that was a great presentation by Eugene. You've been introduced to all the nomenclature. You've had this great foundation. Now it's time to put it into practice. We're gonna be exploring some case based practical aspects of establishing and deploying CGM on the front lines of Type two diabetes in your clinical setting. We're gonna talk a little bit about those barriers and solutions and help us identify. So we're gonna really deconstruct over the next few minutes. A few cases that are actually real. These are some of my real clients that come in every day in and day out and you will find that there are some similarities. So these are very applicable to you and you can take them directly back from this conference and start putting them into play. So let's talk about the 63 year old female. I can picture her in my head. She had Type two diabetes for the last 3.5 years. She comes in as the consulting appointment, medication history, typical trifecta, the A. B. CS of diabetes, blood pressure cholesterol, also a little associated obesity. Her current treatments are metformin. She's had some poor medication adherence due to gi side effects. She really didn't know the benefit of it. Her a one c three months prior was 84. We hadn't had one at the time of the visit. But I really got from her the sense that you know, I don't know if the medicine is doing anything, I don't know if I should take it. And so I said, hey I got an idea. Let's put a continuous glucose monitor on you. Let's have you monitor for the next few weeks. What the impact of your medication adherence is, what your diet is. And then come back in a couple 23 weeks and we'll go through it and you and I can determine what you've learned. So this was her very first download or her a G. P. After I had seen her as a patient identified the need, gave her the C. G. M. And gave her the little homework assignment. So in two weeks follow up her glucose management indicator was 7.44. This is why I love the G. M. I. Because I told you a when she was 843 months ago I told you she had trouble with medication engagement or adherence. And so she comes in with this and I said what did you learn? And she said I learned that if I didn't take my Metformin in the evening it really had a big impact on my glucose is I was like great that's great. She goes I'm still having gi side effects. I'm like all right, we'll deal with that. I said but look at what your glucose management indicator did. She goes what's that? And I said, well if everything stayed the same going forward that if you didn't change a thing and you were adhering to your medication and you learned the things to see G. M. Three months from now to three months from now. your a one c would probably be about 74. That was very encouraging to her that in that short amount of time she got that feedback. I asked her, what else did you learn about it? And she said, I learned certain foods that affected my glucose is, I could tell when I went out to dinner, I didn't really have any risk of lows. I'm like that's great. You know, I don't see it here. You might have been 71% of the time, but we can tolerate that. But you weren't very low. And she says, well what's what am I shooting for? And I said, oh your target range. I said really 70 to 1 80 we really want that 70% or more. And she's like, great. And so she felt this had an increased engagement in her disease and awareness. And I said, hey do you wanna keep utilizing this? She goes, absolutely. So we went on to the next phase of her treatment and after I discussed with her about her previous results, we determined she was going to discontinue the Metformin. It was more than just lack of adherence. It was gi related effects. So I mentioned to her, I said, okay, you know, let's discontinue the Met form and you don't like the effects of it, you have trouble remembering it in the evening. She goes, I really want to keep utilizing C. Gm because you're reporting to me, it really gives you that effective food and stress and activities as well as medication adherence. And I said why don't we add a GLP one receptor agonist to your treatment? We discontinued the Metformin and we've tried and failed. The original drug I mentioned the A. One C. Is not at target. We're having gi tolerance issues. So I did the next step according to the idea algorithm and I started a GLP one receptor agonist to this treatment. She loved it because it was only weakly and I bring her back in and her current point of care. A onesie actual A one C by finger stick was 68 but her glucose management indicator was 6.6. There's always little differences because the last two weeks maybe she did a little bit better that effect of going to see the doctor. Right and so you can see that she has made a significant impact. You as a prescriber have seen the lack of adherence to form and the G. I. Tolerance, the lack of awareness of the glucose values and a person who's not on insulin and the impact it had both on you. Changing the therapy and her awareness of food and her engagement. I mean talk about checking all the boxes right. She continues the C. G. M. She calls it her diabetes accountability partner. That was great. Then you can continue to advance treatment as you see necessary to your target A one C. She can also see that at one point in time, you know at three p.m. Let's look at it three p.m. She had a high sugar. And I said hey what happened here? Oh that was my birthday birthdays happened, right. But this is where the real life occurs in diabetes management. She is above our time and target. She has had no hypoglycemia. We have a better A one C. And we have less time above range. This is why we want you to use this. You've been driving blind and you're trying to prescribe to a person who's also been driving blind. We need to open your eyes to the real life ceemea so that the patient and you as a prescriber can benefit from it. So again, familiarize yourself with these, Look at them, tell me what you're seeing, tell the patient what you're seeing, ask the patient to tell you what they're seeing. Yeah. You can go through the making sure they have data, making sure that you go through the hypo that kind of thing. But this particular case I wanted to give you because it's definitely out of the box. It wasn't a person on an insulin, it wasn't a person that had hypoglycemia. We were looking for better engagement and understanding of how food and therapy effect their glitchy mia. We were also trying to understand where the glycemic problem was. So we could choose the right glucose lowering agent or the right interventional medication. Let's try another case. So this is a 72 year old male that has had Type two diabetes for nine years, coronary artery disease neuropathy stage three A. Two kidney disease. So for those of you who don't know that three A. Being A G. F. R. Of less than 60 and A. Two is the protein urea level that's greater than 30. And so they have advanced kidney disease. Their medication was enlarging 22 units. Metformin 750 mg er two in the A. M. atorvastatin, 10 and 50. Their a one c. is nine. Now they come into this office their G. F. R. 51 urinary albumin creatinine ratio is 1 35. And this is the base line A. G. P. Baseline. They come in I say hey I'm gonna put a sensor on you. You're on large ng I don't know what your fasting glucose is. He says oh they're not that bad. But sometimes I wake up you know above 1 80 but my A. One C. Is high and we get this data now. 14 days of where but only 47% active. Now this is the freestyle libre system. Why is it only 47% active? Did he turn it off, nope. Do you see those data gaps on either side? He's not scanning very often the freestyle libre, you gotta look at every eight hours with the liberal a 14 day and the two you got to engage with the data. You gotta pass off that data. If you're only looking at it once a day, you're not really managing or monitoring, right? So you've got to get the patient to engage in the data. So here's the opportunity where I say, you know, we don't even have enough data to determine what your average glucose management indicator is. I don't really see your variability because you have big data gaps. I need you every time you pick up your phone to scan, I know you pick up your phone a lot. Some people don't pick up the phone a lot. So we say you scan before every meal and at bedtime, you know you eat. So we put it there so you got to overcome those barriers or engagement issues and they're going to be unique to each individual. But this was his baseline data. He had absolutely no hypoglycemia. His time and target range was 16%. His time above range was a total of about 84% but is very high was 23 that segment. But he's not having lows. So there's a couple things he hasn't tight traded as long acting insulin to target but we know that he has hypoglycemia with meals. So we did an intervention with him and we had some considerations. So if we pause for a second, why do you think about it? Not any really perfectly right answer. But what would you consider? Let's go through some of those options. Let's look at his glucose right here in the morning, let's say six o'clock in the morning. His averages about 2 10. He dressed down a little bit. He is not maximally tolerated on his long acting insulin. But if you raise his insulin to a target of less than 1 40 I call that patient driven tight rations. You increase the basal insulin until your target 1 40. Eventually we might be over basil. Realized. What do you mean? Well, we don't know how high is. He started the trajectory up here at this nine o'clock realm. Right? Let's assume it goes up to near 300. And then if you keep adding long acting insulin to get him at target, you're going to have a low glucose in the morning, but a high glucose in the evening, you're going to shift the glycemic burden so you can do that. I I often make sure that they're maximally tight traded on their long acting. But you're not going to fix his A one C. Just with trading his basal insulin need to address the problem. Glitchy mia. It could be that his long acting insulin is perfect of where it needs to be. But his hyperglycemia. Postprandial is the issue. So in my opinion, I would go after the postprandial and what do you do? You could use an spl t. Two. You could use a GLP one. Please don't say so funny area. I know it's possible it is a postprandial agent but you're not going to do a lot for this person who has end stage renal disease and coronary arteries. This isn't an end stage renal has advanced renal. And so funny areas might be cheap at walmart but they're not going to benefit the patient in the cold war videos. You got to go beyond a one C. And you gotta look at the three dimensional person. Okay so let's talk about what I did. So I added an s guilty too because I knew the post brand new was the problem even though it wasn't there on the data because they weren't engaging, I was addressing the kidney advanced kidney disease in the coronary artery disease risk factor, right? I was playing three dimensional medicine. Going beyond just a one C. Now I. D. Seed one of his medications. And that is. He was on a cell phone area that we found out later that his provider placed him on his cell phone area there and we discontinued that because we knew we were going to add an additional agent and I wanted to get rid of the muddying of the water. I reminded him to engage in his uh glucose a lot better. He did better at scanning at different times but his engagement was still not that high. He had some data gaps. We didn't get a glucose management indicator because he had to have so much data. But as you can see his average glucose dropped to 1 33 on these last two weeks. And his A one C. Was 77. So we still have the issue of low utilization or scanning. And so I said you gotta scan right when you go to bed, right when you get up and then when you pee in the middle of the night he had a 3% rate of hypoglycemia in the morning. So now he had uptight traded his large into 31 units. And so we may need to down titrate that if we're going to add a GLP one because we now we know he's on Metformin. He's on long acting insulin. We've removed the self that his his HCP put on I gave him the target of 1 40. We added the S. G. L. T. Two. And so the SGL T. Two is doing a lot of the postprandial but a little bit of the fasting. We still have a postprandial problem right? We still have it above target. So we're gonna add a GLP one. But what do we need to do with the long acting insulin? We need to reverse titrate it. So what I say is you know we still need postprandial coverage. We have you on the S. C. L. T. Two. We're gonna add a GLP one as we go on the GLP one we're going to reverse titrate the Guardian. So every morning you're less than 1 40. You could subtract the unit every three days if you're on insulin every day. If your uncle are gene, if you want to do a tighter target of less than 1 20 that's fine. You pick the target, you let them know and they reversed. I traded as you go up on the GLP one. You go down on the insulin because the GLP one also deals with fasting right? How we hand off people. So he's on edge shield tv he's on Metformin is enlarging you add the GLP one university. I trade the long acting insulin to prevent hypoglycemia. Right? And it depends on how much to GLP one is going to cover for the large and we don't know in some cases I've had to eliminate the insulin altogether. We get two units of 10 and I just stop it. In some cases they might need 15. You see how we're handing it off? We're already getting to this patient's target range of 76%. We want to minimize that lows were starting to approach that hypoglycemia thing. So you see how this one's a little bit challenging, right? And how we have to how shall I say shift the glycerin mia to different areas and we see what happens. But we equip the patient with the tools on how to deal it with it. So those were some of my case presentations. We don't have the rest of the story yet, right? We'll have to see this individual come back and see what affects it. But it's a living breathing document as you shift one thing it shifts another and that's what we do and you're gonna learn how to deal with those shifts. So we wanted to review some of those case presentations with you to equip you without interpreting and how to keep pace with those persons with diabetes.
Related Presenters
