Thank you Thomas for an absolutely brilliant session. I really enjoyed that. So we're now going to move on to finish a symposium. Looking at the practical implementation of continuous glucose monitoring with some interactive case studies from the front lines of diabetes care. So let me set the scene for this first case. I think many of us will have experience of seeing an increasing number of younger adults with type two diabetes coming through our diabetes services. Many countries across the world are seeing an exponential rise in the number of young people living with type two diabetes. And this is gravely concerning because they really represent a really high risk cohort often with suboptimal glycaemic control and multiple comorbidities such as hypertension dyslipidemia, obesity, fatty liver disease and the outcomes associated with that can be tragic. Many are often from a deprived background which also add adds additional challenges into engagement and supporting optimization of therapy. Just to give you some insight from the situation in the UK. Uh Down at the bottom here, you can see the number of Children under the age of 18, living with type two diabetes in England and Wales 20 years ago, this is almost unheard of, but we are seeing more and more cases coming through as the years go by. So, a really difficult situation and with that, I would like to move on to introduce you to a young gentleman in my clinic called Brian, who is a 22 year old male who was diagnosed with type two diabetes in 2019. Like many cases of type two diabetes. This was picked up as an incidental finding in his case on a pre op assessment. He's antibody negative his C peptide at the higher uh limit of the normal range. Many years after diagnosis and he is currently managed on insulin. Aspart 30 to 60 units of meals with clag 30 units. Once a day, we have of course previously trialed him with Metformin but use intolerant with trial but use intolerant. So he's on multiple daily injections at the moment like so many young adults with type two diabetes. His father also has type two diabetes diagnosed in his 13 and both Brian and his father are from an Afro Caribbean background. Brian works as a teacher and he smokes 10 cigarettes a day despite being aware of the risks associated with this. His BM I is currently 41 and his weight is 100 and 37 kg. So I first met him in March 2023 when his HB one C was 88 millimoles per mole. But this is in the context of him having been disengaged from services and actually the year prior, it had been 100 and 20 millimoles per mole. So this is my first chance to speak to Brian and really get him engaged in care. We had a very open and Frank and trying, I try my best to be non threatening to get on board and understand where he's at. And he admitted that he's not checking his glucose levels at all and hasn't done so for an awfully long time. But part of the reason his HBLNC has improved is because he is taking his insulin most of the time now. But he goes on to admit that the thing that he's really struggling with is his diet. He is describes himself as being addicted to eating multiple packets of biscuits as you'll see here and across the day at work, it's just something he's always done. And it's a difficult habit for him to shake. He also loves drinking high sugar energy drinks. And again, despite trying to stop his struggle to get away from these, we moved on to talk about physical activity and although he doesn't do any form of physical activity, he thinks he does around 5000 steps per day but doesn't really know. And we had a discussion about doing some objective activity, monitoring and goal setting around steps per day. So he came back to see me in June. Now during that time, he actually signed up for a clinical trial that we're running and this gave him access to flash glucose monitoring. So he came back using this technology and you can see that his HB A one C or GM I here has improved to 83 millimoles per mole from 88 millimoles per mole. Now I'm being honest, I was actually hoping that the technology would have a greater impact on his um HB A one C level, but he admitted that although the technology is great, he is still having the same struggles with his diet, the same struggles with increasing activity. So we had a discussion about all the treatment options on the table. So here we are, we've got a high HB one C on multiple daily injections, intolerant of G LP one intolerant of Metformin. What are you going to suggest next? So number one, are you going to think about connected pens and titrating the basal bullet regime? Or perhaps you'll think about a once weekly G LP one analog, although he's intolerant once a day. Is that worth a shout? Maybe number three, you'll add a SGLT two inhibitor or maybe number four, consideration about referral on for bariatric surgery. So have a think about what you think you would do in this scenario. Well, I discussed all of the options of Brian and he ultimately opted to add in the SGLT two inhibitor and that's exactly what we did. And actually, I was pleasantly surprised So here we have the data from the end of May start of June and then the end of June start of July. And you can see that the addition of that SGLT two inhibitor has improved as time and range from 21% to 60%. Time below range was 1% is now 8%. And his GM I has improved from 83 millimoles per mole to 53 millimoles per mole. And you can see from the ambulatory glucose profile that things are much better than they were previously. So what do you think now? Have a look at the A GP, have a look at the time and range. What do we do next? So we could increase the bo the bolus at the evening meal. He's losing some time and range there. We could reduce the basal insulin, we could stop the SGLT two inhibitor or we can go back to just continuing to review lifestyle factors. So, what would you do here? Well, we opted to reduce the basal insulin and you can see here that his time below range is 8% and looking at the ambulated glucose profile, you can see that he is mainly having his hypoglycemia overnight. So reducing that basal insulin will not only help avoid hypos, it will prevent him from having to take extra carbohydrates on board to manage that hypoglycemia supporting him with his weight. So at the most recent follow up, Brian Ha is doing extremely well. His HB one C has improved from 88 millimoles per mole or 10.2% to 52 millimoles per mole. And if you look on the right here, you can see now has 76% time in range and 1% time below range with a GM I of 52. And what he remains on his SGLT two inhibitor and the base Ebola regime. But actually he mentioned that over the summer he works as a teacher. So during summer, he gets a decent amount of time off and that gave him time to really focus on his diet and activity. And actually, he's managed to do what he thought would never happen. He's avoiding his biscuits, he's avoiding his high energy drinks. And he reported to me that I can instantly see the impact it has on my glucose. And because of that, he is learning what foods he can get away with and what he can. And he's fundamentally changed his diet. And he also told me living with diabetes is so much easier. Now, I've always had my phone on me, checking my glucose levels is no longer a chore. And of course, you'll remember that Brian wasn't checking his glucose levels at all at the start of this journey. And so he's done fantastically well monitoring his glucose. We've changed his therapy, he has dramatically changed his diet and his time and range is absolutely fantastic. So here we have the before and after a time and range up from 21 to 76 GM I down from 83 to 52 millimoles per liter and the ambulated glucose profile at the bottom there really says it all a great success story for a younger adult with type two diabetes. So my take home messages from this case are that younger adults with type two diabetes are very much a high risk cohort engagement in glucose monitoring and therapy escalation is paramount to protecting them from the longer term complications of diabetes. And the great thing about CGM is it is has the ability to provide immediate feedback on not only the impact of diet and of therapy but also physical activity. And if you capture people at right moment, we can work with them to improve their outcomes and change habits that have previously been difficult to break. So, moving on now, we're moving to the other end of the age spectrum. This is Steve who is a 71 year old male who's been initiated an insulin. So I'll tell you a bit about his story. So Steve was diagnosed with type two diabetes at the age of 46 and he's now 71. He's got a past medical history of hypertension, but he also recently had an admission with SGLT two inhibitor induced diabetic ketoacidosis. In March 2023 he was discharged from hospital on multiple daily injections, nova Rapids two units at meals and glaring at 10 units once a day. In addition to this, he takes Metformin 2 g and oral. So male Ramari and simvastatin. He has an HB and C of 65 millimoles per mole, 8.1% and a BM I of 29. He started on flash glucose monitoring following discharge from hospital and to add into the mix. His daughter is a consultant diabetologist. So he's got a bit of help along the way there. So here we have his initial data. So we can see here that his GM I is 62 millimoles per mole. His time and target range is 48% and his time below range is 0%. And you can see there his ambulated glucose profile shows you the distribution of glucose across that 24 hour period. So what next, what's your thoughts next? He's on multiple daily injections. He's started on insulin therapy pretty low doses. So the options could be, would you reintroduce the SGLT two inhibitor? Would you change from oral to subcutaneous once weekly G LP one receptors or would you continue to treat the insulin doses? So the option we went with was titration of the insulin doses. And the reason for that is he has what I refer to as air under the clouds when there's a clear gap between that glucose threshold of 3.9 millimoles per liter and the distribution of the glucose values we know that the risk of hypoglycemia is low and that tells us that we can optimize insulin therapy and move all of the glucose levels down, hopefully with a low risk of introducing hypoglycemia. So that's what he continued to do alongside his team. And you can see here that he is recording his rapid and long acting insulin doses in his Libre app. And you can see that he's also making notes, for example, bacon sandwich, banana, et cetera. He's noting down what he's eating so that he can then reflect back once he sees the pattern in his glucose value so that he can alter his insulin and his diet to try and optimize his outcomes. And I think that reflection and thinking about what the patterns are, are a key component of optimizing outcomes in diabetes care. And he continued to do that. And we can see here that he has managed to move from 48% time and range in April to 67% time and range in July reducing his HB one C from 62 millimoles per mole to 56 millimoles per mole. But actually what his feedback was that he had learned so much through using this. Now, you know that in the UK, we are big football fans and this gentleman is no different. Now, you may not have heard of his team. They're not the most famous team in the UK, but they're called Sheffield Wednesday and they came into a semifinal game really on the back foot and not expected to do particularly well. But as you can see from the score there, 51, it was a rather exciting game. And our gentleman here has learned a lot through that. You'll notice if you look at his glucose levels during the evening when the football game was being played that his glucose levels were spiking up as high as 21 millimoles per liter. And that gave him some real insight into the impact of excitement on your glucose levels. But his learning goes beyond that. He talks a lot about the impact of diet and the things that he's learned. So he talks about having tea at his brother's a Yorkshire pudding, another British delight at sausages, mashed potato peas, lemon slice, which is a cake and a couple of pints of beer. And I love this quote, delicious but dangerous. And he goes on to say that knowing how foods are more to the point, how carbohydrates affects my glucose. I do try to avoid or limit the intake of my previous favorites such as fish and chips and other British favorites. But at least the CGM reinforces the need for change. CGM hammers home what you might not otherwise know or feel for. There is no instant bad feeling for high glucose. So some really useful insights there. And on the right hand side, you can see the peaks in his glucose that he has associated with some of his favorite foods. But for me, his quote, that really hit home is this one here. Nurses and doctors have been telling me what I needed to do for years. But I was not able to make that change until I could see what was happening. It's a great pity that I didn't have the sensor. When I was first diagnosed, the graphs might have shaken me into action 25 years ago. And another thing and I guess this is something we all experience when we start people on insulin, it can be quite a daunting experience, particularly when it comes to escalating doses. And he goes on to say that the idea of taking a dose of 12 or 15 units of insulin scares me. I was always scared of insulin possibly because my granddad had to use it. I wish I hadn't been scared for me. The facts are a way better way. And CGM gives me the facts and actually coming back to his daughter who's a consultant diabetologist, her feedback was it has been so valuable with dose titration, helping his confidence in terms of those adjustment. The data has really helped him to learn. It's a relief that he has the alarms for hypos and it feels safe and often we forget that it's not just the person with diabetes, but also their carers support their family that also have those concerns about starting insulin. And this made this gentleman's journey a little easier. And here we can see the improvements he's managed to achieve. Moving from an HB one c of 62 millimoles per mole with time and range of 48% in March. And April moving to September where we now have a GM I of 51 millimoles per mole with 78% time and range and 0% time below below range. To another success story on his journey was CGM. So here some take home messages for me would be that regardless of the duration of diabetes, there's no doubt that living with diabetes is a lifelong learning experience and access to CGM data can help by providing insight into the impact of food activity, insulin therapies and actually can also have a role in building confidence in terms of understanding what's happening and why. So moving on shifting gear again, moving on to the third case here, we want to talk about type two diabetes in pregnancy. Now, just to set the scene, you're all aware that pregnancies complicated by type two diabetes are particularly high risk. We know that one in four women will have a large for gestational age baby, one in four, have a preterm birth and one in three babies. Sadly require neonatal intensive care unit admissions. My friend and colleague, Helen Murphy has done a vast amount of research in this area and one of our publications identified that the risk of neonatal death is much higher in women with type two and type one. And actually a key risk factor there is HB one C in the third trimester is an independent risk factor for stillbirth or neonatal death. But across the board, glycaemic control is important in pregnancy. And HB one C remains a key risk factor for adverse outcomes in pregnancies complicated by preexisting diabetes. So with that in mind, I want to introduce you to Zara, who is a 39 year old lady with type two diabetes who like so many women presented with an unplanned pregnancy prior to pregnancy, her HB one C was elevated at 72 millimoles per mole and she was on Metformin and sin. She started on insulin and pregnancy and her lysin was stopped and then we've provided intensive input to support her to achieve high time and range and an optimal HB one C and to do that, she had access to CGN. So here we have her glucose data for review. So let's walk through this. We can see here that her GM I is 49 millimoles per mole. We can see that she has 71% of her glucose values between 3.9 and 10 and 8% of her glucose values are less than 3.9. And you can see her ambulatory glucose profile at the bottom here. So my question to you is what are your impressions of this CGM data? Is it number one time and range is more than 70% she's hitting her targets. Is it number two, she is experiencing a lot of hypoglycemia or is it number three, the data are not displayed using the pregnancy target ranges. So the answer here I would say is the data are not displayed using the pregnancy ranges and just to recap. Um You, we talked about the international consensus on time and range and you'll be familiar with the recommendations for those living with type one and type two, aiming for more than 70% time and range and less than 4% time below range. And then the recommendations for those that are either older or high risk. And then you'll also be aware that there are separate recommendations in pregnancy. Now, if you have type one diabetes in pregnancy, we're aiming for more than 70% time in range. But it's worth noting that the target range, there is 3.5 to 7.8 and time below range is defined as less than 3.5. Now, there's a category here for gestational and type two diabetes in pregnancy, but actually, we don't have a defined target here. Ultimately, we are looking to get as much of the glucose levels within target as possible. But again, the target is 3.5 to 7.8 millimoles per liter. And when we start looking at this data presented between 3.5 and 7.8 millimoles per liter. We can see that this lady is only achieving 48% time in range with 5% time below range and is scanning 13 times a day. So what are your main impressions of the CGM data? Now, time range of 48% too low for pregnancy two, she's experiencing a lot of hypoglycemia or three, not looking at her CGM data enough for 13 views per day. So I would argue that at time and range of 48% I would argue this is too low for pregnancy. And we want to be working to optimize glucose levels further. So when we were looking at this lady's data in clinic, we were trying to scan through and these are the data that we've got. So have a look through here and just scan and look at the patterns of hypo and a hyperglycemia and try to work out what patterns that you can spot there. Now, what we generally find with women with type two diabetes is there's usually low variability and it's normally a bit easier to pick up patterns in type one diabetes in my clinical experience. Um But certainly in this case, we're getting quite a bit of hypoglycemia on some days and hyperglycemia during the same period and other days and it's difficult to work out what's going on. So my question to you is what further information could be of value here to guide therapy adjustment. Number one, do you want insulin dose and timing data? Number two. Do you want the carbohydrate intake data or three? Do you want both the insulin and carbohydrate data? Well, I think we want both the insulin and carbohydrate data and that's ultimately what would be desirable. But with this lady, we're able to start on connected pens. So we got some objective data about what insulin was being taken. When now her verbal report was that she was taking aspart 20 units at each meal and de mere 16 units twice a day. But when we actually started to look at the data, this was not the case at all. You can see that the mealtime insulin has not been taken uh consistently at meal times. But most importantly, the basal insulin is varying. We can see on day one, it's 17 units, day two, there's 36 units and the third day, there's none when the reported dose of 16 units twice a day. And you can see that the doubling of that dose of 36 units on the Monday actually resulted in hypoglycemia during the next day. And that gave us some insight into why it was, we were struggling to optimize outcomes and not find a pattern here because the insulin dosing was changing so much. And actually, this is in the context of a woman with lots of small Children at home, lots of other things in her mind. And she hadn't even appreciated that she was bearing the dosie so much. And this fundamentally changed the conversation that we were able to have in clinic. Again, this is more data just showing some days we've got no long acting insulin. Given some days we've got 30.5 units, some days, 21 some days 17, the doses were changing so much that it made it next to impossible for us to work with her to optimize outcomes. But following that discussion about what was happening with the doses and now that she's got an awareness of what's happening. Although she, she's still struggling with the timing with life being so hectic at home, she is now more consistently able to deliver a basal insulin and the mealtime insulin and we will continue to work with her to identify the patterns and optimize outcomes. So the take home messages here are that connected pen data is really useful in providing objective dose data about insulin dosing. And it can help reveal a potential disconnect between reported doses and actual doses given, you know, everybody with diabetes as a human, we all forget to do things. My policies are incredibly common but trying to identify when they're happening and why it can be really useful in terms of supporting people going forward. Having that objective data on glucose and insulin during the consultations really can make for a more fruitful conversation and more successful optimization. So moving on to our final case, I'd like to introduce you now to Yasmine who is a 69 year old lady who's had type two diabetes for 19 years and she's been on insulin for six of those. She is now on glargine 60 units a day with insulin aspart 24 to 34 units at meals. And she's also on Metformin and she's intolerant of G LP one and SGLT two inhibitors. She take Ramari am loin aspirin and a Tosin and overall she reports feeling great, but her only complaint is morning headaches on and off, which she thinks are probably stress related. Her HB one C is 6.5%. So here we have her glucose data. So have a scan through and see what you think. I'm sure you'll agree that the majority of these were looking in single figures. I can't see any evidence of hypoglycemia there. So, what are you going to do here? Are your options? Are you going to congratulate the patient and continue on the same treatment? Are you going to suggest that the glucose control is too tight that insulin doses must be immediately reduced? Are you going to inform Yasmin that high glycaemic variability is a concern or do you want to make uh more glucose data available to have a fuller assessment? So I would vote for four because we know that there's often missing data when we've only got fingerprint data from 234 times a day. And actually when you pair this alongside the CGN data. It makes for very interesting findings. And what we can see here is that on the overnight period, we are getting significant hypoglycemia. And actually the reason for the morning headaches is starting to become more obvious because Yasmin hadn't reported hypos herself. But there is no doubt that these are occurring as we can see here. So adjustments were made to Yasmin's insulin, including teaching her carbohydrate counting and she managed to go from a pattern of lots of nocturnal hypos with a, a lab HB one C of 48 to actually the same HB A one C. But what I'm sure we'll agree is minimal hypoglycemia and a, a less risky profile overall, but with a great HB A one C without that hypo risk. So I think that again, we also have insight now into the fact that a good HVC is not enough. And even if you've got blood glucose data, it doesn't tell us the full story. In fact, when people now bring in a blood glucose book instead of CGM data, my heart sinks because I just know the wealth of information with CGM just makes such a difference to the consultation. We know that hypoglycemia is really common in insulin users and often goes undetected. But using CGM allows us to have a more comprehensive glycaemic assessment and helps uncover hidden hypoglycemia
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