Video CGM-Mediated Improvements in HbA1c and Noninsulin Regimen Adherence Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides CGM-Mediated Improvements in HbA1c and Noninsulin Regimen Adherence Overview Continue to Test Back to Symposium Thank you, Doctor Bernste. That was really very interesting insight into um ketone measuring. And um I just like to introduce myself. My name is Monica Kellera. I'm professor for endocrinology and diabettology from the University of Tubing and I'm working here in Stuttgart in a hospital here in Germany. So it's a real pleasure to be part of the symposium today and to talk about CGM made improvements in HbA1c and in non-insulin regimen adherence. So these are just my disclosures. And um this is a summary um showing the blaze of diabetes technology in type 2 diabetic patients. It's from ADA and EASD guidelines and in the 2022 ADA EASD guidelines, well, it says that uh technology. Can be useful in people with type 2 diabetes but needs to be part of a holistic plan of care and supported by diabetes self management education support. In the more recent um ADA standards of care from this year, we have more specific recommendations. So, um, for example, For all youth and adults with all kinds of diabetes, and on any type of insulin therapy, um, CGM system is clearly recommended. In patients with type 2 diabetes being not yet on insulin therapy, CGM use should be considered in order to achieve and maintain individualized glycemic goals, and in circumstances when consistent CGM use is not visible. Um, at least periodic use should be considered in order to adjust medication and or to adapt lifestyle habits. I think that's all very reasonable recommendation, but maybe even more important, these recommendations are really evidence-based because in the last Um, several years we have seen numerous trials already showing that CGM system really helps to improve, to keep uh type 2 diabetes people on their HbA1c goal and also on time in range. And for this I show you already here meta-analysis. Comparing CTM users um with uh traditional SMBT users and what we can see here on the forest plot of um which is a meta-analysis of six different trials, we. Can see that the CGM users are doing better in HbA1c reduction. They spend more time in range and less time below range, which means below level of 70 mg per deciliter. So they really they really do better in terms of getting the HbA1C goal and also. Um, spending more time in range if they are on a CGM system compared to traditional BGM system. But we can also see here in this trial is a comparison between people with type 2 diabetes being not yet on insulin treatment, which is here on the blue line, and here the green and the red line are people with type 2 diabetes being on insulin treatment either on basil or on prediel insulin. When all these groups are initiate or start to use. A CGM system, then we can see in all three arms a drop in HbA1c. And when you compare this drop or these curves in HbA1c, you can see that people with type 2 diabetes are just showing the same curve profile, just showing the same reduction in HbA1c compared to the insulin users. So there seems to be no. in the benefit in people with type 2 diabetes being on insulin or being not on insulin. Both groups showed the same improvement in HbA1c levels. And moreover, moreover, this group has also analyzed all causes and Here in the bottom, acute diabetes related hospitalization and what we can see again here in the non-insulin treated group after from basil in gray to 6 months after initiation of CGM or 12 months after initiation of CGM, we see an 11% reduction in oil costs and 30% reduction in In acute diabetes related hospitalization rate and of course this can also be found in insulin treated people with type 2 diabetes. Very interesting. A more recent trial and analysis from Norman and colleagues published in this year. They have also compared hospitalization rate in people with type 2 diabetes being not yet on insulin treatment. And what they found out is if they compare. A patients being on a CGM system, which is an index date, and if they use 12 months before the index date and then analyzed 12 months after the index date, they found 12 months after the index date. So after starting a CGM system, an 18% reduction in all costs and 66% reduction in diabetes. This related hospitalization and that's very comparable here if we have a look on type 2 diabetes with intensified insulin treatment, although the absolute numbers in this patient group is higher because they are on a later disease stage, but we still see the same rate in reduction in hospitalization for all causes and also diabetes. related reasons. So um so reduction at the same rate for non-insulin and insulin treated people with type 2 diabetes. And of course if hospitalization is reduced, that's something which really saves costs because hospitalization when it comes to hospitalization, that's really going to be expensive and very interesting. At this year's EISD meeting, um, Wright and colleagues, a US group, analyzed the impact of CGM um and the benefit of CGMs um with the uh as a cost benefit, um, with the uh perspective of Medicaid insurance people. And briefly they have they have shown in their analysis that if all patients with type 2 diabetes would get reimbursed the CGM system, then 143 hospitalizations could be avoided over 3 years, and this would A safe of course $1.7 billion US dollar because hospitalization is not so often needed with a CGM system compared to patients who do, for example, SMBG. So I think this analysis clearly shows that. Um, the use of CGM system in type 2 diabetics and also reimbursement of CGM system in people with type 2 diabetes can really save costs and can be cost effective. Well, with this, let's switch a little bit to our guidelines when it comes to medical treatment. Um, ADA, ESD and most national guidelines recommend a stepwise approach for medical treatment. The basis always is lifestyle modification, diabetes education, and glucose monitoring. Then usually oral medication is coming in maybe one or two different compounds for blood sugar lowering. And before when it comes to to injectable therapies, then ADA and EASD guidelines recommend to introduce a GLP-1 receptor treatment before going to basal insulin treatment or basal plus bolus insulin. So if we talk about people with type 2 diabetes being not yet on insulin treatment, we talk basically, I would say about this group here being on oral medication plus minus GLP-1 receptor agonist, and that's quite a big group right now, I would say. Because insulin treatment is postponed more often now with the possibilities of treatment we have to later stage of um disease. And in fact, Miller did do an analysis in this group being on oral medication and on a GLP-1 receptor agonist and being not on HbA1c goals. So this group had high HbA1c levels which you can see here baseline HbA1c was 9. 66% here in the dark bar and what they did do is they started to give this group a CGM system and six months later they have seen a quite good reduction in HbA1c, so a difference of 1.7%, and the only intervention was starting a CGM system six months before. And this was in non-insulin. Treated patients being on a GLP-1 receptor agonist, and we can see if we compare these data here with GLP-1 receptor agonist plus insulin treated patients, they are more or less have the same benefit, but non-insulin treated patients really are not doing in any way worse compared to the insulin treat. And so they really benefit from a CGM system which we can see here on the right bars. So with this, I would like to go to write and the publication here. It's a little bit different approach. Again, type 2 diabetic people without insulin treatment, partially some of them had insulin. And they have been out of the gold, so HBA1C have more than 8%. And what they did do then, that's a retrospective analysis, so they analyzed patients who had a GLP-1 receptor agonist to improve their HbA1c levels, and they compared this group with those who had who added GLP-1 receptor agonists together with a CGM system, so a free. Lire system in this case. There was also matching of the cohorts according to age 6 baseline, HA1C, and so on and so forth. These are the data and this on the left side unmatched data you can see that the group which initiated GLP-1 receptor agonist together with Freyle Libre. Um, show better HbA1c reduction, so the difference was 0.7% in HbA1c reduction compared to GLP-1. Um, only initiated group and after normalization for baseline HbA1c here on the right side you can see there's still a beneficial effect for the GLP-1 plus freestyle Libre group. They do better in HbA1c reduction by 0.37%. So at this point, I would do an interim summary. I have shown you that initiation of CGM improves HbA1c and timing range levels in type 2 diabetes, irrespective of whether they are on insulin treatment or not. Adults with type 2 diabetes and prior GLP-1 receptor therapy experience. Significant improvements in HbA1c 6 months after initiating a CGM system, and if people with type 2 diabetes initiate GLP-1 receptor treatment together with the CGM system, they achieve better HbA1c values compared to those treated with GLP-1 receptor agonists only. And with this, I would like to talk a little bit about adherence with CGM-based therapy. And again here at this year ESD meeting in Vienna, a French group will present interesting data from an update from the National Insurance claim database from their country and to make it sure their conclusion. from their analysis is that expanding access to new treatments, including also CGM systems could reduce treatment inertia and improve clinical outcomes for the type 2 diabetes population. And in fact, if you look in the literature about 2 years ago, Harris and colleagues have shown that CGM could help to improve therapeutic therapeutic inertia in A people with type 2 diabetes. What we can see here in this graph is in yellow, these are type 2 diabetes people using a CGM system. This solid bar is without insulin, the dash dash line is. A with insulin and the blue lines here are traditional SMBG measuring. What we can see here is that the probability for treatment progression, so for adding more medication or improving lifestyle or whatever. So the probability for treatment progression is better in the CGM user group with time compared to the traditional BGM user, and I think this data show in some way that CGM may be indeed useful to improve therapeutic inertia in people with type 2 diabetes. Well, that's another interesting part. It's um from last year's ADA meeting and here. A data have been presented by Huang and colleagues showing time in range in a type 2 diabetic population who has been treated or has been on a GLP-1 receptor agonist together with other oral medication in most cases. And what we can see here in the um bright blue lines are those um using a CGM system but with inconsistent use. The dark lines show consistent CGM uses and Um, here you can easily see that time in range, really that's the medium. The time and range really improved with consistent use of CGM, so they spent more time in range by consistent using CGM. And this group here above is the best. They spent most much more time in range, and this is the group who used consistently a CGM system, and this group is also adhering to GLP-1 reserve diagonists compared to this group here down who use consistent. Um, CGM but is not adhering to GLP-1 receptor agonists. So the group using consistently CGM together with good adherence to GLP-1 receptor agonists, has the best data in terms of time and range. Well, if we ask what's the probable reason that um People with type 2 diabetes, when they start to use a CGM uh why are they are improving so much in their HbA1C? A goals why they are improving by time and range and also by adapting to healthy lifestyles, and I think one of the answers can be can be given by this questionnaire here from Erhard and colleagues. So they ask CTM users, and the answers have been the follow. following basically 90% of CGM users said that this system contributed to a healthier lifestyle. 47% said that they are more prone to do physical exercise, and they are more physically active. 87%. Uh said that CGM modified their food choices based on what they saw on their real-time CGM. So I think that clearly points to behavior mod. and it it says to me something like CGM is something like biofeedback which helps to improve glucose levels and also HbA1c levels well. If we switch now from a survey to a randomized controlled trial, we can also see similar data here. So that's an RCT trial comparing CGM users here in orange against traditional BGM users here in green or blue. And what we can see is that 3 after 3 months of use of CGM. Um, the score for diabetes self-care behavior is better in CGM users compared to BGM glucose monitoring. So again, I think that points to that CGM is very helpful also to adapt to healthier behavior and to change lifestyle habits in some way. And with this, I would like to sum up here in addition to the already mentioned, I have shown that CGM can be useful in reducing therapeutic inertia and also that CGM supports people with type 2 diabetes to be more adherent to a healthier lifestyle behavior. And before I'm finishing, um, I would really like to share one of my patients with you. So this is Peter 50. 8 year old man, he has type 2 diabetes since 8 years. Some diabetes complications like peripheral poly polyneuropathy, chronic kidney disease, fatty liver disease. His HbA1c 1 year ago was 7.5%. Now he was high with 9.1%. His blood pressure was pretty OK and his BMI was 30.7 kg per square meter, so He was slightly obese. His most recent anti-diabetic medication have been metformin 1000 mg two times a day, ampliflozin 10 mg once per day, and semaglutide 1 mg subcutaneous once per week. So that's pretty much, I would say, gold standard treatment for a patient like PETA, and it's also according to a national and international guidelines. Some social characteristics of this patient, he's married. He works as an independent management consultant, does a lot of business traveling. He attributes his worsening of glycemic control on his very irregular lifestyle. He eats rather unhealthy, highly processed food during traveling, and GLP-1 receptor injections, he says, occur irregularly, irregularly because He didn't take his GLP-1 pen when he is traveling, so he's doing only injections at home right now. He is worried about his recent eye exam showing new onset diabetic retinopathy, and he's really motivated to get his blood sugar under control again. When I saw him first in my office, I had only a few. SMBG values from his glucometer. He was doing only fasting levels with the finger pricks, and these fasting levels have been really high, so between 170 to 250 mg per liter. So if I could ask you at this point, what would be your first or next step. Choice for our patient Peter and I have here some possibilities or written down. So first, no change in weight he might improve. I think that's probably not the best idea because Peter himself is seeking seeking for help. He comes in and he wants to make a change. Second, since he is not on target with oral anti-diabetics and GLP-1 receptor agonist start basal insulin? Well, that could be an option, but we haven't been really convinced whether he is really should really go to insulin right now, especially also because he was obese. Then the third point, reevaluate lifestyle habits and give advice for improving glucose control. I think that's definitely a good idea and also our guidelines recommend to do this. And 4th, get more information by introducing CGM. And I think that's very important and we really, we choose number 4 1st and thought we try to get more information by starting a CGM system on PETA and then with this data we hopefully can reevaluate lifestyle habits and give him more specific advice. And this is just to show you and remind you that ADA and ESD guidelines are really encouraging us to reinforce lifestyle management before escalating medical or injectable therapy. So that's really conformed also with our guideline recommendations. Well, about two weeks later, Peter came back and we saw his first AGP profile and what we can see here in the bottom that his median values are really high. He spends only 23% of his time in the range. His average glucose was high with 229 mg per deciliter. Glucose management indicator was 8.8%. Um, so what we can really see here is now um very high levels, but in addition, we can also see the profile during 24 hours. And what we um uh already identified when we saw this profile here that he has basically very regularly an increase of his um glucose levels in the late evening. And when talking to Peter, he says he often stays in the hotel bar in the evening and he snacks really a lot there. So what would be your recommendation if I may ask you at this point first, to proceed now with baseline. Lean to reduce his fasting levels. Second, discussed the CGM data with PETA, show the influence of unhealthy lifestyle and try to make a change here. Or third, switch to another GLP-1 receptor agonist. So there are several choices. Well, I cannot hear now what you would go for, but I can tell you what we decided to do. In this case, so with the help of our diabetes educator, we discussed his CGM profile. We gave him nutritional education. We showed this rise to him after snacking in the evening, and we recommended that he should stay away from this snacking and maybe it's better to go to the gym in the hotel and not sitting too often at the bar at that time. Um he was really motivated to make a change and in terms of GLP-1, to tell you the truth, we didn't switch GLP-1 receptor agonist, but we encouraged him to inject it regularly so to take his GLP-1 pen with him, his medicine when he is traveling. Well, after a few phone calls and in between and 4 weeks later he came back and we got this AEP profile from him. Um, here in the evening you can see in the late evening we don't have this rice anymore, so he's doing pretty good at that time and in general his time in range is still not in the optimal range above 70% as recommended by ADA and ESD, but he is still, he is, he is pretty much better with 56%. A glucose average also improved by 173 mg per deciliter. But what we could see is that his glucose variability went up from 30% to 44%. So we thought that's probably due here to some of really some high peaks during the afternoon and also during the evening time. And we tried to get this thing here fixed. So what did we do? We first we really said that he is doing much better, so we encouraged him to proceed with this process and we discussed the CGM profile. And also this high values here to get rid of these high values in the late afternoon and evening. And since he also wanted to lose some weight, Peter was willing, and we agreed with him to try to do intermittent fasting, so no food in his case from 5 p.m. And later and after again several phone calls and then 4 months later he came back and he, we thought we have been really very happy with this profile so he significantly improved only with lifestyle changes together with CGM and diabetes education. His time in range was 92%, so it was really very good. Um, average glucose 119 glucose management indicator 6.2%, and also variation was not high anymore, so it went down to 30%. So we thought that was really a very successful example. The patient himself was motivated. And CGM and diabetes education really helped him also to him to reduce his weight by 6 kg and his HbA1c was 6.9%. And for me it was really, I think, very, very encouraging that he didn't have to use insulin. A which I in a patient like him, I have never good feeling because he will get even more obese maybe on insulin treatment, so. That's another very good point from a medical perspective, but maybe the most important thing is the patient's own perspective. So let Peter talk by himself at this point. And when he was in 4 months later and he reviewed about his his process during this 4 months. He was saying, to be honest, I never really liked to do the finger pricks, and with CGM I got out so much more information about my glucose levels in everyday life. With CGM, I could see the tremendous influence of exercising food in my case, and that was really very, very helpful and changed my behavior. And I think there is nothing more to add from my side, except that I want to thank you for your attention. Thank you very much. Published Created by Related Presenters Prof. Dr. med. Monika Kellerer President of the German Diabetes Society (DDG)Medical Director Center for Internal Medicine I Marienhospital StuttgartStuttgart, Germany
