Video Real World Case Management Sessions: Putting CGM Into Practice in the Real WorldUsing New Glycemic Metric 'Destinations' to Move Beyond HbA1c Play Pause Volume Quality 900P 654P 524P Fullscreen Captions Transcript Chapters Slides Real World Case Management Sessions: Putting CGM Into Practice in the Real WorldUsing New Glycemic Metric 'Destinations' to Move Beyond HbA1c Overview CONTINUE TO TEST Back to Symposium Now we get to put it in practice. Now we get to put the new CGM technology, how we optimize those glycaemic metrics in world rural practice. I'm going to be reviewing some practical implementation of CGM uh in that front line of care. I'm Doctor Eden Miller, a primary care provider by training diabetologist, obesity medicine specialist. I practice at my clinic in Bend Oregon and I'm gonna discuss a few cases with you to really make you feel like you get how to utilize this ambulatory glucose profile, how to utilize the glucose patterns inside the various pieces of data analysis because it will open up a world for glucose management and discussion for you and your patients. So I'm gonna go through these cases. I always like to have a disclaimer. These are real people. Uh These are individuals that I'm going through, I can see them uh appear in my mind. So this is that everyday real world kind of thing. I had an 81 year old gentleman, he had type two diabetes for quite a while, 25 years and the last 10 years he was on insulin, he had the comorbidities which were you know, always tragic of an M I three years ago, he can walk pretty good without any issues. So I'm not worried about what we call that unstable Angela. He had hypertension hyperlipidemia and here's what his current treatment regimen was. He was using me insulin because he always kind of struggled with how much to take and what to do. So we had these two different kind of fixed doses. He was placed on a G LP one receptor agonist and an SGLT two but unable to tolerate it due to pretty much looking at many of the side effects for him. He's on a Torbit and Rama, the Sool, Amlodopine and Aspirin. So he really was doing what we call the standards of care. So here is his demographics looking at his um his uh uh vital signs and his weight and height and BM I his A one C was at 8.9. Uh GFR was fortunately pretty good. He had lived quite a bit but hadn't have any kidney related issues. LFTs were normal. LDL was at target triglycerides were decent and he was doing self monitoring blood blood doses maybe 2 to 3 times if we were lucky. And he was seeing a wide range, not surprising why because he's not really monitoring and he's on a mixed insulin. But most of the time his blood sugars were greater than 100 and 80 mg per deciliter. He was compliant with his medications and diet. He did talk about being sure to take his glucoses and his insulin that he didn't really know how to adjust or do anything. Well, he did complain of getting up in the middle of the night and that was hard for him because as he was aging, his prostate was changing and otherwise he was fit and well for his age and he didn't ever report symptoms of hypoglycemia. Now, if we looked at him, what would you do first? Right. You have an A One C that's high. You've got mixed insulin because this patient has better adherence with it. You know, I know you could make his treatment measurement more complex. But what would you do? Do we just ignore the A one C and say, you know what? You're an old guy, you're pretty good. But, you know, remember, quality of life and secondary complications can be tied to that glucose range as well. Or do we say, you know what? We're gonna buckle down? We're gonna do an eight time a day self monitoring blood sugar before and after meals and at bedtime we're gonna make sure and set the alarm and do it. I don't know how we're gonna get that covered necessarily, but we're gonna try or are we going to stop that SGLT two that he was having symptoms of? Right. He was talking about that he's getting out of the money. His blood sugars are high. He's having that. Let's just go ahead and stop that because you know, it's about how the patient feels and we wanna make sure that we're empathetic to their needs or given his osmotic symptoms. Do we need to urgently increase his insulin dose without fear of hypoglycemia, given the absence of the symptoms and by the way, his A one C is so high, right? That's why we do it understand as they go back to number three as well. SGLT two S often show how much the glycaemic is occurring because if the kidney see it, it pees it. So you see that there are many different options or are we gonna do none of the above? Because none of the above are really going to identify or address the problem or they don't give us more information about what his problem is. They're conjectures about what's going on. So a decision was made to get more information. Right. Let's get more information. Let's not try to fix something we don't know. Right. I don't know what's going on for sure. So this individual was given AC GM in my clinical practice. I talk to them about it. I tell them I want to engage in it. I want to see what they learn about it. I want to get that report card back. I wanna see him in 2 to 3 weeks and you can see already that this patient's blood sugars are overall kind of high. He does have a risk for hypoglycemia in the afternoon. He's got variability but not terrible variability. It's that everything is up. His hypoglycemia is not really at an increased risk and intensification could be completed. So, is the main issue here when you see this individual that they're consuming large amounts of chocolate? I really hope they are because life is too short, not to eat chocolate. Do we see very significant variability? I already alluded to that. Do you see high peaks and valleys? You know, we do see them but they're not ski lifts and ski jumps. In fact, the variability is about 31%. Everything is just all about baseline, right? Generate high glucose levels and additional perennial peaks. Yeah, that's what I would say. That's kind of what I am seeing in that particular type of of printout is that everything is leveled, everything is up and, and that there is some intra glucose variability that can be impacted when you look at the daily modal and the data is very hopeful and we don't need to make any changes because they're not going low. Well, I think there's always an opportunity for data intervention. None of the above. Hm. I actually think we get a lot from this information and we could go in depth to it. We could go into the daily model, we could talk about timing events and we could talk about target blood sugars before meals. We could have them look at the data with any particular type of interventional frequency. So what do we do next with this? Right? What are we gonna do? Given what we see, we're gonna engage the patient and have a discussion with them. OK. What do you wanna do? You wanna stop the SGLT two and increase the insulin dose? It's optional, right? But remember he was having issues with the SGLT two due to the osmotic diuresis because the sugars were high. So it may not impact that. Ok. Number two, stop the G LP one. You know, that's always a good idea, right? Don't follow the standards of care with this cardiovascular risk reduction, making sure that G LP ones are on board. Remember it's an option but is this going to help you with this intervention? Change the basil bolus you could, you could intensify the insulin. You're right. Having a flatter basal less variability, having bolic insulin gotta talk to the patient to make sure they are up for that to make sure that their day is better with it or that their day or their what we call their activities of daily living would be congruent because you could change somebody to that. It doesn't mean they're going to adhere to it. Add glaur right to the treatment. Yeah. Well, you still got more meds, right? You still got some in the, in the uh in the quiver to use. Remember adding glamor, I may impact it but this patients had diabetes for 25 years in addition to his elderly, what do we want to do when you're over 75? Keep you out of the hospital, avoid hypo and hyperglycemia. Not keep everyone see high. That's not what it was said. It was said to be very purposeful with their impact. Really. It's all about exercise and they need to eat less and exercise more. Well, there's always an impact for lifestyle And I can describe that, I can say, hey, I've noticed that with your breakfast, you tend to go up in your lunch, you kind of maintain there. And so maybe we can impact lifestyle with that. I wanna make sure that you're moving your body because at your age, you gotta work on flexibility and strength because that's what lands people in the hospital. Now, what we decided to do was to switch to basal insulin with bolus clean it up a little bit, right? Take that total daily dose of that mixed insulin divide it by a third. That was their basil starting. Then I had them Tiit based on what their a and blood sugar was. And then I added bolus insulin. So now let's look at this report. OK. We got variability a little bit higher. But to be honest with you, it was because I see some particular days that were bad at the bottom. We have a glucose vari management indicator which I love, by the way, it is not equivalent to an A one C necessarily, but it does tell you on average if everything stayed the same during that two week period, our time and target range was 70%. Our very highs were still there. Our highs were there and our hypoglycemia was slightly there. I would wanna make sure that we would monitor because you're at risk for hypoglycemia in the afternoon. I definitely would go down and talk about what happened on the week and beginning of the week because that just seems like a significant change. Right. So what's your main issue here? Not much. Continue the current treatment, discuss the hypo risk. I would make sure we have support and make sure we say, hey, you know what, we might need to pull back on a particular dose around the lunchtime. But at the same time, let's look at his fasting glucose. Is he really at target with his basal insulin? His glucose variability has increased. Let's go to a pump. Oh, no, not for that reason. We have barely gotten started with this guy of how to intervene with looking at the CGM, customizing it for him, looking at a particular time frame and adjusting it. Hypoglycemia is a major problem. We gotta switch, switch back to the premi nope. We like it less than 4% right? We don't want any severe lows in this cohort, but we like it less than 4%. I would really look at hypoglycemia as where he's at risk for it. And so maybe we're gonna borrow a unit at lunchtime and deposit it with breakfast, or maybe we're going to borrow a unit at lunchtime and deposit it with dinner. Or maybe we're going to look at his overall basal titration because is he at a target of less than like 1 20 in the morning? Maybe we need to check that every morning and then titrate that long acting insulin. And those are how we do that. Well, the problem is is we just got him on orals because he's on Basili. Absolutely not SGLT two S and G LP one receptor agonists are gonna help you assist you in Basili insulin. This would be a great time to ask him if his middle of the night peen is better now that his blood sugars are not quite so high. So let's look at before and after I think this is so imperative. This is something you can do in clinical practice. We see that a GP report on the left, we see where he came in with his variability and an A one C initiate at about 8.9 comes in with a GM I of 84. And now he says, you know what, we're gonna clean up his insulin, we're gonna put him on basal wallis, we're gonna keep him on his G LP one SGLT two because we're really hoping that as his glucose comes down, his blood sugars will not have as much of an effect on his middle of the night. Now, I know the glucose variability is about the same, maybe a little higher but lower and tighter on the right. It seems that way. I just think there were a few outlying days that had the impact. So this is what's so important about how we can have interventional change. I often like to go back and show patients how we see that before and after. But remember this is a journey, we still have things to talk about with this individual. On the right hand side, we can still target a blood sugar of a little bit lower at 1 20 in the morning with long acting, we can borrow one of the units from lunch and put it at dinner. We can smooth out that variability in those peaks. But this is going to have the patient feel more comfortable and you've expanded their titration. You've even gone from mixed insulin to baso bolus, which many of us in primary care are reticent to do, but you didn't increase the patient's hypoglycaemic rate. And the patient says by the way, I feel great and I'm not getting up in the middle of the night. So what are our take home messages high? A one CS and older people? It's not what I do, it's not accepted. Your goal is to keep the patients out of the hospital. Your goal is to avoid from hypo and hyperglycemia. And it's to restore quality of life and empowerment for them to help them manage their disease, especially as they age. Technology is not anti-aging issues. They really can effectively be that catalyst for them. Help empower them how to monitor make decisions and treatment, expand treatment. Even when they're older, bas Ebola can be done in older individuals. It doesn't put them at a high risk but make sure that you have CGM with them as a wingman in order to help them manage and navigate the increased complexity of Bas Ebola. Ok. Now, clinical case 2, 18 year old, type one diabetic for the last nine years. So, you know, she is, she started when she was nine years old with type one diabetes. She actually was terrified of having future complications when she was a kid. This is some of the things I talked to parents as well when she was a kid, she was told from a very young age. Oh no, your blood sugar is high. You're gonna have a problem when you're older. Not the greatest way to inspire little kids. They do carry it with them. I also have type ones who carry with them fear of change, of adding different things. Um I also have fear of some of the older Ce G MS which were quite painful to apply. And so you have to remember that there is the psychological barriers that come into play. Uh she continued to use basal bolus insulin. She felt most comfortable with that. We had a lot of conversation regarding insulin delivery devices, but there was this co formulation using uh A um CGM with it. Uh This was her two doses based on her unit per carb and correction factor of about one per 25 as well. And her insulin guine was at 30 units. She was in the normal weight category. A one C was actually really pretty good because she had been told over and over again, you got to keep your A one C low, you gotta keep your A one C low. So when she comes in, she was like, yeah, I'm doing really good. And I said, hey, have you been having any hypoglycaemic symptoms? I, I question that I, I say, you know, have you been noticing any uh have you had any severe? Uh and she says, no, you know, um I'm all is fine. Uh It's infrequent. I have good warnings uh on the sensor and I really am doing fine. And so, um but I'm good and I need to uh my friends are out there waiting for me and so, um you think we're almost done? So what was completed was a download of the A GP. Now the patients when she was 64 and now her glucose management a caters by eight. This was the last 14 days. Sometimes I ask, have you noticed in the last, uh, two weeks, if there's been any increased risk of hypoglycaemia, uh, have you noticed alarms, uh, where is your alarm set off? Uh, but you can see here that when we look at her particular time and range, you know, don't always just look at time and range because she's 72% there. But actually her hypoglycemia is at 23% and her very low is 5%. That's not good. Um She is sacrific the rate of hypoglycemia for trying to get that A one C control and, and it doesn't have to be that we don't have, we can have both. And so right away, I would pause and say, what are our at risk time? The most at risk time is in the morning due to over basil. We also have a secondary at risk that we see a lot is in the afternoon when we see insulin sensitivity. As you remember, her um insulin carbo ratios were the same for the different um uh days uh time of the day. And so, um we really need to look and figure out what's the most imperative thing that we're doing. Oh, the control is great. It's 58. Nope. She has an unacceptable uh amount of hypoglycemia. Now, some of you might see data gaps, data gaps are related to a lot of things if you're away from uh the receiver, if you're not scanning, if you're not doing this particular type um I, I tend to look at that because I call it engagement in this uh the sensor. I think there's still enough data. You may not know the full implication of this, but there's still enough data to make um uh recommendations. Uh but severe hypoglycemia in my book needs to be followed up in 4 to 6 week uh intervals and it is urgent. This is where we go away from A and C and we look at that hypoglycaemic rate and we actually de intensify therapy which might be challenging for her uh because she doesn't see the importance of it as an issue. Now, this concept of what's called sensor compression um comes up and I love to take this opportunity. So sensor compression is where you're laying on a sensor and you're kind of having a localized tourniquet effect or decrease interstitial delivery of glucose. And so we avoid putting it in areas that are high risk for laying on it. So that's why we look at the back of the arm or inside or different areas uh that would minimize. That also compression lows are not gradual lows. We don't see this slow type of low that occurs, they tend to drop the bottom out. And so we see the data coming along and then it goes boom and then as the patient moves, it comes back up to baseline. So that's what really we see compression lows. Uh these are, are real in this individual is, is living in the low zone. And so this is pseudo hypoglycemia related to variability. No, uh pseudo Alyce mia is not a real thing. Uh variability, uh does um uh have a better predictor for hypoglycemia. I use a different term than pseudo hypoglycemia, but some, some people talk about it, I call it relative hypoglycemia. And what I mean by that is, let's say you had an individual that would be different than this. Their blood sugars are always running in the 300. And when you drop them into the two hundreds or the hundreds, they all say what, what they say to me, what they say to you. Oh I feel better over 200 mg per deciliter or I um when I get to 200 I feel like I'm going low. Uh You need to validate that I, I don't like to use the word pseudo hypoglycemia. I call it relative. Uh It's relative to where you're at. That means you've just dropped 100 and 50 points and you're gonna feel lousy because does your body produce glucagon when you drop? Yeah, it does, it sees the rate of change of the glucose. It's used to an average glucose of quite high. So when you drop like that, your body will produce glucagon, you will produce epinephrine, you will feel the symptoms of hypoglycemia. So don't go and devalue it. You just call it relative to that individual to the gly highly glucose, but it isn't even considered clinically relevant or what we call serious, but this patient is serious. This is real true, increased risk of severe hypoglycemia that can actually impact cognition and, and cause accidents as well. So, what are our options? We could talk about tight control how it could be dangerous and we're gonna reverse t trait to an A glucose. Um, you know, I, it can, you know, we talk about how highs can kill you over time, lows can kill you instantly. I, I don't wanna scare the life out of them, but you do want to remind them that hypoglycemia is something we should absolutely avoid. And it has far more complications than a slightly, uh, elevated A one C. So for sure you're gonna see the worst time and I would agree you're gonna reverse t rate the ra long acting and so reverse type the long acting into, to a much higher target of at least for sure, above 90 maybe 1 20. Uh, the other thing too is we want to kind of get it higher for quite a while for the patient to kind of recover from that. We're gonna offer some of that psychological support to talk about. You're going to live your life with diabetes. I think you do and, and that we want it, we want it for a marathon, not a sprint. And that, yes, you were told this information, but it's more than just a one C it's time and range and you've overdone it and, and too much hypoglycemic can have significant, um, impact. We are not going to necessarily remove hypoglycaemic alerts. But what I will do is change the threshold, uh, make sure that she doesn't have an alert. That's less than 60. I'm gonna do less than 80 I'm gonna say you need to deal with something, you need to intervene. You don't need to just sit there and watch it uh and be mindful of those times that you're having hypoglycaemia and do more frequent monitoring all of that. All of that's gonna occur. You're gonna de intensify, but you're also gonna talk about how you can improve that variability. Still get the control they like and maybe you do talk about sometimes about insulin delivery devices with some of the paired things that are done can prevent that. So this might be even another option uh to be completed. None of the above. No, I, I hope you all have learned at this point in time and how that's beneficial. So what we do, so we switched, uh what can happen here? You can switch to a pump. Um I, I think, you know, most closely pumps or hybrids are what, where we're at uh switching to an insulin pump helps with what we call customization. So you can limit um that ability to uh uh uh have hypoglycemia areas by changing because, you know, when you give a glaring dose. You, you're kind of stuck with it. You can't pull it back and so a pump can be programmed to different times of the day. You can reverse, titrate the glaring to a target of 1 20 reduce the bolus or in my opinion, can actually customize the Bolas. Uh, don't just reduce it to one. maybe lunch is a, one per 10, uh, maybe dinner is, you know, one per eight. and you can go from there. A patient could be switched to a closed hybrid pump, which I think are the best way to prevent hypoglycemia between, in my opinion, uh, by looking at, you know, how we uh impact uh that rate of hypoglycemia. Uh It, it's these frequent touch points, uh noticing how, how do you feel with this blood sugar? We have a significant reduction in hypoglycemia. Our timer range is now target 92. It's having different uh conversations with patients regarding uh what their targets are and we have minimized now from what was it? 23 22% of hypoglycaemia, uh to less than 1%. And yet we haven't sacrificed control. I think, you know, that's really uh what we're about. So, here's the before and after uh improved variability. Uh A one c right around the same uh significant reduction in hypoglycemia. But I still think there's more work to be done and I think that we have different uh directions to go with this individual, both with insulin delivery devices as well as close loop. Uh And whether you're a type one or a type two, I think many people can benefit from insulin delivery therapy. Uh And especially those individuals with hypoglycemia, but still wanting uh to get good control. Uh Many individuals with type one do not regard hypoglycemia as an issue because they're so a one c centric. Uh but they can have significant comorbidities related to it. And we need to approach it as their own shared value system, not to just say, oh, you know, blanket statement kind of thing. We need to be sensitive to it, to help them to kind of get out of that stuck. Um misnomer and frequent touch points and encouragement. Hey, way to go. Nice job. Your A one C is doing good. How's that feel? Do you feel less of those issues? And so our final case is one of my favorite cases. It's a 78 year old male with type two diabetes last 12 years. He, he's not really concerned with his glucose control because he says he feels fine. He doesn't have issues of getting up in the middle of the night. He does have a history of coronary artery disease. Uh that's been stable five years ago. He had a stent and he really has declined any of those secondary agents that help modify risk and glucose. He does not want an SGLT two or a G LP one. He says they have high copays and he's not interested in it. Even though I, I've done like, all of you tried very, very hard to, um, educate him on that. I did ask him if he was aware of any of the effects of diet, uh lifestyle on his control. And he says he eats healthy, he always eats at home and his wife's always cooking for him. His point of care A one C when he came in was at 7.5% today with our rapid A one C, he does self monitoring blood glucoses maybe four or five times out of the week. And he says they're usually pretty good between 1 21 60. His current medications are glaring at 22 units in the morning and met form and 1000 mg twice a day. So I had the conversation with him to say, hey, what do you think we should do? Well, we could tell him a good job. That's close enough. A one C 74, close enough for government work. Let's not do anything, pat him on the back and say, carry on number two, we can increase the basal insulin to a target less than 1 20. As you can see, he was at 1 20 to 1 60 but we don't know what his hypoglycaemic rate is. Uh, we have the patient do a trial of CGM in general. The lifestyle effects we could do that or you just say, you know what, I don't care what you say about copays. I'm either gonna add an SGLT two or a G LP one. This is where it's hard because you and I both know that that's impactful on their overall control, but we can lead a horse to water but we can't make him drink. What about type? What about Bull two and three? What about placing a continuous monitoring on this individual is covered by Medicare? He was very excited about that uh because he is on basal insulin and at the same time, um I said, I want you to titrate your glucose or insulin level to a target while you're utilizing CGM. And I want you to log the effects of your lifestyle and food. That's what I did. I did both two and three and this is what he came back with now, I thought it was rather interesting. So I want you to look at the daily models. So let's go on the bottom and look at the daily models because you look at this and go well, you know, that's not that bad. That's pretty good. He doesn't have a risk of low. He goes up a little bit with breakfast, but more importantly is I want you to look at the daily glucose profiles. Let's look at Tuesday and Wednesday, Tuesday and Wednesday. When I asked him, I said what happened? He goes well, I had no idea how much my blood sugar was rising with breakfast and with lunch. And then I made some dietary changes. And then I tried to go back to him and say, no, maybe it was just a fluke. But by the end of the week of the second week of utilizing the patient said, oh my goodness, I learned a lot. And so this is more of a story, right that you look at this patient's overall CGM. And in fact, in a two week period, he already improved his intervention and he actually ended up doing it on his own. And this is what we saw after two weeks of use. Remember his A one C was 74, this is what I call the CGM effect. So he was aware of his numbers. This is where I love the glucose management indicator. I'm not trying to make the GM I any different than what it is. It's a metric, it is a estimated glucose management for the two weeks. Let it be what it is. Guess what? Look at what has happened over the last two weeks regarding your glucoses just by behavior. Look at your variability, look as a result. We also intensified your insulin, but yet we don't have any hypoglycemia and your timing range is now 93%. Then I said to him, what did you learn from this? Because I wanted to discuss it, right? He had told me about the dietary changes. And I said, well, what did you change? He said, oatmeal hates me. And I just found that exceedingly funny. That's how he, he led with that. He goes, I thought I was eating healthy. He said, I thought it was good. My wife would make me out meal, but my blood sugar would go up every time he goes. I decided to do something different. I ate, I had a frittata, I had a fruit and yogurt. And so he in a 48 hour time frame by seeing the data of AC GM juxtaposed with his journal, he started making connections. He started making connections. When he went on a walk, he started making connections on food. At the same time, I told him, hey, by the way, I want you to increase your long acting insulin ti your blood sugars were 1 20. And by the time he came back in that 2 to 3 week time period, he was up to 28 he made those dietary changes all on his own. After the that 1st 48 to 72 hours that GM I improved. That's why I love GM I there. It doesn't mean well. OK. This is final A one C but this was his progress report, not his final grade, his progress report and we improved his progress with no increased risk of hypoglycemia. This is an example of lifestyle improvement as well as basil and and of an individual using CGM who had been otherwise blinded by what his glycaemic patterns were and he made all the changes. I just pointed him in that general direction. So let's talk about basal insulin users. We have coverage now here in the United States, other countries do as well. But remember CGM is not just used to prevent hypoglycemia. I think if you're on insulin in any form, it should be standard of care. It is absolutely for MD I and pumps. But it, it's also for anybody on basal insulin. It also gives a person on basal insulin that illumination of the impacts of food and stress and lifestyle medication and all of their different adherence issues. That's that lifestyle piece, right? In addition, it allows for better titration of basal insulin without the fear of hypoglycemia to target that and reevaluate it because if he is having issues with post brand control, that's when we need to add a post brand agent where it's an injectable agent or an oral agent or a Bolus insulin. It allows you to step from basal to MD I or intensification of therapy. AC GM is a bust for basal insulin users. It empowers that destination. It's that GPS for how to intensify treatment in this cohort. So thank you for joining me for this case presentation of moving beyond A one C really those new standards of care and target destination and how we can optimize glycaemic control with the CGM system Published June 21, 2023 Created by Related Presenters Eden Miller, DO FounderDiabetes and Obesity Care LLCSt. Charles Hospital Bend, OR
