Video CGM-Mediated Improvements in HA1c and Regimen Adherence in the Setting of GLP-1 Agonists Play Pause Volume Quality 1080P 720P 576P Fullscreen Captions Transcript Chapters Slides CGM-Mediated Improvements in HA1c and Regimen Adherence in the Setting of GLP-1 Agonists Overview CONTINUE TO TEST Back to Symposium Thank you, Dr. Jean, for the introduction. So I'm happy to present here at the ATTD meeting. Um, my name is Monica Kellera. I'm an endocrinologist working at the St. Mary Hospital in Stuttgart, which is a teaching hospital of the University of Tubingen in Germany. So the title of my talk is CGM Medited Improvements in HBO 1C and Regiment Adurance in the setting of GLP1 receptor agonists. These are my disclosures. These are my disclosures, and when we talk about state of the art treatment in patients with type 2 diabetes, ADA and EASD guidelines recommend a patient-centered approach implementing an individual treatment plan, as well as providing ongoing support and monitoring. It's also suggested from the guidelines that every person with type 2 diabetic patient, uh type 2 diabetes um should be um emphasized to monitor uh behaviors and monitor also blood glucose um levels or glucose levels in order to achieve the desired health behavior goals. Um. When it comes to medical treatment, then um the foundation is before um any kind of medical treatment. It's lifestyle modification, um, it's diabetes, self-management, education, and of course, glucose monitoring. And then if a patient has to go on medical treatment, usually it's recommended from guidelines to start with oral medication plus minus GLP-1 receptor agonists first, then at if needed base insulin and the and the final step would be addition of bolus insulin in people with type 2 diabetes. When it comes to diabetes technology, ADA and EASD guidelines from the year 2022 um said that technology can be useful in people with type 2 diabetes but needs to be part of a holistic plan of care and supported by diabetes self-management education. The most recent standard of care in diabetes from the ADA from this year recommended use of CGM in all patients with diabetes being on any kind of insulin treatment. Um, CTM use should also be considered in patients without insulin treatment to achieve and maintain individualized glycemic controls and in circumstances when consistent use of CGM is not feasible, it should be considered to use it periodically, um, uh, to, in order to adjust, for example, medication or um to modify and improve lifestyle. Well, um, from the guidelines, um, we, um, have the recommendation that when it comes to injectable therapy, GLP1 receptor agonists should be first before, um, insulin injection. So we have quite good data with the use of CGM and the role and impact of CGM and insulin using patients and of course I think it's also a very important question what is the place of CGM in the background of GLP-1 receptor agonist treated patients and exactly this have been Um investigated by Miller and colleagues. It's a retrospective trial and they investigated from the optims the identified market clarity data, patients with type 2 diabetes being not well controlled, so their HbA1c was above 8%. And they had the definition of a baseline period of roughly about 180 days. After this, the glucose, a continuous glucose system here in this case freesty Libre system have been initiated and patients have been followed for another roughly 180 days. So the Results are shown here on this slide. Um, HA1C was high with 9.8% in patients using already GLP-1 receptor agonists and have not been well controlled. And after initiation of a CGM system, in this case here freestyle liberal system. The HbA1c really improved to 8.3% after six months. So this is a difference of 1.5%, which I would say really compares to one of our most effective medical treatments, but this was not medical intensification. This was initiation of a CGM system six months before and as you can see here on the right side. Um, patients, more patients also reached a goal of less than 7% or less than 8%. Now, um, in the same trial, um, if we look into subgroups of patients um initiating um the CGM system, uh, and here we can see on the very right. uh non-insulin users and they had just the same positive effect by initiation of a CGM uh compared to um basal insulin uses or intensive insulin therapy uses so no difference between. Um, non-insulin uses in the benefit of um CGM system compared to um insulin therapy uses. And also no difference between different kind of GLP-1 receptor agonists as you can see here on this slide, and no difference whether the patients have been treated or Ready for a longer time or a shorter duration with a GLP-1 receptor agonist, so they all they are pretty consistent through all this subgroups. What we, however, can see is patients having at baseline higher HbA1c levels like this year of 11.5%. They got even a more pronounced um um drop in HbA1c, which comes to a difference of even 2.7%, but still the one having moderately increased HbA1c, um, these, uh, patients also show a reduction in HbA1c of 0.8% just with the initiation of the CGM system about six weeks before. So, Um, this is, I think, um, clearly, um, uh, evidence that, uh, in patients being not well controlled on GLP1 receptor goodness, the initiation of a CGM system could. Help for better control and better HbA1c goals. Now how is the situation in patients who started with a GLP-1 receptor agonist treatment, and there are two groups here. It's another retrospective trial from Wright and colleagues published. It's um 240,000 patients being initiated first time on a GLP-1 receptor agonist, and uh 478 patients uh have been additionally initiated uh with a CGM system. So GLP-1 receptor agonist together with a CGM system. Uh, system in 478 patients. Um, the data have been analyzed as unmatched and matched control, matched by age, sex, baseline HbA1c and kind of treatment they had and again the The population here have been people with type 2 diabetes um initiated with GLP-1 and being not well controlled with a medium HbA1c of more than 8% now. These are the data here. On the left side, we can see the unmatched control. On the right side, the results um from the matched cohort. Now, uh, what we can see basically in all arms is um that initiation of GLP-1 receptor agonist treatment. results in a nice reduction of HbA1c. However, these patients having um also um a GLP-1 together with a CGM system, they even show a more pronounced reduction in HbA1c which comes to a difference of 0.7%. In the unmatched group and of 0.37% in the matched group, which was both statistical significance. So again, evidence here that when a patient has been Um, initiated on a GLP-1, he gets more HbA1c reduction if he or she initiates it together with a CGM system. So if a CGM system is used in addition. Um, I'd like to do an interim summary here. So the trial from Miller and colleagues show adults with type 2 diabetes and prior GLP-1 receptor therapy experienced significant improvements in HbA1C 6 months after initiating CGM. And this was um an irrespective of GLP1 recept diag agonist duration, GLP one recept diagonist formulation, or um the kind of insulin therapy used. The other trial I have shown you from Wright and colleagues um here, adults with suboptimally controlled type 2 diabetes initiating GLP-1 receptor agonists together with the CGM had greater improvement in HbA1c compared with those treated with uh GLP-1 receptor agonist alone. So let's switch from this point a little bit to um treatment adherence and let's talk a little bit about adherence and treatment inertia with CGM-based therapy and what's the role of CGM-based therapy when it comes to adherence and treatment inertia. And the first trial I'd like to show you here is from Harris and colleagues. It's data from the Canadian National Private Truck Claim database, and the design of the trial is briefly shown here. There was a selection period defined for 12 months. Then at the index date, the patient got the CGM system for the first time. And uh these uh patients have been further monitored for 24 months, um in terms of um treatment progression, so treatment intensification. Here we can see that the patient cohort has been divided into two groups, a naive cohort having no treatment and no blood glucose monitoring during the 12 month selection period which I have shown you before. And the other cohort was an experienced cohort being already on treatment in here in category 1 or 6, which is oral or or oral together with GLP-1 or no drug treatment, and another category was category 7. With ba insulin therapy. Category 8 was excluded because they wanted to exclude type 1 diabetic patients in this cohort. Now, let's go to the data. And we can see here on the y axis, the probability of treatment progression from the index state during the whole follow up of 24 months. The yellow line on the line from patients with a CGM system, so with a freestyle li system. Solid lines are in non-insulin uses. dashed lines are insulin users, and the blue line are those patients um being not on a CGM, they only did do blood glucose monitoring. What we can see in both cohorts is that patients or people with type 2 diabetes using CGM had a greater probability for treatment progression. So thus, CTM might be useful to improve therapeutic inertia in patients with type 2 diabetes. So I think um these data clearly support um this um theory and um um Another um trial or it's more a survey than a trial from Porta and colleagues. Um they uh put patients um newly on a CGM system and about 24 weeks later. They performed the survey and asked different questions and uh the answers um after um 24 weeks' use of a CGM systems have been that um more than 90% would like to work a CGM. Uh, system on a regular basis, 84% excluded or limited certain foods um due to the data from the CGM systems. 96%, 96% uh self-reported weight loss from CGM use and 84% um. said that they're more motivated to increase activity levels. So I think these small survey suggests. And supports the idea that the CTM might be really a helpful tool for improving treatment adherence. And going from a small survey here to former RCT randomized control trials, I think they also confirm this idea and the conclusion from this randomized trials was also CGM is a useful tool for motivation and intervention. To improve HbA1C CGM helps um for behavioral modification and uh it reduces postrandial glucose excursions. So also from former trials, um, evidence that CGM can have uh treatment to improve treatment uh adherence. So now from former trials to um most recent presentation here at the, at the ATDT trial, uh, the front uh Frontier study um investigated health resource utilization and HbA1C change before and after CGM adoption in type 2 diabetic patients without insulin therapy. So, Um, the cohorts have been divided into two groups, one using GLP-1 receptor agonist plus minus oral glucose lowering therapy, the others have been on oral therapy only. What we could see from this um trial presented at the ATTD overall, uh, the emergency department visits and hospitalization fell in both groups after starting. Uh, CGM HbA1c was statistically significantly reduced in both groups. Lower trends were seen for emergency department visits and hospitalization in DKA and hypoglycemia. And just to show you. The difference in HbA1C before and after initiation of uh freestyle leper system here um in the GLP-1 receptor agonisttrated group, they dropped down from 8.1% to 7.6%, so a difference of 0.6% with the use of a CGM system. And in the oral treated group only a difference of 0.3% um in HbA1c, which was also clinical, uh which was also statistically significant. Another very interesting trial here at the ATTD um congress presented was this one by Huang and colleagues, and they analyzed whether patients being on a CTM system show um different uh discontinuation rates on a GLP-1 receptor agonist treatment. They um um analyze patients uh being on GLP-1 receptor treatment with or without a CGM system and after adjusting for covariants, consistent CGM users were significantly less likely to discontinue GLP1 compared to non-CGM users. So this study suggests that regardless of therapy type, consistency GM use is associated with a significantly lower risk of GLP1. Receptor agonist discontinuation, potentially enhancing uh potentially enhancing adherence and improving long term glycemic control in people with type 2 diabetes. So I think that's also a very interesting study and just to show you the uh graphs here in blue patients being on TLP1 receptagonist and you see the discontinued. rate with uh with time in non-CGM users in the blue line and the red line are the CGM users, and here we see a significantly lower discontinuation rate which supports the idea that CT, the use of CGM really helps for um treatment adherence. Yeah, with this, I would like to complete my summary in addition to the points already mentioned before. CGM has shown to be useful in reducing therapeutic inertia. CGM supports patients with type 2 diabetes to be more adherent to healthy lifestyle behavior. And with this, I would like just to finish with a practical uh clinical case from my outpatient department. Aha, she is a 55-year-old woman originally from India. She has type 2 diabetes for 8 years. Some diabetes complications like polyneuropathy and retinopathy, her HbA1c. Six months before I saw her first was 7.8%, and I saw her first last summer actually with an HbA1c of 9.1%. Blood pressure was pretty good and her BMI was uh increased uh with 28 kg per square meter. Her most recent anti-diabetic medication when I saw her first was Betamine, uh, the SGLT2 inhibitor Aglyflosin and GOP1 receptor agonist semaglutide, 1 mg per week. Some Um, of her social history is given here. She's married, works as a philosophy professor, and commutes often between Stuttgart and Berlin. She attributes her recent worsening of glycemic control on her irregular lifestyle and concerns about her mother's recent health issues in India. And due to some stomach problems, uh, she also sometimes skipped her weekly GLP-1 receptor agonist. And when I saw her first, she said she's really worried about her high glucose levels, uh, which, um, she is afraid that this could cause her even more severe diabetic problems and she has already some complications on Uh, the nerves and the eyes. So when I saw her first, we had very limited glucose data with SMPG values of the last 5 days, mostly fasting actually with values around 250 mg per deciliter, as you can see. See here on the bottom. And um if I would ask you or I could ask you what choice would you, uh, what would you, um, go for the next step in Esher's case. So, um, I have here 4 choices. Give one, no change in weight, you might improve. Second, start basal insulin treatment if not on target with GLP-1 because she's already on GLP-1. Third, uh, re-evaluate lifestyle habits and give advice for improving glucose control, and 4th, get more information by introducing CGM. Well, I guess most of you wouldn't wouldn't go for 0.1 because she's really out of the range and she comes in and seeks really help. So, um, to tell you what we, uh, uh, did do, we vote for. 3 and also 0.4, so we decided to give her um a CGM system to get out more information how her um glucose um is really uh doing and how she is managed. And we also decided to reinforce, uh, reinforce. lifestyle management before escalating medical therapy in her case before um initiating insulin therapy and as you can see um this is also in line with the ADA EASD statement. It's also Um, emphasize that reinforcement of lifestyle and uh diabetes self-management education should be considered before escalating therapy, medical therapy at least. Now, well, she has already mentioned, she got a freestyle Libre 3 system uh last summer for the first time and about 2 weeks later she came, came back and that was the analysis, so the HEP profile. And what we can see, the blood glucose values are um really, really high with 250 mg per deciliter. You, you can also see here in the bars above that her time and range is really low with 23% and her uh glucose management index was 8.8%. Well, we reviewed this um glucose profile with the patient and then she says she has to work late into the night at her desk and she snacks a lot at the desk, and she also often eats fast food during the day because she has to commute pretty often. Well, what we, uh, uh, thought is, and what we saw was that her snacking, especially when she was sitting on the desk during the night, um, uh, during this, this time frame, um, her, um, blood glucose or her glu Those values are really going up. So we tried to to fix that and with the high glucose values she got during the night, she took them over the whole night and basically she kept these high values over the whole day. So asking you again, what would your recommendation be as a next step for this patient? So 3 choices. One, start with basal insulin to reduce the high fasting levels. Could be one choice, of course. Second, discuss the CTM data with patients, show the influence of snacking and motivate to make a change. And third, Increase probably GLP-1 receptor agonist dosage. Well, um, I would say there is no, nothing really wrong, so we, you, we could go for 12 or 3, but we decided to go for uh 0.2. So what did we do? Our diabetes educator discussed CGM profile, gave nutritional education, and motivated the patient who seeks seeks help by diabetes self management education. We did not increase. GLP-1 receptor agonist dosage, but we encouraged her to inject it really regularly and she could see how she reacts on GLP-1 because she could see her glucose levels in real time. So with this and with um weekly telephone contacts we had really with her about approximately 4 weeks later we got this AGP profile from the Free Libre 3 system and as you can see here is that uh timing range already nicely went up to 50, 56%, so still not optimal but already better. Uh, glucose management index was 7.4%, and you can also see her night rise in glucose levels was not, uh, not so much there anymore. So she was, we thought, on a real good way and uh we just, um, decided to encourage her more also for more physical exercise and um. Uh, she was very much motivated, um, with this, uh, strategy, um, we had. And um I saw her last time in January this year, so this is half a year later from the first appointment. And what you, um, and what you really can see here is that she is doing really, really good. She has a time and range now of 92%. Her glucose management index was 6.2%, and she has a nice glucose profile which you can see down here at the bottom. So when I talked to her in January this year, she says to me, to be honest, I never really like to do the finger pricks, and with CGM I get out so much more information about my glucose level in everyday life. This helps to manage my diabetes much better, especially in my stressful situation. And since she's a very intelligent lady. Um, this information with CGM really helped her to start to change her lifestyle step by step, and she could successfully reduce also the weight by 3 kg the last half year and her HbA1c in the lab was 6.6%. So she was really happy and we, um, and the diabetes team have also been happy. And I think it's worth to mention at this point that in her case the introduction of CGM made it possible to postpone the start of the insulin therapy, and I would really like to see clinical trials asking this. A question in a broader population. So maybe there are some trials coming because I think that's a very, very interesting point that CGM could probably postpone insulin treatment. With this, I would like to stop here at this point and thank you very much. Um, for, uh, your attention and wish you, um, a really interesting um meeting and interesting discussions at the ATDD meeting in Amsterdam. Published Created by Related Presenters Prof. Dr. med. Monika Kellerer President of the German Diabetes Society (DDG)Medical Director Center for Internal Medicine I Marienhospital StuttgartStuttgart, Germany
