130
mg/dL
<110
mg/dL
Postprandial (after
meal) plasma glucose
<180
mg/dL
<140
mg/dL
A1c (%)
Goals of Glucose Management
• More stringent (<6.5) may be reasonable:
-No significant CVD
-Short duration
-Long life expectancy
American Diabetes Association
Goals of Glucose Management
Less stringent (<7.5-8+) may be reasonable:
• History of severe hypoglycemia
• Limited life expectancy
• Advanced complications or comorbid
conditions
• Longstanding difficult to control diabetes
American Diabetes Association
Goals of Glucose Management
• Hypoglycemia must be
considered
• “Many factors, including patient
preferences, should be taken
into account when developing
a patient's individualized goals”
(Patient-centered)
American Diabetes Association
Look at these meds
another way…..
Fasting vs Post Prandial Glucose
• Medications primarily acting on fasting blood glucose:
– Metformin
– Basal (long acting) insulin
– TZD’s
• Medications primarily acting on post-prandial (post-meal) glucose:
–
–
–
–
–
Sulfonylureas
DPP-IV
GLP-1 (both FBG and PPG)
SGLT-2
Bolus insulin (rapid acting)
Both fasting and post-prandial must be treated for most to
reach target
Weight Favorable
•
•
•
•
DPP-IV inhibitors (gliptins)
GLP-1 (probably the most)
Metformin
SGLT-2 inhibitiors
Case
• 47 y/o hispanic female
• BMI 33
• BP and lipids are managed on ACEI and
statin
• Diagnosed with FBS x 2 of 240 and 252
• A1C is 9.1
• Symptomatic with fatigue
Case
• LRD, CDE
• Would likely start 2 agents
– Metformin
and something weight friendly
– SGLT-2
– DPP-IV
– GLP-1
Why Basal Insulin In
Type 2 Diabetes?
Role of Basal Insulin in
Type 2 Diabetes:
Beta-cell function declines as Type 2 diabetes progresses
100
Diagnosis
75
Beta-cell
function (%)
50
Beta-cell decline exceeds 50%
by time of diagnosis
IGT
Insulin
initiation
Postprandial
25
Type 2 Diabetes
Hyperglycemia
0
12
8
4
0
Years from diagnosis
Lebovitz H. Diabetes Rev 1999;7:139-153.
4
8
12
Type 2 Diabetes
Who Needs Insulin?
• Many type 2 patients will require insulin if
they live long enough
-5 years or more post diagnosis
-A1C >8 to 9%
-2 or more non-insulin meds
Basal Insulin in Type 2 Diabetes
•
•
•
•
•
•
•
Glargine (Lantus)
Detemir (Levemir)
U-300 Glargine (Tujeo)
Degludec (U-100 or U-200) (Tresiba)
(NPH)
Good, potent add-on for improved A1C
Second line agent for some patients
Basal Insulin in Type 2 Diabetes
• Glargine, Detemir, U-300 Glargine,
degludec U-100 or U-200, NPH
started at 10 units daily (often hs) or
weight based (0.2 u/kg/day)
• Other medications
– Metformin (always, unless reason to stop)
– Often: DPP-IV inhibitor, GLP-1, SGLT-2 inhibitor
– Maybe: TZD, sulfonylurea
Titrating Basal Insulin
Every 2 to 3 days
Avg FBS
Basal insulin dose change
FBS>180
Increase 4 units
FBS 140-180
Increase 2 units
FBS 110-139
Increase 1 unit
Hypoglycemia <70
Hypoglycemia <40
Decrease 10-20%
Decrease 20-40%
Alternative Basal
Insulin Titration
• Glargine, Detemir, U-300 Glargine, NPH,
degludec (U-100 or U-200)
• Start at 10 units daily (often hs)
• Increase every 3 units every 3 to 5 days
• Avg FBS <110 (<140)
• I rarely split basal insulin dosing
(more on this)
Talk to Patients
• Why insulin may be necessary
– Loss of insulin production over time
(not necessarily their fault)
– Protect from future complications
– Not difficult to use
• They may feel better
– Often fatigued with chronic hyperglycemia
(even if they don’t think so)
– Nocturia interfering with sleep
• What to watch out for or when they should call
– Low blood sugar, weight gain
– Good time to reinforce meal planning-often hungry with chronic
hyperglycemia
– Opportune time to involve diabetes and educator and dietician
What do we do?
(when basal insulin + oral meds
aren’t enough?)
Practical Clinical Approaches
Moving Toward
Multiple Daily Injections (MDI)
• As type 2 patients take larger doses of
basal insulin, temptation is to split basal
dose and give BID
Alternative “next steps”:
• Can do basal + GLP-1 as 2 or 3 injection
daily (or daily + weekly)
• Can do basal + 1 bolus (rapid acting) as a
2 injection program
Why Would We Do This?
• Fasting blood glucose may not be a
sufficient target to get to goal
• Post-prandial (usually 2 hour) often needs
to be targeted (I think this is important)
• Some oral agents target fasting, some
postprandial
• Insulin deficient patients
(longer than 5 years, A1C >9)
Goals of Glucose Management
Targets for glycemic control for many patients:
A1c (%)
Fasting (preprandial) plasma
glucose
Postprandial plasma glucose
(usually 2 hours postmeal)
ADA
AACE
<7
≤6.5
70-130 mg/dL <110 mg/dL
<180 mg/dL
<140 mg/dL
More stringent (<6.5) - younger, long life expectancy, no complications
Less stringent (7.5-8) – older, complications (esp CVD)
Fasting and Postprandial Glycemic Excursions
as a Function of A1C
80
Postprandial hyperglycemia
Contribution (%)
Fasting hyperglycemia
60
40
20
0
1
(<7.3)
2
3
4
(7.3–8.4) (8.5–9.2) (9.3–10.2)
Monnier L et al. Diabetes Care. 2003;26:881-885.
A1C (%) Quintiles
5
(>10.2)
Basal + 1
• 2 options after starting basal insulin
– Basal (long acting) + bolus (rapid acting)
with largest meal
– Basal (long acting) + GLP-1
Basal + 1 Programs
Basal (long acting insulin) affects mostly
fasting blood glucose
• +1: GLP affects post prandial glucose
(post meal) and also fasting blood glucose
• +1: Bolus (rapid acting insulin) affects
mostly post prandial (post meal) blood
glucose
I think this is better than splitting basal in 2
Option 1 (+GLP-1)
• Add a GLP-1 agent to basal insulin
(or vice versa)
• Simple, may need to decrease basal
insulin to avoid hypoglycemia
• Targets fasting and post-prandial blood
sugars
• Can try first before basal + bolus insulin
Option 1
other meds?
•
•
•
•
•
Sulfonylureas often stopped
TZD often stopped
Stop DPP-IV inhibitor
SGLT-2 inhibitor?
Metformin- always keep unless a
reason not to use it
Option 2 (+bolus w/large meal)
• Basal (long acting) insulin often given
once daily (sometimes twice daily)
– mostly addresses fasting blood glucose
• Bolus (rapid acting) insulin often given with
meals and maybe snacks
– Mostly addresses post meal blood glucose
– Start with largest meal in basal + 1
Option 2
Adding Bolus Insulin in a
Basal +1 Program
Rapid Acting Insulin
• Lispro
• Aspart
• Glulisine
• (R)
Option 2
other meds?
•
•
•
•
•
•
Sulfonylureas stopped
TZD often stopped
GLP-1?
DPP-IV inhibitor ?
SGLT-2 inhibitor?
Metformin- always keep unless a
reason not to use it
Insulin Based
Multiple Daily Injection (MDI)
Programs
Basal + 1 Bolus and Beyond
3 Ways to Intensify Insulin In
Type 2 Diabetes
• Simple: 90/10: 2 injection program
1 basal, 1 bolus (w/biggest meal)
• Advanced: Non-Carb Counting
1 basal, 3 boluses
(estimated dosing based on meal “size”)
• Sophisticated: Carb-counting
1 basal, 3 boluses (+ maybe snack boluses)
calculated on carb intake +
premeal blood glucose value
Basal/Bolus Injection
2 injection program
140
Rapid (Lispro,Glulisine, Aspart)
Insulin Effect
120
100
80
Long
(Detemir,Glargine, U300 glargine, NPH)
60
40
20
0
0
2
4
6
8
Hours
10
12
14
16
18
20
adapted from R. Bergenstal, IDC
Initiate 2 Injection Program
• 90/10 rule (90% basal, 10% bolus)
for 2 injection regimen
• Start with largest meal of the day
• Often stop TZD, always stop SU, need to
consider dosing of other meds
90/10 Rule For Initiating MDI
• For example:
• Patient on 50 units of basal (long acting)
(Glargine, Detemir, U-300 Glargine, NPH)
• Want to add bolus (rapid acting)
(aspart, lispro, glulisine) (or R, if cost)
with largest meal of the day
90/10 Rule
• Reduce basal insulin by 10% to 45 units
• Add that 5 units of bolus insulin to largest
meal
• 45 units basal (glargine, detemir,U300 glargine)
once daily
• 5 units bolus(aspart, lispro, glulisine) with
largest meal
Titrating 90/10 Rule
• Targeting 2 hour post meal blood glucose
(after bolus rapid acting) to <180
consistently
• Recall that basal long acting insulin may
require additional dose changes as
reflected in FBS
Basal/Bolus Insulin
Multiple Daily Injections (MDI)
• Many patients will accept a 2 injections program
as first step in advancing to MDI (90/10 rule)
• Many patients will resist going from a
1 injection daily regimen to a
4 injections daily regimen
(Basal + mealtime insulin)
• Eventually some will need 4 or more
injections daily
Basal/Bolus Injection
2 injection program
140
Rapid (Lispro,Glulisine, Aspart)
Insulin Effect
120
100
80
60
Long
glargine, detemir, U300 glargine)
40
20
0
0
2
4
6
8
Hours
10
12
14
16
18
20
adapted from R. Bergenstal, IDC
Building On 90/10
• Continue to add on smaller doses of bolus
rapid acting (i.e., 2 to 5 units) to other
meals (+snacks) with similar titration
targeting
2 hour post meal blood glucose <180
• Appropriate changes in basal long acting
insulin dose as measured by FBS
• Ideally will be working toward 30-50% total
daily dose of insulin as bolus rapid acting
Advanced and Sophisticated
Multiple Daily Injection
Insulin Programs
Practical Clinical Approaches
Basal/Bolus Insulin
Multiple Daily Injections (MDI)
• Basal (long acting)insulin daily +
bolus (rapid acting) insulin with each meal
• 2 strategies:
1) Non-carb counting
Simple
2) Carb counting
Calculated dose based on carb intake
+ premeal blood glucose value
Non-Carb Counting
• Fixed dose of basal (long acting) insulin
• Mealtime bolus (rapid acting) insulin is
split evenly per meals or estimated roughly
on meal size
Basal/Bolus Non-carb Counting
Adding Bolus (rapid acting) Insulin:
First, consider reducing basal (long acting)
(glargine,detemir,U-300 glargine, NPH)
by 30-50%
at initiation of bolus insulin
Basal/Bolus Insulin
Add mealtime rapid acting insulin (bolus)
(aspart,lispro,glulisine)
which will be the remainder of total daily
dose
Basal/Bolus Insulin
Example:
Patient currently on 50 units of
glargine,detemir,U-300 glargine, NPH
once daily
-cut glargine, detemir, U-300 glargine, NPH
by 30%
So, down to 35 units daily
Then, calculate bolus insulin…..
Basal/Bolus Insulin
• Add mealtime bolus (rapid acting) insulin
-15 total units daily
(bolus- 30% of total daily insulin dose)
• Can split up into 3 equal doses with meals
- 5 units/meal
(see how this builds on the 90/10 rule?)
Or….
Basal/Bolus Insulin
Alternatively:
Split up bolus (rapid acting) insulin based
roughly on meal size:
~50% with largest meal
8 units
~33% with next largest meal 5 units
~17% with smallest meal
2 units
Basal/Bolus Insulin
Non-carb counting
So, our patient finishes this consult with:
Basal (long acting)
(~70% of daily total) 35 units once daily
---------------------------------------------------------------Bolus (rapid acting) 5 units with each meal
(~30% of daily total)
Or split up by approx meal size: 8 units large meal
5 units medium meal
2 units small meal
Basal/Bolus Insulin Example
Non-Carb Counting
Basal (Long acting)
~70% of daily total
Bolus (rapid acting)
~30% of daily total
35 units once daily
15 units total daily
5 units/meal x 3
OR
8 units large meal
5 units medium meal
2 units small meal
Titration/Addressing Efficacy of
Multiple Daily Insulin Injections
• Bolus rapid acting to 2 post meal of <180
• Basal long acting to fasting of <110
• Overall A1C goal of <7% with no
significant hypoglycemia for appropriate
patients
• Ideal is to have about 50% basal/50%
bolus total daily dose of insulin
Basal/Bolus Insulin
in Type 1 or Type 2 Diabetes:
Carb Counting
Basal/Bolus Insulin Carb-Counting
• Reduce basal (long acting) 30-50% when
starting bolus (rapid acting) insulin
(if A1C very elevated, may skip this step)
• Bolus (rapid acting) ~2u/15 gram carb
• Correction (sensitivity factor)-mistakenly
sometimes called “sliding scale”
~1 u to drop blood sugar 25-30
points typical in type 2
• Need to know pre-meal blood sugar
Calculating Bolus (rapid acting)
with
Carb Counting and Correction
Example:
• Blood sugar pre-meal was 200, target 110
• 60gram carb meal= 2u/15gram= 8 units
• Correction insulin 1u/30pts=3 units (90pts)
• Meal (carb) 8 units + correction 3 units=
11 units for this meal
Basal/Bolus + Correction
Carb Counting Example
Basal
(~50% of daily total)
Bolus
(~50% of daily total
25 units
Meals+snacks:
2 unit/ 15 gm carb
(type 2)
1 unit/15 gm carb
(younger type 1)
Correction:
1 unit drop 30-50 points
(individualized)
Usual target BG of 110
Titration/Addressing Efficacy of
Multiple Daily Insulin Injections
• Bolus rapid acting to 2 post meal of <180
• Basal long acting to fasting of <110
• Overall A1C goal of <7% with no
significant hypoglycemia for appropriate
patients
• Ideal is to have about 50% basal/50%
bolus total daily dose of insulin
Two More Things….
• In those with very high A1C, may do a
smaller reduction (or none at all)
of basal long acting insulin when adding
bolus rapid acting insulin
• Can start with smaller doses of rapid
acting
3 Ways to Intensify Insulin In
Type 2 Diabetes
• Simple: 2 injection program
90/10: 1 basal, 1 bolus (w/biggest meal) or
1 basal + GLP-1
• Advanced: Non-Carb Counting
1 basal, 3 boluses equal split or
estimate based on meal “size”
• Sophisticated: Carb-counting
1 basal, 3 boluses (+ maybe snack boluses)
calculated on carb intake+ premeal blood glucose value
Typical Type 2 Timeline
• Metformin at diagnosis or soon after
• Add something else
• Consider insulin if:
-Duration more than 5 years
-A1C>9
• Multiple daily injections (or pump?) for
appropriate type 2 patients
Other Insulins
Premix
• 70/30, 75/25, 50/50
• Combine R or rapid acting with NPH or an
“NPH-like” component
• Certain applications may be appropriate
• 1, 2, or 3 times daily
• Limitation: change 2 insulins at once
U-500
• Sometimes in severe insulin resistance
Case
• 56 y/o female with type 2 diabetes
diagnosed 8 years ago
• Currently on metformin 1000mg BID and
DPP-IV (or SLGT-2)
• Previously on sulfonylurea
• A1C 9.2
Case
• Diabetes longer than 5 years, A1C>9
• Likely significantly insulin deficient, so
could consider basal insulin with titration
and intensification discussed
• Basal insulin+ GLP-1 could be tried
• Truly insulin deficient patients will likely
need Basal + Bolus insulin
Who’s In Front of You?
•
•
•
•
•
•
Need for weight loss?
Avoidance of hypoglycemia?
Need for large A1C reduction?
Renal Disease?
Elderly?
CVD?
What I Do
• Metformin at diagnosis
(unless contraindicated)
• Don’t use a lot of sulfonylureas (except cost)
• Don’t use a lot of TZD’s
• Often add DPP-IV, SGLT-2 or GLP-1 as 2nd lineweight favorable, more targeting post-meal
• Don’t use DPP-IV and GLP-1 together
• Basal insulin and beyond for those with apparent
significant betacell failure
(diabetes longer than 5-7 years, A1C>9)
• Multiple daily injections (insulin)- good time to stop
sulfonylureas, TZD’s
Summary
• Guideline based intensive insulin
management is appropriate for many
patients with type 2 diabetes
• Appropriate advancement of insulin
programs improves diabetes control in
different settings
STRETCH BREAK!
Reminder: For those of you submitting
reimbursement forms you can begin filling these
out. Please submit to Janet Lucas once
complete. Thank you!
Diabetes Technology:
What Every Provider
Should Know
Eric L. Johnson, M.D.
Assistant Medical Director
Altru Diabetes Center
Associate Professor
Department of Family and Community Medicine
University of North Dakota
School of Medicine and Health Sciences
Disclosure
•
•
•
•
Novo Nordisk speakers bureau
Sanofi advisory panel
American Diabetes Association
I have used/trialed many of these products
as I have type 1 diabetes
The Future
Weren’t we all
supposed to have
flying cars by now?
Objectives
• Review current diabetes technology
• Review what all providers should know
about current diabetes technology
• Discuss and understand closed loop
artificial pancreas and other future
technology
The Realm Of Current
Technology
• We’ll review the basics to give you a good
understanding of how pumps and continuous
glucose monitors (CGMS, “sensors”) work
• Many type 1’s use these technologies, and an
increasing number of type 2’s do as well
• Even if you never prescribe, you could encounter
these patients (more likely all the time)
• Type 1 patients on pumps are frustrated if providers
don’t know anything about the technology
Pumps-Basic Components
3 Factors for Glycemic Control with
a Pump (and CGMS ‘sensor’)
• A1C
– current standard for diabetes control
(ADA, AACE)
• Standard Deviation
– Measure of Glycemic Variability (Range)
• % of time <70 mg/dl
- too many lows>>lower A1C
(not a desirable way to lower A1C)
•
•
•
•
Continuous Subcutaneous Insulin Infusion
(CSII)
‘Insulin Pumps’
Technology origins 1960’s, really advanced
in the last decade
Deliver insulin continuously (‘basal’) and for
food or corrections (‘bolus’)
Current technology still requires significant
user interface
DON’T hook up, turn on and forget about
them
Continuous Glucose Monitoring
(Sensors)
• Technology developed over the last
decade, clinic use first, now also home
use
• Record glucose 24/7, usually displayed
every 5 minutes
• Record interstitial fluid glucose, not serum
or capillary, generally ~15 min ‘lag’
Pumps and Sensors
• Interfaced devices developed last decade
• Close to “closed loop” artificial pancreas
that is consumer ready
• Patient gets info, has to act on it
• High/low alarms, trends alarm (more rapid
rise or decline)
What Do Pumps Not Do?
• Take over care of patient’s diabetes
• Make diabetes perfect
• Lessen the “workload” of diabetes (it’s just
different)
• Pumps are more work, but potential for
more adaptability
• Still need to do the basics…….
What Do Pumps Do?
• Mechanically deliver insulin to the
subcutaneous tissue through plastic
tubing and/or small plastic or metal
catheter
• Small ‘computers’ in the pump assist
the user in delivering proper basal and
bolus insulin dosing
• Mimic basal/bolus MDI insulin therapy
What Do Pumps Do?
• Different basal rates at different times of
day (good to match activity)
• Bolus insulin all at once or
deliver over a specified time period
(dual/square)
CAN’T do either of above with injections
• Potentially less variability and lower A1C
• Data supports pump/sensor use
What Do CGMS (Sensors)
Not Do?
• Completely eliminate the need for
fingerstick blood glucose testing
(although it’s a lot less)
• ‘Take over’ diabetes control
• Give 100% data all of the time
What Do CGMS (Sensors) Do?
• Potential for less variable blood glucose,
fewer severe hypoglycemia episodes
• Potential for less apprehension at work, at
school, while sleeping, or driving
• Give good data a majority of the time (if
used properly)
• Glucose value every 5 minutes
• High/low alarms
Who should have a pump and/or
sensor?
Patient Selection
• Mature, accepting of diabetes
• Psychologically stable
• Good with technologyCan text a photo on a cell phone?
• Younger patients don’t think of these as
exotic electronic devices
• Don’t let technology bias influence
negatively
Patient Selection
• Patients who are not meeting goals on
multiple daily injections
• Usually patients who are good with follow up
(phone/text/in person/e-mail/appointments)
• Patients with a lot of variability
• Patients with asymptomatic hypoglycemia
• Usually start pump first, add sensor later (2 to
4 weeks)
Patient Selection
• Selecting proper patients is important
to maximize success
• Proper training and followup are critical
for success
Patient Diabetes Experience
with Pumps and Sensors
• Complete “reframing” of diabetes
• Usually a much higher awareness of diabetes
right away
• “Zen” diabetes-more in the mindful “flow” of
diabetes all of the time
• Not something in a “box on a shelf” that they
look at once in awhile or crisis management
• Success: Connects patients with diabetes
Revisiting Basic Insulin
Concepts
Basal/Bolus Insulin
Concept is Preserved
Injections (2 different
insulins)
Pump (1 insulin)
Long-acting insulin basal
once or twice a day
Rapid acting insulin
continuous units/hour acts
as basal
Rapid-acting insulin bolus
(meals, snacks, corrections
of highs)
Rapid acting insulin bolus
(meals, snacks, corrections
of highs)
Review: Basal insulin “sits” on blood sugar
bolus insulin “covers” food or corrects high blood sugar
Basal/Bolus Injection
140
Rapid (Lispro,Glulisine, Aspart)
120
Insulin Effect
100
80
60
40
Long
(Detemir,Glargine)
20
0
0
2
4
6
8
10
Hours
from R. Bergenstal, IDC
12
14
16 18
20
adapted
So? How Do We Start?
Insulin Basics for Type 1
Suppose type 1 patient on:
• 30 units of long acting basal insulin
• 1 unit/15 gram carb rapid acting bolus insulin
(type 1 on MDI are usually carb counting for
bolus)
• Basal in a pump is rapid acting units/hour
• Bolus in a pump is rapid acting units/carb
and/or units/correction
So? How Do We Start?
• Usually need a little less insulin on a pump
• 80% of total basal (0.8 x 30= 24)
• Start basal insulin at units/hour (in this case, about
1u/hr)
• Food Bolus can be the same to start (1u/15gm)
• Correction bolus (example: 1unit/50points, this is
calculated)
• Only rapid acting is used in pumps
• Usually strive for ~50% basal, ~50% bolus of total
daily insulin dose
Example Bolus
• Target blood glucose 100
• Premeal blood glucose is 150
(1u to lower 50 points-correction)
• Eating 30 gm of carbs (1u per 15 gram)
• 2u + 1 u = 3 units for this meal
• Pump has these parameters programmedjust needs the premeal blood glucose
entered
Stop! What?
• Basal insulin injection= long acting insulin
• Basal insulin pump=units rapid acting
insulin/hour
• Bolus insulin injection=rapid acting insulin
• Bolus insulin pump=rapid acting insulinmore exact, units per grams of carb and a
correction factor for blood sugar
So….
• Are pumps just giving injections with a
machine?
• They actually can manipulate basal and
bolus insulin in ways that can’t be done
with injections
Basal / Bolus Therapy
Insulin Pump
Insulin Needs
Bolus Insulin
Basal Insulin
-Variable basals (not fixed)
-Bolus-Immediate, Square, Dual Wave
Time of Day
Advanced Features
• Dual wave/square wave insulin delivery
(some now, some spread out over time)
• Variable basal/temporary basal rates
• Neither of these can be replicated with
injections
• To get full benefit, should be using these
features
Temporary Basal Rates
• a (usually) short term change in basal
insulin rate
• With exercise, may have a 50% of usual
basal rate
• Sedentary, may have 120% of usual basal
rate
• Can’t replicate this with injections
Newer Current Pumps/Sensors
How Good Are They Now?
• 2003 was the turning point for these technologies
(meter linked to pump)
• Commercially available CGMS 2006
• CGMS for patient use isn’t perfect, but if user
operator error is limited, good results
• Technology is a good “sell” for many patients- they
are sick of diabetes
• Technology helps patients connect with their
diabetes
• These are some of the steps to the artificial
pancreas
I am NOT promoting a specific
pump or CGMS (sensor)
Medtronic 530g
Low Glucose Threshold Suspend
Blood sugar at a preset low (often 60)
and no action by the user,
turns off for 2 hours
Generates data package- can be uploaded to
password
protected website
First pump/sensor combo on the market in U.S.
Currently uses Enlite CGMS with link for iphone
display
Disclosure:
I wear this pump
Animas Vibe
2nd integrated
pump/sensor,
Dexcom
sensor
platform
Omnipod
Tubeless
Operates with remote
Accu-Chek Combo
• The meter is more of remote control
• Bluetooth connectivity
• Computer software data package
Tandem T-Slim G4
Touch similar to smart phones
Integrated with Dexcom CGMS
Dexcom G5
Medtronic 640G
Available in Europe
Adds more predictive algorithms for
hypoglycemia protection
ADA Consumer Guide to
Pumps/Sensors
• Diabetes Forecast January 2016
Data From Pumps and Sensors
Logbook Data
Omnipod
Logbook Data
Tips For Pump and
Sensor Success
Tips For More Pump Success
• Change sites every 2 to 3 days
• Protect from extreme heat and cold
• Use advanced features- these can’t be
replicated with injections
• Don’t take correction boluses too close together
• If taking a lot of correction boluses, need to
revisit mealtime dosing
• Long time disconnects should be avoided,
except in specific situations
Tips for More Successful
Sensor Use
• Calibrations are MUCH better if done during a
time of blood sugar stability
• Change sites on the appropriate schedule
• If calibrations are done when blood sugars
are changing relatively rapidly, you may
actually be amplifying error
• Wash hands/avoid hand sanitizer for best
fingerstick results
Tips for More
Successful Sensor Use
• If patients tell you their alarms are going off all the
time
• It's usually not the pump and sensor that are
the problemtheir insulin/activity/food are what need to be
changed
Shutting of the alarms is not the answer!
Reframe diabetes awareness
Stop! What?
• Things that cause a lot of variability in blood
sugars
– Long shutoffs or suspends (except in specific
situations)
– Lots of correction boluses
(makes me wonder if mealtime dosing is correct, or if site is
“bad”)
– Fingerstick calibrations done at times when blood
sugars aren’t stable
– Too little basal/Too much bolus (or vice versa)
– Inappropriate site changes
(waiting too long, i.e., more than 3 days, not changing when bolusing not
correcting highs)
The Future
(Investigational)
“Closed-Loop” Pumps and Sensors
• Current technology available- pumps and
sensors don’t have complete integrated
communication
• Data presented on closed-loop systemsthe sensor tells the pump what to do with
insulin delivery
• Pathway to the artificial pancreas
Closed-Loop
• Data presented in different settings
• Closed loop in young children reduced
overnight hypoglycemia (low blood sugar)
• Other studies looked at lowering overnight
hyperglycemia (high blood sugar)
• Other closed loop systems used “dual
hormone” treatment:
-insulin + amylin
-insulin + GLP-1
-insulin + glucagon
Closed Loop Schematic
Delivery device
Sensor
Computer running algorithm
Artificial Pancreas Studies
• More than 40 studies since 2010
• Ambulatory studies, including diabetes
camp, have been recently performed
• Typically less time in hypoglycemia and
hyperglycemia
• More emphasis on dual hormone systems
(i.e., insulin + glucagon)
• Some studies with smart phone platforms
(android, iPhone)
T-slim+Dexcom+iphone
T-slim + Dexcom + iPhone
2 pumps- 1 insulin, 1 glucagon
Not approved for consumer use,
Investigational
University of Virginia
University of Padova, Italy
University of Montpelier, France
University of California, Santa Barbara
Diabetes Care. 2014 Jul;37(7):1789-96
“Artificial Pancreas”
“Bionic Pancreas”
“Closed Loop Pump/Sensor”
• These are all the same thing
• These look a lot like the pumps and sensors
we use now, they just have “hopped up
software”
• Suspend for lows, correction for highs
• Computer/smart phone interfaces
• Medtronic 640G likely the closest to market
right now (available in Europe)
Just Another Day at the Office
Arrow Down at 10:07 am!
Note overnight elevation with correction bolus
-takes over 2 hours to correct- Reality check!
Note- I am not promoting this pump!
11:33 AM
Following a
50% temp basal for 1 hour,
15 gm snack,
and a small bolus
Avoided hypoglycemia
(and didn’t overtreat potential low
Note- I am not promoting this pump!
Wrap It Up Dr. J…..
Insulin was discovered (1921)13 years AFTER
the Chicago Cubs last won the World Series (1908)
Home of the Chicago Cubs
Troubleshooting (what you need
to know)
–
–
–
–
–
Last site change (should be every 2 or 3 days for most)
“Bad” site? (consider if boluses to fix highs aren’t working)
Total daily insulin dose (units/carb and correction factor)
Is basal/bolus about 50/50 ?
Is the patient using the technology as prescribed?
Do they disconnect or shut off?
Are they taking a lot of correction boluses?
– Do they have their data easily available?
– In trouble? Can always take an injection or switch to IV
– Is prescribing provider or CDE available?
(could also call pump manufacturer)
Stop! What?
• Things that cause a lot of variability in blood sugars
– Long shutoffs or suspends (except in specific situations)
– Lots of correction boluses
(makes me wonder if mealtime dosing is correct, or if site
is “bad”)
– Fingerstick calibrations done at times when blood sugars
aren’t stable
– Too little basal/Too much bolus (or vice versa)
– Inappropriate site changes
(waiting too long, i.e., more than 3 days, not changing when
bolusing not correcting highs)
Smart Insulins, Ultra-rapid
Insulins,Transplant
“Smart” Insulins
• Several in development
• Have some reactivity to be more active or
less active depending on blood glucose
lelves
Ultra-rapid Insulins
• Several in development
• Faster onset and peak that rapid acting
• Will be necessary for “closed-loop”
systems to be optimal
Transplant
• Whole organ pancreas transplant since 1966
• Often in those with kidney disease (kidney
transplant, too), not always
Betacell Transplant
• Exciting recent developments in the last
year
• Harvard “encapsulated” embryonic stem
cell derived betacells-protects from
autoimmune destruction
• Johnson & Johnson/Viacyte- similar
technology, encapsulated betacells
derived from embryonic stem cells
Summary
• Insulin pumps can be excellent tools for diabetes
management
• Sensors can be excellent tools for diabetes
management
• Still need to do basic diabetes cares
• Choose patients selectively for best results
• Training and followup are critical for success
• Knowing some basics can help these patients
• Future is promising with artificial pancreas
technologies and new betacell transplant technology
Questions?
Thank you!
Please complete the Post-Test for Day 1
(Blue sheet)
Reminder: For those of you submitting
reimbursement forms you can begin filling these
out. Please submit to Janet Lucas once complete.
See you tomorrow!