So now let's take a look at a couple of cases that I hope really kind of brings everything home for you and it really helps with the application of everything we've already been going through. So this is a patient of mine who is actually quite near and dear to my heart. She uh is a 68 year old, uh wonderful sweet lady that I met during the beginning of the pandemic when we were doing everything online and she was referred to me in the spring of 2021 for the management of uncontrolled type one diabetes. So she was diagnosed in 2009 and had been managed by an endocrinologist with multiple daily insulin injections. She was on bail basal bolus. So she did intermittently check her fingerstick blood sugars, medical history. Significant prohibit tension, slim anemia, anxiety, seasonal allergies, breast cancer, chest stage two chronic kidney disease, egfr 76 and negative alia. So when I was talking to her and asked her what her insulin regimen was, it was insulin glow gene 64 units a day and she was using U 100 A spark 20 units with each meal so fixed uh three times a day. She didn't count carbs. She didn't use correction doses. She just, yeah, used those exact doses. She reported when I asked her that she wasn't using Glucagon and reported treating hypoglycemia with orange juice. Her most recent weight was 100 and £70 and her BM I was 31 when she was referred at this time, her incy was 10.4. Everything else was within normal limits and she said she was adherent to her insulin doses. So remember I'm seeing her on video conferencing. So what I'd like you to kind of think about is what would you do or if she was even in front of you, what would you do? And so let's talk about it. So what I did was I taught her how to use CGM because 10 years type one diabetes on all that insulin. It was see 10.4 not checking her blood sugars. So she didn't suddenly get high, right? Her 10.4 has been going on for a while. So I taught her how to use AC GM and I said, I'll see you in two weeks and then we'll see what to do then because without any data, how am I gonna manage her with all those insulin doses? So two weeks later, this is what I see on her HEP report. So it was active for 14 days. Now at, at the time this was the second generation of this particular CGM. So you have to scan at least once every eight hours for the second generation. So you um in order to get 100% of the data. So with the next generation, you don't have to scan every eight hours, it's passive. But for this one, you had to scan and she sleeps um nine or 10 hours every night. So she wouldn't get that full uh eight hours. So that's why you see some missing data there. But you, you can really get a good understanding of what's going on was. So it was about 68% active. It needs to be 70% or more to see that GM I glucose management indicator. But what you can see during the almost 70% of the time that it is active, that it is high 100% of the time so high or very high. She is in target range, 0% of the time. Not one single minute is she in range? So 100% of the time you can see that her blood sugars are in the three hundreds straight across. The other thing that's very interesting here is that a glucose variability is 14.2%. So it is pretty tight that she is just always in those three hundreds and her average glucose is 300 here. So what are you thinking? Here's an example. So once I look at the A GP, I look at the logs and I asked her to write notes to me during those two weeks because I hadn't met her before. I wanted to get an idea of what happens with her insulin doses. What happens with her food? It didn't matter. Her glucose variability was very tight regardless of what she ate. So you can see, here's an example of just two days of the logs and why you can see how it's helpful when they write down notes for you when you're trying to dose their meds. If I do have patients who um also I'm having them do other things like blood pressure checks. I also have them write it into their app, but you can see what she's eating and it's consistently high. I go over her insulin doses again. She tells me she is adherent. So what, what do you think? So, I'm gonna tell you what I did but just for a few seconds, think about it. She's on glaring 164 units a day and a U 120 units three times a day. Would you increase her glargine to 70 units and increase every few days until she's at go fast and gold. Would you increase her U 100 at those meals from 20 to 30? Would you do both of those things? Would you do none of those things? So let me tell you what I did and what happened and I actually published this, uh paper and you can see uh all of the details and all the CGM and um more information if you want to email me, I'm happy to send it to you or you or the references on the slides, you can certainly, um, grab that paper yourself. So based on what she told me on the, actually on the first visit I suspected type two diabetes. So despite 10 years of type one diabetes, the fact that her doses of insulin were so high and she weighed 100 and £70 and it wasn't doing, you know, anything with an A one C of 10.4. I suspected type two, but CGM confirmed it for me. So what I did on that visit, even without having any lab tests is I said to her, listen, I really think you have type two diabetes. I'm gonna give you some Metformin. If you have type one diabetes, it's not going to hurt you. But if you have type two diabetes, it's going to make the world of difference. I will also order some labs for you. And I ordered some traditional antibody type labs for type one diabetes. So because I was using CGM and I had the her signed up in my portal. I was able to look at her blood sugars from home, her CGM from home and I could see with one dose of Metformin, her blood sugars were down 100 points just with one pill So that was confirmatory. But I did again get those labs anyhow. So I knew that she had that. And so I traded her uh insulin. So what you can see here on this chart is time and range. So when she came to the next visit, her, she was on 64 units of U 100 gla she was on 20 units three times a day of um insulin of spark and she was on the full dose of Metformin and her time in range went from 0 to 71%. Her very high went down to 2%. Oops, let's see. Down to 2%. So clearly type two diabetes made a big difference that we could do that. So, based on these results, what do you think? So you saw that, adding that um Met Forman made a big difference. Would you continue everything and make no change and leave everything as is, would you continue everything and add an SGLT two inhibitor? Would you continue the Metformin and the insulin glargine and stop the Aspart and start a G LP one receptor Agnes once a week or would you continue everything discon, discontinue the Aspart and start an SG LP two inhibitor. What do you think about that? Of course, I want to tell you what we did. So, what I did was I stopped her mealtime insulin and started and I lowered her uh her insulin dose, her den with back to 56 units and I started dila uh 0.75 once a week. Then I continued the Metformin and lo and behold her time and range decreased to 27 which is what I actually expected to happen. So when you're stopping 60 units of male time insulin, I knew that doing this, that the would be a work in progress. And that included getting her off some of those insulin doses that will help decrease risk of hypoglycemia also um help with some weight loss. So I did that. She also had complained to me about G I side effects from the Metformin. So I lowered the dose to the 1000 mg a day. So when she came back, II, I had increased her delete to 1.5. So we increased the dose. She self tid her insulin to 82 units, Diago 1.5 and the Metformin 1000 mg a day and her timing range is 37%. So what are we gonna do now? Now, I and I had anticipated that we'd be using a G LP one receptors and an SGLT two inhibitor. So using that combination, you know, we have lots of other benefits, but SG LP two inhibitors help also target postal triggers. So by adding pagla flows in 10 mg to her regimen that increased her time in range to 92%. And her A one C at that visit had gone down to 7.4 from that 10.4. So what do you think we should do now? Should we keep everything the same, everything at 92% for 10? Any, any thoughts? Think about that. So I actually lowered her de de to 60 units and I increased her empa to 25 and I did that because I had the benefit of having CGM. So I could see that a big portion. That's 7.5. The closer we get to gold, the closer we get to that A one C goal is more post brand. So I increased her empa decreased her basal insulin because I could see CGM that her fasting and in between meals were lower. So, so there was room there and I did actually just see her about a week ago and she's doing spectacular. So now let's take a look at another case, another favorite lady of mine and this is somebody I've been seeing probably, oh at least 10 years. And when I first saw her, I'll never forget she came in, she weighed about 100 and £90. She was on a cell phone ar and had a serious diarrhea with Matt Forman. So she, she was really not doing well. So lots of different changes that occurred o over the years leading up to now. So, you know, diabetes is progressive, type two progressive and, and it gets worse over time and things have changed. So at this time, when she came to see me, had obviously got her off the cell phone a long time ago and weight loss was important to her. And I actually had been seeing her and she was using, uh, uh, 3 mg a week in addition to and Metformin. And she had lost so much weight that she actually, um, didn't like it. She, she liked it but she didn't like it. So she was probably down to about 100 and £10. Very thin. I mean, she looked beautiful but very thin and her husband was concerned and she really wanted um to gain some weight. So at the last visit when she was on that 3 mg of delatte her time and range was, was 61%. She was also taking Metformin, the combination pill. So twe 12.5 1000 2 a day. So she was on the maximum dose of and the maximum dose of Metformin and I had decreased to 0.75 and I added uh U 300 glaring and I did that because cutting back on that and the fact that her, I could see her time in range was uh was low that I knew she needed some Larine uh needed some basal insulin. So she comes back with the basal insulin. She's on went from 10 units to 20 units. So I gave her a self titration of two units every three days and she came back and her time and range is here on the right. So take a look at this. So now she comes back, she's active 87% of the time because she has the version three of this sensor. So it's uh passive 100%. It's um active, the the majority. Um you can see her GM I is 8.5 which is an estimate of what the A one C would be for the last two weeks. Her average glucose is 2 15. Her glucose variability is less than 36% but it's kind of pushing up there. And that's something that I would look at. And you can see that her time and target range is only 39%. She's high, you know, more than 50% of the time. So looking at this, looking at his her inventory glucose profile, what would you do? So would you increase her glargine? She's on U 300 gloin 200 units or would you add mealtime insulin? She's already on the maximum Metformin and she's already on the maximum. Which one would you do? Of course, I'm going to tell you what I did. So what I did was I continued her meds as was as it was, but I added mealtime insulin and I'll show you where and why we'll come back. But I added four units to her biggest meal and I told her to monitor the impact she's historically sensitive to insulin. So I started low stop low, go slow, you cannot hurt someone if you stop low and go slow. And I looked at her CGM remotely for a few days and I lowered her U 300 Lygen to 16 units. Now, without CGM, without being able to see this, we wouldn't know that that was appropriate to do. And then I added two units of a spa with her breakfast. So let me show you what happened two weeks later. So here you can see she's on 16 units of U 300 large, her um a spark two units at breakfast, four units at dinner, 78% target range. And if you look here at the inventory glucose profile, what would you do? We're gonna continue the, the same add 2 to 4 units at the lunchtime dose or increase the dinner dose. So you can see the times and you can see when she's high. So with, in terms of follow up and what I did, I actually increased her dinner to six units. Um She had originally been complaining of dizziness and fatigue and it was being blamed on long COVID. And it turns out when she had that follow up. Um And when I had seen her, I told her, I thought some of her symptoms were, were related to hyperglycemia. So adding that mealtime insulin when she saw her, the primary care doctor for the fatigue, the myalgia, the malaise that she was complaining of. She said she felt fabulous and attributed to the addition of short acting insulin. So what are these pieces and everything we've talked about? Tell us, it tells us that this considerable differences between people, right? Heterogeneity and everybody's different. This inter person, inter person variability. These are two very different people, one extremely insulin resistant who was on huge doses of insulin and was misdiagnosed type one and she ended up with type two. But someone with type two diabetes on huge doses of insulin. And then we have another lady with type two diabetes on relatively small doses of insulin. But they both end up with this great time and range right, things that we would not be able to do without CGM. So these glycaemic patterns give us insights into what's going on for each individual person. It helps us identify glycaemic variability and and succeed uh with certain barriers that we might have. It helps us look to decrease risk of complications and hypoglycemia like in that first patient, for example, eliminating the mealtime insulin and helps us improve adherence and decrease that disease burden. And with this, it also allows us to decrease clinical inertia and move patients forward. It helps really devise a safe, effective and personalized treatment strategy. So I hope that these cases have been helpful to bring these messages home for you.
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