Hello everybody and welcome to the foundational importance of Sensor based CGM in the diabetes specialist setting. My name is Dr Emma Wilmott and I'm an associate professor at the University of Nottingham. I'm a clinician working in Derby and I'm the founder of the Diabetes Technology Network UK. So this is going to be a fantastic CME symposium that is jointly provided by the UMass Chan Medical School and CME education resources with commercial support from an educational grant from Abbot's Diabetes Care. And I am absolutely delighted by to be joined by the world's leading experts in diabetes who really need absolutely no introduction. We have Pro Richard Bergen Style from Minnesota in the USA. And you will be aware that he's been involved in many, many trials, including the infamous DC CT, but he is very much a technology expert and I can't wait to hear his talk. We're also joined by pediatrician professor Thomas Danny from Hanover in Germany and again, an absolute leading expert in diabetes technology and all aspects of diabetes. So here's the program, I'm going to start by talking a bit about the importance of sensor based CGM in the diabetes specialist setting, thinking about identifying glycaemic destinations beyond HB one C, I'll then hand over to Prov Bergen Style who is going to walk us through an evolving standard for optimizing the quality of diabetes care. How do ambulatory glucose profiles and glucose profile inside reports, improve diabetes management, clinical outcomes and provider interventions in people with type two diabetes. We'll then move across to Professor Thomas Danny who will talk about maximizing patient engagement, satisfaction and clinical outcomes with sensor based glucose monitoring in those with type two diabetes. And he'll be sharing some new real world insights and then it will come back to myself. I'm going to walk you through some interactive case studies to explore how we can really make the most of continuous glucose data in real world clinical practice. So let's get started. These are my disclosures. So here we are in 2023 and what a privileged time it is to be working in diabetes care, things have moved on dramatically and it breaks my heart to think that in the 19 seventies, the way that people were expected to alter their diabetes therapy was through passing urine onto a stick and depending on the color they worked out whether to adjust their insulin. Now, the transition to blood glucose monitoring from urine monitoring was actually quite difficult with some clinicians being quoted as saying that patients wouldn't understand what to do with the data that clinicians might not know what to do. With the data and there were a number of barriers until it eventually became widespread use. And actually, in recent years, we've seen similar challenges, but I am delighted to see that more and more. We are seeing continuous glucose monitoring become the standard of care for glucose monitoring in people living with diabetes in the UK where I work. And certainly if you have type one diabetes CGM is very much the standard of care. And we're starting to see increasing use in those living with type two diabetes also. And part of the reason that we've got to this point is actually the wealth of evidence which has emerged over recent years investigating the impact of CGM on people living with both type one and type two diabetes with some trials reporting reductions in HB A one C hypoglycemia and improvements in psychosocial outcomes. One of the recent trials that I had the pleasure of being involved with was the flash UK trial. This was a diabetes UK charity funded trial led by Dr Lalana from Manchester and this was recently published in the New England Journal of Medicine. This was a randomized controlled trial investigating the impact of the freestyle libre two on people with type one diabetes with elevated HB one C levels. And what we were able to demonstrate was that by six months of follow up, there was a significant between group difference in HB one C as you'll see here with a 0.5% reduction in HB one C in the intervention arm. Compared to the control arm, the intervention arm are also more likely to achieve HB A one C targets of less than 7.5% or less than 7%. In addition, we saw reductions in hypoglycemia and improvements in glucose monitoring. So we have this as a standard of care in type one diabetes. And I think many of us are aware of the clinical evidence supporting the use of continuous glucose monitoring. However, I live with diabetes and I very much understand the benefits of CGM on a day to day basis. And I want you to come up with an analogy so that if you don't live with diabetes, you start to gain some insight into just how important this can be to the person living with diabetes. So I have a challenge for you. My challenge to you is to drive to a road that you've never been to in a city that you're not familiar with more than four hours away from your home. Now, to complete this challenge, you have access to a car and you have access to a SAT NAV system. I can hear you thinking, no problem. I have got this. But during that journey, you are only allowed to look at your SAT NAV four times, feeling uncomfortable. Yes, I thought you might. But actually this is exactly what we've been expecting people with diabetes to do for decades when they're finger pricking their glucose only intermittently understanding what's happening rather than having continuous access to critical data. And if I were to ask you what your preference would be. Of course, on your journey with your SAT NAV, you want unlimited views throughout that journey, checking in on where you are, what direction you're going in, how the journey's gone so far. So you can ultimately arrive safely at your destination. And the journey for people living with diabetes is no different. They need access to that data continuously to be really able to understand what's happening and what they need to do next. And thanks to the widening access in CGM, we are moving into a new era. I refer to it as the time and range revolution. And my colleagues on the stage here, Rich Bergen Style and Thomas Danny have very much been part of this journey and we important co-author alongside Taddy Bao and Mosie Phillip, this international consensus on time and range. But certainly from my perspective, has fundamentally changed the conversations that I have in clinic and has changed the goals that my patients use in terms of optimizing their diabetes therapy. And I'm sure you'll all be familiar with the recommended aim of achieving more than 70% time in range. But simultaneously ensuring that the risk of hypoglycemia is low, aiming for less than 4% time below range. So as a result of these recommendations, I feel the conversations in clinic that we're having have fundamentally changed and they have really put the person with diabetes in the center of those conversations. If you reflect back to the day where it's all about HB A one C, this was a blood test that the clinician had the results of the person who came into the room and it was very much your HB A one C is this and you need to do this. Whereas now we're in a different place. The time and range conversations are very different. The person with diabetes knows their time and range knows whether they've set it. They're hitting their goals and can actually review the patterns and have a think about what they need to do prior to entering our office and often the conversation as well. Doctor, my timing range is now this, I was hoping it would be this and actually I'm not quite getting there. I've looked at the patterns, I'm thinking, I maybe need to think about doing this and this. What do you think? And it's a much more of a two way conversation which I think is a direction we need to go in. And actually, if you ask people with diabetes, what's important to them. Here is a diatribe survey where they ask what matters, what factors matter to people living with diabetes. And you can see that whether it's insulin treated type two diabetes or noninsulin treated type two diabetes. The factor that came out the top time and time again was time and range. Outranking. HB one C. Now, why is that? You might ask? Well, again, the person with diabetes can see the time and range on their phone, they can monitor it day in, day out and understand how they're doing in a way that HB and C has never been able to facilitate. But importantly, it allows them to have an objective idea about just how much hypoglycemia they are experiencing. And that is fundamentally important. If we expect people to hit their targets every single day, the person with insulin treated diabetes walks this tight rope of trying to strike that balance, achieving as much time as possible in the target glucose zone, but equally trying to avoid hypoglycemia, which makes them feel awful and can stop them in their tracks. And CGM is a tool which a time and time again has been shown that when used alongside their therapy can allow them to achieve more time and range with less hypoglycemia. So let's take all of this and put it into some clinical context. I would like to introduce you to John. John is 62 years old and he's had type two diabetes for 16 years. He's got a past medical history of obesity, hypertension and some background retinopathy. He manages his diabetes with once daily basal insulin of 40 units. Once a day of glargine, Metformin and some empagliflozin having previously been intolerant of A G LP one. He's also on a Tosin and Rama and he last came to clinic four months ago when his HB A one C was elevated at 70 millimoles per mole or 8.6%. And he was given some information about basal insulin tid at that point and he's come back to clinic. But his pre clinic HB one C is pretty similar at 69 millimoles per mole or 8.5%. So let's imagine how this conversation might go if this is an HB A one C orientated discussion without access to CGM data. Hi John, great to see you. How have things been? Um OK. I think how is my HB one C? Oh, it's 69 millimoles per mole similar to last time. How are your sugar levels though? Um I don't have my meter actually. I think they're probably OK. Although I have to admit I don't really check them very often. Now, that's a very similar uh unfamiliar situation for many clinicians and it can be difficult because we want to support optimization, but we're often left in a situation that we have limited data to do so. So let's compare that to AC GM guided consultation. Hi John. Great to see you. How have things been? Well, my predicted HB one C is coming out at 69 millimoles per mole. So I've been thinking about things I might need to change to improve it. Ah Great. What patterns. Have you noticed John? Well, my timing range is still low, but I'm also having quite a lot of hypos overnight. And that's despite me reducing my basal insulin down a bit. Oh, ok. Let's have a look at that. Here. We have John's data. We on the right hand side here we can see is 33% time and range 13% time below range. And if we look at the pattern of glucose distributions there, we can see that there's a lot of hypoglycemia overnight and he's losing out on his time and range really during the day when he's running high through most of the day. So I said to John, ah yeah, I can see exactly what you're talking about. Let's look at reducing your basal insulin and actually you're running higher during the day. We could have a look at adding some mealtime insulin in to help get you more time and range during the day. Ah That would be great. Thank you. So, very different conversations with very different outcomes. And I think this is where we are at. As clinicians, we have had access to CGM in our clinics for a long time now. And I think the more you have access to the data, the more you realize that actually HB A one C is a really crude marker of glycaemic control. To make this point here, we have data from two different individuals who both have an HB A one c of 8.5% or 69 millimoles per mole. On the left hand side, we have John's data, which we've just looked at and he has 13% time below range. If you go back and look on the right hand side, you can see that this person has 1% time below range. And actually their pattern and distribution of hyperglycemia is the complete opposite to John. They're high overnight with more time and range during the day compared to John who's low overnight and high during the day. And these two cases for me, beautifully highlight the fact that different individuals with diabetes can have exactly the same HB A one C value but very different glucose profiles, very different patterns of variability and very different patterns of hypoglycemia risk. And ultimately, our therapeutic approach to these two individuals would be very different in a way that if we only had HB A one C, we simply could not pick up on. So there are pros and cons to HB A one C. There is absolutely no doubt that it is an established marker of glycemic control. And thanks to Ritchie's work on the DC CT and many others as well as a work done in the UK P DS. For those of type two diabetes, we now have that established curvilinear relationship between the HB A one C and microvascular outcomes. And as a result of these landmark trials, HB A one C has very much become embedded in clinical care and it's relatively inexpensive. However, we're in a different era now, in 2023 where we have access to CGN data, we have insight into the fact that this is a really crude marker of glucose levels. It provides no information on glycaemic variability, no information on hypoglycemia risk, and most importantly, no information on how we go about optimizing glucose levels and supporting people to better outcomes. So I would argue that we need to think beyond HB one C. We've got the limitations that I've just mentioned. But actually, there are also other factors. There are many issues that affect the accu accuracy of HB one C such as anemia, hemoglobinopathy, chronic kidney disease, pregnancy. The list goes on but it also fundamentally delays therapy, escalations. As I showed in that conversation with John and myself. If you've not only got HB A one C with no glucose data, it's very difficult to adjust just insulin therapy without that additional data. And you therefore have to wait for additional data before you can escalate therapy further. It doesn't address the effect of daily life on glucose. And this is what people with diabetes very much understand and get frustrated about that. What they do day in day out has a huge impact. And HB and C doesn't even start to describe that relationship. But most importantly, it just doesn't measure what matters. It doesn't tell us about the amount of glucose time in the target range. It doesn't tell us about hypos and it doesn't tell us about glycaemic variability. And I think we very much need to be balancing our clinical outcomes with the lived experience of the person living with diabetes. I think we all agree that HB one c very much has a role and it is there as a marker of the risk of complications in the future. But actually, what we really are interested in is the lived experience of the person with di living with diabetes. Their experience of hypoglycemia, their experience of the fluctuations in glucose level which occur across the day and can be extremely frustrating to manage. And ultimately, we want to support them to be achieving as much time and range as possible. But crucially without that being at the expense of lots of hypoglycemia. Now, just before I go to my conclusions, we've got a couple of abstracts from the conference this week which we'd like to highlight that you'll be able to look at in more detail. The first one here is looking at outcomes and a group of adults with type one diabetes in Sweden from. And you'll see here that this was a retrospective control study of those using blood glucose monitoring compared with flash glucose monitoring. And they looked at the impact of using this technology on HBO ONE C and hospital admissions in adults with type one diabetes in Sweden. And for over more than three years. And what you can see here is over this large group of over 11,000 individuals. There was a significant and sustained reduction in HB one C out to 24 months. But also looking at hospitalizations for hypos DK or hospitalizations. For any reason, there were significant improvements across the board as you can see here if you scan across the relative risk. So please do look out for this work. But they've also got data from Nathanson and colleagues from Sweden. Looking at the outcomes in a group with type two diabetes on insulin therapy. Again, a retrospective control study of those using blood glucose monitoring versus flash glucose monitoring. Looking again at HB one C and hospital admissions in adults with type two diabetes. This time over a more than three year period overall, they showed a reduction in those treated with multiple daily injections who had type two diabetes, a lower relative risk of admissions for severe hypos or hospitalization for any reason. And here we can see the data on HBO one C showing a significant and sustained reduction in HB one C up to two years. So again, please to look out from that work from Nathan um during the conference this week. So in conclusion, HV and C I think we would all agree is a very useful marker of the risk of complications from diabetes, but the technology has moved on. And so does our thinking need to beyond HB one CCGM is there to provide a detailed picture of glucose patterns, ultimately facilitating improved optimization of therapy time and range. Alongside the ambulator glucose profile, can guide a guides intensification of therapy while simultaneously focusing on minimizing hypoglycemia. I'm really this has just been an introduction from what we're about to hear from the wonderful Rich Bergen Style because he has fantastic insights into how to make the most of those ambulatory glucose profiles and the glucose profile insight report. And I am really looking forward to his interpretation and practical recommendations about how we make the most of this data in our clinics. So over to you, rich. Thank you.
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