Now it's time to move into our uh interactive uh case study uh forum. So I'm really pleased to in invite back, Doctor Sheer and uh Doctor Mucci to join me as we go through a few cases and we'll interact uh the best we can uh and, and give you some advice on how we look at uh glucose data or clinical situations. Uh And so let's begin, I'll start off with a, with a case and ask my colleagues to uh to comment as we work through. So I'm gonna start off with a 60 year old gentleman who's had type two diabetes for eight years and this is a real case that uh our diabetes educator team brought to me. Uh And I think uh it'll convey uh several points. So this is um he's, he's had diabetes for eight years, £250 A BM I 37 A one C is 87. As you can see on Metformin alone, maximal dose twice a day, has some renal issues and pretty strong cardiovascular risk factor, if not disease. So, pretty typical blood pressure lipids, uh high A one C. Um Now, in this particular case, we don't have uh AC GM or glucose data. This is the first console and we're asked to do something. Um Let me ask doctor uh munchi. Uh what do you think? Uh a type 28 years overweight? What, what would be a good agent to select pending any other data except for the A one C? Yeah. So, so this is, this is a fairly uh typical uh probably patient that I see on my clinic too. For a change. We overlap. But I I think there is a really uh a phenomenal data now that this individual with the cardiovascular risk factors uh would benefit from the, from the newer agents, the G LP one receptor agonist or perhaps also the GLT two inhibitor. So um there are, there are uh patient preferences very significantly, especially considering the injectable nature of G LP one so far. But that would be my first option to discuss. Yeah. No, excellent. And we had that discussion checked insurance, a big issue and uh weight was high on this person's mind. So we did go with the G LP one and we selected the one that was covered by this person's insurance. AC GM was ordered. Now, you might say why? Because this person is not on any glucose lowering meds but was very anxious to know where his blood sugars stood. And the diabetes educator suggested it back to me and I said yes, by all means So here we go. Um This is the first CGM then done a couple weeks later, still on that beginning dose 0.75 mg per day of DECLA. And you see the CGM and it's not at all normal. Um But it's probably better have, having been on it a couple of weeks because the estimated A one C is 80 versus the 87. But before a pretty tight CV, I'll blow it up a little bit. So you see the time and range uh is 51%. There's no lows and we're aiming for 70. So we've made progress. Um uh even though we don't have a previous CGM any, any advice on where to go next? Well, I would say keep going. Uh I, I still, there is still uh there are still those huge peaks, postprandial hypoglycemia and no hypoglycemia. So I think we are on the right track and keep pushing. Yeah. All right. So here we go. Exactly right. So we look at this and say, look at those peaks, look at the fasting glucose stills once. Well, well, you saw uh 175 fasting, the average is 190 we gotta go further. Now, I'm adding one little twist because remember the audience will know that uh we looked at this grid earlier, um glucose variability and average glucose. And we saw how this is an interesting plot of 20,000 patients and where they end up and here's our patient uh right here with a CV of about 26 and an average glucose um around 190. And this grid predicts you should be around 50% time and range. And, and that's right where this patient is. So let's look at now going up on the dose to 1.5 mg. And here's the new A GP and it, it is better. I'm just gonna show you where it was before. Those arrows showed how high the peaks were and the fasting. So the, the drug did just what it's supposed to do, reduce some post brand, reduce the fasting because these weeklies do now, we're at 167 and 7.3 uh estimated. And I'll move my little man over here or um be uh so the average glucose got better, the time in the CV got better. So we're on the right track. Doctor Munshi or, or Doctor Sheer. Now. What? So I would say, you know, it's really interesting being able to explore the CGM data and you know, pinpointing in on certain days like Thursday the 14th and the excursion. That's that evening. You know, it's great to be able to dig in and say, well, what did you have for dinner that night? And what happened here? And how can we make smarter choices in terms of the foods we consume or understand the, the glucose excursions that may occur? I completely agree. II, I think that this, this measure helps as much for us to, uh, uh, optimize medication as it helps the patient to understand that three slices of pizza versus two slices of is a big one, big difference. So, yes, I agree with you, Jennifer. Yeah. Yeah. No, I, I agree completely and I think we'll come to that component in just one second. But we were on a roll and as Doctor Munshi said a minute ago, um why not keep going if you're on a roll? Uh But, but I agree with both of you completely don't be completely uh drug uh dose based, but we went up to 3 mg uh next and you see a little more flattening. Um Now 158 is the average glucose that the, the coefficient of variation, the CV didn't really oops didn't, didn't really change very much. Um um but we're making progress. So now we're at 73% time and range and you might say, well, gosh, that's where you wanted to be, right? You wanted to be over, over 70. Uh and you made it, is there anything else to do? So I'll just before asking you that question, I'll come back to what you just said. Well, where's your biggest meal? What's your biggest meal? And, and what do you eat? And how much are you eating? Just exactly the comments you made. And so we said, let's work on that. You're down to 238. Remember it was 250. So we've already down £12 but can we tighten up? Maybe it's lunch, maybe it's dinner where you see, they're cruising up to 180. So we said, let's do that. Plus let's go ahead up to the maximum dose of the dulaglutide. Um, since weight is still an issue and portion size and consistency. Um, so there we are on the 4.5 pretty tight, 76% pretty flat, pretty narrow. Now, the CV is all the way down over here to 20. Um, and so it's looking pretty good. Are we s do we stop here? They, they must have changed the eating a little because the meals are tightening and we're on 4.5 Doctor Mucci. Anything else to do or pat the patient on the back? II, I think it's time to, I, I would give him a little bit room now to work on himself and continue the behavior to get used to that. I think, I think this is the benefit of this amazing time we live in where the, where the types of medications available allows us to do that. I mean, 66 year old is quite on that. That, that sort of a range of who people call old versus, uh, for adults. But if we can do this without any, any risk of hypoglycemia, then there is no reason for us to not, not, uh, stick to that and let him work on his behaviors continue to work on. So that's what we did. We gave him a, a bit of time, but I will say he did come back to us and we talked about the question of his renal status. His A one C had gone down to 87 to 73. We were still stuck with this uh a craning ratio of 77 you know, more than two times normal but not up to 300 or um but the notion of adding a, adding a SGLT two came up again. This wasn't immediately um this was down the road, but it's nice to have longitudinal data sometimes on patients. So you can see how these drugs really work. So we did, he did eventually get S uh uh SGLT two inhibitor and I'll just show you it just tightened it a little bit if I go back and you see those values above 180. Remember, these drugs tend to start moving the urine out the glucose out in the urine. And so there's now very little values over 180 88% time and range. And so I summarized this case to say, um here's a gentleman now on three drugs, a one C 51 to 88 happy with his weight um improvement and he's reduced both his cardiovascular and his renal risks. So, and you can follow it also nicely through the CGM. Any any other closing thoughts from my colleagues No, iii I think this is, this is a great example of not only what one might, might treat but what might one might prevent with this, you know, direct benefits to the cardiovascular and uh, and uh kidney disease risk factors. I think it's great, great case. Ok. Well, th thank you all and um, we'll, we'll move on to uh the next case and ask Doctor Shearer to uh present uh her case to us next. So this has been a really interesting discussion that we've had today and I, I definitely, uh, have a slightly different case that I wanna share, which I hope will fall in line with what we discussed just a little bit earlier. So for my case, I wanted to share some information about a 10 year old with type one diabetes who's managed on an automated insulin delivery system. She was diagnosed with type one in April of 2022 and her parents are extremely engaged with her care. She's got a really great family unit. They're involved. They're working on this together and she came in on January 19th 2024 with hyperglycemia, lethargy, nausea and multiple episodes of MS six. And by report, the family said, well, you know what, we thought she just had a viral illness. Things have been going on around the house. So we weren't really concerned, but things got much worse in the past 24 hours. And when she arrived, her initial laps showed her glucose was 743. Her ph was 7.15 bicarbo 11 and beta hydroxybutyrate of 5.94. So clearly in diabetic ketoacidosis, she was admitted to the pediatric intensive care unit and started on the two bag system for correction of acidosis. So just to contextualize how this girl does with her management overall, we pulled some information from her office visit. Last office visit which was November 14th and she's really engaged. Her hemoglobin A one C is 7.6%. And here we're looking at data from her Omnipod five system, the A GP report on it. And what you'll note is that her time and target range is at 59%. I know it may not seem as good as our 70% that we're shooting for, but in kids pretty darn good. What you'll note however is that her time below range is at 4%. And so during conversation from that last office visit, it was acknowledged that she's overriding what the system recommends in terms of corrections and sometimes she's stacking her insulin doses. She reported that she was frustrated by post male highs. Again, I think this just indicates the degree of engagement that even the 10 year old herself has in terms of her management. So to go ahead and make things better, the discussion was to have greater parental oversight, make sure she's not stacking insulin and then to strengthen her insulin carb ratios to allow the system to do more. And you know, don't worry about overriding what the pump does just follow the pump recommendations. And so as we think about what brought her in on the day of admission, we wanted to get to the bottom of the current issue. And I think this is something where as we saw with the other cases, you can really use sensor data to guide discussions about where things go. So we pulled up the information with her family and as I said, she presented on the 19th, but here's January 18th and she's doing quite well. And what happens? She had a scheduled site change on um the 18th. And so she went ahead and did that. And what you'll note is that afterward, her glucose crime significantly. When the family is responding, you could see from these purple bars that they're trying to correct. They're stacking the insulin a little bit. We see those frequent erections back to back and they're staying up all night because her center glucose is reading high for the vast majority of time and they continue to try to correct. In fact, some of our sick day guidance for our clinic says if you remain high, go ahead and get out of automation and start using temporary basal rates. And so early morning, they actually did some of that and got out of automation, set those temporary basal rates. But she had continued emesis during this whole period, which finally led to her presentation at the hospital at about three o'clock. And that's when she was diagnosed with DK A and we discontinued the pump and the drip was started. So I think a really great story of a family who's engaged, trying to fix something, thinking it's a v illness. And so in our clinic, we have a tool that we use at every single visit And we've modified it, we keep tweaking it slightly, but it's actually um allows us to use somebody's total daily dose and it's individualized for each person based on their total daily dose. And we really got specific with naming it, we say it's a sick day pump failure, prolonged high blood sugar and vomiting plan because previously it said sick day plan and people would be like, well, my blood sugar was just high but I wasn't sick. So we're trying to be very concrete in how we give this management and it talks about when you need to go to the emergency room, when to check ketones, how often and what to do um including changing your pump site, getting an injection and mes measures to go ahead and uh check ketones whether it be by blood or urine. It also has specific guidance based on blood glucose levels, how much fluid to drink and what to do in terms of corrections. So what strikes me about this case is that, you know, this is somebody who's extremely engaged with care. But her ketosis went undetected and she had progressive metabolic decompensation and coming in in DK A and the question becomes, could a continuous ketone monitor help alert somebody sooner? And you know, I think that the point of this entire case is really, we know that, you know, this is somebody who's engaged and there's lots of people who are suboptimally engaged with their management. I see a lot of adolescents, I see a lot of people who don't want to have diabetes, they run an even higher risk of having ketosis occur. And just to make sure that, you know, people in glass houses should not throw stones. I wanted to share some information for myself. And so here, what you'll see is uh Sunday, February 4 and going into the morning of Monday February 5th. And what you'll see is my system noticed that my glucose was rising and it tried like heck to bring me down. You can see, I shut off an alert overnight and that early morning I tried to give a correction dose, but I was really struggling. And at 6 a.m. when my alarm went off, I finally remembered, ok, I should check for ketones. I checked for ketones. I gave an injection, disconnected the pump. And then finally, two hours later, when I was feeling a little bit better, went ahead and did that site change. And so I think what this demonstrates is regardless of the degree of engagement, regardless of the education, the potential of having technology, go ahead and help us understand happening and indicate times we need to go ahead and have greater involvement is extremely helpful. Um So I just wanted to open up the conversation in terms of everything. Um As we think about this case, I really wanted to go ahead and see what you guys thought as we come into this potential of having continuous ketone monitors come into clinical care in the future. How you guys go about talking about ketone measurement in your current clinical practice. I'd like to just start there if that's OK. Bert, do you want to go first? I can start and I, I really appreciate the, the case. I just, I just, I continually struck that no matter what we say in clinic. And if you, if you've got the sensor in and you, your system's working and you're high for X number of hours, you, you know, you've gotta just change the site. I mean, it just doesn't matter but nobody does it. I mean um So a, a good example, no matter how engaged, I'm gonna wait a little longer, wait a little longer. Had I had the ketones. Would I have done something sooner? I think so. So II I really think so cause people are kind of used to high glucoses. Oh I can live with this or whatever. They don't really like uh those ketone. So anyway, great case. Um I, I would love to have ketones available. Uh We talk about it but I don't know if people can find their ketone strips or they have a meter or they have urine. Um It's not readily uh something they reach right for. So, and the other thing I'll point out, I think in this case is I know for myself like I had that instance, I was high all night long, my blood sugar is high. So I'm super tired, right? So it's harder to have that decision making and God loved my husband. But he said, I, I sort of told you that you had a high alert, but I figured you would just take care of it. So even caregivers at time may not be able to get this support necessary. So I think having that safety net underneath us becomes really critical. Doctor Mucci, as we think about continuous ketone monitors and you know how we measure ketones. How would you think about getting alerts from such systems? Would it be a binary alert or would people want it at all times? What, what do you envision this? So, um you know, again, being a geriatric diabetologist and, and not liking a whole lot of even people in their seventies in my clinic because I really enjoy those in eighties and nineties. I, I do think that, you know, I have been seeing lot less decays in my older population compared to when I used to be do endocrine uh in younger ones. And I'm not sure whether it is because they are a little bit more, um, uh aware and, and are, are more strictly sort of following what we tell them. But that's not the whole picture here, right. Strictly following th this sort of helps me understand how important it is to really look at the whole picture about use of technology to improve something because there is certainly AAA sort of flip side of that. And um we say that pediatrician uh li like to have a step behind the cutting edge because we try to see where everybody else is going before we jump in there. But, but this is really if I think about my uh seven or 80 year old type one individual on a ID going through that, this really would worry me that, that, you know, that we do, we are really quite advanced in what we can use. And that's amazing for a 10 year old at the same time, uh as as 80 year old patient, I don't know whether they can do it or not. And uh uh certainly, I mean, having a keytones are, are imperative with, with that kind of picture what you're saying. But this really uh uh uh sort of uh fascinates and concerns me quite a bit. Doctor Bergens. I ask you the same question in terms of how you envision you know, the use of continuous ketone monitors, whether there would be a, a threshold alert almost like we have. Um, for, I, I hope so. I, because I, I think I got my hands full with the glucose and if the ketones are good, I don't wanna hear about it until, until they start to go up. Um Is what I'm thinking. So I, I like, I like, I like thresholds. I like to know and I'm not sure that's what we have to decide on. I'm sure you'll give us some guidance, maybe of when it's over normal or when it gets, do I have a double threshold when I'm up above a certain level? But yes, threshold is how I'm hoping it will be. I think that's great. I, I envision it the same way you don't want more data. Like we've learned from CGM when you first slap it on and people are overwhelmed with the amount of information. And so I think that, you know, potentially just having it toggle on to draw attention is gonna be really critical. Um One last question for both of you, how do you think this will change the approach of offering greater technology to a larger mass of individuals um living with diabetes like those with um higher A one CS or GM I baseline? Um I, I'm, I'm not sure Jennifer to tell you the truth. II, I don't, I, I think it's the ease of use which most of our patients are looking for and, and, and do no harm sort of thing. So, II, I, I'm not quite sure actually, if this is necessarily the one that would be uh uh is the, is the uh you know, barrier to it. I hope, I hope you'll tell us if you envision it being integrated into one sensor that would help if uh if uh if you tell me we need two sensors on one for glucose, one for ketones, then I'm worrying as Doctor Munchy is saying, uh if it's integrated, um then I might feel a little more comfortable with people with fluctuating history or um that I really want them to have ketones and I'm not sure that they're gonna follow my sick day guidelines without it. So might o open up those patients. Absolutely. And I, I would just highlight that, you know, Abbott is developing a single sensor that would have both glucose and um beta hydroxy rate. Um And actually, I'll be sharing some information about a recent feasibility study based on insulin interruption um at att D. So I hope people will go ahead and check out that presentation because I can't share it until after we do that talk. Exciting time. So, very. All right. So, so that was a wonderful discussion by Doctor Bergen and doctors. And uh we sort of uh uh uh going from one spectrum of the life here to the other uh I hope that uh during my presentation, we talked about why we need to think about older adults with diabetes a little bit differently than others. And let's see if we can see some of this uh practical cases to underscore um uh how uh that is. So, as I had explained earlier that uh in my practice, when I put anything additional on uh older people's uh regimen, I typically want to know why I'm doing that. So let's see. So here is a 77 year old man uh who lives at home with his wife. His current ac is 8.4% only checks fasting glucose levels. This is so common in our older population. Do you see similar uh like people only check fasting and after saying over and over again at every clinic visit, I still end up with uh 200 readings right before breakfast all the time, all the time. All right. So this is not, this is not a right. Um So this is this patient um when asked says that he's not feeling having any hypoglycemia comorbidities. He just had an M I and had a bypass one year ago. Uh bilateral carotid stenosis was identified. He has elevated PSA for which he is currently on surveillance and um uh hypertension hyperlipidemia and then history of urinary detention for his diabetes regimen. He is on glargine 22 units once a day in the morning and Metformin are 500 in the morning and 1000 in the evening. And of course, we want to know what else is uh he's taking amLODIPine Olmesartan toast, Clothy Ione uh senna. So, believe it or not, that's a pretty short list for our patients. So, you know, he is actually we have, I was trying to get him to uh use uh uh personal CGM, but he really didn't want to do anything new. So he agreed to actually use a professional CGM. And he is what I found in the professional CGM after two weeks. Um So one of the things that we have seen and that is specifically, I believe in older adults. But you tell me whether you see it is that there is a uh you know, there are really elevated numbers at bedtime and then there is a over overnight decline of glucose level with the fasting glucose being the lowest. Uh is that something that you see, I mean in the medical school, you hear about why you should start in the at night because you want to suppress gluconeogenesis and control fasting glucose first. Um But, but in my um practice, I start basal insulin in the morning to avoid this uh any thoughts on that from uh doctor Bergens or doctor she Yeah. No, II I struggle with that too. With all the clinical trials being done with it starting at bedtime, everybody just thinks that's how you use it. It's a bedtime drug and So you did what I think is just right, particularly with his profile to give it in the morning. But despite that, uh, it's, it's still carrying through, you know, you sort of hope it will wear off and, and not drop overnight. But, so there's some work to be done in the daytime, I guess too. So, yeah, what do you see in the younger people, uh, uh, opposite to this, uh, do they wake up fasting high? No. So the interesting thing is I think with the younger people, especially who are on multiple daily injections, there's a lot of unnecessary feeding. People are extremely scared of lows. And so we often see these patterns of, you know, highs after dinner highs overnight and then slowly because they're no longer feeding, they come more into target range, not necessarily going low by the early morning. But I think CGM gives us that opportunity to understand that may be occurring at home, which mean we may not be privy to without it. All right. So, uh again, he was on, he was already on morning um uh Glargine. So typically without the benefit of CGM, if on one of my colleague was seeing that and the A one C is 8.4. And on Metformin and Glargine, one would say, well, let's go up on, you know, insulin because let's bring down the, the A one C and, and we can see what would have happened if that's what uh you know, that was the, the plan. So, uh again, I tend to actually uh stack up all my uh noninsulin agents in the morning and push all the almost uh 2000 mg of Metformin in the morning. If I do that, then I might be able to increase the glargine a little bit. Uh If I flatten out this, this line here and then of course, we need to add something more for posterial, not only for that, but he just had M I, so uh GLP one or SGLT two. That was my thought. Any other thoughts on that? Um No, I think, I think you're right on track with the only issue being I guess my question back to you is what are you gonna do with the glaring when you add the, the next medication? So, um once, once I uh the benefit of having glargine in the morning is that I can titrate that to the fasting glucose level. So if adding the G LP one drops the fasting, I can always back off on the glargine. And, and so because that's about the only thing that's now causing that overnight cough. So that, that, that's, that was my plan. I haven't seen him again, but that's, you know, this is a very personal case. Is that, oh, what am I trying to say is that it, is that if it drops it or, or when it drops it, I mean, would you, would you reduce 10 or 15% when I anticipation? I absolutely, I absolutely would. When I start somebody on something that is going to drop that, uh, daytime postal numbers, uh, significantly, I do drop it back and then I go back. In fact, I don't mind adding it again if the fast stays by too much. But you are absolutely right. And on the side of safety. Absolutely. One question, um, if that's OK, were you able to convince the individual as you go ahead and make changes to integrate CGM real time CGM into their care? So what happens is that many a times? And, and it's quite peculiar and it's very hard for many of my endocrinological colleagues to understand that people actually refuse to, to go on personal CGM. They just do not want one more thing. So I tend to start them with a professional CGM. I use it a lot even in my primary care practice and when they see this and as we had talked about how different types of food items uh affect the numbers. And I sit down and go with it and said, you know, you can actually do that on your own and many of them then would say, OK, now they understand why. So that, that was my point earlier as well that tell them why you are doing it. It's not just because we have something available, but there is a very specific logic behind why we are asking you to, to do this. Um You know, so sometimes that works sometimes. So here is another case, 77 year old man at home, lives at home with spouse. Uh AC is actually 5.8% but he had AC KD stage three B and again, you ask about hypo symptoms and says none, he was again doing only fasting and he had few numbers in seventies but really no, um uh fasting uh uh no g hypoglycemia and these are the comorbidities. He had pretty significant CHF with uh biventricular I CD placement, atrial fibrillation, aortic aneurysm CK DC three BC OPD gout prostate cancer. Uh just went through cyber radiotherapy hypertension hyperlipidemia, pig osteoarthritis and recent fall with right hip injury actually was just going through physical therapy. He was on Metformin year 500 in the morning and glimepiride 0.5 mg in the morning. And then these are his other medications. Warfarin carves, Meon are allopurinol, torsemide, Losartan, atorvastatin, albuterol, um in a patient like that. And Jennifer, I'm going to pick on you because you probably don't see this. What would worry you here or you would say 5.8. Well, finally you are doing something right? Is that what you were telling me? No, I think that, um, you know, being well outside my scope of practice, I try to see patients with only one or two problems, mostly just diabetes and no other medications, but I think here given the, um, low fasting glucose levels that we're seeing in the A one C of 5.8 getting rid of the Gipper might make sense. Um, and I don't know if that's correct, but I'm gonna throw it out there. Um, and see how we might be able to do obviously with using sensor to be able to track how things go doctor began, tell anything to add. No, it's a great start. Ok. So, so what bothered me here was that he was, of course on glimer, what bothered me was he was on anticoagulant. What bothered me was he had a fall and he had a I CD. So, you know, the, the, the um risk of getting uh arrhythmia if he gets hypoglycemia. Well, here is what his professional CGM showed. So he was spending about 26% of uh below ran 70% in target. So, uh, as you, as you, uh said, stop glimepiride, I wasn't even sure whether he needed Metformin. So I actually, and then once we stopped, he, when he came back, he says, you know what, I really don't feel this tired anymore and, and my balance seems to be better. So, uh hypoglycemia symptoms can be quite deceiving in this population and in a month without Lamaar, he was doing pretty good. So we left him on, on Metformin. Uh, but again, um, you know, this was, this was not on insulin. Again, makes the case, that lot of these people require CGM to hear for making their therapy safer. You know, why are we doing that to make their regimen better uh safer? Let me show you the party one by me. You know, a great case. I mean, the only other point I'd make on that case is I hope, I hope he continues to use CGM because I'm not, I'm not completely confident in the A one C and these renal insufficiency patients either being a good marker. So, anyway, no, I I agree with you and II, I feel like a professional CGM every 3 to 6 months is, is an excellent replacement for doing any A one C uh because I don't know how to interpret that. Um So this is an 88 year old uh individual who ha who lives in the, with the daughter in the same house. Her daughter lives on the upper floor helps mother uh uh A one C today, 7.3%. He, she really, she has pretty significant dementia so she can really tell us about hypoglycemic symptoms. Um comorbidities, Alzheimer's disease. She's nonverbal uh CLL, she has multiple falls and one of them ended up with the subdural hematoma in the hospital. Um The supraventricular tachycardia with recurrent tachyarrhythmia, cervical spinal stenosis osteoarthritis and she needed steroid injections off and on causing severe hyperglycemia. So she is on twice a day, mixed insulin uh given by daughter. She works. So she gives before going and then come, they have dinner together and, uh, you know, she is on Dozy Mement for her Alzheimer's QUEtiapine for behavioral issues. Mertazapine traZODone. So lot of uh psychotropic drug. And here is what her numbers are when they are downloaded from the glucometer. Oh, what, what are your thoughts do I about? Right. Ok. For her, given her, um, given her comorbidities. So she does it before, uh, giving each injection. I, I know what I mean. You know, you would have done probably what I did, which is what I mean, what's, what's hiding where? Yes, but it is such a great example of how, how well it hides. And so this was 17% range with 50.50 0.5% variability. And, and I mean, there is no other way to identify that without CGM. So my, my go my lo you know, the why we are doing it to make the regimen safer and alleviate caregiver stress because I cannot tell the doctor to check finger stick four times a day that's not going to happen. So instead of uh twice a day, mixed insulin, again, changing it to basal insulin in the morning and then continue to titrate that to the fasting glucose. And then again, postal coverage with once a week GLP one receptor ago, two or Metformin in the morning depending on what she tolerates. Fortunately, her EFR was pretty good, but again, noticing the drop in this overnight glucose level is as people get frailer that they are so high at bedtime and then such a precipitous drop overnight happens. Any thoughts? I think this is an incredible case to be able to, you know, see the frequency of hypoglycemia and you have somebody who's trying so hard to care for somebody who can't verbalize and and now to have CGM tell a story to guide the decision making I think is exceptional. Yeah, this will be, this will be interesting. It'll be a challenge. I think that for the G LP one to, I mean, here's 100 units of insulin almost and uh and, and still, but that's this up and down pattern. So I, I think the basil will be good and hopefully a GOP one can flatten out some of those. That's what I was looking for, flattening it out, unfortunately, right. Um before I, when we made the changes and before I could see her back, she fell, ended up in the hospital and ended up in the nursing home. So, uh again, the, the hypoglycemia uh risk uh and the consequences are so significant in these individuals that it really without the CGM, there is no way to provide a safer regimen uh in, in that that and, and, and the benefits of, of tighter control for any at any uh measure are absolutely non-existent. So uh couple of quick cases on the, these are now the long term care facility cases. This is one of the operational study that we had done in long term care. And and again, not, not really uh uh managing patient, but just to see how you know how big the issue is 80 year old lady with on the long term care. Even when she was 5.9 the latest one, no mention of symptoms, cerebral palsy if repeated falls, incontinence, osteoporosis, hypertension, neuropathy, depression, and she was dependent for activities of daily living. So these are basic activities. So requiring a lot of caregiving here is the regimen le made 30 minutes at bed time. Hold for glucose, less than 120 HumaLOG five units at mills for blood glucose. Over 150 Metformin, 500 mg once a day and trata 5 mg once a day, Jennifer, are you still uh uh sort of sitting down or you like? This is so much, I'll give you guys credit has seen this but you probably are like what? And then again, if, if you look at the type of medication that she's taking, there are so much uh s you know, interaction side effects and so forth. And the point I'm trying to make here is that, you know, she has no laws and and 35% time in range, but she is getting poked four times a day. And if you look at it, I mean, really there are not a whole sort of uh you know, rhythm you can see when you just look at the numbers versus when you look at the uh you know, at the uh sort of CGM data. So 11 could say that you know what you could help with this uh hyperglycemia. Uh But instead of uh Levemir at bedtime, again, change the basal insulin to uh morning and time to the fasting glucose and do once a week GLP one or Metformin and get rid of this four times a day monitoring. So here, what we are proposing is that CGM could lower monitoring burden and treatment burden. I mean, this is wrong in many different ways, but we could, we could really simplify that if we understand what the pattern is. Anytime. No, I think that would be a great, a great change for helpful for everyone, for her and for the staff and everybody. And similarly, this was another one, a a young patient and we saw a lot of them uh with the ac looks fine, uh no symptoms mentioned, but so many comorbidities, most primarily the hepatic neuroendocrine tumor again, twice a day, mixed in Sua with a sliding scale. Uh And uh and you can see uh uh you know, there are morning lows once in a while, very high hypoglycemia hyperglycemia and this is going on and on and on for forever. And again, looking at the pattern. One could again, think about uh you know, the basal insulin with the coverage. Uh in the panel basis, but a little better than what he was getting because apparently it's not working and it was still causing hypoglycemia. So, again, lowering the monitoring burden and safer regimen, uh that could be CGM could be used in the long term care facility. People can, people sort of think about CGM as improving glycemic control. And I'm just trying to make a point that there are other roles one could use even in, in the uh in the patient population that does not require perhaps tight control. Any other thoughts, Dr Ben? Well, I mean, it's kind of interesting 60 units twice a day of that, you know, premix, you could almost get rid of the evening dose and, and increase the morning to 80 just be a one shot of the day be used. Yeah. Yeah. So anyway, yeah. But, but, you know, but without seeing the pattern, it's very difficult for them to, to get and uh it, it, it's such an important use of this, this technology that is actually quite simple, especially the professional CGM J uh doctor Sh any thoughts uh on this out of the box case for you? Well, I think it's out of the box but the thing that it really strikes me is we have many kids in daycare and in school and there's lots of fear about getting insulin. And so I think similar to these individuals you're talking about in long term care facilities our kids spend, you know, a third of the day in school or at daycare. And so having, um, care providers who can see the data, understand the data be engaged with the care regimen. I think it's so huge, um regardless of where you are on the spectrum. Yeah. And, and when you see a picture like that, it takes the myth out of that. Right. It is almost mathematical now. It's not about, you know, different, different numbers and where, where they are, it's, it's simply mathematical. Uh and, and so, II, I think there are a lot of use and, and, and we are thankful for this technology. Excellent. Yeah, good cases. Do you do? Are the, are the staff, have you had much interaction with the long care terms? Staff, I know it's new and they're just getting used to it. But do you think they'll be receptive to something new? So I, I, you know, the, it is not yet approved for use in the long facility however, and, and so because of that the staff members are, they do not know that. And, and you can see from the insulin regimen the way it was that holding for the low fasting, the basal insulin and so forth. It is a lot of education, I think, I think to use any kind of uh such medications or technology, they really require significant amount of education and, and it's a very protocols environment. So we need to give them, you know, if that, you know, sort of thing, we could do that though. We can do that, but we just need a more data and, and more uh sort of uh uh studies on that. Can we put the light last plug for that? I also think that this is where we pediatricians and individuals following elderly individuals can really come together because we've had school forms and, you know, teaching of individuals with varying degrees, sometimes no nursing staff. Um And so we've really overcome it and there's been a lot of legislation to ensure our kids can have continued access to technology. And I think the time is right to do this to this area. Absolutely. Absolutely. Say, look, well, that was just a, a great series of cases from kids to elderly adults to uh what's the right choice of, um, monitoring and medications and training. So I really appreciate it and I hope the audience, uh, uh learned as much as I did from these cases. Uh Thank you, uh, Doctor Sheer Doctor Munchi for, for your presentations. Well, thank you. This was wonderful to participate with this uh, esteem uh, faculty here. Agree. This has been a pleasure and I hope the learners have really enjoyed the presentations.
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