Hello and welcome to APA 2025. We're here talking about the foundational role of CGM for outcome optimizing behavioral and lifestyle-based interventions. So how CGM can play a role in that sometimes elusive but essential role of patient engagement in terms of behavioral lifestyle intervention. I'm Ashlyn Smith. I'm an adult endocrine PA based out of Phoenix, Arizona. I'm the immediate past president of the American Society of Endocrine PAs and adjunct assistant professor at Midwestern University in Glendale, Arizona, and we'll be talking with you through the first part, which is really that foundation of what some of those barriers are and what some of the opportunities we have in some of the tools that are available. So we'll start through reviewing those potential barriers and opportunities um to achieving optimal glycemic and extraglycemic success, so we'll not just talk about glucose optimization, but some of those other factors that play such a crucial role in in really determining Diabetes success. We'll describe the role of CGM in improving outcomes and patient engagement that can be so powerful, and discuss really practical pearls to utilizing CGM and clinical practice, so things that you can take to the clinic on Monday morning and apply right away. I have nothing to disclose for this program. All right, let's jump right in. Uh, a really relevant, very common, uh, situation many of us have seen. I know I have seen it many times. It's the middle of the week, it's Wednesday, and there's one patient between you and lunch. You have Max, who's a 52 year old male, he has hypertension, hyperlipidemia, and type 2 diabetes complicated by microalbumenuria and peripheral neuropathy, and he also has OA and anxiety. Uh, he is on metformin, citolitin, glipizide, lisinopril, and duloxetine. You take a look at his, uh, his vitals and his lab evaluation, blood pressure 132/74, A1C is a bit down from 8.5 3 months ago to current 8.3%, and fasting glucose on those labs was 105, and his LDL is at 65%. He did bring in a blood glucose log. We don't always get that information, so he did. He's checking his blood sugar, and he's, uh, he's written it down and brought it to his appointment. So I love a small win. I'm gonna celebrate that win. Uh, but I want you to take a moment and look at this information, look through his history, his current labs, his blood sugar. Log and think for a moment. OK, well, we have some that aren't too bad. We have a 126. We have some that are high 100s, we have a 201. We have this 84 that kind of snuck up on us, so we have, you know, maybe could we be dealing with some low normal numbers. So think about this information, which is very often what we have available to us. And think, what would you recommend for Max? And keeping in mind too that that clock is ticking, and we have maybe 15 minutes from the start of the appointment to go through everything and educate. So we need to make some decisions to help Max fight against that clinical inertia and make some progress on his diabetes control. We're often faced with a lot of struggles, and I'll start by saying that I've put together these lists, but they are by no means exhaustive lists, that the struggles can be um many and can vary depending on the individual circumstances, but we do have have factors that we bring as providers, um, as barriers to, to some of those treatment successes. So some of the barriers that we might bring our knowledge. Barriers, and this is kind of a natural phenomenon when it comes to this really increasingly complex world of medicine, that it's very difficult to stay on top of all the new information and be completely relevant for all the new guidelines. So it's not an indictment on any provider, but it's just a a sign of the complexity of the field that we work in. Uh, the availability of glucose data and the trajectory, that could probably apply to any of these columns, uh, but really, you know, do we have the tools and the resources and the knowledge to feel prepared to provide our patients with the tools that they would need to get the glucose data that we need to make those safe treatment decisions. And not to mention just medicine in general, but diabetes specifically is a very rapidly evolving area. So we have complex regimens. Is it A daily pill, multiple times a day pill. Is it a daily shot, a weekly shot, uh, mealtime shot? Does it need to be taken with food? Does it need to be taken on its own? Um, and then, of course, the rapidly evolving landscape of diabetes treatment options and indications. Which one is indicated for reduction of major adverse cardiovascular events? Which one is for renal protection, which one is for heart failure protection? So it's, it's a lot to keep up on. A fear of hypoglycemia, we have a a very reasonable fear of causing hypoglycemia in our patients. Uh, we may be dealing with perception bias. This could be something as overt as racism or sexism, but it could be something more subtle like I don't think this patient has the knowledge or the resources to be able to understand this, this level of complexity or this treatment option without really delving in and figuring out where they are based off of, of some of those, you know, truer picture versus what our perception might be. And patient empowerment, that's a struggle. We have very little time, we are overworked and overstressed, so engaging and empowering our patients is challenging. Of course, we have patient factors, so knowledge barriers, just like we talked about, they could be just general education barriers or barriers about diabetes in uh, in particular, could be an injection barrier, but don't assume that there's an injection barrier, but that may be a valid concern for patients. Diabetes distress and fear of hypoglycemia. So some of The psychological factors that could be interfering with getting their diabetes under control or uh with really taking true empowerment of diabetes could be interfering with medication adherence. I talk about this a lot, if you've seen me lecture before, you've heard this before, but I screen every one of my patients with diabetes for diabetes distress at every visit. Even if it was negative last time, it could be positive this time. And it really does open up that conversation of addressing, you know, what are those stressors and how might I be able to alleviate them or mitigate them, or how can we come to a, uh, a better solution, setting those small attainable goals so we can get back on track. There may just be misperceptions in general. A common one that that I hear is, you know, I don't want to go on insulin because my neighbor or my cousin or my friend started on insulin and then they ended up on dialysis, where really if they had started on therapy earlier, they may have been able to avoid that. Could be language barriers that speaks for itself, um, much like it's complex to navigate the rapidly evolving landscape of diabetes for us, uh, managing complications and comorbidities. Diabetes can be a challenge, because more often than not, our patients don't just have diabetes. They have many medical conditions that they're having to manage at the same time while living their lives and working jobs or hobbies, or managing their families. So it's, it can be a lot. So that engagement can be a struggle, and then the complexity of the regimen, which one is this one? Which one should I take every week, which one should I take daily, which one should I take multiple times a day? That can be tough. And then there are system factors, so time limitations, cost is always a consideration, a related concern, uninsured and underinsured individuals, level of ancillary support. Do you have the support that you need to properly educate? Do you have access to diabetes educators? Do you have access to trained staff that's able to help onboard your patients to new medications or new diabetes technology. Do you have the support to be able to get that data from that technology. Those can all be considerations. Cultural and social biases, this can be varied, but one common is this perception that people that have type 2 diabetes are somehow to blame for the illness. That's unfortunately when we are still hearing and the availability of healthy food sources can be um a system factor, a barrier to getting good control. So all this to say, not to be a Debbie Downer, but to really highlight that we need better tools to overcome these barriers, and thankfully we have tools that are available. So expanding on this, we'll dive a little bit deeper into this concept of of not all A1Cs are created equal. You may have heard this before, but it really bears, uh, bears emphasis for a number of reasons. One, an A1C has a lot of clinical data behind it. So we're not saying don't check an A1C, we're not saying don't pay any mind to what the A1C is. We have good data behind that. But what we're saying is an A1C alone is not enough information to determine where we need medication or lifestyle adjustments. It's not enough information to tell us if we have good diabetes control. We need to pair that with glucose down, so that real-time information to see what our control is, and we'll talk a little bit about this in a moment. Unfortunately, the availability of blood glucose data, or finger stick data does vary anywhere from no data at all to, you know, a couple numbers and dates scrolled on the back of an envelope. I've had that a few times, uh, to very detailed logs that are amazing but can be kind of overwhelming to navigate through in a very short appointment time. And no matter even if you have the most blood glucose data you could ever dream of, it is just a snapshot in time. It doesn't tell us what the glucose is in between those finger sticks, it doesn't tell us how the trajectory is, are we stable? Are we rising, are we dropping, and how fast. So we are a bit limited if we're relying on A1C alone. We want to spend some time talking about this concept of glucose variability. This is not new information. It's something that we've talked a lot more about recently, but this data has been available, you know, as far back as the DCCT where we had just finger sticks, but we're able to track that glucose. Variability and related to outcomes. Um, this can also be called coefficient of variations. You will hear that term throughout this program as well. We do know that glucose variability drives complications. It increases the hypoglycemia risk, so as you can imagine, if you're on a roller coaster throughout the day, Blood sugars unpredictable, we may not be able to predict what our medication is going to do. So we are at risk for hypoglycemia and related to that, we see non-adherence rates go up when we have more variation, which makes sense, right? I don't know what my blood sugar's gonna do. I don't feel confident taking my medication right now. This does prolong clinical inertia, uh, for a number of reasons, and it does impact disease burden because we do see higher, uh, higher rates of that diabetes distress, uh, that kind of overwhelmed feeling, feeling out of control when we have that variability. Data speaks volume, so we do know that higher coefficiency of variation, higher glucose variability relates to an unfavorable metabolic profile. We see it increases the rates of both micro and macrovascular complications, as well as mortality. And what is remarkable is that the association of coefficient of variation of glucose was more consistent than A1C in predicting metabolic outcomes and complications. So this is a number we need to be looking at, and we need to have tools to be able to assess it. This dives into that idea of not all A1Cs are created equal, or how I explain it to my patients sometimes as I say, you know, you could average a glucose of 30 and 300 and get a pretty decent A1C, but that's not good diabetes control. So if you were to look at each of these patients, these three patients in front of us, they're examples of patients. All of them would equate to an A1C of 7%. But as you see, our patient on the left, 100%. Time and range. That is a gold star moment. Congratulations. Uh, very well done on diabetes. Your patient in the middle. We'll talk about our time and range and our time above and below range goals, but in no situation do we want 5% low. So I'm a bit concerned about the middle patient, and then our patient on the right, very concerned about this individual. We have very poor time and range, very high time below range. So, really looking, yes, looking at A1C, but looking beyond just A1C to looking at that glycemic variability and that time and range to look at more of a holistic picture of how the glycemic control is. CGM considerations, just like all diabetes technology and all diabetes medications comes with pros and cons, and again these lists are not exhaustive, but there are things to be thinking about as you wherever you are on your CGM prescribing journey. So some pros, we've talked about this a bit, so increased glycaemic data depending on the brand, uh, where on average we're talking about a glucose reading every couple of minutes. We do get information about that glucose trajectory. Are we stable? Are we increasing, decreasing, and how fast? Your patient is able to identify some of those glycemic triggers throughout their day? Is it, you know, sleep deprivation? Is it stress? Is it certain foods? Is it, um, a certain medications that are causing either highs or lows? It can unveil periods of unrecognized high and low blood sugars. So if we're only checking those blood sugar readings and your patient doesn't have full hypoglycemia or hyperglycemia awareness, they may not realize in between checks or maybe even overnight that they're having those glycaemic excursions. This can definitely facilitate patient engagement if they are able to see in real time what their different factors within their life due to their blood sugar, that can be very empowering. And we do know that 42 factors throughout the day impact glucose. So if we have a tool to identify which or how many of those 42 factors we're dealing with, that can be very helpful. And it more easily enables treatment intervention because if I know that we're we're low in this time of day and we're high at this time of day, then I know much more easily what medication options we need. So it helps fight that inertia. But there are definite cons that we always have to consider with any intervention. So we talked about that ancillary support level, that is a consideration. Do you have that CGM champion that you could reach out to for onboarding and then for uploading and connecting them to the clinic? Potential barriers, although don't Assume their barriers, but to have a conversation about it. Uh, technology might be a a barrier, uh, connectivity depending on their, their access and their location, uh, and knowledge could be a barrier as well. We can overcome some of these, but it, it's worth having that conversation to see if they are a factor. Cost, everything in medicine we think about cost, um, and then time, again, depending on your level of support, uh, I put a question mark there because as I have had my own experience with um diabetes management using CGM I have actually found that using CGM is faster than using a blood glucose log or having no blood glucose information. So over time, I would argue Ashland, that um I would argue that it actually um lessen the amount of time, but there could be a time factor. These are statistics from my own experience as uh as part of a teleendocrinology program where we manage rural and highly rural, predominantly elderly individuals that have type 2 diabetes on CGM. Not all of them have a CGM, but those that do. We did a review and found that over 97% of those were on CGM were sharing data with the clinic, and over 91% of those were sharing their data remotely, which means that they did not have to go into a clinic to upload their device. They did not have to, uh, manually upload that, um, that information in some way with the help of a, of a clinician, um, a nurse, a medical assistant. They were just sharing that data. Remotely. So in this population, one might have assumed that, OK, rural and highly rural, we're dealing with connectivity issues. We are dealing with socioeconomic, uh, uh, factors that that would interfere. Elderly, we must be dealing with technology, barriers and such, but actually in this population, my anecdotal experience has been quite successful in sharing CGM data successfully. I say this to encourage you to think critically about perceptions of connectivity and knowledge bias. We have very clear guideline directed therapy, um, as we know, guidelines do take some time to update, uh, so that has to be kept in mind, but we have 2025 ADA guidelines that that speak very clearly about recommendations for real-time and intermittently scan CGM. So for the ADA specifically, they recommend CGM, uh, either real time or intermittently scanned. Um, for diabetes management, for youth and adults with diabetes on any type of insulin therapy. So we don't need the 3 shots a day anymore, that's been long gone for a couple of years, uh, so really on any type of insulin therapy. And uh the CGM intervention should be considered in adults with type 2 diabetes who are treated with glucose lowering medications other than insulin to achieve and maintain individualized glycemic goals. So we'll talk about this uh soon about how this can be used in patients who are not on insulin therapy. And the choice of CGM device should be made based on the individual circumstances, their preferences, and their needs. So essentially individualized care like you would with anything else. Very importantly, there was a mention that in circumstances when consistent use of CGM is not feasible, so we could think of many reasons why this would be. Consider the periodic use of professional or personal CGM to adjust medication and or lifestyle. So one way that I have implemented this and say folks who don't want to wear a device, uh, for a prolonged period of time or maybe cost is an issue, they where their their CGM for the two weeks before they see me, so they're able to see their glucose data, and then I'm able to pull that for their appointment, and we're able to have a conversation about that. So that's a way to help navigate some of those barriers. The ADA, uh, the ADA recommends considering, uh, intermittent use or professional CGM use. The most recent update that we have from AC is in 2023, who recommends that real-time glucose monitoring or intermittently scan g continuous glucose monitoring, um, is used for persons with type 2 diabetes who are treated with insulin therapy, again, not specifying number of injections just on insulin therapy. Who have frequent or severe hypoglycemia, nocturnal hypoglycemia, or hypoglycemia awareness. So they have some risk factor for hypoglycemia, and they do recommend intermittent scanning, um, CGM that can be used in newly diagnosed individuals with type 2 diabetes and or those who are at low risk for hypoglycemia. So not just relegating it to those on insulin, and this was as far back as 2023. This is a great visual of um actually the 2022 um endo uh guidelines, end of society guidelines that show our I'm sorry, ACE guidelines that show the kind of correlation between complexity of glycemic regimen and related complexity of glucose monitoring. So it's not an exact science, but it kind of gives you how much reliability we need to have on that more intensive glucose monitoring. So say individuals who have um who have Regimens that are not very complex, they're unlikely to have low blood sugar, and um they're doing pretty well, they're stable, then you can consider CGM but you don't have as strong of that need of CGM, so using real-time or intermittently scanned continuous glucose monitoring could be considered for those individuals. Certainly as we move to the secretedos, we're seeing hypoglycemia risk develop, and as we move into insulin therapy as well, our complexity and our risk starts to increase. And then toward the end, where we're talking about those insulin pumps, the sensor augmented, um, hybrid closed loop pumps, then we are seeing higher risk of hypoglycemia. And more reliance on continuous glucose monitoring. So those are the individuals where we're thinking that real time continuous glucose monitoring. But it's important to see that even from these 2022 ACE guidelines, we're still seeing across the entire spectrum of diabetes down to and including those agents that are unlikely to cause hypoglycemia. CGM can be considered. This is a lot of information, but really the, the take home message is breaking down. We'll talk about uh randomized controlled trial information and then real world data on type 2 diabetes and CGM specifying the glyceemic benefits, which are definitely important, but also highlighting those extra glycemic benefits that sometimes can be very influential in treatment success. So we see um Remarkable things like lower A1C and increased time and range and our individuals who are on MDI, um, and this what are far on our left was largely without any change in insulin or other medication doses. And similarly, on the far right, we have those improvements in the glycemic parameters again, um, without a difference in diabetes medications. So we're not increasing doses, we're not adding a new medication, a new complexity, new side effect, new copay, uh, for medication, we are seeing those improvements in glycaemic status without that just with monitoring. We see lower hypoglycemia for individuals who are on insulin, lower A1C increased time and range, lower time above range. And importantly, over here, second to the end on the left, um, these are individuals who are not on insulin and were also only intermittently using CGM. They also saw a decrease in A1C, decrease in time below range, time above range, and improvements in time and range. Like extraglycemic benefits that we can see is increased monitoring, increased insulin administration, and a, uh, increased diabetes management. So this is engagement. We have our patients, they're monitoring, they're giving their medications, and they're actively managing. And importantly, we see improvement in quality of life in youth, which can speak to those diabetes distress factors, can speak to those non-adherence factors, etc. We see improved user satisfaction for individuals who are not on insulin and only with intermittent use CGM. So when somebody may have some of those barriers, we talked about, we still see improvement at user satisfaction, which can be so important with engagement. And then similarly improved diabetes treatment satisfaction questionnaire, so a an actual questionnaire with with uh with strong um strong empirical data there in adults on insulin, so across the board improved engagement and satisfaction. Shifting now to real world data in type 2 diabetes, again looking at glycemic benefits versus extraglycemic benefits, we see lowered A1C and hypoglycemia in our adults that have MD are on multiple daily injections or uh basal insulin. Then we see lower A1C in adults who are on basal or non-insulin therapy. Meaningful is our third bubble here. Lower A1C, fewer ER visits and hospitalizations for hypoglycemia in adults on on insulin, and then we have reduced mean glucose, uh, reduced glucose management indicator, which is not an A1C but has kind of similar metrics that we're looking for and decreased time above range. And what's really interesting is we saw higher time and range, but also tight time and range for adults not on insulin. So regardless of where we are in that diabetes treatment spectrum, we're seeing those glycaemic benefits, but again, Those extraglycemic benefits are a lot of what we're gonna talk about today. So, increase, um, decrease, uh, diabetes complications. So diabetic ketoacidosis, decreased severe hypoglycemia, diabetes related coma, and hospitalizations for either hypo or hyperglycemia in adults. Thankfully reduced uh acute diabetes events all cause hospitalizations in adults with basal insulin or non-insulin therapy, and then that user satisfaction that we've talked about in adults on MDI or basal insulin. We'll talk over the next two slides about a comprehensive look at the available CGM and biosensor technology. I do not expect you to leave here today memorizing all of this, but good to use as a reference. And then on the third slide, we'll talk about just the most recent technology that's available so we can really highlight that information for what's most relevant right now. So in alphabetical order only, uh, we start with the the lines of the Libre CGM, so Libre 2, Libre 2+, Libre 3, and Libre 3+. Uh, 1 of the biggest differences between the 2 and the 2+, and similarly the 3 and the 3+ is moving from 14 days to 15 days, and That may seem like a small thing, but it's a lot of feedback that we were getting from patients is, you know, having to refill their prescription every 28 days versus every 30 days was rather frustrating. So that extra day made all the difference for many of our, our, um, our patients. Um, as you can see, the asterisk there is highlighting those. Technology, which are being phased out, not for safety concerns, but just from the manufacturer. Um, and then we do have Lingo, which is technically a real-time biosensor, uh, because it's for individuals that do, uh, for adults that do not have diabetes and are not on insulin. Um, this is something that's available over the counter. We have the EverSense uh line, so we have E3 and Eversense 365, both real-time CGM. These are both implantable CGM. Uh, the E3 is 180 days, and the 360, uh, yeah, the 365 is 365 days. Uh, with, um, these two, it's important to note that, um, Of these two implantable sensors, the E3 does need to be calibrated 1 to 2 times a day for the 1st 21 days, and then ever since 365 does need to be calibrated anywhere from 1 day to 1 time a week, depending on where you are in the wear time, and those are both by prescription. Again, in alphabetical order, we move on to the Dexcom line, Dexcom G6, G7, um, G715 day is the new kid on the block in the um the G series. So again, moving from 10 days to 15 days, 15.5 technically, um, it is currently FDA cleared, so stay tuned, it should be available soon. As with the previous brands, uh, we do have a manufacturer phasing out the G6, uh, for, for our patients, so keep that in mind if you have somebody who is on G6 technology. And we also have an over the counter option, the Stillo uh real-time biosensor, again, for adults, but that is used in patients that have diabetes or pre-diabetes, but not at risk for hypoglycemia. And that's available over the counter. And then when we have the Medtronic Li Guardian sensor 3, which is being phased out, but we have the Guardian 4 as well, and that is worn for 7 days with no calibrations, and then the Simplera real-time CGM is again worn for 7 days and does have Um, the interconnectivity to either be used with an in pen FDA cleared, so it should be here soon, um, or used just for the app. So where the Guardian 4, we would be using that pump integration, the Simlara is an option if your patient is not on a pump using the app and soon to be in pen. As promised, here is a highlight for the newest CGM technology. I won't go through all of them again, but this is a quick reference that you can use for just the latest developments in in diabetes technology and CGM or biosensor information.
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