Video Early Application of CGM to Proactively Manage Type 2 Diabetes in the Real World—Interactive Case-Based Clinic Play Pause Volume Quality 720P 720P 576P Fullscreen Captions Transcript Chapters Slides Error loading media: File could not be played 00:0000:0000:0000:00 Early Application of CGM to Proactively Manage Type 2 Diabetes in the Real World—Interactive Case-Based Clinic Overview TranscriptChapters Continue to Test Back to Symposium Ok. So it's always my luck to have to follow someone as phenomenal as DaVita. But let's see if we can share a couple more um, cases to help you with a, applying CGM to patients in the real world. So the first one is a 68 year old woman who has had type two diabetes for two years and her A one C is currently at 6.8. She's on glargine insulin 10 units every night. She's also on a sofa urea this particular one on his glipiZIDE twice daily. Um, she stopped, however, the Metformin because it was causing low blood sugar. She has gained £20 since her diagnosis. She says she's eating all the time not to go low cookies, candy cake, whatever. Sometimes patients love having low blood sugar so that they can indulge in cookie cake and whatever review of her glucose. Uh her meter shows that she's anywhere from 50 to 320 there's really nothing else unusual. She's got a history of the Buy One, get three free, the dyslipidemia, the hypertension, sleep apnea, obesity and other than the additional weight gain, everything else. As far as her health has been stable. These are her labs. So we got a, a point of care a we see in the office she's at 5.9 let's go back. She was 6.8 before. Ok, 5.9. Um, you don't need to get home IRS but for this, for this particular patient, um we did somehow manage to get a fasting insulin and as you can see, she's got an, a fasting insulin level of 17 with a glucose of 85. So when you look at your uh insulin res uh result and you look at the normal parameter, it actually says that it's normal all the way up to um a level of about 25 24.9. I'm here to tell you that a fasting insulin level above 10 in any person is abnormal and is a sign of insulin resistance. So what this is showing you is that for her glucose of 85 she is churning out a heck of a lot of insulin to have a fasting insulin of 17. So her homa which is the um insulin resistance marker is 3.6. Anything above two is consistent with insulin. So that was just a little nugget to throw your way. I don't recommend drawing fasting insulin levels. Um just for uh whatever reason, it's not necessarily go, it's not gonna change what you do for your patients with diabetes unless you're wondering if they have type one. So her other labs were normal thyroid lipids, her liver, um associated enzymes are stable. She's got good kidney function. And so, um, we put AC GM on her, we needed to find out what the heck is going on. Um, especially because she had that A one C now 5.9. And so, oh, my goodness. What does the professional CGM show? So, a professional CGM is something that I really encourage all health care providers to actually be using in their uh uh clinic appointments with their patients. I will put a professional CGM on any new patient that is seeing me for diabetes for the first time, especially if they're not already using AC GM. Um I'm going to get a good two weeks of data. If they're new to me, I probably need to get a bunch of labs. I may need some additional information and in the interim of getting all of those results, they're gonna be wearing that CGM. Professional CG MS are blinded, the patient will not have access to the data. And so that can be good because it's not influencing what they're doing, but it can be bad because it's not influencing what they're doing. But for the professional, it is a blinded CGM patient does not have access. So two weeks later, she comes back in and I am seeing a whole bunch of low blood sugar. She's got 15% of her time is being spent below 70. And is there a particular pattern? All I know is when I look down at the, um, the graph, there's a lot of red throughout the day. There's another report that comes with this, it's called the snapshot. The snapshot will actually show you what I love about the snapshot is that it will actually show you how many low glucose events this person has had over the past two weeks, she has had 27 low blood sugars for an average duration of 100 and 38 minutes. And the darker the red, the more often it is happening during that particular time frame. And again, what we're seeing is that it really doesn't seem to matter what time of day she's having lows all day long, but it seems that she's most at risk, especially at night and remember what I said about dying in fires. The other report that comes with the 24 with the C with a professional CGM is the daily. So you can actually see what's happening every day and what their average blood sugar has been, how often they spent below se uh that 70 mg per deciliter and how often have they been above that 180 outside of that time and range. And so it's another way of looking at the data, don't have to use this report, but it is something that comes with professional. So what do you typically see happening with her, are you seeing that her low blood sugars typically occur after a high, it looks like she's going too long between meals. Her risk for a low is greatest between 9 a.m. and 3 p.m. or there is no pattern. She is just low a lot and I'm gonna go back to her patterns. What are you seeing here? So, where are we seeing problems? Ok. So based on what you've decided, um, is her problem? What are you gonna do now? Ok. Remember what we talked about earlier. We want to address the hypoglycemia first. So are you going to discontinue the insulin? Continue the Sulfon urea and resume her Metformin because she stopped it thinking that was what was causing her lows. Are you going to continue the insulin, stop the Sulfon area and resume the Metformin? Are you gonna discontinue both the insulin and the Sulfon area and maybe start her on something else like a TZD? Are you going to discontinue everything and not do anything new for her right now? So think about what you might do. I can show you what I did. There's not necessarily a wrong answer as long as you're communicating to her, what you're expecting and what to be monitoring for. I decided for her especially because her fasting insulin level was so high. She really needed a medication that was going to address her insulin resistance, meaning that she looks like she was making enough insulin that she might not need um, the insulin and the sulfon urea. One of the worst things that we can do as health care clinicians is add insulin to someone that's on a sulfon urea and not stop the sulfon urea. Remember that medication helps the patients secrete insulin. So if they need basal insulin on top of the suona, the sulfon areaa is a no longer very effective and b the secretion of the insulin becomes very unpredictable. So it actually increases the risk of having a severe hypoglycemia episode quite high. So I don't like to use insulin and sulfa areas together. So that would be for sure not to use them. I decided for her to just stop the insulin and the sulfa area and start her on just a TZD, um 15 mg low dose and this is how she looked just a few months later. Um And as you can see, she went from being really awful as far as how low she was going 15% of the time she is now 95% within range. She's not having any glucoses below and her A one C really hasn't changed. She was 5.9 with 15% of her blood sugars below um 70 here her A one C is 6% and she's not having any low. So again, the quality of that A one C is a big difference and um if, if she was on insulin and sulfa rhea and had an A one C of six, I would be concerned and I would want to get some additional data. So now we're gonna look at our initial, um, uh, another, uh, person that we're seeing for the first time. This is a, uh, 46 year old gentleman who was diagnosed with diabetes, um, in 2019. So a few years ago at this point and his initial appointment with me was just this past January. He presents with hypertension dyslipidemia and he does complain of numbness and tingling to his feet. He is on, at the time he was on Glargine 10 units at night. He's taking Lispro just before dinner. He's on Metformin long acting 500 twice a day because he experienced diarrhea with anything that was above that dose. And he actually says to me that he prefers to use insulin. The pills don't seem to work. So I do have patients, especially in our folks with type two that are on so many medications oftentimes they would much rather do an injection than to take another pill. So this guy kind of had my attention when he mentioned this to me because that's not something you hear a lot. So what about glucose monitoring? Well, he's not monitoring but his rationale is different. He said no matter what his blood sugars were always high, no matter what he did. So he was frustrated and just stopped testing. That's something I hear quite a bit. Another one would be I used to test, but I would bring in my data and no one would look at it. So if no one's gonna look at it and I don't know what I'm looking at, I decided it's not that important. So if patients are testing blood glucose or monitoring in some way, we owe them that of um responsibility of looking at that data with them. So he's been drinking juice, soda, eating a lot of fruit only God knows what a lot of fruit is. Ok. But this is his story and these were the labs. So I saw him in January of 2024. The labs that I had were what he brought to me in July of 2023. His A one C at the time was 7.6. They did, he did have um A U AC rau urine albumin creatinine ratio, which should be done at least once a year was less than five. We know that normal is under 30 his LDL was 68 for people with type two. We want to get that under 70. If he had a history of established cardiovascular disease, we want it even lower. 55 vitals, blood pressure. 1 26/78 looks pretty good. He had a random blood glucose in my office of 326. He has a BM I of 24 and as other than the um diminished um sensory to his foot exam. His exam was unremarkable. So we were gonna send him for labs. I'm not actually convinced that he has type two diabetes. Um So I sent him for an A one C got a CPAP tide included the comprehensive metabolic panel, got a lipid, ordered my full autoimmune type one diabetes profile that includes the gad 65 the zinc transporter eight, the I A two. Um I did not order the insulin auto antibody, the IA A because he was already on insulin and that could give me a false result. But I did order the um IC A which is the islet cell antibody. So I did that to include to make sure that we were dealing with the right type of diabetes. Got an updated um albumin creatinine ratio and of course, got thyroid labs um told him to stop drinking crap in those exact words and we put AC GM on him and he was going to come back in two weeks. So these are um his CGM results on the left of that screen and his lab results. So his more current lab was an A one C of 9.3 all of his autoimmune um antibodies, they were all negative and the C peptide was elevated at 4.2 with a glucose at 182. So you do if you're doing C peptides, make sure you're getting those glucose values because you need that information to know if they're insulin OIC or if they're insulin resistant. So I now have evidence that he does not have type two diabetes. And when I look at the other parameters, his cholesterol, his triglycerides are elevated at 164 and his HDL is actually a little low for a male at 42. So, again, symptoms of, uh, insulin resistance. And so I'm looking now at his CGM and he's 11% in range. Isn't this great? It's great for me because I'm thinking, you know what, no matter what I do, I'm gonna look like I walk on water because I am going to be able to get him above at 11%. And so I'm going to show you all the rocks that will help you look like you also walk on water. So what are you gonna do for him? Are you going to stop the insulin? Increase? His Metformin add a G LP one and send him to a CDC ES or are you going to continue the insulin, stop the Metformin and add the G LP one. And of course, refer, are you gonna stop the insulin? Continue the Metformin add the weekly G LP one and refer. Are you gonna continue the insulin? Continue the Metformin add an SG LP two inhibitor and refer or you just gonna keep everything the way it is and send him to a certified diabetes care and education specialist. Well, what I did was I continued the insulin because he's only 11% in range. I did not want to set him up for fail, but I'm gonna stop the Metformin. It's causing him some significant G I side effects. And I really wanted him to be successful on a weekly G LP one and I didn't want Metformin that could be causing any issues to make it problematic with the G LP one. And of course, send him to a certified diabetes care and education specialist and I wanted him back in a month. Ok. It takes about four weeks when you're initiating a weekly G LP one to actually see any um effect on glucoses. It takes a good four weeks to reach steady state. So there might be a slow but most of the G LP ones we have, you start out with a loading dose anyway. And so I want to make sure he was doing all right, even though I wasn't expecting to see anything huge. So as we said, we kept him on his insulin, which consisted of the glargine 12 units before um once a day and then the Lispro four units before every meal. And now he's been on his G LP one receptor agonist times four weeks. He stopped the juice, which is huge, but he's still working on his soda. Ok. And he wants to um we reviewed his CGM so we could decide on a plan. But look at this just one month later, he went from an 11% time and range. He's at 49% time in range. And his A one C based on this information is 7.9. Fantastic. So, what did we do? Well, he does have an appointment with the registered dietitian. We increased his glargine to 20 units based on what we're seeing. Ok, we stopped the mealtime insulin and we encouraged him to increase his G LP one to the next dose. So why did I stop the mealtime insulin? Uh because I wanted to get him going with uh meeting with a dietician. Remember he's working on the soda, just eliminating the juice went a long way. We wanna reduce some of the burden of care and we are already seeing the impact of the G LP one on his appetite. Hopefully, that is what helped him to also reduce the juice. So now that I know that he's gonna titrate up, he's meeting with the dietitian. I said, you know what, I will see you back in three months, but sooner if you need to see me. So he comes back and now he's on just glaring 20 units. He's still on his uh G LP one receptor agonist. He has increased his water intake, still working on his soda. But look at his CGM. Now he is 78% within range. But now we're starting to see that he's starting to have a little bit of issue with blood glucose is dropping only 1% of the time below 70. And we, you know, we're ok with up to four, but I don't really want any because what happens when you have a low is you're gonna wanna eat to bring that blood sugar up? He's on a G LP one receptor agonist. He may not have an appetite. And so I don't want to pose any risk on him having a low blood sugar. So based on his CGM, what did we do? Well, he continues to see the registered dietitian. We decided let's reduce the glargine to half. Ok, see if that will help him stick to his nutritional plan that he has in place. And at the same time, let's go up to the next dose if it's applicable on the G LP one. And he was agreeable to that. So just in four months, we went from 11% time in range to now 78% time and range and he's getting better and this is when you show them, look at what you've accomplished since I started uh seeing you. And it's just like night and day when you can put CG MS uh reports side by side to actually show a patient how well they are doing. And this is the kind of stuff that makes what I do why I love doing it because to see the patients engaged and doing well, makes all of the head hitting on the keyboard that we all experience some days. Well worth it. Published Created by Related Presenters Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC Certified Nurse Practitioner Diabetes Expert Capital Diabetes & Endocrine Associates Silver Spring, MD
