Speaker 1:       
Welcome to the Diabetes Technology Information Session, brought to you by the Certified Diabetes Care and Education Specialists at the Ohio State University Wexner Medical Center Division of Endocrinology.

We will be reviewing the FDA approved continuous glucose monitors and insulin pumps in addition to the other diabetes technology that is currently available. We will then discuss the protocol at Ohio State and what the next steps are in obtaining the technology. Please note that there is a link on the homepage to a short survey for you to complete at the end of the session. This will allow you to communicate your device preferences with the education team.
                        
We will first cover the continuous glucose monitors. These will be referred to as CGMs throughout this video. We will discuss the basics of what a CGM is and how it works. We will then cover each of the CGM options. There are three main parts to the CGM system. The sensor is the piece that is placed directly under the skin and held in place by an adhesive patch. The transmitter wirelessly sends the glucose reading to the receiver. Lastly, the receiver, which may also be your smartphone if you have compatibility with the mobile app, will display your sensor glucose data. The sensor is measuring the interstitial glucose level, which is the glucose that is found in the fluid between the cells. Due to this, the sensor data can be approximately five to 15 minutes behind the actual blood glucose level.
                        
A CGM is a device that tracks glucose levels in real time 24 hours a day and updates readings every one to five minutes. CGMs can be used alone or with an insulin pump and can be used for people with both Type I and Type II diabetes. A blood glucose meter provides a single snapshot of where your glucose level is, while a CGM is like a video that provides a continuous stream of information on glucose levels, trends, and overnight data. Not only does it provide a sensor glucose value, but it will also show you the speed and direction that your glucose is headed. Another helpful tool is the optional alert feature. Most sensors have high and low alerts that can be individualized for the user. You may also choose to have alerts when your glucose is rising or falling rapidly.
                        
There are many advantages of CGM therapy. It provides more than just a static number. It also provides the trend information in real time, so you know where you are headed. With this glucose trend information, you are in a better position to make an informed choice on what to do about your current glucose level. By having personalized alerts, it can help you detect low blood sugar that you may not feel coming. It can also help you catch the highs that you may have otherwise missed. Some of the CGMs allow for the user to share glucose information, including alerts, with friends and family members. CGM data gives the user a visual representation of their patterns on a daily basis. This helps to assess the effectiveness of your current insulin doses as well as the effects of food and exercise on glucose levels. As previously mentioned, CGMs can be combined with certain insulin pumps but can also be an extremely effective tool to use on its own.
                        
Despite the many benefits, all technology can have some drawbacks. There is an upfront cost for the CGM system as well as the ongoing cost of supplies. It does not entirely replace finger sticks, although it can significantly reduce the frequency of them. Some CGMs do require calibration. Calibration is the process of entering a blood glucose reading from your meter to calculate the sensor glucose values. Finger sticks are recommended anytime your symptoms do not match your sensor glucose reading. Due to this, you will want to make sure you still have your glucose meter and test strips. Some people experience skin sensitivities from the adhesive tape. However, there are many products out there that you can use on your skin to prevent or alleviate this.
                        
A sensor is something that is worn on the body. If you are wearing both a pump and a CGM, this is two insertion sites to get used to and two site changes to keep up with. Finally, CGMs provide a lot of data so it is possible to feel overwhelmed. Sometimes it may feel like there are too many numbers to know what to do with. A training with a diabetes care and education specialist is essential in helping you better understand how to use your system, interpret the data, and make appropriate treatment decisions.
                        
There are four CGMs available at this time. These are Dexcom, Freestyle, Libre, Eversense and Medtronic Guardian Connect. Dexcom has two products, the Dexcom G6 and the Dexcom G7. A one-touch applicator is used to easily insert the sensor just beneath the skin. The sensor is changed once every 10 days. The G6 transmitter is changed once every three months while the G7 sensor and transmitter is combined into one device and changed out together every 10 days. The G6 is approved to be worn on the abdomen and the G7 is approved for the back of the arm. The G6 warm-up time is two hours, while the G7 warms up in 30 minutes.
                        
There are no calibrations required from the user. The sensor glucose values are updated every five minutes. Optional, high, low and predictive low glucose alerts are available to be customized by the user. You can share your data with up to 10 different followers. You can also review your own glucose reports and share your information directly with your diabetes care team using Dexcom Clarity. You may choose to receive your data using the handheld receiver or if you have a compatible smart device, you can download the mobile app and have your information sent directly to your phone using Bluetooth without the need for a receiver. If you use the phone and have a smartwatch, that is an additional avenue to receive your glucose information. Both the G6 and the G7 are compatible with insulin pumps.
                        
The Freestyle Libre has two products, the Libre 2 and Libre 3. The sensor is worn on the back of the upper arm and is changed every 14 days. Glucose data can be viewed using a handheld reader or a compatible smartphone with either product. There is mobile app compatibility with both Android and iPhone. When using the mobile app, you can share data with up to 20 followers. Using Libre View, you can see your own glucose reports and share your information directly with the diabetes care team. This system does not accept calibrations by the user. Both systems have optional high and low glucose alerts. The Libre 2 sensor glucose value is displayed with a one-second scan using either the reader or the phone. Libre 3 readings can be viewed continuously without the need to scan. Libre 3 is currently the smallest sensor available.
                        
The Eversense is a six-month sensor that is professionally placed under the skin by a healthcare provider. It is inserted into the upper arm. Real-time glucose data is received using the mobile app on a compatible iPhone or Android device. The sensor provides on-body alerts from the transmitter even when your mobile device is not nearby. The transmitter can be removed temporarily without wasting the sensor. It does get removed once daily to charge, and it is reusable for up to one year. Sensor glucose values are updated every five minutes. Two calibrations are required daily for the first three weeks of using the sensor. After day 21, one finger stick is required for the rest of the sensor life. After the sensor is placed, it does take 24 hours to warm up before glucose data is received. Your healthcare provider will remove and replace your sensor for you in the clinic every six months.
                        
The Medtronic Guardian Connect is the last standalone sensor. Current glucose levels and trends are seen using the app on your mobile device. There are optional alerts including predictive alerts up to 60 minutes in advance of a high or a low glucose event. The sensor is approved for use on the back of the upper arm or the abdomen. It comes with a one-press serter for insertion. The sensor is changed out every seven days. The transmitter is reusable for up to one year. The system requires a calibration from the user, a minimum of once every 12 hours. Data can be shared with up to five people. The Sugar IQ diabetes assistant app works with the Guardian Connect and can help the user identify patterns and understand trends. The transmitter that is used for this Medtronic standalone CGM is different than the transmitter that is used for the CGM that connects with the Medtronic insulin pumps.
                        
We will now switch gears to insulin pumps. We will cover the basics of insulin pump therapy and we'll then review each option available at this time. An insulin pump is a small mechanical device that continuously delivers insulin through a small cannula placed under the skin. It is designed to mimic the way that a pancreas delivers insulin, and this is done in two ways. Bolus insulin is the amount taken for food as well as correction. Basal insulin is your background coverage that is delivered in small amounts every couple of minutes to help keep glucose constant in between meals and overnight. Rapid acting insulin is used in the pump and this insulin is programmed to be delivered in these two different ways.
                        
Pump supplies will consist of the actual pump itself, the part that holds insulin, which is called the reservoir, the cartridge or the pod depending on which pump you have in the infusion set. The infusion set has the tubing that carries insulin to the body and the cannula that is placed under the skin. The tubing is easily disconnected from the site on the body for situations such as bathing or swimming. Lastly, you will have a blood glucose meter. Some meters can be connected to the pump so your blood sugar results can be transferred automatically.
                        
As we discussed with CGMs, most devices come with both advantages and disadvantages. Pumps allow for very precise insulin delivery. If you are coming from injections, you are used to giving whole units of insulin at a time. Pumps can provide very small fractions of a unit that can make a difference for those who are especially sensitive to insulin. Pumps offer freedom from multiple daily injections. All pumps have built-in calculators. When carbohydrates and blood sugar is entered, the pump calculates your insulin dose based on your program settings. It always keeps track of how much insulin is active in your body to help prevent insulin stacking.
                        
Another advantage is being able to set temporary increases or decreases to your basal rates. This may come in handy for sickness or exercise when you temporarily need more or less insulin. Pumps allow for flexibility and convenience. Adjustments can be made easily to accommodate the normal changes in your daily life. Each pump comes with a free software that is used for data collection and analysis to assist in making adjustments to your treatment plan. A pump eliminates the unpredictable effects of long-acting insulin. Pumps use rapid-acting insulin only that has a more efficient and predictable action time. Overall, having a pump may lead to improved A1Cs, reduction in glucose variability, and ultimately an improved quality of life.
                        
One disadvantage of a pump may be the cost. Insulin pumps are more expensive than insulin pens and needles. Although most insurance plans cover insulin pumps and supplies, there are often copays and deductibles to take care of. There is a higher risk of developing diabetic ketoacidosis if the pump malfunctions since you do use rapid-acting insulin only. A pump is a device that is attached to you at all times. It is possible to have skin sensitivities to the adhesive tapes and develop scar tissue where the cannula is inserted if you do not rotate your sites well enough. It is possible for the user to feel overwhelmed at first. There is a steep learning curve, and it may take some time for the user to get familiar with changing infusion sets, being attached to the device and regulating the pump settings.
                        
We will now cover each of the pump options. These include Medtronic, Omnipod, Tandem T:slim, and the iLet Bionic Pancreas. The Medtronic 780G is the newest pump available from Medtronic. This pump works with the Medtronic®-Guardian®-IV CGM, and will automatically adjust the background insulin delivery every five minutes based on sensor glucose values. This system allows personalized glucose targets of 101, 110 or 120 as specified by the user. Insulin delivery is suspended in advance of a predicted low blood sugar. Automatic correction boluses are also given when glucose levels are predicted to be above target.
                        
The new Medtronic®-Guardian®-IV CGM does not require calibrations. The 780G transmits data to your smartphone using the MiniMed mobile app. You may also share data and alerts with followers using the CareLink Connect mobile app. The Bluetooth connectivity enables automatic data uploads to your diabetes care team. All Medtronic 770G users will have access to a software upgrade to the Medtronic 780G, but a new prescription is required. The Medtronic 630G is often used by those with Type II diabetes with commercial insurance, and this pump does not automatically adjust the background insulin.
                        
The 630G does have the ability to suspend insulin delivery in advance of a predicted low blood sugar when using the Medtronic Guardian 3 CGM. Both the 780G and 630G pumps have a linking blood glucose meter. When using the linking meter, the glucose result will be sent automatically to the pump. They have a colored screen with auto-brightness. The smallest increment of insulin the pump provides is .025 units per hour, and it holds up to 300 units of insulin.
                        The Omnipod is the only tubeless pump option. It is completely waterproof and is held on the skin by a durable adhesive backing. All pump activity and adjustments are done through the handheld device, which is called the personal diabetes manager or controller. There are two options for the Omnipod system, the DASH and the Omnipod 5. The newest Omnipod 5 is the first tubeless automated insulin delivery system and communicates with the Dexcom G6. This system predicts sensor glucose values 60 minutes in the future and will increase, decrease, or pause insulin delivery using the SmartAdjust technology.
                        
To use the Omnipod 5 Automated Insulin Delivery System, the user must be using the Dexcom G6 through the mobile app. It will not work using the Dexcom receiver. Target Glucose levels can be customized between 110 and 150. The bolus calculator uses both the CGM value and trend to determine an appropriate dose of insulin. This system can be fully controlled with the Omnipod 5 mobile app on a compatible smartphone. If the user's smartphone is not compatible with the mobile app, the handheld controller will be used.
                        
The Omnipod DASH delivers insulin based on all program settings and does not communicate directly with a continuous glucose monitor. The personal diabetes manager is a lightweight touchscreen device. It can connect with a mobile app called the Omnipod View, which allows information to be shared with family members and caregivers. The DASH has a linking blood glucose meter that will eliminate the need for manual glucose entry when delivery in a bolus. For both the Omnipod 5 and DASH, the smallest increment of insulin the pump provides is 0.05 units per hour. The pod holds a minimum of 85 units and a maximum of 200 units. The cannula inserts automatically by a press of a button without being seen. Both systems can be set up to enable automatic data uploads to your diabetes care team. Omnipod and Omnipod 5 are both supplied through pharmacy. When received through pharmacy, there is no contract or warranty involved.
                        
Tandem has two pump options, the T:slim X2 and the Mobi. Both pumps use control IQ technology and adjust background insulin levels based on sensor glucose readings. This pump communicates with both Dexcom G6 and G7. Sensor glucose values are predicted 30 minutes in the future and the pump will adjust background insulin based on these predictions, targeting a blood sugar of 110. It will automatically suspend insulin delivery in advance of a predicted low blood sugar. Automatic correction boluses are also given to help prevent or treat high blood sugar. The T:slim X2 pump can be paired with the T-Connect mobile app, which enables automatic data uploads to your diabetes care team. The mobile app also allows users to bolus directly from the phone. The T:slim X2 has a colored touch screen. The cartridge holds a of 85 units and a maximum of 300 units.
                        
Tandem Mobi is the world's smallest, durable automated insulin delivery system. It is powered by the same control IQ technology as the T:slim X-Two pump, and is less than half the size. This device is completely controllable from the user's compatible iPhone. The Tandem Mobi has a small five-inch tubing option and it holds up to 200 units of insulin. Both Tandem pumps are rechargeable using a USB cord. All software updates can be completed remotely. This prevents users from waiting until the warranty is up to get the latest improvements.
                        
The iLet Bionic Pancreas is an automated insulin delivery system that communicates with the Dexcom G6 and G7. This pump is unique in that it only needs a person's body weight at initial setup and requires minimal input from the user on an ongoing basis. Basal insulin delivery is adjusted every five minutes in response to CGM values and trends. Insulin delivery is paused in advance of a predicted low blood sugar and automatic correction boluses are given if glucose is trending up. This system's algorithm continuously adapts to the individual's insulin needs over time. Meal doses are determined by announcing a meal as a usual meal, a larger meal, or a smaller meal. This advancement removes the traditional reliance on carbohydrate counting for mealtime insulin dosing. There are no basal rates, carb ratios, or correction factors programmed in this pump. The iLet Bionic Pancreas can be paired with the iLet mobile app, which enables automatic data uploads to your diabetes care team.
                        
For those who may not be ready or interested in an insulin pump, there are some other insulin delivery devices to consider. The InPen is the only FDA-approved smart insulin pen that combines a reusable Bluetooth enabled insulin pen and mobile app. Based on the settings that you have programmed, which include your insulin to carb ratio or set meal doses, correction factor, insulin action time and blood sugar target, you will receive personalized insulin recommendations right from your mobile app. After entering your blood glucose and carbohydrate intake, it will calculate how much insulin you need for food and correction while keeping track of all insulin previously taken to avoid insulin stacking. The InPen system offers a series of customizable reminders. The InPEN delivers half-unit doses, is compatible with refillable cartridges of Humalog, NovoLog or Fiasp, and it can sync with your continuous glucose monitors or blood glucose meters.
                        
The V-Go is an all-in-one insulin delivery system that is applied like a patch and is most often used in people with type II diabetes. Designed to replace both your long-acting insulin and your multiple mealtime injections, V-Go delivers a continuous basal insulin rate over 24 hours, in addition to on-demand dosing at mealtimes in increments of two units. The V-Go uses an adhesive to stay on the skin. It is waterproof and is changed out every 24 hours. They do come in three different sizes: 20, 30, and 40 to match the amount of basal insulin that is needed by the user.
                        
CeQur Simplicity is a mealtime insulin delivery patch that replaces insulin injections taken for food and correction. The patch is filled by the user with Humalog or Novolog. It holds up to 200 units of insulin with a minimum fill of 100 units and is changed every three days. This patch is FDA approved to be worn on the abdomen. Insulin is provided by a press of a button and is delivered in two unit increments. CeQur Simplicity is covered on most commercial and Medicare Part D insurance plans as a pharmacy benefit.
                        
Our protocol at Ohio State is developed to ensure that you are equipped with the best possible self-management skills to be successful long-term on your device of choice. After completing this information session, the next step is to attend one of our two-part diabetes education classes if you are pursuing an insulin pump and if not had any education with our team in recent years. Upon completion of the class, our patient navigator will assist you in completing and sending all necessary paperwork to the device company of your choice.
                        
Once your device is received, you will schedule an appointment for training with one of the diabetes care and education specialists who is also an insulin pump and CGM trainer. Depending on education needs and insurance requirements, it is possible for this process to take up to three months from start to finish.
                        
[Text on screen
Phone: 615-688-9147
Email: diabetes@osumc.edu]

This completes our information session. Next, you will find our contact information as well as some frequently asked questions. We ask that you please complete the quick survey that can be found on the home page as this will allow you to communicate your device preferences to the team. We thank you for listening and we look forward to working with you.

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Frequently Asked Questions

What type of insulin is used in a pump? 
Rapid acting insulin such as Humalog or Novolog

Where do I put a pump?
Infusion sets are placed anywhere that you would normally give an injection, including the abdomen, back of arm, hip, leg – infusion sets are changed every 3 days

Will insurance cover my device?
All insurance plans have different coverage. Our patient navigator will assist you in determining your device settings.

How do I decide what is best for me?
We are happy to speak with you and help you decide what device may best fit your needs. You can also refer to the device websites for further information.

How can I keep my CGM from falling off?
Adhesive patches slash tape or liquid adhesive agents can be used if the sensor is not staying securely attached to the skin for the duration of the sensor session.]