Video The Foundational Role of CGM for Personalized A1c Optimization Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides The Foundational Role of CGM for Personalized A1c Optimization Overview Continue to Test Back to Symposium Hello everyone. My name is Ramzi Ajan. I'm a professor of metabolic medicine in Leeds, UK, and I'm going to talk to you about the foundational role of CGM for personalized HbA1C optimization. This is my disclosure slide. And moving on. Managing glycemia and diabetes, if you think about it, in type 2 diabetes is about exercise diet, we shouldn't underestimate the importance of exercise and diet, and of course medication. So you have this triangle for the management of these guys. In type one diabetes, we start with medication, insulin because these uh patients are insulin deficient. But of course, exercise and diet also becomes important in this group, particularly in those who develop features of insulin resistance, which is not uncommon, partially related to the administration of insulin subcutaneously. Now, one key problem with diabetes is that hyperglycemia can be asymptomatic, and we do not react to things that we do not feel. We can feel absolutely fine. And even if you feel a little bit tired, you have a little bit of osmotic symptoms, you may not take notice of that, so you don't react to hyperglycemia and um as by nature, we don't do much about it. Now CGM has been shown to be a good behavioral modification tool. And um in a study around 5 published 5 years ago, 40 participants with insulin treated diabetes, around 80% were on pumps. Surveys showed that almost 90% noticed that futurechosis affected glucose levels. 43% reported being more active after CGM uses. And importantly, 90% felt that CGM contributed to a healthier lifestyle. I can tell you that I did wear CGM not a long time ago, actually, and I don't have diabetes, and I had a much healthier lifestyle only. A few days after wearing this CGM because I discovered that some food can really shift that sugar levels quite high, so you have to be careful what you're eating. Oh, you eat what you want or you do a bit of exercise and that, that sorts things out. And this is, you know, the, the, the banana effect is one of my favorite things to mention, and I'm sorry if you see me, uh, uh, with this slide before, but this is one of my patients who came to me very irritated because this patient likes to have a banana before bed. As you can see, the glucose levels go quite high, corrects the high glucose. Patients insulin treated and then gets hypoglycemia, which we all agree can be very irritating. And I haven't done anything myself. This is the patient showing me that just a week after, this is the same month, 1 week later, you can see that he stopped getting that hypoglycemia and that high glucose levels. And I said, what have you done? And he looked at me with a big smile and said, I'm eating only half of the banana now. So. The patient recognized the effect of the banana and managed to get something very simple to get the glucose under control. And that wouldn't have been possible without CGM. And indeed, when you go to the CGM studies on people on insulin or basal insulin or even non-insulin therapies, and this is one of my favorite trials, the the the PDF trial, where they looked at the effects of CGM plus very simple structured education, and this is to motivate lifestyle modifications through patient-driven healthier food choices. That's how the study was designed. You can see that in the intervention group there was significant reduction in HbA1c. The intervention, which was the structured education and it's mainly of healthier food choices, you can see in the red line is moving is shifting. To the left, indicating lower HP1C compared with the control. So it really helps the CGM that healthier lifestyle choices. This is another study that looked at the effect of CGM alone versus CGM plus food diaries. We, we quite like food diaries because we think that food diaries can help us to choose the right food that is good for us. And uh there was no medication change in the 1st 3 months and after that medication changes were allowed. So if you look closely, the CGM alone is the black line, the red line is the CGM plus food diaries. In both those arms, you can see that the time of of range is reduced. The timing range increased and it increases in the 1st 3 months without any medication changes. These are things mediated by patient chores and the HbA1c uh falls as well. And you can see that there was no real difference between CGM plus food diaries versus CGM. So it's the effect is CGM driven mainly. Let me take you to another clinical case, and this is what, what I want to demonstrate in this case how CGM can give you a lot of information about one single um clinical scenario, not event but clinical scenario. I mean you see what I mean in a moment. This is Caleb, he's a 25 year old gentleman, uh, MDI treated. Not keen on an insulin pump, seen in clinic and wanted to talk about hypoglycemia. And if you look at the AGP, the timing range is not bad, 71%, but if you look closely at the hypoglycemia, it is excessive, isn't it? It's 7%, is a, is a bit too much. And if you start looking at the hypoglycemia, actually each one was caused by something completely different. So if you look at the um evening of the twenty-eighth, the Saturday, that hypoglycemia here occurred due to overcorrection of the high glucose. Whereas the hypoglycemia on the 30th, that was due to overestimated body sensor. Then you've got the one that the patient said really scared me. That was on the 3rd. And then the patient says that on the 2nd, we had a team building activity. Uh, at, at work, we went go-karting, then went for a few drinks. And if you haven't been go-karting, please try it. I have tried it. It's absolutely fantastic. Um, they went after that for a few drinks, and you can see that in the night of the 3rd. He gets pretty significant hypoglycemia, which the patient was very worried about. And what was even more interesting. Is that on the 5th, he more or less repeated that activity of the 2nd, but there was no hypoglycemia at this time because the patient learned how to manage it. So this is a patient with multiple hypoglycemic events, right? Same scenario as hypoglycemia, but each one is caused by something different which which the CGM managed to pick up and we managed to do something about it. And after the 5th, you can see there were no significant hypoglycemia after that. But of course you will ask, was that actually maintained. So this was the um CGM between June and July this year and. July and July. Three weeks later, no hypoglycem whatsoever and um I mean it's only 1% uh level one which I'm quite happy to live with, and the timing target increased from 71 to 180%. And of course, it is well known now that the hypoglycemic changes following CGM are mainly patient driven. This is a publication that I was lucky to be involved in where we've shown that in high risk hypoglycemia patients, the reduction in hypoglycemia, no matter what level you're looking at, less than 3.9, less than 3.1, less than 2.5 million more per liter. 74% of that reduction in hypoglycemia occurs in the 1st 3 days of sensor use. So this is something to do with the patient, it's not something to do with the healthcare professional. It's the patient picking that problem up and uh doing something about it. Let's tackle case number 2. this is a 21 year old man, had type one diabetes for 9 years. Uh, comorbidity is nothing, but the patient is terrified of future complications. We know that those guys like to keep, quite rightly, like to keep their glucose levels very tight. Medication on a decent dose of insulin largine and also on short acting insulin does not want to have a pump. I do have some younger patients who just don't want to pump out at that stage and are quite happy with the MDR. That's the weight BMI 21. I wish my BMI was 21. HbA1C 6.4% or 47 mil. says all is fine and hypoglycemia is infrequent with good warning. But when you start looking at the CGM actually, the hypoglycemia is at 25%. So this is pretty high. Which of the followings is correct? Is this excellent control supported by GMI of 43? 12, hypoglycemia needs urgent attention. 3, hypoglycemia is not an issue as it is clearly related to sensor compression. 4, this is pseudo hypoglycemia as glycemic variability is more than 45%. Now 4 is something I just made up because I'm like that, that doesn't exist. Number 3, when you have sensor compression is actually a line, and this you can see is oscillating a little bit, so this is not 3, and actually 2 is the right answer, this is. Real hypoglycemia, that does need urgent attention. I mean 25% is very high for hypoglycemia. And actually the patient was seen on that particular day and immediately things changed after that, changed the management of the patient, educated the patient and hypoglycemia is not an issue anymore. So what about this one? This is Rosie, who's 67 year old lady, very active lady actually, um, um, good for her age, um, type 2 diabetes for 19 years, and she's got a strong family history of ischemic heart disease. That's the weight, that's the BMI, the A1C is 8.5% on a decent dose of neurologix 25. Also, you'll be pleased to know on cardio protective agents in the in the form of the zepatide and Mbeliflozin and also and metformin. And this was the AGP. So you start looking at it, it's uh not too bad overnight. Time in to is 47%, hypoglycemia is slightly more than I would like to see, but still it's all level one, there's no level 2. And the GMI is 7.9% over those two weeks. 7.9% versus A1C of 8.5%. I'll come back to that later on. So, you start looking at this and you think maybe she does need more insulin during the day, you know, it's, it's a bit high, isn't it? Are you happy with the glucose levels? I hope the majority will say, no, not really happy with the glucose levels. She's 67, she's got still quite a few years ahead of her, so we need to reduce that glucose level. So this happened as you can see pretty quickly between June and July 2024, the timing range went from 47 to 61%, and the hypoglycemia, if anything, reduced to only 1%. So what happened here? Insulin doses increased, the satide dose increased. Or patient is undertaking more exercise, or is it a combination of 1 and 2? And you may have formed your own opinion, but actually the right answer is 3. The patient started to take more exercise. Yes, she was quite active, but she wasn't sort of exercising that much. She was active in the house, but didn't go out and, and walk and so on. So she started to undertake regular daily walks, which helped quite a bit. And if you want to see the progress, this is June 3rd to 16th. This is July 11th to 24th. And then this is later in July to August. So you can see the timing target climbs to 70%, but there's something slightly worrying, which is the hypoglycemia. And here, of course, insulin doses were reduced. She was very successful at what she's done, and we had to reduce the insulin doses. So the take home message here. Do not underestimate the role of exercise. It is actually quite big. What you want to focus on is gentle and regular rather than intense and infrequent. It really helps. So one more thing, I did point out to you earlier, slight discrepancy between the GMI and the HbA1C. Yeah this lady A1C was 8.5%. Of course you will say, uh, but this is over two weeks, the A1C is over a longer period. And of course we looked at that, looking at 90 days CGM prior to the A1C, the GMI was almost identical, if anything, a bit lower at 62 million per more, or 7.8%. So the question is, shall I rely on the GMI or HbA1C if you're still doing that, you may say I'm going to rely on timing range. Yes, but maybe you won't be doing CGM all the time with somebody in type 2 diabetes, so you need to make a decision. What am I going to do here? And I'm going just to tell you something that we are presenting later in the ESD on Thursday, which would be the 18th of September. And I want to take you through because I think it's quite important. The current GMI overestimate HBOC at lower glucose levels and underestimates it at higher glucose levels. What do I mean by that? What I mean is that you have this slope um between GMI and HbA1c, you can see the line of unity is the dotted line, and you have slope there is not on top of the line of unity. And this is why, at lower levels, GMI can be higher than the A1C and actually you, some people who are quite healthy may think that they've got diabetes when they don't. And at the higher end, it can gives you this reassurance that actually things are not too bad, but they can be worse than they are. And let me just show you here, this lady, so this is the slope I was telling you about, but. This lady had an illness of 8.5, and you can see that her GMI would be less than 8%, which is exactly what we had in this lady. The other thing you've got is a spread of data and I'll come back to that. So there's a an updated GMI formula. That fixes the slope, right? And you can see that the slope now goes from 1.245 to almost 1, 0.98. However, you still have a problem. The problem here is that there's a spread of data still. So the updated GMI fixes this problem that is CGM data related. But the other problem that you don't always have that good correlation between GMI and HbA1C is related to personal differences in red blood cell characteristics. So for instance, if your red cells living longer, which happens in some people, then your HbA1C is going to be higher and if they live for shorter, your A1C will be lower for the same glu forms. And actually you can adjust for that as well, using. Personalized A1C and once you do that, you can see that R square going from 0.81 to 0.93. So you get, you get rid of the slope with the use of updated GMI and you get the data far more time with the personalized A1C. So if you're interested, please come to the presentation on Thursday. What about the next case? This is clinical case 4. He's a 52 year old gentleman, type 2 diabetes, works in a supermarket, works in shelter. So the moment you hear that, you know there's quite a bit of exercise there. Me on metformin, semaglutide, and also insulin virgin, it's got this shift patterns, so worksday Thursday and Saturday night shifts, Tuesday, Wednesday, and then off Sunday, Monday, right? Please look at the AGP, right? So if you look closely, Sunday, Monday, much or significantly higher glucose levels, and this is when he's not doing exercise. So you can see this relationship between glucose levels and exercise, and I see that again and again in my practice, and this is when I tell patients just try to do gentle, regular exercise. And that actually works very well in type 1 diabetes patients, and this is a study that we conducted, published a couple of years ago, in people with type 1 diabetes, and this was a randomized crossover study with a 7 day washout. And what we've done, randomized into two groups. One group had uninterrupted city for 7 hours, so they had 2 meals, watched TV for 7 hours. The other group had exactly the same setting. Same meals, except that they had interrupted sitting every 30 minutes. They had to just to stand up and walk at leisure, no running, nothing like that, work at leisure for 3 minutes. This was their HBA1C was 8.4% when they were enrolled, and you can see there was a big difference between the two groups. This was the uninterrupted sitting. And this was the interrupted certain difference in time and range was an incredible 17%, and there was no increase in time below range. It was even more interesting that 48 hours after the intervention, there was still a difference between the two groups. This this is sort of free living after that. So it shows you how effective gentle exercise is. What about this case? This is case number 5, the type 2 diabetes on metformin, sliptin, dapagliflozin and basal insulin. Does they do gardening, regular walks with the dog. I like that. Sometimes I prescribe a dog for my patients because they make you walk. BMI is respectable, 24. Um, A1C in the past two years, and I stress, past two years above 97 million more per more or above 11%, which I, we all agree is unacceptable. So the AGP you can see it on the, on the left when we um did the CGM timing target is only 13%. Not great to it. But if you look at it from September to October, within a very short period, it jumps to 44%. So what happened here? Did we 1 switch from gliptin to GLP1 receptor agonist, 2, increased basal insulin, 3, started with the sensor, or 4, gone go-karting, or 5, all the above. So. Let me actually show you what happened here. So this was the start. This is after a very short period of time. And this is, um, again, a relatively short period of time after that, the, um, timing range climbs to 54%. And guess what? His insulin is now 36%, it's lower, not higher. And what happened here that because the patients started to see what's happening with the sugar. Started probably to give the insulin more regularly. Was doing exercise, the exercise was not an issue, but needed more insulin and, and this just helped the patient to give the insulin regularly. And actually this is a, is a problem in inertia when it comes to glucose management in type 2 diabetes. And this is a very nice study that is getting presented on Tuesday, um, at the ESD. And this is from the National Insurance Cla Database in France, which is representative, it gives a representative overview of the type 2 diabetes population. The incidence of hospital stay or admissions for micro and microvascular complications was up to 4%. And compared with the 2013 data, if you look at what people are treated with 40% are hormonal therapy, 25% of dual therapy, 13% triple therapy, and 20% or insulin, it has not changed that much. What's really worrying if you look at the HGLT2 inhibitors, prescribed in only 10% of patients, GLP-1 receptor agonists 17, and CGM in 6%. Even more worrying that 65% of patients maintain the same pharmaceutical treatment throughout 2022. So this tells you that a hospitalization for vascular complications of type 2 diabetes remained pretty significant, and treatment inertia is a major challenge and this is the same in most countries. So we have that problem and I believe that with the use of CGM it does help you to get rid of that inertia because you can see what's happening and you alert the patient as well as the healthcare professional of what he's doing. I always say that when you have CGM data, you can choose treatment not only effectively, but also safely. And my last case, this is uh um diabetes with difficult comorbidities, and this is actually, there's a group of patients that is. Quite close to my heart is really important because they can really struggle when they have diabetes and we know that their outcome is not good when they have diabetes, and that's the cancer patients. So this is a 64 year old retired nurse, type 2 diabetes, and she's also got breast cancer on Metformin, sitta and leappara so not on insulin, BMI 22, A1C is pretty good as you can see. Now with each chemo cycle on Tuesdays, it includes giving high dose dexamethasone. She finds it very difficult because glucose levels rise quite a bit and she starts getting osmotic symptoms and, you know, when you have osmotic symptoms, you're not feeling well on top. That's not a nice combination. It's clearly when you're worried about your diabetes. So this was the patient, you can see that the timing targets is 58% um and in this particular two weeks, and the uh GMI was 7.6%. You can see how in Tuesdays, the well on Tuesday, the levels go up, they stay high and on Saturday they settle. But the patient is quite symptomatic. You look at it and you think, oh, it's not too bad, but actually it's pretty bad for the patient because it's not used with those high levels. So what are the options? 1, explain this is to be expected and it's fine as it only lasts for 3 days. 2, increase the dose of glemaparide, just make it 2 mg, or 3, increase the dose of glebeparide but only for 3 days. 4, adding insulin for 3 days, or stop HRT2 inhibitor to protect from heart failure. And let me show you what happened. So this is the lady there. And what we've done, the first change in diabetes treatment was here the week after you can see, the glimeparide was increased to from 1 to 2 mg for 3 days. And you can see although the sugar levels go a bit high, they're nowhere near as high as before. And she was much, much happier with this. But even more impressive is what the patient then suggested because the patient said, what I suggest I. I increased the phroide to 4 mg once a day, then 2 mg for 2 days, then I go back to my 1 mg. And look how lovely the glucose levels became and the patient was absolutely over the moon. So this is sort of a combination of patient healthcare professionals working together. And let's face it, this wouldn't be possible without CGM. It's just almost impossible. Patient remains very well indeed. So to conclude, CGM helps to engage individuals with diabetes, and it does inform early, early on the success or failure of a particular management strategy. If you rely on HbA1C, it'll take you ages to know whether a particular treatment worked and you don't know whether you predisposed the patient to hypoglycemia if you're using that cause hypoglycemia. And specifically CGM can help with glycemic management through lifestyle modification, obviously. Keeps individual informed of the effects of daily life activities. Now this is something very important to our patients, they keep telling me, we want to know. What happens to our sugar when we walk the dog? We want to know what happens to our sugar when we eat this and that. And I was personally, I got absolutely obsessed of knowing different foods and what they do to my blood sugar. And I even conducted experiments of, of having a lot of sugar and sitting watching TV, having a lot of sugar and then doing some exercise, and the difference was very, very significant between the two. And um it it is like, you know, CGM likely to assist in the adherence with therapy, which we know can be a challenge in type 2 diabetes. So CGM overall increases patient engagement with diabetes management. Thank you very much for your attention. Published Created by Related Presenters Ramzi Ajjan, MD, PhD Professor of Metabolic MedicineConsultant in Diabetes and EndocrinologyUniversity of Leeds and Leeds Teaching Hospitals TrustLeeds, United Kingdom
