I thank you, Doctor Miller for leading us through that great information for our patients who are elderly and using CGM. And now we'll circle back to our original case study with our patient Janice. As a reminder, she is 57. She has type two diabetes with C AD and CKD. She's not getting a lot of traction with that. A one C she's frustrated and she has a high diabetes stress some bedtime snacking, but otherwise really doesn't know where some of those highs and lows are coming from. So for Janice, uh, the provider start talking about a continuous glucose monitor. She has some concerns. You know, what is this gonna hurt? Is it gonna be poking me all the time? Is my insurance gonna pay for it? What's it gonna cost? Oh, it's too complex. I don't know if I'll be able to understand it. So after some discussion, the patient agrees to a one month trial, you know, start low, uh, and go slow. That's ok. So she returns to the clinic with a sensor and with that, uh, support in the clinic, she's able to place that first sensor, uh, the, uh, support staff works through downloading the app on her compatible smartphone. And then the clinic shares an email to uh for her to accept, for sharing her data with the clinic. They're able to make that connection right there, which means she set up for the duration of the that CGM, the time that she's using the CGM to share data with the clinic even remotely. So I find that folks who are able to do that uh with the support of the, the clinical team have a higher success rate. Uh even in our program, which is almost 100% virtual, we still do a virtual visit, setting it all up connecting them to the clinic and making sure that they are 100% comfortable. And that is done sometimes through nursing support, sometimes done through a diabetes educator. It really can be whatever champion you have at your office who can walk through the steps with a patient. So let's walk through her A GP report. So we're, we'll start with the, the biggest broad picture on that 1st 1st page with the first half of it gives us these stats. And so I encourage you to kind of look through and see what are the things that pop out for, for you. When you're looking at this A GP report, the good and the bad and some of the things that we want to think about, we wanna think about CGM active time. So we got pretty good. 96%. She's got an active CGM most of these two weeks, which is great. Her average glucose pretty high. 215. But we knew that her A one C was high as well. What's interesting here is that her GM I, her glucose management indicator, which I explained this as, uh to my patients. It's sort of like an A one C if this two week pattern continued for the next three months. So it's not gonna match the A one C we just had, but it's sort of like this most current um A one C pattern. And what's interesting here is we have an A one or GM I of 8.5 which is a little lower than her. A one C I do sometimes see this. People start wearing the CGM, they start noticing those triggers of highs or lows and start making accommodations for that. So that is not uncommon to see, I want to draw your attention to her glucose variability. So that coefficient of variation is pretty high, 41.2%. And she's got a lot of, she's got a lot of, she's got a lot of um of yellow and orange, a little bit of green and a little bit of red too. But this time very high is quite markedly high. She's got 3% low, which for her age isn't terrible depending on when it is, but only 32% in range. So there's a lot to unpack here when we look at her A GP, which is her, um, her glucose patterns. All of the numbers over the last two weeks from midnight to midnight, laid over top of each other where we have that dark blue line as the average, the medium blue as the majority of readings and then outliers with the light blue. So as you can see, there's quite a bit of spread. We've got some good, good spread here. Even at the same time of day, you know, 10 a.m. 11 AM, she can be over 350 or she might be in the 100. There's a lot of variability here. So this is a situation where it's really helpful to look at the day to day because the big pattern, the big picture here is not gonna give us what happens to cause such variability. So when we break it down, we look at the, the daily glucose profiles, which is at the bottom of that first page. A lot of information right on the first page, you'll see this pattern starts to emerge where she has kind of these overnight low or near low numbers. And then during the daytime, we've got some pretty big spikes going on. So that is helpful information that no A one C told us. And in fact, her blood glucose log didn't tell us even though she was checking in the morning. This is another way of looking at the day to day, if you want to actually look at some of the numbers and it, it reveals a similar pattern of these overnight lows or near lows. And then we start to see that number go up. So that's not uncommon to see kind of that swoosh where we go down and then swing up um overnight because we get rebound hyperglycemia after low blood sugar. So not uncommon to see. So what did we learn? She's got good CGM. We time, great. Her GM I is a little bit better that uh than her A one C had suggested time and range is not great. Uh She does only have 3% hypoglycemia, but it's nocturnal hypoglycemia. So we're more concerned about that. We wanna get that as low as possible versus intermittent daytime hypoglycemia we're not as concerned about, but nocturnal is concerning her time. Above range is pretty high, including that 35% time, very high. She's spending a lot of time quite high and she has that high glycemic variability. So, what we learned is we have these periods of asymptomatic nocturnal hypoglycemia and then that rebound hyperglycemia. And we do have those sometimes very high posterial hyperglycemic excursions, but other times not as much. And as a reminder, we wanna address that, that coefficient of variation because that's going to drive our complications. It's gonna drive disease burden and it's gonna drive medication, non adherence and clinical inertia. So we've got some work to do, but this is not gonna be fixed in one visit. We wanna do our most essential steps first. So for her, we wanna address this hypoglycemia and we wanna start to work on some of this. Our next step might be that time very high. So what we wanna do for Janice are, are, you know, most essential goals for her. We wanna decrease those episodes of nocturnal hypoglycemia, which is a safety concern, but it will have the uh the added benefit of reducing some of that rebound and hyperglycemia. So what's interesting is by getting rid of the lows, we often will get rid of some of the highs. We do have some of that overnight of variability. So sometimes it's running pretty high overnight. So this is when it's a good uh good conversation to have about a couple of things. Uh One of them might be a normalized discussion about missing some of the medication. So how that looks is it's a nonjudgmental way of talking about non adherence because if you can put yourself in Janice's shoes, she's not sure what her glucose is gonna do in the morning. So sometimes she may not feel comfortable taking all of her medication or maybe taking any of it. So how that can, um how that can that competition can go is something like, you know, with these numbers all over the place, it can sometimes be hard to know if your medication dose is right? Or if it's safe to take your medications. So, how often in a week would you say that you're skipping your Lantus dose or you're skipping your GOP one? I would say it like that as in how often is this happening? Versus are you ever skipping it? Because we're much more likely to say no, if it's approached that way versus normalizing it and just asking how often does it happen. And then, uh I would start a little conversation about that bedtime snacking too. Sometimes lets get into that habit because it's compensatory to reduce the overnight lows. They found out that if they eat before bed, they have a better number in the morning. If they eat before bed, they don't wake up with sweats overnight, they don't wake up with nightmares so we can have a conversation about whether that's something she likes to do because she wants to eat a bedtime snack or if it's something that's compensatory because of her, her los. So for her treatment plan, decrease basal insulin dose. Yes, you heard that right? Her A one C is 9.1 but we are reducing her basal insulin dose because that way we lower that overall nocturnal hypoglycemia, which decreases that rebound hyperglycemia. And we have the goal to reduce her bedtime snacking. So my goal for her would be to set her on a dose of Largy that would, would allow her to not eat a bedtime snack and still wake up in a safe range in the morning. So that way we're decreasing some of that caloric intake too. And then we wanna really hand the reins over to the patient and start to say, I want you to identify some of those triggers, not all of the triggers, but see what kind of activities or what kind of, of foods or you know what kind of situations cause some of those highs or lows. And that can start giving some of that power back to the patient. Definitely want to keep her on A G LP one that's cardio uh favorable, given her history, it's weight, favorable, low risk of hypoglycemia. So that's a good one to keep on board. And then in the future, what we, our next steps might be is maybe we think about other cardio renally favorable medications such as an SCLT two inhibitor. We wanna reassess that diabetes distress and overall disease burden and see how she's doing after she has some of these new tools and new empowerment. So that's what we think about for treatment plan. We hit our safety measures first, we get rid of the low blood sugars and then that gets rid of some of that compensatory uh uh caloric intake, it gets rid of some of that rebound hyperglycemia and then start to identify some of those high. So that's how we kind of prioritize our treatment plan. So what does all this information tell us about when we're talking about CGM for type two diabetes. And unfortunately type two diabetes is complex and heterogenic. It's not the same, no, two people with diabetes have the same glycemic patterns or even have the same pattern from day to day. So there's a lot of variability between people that have diabetes and even the same person from day to day. So there are so many variables that can impact, uh, blood sugar readings, not just diet and exercise, but we can think about different medications that impacted medication timing, some of their comorbidities, uh even their stress level can have an impact on blood sugar variability. What CGM helps us to know is some of those key insights into the disease process that are individualized to each patient. So it can identify some of those unrecognized patterns of glycemic variability and it can help remove some of those barriers that we talked about. If we can safely, where those numbers of those glucose numbers are, we're less concerned about hypoglycemia. We're able to advance treatment if we're able to see where some of those high numbers are. Now, we know what, what uh agents we need to use to bring down some of those numbers. So it helps reduce that clinical inertia and overall continuous glucose monitoring is a tool that may help us devise a safer, more effective and more personalized treatment strategy in a complex disease that can be riddled with barriers. This can be a way to help remove some of those key barriers in patients where it's appropriate. But thank you so much for learning about continuous glucose monitoring. And hopefully, we gave you some insights that you can take to the clinic on Monday morning and help to empower yourself and empower your patients to make real change with continuous glucose monitoring.
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