Thank you DR Isaacs for a wonderful presentation. My name is Dr schumacher and I'll be talking about my experiences using continuous glucose monitoring at our clinical practice at Advocate Medical Group Southeast Center in Chicago Illinois. So I'm a professor of pharmacy practice at Midwestern University and I'm also the P. G. Y. Two ambulatory care residency program director for Midwestern University diversity and advocate aurora health. And I also have a role as a clinical pharmacist where I work at Advocate Medical Group Southeast Center four days a week on the south side of Chicago managing people with diabetes, heart failure, hypertension, COPD asthma and a variety of other chronic disease states. My presentation today will focus on how to implement continuous glucose monitoring into your practice To improve cardiovascular risk reduction in people with type two diabetes. And here are the learning objectives for the presentation. So by the end you should be able to describe the different the difference between personal and professional use CGM systems. You should be able to discuss how to initiate a C. G. M. Service including best practices and patient selection, clinical integration documentation and reimbursement. And you should also be able to design a patient centered diabetes treatment plan. Considering continuous glucose monitoring data. A one seagulls comorbidities and the patient's current medication regimen. Okay so cardiovascular disease and diabetes. So why is it important? Well cardiovascular disease is the leading cause of morbidity and mortality in people with diabetes. And each year we spend about 37.3 billion in cardiovascular disease related spending associated with diabetes. So what can we do as pharmacists and practitioners to improve the care for people with diabetes to prevent cardiovascular disease and manage their current cardiovascular diseases. Well it's important that we think about aggressive modification of cardiovascular disease risk factors, so achieving better glycemic management. If they have diabetes, improving their hypertension and getting them to gold, they have high blood pressure, managing Disl epidemiology, i cholesterol, making sure everything is appropriate. And we're preventing the progression of chronic kidney disease. And of course smoking cessation is important as well. And in our clinic we manage a lot of people with both heart failure and type two diabetes. So I actually started as a heart failure pharmacist. And what I found is I was managing these people with heart failure is that they would continue to go to the hospital if their diabetes wasn't well managed if they weren't taking their insulin correctly, whatever it may be. And looking here at the stats now that we've seen a recent shift where we're thinking about heart failure and diabetes can confidently and lot now with SGL T two inhibitors, We know that about half of people with type two diabetes may develop heart failure and the risk of developing heart failure is more than double if the person has type two diabetes And there's an 8% increased risk of heart failure for every 1% increase in a one c. So people with both Type two diabetes and heart failure also have double the mortality rate compared to heart failure, patients without type two diabetes. So it's important. This is a population people with heart failure and type two diabetes that we really need to focus in on to prevent morbidity and mortality. So that has kind of driven that 2022 a. D. a. standards of care here. So just as a reminder, first line of course is Metformin, it's still cost effective. However, now what the A. D. A. Says is if the person has a S DVD years at high risk for A S. D. V. D. Independent of a one C. Metformin use or a one C target, we should really start to consider SGL T two inhibitors with cardiovascular benefits. So impeccable flows in and flows in and people with diabetes and in GLP one receptor agonists with proven cardiovascular disease benefits. So, La Regla tied from the leader trial, The legally tied from the rewind trail and semi tied from sustained six and Pioneer six. And then these are the trials as well that supported the use of empirical flows in and flows and and people with Type two diabetes and A. S. C. B. D. And then for heart failure as well. We now know that based on the S. G. L. T two inhibitor trials, S. D. L. T two inhibitors should definitely be used in people with with heart failure even as well as people with diabetes and heart failure. And what we've seen here from the different trials is that this is definitely a class effect. Regardless of which agent used. They decrease they all decrease the risk for heart failure, hospitalizations and all the clinical trials with a focus on empirical flows and in typical flows in as in the emperor reduced emperor preserved as well as the Dapa HF trial showed benefit in those with and without diabetes. So why is this important? So we think about all these new medications that were supposed to use to decrease cardiovascular risk, decrease the risk for heart failure, hospitalizations. Well, many people come to us in clinical practice and they're on insulin there on symphony areas. So one of the things I like to do is actually use C. G. M. To optimize anti hypoglycemic medication use because sometimes when we're switching between medication classes and the person is only checking their blood sugar one time a day, it's hard to figure out exactly what's going on in the clinical picture. So in our practice we use a lot of C. G. M. Whether it be personal or professional, you see GM to optimize anti hypoglycemic medication use and improve outcomes for our patients with cardiovascular disease and type two diabetes. So, as an overview of C. G. M. So what are they? So we have two types of C. G. M. They are either owned by the user, which we call personal, you see GMS or the system is owned by the health care system and that's called a professional. You see Gm. Both of them are the same. I have a picture slide coming up but they both require the insertion of a thin filament under the skin which measures interstitial glucose every 1-5 minutes. And in that small sensor connects to the filament and spends readings by a wireless transmitter to a receiver or a compatible smart device every 5 to 15 minutes. So overall what you're really getting is a 24 hour picture of what the person's blood sugar trends look like. Which is amazing. So it's really been a game changer for diabetes management. So who should get A C. G. M. System? Well in my opinion everyone should have a C. G. M. System. If you think about the information that we're getting from self monitoring blood glucose or now blood glucose monitoring at home what you're seeing is one spot in time. But the person could always be checking before meals and we'll never really know how high their blood sugar is going after they eat. So the guidelines actually now recommend that personal. You see GM should be used in all people with Type one diabetes especially in Children and adolescents with type ones. And then they should be available to lower a one C. And reduced hypoglycemia risk and adults who aren't meeting their glycemic goals. Kind of hypoglycemia unawareness or episodes of hypoglycemia. Personal use CGM can also be used in people with type two diabetes and that really is just in conjunction with insulin therapy to help lower A one C. Is with the guidelines state. So as we know it would be great if everyone could afford a personally you see Gm. However we know that's not the case. So in our clinic what we'll do is we'll offer everyone to wear a professional you see GM and they can wear that usually up to twice a year if they're a Medicare patient sometimes more frequently for commercial pairs you'll have to call the insurance company and check to see how often it's covered. But we've had success getting professional you see Gm covered at least twice a year and they're excellent for people not using personal use C. G. M. And the guidelines state that they are recommended in addition to diabetes self management and education to improve glycemic management and people with Type one or type two diabetes, they're also great for those patients looking to learn a little bit more about the C. G. M. Systems and improving basically increasing the understanding of the patient's knowledge of high and low blood sugar. So when is there blood sugar, high when is there blood sugar? Low. What we'll do in our clinic is well placed. The professional you see GM. We'll bring them back possibly even intermittently during the wear period. Will scan the sensor download the data and we'll sit down and go through the glycemic trends with the person with diabetes and it really does help improve their a. one c. And their overall glycemic management. Because like I mentioned before the self monitoring of blood glucose is just one snapshot in time. This is providing trends of what their blood figure looks like all day. And then they can look at different weekdays especially if they're keeping a diary. It's helpful and they can really see what their blood sugar is doing and start to make lifestyle modifications as well as it's helped us basically teach the patients the importance of the different medications and how the medications affect their blood sugar. So why routine use of sensor based, see GM technology. So why is this important and what do we know? So this is a meta analysis of clinical trials from a weird world observational study and what we can see here is that if you're looking at the graph on the left just by placing a C. G. M. System, The A one C lowered .6 percent. So definitely clinical significant lowering in A one C. And as you can see here on the right a lot of that the more A one C. Change you saw was based on the if the higher of the A. One C. Was higher at baseline. So we've noticed this too in our clinic we did a pilot study and we found that just by putting a purse or a professional you see GM system um are using the professional you see GM system on our patients we were able to lower a one CS 0.6%. So definitely by having the patient see the trends of their blood sugars. You're going to start to increase awareness. You're going to improve that. You're going to see improvements in self management medication, use diet and exercise. And then again this study was recently conducted in the Journal of Clinical endocrinology and metabolism. And what they found is that also what see GMS do not only do they help improve A. one c. and help patients reach our a. one seagulls but they also decrease hospital related emissions as well as work absenteeism. So the C. G. M. Systems now have alarms so the patient will be alerted if their blood sugar is going into low going too high and it really makes it more adaptable for the person with diabetes. They don't feel like it's such a burden to have this on at work. They don't have to consistently go and check their blood sugar. They're always kind of in tune with what their blood sugar is based on the C. G. M. Data. And a national nationwide cost reduction of $345,509 was found during the rescue trial period. So we can definitely see here that even though C. G. M. Right now it might be a little more expensive up front for the person with diabetes but in the long run it definitely saves money for the total cost of care. So as I mentioned I talked about the professional use system and the personal use system. So you might be wondering what's the difference. Well looking here actually you can't tell the difference between the two systems. So on the top left here we have the freestyle libre system. So the blue one is the freestyle libre two. Well the white one is the freestyle libre pro. And they both use a very similar looking or they both use basically the same size sensor. So the sensor here is in the middle for the freestyle product. And I'll go over the differences between the freestyle and mexican products and the upcoming slides. And then in the bottom right you can see the decks com G. Six pro so it looks exactly like the decks calm. So when we're thinking about professional and personal use systems they're really not a lot different. The only thing is that with the professional use systems the reader stays in the clinic. We're with the personal use systems. The patient keeps the reader with them at all times. So the professional use systems are purchased and owned by the clinic or practice and they're used intermittently by the patient and healthcare team to help facilitate diabetes management with the professional use systems the data collection can be blinded or um blinded. So what that means is that well with the freestyle libre and pro it's a blinded system. So the patient just wears the sensor will put it on in our clinic, They'll wear it for 14 days. And then any time we can scan the sensor and download the data and retrospectively go over the data with the patient. The mexican G. Six pro does have the option to be an un blinded mode. So what that means is if the person with diabetes has an up to date smartphone device you can actually set up the decks come G. Six app and the sharing system with the patient through their smartphone and then they are able to see the results of the C. G. M. The decks come G. Six pro while they're wearing it. So the un blinded mode setup does take a little bit more time during the clinic visit. So data can definitely be blinded or um blinded. Um We used a lot of blinded mode in our clinic just for time constraints as well as our patients don't necessarily have the technology. However the un blinded mode is excellent as well if you have a patient that's tech savvy you have the time to set it up the un blinded mode during your clinic visit and in your center. So really just depends on your patient population and the time you have allocated for C. G. M. In your clinical practice. So which patients may benefit from professional use C. G. M. Well as I mentioned earlier, everyone really should have the opportunity to wear a C. G. M. So when insurance doesn't cover personally you see Gm we will definitely consider placing a professional. You see Gm at least twice a year on each patient in our center really. Just to make sure we're optimizing their glazing muk management and making sure we're not missing anything. We've placed professional use CGM systems on patients and seeing great charts and graphs definitely what we expected. But we've also uncovered some nighttime snacking, nocturnal hyperglycemia and different things that the patient with diabetes didn't even know what was going on. So it's definitely good just to make sure everything is going well for the person with diabetes. It's also great if the person with diabetes has a discord in in A one C. And S. M. B. G. So let's say their A one C. Is consistently eight or nine but they're fasting blood glucose in the morning is always 80 90. You can't seem to figure out when their blood sugars are high throughout the day and you're kind of shooting in the dark when you're trying to optimize their medications. It's a great time to put on a professional U. C. G. M. And kind of start to uncover what's really going on over the 24 hour period. Also it's good for people with a one C. Is greater than nine just to help you optimize medication use those with postprandial hyperglycemia as I know in our clinic a lot of our patients only check their fasting blood glucose when they wake up in the morning. So people on insulin will always tell them to check four times a day. But if you work in clinical practice you know that's not always what happens. So it's great to have a professional. You see GM for people that don't have a personal use one and you really want to get a better picture of everything that's going on. So there's a lot of different reasons that we can consider this. So as I mentioned there's two types of professional use GMOs that we can use the decks. Com G six pro and the Abbott freestyle libre pro. So as I mentioned they're both one time disposable use sensors and transmitters and then the clinic does keep the receiver for both of them. However, if you have the DXc MG six pro, it can run in and blinded mode and be set up to link to the person's smartphone. The mexican. G six pro is worn for 10 days where the library pros warned for 14 days. And similar to the personally systems the decks come G six pro goes on the abdomen and the library programs on the back of the upper arm and in the data software is the same. The clarity and the library view and what's nice is that neither of them require calibrations. There are alarms if it's running on blinded mode for the MG six pro and then hydroxy areas, the interfering substance with the G six pro and then salicylic acid and ascorbic acid or vitamin C. Greater than 500 mg a day for the Library pro. And if you're thinking about the two systems, the decks come G6 pro is approved for those over the age of two. So if you have a pediatric population then you're definitely gonna need to go with the G. six pro Where the library pro is good for those over the age of 18. And usually when we decide, I also like to think about how long do I want the person to wear the device? So we'll use the Library Pro if I'd like them to wear a little bit longer like the 14 day period to get more data. And a lot of times I'll bring the person back at five days, 10 days and then again at 14 days to remove it if I'm making a lot of different insulin adjustments. So the wear period also depends on how many medication adjustments I'd like to make and then how often I need to bring them back. So we actually did a survey. So dex the dex calm G six pro and the liberal Pro. They're not new. They've been out for a few years. We've been using the liberal Pro since 2017. And when I talked to my colleagues around the country, a lot of them aren't using professional. You see GMS. So a little complain well we can't get our patients personal. You see GMS. You know we're just not really doing it and I'll ask them well why are you not doing a professional? You see. Gm. So we actually did a survey to figure out what some of the barriers were and for those that were using them, what kind of information would they like to share? So for barriers we found that lack of funding for start up costs was the biggest barrier at 66%. And in lack of sufficient reimbursement I'll talk about reimbursement on an upcoming slide. But every time we placed a professional you see GM and use code 9525 oh we can actually get reimbursed on average our clinic gets about $150 every time we use a professional you see Gm in place it and it really only takes a couple of minutes to place a professional. U. C. G. M. Other barriers cited were unpredictable patient follow up and in lack of time for device placement and interpretation. But when I surveyed those that did integrate professional you see GM into their clinical practice About 46% spent less than 10 minutes at each visit in 25% spent 11 to 20 minutes. So basically almost three quarters of the people that completed the survey that used professional you see Gm Spending less than 20 minutes integrating it into their clinical practice. And they've also mentioned that 76% of patients follow up within two weeks. So they have had good follow up as well to review the C. G. M. Data and then we did an internal analysis and what we found is that CPT code 95 to 50. Which is the placement code for the professional you see GM Which can be built by a non provider. So pharmacists can use this code. We received a meeting payment amount of $126.87 cents and that does include Medicare, Medicaid and commercial payers because we have a variety of different pair. Mix it in our paper mixes different our population and then we've received $39.17 for the provider code? 95251. So I think a lot of times there's confusion because the provider code actually makes a lot less money or generates a lot less revenue than the main payment amount for the 95 to 50. Which is the placement code which pharmacists can do? Mhm. So when integrating C. G. M. And the clinical practice, what are the things that you'll need to think about? Well one of the things I think about is how many interventions do I want to make? So when I place the C. G. M. On our patients, what am I trying to gain from it? Am I trying to make a medication adjustment in the middle of the wear period. Maybe they're on basil bullets insulin and don't have a personal you see. Gm. Yeah so maybe I want to make some dose adjustments. Maybe I just want to increase patient awareness to what their blood sugars are. We've had patients that haven't been open to mealtime insulin. They think their blood sugar is fine. They're only checking the fasting blood sugar but their A one C. Is always eight. Well one of the things we found is that if we place a professional you see GM they can see that their blood sugar goes up to 350 possibly after dinner and then they're more open to starting mealtime insulin. Another thing I would recommend though is think about your availability. So if you place a G. Six probe the patient should be brought back to the office within 10 days and for the library pro within 14 days. So also do you have a follow up visit that's open on your schedule during for the patient to come back during the winter period to review the results. So one of the mistakes we made when we first started was we ordered 35 sensors which was great. We were like yes let's get going with this. However we wanted to have a lot more frequent visits. So sometimes patients that were coming back every month for diabetes management All of a sudden need to come back every 1-2 weeks. So definitely keeping in mind what your availability looks like. So what we what I would recommend is probably only starting with 6-8 sensors until you get the integration of the professional you see GM into your workflow. And then another question I get frequently asked is, well how do you know if you're going to bring a person in for a professional UCG? Emplacement? Honestly I don't. So when the patients are coming in for their regularly scheduled diabetes management visits, what I'll do is I'll be going through their blood sugars with them. I'll go through their A one C. Will go through their medications. And if I'm kind of confused I feel like I'm missing part of the clinical picture. I'll ask the patient, you know, can I place a professional you see Gm. And you'll just wear this for 14 days. Sometimes I'll bring them back as I mentioned at seven days. Depending on if I want to think I may need to make an intervention and usually the patient's agreeable and honestly I'll just set it up right there and it takes me less than five minutes to set up a professional. You see GM. And non blinded mode and just counsel on the use. So we have little handouts that we give the patients to track what they're eating when they're taking their medications as well as exercise patterns so that when we when they come back and we download the data we can sit down with them and relate it back and forth to the logs that they've been tracking at home. And then I would also recommend creating a process for the CPT code use so as I mentioned and I'll talk about in future slides 95 to 50. Which is the professional used placement code as well as 95249 which is the personal use placement code. Can both actually be billed by pharmacists. It's not a provider code however you do need 72 hours of data. So what we'll have to do is we'll place the C. G. M. System and then we'll have to build those codes at the first follow up visit once the patient comes back and we can download 72 hours of data from the C. G. M. System and then we have to put it into the EMR So as I mentioned these are the three codes. So the cpt code 95249 is can be used by any trained healthcare professionals. So that includes pharmacists. As long as incident two requirements are met. 95,250. Is the professional you see GM code. So you can use that one as well. A pharmacist can use this one as long as incident two requirements are met and in 95251 is the interpretation code. So a physician or licensed nine non physician provider may use this one and it can be built on the same day as 95249 or 95,250. So usually what we'll do is we'll place the C. G. M. System whether it be personal or professional when the patient comes back for their follow up visit will download the data, will review it and then the physician can sign off on our note and they can use the 95251 and then we'll build the 95 to 5 or 95249. So thinking about a billing timeline. So as I mentioned you need 72 hours of data. So what we'll do is we'll place the sensor and we'll set up the C. G. M. System provide training and education then that their first follow up appointment which has to be three days later will download the data and provide a disease state management visit. And then we can use cpt code 95249. If we trained on a personal you see GM. Or 9525 oh If we trained on a professional C. G. M. And then the next provider appointment they can download the data again as well and then review the A. G. P. Report and the provider may bill Cpt code 95251. So other tips for clinical integration. So when we're thinking about ordering professional you see GM. So what do you need to set this up in your center? Well so personally you see GM will just order the CGM system to their local retail pharmacy. Or maybe the patient gets it through D. M. E. And then it will get mailed to the patient or the patient will pick it up the pharmacy and then they'll bring in their personal use system. We'll sit down with them. We'll set it up and train them on the system for professional. You see GM. It's different so everything is ordered through our clinic. So the readers are a one time purchase and I recommend getting two. You'll always want one as a backup just in case the battery's dead or for some reason it stops working. We haven't had this yet but the last thing you want is to place a sensor on a patient. Have them come back and then you're unable to scan it and get the data after they've been wearing it. So I would definitely consider purchasing two. So the readers are purchased by the clinic, they can be scanned multiple C. G. M. S. It doesn't have to be like this one's with this person. This one's with this person you can scan multiple patients and then basically the reader just stays at your clinic site or at your practice site and then the person just wears the disposable sensor. I would recommend ordering sensors based on needs. So if you are going to integrate this into your workflow? Start with a smaller number 6-8 sensors get the hang of placing it working it into your workflow. Also to the sensors do have expiration dates. Some could be as early as three or four months. So you want to make sure they also don't expire on you while you're establishing your integration process. It's also important to put someone in charge of ordering and inventory just to make sure you don't run out of sensors. And also I know our organization we have to contact I. T. To download software. So many organizations they'll have firewalls up for different things. So freestyle goes through library view index com goes through clarity and when the person comes in and you scan the sensor you'll actually take the reader whether it be the personal use reader. If they're not hooked up through their smartphone and uploading automatically into the clarity cloud, the freestyle libre cloud, the library view cloud. Sometimes our patients will come in and they'll still be using the reader. So we'll actually have to plug it in through a USB into our computer and download the data. So we have to contact I. T. To make sure we have the correct downloading software that the drivers are downloaded. So you want to do that before you start using um see GM in your practice. Also important to think about is establishing a training process. So how are you going to make sure all your staff is trained on this. Are you gonna put one person as the C. G. M. Expert and trainer and have them responsible for training everyone else at the center. We actually brought in the representatives from the company and they trained our staff on how to use the C. G. M. System. So thinking about the training process for your employees and also thinking about considering the workflow. So as I mentioned, maybe if you were bringing patients back monthly for diabetes management visits, they may need more frequent follow up appointments while you're while you're wearing the professional. You see GM to make the most out of the information during the wear period. Other troubleshooting tips we always get asked well what if it falls off? Well of course if it falls off the company will replace the sensor, it's really easy if a professional you see GM falls off, we'll just call and it probably takes two minutes on the phone to have him another one mail to us and it will come in the mail in a couple of days. But one thing to do to help them help prevent them from following off is we actually use skin tackle will recommend it for our patients. But really any bio directional adhesive which makes the skin stickier, so to speak, can help with adhesion. So what we'll do is we'll clean up the skin with alcohol, then put down the liquid adhesive such as skin tack and then we'll place the sensor and then I'll even put a little extra skin tag around the outside of the sensor to help it stay on. If the patient complains of skin irritation you can use Flonase nasal spray and just apply it topically to prevent skin irritation. So those are just a couple of tips to help with the help the patient wear it during the wear period. So shifting gears into clinical target. So we talked about the value of C. G. M. But really what do we do with this data? So we place the C. G. M. System on the patient, we bring them back. What kind of data are we getting from the C. G. M. System? So this is an important guideline to know. So the Battellino article, if you're not familiar with C. G. M. I would definitely recommend starting here because it talks about all the different goals and recommendations um for time and range with CGM systems. So this slide discusses the goals for time and range. So as you can see here the percent of readings that should be in range which is defined as 70 to 1 80 should be greater than 70% are greater than 16 hours and 48 minutes a day. The person with diabetes should be in that target range. So that's the goal And in time below range are basically having episodes of hypoglycemia should be less than 4% per day Or less than 1% a day if they're an older person with diabetes and in the time above range Less than 25% should be greater than 1, 80, less than 5%. Should be greater than 250s. So you can see here there's different recommendations based on age as well as how high above range or below range. And then again there's also different recommendations for pregnancy as well for your review. So this is an example of what it looks like. So when we pull this C. G. M. Report we get a really nice chart what tells us the time and range the time above range and the time below range. And I have some examples coming up later in this presentation. But basically it tells us what percentage of time the person is in range above range or below range. Other things you can get is the main glucose value, which is helpful. The glucose management indicator is basically an estimate of the persons a one c while they're wearing this sensor or device and in the coefficient of variation which talks about or gives us an idea of what the glycemic variability is. So is the person really low really high. The coefficient of variation might be a lot larger than someone that has very little variation in their blood sugars throughout the day. And this is a picture of what the HDP report looks like. So this is what we'll print out and start with. So there's a lot of different data that you can download from libre viewer clarity or one of the C. G. M. Platforms that you're using. This is just an example of a liberal view print out and really what you'll see is on the left hand side there's glucose statistics and targets. So we can see here that this person worked for 13 days and the C. G. M. Was active basically. Almost 100% of the time. We can see their average glucose was 1 73 and their glucose management indicator was seven I believe. That's a 7.6. However, they have a high glucose variability. So you can see here, it's over 49%. So there blood sugar is very variable throughout the day. So what we can see here looking at this graph is that they definitely have huge peaks at nine a.m. And then again between six and nine p.m. And then at the bottom we can look at their daily glucose profile and start to show the person with diabetes this is what your blood sugar is doing all day. And then they can start to make associations based on this data to their meals that they're eating, how they're taking their medications if they're exercising at all, it really helps them put it all together And then we can see in the top right, we have our time and ranges. You can see here they're high 23% of the time and it tells you the exact time in hours and minutes that they spend high and very high. Which is nice as well as low very low and in their time and range. So this is just another pictorial chart for GM targets. So for people with type one and type two diabetes we can see the target range is about 70% of the time. They should be between 70 and 180. It is nice that adjusts for older adults. So the target range they only have to be in target range greater than 50% of the time. And again you can see here the focus shifts to actually even having less hypoglycemic events so less than 1% of the time below 70 And in a little bit tighter range for people that are pregnant with type one diabetes. So if you're looking for more resources I know I kind of went through a lot of information in a short amount of time. Here's some C. G. M. Interpretation and training resources that you might find a value. So there's the idea project which is available at that link as well as the ADCS has personal continuous glucose monitoring playbooks as well as professional continuous glucose monitoring playbooks. So those are useful resources as well. Now I'm going to go over a couple of patient cases and demonstrate how we've used the G. M. To improve care for people with diabetes and cardiovascular disease. So this is an example of a patient RV. And we use C. G. M. Because he had high A one CS lower sm Bgs reported at home. So we were really helping this patient make the connection between what their blood sugars were and what was really happening throughout the day. So RV was a 71 year old Hispanic man who presented for a follow up visit for chronic disease management for type two diabetes hypertension, Hyperloop anemia cirrhosis. PVT and smoking cessation. He has type two diabetes hypertension. He uses tobacco and previous cocaine abuser severe PVT. And he has alcoholic liver cirrhosis. And he now abstains from alcohol. He has a bio prosthetic replacement. He had osteomyelitis of his right toe. So you can see it's a pretty complicated picture here, definitely someone that we have to keep under good management for chronic complications. Keep him out of the hospital. Well RB was only reporting sm Bgs are fasting plasma glucose readings when he was waking up every day at six a.m. So you wake up every day at six a.m. 1 35 1 26. He had one reading that was 64 he was always reporting that he feels low when he wakes up don't increase my medication. I don't feel well when I wake up. Well his most recent a one c. was 8.8 at the time. And he was taking that 400,000 twice a day, clip aside 10 twice daily, 55 units that receive a daily oh xem pick one mg weekly and guardians 25 mg daily. And he really didn't want to make any medication changes because he was low when he wakes up. So at this point you're kind of stuck you know, as a one c. 8.8, you're not meeting your therapeutic targets. You're not meeting the outcomes measures that are desired. And really for this person, they feel low when they wake up, they don't want to make any changes. So how do you help them identify and better manage what's actually happening with their type two diabetes throughout the day. So what adjustments would you make? Two RVs medication regimen and what lifestyle modifications would you recommend? Well, this is a situation where I placed a professional U. C. G. M. So this is an older patient on Medicare. So professional you see GM was our option just because it's only personally you see GM is covered in Medicare patients on basil um bolus insulin. And he's only on basil insulin as of right now unless he wants to pay out of pocket for the CGM system. So this would be an example of where I would use a professional U. C. G. M. So here what we did is we placed the professional, you see GM and as you can see he wore it for 14 days. And this really gave us a better idea of what was going on. So as glucose management indicator, estimated a one c. 7.8%. But the glucose variability which we want less than 36%. We can see was 42.3 And we can see as time and range is well below the goal of 70% at 47%. So this was an eye opener for him that he was spending five hours and two minutes very high over 250. Then looking here at his graph, we can see of course he's low in the morning as we expected based on his fasting plasma glucose readings. However, once he starts to eat breakfast he's high the rest of the day and in the long 18 and slim brings him back down overnight. And then again, we can see here is Daley logos profiles from the ADP report and we can see that he definitely goes high after breakfast, lunch and dinner. And then again this picture also just tells us it's another chart that's available in the C. G. M. Report um that you can discuss with the patient. This one shows you that he's having lows overnight. So what did we do for our b well we were able to talk him into starting mealtime insulin for units before each meal and since he was going low in the morning we decreased his basil insulin. We also usually when I start mealtime insulin, I don't necessarily just stop clip aside right away just because it is a pretty powerful anti hypoglycemic agent. So I decreased the basal insulin started mealtime insulin. And my goal is to taper off flip aside at a future visit once we get those postprandial readings and or better management. And then that was information that I was able to get a better optimized his therapy by using a professional U. C. G. M. Here's an example of patient case Sm and this one I use E. G. M. Again to optimize medication therapy and this one was a little bit different. I actually used a personal you see GM for Sm But I used it transient Lee. So sm is a 78 year old man and he presents for initial visit for chronic disease management For type two diabetes Parkinson's disease. So we had a little bit of dexterity issues and he has C. A. D. Status post Pc. I. His a one c. 8% prior to when I met him And he was checking two times a day. It was 90 210 when he woke up in the morning salary reports that every night he wakes up in the middle of the night at three a.m. In his self monitoring blood glucose Was between 50 and 60 in the middle of the night. So here we have a 78 year old man who's waking up hypoglycemic basically every night at 3:00 AM. So what can we do to improve his quality of life? Well, looking at his medication list, he is on Bezel am bolus insulin as well as Metformin er 7 52 tablets daily. So the first thing I did, I thought well he's waking up in the middle of the night so I definitely need to decrease his long acting insulin. So I decreased it down to 10 units a day. And I ordered him a freestyle libre two CGM system. So he was on basal bolus insulin. So he qualified for a personal use system and the first time I brought him back after wearing the system, this is what I found. So no surprise, definitely a lot of lows in the middle of the night. And another thing that's interesting about the freestyle system is even though it is an intermittently scan system so that the next time G six, it's just consistently reading with the freestyle libre two system as you may know, the person with diabetes actually has to scan it in order to get the results. But one of the things that's kind of neat about it is you can see the number of scans as well as the numbers. So you can see how engaged the person is in their care. So I'm looking at this graph and I'm thinking, Oh my gosh, this guy scanned over 10 times Between 12 am and two am here this one day? So he's really nervous about these lows. He's not just scanning it, thinking his low treating it and going back to sleep. He's up all night scanning and being worried about being low and checking what his blood sugar is. So again definitely a quality of life issue for this person. So what adjustments would you make the sms medication regimen and what lifestyle modification would you recommend? So the first thing I did was I just stopped his insulin gar gene usually I don't stop basil insulin before bolus insulin. However he was low all night so I definitely wanted to make sure I corrected that first. I could see he's concerned about it based on the number of times he's scanning. I also decreases insulin list bro from 10 units with meals to eight units with meals. And because he has a history of C. D. And P. C. I. I went ahead and started guardians from paying close in 10 mg daily And continued his metformin 752 tablets daily. So where did that put us? So one week later I brought him back And this is his ADP report. So we can see now as time and ranges up to 87%. He's spending only 2% low. No and we can see his blood sugar's look much better. He's still scanning frequently but definitely not having those lows in the middle of the night, waking him up. So what would you do now? So I continued the mpeg close in 10 mg daily because he'd only been on it for a week and usually will titrate it after a month. And I decreased his insulin list pro again from eight units to four units. So at this point I'm thinking does this guy even need insulin? He's having a lot of lows, he was having a lot of fluctuations. He's got C. A. D. He definitely needs to be on an SD LT two inhibitor or a STD reducing agent. So making sure that medication is optimized and then I continued his Metformin. So two weeks later this was his next ADP report that when he came in for his visit And as you can see here his timing range is increasing. He's now he's at 87%. So he's only got a little bit of um Bolus insulin. Metformin and Guardians. So what adjustments would you make to his regimen And based on that a G. P. Report and what lifestyle modifications would you recommend? So overall his blood sugars look pretty good. His time and range between 70 and 180 was 87%. Overall theoretically you could potentially just leave it as is But again he's a 70 year old guy. He's got Parkinson's he didn't have great dexterity. I went ahead and decrease his insulin levels. Pro improved his quality of life. Let's just take him off insulin. Let's increase his impeccable flows into 25 mg daily and continue metformin 752 tablets every morning. And then here was his final ADP report. So we can see here on just metformin and guardians from Pagan flows in 25 mg daily. We were able to get his blood work a one C. Down to 7.1%. So getting him at goal and you can see here he has a lot less variability In his a GDP report and his blood sugars throughout the day. He does go high sometimes but again he's 78 years old. So that's expected. We'd rather have him go too high than to go too low. So this is an example of how I really optimized medication management, improved outcomes. We've got him on guardians which we know as a cardiovascular risk reducing agent and now is a one C. Is down to 7.1 as well onto oral medications. And with that that's how I use C. G. M. And our practice to improve care for people with cardiovascular disease and diabetes. So thank you for attending our session today
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