Video The Actionability of the Ambulatory Glucose Profiles (AGP) for Guiding Therapeutic Decisions on T2D Play Pause Volume Quality 720P 720P 576P Fullscreen Captions Transcript Chapters Slides The Actionability of the Ambulatory Glucose Profiles (AGP) for Guiding Therapeutic Decisions on T2D Overview Continue to Test Back to Symposium Well, hello everyone. My name is Lucia Novak. I'm a nurse practitioner, board certified in both adult health and advanced diabetes management. I am tickled pink to be partnering with DaVita Kruger on this awesome presentation for all of you guys and I am practicing out of Rockville, Maryland. So super excited to be part of a ANP this year in Nashville. So my portion is going to be the action ability of ambulatory glucose profiling or a GP for guiding therapeutic decisions for people who have type two diabetes. So let's take an example. You have a patient that comes in and this is the information you have an A one C 7.5 not quite at goal but not horrible. They're on Metformin twice daily, they're on a sofa urea twice daily and you started them on a G LP one receptor agonist two months ago. They feel great. They don't have any complaints, they deny any issues with hypoglycemia and they only perform blood glucoses when they feel badly. So this patient has not performed any and there's three things I tell my patients that we never do based on feelings alone. One is to get married two is to vote and the third is to know what your blood sugars are. You can't do that just based on feelings. And unfortunately, with people that have had diabetes, they will start to lose recognition of symptoms. And we do know that both high and low can kind of be the same symptom for many, many patients. So this is another infographic and it similar to what DaVita had brought up, just the different faces of what an A one C of seven can look like. So our patient had an A one C of 7.5. She's on medication that could cause hypoglycemia. She was denying any, her A one C was 7.5. Would you do anything based on that information? Well, it really depends on the quality of that. A one C of 7.5. Is she a number one patient? Is she a number two patient or is she that number three where everything is within range? And when we say within range le no less than 70 when not eating and no greater than 180 after eating. So that's really what we mean when we're talking about time and range. So this is the original A GP or the ambulatory glucose profile report. And um it's not very fancy or flashy and some people look at it and go, I don't know what the heck I'm looking at. Uh probably the most user friendly is the red, green, yellow bar that's up at the top. But this was actually designed by endocrinologists and diabetes specialists. And so it is primarily used by people in those areas. But you know, 80 at least 80% of people with diabetes are not being seen by an endocrinologist or a diabetes specialist. They're being seen in the primary care arena by a primary care provider such as yourselves. And so this piece of information, even though I think, oh, this is great. Since sliced bread, you're looking at it going. This is way too much. I don't know what I'm looking at and I really need some help. So this is the same report, but it's known as a GP I or a glucose pattern insight report. And what's beautiful about it is that it is in color and that red green bar that we looked at at the top of the page is reflected. So that ambulatory glucose report, what I call, I'm gonna go back a slide that blue river that's in the middle of the screen that overlays all the data for the 14 days that I'm looking at and showing me what the actual pattern is here. Is that same pattern. Except now we're seeing it in the red, the green, the blue, it makes it so much easier for people to look at and right away. See uh oh, where are the trouble areas? So this is actually designed for non specialists that are managing the vast majority of patients that have diabetes. We still have the red, green, yellow bar at the top, but we've simplified it. And what I really love about this particular piece of information is that it helps you when you're looking at it to think about what you're gonna do when patients look at their data, what they're focusing on are those high numbers. Ok? It doesn't matter if their high number only happened once or twice when you're, when they would tell me about their blood sugars, they would say, oh my God, I'm a 200 almost all the time. And they've only seen that number maybe twice. And it's because we put such an emphasis on the dangers of hyperglycemia. But what this um says in the middle of the screen where it's giving you some considerations for the clinician is that if you address the highs, you could actually cause more problems with lows. So it makes you pause and say, OK, I know there's a lot of highs, but the patient is also having lows. And so it helps you to just pause before you do a knee jerk reaction about adjusting medications. The problem that is associated with diabetes is also how do patients interpret what they're seeing? How do clinicians interpret what they're seeing? And so we already have an issue with health literacy, being able to understand the written side of health care when we're talking about a disease such as diabetes, it is very, um, numeric centric. And so numeracy becomes very important. How many times has a patient said to you? What's my ac one? And then you kind of look at them and they say, you know, my three month average and I'm like, well, at least they got the letters and the numbers, maybe not in the right order. But then, um, you tell them, well, your A one c was, you know, 8.2. They were like, well, what did you say my goal was? And we have the conversation. Oh, it should be less than 708.27. I'm almost there. They don't understand what the um, significance is for every 1% that they are above that 7%. And so numbers don't necessarily jive with patients. They don't necessarily feel any different when their blood sugars are 160 when they're 120. So having that kind of information doesn't always jive with them and then to give them the percents while you're, you know, 58% time and range. What does that mean? I don't know what that means. Ok. But if we look at colors and everybody understands colors, right? We know green is always good. We always wanna be in the green. We know that yellow is a warning and that's that information above the green. So either they're high and it's yellow or very high and it's orange. And then of course, the red, the red is the danger zone. Everyone understands these colors. We green light, yellow, light, red light, right? So this is what the um glucose profile can actually help us with. DaVita touched upon, you know how we use these targets to individualize treatment. But for the vast majority of people with both type one and type two, we want those numbers to be within 70% of that time and range that no less than 70 no greater than 180 with very little time below range. I tell my patients you have diabetes, you're supposed to have hyperglycemia. That's what I call job security, but it's what we do to help them get those blood sugars down into an appropriate range that can cause the hypoglycemia. And that is what I need to be mindful of. What am I using and how well are we doing to avoid the low blood sugars that could occur? This is showing you pregnant patients and we recently just saw CG MS get approved for use in patients that have type one or gestational diabetes or type two that are pregnant. So fantastic. So how do we go about looking at this data? Is there a way to do it? That's quick. Absolutely. First, you wanna make sure that the data you're looking at matters and so how many days do we really need? Well, in the early days of CGM, they were only in place for three days and so three days of data gave you like a glimpse into what was going on into someone's life. But it really wasn't long enough to capture their real lifestyle. What are they doing when they're not at work, when they're not in school, when they're home, when they're sleeping so on and so forth. So the consensus statement is that we really should be looking at about 14 days of data preferably. And so when you go to the next piece, which shows you the percent in use, that's telling you how much data was actually collected over that 14 days, you have the ability to change the timeline, like how much worth of data you're looking at and the percent of usage will reflect again based on those many days. And then you wanna try to plot it out, this is where the patient is gonna come in. So I typically will have these printed, they're not necessarily in color, but it's still good to, to write it down and you kinda ask the patient, ok, what medicines are you on? When do you take them? How much are you taking? This really matters when they're on medications that can cause lows. But it also is helpful for people who are on medications that don't necessarily contribute to lo to lows, to make sure that they're actually taking their medications at an optimal time. And so have them plot out what are they doing? When do they sleep? When are they waking up take some time. But once you do it with them, once in the office, they will know what to expect and probably already have that information for you. So I have my patients. Ok, tell me, what do you see, what do you see here that you think is troublesome? And I will guarantee you, they tend to go to those higher numbers. They don't really notice the lows unless that they're being impacted by them. So I have them tell me what they're seeing. I have them identify first the low blood sugars. Again, they're gonna have high blood sugars, they have diabetes. That's what it is. I wanna make sure that whatever we're doing about it isn't causing the low. So we identify those first and then we look at, well, where are the areas of hyperglycemia? And sometimes what you'll start to notice is that the hyperglycemia is oftentimes something that follows a low blood sugar, what are their patterns? So remember this is data that is being overlaid on top of each other. So 14 days of data. So instead of having to go through, what did you eat last night? And 20 minutes later, you still don't know what they ate last night because there's a whole story about what happened at dinner last night and you don't have that kind of time. This actually shows you so that solid line that's right in the middle of the, um, of the, of the uh data that's overlaying their patterns, that's what's happening. And it helps you to see how predictable things have been and what is the time of day where they're having the most issue? And then of course, we want to look for variability. Variability is the more extreme the blood sugars are during the course of a day. So, are they going down to 30 then they're up to 300. How often is this happening? And the greater the variability, the wider the data is going to be? So what that orange arrow arrow is showing you is, you know, there's a lot of variability. That's a very long arrow just connecting the top with the upper, um with the upper top with the lowest of the, of the bottom uh ranges. And then that blue line that's in the middle, that's a much more narrow arrow and the more narrow the arrow or the more narrow that space, the more predictable the blood sugars are. So it's unpredictability about blood sugars that increases the risk for a hypoglycemic event because patients are changing, they're chasing something right. They're making decisions and they're causing their blood sugars to bounce all over the place. They may be holding their meds, they may be eating extra, they may be overshoot with their doses so on and so forth. And it always helps if you can compare their current CGM with their previous one. You don't see the forest for the trees sometimes. And it helps to say, well, this is where you were before, this is where you are now. And I think one of the systems that does this best is actually Dexcom. And that's what I'm showing you here because you can actually uh go to a compare report. And this is the one I use most frequently for my patients that are using a Dexcom CGM. And I will plug in two weeks of data and so on the right are the more current two weeks of data. And on the left are the two weeks of data immediately before that. And, and just by glancing at it, we can see, oh my goodness, you have much more time and range. They went from 50% in two weeks to 62%. So that's huge. And it's a, it's a nice way to show them how well they actually are doing. So what does that Blue River or your rainbow uh uh peaks and TRS Valley thing should, what it should look like. OK. So we're saying we want that time and range to be at least 70%. We don't want below more than 5%. And we're talking about no more than 30% above range. OK. So we want something that's gonna look pretty flat and narrow and in range. And so as you go down on this particular slide you're seeing at the top, it's not flat, it's not narrow and it ain't anywhere in range. So we didn't hit anything there. Um, on the, the next slide down it's flat. It's rather predictable but it's not narrow. So there is a lot of, uh variability in there and it's not in range and the next one is flat and narrow. So they're doing pretty well, but they're doing well either too high and then some folks may be too low, but that last one is showing flat, narrow and in range, we want it to be flat line. We don't want CGM to look like an EKG OK. Coefficient of variation is just a number that we associate with variability. And so the higher that percentage above 36% the more variability you will see in their blood sugars. So now let's go back to that first patient that I introduced you to a one C 7.5. Previously, she was 8%. She's on that Metformin twice a day. She's on the sofa area twice a day. She started that clip is the um the G LP 12 months ago. She feels great. No complaint denies hypoglycemia and only checks the blood sugars when she feels bad and she's not checking. Now, all you had the first time was for a one C of 7.5. Now we have the CGM. It's telling us a very different story than what the patient believes is happening. So what would you do at this point? This is showing that uh, her glucose management indicator, which is a fancy word of saying, an estimated A one C based on the data at hand. Ok. Um, is 7.1. So she's actually lower than her 7.5 and she's having 6% of her time below range. So she's less than 76% of her day. And if I'm looking at it, it looks like most of those are occurring over night, people don't die in fires because of the fire getting to them, they die in fires because at night, your senses are blunted and you don't smell the smoke. Patients with nocturnal hypoglycemia do not smell the smoke of that low blood sugar. So, when you are looking at, um, managing diabetes, the first thing you wanna do is address hypoglycemia first. They have to be on a med that's gonna cause it. You will not have hypoglycemia. If you're just on Metformin, you're not gonna have hypoglycemia if you're on diet and exercise. But if you're on a Sufa urea or insulin, the chances of hypoglycemia exist, ok. And so that's what we wanna look for. First. Are they having it? If they are? That's what needs to be addressed. Even if they're having a lot of their glucoses above goal. Again, once the hypoglycemia has been addressed and resolved, then you can safely address their hyperglycemia and this may be what they're eating, what they're drinking. How much exercise are they doing and that's an, a very good time to refer your patients to a certified diabetes care and education specialist to get that in depth education that they need. And then looking again at what other medications that they're on and what else can you add that won't increase that risk? In summary, the A one C alone is not an appropriate actionable marker when making therapeutic changes, blood glucose testing has significant limitations as well and lack of symptoms does not mean patients are not experiencing dys glycemia. Remember what I said about the three things you don't do based on feelings alone. The goal of therapy is to reduce hyperglycemia without causing hypoglycemia. And the reports that we have the A GP and the GP I allow for you to actually visualize the patterns and it's the healthcare professionals, the person with diabetes and their caregivers su for just about all reading levels because there's no words and there's a reduced language barrier because we can see up and down and we can read the colors, red, green and yellow. So, numeracy is not required. Thank you so much and I'm gonna turn it back over to DaVita. Published Created by Related Presenters Lucia Novak, MSN, ANP-BC, BC-ADM, CDTC Certified Nurse Practitioner Diabetes Expert Capital Diabetes & Endocrine Associates Silver Spring, MD
