Video The Profound Positive Impact of CGM on Glycemic Control and Patient Engagement Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides The Profound Positive Impact of CGM on Glycemic Control and Patient Engagement Overview Continue to test Back to Symposium Thanks so much, Doctor Gavin. You know that concept of CGM improving the care of those people on GOP one very near and dear to my heart, you know, reviewing through those trials that I've done. So, I so appreciate you uh illuminating for that. Now, we're gonna transition a little bit. And talk about the profound positive impact of CGM on glycemic control and patient engagement. I'm Doctor Eden Miller. I'm a family medicine by training. I have my diplomat status in the American Board of Obesity Medicine, as well as a diplomat of the American College of Diabetology. These are my disclosures. And you know, I hope by the end of this program, I'm so appreciative of Ashlyn starting us off, but you know, what we want to communicate to you is this, that all persons with diabetes could benefit from CGM because we now have a tool, an interventional tool that is both forward facing to the patient and illuminating to the provider. And I believe CGM equips us as healthcare practitioners to share in the journey as patients become experts in their own disease. I often say that I am a diabetes Sherpa. I tell the person, listen, this is your journey, you're unique. I know the different paths. I've been up the mountain of diabetes many times. But I wanna go on the journey with you, of how to illuminate those different things that you're experiencing as an individual, and then bring the tools, both, you know, lifestyle and medication intervention. And this is why we're so excited about it, because we don't feel like you can effectively manage diabetes without continuous glucose monitoring. OK, there are big impact factors. In other words, people living with diabetes, they got a lot to do. Many of you know that I have type one diabetes and I'm always trying to balance, you know, did I make a good food choice, you know, with my own CGM? am I looking at time and range? And what about those unexpected highs, like when I had cheesecake or, God forbid, pizza. And then there's dosing insulin, and many of us struggle with it through either external multiple daily injections or now many of us are on AID systems. And so it's so imperative. We're always afraid of the big H, right? I think all persons with diabetes, all clinicians with diabetes are afraid of hypoglycemia. And then we've got that metric, right? That A1C metric, the grade. How good are you? Are you a good diabetic? Are you a bad diabetic? And, you know, one of the things that I think CGM allows us for is to go beyond A1C. It's an average. It allows us as clinicians to talk to persons with and with with type 1 and without type 1, with type 1 and type 2 on insulin and not on insulin, how well they're controlling on kind of a couple week basis. I call it the Atta girl atta boy report, and, and we'll talk about that a little bit later. So you can see that we have a lot to balance. I don't care whether you're on insulin or not. There's just so many things, and that's why diabetes has quite a bit of distress. And that's why when I talk to persons who are maybe a little reluctant to do CGM, oh, my, my patient can't benefit from it. Really? They can't benefit from having a tool that will help them monitor and manage their own disease and their lifestyles and their food choices. Like, come on, you're missing the benefit if you don't see what CGM provides. And so one of the things is we want to have a positive mindset. And that positive mindset is diabetes is depressing. It really is. In fact, I'm sorry, but us as clinicians are equally depressing. It's kind of the shame and blame disease. I mean, you gotta check yourself out the door cause I, I know how we practice. I know that we figure if we're gonna be negative and tell them, do you want to lose your feet, your eyes, and that kind of thing is gonna help. No. We need to alleviate diabetes distress. Diabetes puts enough pressure on the person, right? And so we need to do this positive mindset. So that's why when we look at CGM and we try to increase time and range, we can improve that positive mindset. We, we can equip them to exercise. You know, that's one of the things that all persons with diabetes have trouble with. What about exercising and hypoglycemia, especially those with type one. In addition, those it's those food choices, right? We're always telling them, oh, this is bad, oh this is bad. But what if we develop their own personal nutritional profile looking at continuous glucose monitoring? I mean, it's possible. And then finally medication engagement, right? Many of you, we struggle with people taking their diabetes meds related to how they're prescribed or even, you know, insulin at different stages of the disease. And so this is where it illuminates and kind of empowers the patient to see that impact, because otherwise they're blind. They're just taking your word for it every 3 months of whether their A1C was good. And so really, it's kind of like in every 3 months, I hope my randomness without direction paid off. And so that's why we're wanting those individuals with diabetes, all those individuals with diabetes, to have the opportunity to use CGM. So when we looked at this really interesting survey, about 3500 people and 62% had a response rate to the various questions. It was about how successful do they feel with their current care and You know, priorities for diabetes care improvement and how it impacted quality of life. And so when we look at both type 1 at the left, type 2 on insulin in the middle, and type 2 on oral anti-diabetic agents or injectable GLP-1s, this is how they ranked in terms of their top of mind as the big impact. Time and range. They know about that. You should know about it as well. For type ones, it's the unexpected because we're highly variable. We go up, we go down, and so we worry about hypoglycemia that comes into those unexpected numbers. Type 2, they're more A1C driven because that's how they have been graded. And you know, they also struggle with what we call health-related issues beyond their, their diabetes. And I would also add to that the chronic disease. They're afraid of dying of heart attack and stroke. And so you can see that all persons with diabetes have kind of similar kind of concerns and worries, but they rank them differently, but they all put at the very top, time and range. So when we look at the association of CGM and treatment satisfaction, let's talk about elderly persons with type 2 diabetes. Why did I put this here? Cause many of my colleagues think that if you're of advanced age, 65 or over, kind of the non-tech generation, that they're not gonna want to do CGM, B, have the ability to do CGM and really find it beneficial. But there was this great study looking at advanced stage type 2 persons, and they had an increase in diabetes treatment satisfaction, and they had a perception of less hypoglycemia after using CGM compared to blood glucose monitoring. In addition, when you increase the engagement, we call that scan frequency. Now, this particular one was the swipe and see kind of study. We now know that all sensors going forward from today are all streaming, so there's no scanning. But really, let's call it viewing. So every time they viewed a glucose number, which was more engagement, it didn't lead to distress. It actually led to increased satisfaction and a decrease in an A1C. So what's the conclusion? Using CGM was associated with significant diabetes treatment satisfaction, in other words, burden, among elderly patients with type 2 diabetes, improved A1C and significantly less hypoglycemia. Not only that, that population is necessary. Now I know some of you are thinking that, oh, they don't need to have that good a control. I disagree. We used to set the standard of an A1C a lot higher because these individuals had risk of hypoglycemia, but now we know the higher the A1C you set, it actually has more variability and they have a higher hypoglycemic risk. Remember, it's not the destination A1C that confers risk, it's the rate of hypoglycemia. And those persons of advanced age should avoid hypoglycemia at all cost, and I can tell you. Your A1C will not help you avoid hypoglycemia. It's monitoring, using continuous glucose, and I think it should be standard of care of those with advanced stage. Let's dive a little bit further into it. So the kind of teal is the blood glucose manage gene and and the salmon or pink color, depending on what color color scheme you see, is the freestyle libre. So as I told you, this was a study looking at the intermittently scanned sensors. So it was a few years back. So we can see kind of that patient satisfaction. Those are hard to do. Many of these trials, not using concrete outcomes like A1C, time and range of hypoglycemia, these are perceptions on how well we do, but look at how significant we saw that satisfaction. These are perception scores, OK, of how well they felt empowered. Now, one thing I will tell you is perception scores are massively influenced by the provider who equips them with how to manage their, their, um, data. If you just put it on, they're gonna have a benefit even if you don't even participate in that. But you are going to see improvement if you can give people direction on like, hey, look at food and see if there's any correlation with hypoglycemia, look behind you. So a lot of these data can even be improved if we had a very engaged provider. But the overall treatment satisfaction was significantly improved. And so we do see that those individuals do benefit. So this is a study near and dear to my heart, as you can see, I was a principal author on this a few years ago, and I believe that this is a metric that could be passed on to what we call our payers. And so we use this particular metric a lot in the payer uh payer scene, uh, the insurance, uh, or healthcare management administrators groups. I send this a lot to hospitals, and that is the reduction in hospital admissions and work absenteeism when we looked at uh a retrospective study at acute-related diabetes events. Now, what's interesting to me is, imagine, in our county, one of the number one transport reasons, you know, call the ambulance, go to the hospitals for hypoglycemia. I'm not making this up. I actually asked a friend of mine who's a head dispatcher for our county. And what happens is these individuals get picked up because the hypoglycemia can be very life-altering, it can be disruptive, and then they get sent to the emergency room and oftentimes either admitted or returned home. They can also have the same thing if they have hyperglycemia, right? Really, really high sugars, other reasons, DKA, you name it. This, but these were type 2 persons, so these are gonna be non-DKA related. And you know what's fascinating to me is, imagine if you and I were stung by a bee, and let's say we were allergic, God forbid. And we got transported to the hospital with a really bad allergy to a bee. What would we leave the hospital with? We would leave the hospital with an EpiPen. Yeah. We would all think that was ridiculous if we didn't leave with one. But you know what's amazing is you could be transported in acute related diabetes event, both high and low, and not leave with a CGM not leave with the CGM. Nothing to monitor or prevent it. In addition, we see on the social side or the economic side is that is when you do have an acute related event, you are like ruined for the next day. You feel horrible. It's a hungover feeling, trust me, you don't want to experience it. And so we see a significant economic and complicated events related improvement when we add CGM to individuals. OK, this is another one that's one of my favorites. Again, my name's at the lower hand corner. I just get so excited involved in these things. But this is a study that I believe really had an impact on CMS, you know, Centers for Medicare and Medicaid, of approving continuous glucose monitoring and those people who are not on, uh, uh, MDI. So we still have a long way to go. So many of you know that it used to be you had to have 4 shots or more a day and records and all that kind of thing for Medicare and Medicaid to cover CGM. Well, now it's approved for those on basal insulin or more, or any agent that causes hypoglycemia or any cognitive deficiency, site, cognition, you name it, plus chronic disease or any acute related. Event both with HIPO and Hyper. I just gave you a rundown of how to get, uh, CGM approved, uh, in the Medicare and Medicaid place. But this particular study looked at CGM and type 2 diabetes, whether you're on basal only with other OADs, or OADs. And we did a retrospective analysis of Lee Bree. We went and matched a propensity scored at the A1C, and we looked at that baseline A1C pre-index and then 6 months and then 12 months later. And what did we see? OK. We saw a reduction in A1C after freestyle Libre initiated in all persons. So remember, you know, lump everybody together. You were on basins and you weren't, and we saw a reduction at 0.8%, and then still a legacy effect at 0.6%. But look, look at the right hand side. That's the one that really stood out to me. I mean, I kind of knew it, but I was astounded. So that right hand side grew. is those who are not on insulin at all. Now, yeah, I'm talking about those people that are currently not covered under CMS for for uh uh continuous glucose monitoring, but just take a moment. So when we subsetted those not on insulin, OAD GLP ones, GLP ones, by the way, like Doctor Gavin just talked about, look at the A1C reduction, 0.9. And 0.7. That's massive. This is a group of people that we have historically, not me, but many of my colleagues historically have said aren't gonna benefit from CGM. That's because we never gave them the opportunity to improve their lifestyle and their medication adherence. And so this is something I want to bring top of line to you. Many of you go into the CGM world because you follow the standards of care. Well, I'm fine with that, but make sure you follow the standards of care. It is now standard of care for all persons with type one. We still see about 35% who are not on CGM and the standard of care if you're on basal insulin or hypoglycemic agents if you're type 2, about 60% of them are not on CGM. So if you want to follow the standards of care, great, do it. But I'm here to tell you that there's much more to be gained and that all persons with diabetes, even some murmuring of those with early diabetes, were doing a study with those with pre-diabetes to benefit from continuous glucose monitoring. Because what tool do you have to help equip you in making lifestyle decisions? Get my drift. OK. So, let's look on the impact of daily activities in CGM. So there's really great observational outcome looking back in 2023 about uh acute diabetes events uh using freestyle Libre from about 2017 on, using bao and bolus insulin, and the primary outcome was the hospitalization in a hyper hypoglycemia, primary diagnosis outpatient emergency room visit with a code of hypo and hyper. So this is what we saw again. If you go into the hospital with an acute related event, I don't care what kind, you should be leaving with a CGM because look at the before and after, OK? That's that risk, OK? That means that we had this events per patient year per patient, right? In the blue line on the left and the right, we have acute related events and all cause hospitalizations, but you gave them a CGM. And everybody improved. In fact, it flatlined as it went out. We didn't see this increased risk. Not only that, imagine if you were to give them that CGM and then empower them to prevent those things as well. So the data is there. The data is there. Now, let's talk hypoglycemia because we all know that our persons with type one diabetes suffer from hypoglycemia because of the variability. And so that was called the impact trial. So we saw with using CGM in this, in this group, that's why it's standard of care for all persons with type 1 still don't have a 100% penetration. So blood glucose monitoring is in the gray and CGM is in the blue. And we saw that when we incorporated CGM we had a 38% reduction in hypoglycemia. Now, that went from 196 minutes in the blood glucose group to 122 minutes in the CGM group. That's a reduction per day, per day, not per. Period of the study, that's per day. Now, many of my colleagues don't think type 2 persons get hypoglycemia. Now, we don't see it as much. We know that there's a significant increased risk of type 1, for several reasons, modality, sensitivity, type ones are not very bulletproof to hypoglycemia, but type 2s definitely get significant. Hypoglycemia as well. We also don't know how it's related to balls, cognition changes. So in the replace trial, we saw that the CGM conferred a 41% reduction in the time of hypoglycemia from 59 minutes per day to 35 minutes per day. Now let's talk cost. This is big. So these are those metrics that we try to give to the health systems, to the policymakers, to the payers. In fact, just next week I'm supposed to testify for Oregon for the utility of using CGM. And we see that with type 1 diabetes, that if you went from a time and range of 70%, which is what we want, to 80%. We see a cost savings, billions of dollars, billions of dollars, because you're directly impacting the control and the complications, and you're empowering the patients to manage and monitor their own disease. We don't have time not to do CGM. So don't you tell me, well, CGM takes time. Yeah, it takes very experienced hands, maybe 10 minutes to get it going. And then there are so many resources out there. In fact, it just uh uh reviewed some of the resources related to all the CGM groups, you know, just get it started, have the patient be equipped to do their own journey. OK, Mary, I mentioned the standards of care, right? Doing those standards of care are quite imperative, and we're gonna go through that a little bit with Doctor Bergensta. Now, he suggests, I hope he's gonna talk about this as well, because he's, he's quite well known in the treatment, uh, uh, time and range. I call him the father of time and range, even though he would probably not take that title. But when we look at the ADA standards of care, it talks about we have a goal, right? We have maintenance of glycemia, improvement of weight, you know, if A1C is above goal or significant hypoglycemia, then we're gonna refer to DSMES, in other words, CDCES is in their education, always do it. And we're gonna consider technology, and then we're gonna address the standards of health. Now he suggested on the right hand side, which I think is brilliant. Why wait for disaster? Why not start at the beginning? Why not refer your persons to CDCES and initiate technology, identify those determiners of health, and then check their A and see and then improve some of the impacts by reviewing through it, making medication changes and lifestyle intervention. I agree, Doctor Burgensall, this is how we should do it and in this order. So, CGM can improve A1C in patients with type 2 diabetes receiving GLP-1 therapy. Now I just gotta mention it because I was a principal author on it. I'm so glad that Jim went through this, but a lot of my colleagues think that if you're on an A1 if you're on a GLP-1. That it's gonna do all the heavy lifting, you know, yeah, I can just lean on it. I don't need to have a sensor because why do we need to have a sensor? I'm not having hypoglycemia. And it's like, yeah, but you're also missing the impact on lifestyle and engagement of the patient. So we looked at those at GOP 1 receptor agonists, and then we added a Libre onto it. So they're already on baseline GLP-1, then we added a Libre, and then we looked at them at 6 months, and we saw that those who were given a libre, freestyle libre system on top of the GOP1. And improve in a 1.5% A1C reduction. Yeah, I'm pro GLP1. Let's do it. But you're still blinded to your data. You're still blinded to the effects of lifestyle and adherence. Not only that, there's gonna be a study coming out that looks at using sensors with GLP ones, improves GLP-1 adherence because they can see how it improves their numbers. So there's a lot to add with that. Now this was my dear friend Doctor Jean Wright. He looked at a different type of thing. He looked at those with just GOP ones and then he looked at those with GOP ones and we added a freestyle libre system and then we compared the two at 6 months, and the data still bore out. This particular one had a much better system, but remember they were adding the GOP one. So some are just GOP1 add no libre, some are added GOP 1 and Libre at the same time. 2.4 to 2.19. That's big. That's big. Again, the tool of a sensor is more than just prevention of hypoglycemia. Yes, sensor CGM prevents acute related events, but it also empowers the patient to have their own control. You know how those things where you have to say, oh, I got to inspire them to do diet and exercise and medication adherence. That's what it provides to persons, and that's why we get so excited with it. So this is another great study looking at a DSMES or those CDCES's that are really helping us out there in in the field. I really think that they should have the ability to to apply sensors and build for it, but that's a whole another thing. But these were looking at non-insulin users, right? Again, those dietary lifestyle intervention and it was the primary outcome showed time and range was greater in those CGMDSMES arms than those just that who wasn't. Who weren't using the CGM as well, and time below range uh was improved, and time in range was improved and time above range was improved. It didn't matter whether you had type 1 or type 2 diabetes. So again, confirmatory that this is that tool that we're looking for. This is a nice little analysis. This is looking at phone-based app experiences, right? So this is, yes, readers are out there and and and I know that you all know if you're on Medicare, you have to do a reader. That's what Centers for Medicare and Medicaid say. So you do a sensor, you gotta do a reader, even if the person is gonna be using their phone-based technology, which I would agree with you because the phone is everywhere, right? So this is those individuals using the app. And what they found is that they had a better understanding of their glucose fluctuations, significant improvement in hypoglycemic episodes. They found it better to mealtime manage, engage in exercise, and then the family member, following on. So this is that app base. So if you can, we seem to have a little bit better success with using the app, but understand. That the reader is still an option out there, but I encourage your your practice to get those patients on the app because they allowed to share, they allow to have uh a better transparency in what's occurring, and also I want you to stay tuned because many of the apps related to CGM are allowing for notes and documenting insulin. And I just saw some that are looking at food recognition software and AI and artificial intelligence. So stay tuned because there are things that are equip your patients to go beyond just what we're currently doing. Now, let's go through a person. This is my patient, real, real person who agreed to um provide their data. And this was a 70 year old woman with type 2 diabetes for 20 years, and she struggled with excess adiposity. Her A1C was a 75. Many of you with a 70 year old woman would be like, that's good enough. And I'd be like, really? What if she has 15 years to live? What about reduction in cardiovascular outcomes? We're trying to keep her out of the hospital. And the medication she presented with was ampagliflozin at 25 mg. Thank God she's on SLLT2 to prevent cardiovascular related and kidney-related, but she was on 70/30, 60 units twice a day, 60 units, 120 units. She's got some insulin resistance going on. And this was her baseline AGP. So, so let's highlight those cause you guys are knowing how to read these now. This is that heads up display. Glucose management indicator is very similar to the A1C. Now some are like, oh, glucose management indicator isn't the A1C. Yeah, I call it the sensor derived A1C. I'm gonna give you a little hint. When the glucose variability is below like 20 or even 25%, it tends to correlate with the A1C. Because they haven't been variable. They've been consistent. That means what you're seeing on the sensors what they've been doing for quite a while. So, it's one of those metrics that if you see it, you can actually have a conversation and you know, do you know that NCQA or heatus, those metrics for control, will take the GMI now. They will, even if you don't have an A1C. So if you see a variability that's low, you can pretty much assume that it's similar, but, but also remember, if you have somebody who maybe you just put an A1C uh just put a sensor on and you just brought them back and their GMI is lower than their original A1C, I say at a girl, atta boy, way to go. Look at you learning. And then we all know the time and range, right? 70%, 7180, time above range, time very above range, time below range. So these are all those metrics that I would highlight to her. You're pretty consistent, nice job, this is where your A1C lies, and this is your time and range. And so this is the before, right? And we can see if you wanted to, you know, go down and drive down into the different days. We also see the weekends are a little bit worse. She's probably going out to eat. But this top AGP you're supposed to be able to just look at it and tell me what the problem is. First of all, she have any risk of lows? Not really. When are her highs? Breakfast and dinner. You could see that, right? Not only that, I want to tell you something. Is she taking too much insulin? Not really. But she's never going down the baseline, right? She's never getting down into time and target very often, so you can see how you can get a lot out of this particular thing. So, what do you want to do for her? What do you wanna do? Increase your insulin? You could, I suppose, but remember, that's mixed and it's kind of lousy and Doesn't, you know, lunchtime is not covered per se, so we could go low. So what do you wanna do? She's got other needs, right? She has excess adiposity, she has advancing age, we don't want her to go hypo. I know you're all thinking the same thing I'm thinking, and you did what I did. I put her on a GOP one, cause she used GOP one naive. Now, what I did is I put her on a GOP one. I added the ruzeetite according to the, to the indication, the label, and then I reverse titrated the insulin. How did I do that? So every morning, she was less than 120. I started taking away units from her insulin. And as I went up on the GLP when I went down on the insulin. And when I got to about 10 units of both, I told her just to stop it. Just to stop it. How long did it take me? It didn't take me long. Probably 6 weeks or so, because you know that Tzepaite initial dose is gonna be pretty potent. The subsequent doses are gonna help with other secondary measurements. So she came back, you know, she's now been seeing me for a couple of years and what's her career in A1C? 5.9. What's her BMI? 34. Significant improvement, greater than 10% body weight reduction. Time and range, 98%. This is where she's at. Her glucose management indicator was a little different than her A1C just because of how I caught her in this in in this particular thing. Actually, look, it's during the holiday season, right? And it happens, right? We do things, but look at her time and range. Look at her hypoglycemia. I took her off of insulin, lost weight, better drug adherence, using a GLP one, using a CGM to reverse titrate the insulin. So You know, It's hard to manage what you don't monitor. CGM takes diabetes out of the past. Into the present and predicts the future. It reveals the individual glycaemic journey, empowering the person to make their own meaningful lifestyle choices and engagement in their own disease. Don't tell me they're not gonna benefit from it. If you don't think they're gonna benefit, you don't know the benefits of CGM. And it guides you as an ACP because you've been blind. You can't tell me if you look at an A1C where the problem glucose is. You can focus the treatment with the appropriate. Medications, the appropriate interventions, overcoming inertia, and you and the patient could have a shared journey that increases their satisfaction. Not only that, you look good, because you are empowering them to manage and monitor their own disease. So thank you so much for joining us. We appreciate you participating in this educational program. You can tell we're very passionate about utilizing CGM. Take that first step. To incorporate it in your clinical practice and to change the lives of your patients. Published Created by Related Presenters Eden Miller, DO FounderDiabetes and Obesity Care LLCSt. Charles Hospital Bend, OR
