welcome and thanks for joining us today. It is my honor to be here with you to present and especially following dr Hirsch, I don't know what more a woman could ask for, you know, it's very exciting to be with such a prestigious group of folks. So anyway, my name is Susan Cornell and I'm a pharmacist and a certified diabetes care and education specialist bring practicing and diabetes for more years than I'm willing to tell anyone because I don't like to share my age. But with that, what I want to talk about is what is the role of continuous glucose monitoring in the managed care pharmacy and specifically like what can we do to kind of make things better and make a difference. So for folks who have possibly heard me present before, you know, I'm not one to sit here and read slides to you. I always joke that my slides are for your sleeping pleasure, but you know, I do want to highlight key thing. So here's today's objectives and one of the biggest things if I could say a takeaway right now is we as pharmacist as well as health care professionals and providers, we really need to embrace continuous glucose monitoring, see GM because this is the wave of the future. You know, I look back to when I graduated pharmacy school million years ago and self monitoring or home glucose monitoring was the hottest thing that was coming out. Okay now now you guys know how old I am. But anyway bottom line C. G. M. Is today, the hottest thing coming out and finger sticks are going to be what urine dip sticks were to my generation of pharmacists. So again we need to embrace this new technology. So with that I have to go through of course my faculty disclosure slides for you. Um once again slides for your sleeping pleasure. Now let's jump into a lot of material a little bit of time. What are the highlights here? You know we need to start thinking prevention because we are growing as a country and when I say that our waistlines are growing and when our waistlines are growing we're looking at obesity and of course an increase in diabetes specifically Type two. But even type one. But bottom line is if you think about it, a person doesn't wake up one morning and say hey you know what gosh I just don't feel good. Something's wrong. I think I have diabetes. No that's not what happens. The person wakes up and they're having blurry vision or they have a wound that won't heal or oh my gosh I'm having a heart attack or a stroke. And so a complication presents. And the person goes in to see there family care doctor, they're specialists, the hospital. Uh and what ends up happening? Oh by the way you have diabetes it's the complication that brings the person in and it's actually estimated that people have Type two diabetes for nine years before it's actually diagnosed. And that's a big thing. So what can we do to intervene sooner is a big question and that's of course obviously a different lecture for different time. But when we think about glucose and testing and there's a lot of people who are at risk for diabetes that kind of want to know they have a family history. Maybe they know you know, okay I've put on some few pounds here since Covid I want to know what's going on and so they home check their glucose and they may do so with a meter. But we'll talk about C. G. M. Coming up. But bottom line when we look at finger sticks, when people test their sugar finger stick in the morning and the morning fasting glucose is elevated. That tells us micro vascular complications are on their way. So Lord I like to tell patients is okay. You check your sugar in the morning and the sugar is above where your goal is. That's telling you when you're going to have eye problems or kidney problems or nerve problems. But when you check your sugar two hours after a meal, that's telling you when your heart attack is coming or your stroke because the postprandial is macro vascular complications. And if you think about it, this just makes sense because postprandial, it's all about the food fasting. It's about what was happening overnight. And so when we look at it you can actually look at complications. But what if we could look at this all the time. So thinking about it finger sticks, it's one point in time. So I check my sugar right now and maybe it's two hours after I ate. Is my sugar going up or is it going down? We don't know it's one point in time. What about A one C. You know A one C. Is the way we monitor sugar. Really? A one C. Is an average over the last month two maybe three months. I'm gonna come back to that. But bottom line is that really giving us a good picture which leads us to continuous glucose monitoring. And this way we get a reading every 5 10 15 minutes to see what our sugar is and what trends are happening. So once again, if I check my sugar now and I have a C. G. M. I know which way it's going oh my gosh it's going up. I better maybe take my insulin or my diabetes medication or you know what? Maybe I better get up and take a walk instead of sitting at a desk. So again continuous glucose monitoring gives us a continuous data and information. Now I mentioned A one C. You know, everybody uses it. Well we're going to lower a one C by so many percentage points. But A one C. Is an average and really folks it's an average of the last 30 days. I like to tell my patients you can study for your A one C. Test. They'll look at me like what? Yeah, you can study for this test 30 days before you're going to get your blood tested, eat healthy exercise more, get a good night's sleep, take your medications the last 30 days, 50% of the A. One C values coming from the last 30 days From day 31 today, 60, that's 25 of the A. One C value. And of course obviously it goes down from there, you know, half lives. So really the 30 days before the test, if people do really well, they can actually pass, I will tell you my mom was great at this. She would 30 days before she would go for her blood test. Should do really well. She'd go in, should get a blood checked and you know, 6.4. And she would celebrate by going to Arby's or Mcdonald's. But you know, and when that happens. But bottom line is we're hoping to create better behavioral habits. The thing is a one C. Is an average and it's not a direct measure. So if you think about it, what contributes to A one C. Because it's an indirect measure, the fasting contributes as well as the postprandial And people with an a one c. Very near normal, it's all about postprandial. So I look at an a one c. of 5.5, 90% of that value is coming from postprandial glucose. If I look at an a one c of seven 70% of their values coming from postprandial glucose? And if I look at an a one c. of 10, 30% is coming from postprandial and 70% coming from fasting. So the closer to normal A. One C. It's more about postprandial. The further away from normal. So the higher the A. One C. The more fasting contribution, which is the reason why is fasting goes up, the A. One C. Goes up and we really need to fix that fasting first because of course postprandial has been up and and has stayed up for quite a while. So hopefully that made sense to folks. Now just put this into perspective here are let's see we have seven people here With a one CS of 6.5. What do you think is this good control? So here's seven people, seven different people. Their a one c. 6.5. Can't say I think this is good control. So this is once again and we're looking at a range of basically 70 to 1 80 here. So look at our person in Green is kind of near in the two seventies there and yet the average over three months. They're doing pretty well. So again, a one C. Doesn't quite give us the information and that's why it's important for us to put the puzzle pieces together the glycemic variability. The ups and the downs damage the end? All filial tissue. So what is the frequency that we have these fluctuations? How high does our sugar go? How low does our sugar go? And when we look at that variability, we have to start wondering what impact it has on the body. So number one we know variability impacts our heart again. It affects the entire epithelial tissue. The other two thing too big thing is cognitive function. When we have our sugar bouncing all over the place, you know, you don't feel good, you feel as I like to call it Muzi in the head, your little sluggish. And actually, as we all know, diabetes is a risk factor for dementia and alzheimer's. So in this particular case, a lot of that cognitive function from variability of glucose can really be enacted? Think about it. It's thanksgiving Day you go and you have your big dinner, big turkey dinner with your family, you know, lots to eat. Your kind of overloaded. You want to go sit on the couch and relax afterwards. Nobody feels like taking an exam or doing some type of a cognitive function test after eating a big meal. And that's because of the glycemic variability. So how does that impact quality of life for folks? So just some things to think about. That's the reason we need to start thinking not only a one c lowering effect, But what is our time in range? And what do I mean by that? In a 24 hour period? How much time in that 24 hour period is our sugar within range. And when we start to find therapies, Be it medication, be a lifestyle that keep us time in range. We're going to find things work better. So what I want to do now is talk about this time in range and there's actually standards that have been made. Um these came out I want to say it was in 2018, as continuous glucose monitors are starting to become a little bit more of again The norm. You know this is this is the future of testing. So when we look about it not get to what percentages in a second but we're looking what percentage of time is the person in what we consider the current standards, 70-1, 80 mg for desolate er time in range. How much are they above that? How much are they really above that? So is it a level one or level to above? Is it a level one or level two below? And how much does this happen now? One thing I do need to point out is you do need to try to have enough data. Enough days worth of data which is usually a bare minimum 10 days worth of data to get a good reading on these. Of course most C. G. M. S are are worn for 10 to 14 days but you need to have at least 70% of data from 14 days uh in order for us to actually make these these assessments now with that here is time and rain so time and range. So for most people, Most people with Type one or Type two diabetes, nonpregnant individuals already mentioned time and range 70 to 1 80. And we would like to see 70% of a 24 hour period for people to be in this range. Now as we know, we need to individualize therapy as we Get older. As people get older, 50% of a 24 hour period time and range of the 70-1 80 is appropriate. I mean obviously if it's more that's wonderful. But you don't want it to be less now where it gets really as I like to call it tight time and range is when we start looking at pregnant women. So we're looking at pregnant individuals here obviously look at the time and range difference for them 63 to 1 40. That's what we would call more of a tight time and range. And for those with gestational diabetes, they're looking to have time and range of the 60 to 1 40 90% of the time of a 24 hour period. So again the tighter time and ranges better, especially in pregnancy. But again looking at individuals that are not pregnant, we want to see greater than 70% time and range now this is criteria and guidelines that have been developed in the past five years, five years from now this may change and you know I would not be surprised if we got tighter and we start to look at all people with type one and type two um you know nonpregnant people, maybe it's going to be like 70 to 1 40. There is talk about that. So again these numbers are changing but right now this is what time and ranges looking like when we wear a glucose monitor, a continuous glucose monitor. This is a summary of the information you get. So this is the wonderful thing about C. G. M. The data the information. So not only do we get glucose statistics but we get something called the ambulatory glucose profile and then of course the daily glucose profile and pharmacists, we need to look at this as three parts here and kind of you know, what is this information that we're getting? So when we look at the data, the statistics here, once again we want to look at the fact how long was the C G. M warn? 10 days is really the minimum for you to get a good profile and hear how much of the time is the C. G. M. Active. So 99.9% of the time that someone who's wearing it pretty pretty constantly. As long as you're greater than 70% of C. G. M. Active you're getting sufficient data. So those are things to think about. And then now looking at the data that we have. So in this particular case here, the green bar, you know, so our target time and range 47% of the time. But this particular person, their high 23% and very high 20% of the time. The law not too bad. So this is a good thing. They're not low. And when we look at this, we always want to fix hypoglycemia first because hypoglycemia is definitely a cardiovascular risk factor and can be deadly. So we always want to take a look at and if we have a person who has some hypoglycemia going on, we want to fix that after we fix the hippo, then we tackle the hyper. But again, looking at the data we're seeing here, what we get is called kind of a glucose management indicator. And that's basically estimating, it's an estimated a one c Based on 13 days of data here and these glucose fluctuations. So here the G. M. I, the glucose management indicator is 7.6%. So that tells us, Okay, there's some room for improvement. But what's a bigger room for improvement is the glucose variability. As I previously mentioned, all those fluctuations do a lot of damage to the body and so we want to reduce the fluctuations and that variability if it's greater than 36% an intervention is needed. So that's when we need to definitely make an intervention. So looking here this person, their glucose variability is 49.5 clearly something needs to be done. So having this data not only helps the provider in making some decisions about therapy, it helps the patient because they know where their problems are. They can start to look at their daily profile and they can see oh on Thursdays I go bowling and after bowling we go out for beer and pizza and oh my gosh three pieces of pizza. Look what it did to my sugar. But yet on sunday when I'm active and I'm doing my gardening, my sugar is really really good. So again all of this data the daily report with the statistics helps the person to make informed decisions about better managing their diabetes. It helps us as the providers to also help that person we know now okay an intervention is needed because again the glucose variability is high so opportunities to make a difference. And if we look at the correlation of time and range and anyone see you can see here the more a person is in range, the lower their A one C. Is. So once again proof that time and range actually provides better glucose management. So these are things we want to look at when we're working with our people with diabetes. So the question becomes well who should wear A C. G. M. And actually I'm going to change that question too. Who should not wear CGs C. G. M. Is going to become a mainstay for people it's going to become what prevention is all about. Um I can tell you I know a lot of people who will pay out of pocket for a C. G. M. Device. You know the ones that over the counter right now are affordable and people want to know people that are at risk of having diabetes. People with pre diabetes and people with diabetes not on insulin are actually paying out of pocket to get a C. G. M. Device because of the information and the ability for them to help better self manage their diabetes is given. So bottom line is obviously people with Type one you know pretty much everyone with Type one is a candidate but people with type two in prediabetes as well, people who want to improve their glycemic management. This is an opportunity to actually do that. Now. See GM by itself gives us a lot of information but we do need to use the A. One C. To really do a thorough assessment and that's how we make our therapy adjustments as well. So no longer is a one C. Like the only thing we're going to look at. Let's look at c. g. m. with an a. one c. Now the other thing too people need to be able to understand what these devices are and how to use them and they are going to become you know in the future kind of just part of ordinary life for many people you know you see all over tv the cardiac mobile and anyone can buy one and you know put their fingers on it and get a medical grade E. K. G. This isn't far behind. You're going to see this with C. G. M. There's talk about it actually being put in a Fitbit or an Apple watch. So you're going to see this become more of standard of practice for healthy living. And so as pharmacists what's our role is to be familiar with this concept? We need to understand against C. G. M. Today is finger sticks of 30 years ago and we need to be able to understand and know where it's going now. Not every pharmacist is an expert on diabetes. Not every pharmacist is an expert on C. G. M. And that's okay but we need to work together as a team. So at bare minimum at least understand the concept and no one to refer to somebody for further evaluation or further care. So know your limitations personally for me my limitation has to do with nutrition. I'm going to refer to a dietician on something like that. So again no the limitations know where we need to refer out now in an ideal role. Obviously pharmacists should be able to at least educate the basics about C. G. M. And the benefits assist the diabetes team in helping to select the appropriate device for that person recognizing there's different devices out there. So what works for them and especially for people buying the over the counter C. G. M. Yeah there are some cost saving coupons and there is the ability for people with diabetes and prediabetes to actually purchase with a prescription. They can purchase this for a reasonable price. And of course as any device that's out there if the person does not know how to use it and uses it correctly, the information is worthless. So again in a perfect world we need to train the person how to use the device. The other thing too is to train that person how to interpret the information and then provide them with guidance so they can self manage their diabetes without us. I mean think about it. People live 24 7 with diabetes were not there, 24 7 with them so we need to provide them with the tools and the resources for them to lead a good quality life with diabetes when we're not around. So with that you know, again our role is the pharmacist diabetes is evolving every day. New things are coming out left and right. We need to be at least aware at bare minimum and you know more and more pharmacists have a role in the diabetes care team. So getting involved, making sure our role is safe and secure and then helping patients to understand monitoring is more than just finger sticks or a one c having the concept of time and range, knowing where we can help a person to improve their time and range, prevent that variability with dementia and Alzheimer's and of course overall just improve quality of life and diabetes management. So bottom line as a pharmacist, our job is to help people better manage their diabetes. And with that, I want to thank everyone for their time and hope you learn something valuable today to move forward into your practice. Thank you.
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