:

.. lispro (Humalog),
(vo Rapid)
glulisine (Apidra).

(Regular, Actrapid)

 :
/

(.
, dwn)


.

1. 12 am @ 0.6 u / hr.
2.

3 am @ 0.7 u / hr.

3.

8 am @ 0.5 u / hr.

0.5

0.6
0.6

0.5

0.6

0.5

0.7

0.5
0.7
0.7

0.7

0.7

1. .
2. depot .
3.

Smart Insulin Pumps

Photograph reproduced with permission of manufacturer.

 ?
Insulin pump
Reservoir
Infusion set
Serter

4:00

8:00

12:00

16:00

20:00

24:00

4:00

8:00

6.00

12.00

18.00

24.00

6.00

6.00

12.00

18.00

24.00

6.00


(MDI) 3

6.00

12.00

18.00

24.00

6.00


(MDI) 4

6.00

12.00

18.00

24.00

6.00


Basal-bolus
Glargine Detemir

Effect

HS

Variable Basal Rate: CSII

Program
Plasma insulin

Breakfast

Lunch

Dinner

Bolus Bolus

Bolus

Basal infusion
4:00

8:00

12:00

16:00

Time

20:00

24:00

4:00

8:00

 MDI

(dawn dusk phenomenon)

1
,

MDI ( 6 )


(1)

-

-

(
,
, -
snack, ,
)


(1):
:
( ,
, ),
,
,


(1):

(.
, )



25%

50%

50%

bolus

24

/ =

17%
bolus

bolus

17%

17%
bolus

[I.U./h]

10

2.0

1.5

1.0

0.5
0.1
0

12

15

18

21

24

0 1 2 3 4 5 6 7

9 1
0

1
1

1 1
2 3

1
4

1 1
5 6

1
7

1 1 2 2
8 9 0 1

2
2

2
3

Bolus


(SF)
SF

1800

1

bolus =

SF
. 200 100 = 2
50


ICR =

500

. 500 = 10, . 1
50
10 gr (ICR)
Bolus =
ICR
. 60 gr = 6
10
. 2 , SF
50 200 mg/dl,
: 200 - 100 = 2 bolus ,
50
estimated bolus : (2 - 2) + 6 = 6


(Bolus Wizard)
;
...

Bolus Wizard...

Time
Exchanges FExch

Time
BG BGTar
get

SensitivityTime

I .E.still .active

,
,...

...Bolus-Estimate!

 bolus
Bolus

Normal

Square wave

Dual Wave

[I.U./h]

10

2.0

1.5

1.0

0.5
0.1
0

12

15

18

21

24


(CSII)

6.00

12.00

24.00

18.00

(
)

6.00

(

)


2 - 5 .
- (
) -
( ).

18.0

24.0

06.0

12.0

,
, .
quoted from R. Renner, Munich-Bogenhausen (Germany)

 CSII
MDI (I)

( a/)

(depot)
( )

( )

(
)

 CSI
MDI (II)

(
), HbA1c

,
( ,
,
)

 CSII
MDI (II)

LDL VLDL

HDL



24


, ,


1 (DCCT)
HbA1c*
CT

MDI

HbA1c 10 %


43 45 %
.

- 45%

-43%

HbA1c.
* DCCT Research Group; Diabetes (1995); 44: 968-983

 HbA1c,
*
24

HbA1c = 11 %

(730 )

20

10 %

9%

16

[ 100 ]

12
8%

8
4

7%

0
0
24

(711 )

20
16
12

HbA1c = 9 %

8
4

8%
7%
6%

HbA1c

3
4

56
()

(DCCT evaluation of ~ 16000 HbA1c)

* DCCT Research Group;

Diabetes (1995); 44: 968-983


CSII
125I-
,
*

[%]
60
10 - 52 %
50
40
30
20
10
< 2.8 %
0

*Lauritzen et al.; Diabetologia (1983); 24: 326-329

 - MDI CSII*
[mg/dl]
200
MDI
CSII

150

( )
.

100

50

MDI
(n = 12)

CSII
(n = 12)

104 61 mg/dl
5.8 3.4 mmol/l

35 28 mg/dl
1.9 1.6 mmol/l

p < 0.002
* Hoss, U. et al.; Diabetologia (1996); 39;
Suppl. 1: A 214, 812

 , HbA1c 14 1
CSII MDI *
11.2 2.2

[mmol/l]

9.3 1.6 **

4.9 1.0

[mmol/l]

3.6 0.6 **

: 41 8

:
19 9

MDI :
> 6

:
6

8,0 1,3
HbA1c [%]
7,0 0,9 **

43,8 12,4

[I.U./d]

34,4 10,6 **

MDI

CSII

** p < 0,01

* Wredling, R., Hannerz, L., Johansson,

U.-B.;
Practical Diabetes Int (1997); 14: 5-8

 , HbA1c
MDI CSII

[mmol/l]

[mmol/l]

9.70 1.8
9.16 1.5 *

4.55 1.0
4.05 0.8 **

HbA1c
[%]

8.24 0.77
7.89 0.77 ***

[I.U./d]

47.3 14.9
38.5 9.8 ***

,
41

1

(pen) (MDI)
(CSII)
4 *.

MDI: 3
lispro (-l )
2-3 NPH

* p<0.05

CSII: lispro

*Hannaire-Broutin, H. et al.; Diabetes Care

(2000); 23 (9): 1232-1235

** p<0.01

*** p<0.001

HbA1c (MDI)
(CSII) Yale Adolescent Study
HbA1c 75 1( : 12 20 )
(n = 50) (n = 25).*
HbA1c [%]
9.50
9.00

MDI
p=0.003

8.50

8.00

CSII

7.50
p=0.02

7.00
6.50
6.00
0

6
[]

HbA1c : 4.3 - 6.3 %

* Boland E.A.. et al.; Diabetes Care (1999); 22 (11): 1779-1784

12

 , HbA1c CSII
MDI

[mg/dl]

[mmol/l]

300
280
260
240

17
16
15
14
13
12
11
10
9
8
7
6
5
4
3

MDI

220
200
180
160
140
120
100
80
60

CSII

11

15

18

22

[I.U./d]

HbA1c
[%]
10
9

80

60

40

20

19
3

*.

0
(MDI)

4
(CSII)

12t week
(CSII)

0
(MDI)

4
(CSII)

12
(CSII)

* T. Lindner, University Hospital

Dresden (1994), Germany

 , HbA1c MDI
CSII

100

140
120

55 1

12 MDI
12 CSII*.

138

100
80

60
40
20

[I.U.]

22

39

36

37.7

37.8

7.4

7.4

26

0
45
42.9

40
39.6
36.4

35

30

HbA1c
[%]

8.0
7.5

7.7

7.7

7.4

7.0
6.5

6.0
MDI
(n = 55)

CSII

)
1 2
3
n = 55)
(n = 50)
(n=33)

(n = 25)

* Bode, Steed, Davidson; Diabetes Care (1996);

19 (4): 324-327

CSII Reduces Incidents of Severe

Hypoglycaemia
Severe Hypoglycaemic Episodes: CSII vs MDI

1 Rudolph JW, Diabetes Care 1996, 19:325-7.

3 Boland, EA et al., Diabetes Care 1999, 22:1779 - 84.
4 Pickup JC & Sutton, AJ. Diabet Med 2008;25:765-774 Hirsch IB. Endocrine Pract 2002: 8; 401 405
2 Bode, BW et al.,

1/4

In the 5-Nations Study CSII Decreased Risk of Hypoglycaemia,

while Decreasing A1C
n = 272 Type 1 patients

Hoogma RP. et al. Diabet Med. 2006; 23:141-147.


(CSII)
2 8 12 C 1 (
:
30 2 , : 11 2, HbA1: 8.9 0.3 %, : 6 - 9 %)
8
[mmol/l]
7

10 ( 12)

.

,



.

* Koivisto V. A. et al.; Diabetes (1986); 35:

78-82

 (CSII)
(MDI)

MDI

CSII

8.3

6.5

56.5 + 23.4

49.0 + 17.0

BMI
[kg/m2]

25.1

25.1

[ 100 ]

29.7

17.0

[ 100 ]

12.3

5.0

HbA1c
[%]

[I.U./d]

/*
118

15 :

* Schreckling, H., Bergis, K.-H.; Diabetologia (1997); 40; Suppl. 1: A 643

: 38 13
:
17 9


MDI CSII:

31
10

6

( 8 16 )

CSII.*

[]
125

,
($ 4000.00 /
) ($ 85.00 / )

30

[$]

175 963.00
76 572.00
* Steindel et al.; Diabetes Research and Clinical
Practice (1995); 27: 199-204

/
(,
.)

1000

2000

3000

4000

* 1998; EASD.
6.890 , 3 3 .

5000

6000

 MiniMed 508

(Bolus)

Child block

Bolus

Quick-serter

Quick-set

Sil-serter

Sof-serter

Silhouette

Sof-set

Guardian RT

,
,
(SenSerter).

3 ,
(288
/ )
monitor

real-time 5 .
monitor,

4 .
Guardian RT
PC

The MiniMed Paradigm REAL-Time System

,
,
(SenSerter).

, ,

72 (3 )

522.wmv

, 2-4 .

MiniLink REAL-Time
MiniMed Paradigm REAL-Time
with MiniLink

Bayer Contour

Menarini
GlucoDay

Roche
GlucoOnline

Abbott
Navigator

SpectR
x

DexCom STS

Sonatra
Medical/Bayer

Cygnus
GlucoWatch

Pendragon
Pendra

45

24 5

REAL-Time
:

,
,

.

1 - T. M. Gross et al, Abstract 124, EASD/IDF 2003 (Diabetologia)

2- Tavris DR et al, Diabetes Technology & Therapeutics, Volume 6, Number 4, 2004; 518-22

150
70

Finger stick
testing with
meter/strip

Continuous
sensing showing
trends

Continuous sensing
with alerts

.

1,2

1. Bode et al. 2004 Diab.Tech & Therapeutics 6(2): 105-113.

2. Garg et al. 2006 Diabetes Care 29(1): 44-50.

Fictional illustration of alerts in use

CGM Alerts Reduce Duration of Hypoglycaemic

Excursions1

71 Type 1 patients wore sensors over a 12-day period

Multi-Center RCT where patients were randomised to:

p=0.004

Minutes per event

1. Alert Group
Alerts On 50%
Alerts Off 50%
2. Control Group
Alerts Off

Period 1
Period 2

p=0.03

80

69,6
64,4

63,8

60
33.6

40

20

Alerts
off

Alerts
on

Alerts
off

Alerts
off

0
Alert Group

Control Group

CGM alerts improve glycaemic control

1. Bode et al. 2004 Diab.Tech & Therapeutics 6(2): 105-113.


-



- MiniMed Paradigm Veo System
.



(Low
Glucose Suspend (LGS)

Low Glucose Suspend In Use

Fictional illustration of Low Glucose Suspend
function in use

Low Glucose Suspend CareLinkTM Therapy

Management Software Tracing

Low Glucose Suspend

Feature Details

User settable: On/Off

Range: 40 110 mg/dL; 2.2 6.1 mmol/L
Suspends insulin infusion for a 2-hour period
If interstitial glucose remains low 4 hours after resuming insulin delivery,
pump will re-suspend insulin delivery
All other sensor functions and alerts remain operational during insulin
suspension

Feature Overview: Schematic

Low Glucose Suspend
Triggered
Patient does not
respond to alarm

Patient responds to alarm

Pump suspends and alarms

I have diabetes,
call for emergency assistance.

Patient can choose to suspend or

resume basal

Pump suspends insulin delivery

for 2 hours

If suspend, pump suspends

Insulin delivery for 2 hours

After 2 hours
pump resumes
basal

After 2 hours
pump resumes
basal

If BG still low 4 hours after

resuming basal,
insulin re-suspends

If BG still low 4 hours after

resuming basal,
insulin re-suspends

Patient can interrupt Low Glucose Suspend at any time

Long Term Sensor/Pump System

(LTSS)

Long Term Implanted Sensor/Pump System

Long Term
Glucose Sensor
in right atrium
Abdominal
lead

Insulin pump
placed
subcutaneously.
Stores sensor
data, delivers
insulin, and send
information to PPC

Insulin
Delivery
Catheter
in peritoneum
Personal Patient
Communicator
(PPC)
External device.
Receives data,
displays and
sends
information

VGMS SYSTEM
Clinical Trial:

Extension lead

Transceiver:
Receives digital
sensor signals,
calculates glucose,
and telemeters data
to PPC

Central
Venous
Catheter:
Multiple lumen

Glucose
Sensor

Display unit (PPC):

Receives telemetered data,
displays, and communicates
information

10 Diabetic subjects with

scheduled surgery (T1 or
T2)
No restrictions on infusion
through catheter
X-ray for placement at
SVC-RA junction
BG every 30 min for first 2
hours; then every 2 hrs.

Fully external system

3-day subcutaneous sensor
External pump ( 3-day infusion set )

FUTURE:
Telemetered
signal from
sensor into pump

Subcutaneous
glucose sensor
measures glucose in
insterstitial fluid

External insulin
pump delivers
insulin to the
interstitial fluid
(subcutaneous) at
constant rate or
bolus

Hybrid system
Alternate components
communicating with one
another or external control
unit

Implanted
sensor /
external
pump

Subcutaneous
sensor /
implanted
pump

Fully implanted system

1-year intravascular sensor
7+ year implanted pump ( 90day refill )

Intravascular glucose
sensor near right atrium
of heart

Abdominal extension lead

connecting sensor to pump
Insulin delivery
catheter

Subcutaneous insulin
pump delivers insulin
to peritoneum

Display unit (PPC)

recieves and sends
information to pump
via telemetry

( )

(Glucose sensor
lag time)
.

37,
: (GFR = 32.8
ml/min, = 1.8 mg/dl), (4.4 gr
24), , ,


HbA1c = 7.7 % (HbA1c = 9.2%, 6)

,
(glargine 16
glulisine - 11
/)
-
,


:
=
+
bolus
= 16 . + 11 . =27
25%
= 20
10 10
bolus
10/24
0.4 / =

Basal rate and bolus wizard settings

New Basal rate

Increase of night basal rate