We're back again. Now we're gonna be talking about how to use CGM practically. So we may, I think that the best way to do this is to give you some cases and these are real life cases. I've got some videos to show you as well, but we're gonna take a look at patient experience using CGM. And I'll be joined uh in this discussion by, by esteemed faculty members. So this is one of the weirdest patients I've ever seen in 40 years of the practice of medicine. He's a very, very smart guy, but he comes to see me uh uh for treatment of type two diabetes. He's a retired American Airlines pilot. Uh So he's not stupid. Uh and he uh was diagnosed by somebody who's having diabetes five years ago. So he was sent to me by his ophthalmologist who is very concerned about him based on his uh retinal examination. So I started asking the patient some question. Remember this is a pilot for, for one of the major airlines uh in the United States. Are you a, are you checking your blood sugar? The answer is nope one word. What medicines are you taking, uh, I didn't bring him with me today. When were your labs last done? I had something done for a flight physical back in 2022. But they just told me I passed next question. Do you know the results of your last A one C, you know what his answer was? Huh. So if you look at some of the guidelines, how are we gonna treat somebody like this? His glucose levels are not under good control. So, in general, if you have somebody that's over age 55 they have risk factors including obesity, hypertension, dyslipidemia, albuminuria. We really gotta consider using in to get our glucose levels under good control. You don't have to, but that's something you need to consider. But look what it also says, use technology in these patients as well. This patient has been out of control for many, many years and I think I could get him better in a period of 4 to 6 weeks. This is a uh study from Doctor Kuti. Doctor Kuti is a really interesting guy. He's a family physician uh located in uh United Kingdom, but he's also an epidemiologist and there's a lot of stuff on the slide. But the, but the slide basically says if you have somebody that has an A one C at baseline above 8.2 and they're newly diagnosed with type two diabetes, you've got to get their glucose levels down to their A one C is below 7% within two years. If you can do that, your risk of developing uh cardiovascular disease is reduced by 62%. I don't have a whole lot of time to waste on these people. We gotta do this quickly. Remember our pilot there? He's been out of control for years and nobody's really uh given him the treatments that he's needed to be successfully treated. So, here's our pilot, his physical exam, he's got a BM I, that's uh very high. He, he's hypertensive, he's got proliferative diabetic retinopathy. Uh He's uh he's overweight. He's got loss of ankle jerks, hot pulsation. So he's got diabetic neuropathy as well. This guy just didn't uh develop diabetes yesterday. His A one C is 10.9 his uh lipids are out of control. He's got uh diabetic kidney disease stage three A and it looks like he's got a strain pattern on his EKG. So I'm very concerned about this patient as well. So the question is, what are you gonna do first? And I know we're all busy, we're all busy practitioners, but we've got to do something to help this patient. We can't just let him walk out that door and say, let's get some labs. You'll be OK? See you back in three months. So it's not gonna happen. So what are you gonna do on this one? You gonna start on an insulin, maybe start up on a GOP one. They can place him on CGM and have him come back for a download. By the way, if he's an active pilot, you can even download this information remotely. It's up to you. Would you refer him to an endocrinologist? Because, oh, this guy is really, really sick. And remember 90% of all people with diabetes in this country are managed by us, family doctors, primary care doctors. This is my favorite thing that would say. What about this? Why don't you just tell him he didn't take this disease seriously? Do you really wanna lose a leg? Believe it or not? You'll see in the next case, this happens a lot. So two weeks after his initial visit on day one, we put him on the sensor, we have them come back in just two weeks. We download the data and you can see the time and range is 24%. Do we yell at him? No, we don't do anything. We don't yell him at all. We just show this to him and what we're gonna do is gonna place him on uh GOP, we're gonna titrate the GOP one and they haven't come back in two weeks for another download. He's also based on his labs. He's always gonna be based on a high intensity statin an Aone Scot two inhibitor, Aspirin and Valsartan. Remember we're, we're cooking the soup, we're making the soup here with this patient and we're telling him why we're doing this as well. So we ha so when I did this, we called the ophthalmologist and said, you know what, thank you for referring him to me because you just saved this guy's life. And what's gonna happen here is not only is the ophthalmologist gonna feel good about this, but you're gonna get a lot more referrals moving forward. So this is the uh uh pilot four weeks after his initial visit and you can see that the time and range has improved to 52%. Now, this is just uh in, in the matter of uh four weeks. So he's gone from 20% to 52% in time and range. I like that. And then the GM I now shows 7.9%. That means that his A one C initially was 10.9. Now we're at 7.9 because we put him on a GOP one and some other medicines including an SCLT two on the right of the screen, you see something called a glu glucose pattern indicator. You see all those dots, those are all the sensor readings over a two week period of time, all of them. And you can see this just as easily as I can. He's got significant postprandial hypoglycemia, but the good news is he's not going low and we're seeing a little bit more time in range. So just looking at this pattern gives you uh uh pause for being a little bit happy. Remember with GOP ones, you kinda have to titrate the dose. You start low and you titrate the dose over a period of uh uh 4 to 8 weeks. So here's our GP I, how would you interpret this already explained? You've got postprandial hypoglycemia, but the good news is you gotta give him credit. You would say Mr Pilot. Good for you. You've got your A one C down from 10.9 to 7.9. Now let's fix those post meal spikes. So six weeks later, six weeks, not six months, not six years. Look at the time and range 76%. Remember when I said flat line flat is good. Look at this, you've got a flat line there and you've got no hypoglycemia. You've done your job, your, your weight's going down, his blood pressure is going down and this is successful diabetes management. You cannot do this without using technology. So the patient, he also knows all of his meds. We kind of chewed him out a little bit, kind of joked about it. And now he is like a professor of diabetes. He's taken interest in his own diabetes management and that is successful diabetes management. So the questions here. Do you see this commonly in your practice? Can you, do you feel comfortable rapidly improving these patients? Diabetes control? And also when's the last time you actually praise somebody for doing the right stuff. So with this case, I gave him a hug, I said, oh, Captain, you made me so proud, you made me so so proud of you today. You are number one in my book. Thank you very much. I look forward to seeing you again in a couple of weeks and that patient will do anything, anything you want him to do because everybody likes being praised. He gets the medal of the day. So here's the take home message for our pilot. People with diabetes should be provided with the tools they need to successfully manage their diabetes. 12 things we want to get the A one C less than 7% with minimal hypoglycemia and we want the time and range to be over 70%. So if we do this and flatten the curve, we reduce their glycemic variability, we're doing the best we can to manage these people die with uh diabetes and that makes them happy and that makes you happy as well. So let's take a look at case number two. This is Marcos and Marcos is really not happy. He comes into my office with a uh history of type two diabetes. 15 years in the making. This is his first time to see me A one C never below 9.2. I believe I'm doctor nine that he's seen on his list. He's taking Metformin and glipiZIDE. So here's uh Marco, some of the cities that he has. He's hypertensive, he's got uh diabetic uh uh sensory neuropathy, proliferative di diabetic retinopathy. He's already got amblyopia. He's lost an eye due due to a stroke. You might have seen it on the video there, he cannot afford to lose another eye. He lives by himself, which increases the risk for developing severe hypoglycemia won't be able to reverse the woes. If he's living by himself, he doesn't smoke, he doesn't uh uh use alcohol, he doesn't exercise. He works as a long haul truck drivers. A one C is a really bad and I 0.3 his C peptide is high which means that he's got type two diabetes. We also have something called A F four score. Uh This, uh you may not be familiar with this, but this is a way that we can figure out if the patient has uh uh non-alcoholic tal hepatitis or fibrosis and the level is high. He's got fatty liver, he's on Metformin glipiZIDE, uh S Simvastatin and Lisinopril. So ask the patient, what scares you the most about having diabetes? I've, I've mentioned this before and what they're gonna say is they don't wanna lose my eyes, my kidneys, a leg. I wanna be able to walk my daughter down the aisle someday. And what your answer is because there are 100% of these paper papers, patients are gonna say the exact same thing you gonna say with the medications and technologies that we have today. I guarantee you that you're gonna be ok. I've got your back and at that point in time, the patient is gonna have confidence in your ability to help them get their glycemic measurements. Uh under control. Would what I'm sorry, what medicines would you consider using for Marcos? And would you want finger sticks or would you want to put him on a sensor? So let's take a look at marcos' uh initial CGM. So this is downloaded after just a week. We don't waste a lot of time. We put them on the sensor. I don't even give them a chance. I, I do not give them a chance when they come in. They get AC GM. I put it on their arm. It takes about four seconds to do this. And I, I don't even say, would you like a sensor? I put it on their arm before they even ask permission. They always look at them, their arms. Well, what would you do? Do you like doing finger sticks? No? Ok. Now this is a sensor. It's gonna check your blood sugar every minute of every day for two weeks. Let's give this a try. They love it. So what do we see with this picture? What we see are highs and lows overnight. The, the uh sofa is causing treatment emergent hypoglycemia and it's lasting for a long time. He lives by himself. He's also getting hypoglycemic a little bit at six in the morning when he wakes up. Is that his fault? No, he was sleeping. It's the glipiZIDE, the sofa rhea, and then what happens? He starts eating the glucose levels go up. So this is the roller coaster that we commonly see in people with diabetes. If you look at the daily glucose profiles all day long, all the time, he's going high. This is post meal hyperglycemia, but look carefully. You see hypoglycemia, hypoglycemia is occurring overnight in this patient as well. This is very dangerous for somebody that has a high risk for cardiovascular disease. And the hypoglycemia is lasting for more than 15 minutes at a time. If you get hypoglycemic, once during the day, you're gonna get hypoglycemic again. And that's shown here in this particular slide. So, one of the issues here, he's got glycemic variability. He's up, he's down, he's all over the place. Uh He's got a postprandial control, that's not very good. And the soa is problematic because he's got diabetic kidney disease and that increases the reabsorption of the suona. So that's gonna make the hypoglycemic episodes even more significant. So, what are we gonna do? So what about maybe stopping the suona, maybe even putting him on a GOP one receptor agonist and use medicines that are uh uh protective against uh cardio uh renal uh disease. At least that's what I would do. What would you guys wanna do? So, let's bring Marcos back now and we can see just after a few weeks, uh you could see that the A GP report shows he's gone from very poor glycemic control to near perfect 92% of his numbers are in target. Look at the GM I, that's a glucose management indicator. That's our A one C. Again, the reason we get this GM I is because we're doing glucose readings all day long, every minute of every day. OK. So we have a mathematical algorithm that calculates what that uh A one C is gonna be And it's very, very good. So 6.2 is this A one C? And it was over 9.2 just four weeks before that. How's that sound? And look how flat that light is. Isn't this good? Isn't this fun? So the baseline A one C is 9.23 months later, we at 6.7 time and range has gone from 42% to 92%. Lows have gone from 3% to 1%. But most importantly, what's his mood? He was angry and now he's happy. So take on messages here. If the patient is not doing well and getting to their uh prescribed metabolic targets, find something that works. Give them something to be proud about and using CGM and the medi medi medications that may be beneficial would be your best option. Remember, we're the coach, we're not playing uh for the Super Bowl here. We are coaching so that our patients can get into the so and win the game. So together we can make amazing progress and, uh, go from failures to successful treatment. And the best way to do this is by using appropriate medications and technology to minimize the risk of hyperglycemia. How about Lee? He's patient. Number three, he comes in, he is a train wreck. He's got everything that you can imagine wrong with him and he's being followed by family medicine. Good for us for doing this. Do you think an endocrinologist can take care of? Le let's take a look. He's got any cardio and antibody syndrome, which means that he's gonna be clotting all the time. In fact, he's got complete occlusion of his inferior vena cava. Uh he's got a panic in uh panic insufficiency, portal hypertension. He's abused opioids in the past. He's got fatty liver. Then he had a really bad weekend. He actually got really sick and started getting all the symptoms suggestive of uh type one diabetes. He started uh getting blurry vision, fatigue, peeing a lot, uh losing weight. He ends up in the emergency room where the A one C was at 10.2%. So he comes back to see us and he's on Metformin. We put a sensor on and we download in a period of uh nine days and you can see on the right side there on Metformin, he's only got 13% of his numbers in the target range, not going low. But if you look at the A GP report there is very little evidence of time and range. Remember in the hospital, his A one C was 10.2 on the sensor. It was 9.6. So you can see with the GM I and the A one C how they compare. You can see on the daily glucose profiles. Those glucose levels are absolutely terrible. So this is after just nine days and again, with the AD A and the easd uh uh consensus panel guidelines suggest is that if you have somebody like Lee that comes in your office, it's probably a good idea to put him on insulin, but you've got to put him on CGM as well. So the question here is he's complaining of weight loss fatigue. He's peeing all night long. He's on Metformin uh twice daily. How would you manage? Would you put him on CGM? On the first visit? Does Medicare cover the cost of CGM? Let me explain this because everybody again is gonna say all these things are really, really expensive. No, it's $36. It's $36 for a sensor for a two week wear and not everybody has to wear a sensor all the time. Intermittent use of CGM has been shown to reduce a one CS 5.8% as well. So the sensor is very inexpensive. Medicare does cover CGM if the patient is using insulin. So in Lee's case, if he had Medicare, it would be covered. Why is improving time and range by 40% so important for the patient. And the answer I already kind of gave this to you in a prior, uh, uh, uh discussion. But we know if we can get the, uh, the time and range improved by 40% we can have significant improvement in their long term diabetes related complications. So here he is on day one of, uh, actually, uh, after just nine days weighing the sensor, again, 13% of his numbers are in target. Uh and he's not going low, high GM I and we, we're gonna put him on the RLA Insulin and we're gonna come up, have him come back in a few weeks and look at the difference. So we've got before and after after eight weeks, he's gone from 13% and range to 98%. The line is flat good for him. GM I has gone from uh uh 10% to looks like 5.4%. Amazing. No lows. And he's on the ratite insulin dego that didn't take very long. And the patient I I'm still see him. His A one C is perfect. His time and range is perfect. He's still on the same medicines. It's been over two years doing just fine. So what about trace's successful initiation of CGM in primary care? Make it easy. Put the sensor on in the office for the patients, show them how to connect to the reader or to their cell phone. It doesn't take very long to do this and explain what is the CGM gonna do? Well, we're gonna be able to get more time and range. We're gonna be able to identify highs and lows. We're gonna improve glycemic variability. Remember the ups and downs the roller coaster ride of diabetes? Nobody likes to be on the roller coaster. You don't feel well, we can get information about what's happening with their sleeping. We can look at uh uh uh perspective A one C levels as well. Reduce the risk of h uh hospitalizations and minimize their uh rates of absenteeism at work. Because reducing hypoglycemia, the patient has to be confident putting on the sensor, it takes no time at all to do this and the patient is very, it's very simple, just put it on and uh we, we show them how to do this and they can apply it. They've got to be able to scan or some of these sensors actually stream. In other words, you don't have to scan, use the cell phone, scan over a sensor. The data is actually streamed uh to their cell phone with Dexcom and uh also with the Abbot uh uh sensor uh uh families. So if the sensor falls off, they can contact customer service, but bring the data in at every visit, you just also download this information and share the data with your loved ones. If somebody uh has evidence of hypoglycemia, remove the suona reduce the basal insulin. You can do this and you can do it very quickly after just having the sensor data. Uh a week. Remember that alcohol can cause hypoglycemia as well. It prevents the liver from producing uh hepatic glucose uh levels by rising those levels. So, if you're on uh a, uh uh if you're using alcohol, you may need to stop that to be safe. And uh, if your time and range is less than 7% find medicines that will help them get their levels to, uh, the appropriate, uh, range. Finally, let's, uh, let's talk about Emily, 78 years old, female type two diabetes for 12 years says feeling pretty good. Uh, she had a heart attack, uh, five years ago and she does not want to be in an SGLT two or a G LP. One says the two do, the copas are too high. She's just not interested. Uh, we asked her if she was aware of the effect of diet on her diabetes control. And she says, you know, I eat as well as I can. I'm healthy. I'm always eating the right stuff at home. It's important to remember that her A one C is 7.5. She's not really overweight. She's, uh, a little bit on the high side. Her blood pressure is ok. She doesn't do blood glucose levels very frequently but the blood glucose in the mornings are ranging between 100 and 20 to 100 and 60. How do you interpret that? I don't know. Uh, she's currently on insulin guarding 22 units in the morning and she's on Metformin 1 g twice a day. All right. So, what are we gonna do at this point in time? I gotta tell Emily, remember she's in her seventies and say, you know what your A one C is close enough. Let's continue on or are we gonna increase the basal insulin to get her glucose levels in the morning to less than 1 20? That's mainly a lot of times we try to do that, we try to uh increase the uh uh basal insulin. Uh so that the glucose levels in the morning are less than 1 10. And as I showed you before, her finger sticks are showing that they're much above that. Would you have the patient put on AC GM and see what happens in regards to uh her uh lifestyle intervention? Or would you just insist that she add an Scot two and GOP one? Even though she has a high copay, there could be multiple options in this. So go ahead and choose one. Here's a problem with A one C I already kind of mentioned this in the, in the prior uh discussions, but the A one C may over or underestimate the average glucose level. Let's take a look at Emily her A one C is 7.87 0.6. If you have an A one C is 7%. The glucose levels can range anywhere between 1 23 and 1 85. How are you supposed to dose insulin based on those levels? This is not taken into account glycemic variability. It does not tell you how to dose insulin. And uh it uh the other problem is as you know, people that have uh uh that are anemic, uh people that are pregnant people that have diabetic kidney disease, you don't get accurate A one C levels. So you can't base your decision, your clinical decision on A one C alone. So, what we're gonna do is we're gonna put a sensor on Emily and you already know, I don't give Emily a choice. She's gonna get a sensor and what you see is not so bad. The numbers don't look that bad, but look what happens after she eats breakfast. There's a little spike after lunch, little spike after dinner as well. But overall there's a spike. So we're just gonna ask Emily some questions here coming up. Her time and range is not bad. She's got 93% of her numbers in range. She's got no lows, which is good. Her GM I is predicting 6.6. Huh? Well, her A one C was 7.6 which is the most accurate. I'm going with the sensor here because the sensor shows not much glycemic variability. When you go up and down, then you're gonna have uh a one CS that may not be as accurate. So we're gonna ask him, look at the sensor data here. What did you learn from this? And she says, you know what oatmeal hates me whenever I eat oat meal glucose levels go up. And so she's gonna adjust that. She's gonna eat uh different breakfasts, try different things. We're also gonna uh titrate her dose of basil and so we can do that safely. Now, by the way, she's, if she's on 20 units, let's go to 21 units and see if we can get that glucose level uh lower in the morning without low. I think that's uh that's, that's a good idea. So we wanna increase uh the baseline by one unit per day. Uh And uh she could look at her sensor readings when the glucose levels are less than 1 10. We've done our job, stop the titration at that point in time and we should be ok with that. So CGM can be utilized to assist the titration of basal insulin usage. Individual awareness using CGM is important. It really impacts food choices, exercise where you could look at stress, travel medication adherence and so forth. And then using CGM, we can safely titrate insulin, whether it's prandial insulin or whether it's uh basal insulin. We could do that with the CGM.
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