let's now move to the clinical environment and I'm inviting you to discuss with me the cases, the discussion of applying flesh based CGM to the front line of diabetes care. In the real world, Our first clinical case is a person with diabetes that is 60 year old has type two diabetes for 28 years On MD. Already for 15 years has hypertension, hyper epidemiology A Bmi of 26 and the body weight of 83 kg. No chronic complications detected so far. And the recent deterioration in metabolic control With his current measured a one c. of 78 million more per mall or 9.3%. As you will immediately realize there is a discrepancy in between the measure A one C. And the glucose management indicator. The C G M. Calculated a one C. Why is this so well as you can see and this is in my local language, I will just try to tell you that this is a download of 90 days that ended just a couple of weeks ago. It's a 19 days of data and here as you can see the calculated a one C is just 7.8 because this is a three month period and an average of it. And as you can see during this, the variability wasn't that high. But the time in range was very low of only 44 and with a little bit of hypoglycemia but a lot of high glucose if you look at this ambulatory glucose profile. Over the day. You see that most of the hyperglycemia actually is after the dinner and during the first part of the night, although also after breakfast and lunch. There are elevations and here during in the day by day. This is july as you can see here and the lines are quite okay. They're pretty straight and they are close to the target here in september however, they seem to be very high When we look this into a more to me an easier way to look. This is again March as you can see here. Good management, sometimes hyperglycemia, but overall good management with 36 units of perennial insolence and 18 units of basal insulin. Whereas in june already the elevation start here the same units of insulin. But when we go to september the insulin was diminished. Brandel insulin was diminished. There were missing Bolasie's. As you can see no correction bolus is interestingly so lower total dose here. Less Brandel insulin and no correction, Volvo says which of course caused the deterioration that we saw in the recent measurement of A one C. Because as we know, the A. One C. Measured actually mostly represents the last month of the average glucose. So what are potential areas of concern? A clear deterioration in glucose control over the 90 days measure A one C. That reflects predominantly the last 30 days and this therefore significantly higher reduction of insulin and the mission of Prindle bonuses no correction bonuses whatsoever. Perhaps self control fatigue. And what would you in a discussion should we be able to have it in your presence? Do what would you suggest? So first I always discuss this G. P. Together with a person with diabetes and then identify causes for deterioration and immediately discuss potential solutions. One potential solution is more organized and better meals. It is fabulously difficult to do, but it is not impossible. So I always try to have this discussion and also evolve involve a dietitian more daily physical activity. Walking in this case would be just enough and of course set clear glucose targets for time in range and time below range, particularly time in range. In this particular case, I would also suggest scheduling remote contacts with the diabetes team within the next month or so to follow up whether these suggestions were actually inside the new lifestyle of this person or perhaps additional challenges are still in existence. And I'll be happy to discuss a little bit more each separate case with you. In the end. For now, perhaps we move to the second case and for all that I am presenting particularly with the MD. We have an additional possibility we have artificial intelligence that is now available as decision support systems. And we just recently presented data where we compared this artificial intelligence in type two diabetes on MD. And again, the artificial intelligence system was non inferior to diabetes. Ologists from different re known centers in the world. Not only for type one, but only for type two on the therapy, which of course could be an additional way to help our individual from the clinical case number one, But also for the from the clinical case. # two here we have a lady that reports pull Yuria reports signs of depression and is referred to us for evaluation. She is 56 year old has type two diabetes for eight years on mid foreman. Have you got a semi ketosis on SGL- T2 inhibitors and were stopped? Is currently on deck logically regular, tight 50 for one year has hyper epidemiology and hypertension. A BMI of 35.7 and a weight of 102 kg, no chronic complications so far detected. And in the recent a one c of 91 million more per mole or 10.5%. This is a very good match. As you can see here with the estimated a one C. The glucose management indicator, exactly the same number is calculated so very stable. Uncontrolled diabetes. Most of values as you can see our way above the target range throughout the day. Same when you look this patterns when you look day by day. She does scan from time to time. But as you can see also measures once a day. But as you can see here, all Lucas is are very high and she doesn't do anything. So potential areas of concern is a constant hyperglycemia measured a one C that of course matches the calculated me they met very well unless there was a change in time needs therapy intensification and this is a very, very important area of CGM use time. Timely therapy intensification is to me a crucial, a crucial area of the use of CGM need psychological support and likely as we discuss nutrition support. So I would again discuss the A. G. P. Together with the person with diabetes and suggest potential solutions starting and the FBI is clearly one way to go if the hyperglycemia is so high and so persistent, More organized and better meals. Again, as we discussed previously, more daily physical activity again, simple walking 30 minutes a day would do beautifully set glucose targets for the time in range of course here we should start a little bit with less ambitiously initially to get to the right timing range with time and schedule again, an additional remote contact and a stated perhaps a artificial intelligence advisor would also be of benefit if you allow me now to move to our clinical place number three, which is a more advanced type two diabetes, a 73 year old female type two diabetes for 13 years. Random cPAp tight until recently. Present 1.1 pickle muller in to 19 3 years ago on Metformin LG LT two inhibitors not successful On Deck Ludek really tight 50 for one year Hyper epidemiology hypertension smoking for 40 years, mild Heart failure and a bmi of 37 with 83 kg. Her current a one c. 67 million more per mall or 8.3%. No diabetic retinopathy. Net property or peripheral neuropathy detected But recently switched on Life's Pro three times a day. And a basic Galardi. The long acting and I am insulin analogue with sometimes a feeling of hypos When we downloaded deliberate this is what we saw. So even better estimated A one C. Which of course reflects the last 14 days because it's only one sensor download here as you can see a very good average glucose. And the system identified some hypoglycemia with this lady. When we look at the ambulatory glucose profile we see that this hypoglycemia actually hits around three a.m. During the typical time but sometimes also postprandial E. In a milder way. When we go to daily profiles, we confirmed this actually that yes it's around 2 to 3 a.m. It's postprandial E on the stable basal bolus regimen of this rapid acting. A dialogue and a long acting analogue. And of course this was confirmed. So it's confirmed mild hypoglycemia during the night and post perenially. So with this lady potential areas of concern is Number one a significant improvement in metabolic control from 3 8.3 on the previous therapy to 6.3 on the current therapy She actually has occasional might hyperglycemia with her age of over 65. And her comorbidities with mild mild heart failure. Perhaps there is a room for adjustment of this therapy, no age appropriate physical activity and of course also she needs nutritional support. So again I will discuss this download with this individual with diabetes with this lady and potential solutions. I would certainly suggest changing a bass angler to a second generation basal insulin because they have a proven reduction in hypoglycemia, particularly during the night in type two diabetes. On MD. I would suggest more organized than better meals as discussed previously. And I would also suggest physical activity here. Perhaps even less amount of walking per day would do a very nice job. I would set clear glucose targets. She is very good but I would perhaps set the lower limit for hypoglycemia to 75 And consider the very importantly, liberal to or recently Liberal three with the possibility of alarms to prevent a more serious event of hypoglycemia. With these three cases altogether, I would like to propose to you a couple of conclusions intermittently scan. See Gm with liberal is an essential clinical tool for managing type two diabetes. So the standard of care, particularly Type two or MD, but also Type two on basal insulin with any possibility of hypoglycemia or pronounced glucose variability. The standard of care should be a C. G. M. Managed care. It's particularly helpful for individuals in need for therapy, intensification. This to me is the most important thing we have to be timely to prevent long term complications and several day to day challenges like meals, physical activity and of course hypoglycemia. Finally liberal to or hopefully very soon libre three with alarms and the c g m. B. You will additionally improve time in range. With this, I would like to thank you very much again for your attention and I'll be more than happy to discuss. This case is with you should our technology allows us this. Thank you.
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