Hello and welcome to Houston. My name is Ashlyn Smith. I'm an endocrine P A and I'm the immediate past president of the American Society of Endocrine Pas and an adult endocrine P A in Phoenix Arizona. And I'm excited to be part of this presentation talking about CGM. And really looking beyond the kind of the basic information that we can see when we're looking at diabetes control, looking beyond A one C and looking at kind of the full spectrum of diabetes control. So we'll start off by looking at what some of our newer destinations are beyond. Just an A one C. There's a lot of value in A one C but it is not the whole picture. And we'll talk about that. These are my disclosures. So we'll start off first thing with a case. I want you to think about your, your uh clinic this last week. Does this sound familiar something you've seen? So we have Janice who's a 57 year old female with type two diabetes and she does have a comp complications. She has coronary artery disease and chronic kidney disease. Uh This definitely sounds familiar to my patient population. Uh she's on basal insulin and a weekly G LP one. Her A one C is 9.1. It was 9.3 down from 9.4 and I'm all about small wins. I love taking small ones where I can, but this is pretty slow progress. So, while I'm glad that we're heading in the right direction, we need to be doing more for Janice. It's great. We've got a blood glucose log, but we're seeing numbers pretty variable from 72 to 230. We're not really sure what to do with that information. Uh, Janice herself is not able to kind of figure out why some of those numbers are higher and some of them are lower. She says she eats sometimes at bedtime but doesn't really know if that's trigger or not. She is frustrated as well. So the clinician and the patient are both pretty frustrated that this is not improving and you do a screen for diabetes distress and her scores are high. Uh, as a side note, if you're not already doing it, I would encourage you to think about screening for diabetes distress. It is something that can contribute to, uh, some of the barriers in advancing, you know, diabetes control, advancing therapy. So it can help open up that conversation and identify some of those barriers. I know that in our program, we do screen for diabetes distress at every visit. Uh, maybe something that could be periodically in place at your clinic. So just like with Janice, when we're talking about managing diabetes, we require a balance. We want therapy to be effective. We want it to help quickly. We wanna get uh prevent those complications or prevent the worsening of complications in cases like Janice. Uh We wanna help lower the, the health care cost and healthcare burden and utilization and we wanna try to set our patients up for success. So utilizing regimens that are uh less restrictive, uh more suited to their lifestyle can help improve adherence and lower overall burden. But at the same time that we want these kind of aggressive, effective medications, we do want to lower the risk of hypoglycemia. We want to lower that fear of hy glycemia, both for the provider and the patient. So we can advance those therapies. And it helps facilitate that medication initiation helps improve adherence and it overall helps with uh reducing morbidity in health care utilization. So that's a lot to ask, that's a lot to ask of clinicians and of patients when we're trying to make progress in this complicated disease state. Now, there are a number of barriers we'll talk about some of them. This, this is not an exhaustive list by any means, but just some of the things that we're thinking about when we are trying to get to these goals, there are certainly provider factors that are barriers we are all pressed for time. There's not a lot of time to go through all the aspects of diabetes management and they may not be there just for diabetes. They might also have high cholesterol, high blood pressure, anxiety, depression COPD. They are meaning many things that you have to address in a short amount of time. There may be knowledge barriers, diabetes management and especially diabetes, technology is rapidly evolving. So there are, there's quite a bit to keep up on. And if that's especially if you're not immersed in the world of endocrinology, like I have the pleasure of doing, that's a lot to keep up on. Like we talked about providers and patients have that fear of hypoglycemia. We have to understand that there is a perception bias that may be present. So we may perceive that certain individuals may not be open to certain therapies or technologies or may not be able to, you know, handle technology without actually assessing and kind of going through that conversation with them. So for instance, people of certain age, certain rurality, certain races, certain education levels, we may have this perception of what they are are and are not able to um to manage and that may or may not be the case. And of course, our level of support if we are, if we are the only ones who are handling the the you know, injection demonstrations, applying the sensor demonstrations, doing diabetes education, that can be really challenging if we don't have that support. And similarly, for for patients, there are knowledge barriers there because again, this is a complex disease state. We have to think about social determinants of health. It's a huge area in diabetes right now. There may be injection barriers, but don't assume that there are, you want to have that conversation, a fear of hypoglycemia just as in providers, misperceptions about what certain regimens mean, misperception, about what insulin therapy means and so on and so forth. And then of course, other barriers like language barriers. We also have this barrier that's inherent in one of our key markers. We look at an A one C to determine if we have successful diabetes treatment or not, but unfortunately, not all A one CS are created equal. So we have to pair an A one C with glucose data. So luckily in the con conversation, like we're talking about with Jan, uh with Janice, she does have glucose data, but the availability of that blood glucose data varies. Sometimes we get a lot of information and sometimes we get very little. Uh sometimes they may have left it at home or they, you know, they may check once or twice a week and we don't get a lot of information. But even when we do get information that blood glucose check is just a snapshot in time and does not tell us the trajectory. We don't know if we're straight across if we're heading up or if we're heading down one of the things that we have to acknowledge. We'll talk quite a bit a lot about during this program is this concept of glucose variability. So in uh the world of continuous glucose monitors, we claim this the coefficient of variation. So the CV, you'll hear us talk about that. So we do know that a high coefficient of variation or a lot of glucose variability drives complications. And when we're on that roller coaster, we do see a higher risk of hypoglycemia. As you can imagine if you find that your blood sugar is unpredictable, you may not be as adherent with taking your medications for fear of what your blood sugar might do if you took that medication in that moment. And this does prolong clinical inertia. If we see a blood glucose log like genesis 70 to 230 there's so much variability there, we're not sure what to do and it of course impacts disease burden. So we know that a higher coefficient of variation is proven to increase the risk of complications and mortality. And it the association of coefficient of variation of glucose is more consistent than an A one C in predicting those complications and poor metabolic outcomes. So it's something we need to be thinking about and we need to be a assessing this is that concept of no two A one CS are the same. So if we thought, look at an A one C of seven, somebody we would consider in very good control. We see an A one C of seven, we think this is going to be a fast visit check. However, we could have uh an A one C of seven like patient out patient on the left nice 100% time and range. No hypo, no hyperglycemia or could be like our patient in the middle. Ok. We've got 70% in range, but we do a 5% low. We need to address that or we could have our big adventure seeker on the right side, lots of highs, lots and lows and it just averages out to an A one C of seven. However, this, this concept of glycemic variability that we pair with the A one C, we need to look at the time and range. Are we having a lot of glycemic variability? Are we seeing enough time and range? Are we dealing with hypo and hyperglycemia? So, looking beyond just the A one C, we have a lot of ways to look, I'll be on the A one C and get a lot more glucose data. We'll be talking about these throughout the program today. I won't be labor every point on here. This is a good reference slide of the technology that's available at this time. Uh that this program is happening as I said, this is a rapidly evolving area, but we have the Dexcom family we have right now, Dexcom G six and G7, which are available, the biggest difference between G six and G7 is that the G7 does not have two pieces anymore. We don't have the sensor and the transmitter that click together. It is just one piece um and a little bit lower marred or kind of standard deviation. And we do have approved the over the counter version of Dexcom. That's a, a plan to be available here very soon. But an over the counter option, we have Everen E three, which is the implantable CGM. And we have our Freestyle Libre family Libre two Libre two plus, which is available to be integrated into the tandem T slim pump and the Freestyle Libre three of the integration here, we're not going to talk too much about integration with insulin pumps, but we do know that Dexcom G six is integrated with Omnipod five and the T slim pump G7 is at this point, just the T slim pump. And then of course, our Metronic uh sensor is integrated with the Metronic pump. When we're thinking about AC GM, there are pros and cons just like anything that we're thinking about for intervention or for monitoring. So we do get a lot more glycaemic data which can be very valuable. We have to make sure that that information is not overwhelming to us or the patient. So we'll talk about how to really use that information effectively. It does give us that information of glucose trajectory. So we have that snapshot in time from the blood glucose check. But then where is that going? Are we staying flat? Are we heading up? Are we heading down? This is a really great tool for empowering uh typically patients who wear the, the, the technology to identify some of those triggers for hyper or hypoglycemia. One of the my most favorite things is when I start somebody on AC GM and they come back to me with all these different insights that no textbook could ever teach somebody. They'll tell me things like, well, I learned that I can have tortillas, but I can't have rice. I I found that potatoes are terrible for my blood sugar. But if I have fruit, I'm OK. And those little insights that they can glean from that CGM data is invaluable because we can't go home with them and find out why these triggers are happening, but they're able to see it there in real time. So it, it unveils areas where we might not know there are low or high numbers. It helps with that patient engagement, that patient side of it in that shared decision making, they're sharing their side of the story and it helps to enable treatment intervention because then we're see, able to see a bigger picture and we're able to know what kind of intervention we really do need cons, we have to make sure we have the support. So we need to make sure we have the knowledge support and we have the ancillary support to be able to set these folks up for success. There are some potential barriers like technology barriers, there's some learning curve there. Connectivity concerns can be um can be part of the picture and knowledge. There is some uh a bit of a learning curve. There cost is always a consideration when we're talking about new technology and then potentially time depending on what kind of support you have. This is of course not, not an exhaustive list area but some things to think about when you're thinking about AC GM for your patient. However, I wanted to share some statistics. This is uh the statistics from our program. So in our uh tle endocrinology program, we have a an overall uh predominantly rural and highly rural population, predominantly elderly folks that have type two diabetes. So of that population that are on CGM, we have over 97% that are sharing their CGM data with us successfully. And over 91% of it are sharing that data remotely, which means they don't have to step into a clinic to share their data. Over 91% are sharing it just in real time from home and we'll talk about how you do that. So that is kind of breaking down some of those perception biases that we would think people that are elderly, people that have high rurality are less likely to be successful with technology. But we've seen that with the appropriate level of support. That is not the case. We have some specific guideline directed therapy for when we start to think about CGM for individuals. And the ace 2023 update outlines that below. I won't read it word for word. But when we're talking about type two diabetes, we wanna recommend that for people who are on really any insulin therapy, it's not a specific number of injections or type of insulin just on any insulin therapy. Then you'll see. Bullet number two is that they have frequent or severe hypo, they have nocturnal hypoglycemia or hypoglycemia unawareness. This doesn't specify that they have to be on insulin. Other medications like Sophon urea can increase that risk as well. And then what I love is that third bullet point uh recommending that the intermittent scanning CGM can be used for newly diagnosed folks with type two diabetes and or at low risk for hypoglycemia. So even those who don't fit into those top two category categories can be considered. This is a figure actually from the 2022 A guidelines, but I thought it was just such a beautiful visual representation of when we're starting to think about CGM. So you'll see along here at the bottom, the lower the risk of hypoglycemia, the more we can just rely on finger sick blood glucose monitoring versus along the spectrum, the higher risk of hypoglycemia. We start to see more and more reliance on the CGM and you'll see that that conversation starts to happen. Right from the beginning, we start to be thinking about CGM on our agents that aren't necessarily associated with hypoglycemia. That could be those newly diagnosed folks or at lower risk of hypoglycemia. But then we start to see even here with the oral insulin secreto. So those are like your sofa area. We're starting to think a little more about CGM and so on and so forth. Similarly, for the AD A, this is our 2024 update. Uh They are recommending um in continuous glucose monitoring for people who are on MD I who are on an insulin infusion of course, um or they're on basal insulin therapy and have the appropriate level of support, either they're able to use a device themselves or with the assistance of a caregiver. And with that, I will turn it over to uh to doctor Wright who will talk us through how we use this wealth of glycemic data and actually interpret the A GP report for our patients.
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