So this is Ramsey john again and we're going to have some fun. Now we're going to move to some cases. So before I talk about the cases there are just a few things I would like to point out to you, I would like to talk a little bit about G. P. I. Or glucose pattern insights. Right? So these are sort of a new, relatively newer way of presenting glucose data. So you've got to remember that the C G M was really limited to specialist with diabetes but now we are using it more and more primary care physicians will need to understand it as well. And you've got to remember that primary care physicians have got huge amount on their plate. I have huge respect for my primary care colleagues because they've got to deal with so many things. So you need to simplify things for them and make it easier. So when we talk about the glucose pattern insight, you can see that it's different to what we've been using in terms of the IGP before and the whole idea that this will simplify the understanding of what's going, what's going wrong with the glucose data. And just by looking at it within seconds, you can tell what's dangerous, what's not dangerous. What do I need to do at this stage? Now one way to tackle this is to address low glucose patterns first because we know that hypoglycemia can be very dangerous in the short term. Well as well as a long term, as I said in my previous talk, but in the short term can be quite dangerous. So address low glucose patterns first and then address the high glucose now things can get quite complicated when you have high variability. But usually as I alluded to earlier, the high variability can be linked to hypoglycemia. So as you get rid of the hypoglycemia, the glycemic variability improves. So targeting hypoglycemia and if you see the glucose data this way targeting hypoglycemia first thing will solve a lot of problems. Now this was the old A. G. P. Report and this is the new GpR report. So what are the main differences? So let's just talk about the differences quickly. The consensus target for timing range is removed. So you've got less clutter I guess the the GDP figures got a different design now for the people are used to the A. G. P. They can tell what's wrong, but if people are not that used to the KGB, they don't use it all the time. I think you probably agree that looking at the G. P. R. Report is easier because Green is great Red please address immediately and that amber, those are the high address after you managed to get rid of the hypoglycemia. So it makes it quite easier for the Healthcare professional to understand what to do. Now the medication and lifestyle is included here. So the healthcare professional can have a look and see everything at one go. The daily glucose profiles have been removed Now you can argue that that could be potentially an issue because quite frequently we discussed, what did you do saturday? That was different from Tuesday. But this is something that can be discussed and glucose variability was removed because actually you can see it by looking at the G P. I report, the glucose variability becomes very obvious. So the question is does the G. P. I improve the primary care physician decision making because that's important question for me. I've been dealing with this with this for many, many years and I'm happy with either. Now a small study, a really to me, although it's small, it's a really important study. They generated a G. P. Report as well as GpR report similarly from from the same patients. And then they asked the healthcare professional, what do you think, which one is better? So very simple question, but an important question. What they showed that 23 out of 35 primary care physicians preferred the G. P. I report because it's less busy, easier to interpret. The color coding is really helpful. And then you've got all these important things with the that you need to be familiar with the, it shows it to you explicitly. You can see it very, very well. Now some people did point out that I like to see those daily glucose traces six out of the 12 users. Six out of 35 users actually wanted to see the daily glucose profile, which as I said, in my experience, it can be helpful because you can compare this was a really good day. What did you do that they compared with another day. But overall there was a preference for GpR Now when it comes to the effect on glucose reporting. And this is quite interesting because When they looked at these reports there were therapy changes in 79 instances 67 of these and I repeat 67 of these were related to hypoglycemia. So they were related to hypoglycemia that was unknown previously. So it had a major effect on how these health care professionals managed their patients. So G. P. I. Reports certainly aid in the identification and treatment of hypoglycemia that would otherwise be missed using current current report. So you know like everything in life has got positives and negatives but it appears that at least for the primary health care physicians, the G. P. I. Has got more positives than negatives. So moving on then to case number one this is a 41 year old lady referred by her general practitioner. She had an A. One C. 0. 47 which was repeated three months later and became 49 and this was checked because she had a family history of tattoo diabetes. Now the fasting glucose was done after the 1st 47 it was 5.3 and the second instances when it was 5.1 it was done simultaneously with the H. B one C. And the general practitioner. The primary healthcare physician really confused what's going on here because the fasting glucose looks good. But the H. B. One C. Is high and quite rightly ask for advice. The patient is asymptomatic. The only past medical history of notice heavy menstrual bleeding and referred for specialist advice. Not on any regular therapy. Her weight is 71 B. M. Is 24 that's her blood pressure there. So the gps asking does she have diabetes is it a yes is it to know what does she need more investigation? I'm pretty sure. Look going through this. You're already formed an answer in your head and of course this is not clear at this stage and we need to look into it in a bit more detail. So the options keep repeating a one c every 3-6 months and I would like you to commit to one of these in your head to keep repeating A one C. And fasting glucose. So let's do both every 3 to 6 months. three investigators for an HB variant because you could have an HP variant where the HBO becomes inaccurate or request an oral glucose tolerance test or five other. So hopefully you've formed an answer in your head. And actually I we went for two things. I mean usually in my practice when I have a disconnect for the diagnosis, I usually go for an oral glucose tolerance test to tell me what's happening. But we also used a sensor in this lady and you can see that her timing target was 98%. And if you look at the different days she's got glucose profile. It's probably better than mine. And I was very jealous to be honest with you. And if you look at the O. G. T. T. In the bottom right you can see that essentially it is normal. She's not even in the prediabetes so it's it's completely normal. So what's going on? She was fun to have low HB low M. C. V. And her ferreting was very low. So essentially this lady had iron deficiency anemia probably because of her heavy menstrual cycles. And those were managed by a specialist repeat H. B. O. And see what was it? No surprise it dropped significantly dropped from 49 which was in the diabetes range to 39 which is not in the diabetes range anymore. And some may argue all has she gone on a diet because her HB one C. was up her weight. Well it's gone down 2.6 kg which is what two cups of tea. But that was it. So essentially no change. So this lady did not have diabetes. The race H. B. O. N. C. Was due to iron deficiency anemia and iron deficiency anemia is not uncommon. So take home messages. H. B. And C. Can be misleading consequently causing an incorrect diagnosis. So just be careful when you rely only on HB one C. I still like HBO and see I'm not dissing HBOC but be careful with it. Common clinical condition can affect the accuracy of this classic marker and actually see GM helps to clarify this disconnect between HB one C. And glucose levels. What about case number two. So this is a 67 year old gentleman type two diabetes for 11 years. And the recent market in function. This is his second in five years had repeated urinary tract infections. And this is under active investigation treatment private admission with his M. I. He was on Metformin. He was in a certain area in the form of glamour parade and it was on a cocktail of cardiac drug aspirin, atorvastatin. Rem april. And by supper law was treated with a stent and reviewed two weeks post discharge. His B. M. I. Was 33. But please look at that. A one C. Was very high at 100 million more per mole or 11.3%. For a slightly low at 54. This was his A. G. P. So if you look at the estimated A one C. Is 97 which is very similar to his laboratory. A one C. That was 100 and what you see on the right is the various glucose reading. So it's always very high virtually non below 8.6 and of course no hypoglycemia whatsoever. So based on these results you believe the best treatment course in this gentleman with tattoo diabetes would be to one start insulin immediately and again please commit to an answer in your head to increase those of right remember he was on two mg, Start lifting therapy, start GLP one receptor agonist therapy or start SGL T two inhibitor therapy. Now given his very high H. B. O. N. C. I battle off you thought he does need insulin and I'm just putting up his profile again and he's relatively flat but high all the time patient not keen on starting insulin. And actually if you can avoid hypoglycemia is great Lipton's well consider efficacy also is not cardiovascular protective SGL T two inhibitors may be an option but he's got repeated U. T. S. That are on the investigation so I wouldn't start it. The other reason I would be very cautious with guilty to inhibit her because she is so high this patient could be insulin deficient and they could push them into diabetic ketoacidosis. If you start an SLT two inhibitor. If you take everything above together then the issue with his weight is BMR was 33. The fact that he doesn't want to go on insulin. Let's give him a trial of GLP one receptor agonist. Now given his already on the fly C. G. M. He can be closely monitored. So if he was monitored with sMB G. And we're relying on the on HB one C. I don't think GLP one receptor agonist would have been practical because you really worry about leaving this gentleman within 100 for many many months. So it's reviewed in six weeks and of course in between the patient was contacted as well and in six weeks on the GLP one receptor agonist this was his A. G. P. Major improvement. So if you want to see that before and you want to see that after. This is what happened in this gentleman. You will say always got large variability at around 11 p.m. But this was simply due to a single day where the patient has gone to a wedding and relaxed his diet. So you can see massive improvement and this can be done safely because the patient was on C. G. M. So very high. HBOC does not necessarily mean that insulin is needed. Use of flash CGM helped to safely monitor progress following non insulin therapy in an individual with type two diabetes and recent vascular event. So C. G. M. Use is likely to be helpful following therapy changes in type two diabetes because you'll get a very quick answer is this working or not? And if it is not working you move to something else. So my third and last case this is jasmine, she's a lady who is 69 years old had type two diabetes since she was 15 and has been on insulin for six years. She's on enlarging 60 units and the short acting 24- 34 units with meals. Metformin one g twice a day. She could not tolerate anything else. And she's on RAM april deep in aspirin, ibuprofen and paracetamol. She feels very well. She's a really good 69 year old, physically brilliant, quite active. Her only complaint is morning headaches on and off and she thinks this is just related to some stress. HB one C. is pretty good. 48 million more for more. And she's using SMB G. And these are her sMB G readings depicted both in milligram per deciliter and millie more per liter. And as you can see she tests three times a day. And if you look at her readings to me, they look pretty good actually reflective of her HB one C. So options congratulate the patient and continue the same treatment. Glucose control is too tight. Insulin doses must be immediately reduced. If we look at her readings, the lowest is 4.9. So it's not too bad, inform her that high glycemic variability is a concern before she needs more glucose data to make full assessment. Now in the old days, I must say, I would have probably gone for number one, congratulated the patient because these readings are pretty good. Right? The glucose variability is not bad, Nothing below 4.9. But given that she's got these headaches and given that we've got the facility to check it. Why not? Just to do a quick check of her glucose sort of more extensive check of her glucose particularly because she's on a quite a high dose of insulin. We've done that. We had a bit of a surprise because this was her IGP. And if you want to look at the individual readings, she had pretty significant hypoglycemia after 11 p.m. This was the time when she was not testing, she was not doing S. M. B. G. So it wasn't picking it up. And I guess the reason for her morning headaches is now becoming far more obvious. So adjustments were made to her insulin and she was told some carbohydrate counting and this was her pattern initially and this was her pattern after. And please note that it's like a miracle really because her a one C remained exactly the same. But hypoglycemia is not an issue anymore. Take home messages if you have good hb one C and S. N. B. G. Readings, this does not necessarily mean that all is good because you can have hidden hypoglycemia and hypoglycemia indeed is very common in insulin uses and often is not detected. CGM us gives a comprehensive glycemic assessment and uncovers this hidden hypoglycemia. So thank you very much for your attention. I'm going to stop here
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