All right, so we're changing courses here. We've just heard a lot of information about how CGM can be used in our patients who are on the spectrum of medication options, and now we'll be applying this to a a case study and how we can actually use this information to not only improve glycaemic uh glycaemic metrics, but really improving that patient engagement. All right. Moving to our case number one. This is a patient, um, who is a real patient and a real outcome that, uh, that we had with this individual. So on January 21, 2025, he was seen for a follow-up. He's a 69 year old male, type 2 diabetes complicated by coronary artery disease. He also has hypertension. Hyperlipidemia. He's on metformin, pioglitazone, he's on glargine 25 twice a day, Aspar on a fixed mealtime dosing of 20 units for breakfast, 18 units for lunch, and 16 units for dinner, and he is using a correction factor of 100 for glucose over 200. In the past, he's tried a semaglutide 0.5 mg weekly but didn't tolerate it because his appetite suppression and weight loss were too severe, and then he did not tolerate alloglutin due to GI upset and poor appetite. There is a, um, there's also a side effect that he experienced with SGLT2 inhibitors. He had worsening of his overactive bladder symptoms, so he did not tolerate that medication, which is unfortunate because we see that with the GLP-1 and the, the SGLT2 inhibitors, we cannot use those agents that have the cardio renal favorable um effects. So unfortunately, we don't have that added. Extraglycaemic protection. So we do need to really highlight that we're controlling the factors that we can, so A1C, blood pressure, cholesterol, etc. What's particular about this individual is that he has a long history of depression and passive suicidal ideation. So mental health factors are a common topic that we talked about during his visit. Over the last year, though, thankfully, his depression and suicidal ideation has stabilized through mental health treatment, and he has the support of his son who lives nearby. Now, when I talked to him in January, he reported that he was traveling since I saw him last, and his daughter had recently gone through a miscarriage. So we're thinking extra stressors, travel, the distressing situation for his daughter, and then he mentions that while he was traveling to see his daughter, he left his Cla Jane at home. He reports that he has overnight lows in the 50s, about 5 to 6 times a week. This is his actual AGP report, so we'll walk through this. And what we'll go through is actually all available on that first page. So there's so much information that we can quickly glean just from that first page. So first of all, making sure the upload is the correct date. So yes, we have January 21st, and we have 14 days of data. So we need a minimum of 3 days, minimum of 72 hours to build. 14 days is a good representation of what we would see for patents, so we can feel confident if we're looking at 14 days of data, we have a good sample here. CGM is active 84% of the time, so that means that both he's wearing it and it's transmitting data. As you can see, his average glucose is pretty high, 253. That glucose management indicator that we referenced earlier was 9.4. It is not an A1C, but we have similar goals for that. So glucose management indicator is high, and that glucose variability is such an important part of preventing complications in diabetes, and we see high glucose variability. We want that number under 36 and we're at 43.8. And then we have our our green, or orange, and our red, uh, that we talk about with our patients, so we want more green, less red. Uh, time in target range is 28%. At his age, I want at least 50%. His time below range is at 4%. I want 1% or less for for his age. So we've got some work to do. Now, as you can see, the the AGP report that's available on that first page is our uh all of our 14 days laid on top of each other, uh, from midnight to midnight. So all of our days laid on top of each other for the last 14 days. The green bracket is where we, our target range is. The dark blue line is our Average, the medium blue cloud is the majority of our readings, and then the light blue is the remainder, those outliers. So as you can see, we have definitely a, a, a peak in the morning, but we do have quite a bit of variability. You can see that light blue cloud is very wide, especially overnight. I often find it helpful to look at the daily profiles as well, because as you can see, there's quite a bit of difference here. We have predominantly high over these several days, and then we start to see some of that improvement. So it's gonna be important to to know when did he return from his trip and how, how did that correlate with taking his medications? Does that correspond? Because we don't see the. here, but then suddenly we start to see some of those lower numbers. So I would want to find out what was the difference there. What happened between Saturday, Sunday, Monday, What, what changed there. So we can think of a lot of information just from this AGP report versus maybe no blood glucose data. We're not sure what to do. We actually have quite a bit of glucose data with this information. So at this point, we reviewed the hypoglycemia safety plan. We always want to address hypoglycemia first because it's a critical safety concern. So as such, his glargine evening dose was reduced. We talked again, as we do at many of his appointments about the importance of mental health care, keeping his appointments, self-care, and that psychosocial support that's so crucial. Uh, I did recommend additional support by the endocrine team, which for our team looked like, uh, a visit, uh, a phone visit with the nurse who's also a CBCES, uh, reviewing the CGM data, and uh she and I would talk about what that data was and make some recommendations. She could also provide some additional education at that time. On March 25, 2025, so a little bit longer than that month follow-up that I recommended, uh, again, the, the changes that we talked about, so we lowered that evening dose of glargine to 20 units, uh, at our last appointment. And today he reports that he's been taking only half the dose of aspart at lunch and dinner, and then if his blood sugar is, or his glucose is high 1 to 2 hours after the meal, he'll take a correction factor, which if your spidey sense is tingling, that's a good thing. It should be tingling because this is stachy. So he's giving a correction dose for his food. Uh, 1 to 2 hours later. So, uh, with stacking, we see a 1 + 1 equals 7 situation and we risk hypoglycemia. The patient reports that he doesn't trust the fast acting insulin since he finds himself dropping below 80 within the 1st 2 hours of using that correction factor. But again, we're dealing with stacking here, so we're using the correction factor inappropriately. He does treat the hypoglycemia well, so he's using glucose tabs or orange juice. He's using his fast-acting glucose, very well done. So again, let's take the the small ones, we need them. Um, but he did share that he was trying to alter his diet to minimize carbs, increase protein, using more protein powder, and selecting less sugary, uh, vegetables. So he is working on some of those lifestyle interventions. But again, very dynamic situation, right? We have medication that's being used, kind of interestingly concerningly at times. He's also modifying his diet, so we have a lot to balance here. We really need to make sure we have the tools to do so. So is March, March 25th AGP report, uh, as you can see, our glucose went down from 253 to 217. Glucose management indicator improved, glucose variability improved quite a bit. We're near our goal of less than 36% variability. Time and range, I'm gonna take the win from 28% to 33%. Again, time below range improved from 4% to 1%. But with that stacking situation, I think we could do. Looking at his AGP report, again, all those days laid on top of each other from midnight to midnight, we want to see more time in that green bracketed range. It is getting better, but we do see that similar peak in the morning, um, early, early kind of midday, and then more of that vigorate. overnight. Uh, similarly, we're seeing these really sharp drops that are happening, um, after a high. So I'm definitely concerned about that, that stacking and the overnight lows that are sometimes happening as well. So at this time, a lot of education was spent on avoiding stacking due to the hypoglycemia risk, always reinforcing that he's very well educated on on treating hypoglycemia. And discuss the importance of making sure we give the the aspart preprandily, and then if we are giving a correction factor, it's based off of that preprandial glucose, because if we're giving a correction after we've eaten, not only do we have stacking, but then the blood sugar was high because we, we had food. So if we give a correction dose after the fact, then we're essentially dosing twice for the food. Again, CGM upload at a month so that we keep that closer eye on him, help support him through these changes, and thankfully now he is open to a meeting with the CDCES, um, RD, so diabetes educator, dietician, and to help with the changes that he's making as well. On April 14th, he was seen for a follow up, and again that the interim changes that we did was just talking about that avoidance of stacking, giving the aspart preprandial, correcting only based off of the preprandial glucose. So let's see how he did. He reports that he's now only doing half the dose of aspart at dinner, so he's giving the correct dose at lunch. We are all about that progress. We're making progress. And then, of course, his glucose is high, so he's using that correction. Uh, we did elucidate some fear of hypoglycemia, so he spent some time deliberately keeping the glucose high while he was in a church pageant because he didn't have the time to treat low glucose. Uh, he did have a hypoglycemic event once on Friday while he was active, and he treated it appropriately. Again, working on those dietary changes, uh, he's really trying hard, and then he has an RD appointment next month to discuss some more, um, some more tips and some more progress. What was so remarkable about this conversation was he talked a bit about motivation to change, and he stated, your team is wearing me down with kindness. So after clarifying if that was a good thing, and it was, it really, um, helped highlight that the changes he was making at home, he felt supported. So he felt like with the changes we were doing, the education, he was getting, the CGM data that he was able to use, he was really making a difference at home. So working through his AGP report, again glucose, the average glucose is down again, 198, his GMI is at 8, his glucose variability we went up a little bit there, a little bit more variability, but time and range we're at 43% now, thinking back from our original meeting, 28%. So we're getting a lot closer to that 50% goal, and we are still contending with some of that hypoglycemia. We're seeing that line lower, that dark blue line, uh, for the average is coming down, so we are making some progress. If you break down to the daily glucose profiles, you, you'll see some of these little lows are sneaking in. They seem to follow a high, so good conversation about avoidance of stacking and using aspar correctly. So we first talked about good job, time and range is improving. We are making progress. Spent some time on whole health principles to, you know, treat him as a human being, not just a set of glucose data, and then re-educating about stacking and avoiding hypoglycemia. Based off of the information that we had, it seemed like even when he was giving the the Aspart dose for dinner, he was still running pretty high and giving a second dose after dinner, so we nudged that up a little bit, but again reinforcing to give that pre-prandioli. So following up with our support system, following up with the RD and following up with the endocrine provider as planned. So this is a wonderful example of somebody who I would consider very high risk given all of the factors. We already have macrovascular complications. We're not able to use a lot of our agents that we normally would, our GLP ones or SGLT2 inhibitors to help reduce that cardio renal risk, and we're dealing with that dyslycemia, that glucose variability that we know drives complications and non-adherence and overall disease burden. So in that situation, then we have the the mental health uh crises that have been going on, the psychosocial factors that are involved with his family support and difficulties with taking his medication consistently. So this was such a wonderful win for for the patient and for the team to really see that giving somebody the appropriate tools and the appropriate education. To use those tools is actually making a huge difference, not just in those glycemic parameters, but in his engagement, that he felt like that support was giving him, making a difference in the changes that he was making at home. So what we can really see is there is a lot of work that still needs to be done for diabetes management, but there are tools available that can help with those both glycemic and extraglycemic factors, and importantly, give patients that empowerment to see their glucose data at home to really In real time, how their choices, their, their medications, their stress, their sleep, uh, their food, their activity level, everything, all those 42 factors, how are they impacting their individual glycemic levels? And that can vary from person to person. So, so using CGM and the appropriate person can be so helpful for that individual, and then it's not something relying on the clinician to Say what the next steps are. We're really able to partner with our patients. What do you see here? What did you notice triggered this? What was going on around this situation? Tell me what was happening from that Saturday to Monday where we saw such a shift in your glucose, and that, that partnership with our patient really helps with the ownership that our patients feel of owning what's going on with diabetes management and helping. them to have a voice in their management as well, and that empowerment can be crucial in fighting clinical inertia and reducing risk of complications in our patients with diabetes. So I hope that you learned some great clinical pearls for Monday morning, and wherever you are in your CGM journey, uh, let's work on just stretching that comfort zone a little bit more to help get uh meaningful tools into our patients' hands.
Related Presenters
