Now that Doctor Wright has helped walk through how we utilize these A GP reports in practice. And Doctor Goldman has helped with that very key patient engagement component. We're gonna put it all together and walk through a couple case studies about how we actually use this in the real world world. And this is our chance to kind of show you how to think like an under provider and walk through each of these reports and really engage with the patients and apply what we've learned today to uh enact really meaningfully uh meaningful outcomes. When you go to back to practice on Monday morning, we'll start with uh clinical case number one. This is a real case. Uh All of these cases are actually real cases. This uh we have our first case studies, a 75 year old male with pancreatic genetic diabetes. And that's a fancy way of saying that the diabetes was caused by a some sort of pink source. So for some people that could be chronic pancreatitis leading to diabetes, it could be I I've had folks who had a uh who had diabetes develop after they were in an, in an M B A and sustained damage to their pancreas. Uh This particular individual was diagnosed with diabetes during a hospitalization for an M I. So there were a lot of theories as to why that might have developed at the same time. But in any case that this individual was diagnosed with a heart attack and diabetes in one hospitalization. So he was dealing with a lot and relatively new diagnosis for, for each of those, he uh was on a, the uh therapy of of semi glute or once weekly G LP one and a basal bolus uh insulin regimen using a carb ratio and a correction factor. So a pretty intensive regimen and the reason for that is, is people that are diagnosed with pancreatic uh diabetes or some sort of pancreas source. They are technically type two because they don't have that autoimmune component of it. But the uh pancreatic production is very low. So they essentially kind of function like type one. So they're in a little bit of an in between type. So that's why it's important to distinguish that that pancreatic source. So he technically, since he's type two, he was on a G O P one, but he also needed to be on lifelong insulin therapy. He was on a, a continuous glucose monitor. And this was one of the follow ups when I saw him, his A one C was at 7.1%. So at that age and a age 75. That's considered a great A one C and we have his A GP report here. So I want you to kind of walk through this A GP report and think what you might, what kind of questions you might ask this individual, what kind of recommendations you might have or would you think? I, I think he's doing well as a one C is at Target. He, he looks relatively flat on the A GP report that that looks pretty good overall. So let's start breaking this down. We have a lot of information on that first page of the A GP report that is so helpful and we can, can glean so much information from that. There are a couple of great things that I see here. First of all, 100% C G M active. That's great. So he's wearing it and the technology is functioning and that 14 days is usually a good representation kind of a, a good overall view of how the glycaemic control is. Our average blood sugar, our average glucose was 1 52. The G M I is the glucose management indicator is showing maybe a hair lower than we would have expected for that. A one C just a bit though 6.9%. And we've got nice glucose variability that coal fish in a variation is under 36. So we don't have a lot of that roller coaster that glycaemic variability. And we always want to see more green, less red. And particularly at this age, we want to try to get that red as close to zero as possible. So at first glance, this seems pretty good. So we've got time and range at 75%. Time below range is at 0% and the rest is high. Now at his age, his age is 75 his target time in range is set at over 50%. So we have to shift our, our thinking and shift our goals depending on the overall risk of the patient. So as we get older, we are more likely to have the adverse effects of hypoglycemia. So we want to be farther and farther away from that. We liberalize our, our A one C targets as people get older and we reduce the time and range requirement as people get older as well. So let's break this down a little bit more. We have the, the overall look at all those days kind of later on top of each other. And again, it looks pretty reassuring, right? We are not seeing anything touching the the green bar on the bottom. We're seeing relatively flat on our, our glycemic control. We got a couple of outliers here and there, but uh overall not too, not too shabby. However, even lower down on that page, I would encourage you to look at the daily glucose pro profiles when everything looks like it's on target. Let's look at the day to day variations. We don't have to belabor each individual day, but this gives you a little bit of insight as to what they're seeing, not just all the 14 days laid over each other, but day by day, what that patient is actually experiencing when they are looking at their, their sensor. So what, what I was able to identify on, on this uh individual was that we are, are seeing uh our peaks followed by a pretty good dip afterward. We don't necessarily hit hypoglycemia every time, but we kind of kiss hypoglycemia and come back up. So this was happening multiple days out of the week where we were, we seeing uh a, a peak that came down and almost went low. So it's important to, to at least when everything looks good. Let's break it down day by day, make sure we're, we're still nice and flat and if not, we need to make some adjustments. Similarly. Uh If you, if you go to the subsequent pages, if you've identified something on that, that daily log, doesn't that uh that overview of the daily log doesn't look quite right, we can go into a deeper dive. And as you see here, we are seeing, even though it's not showing up on the A GP report, there were isolated incidents of hypoglycemia typically in the afternoon. So this is an, an an important time to engage with your patient and talk to them about what's happening throughout their day. So we can figure out what that trigger is for hypoglycemia. We know that this individual has pancreatic genetic diabetes. So we may or may not have as strong a gluon response depending on what the source of the pancreatic injury was. And we add the, the age that this individual is 75 years old, he has had a history of an M I. So we really want to avoid that hypoglycemia if we can safely do so because that, that hypoglycemia does increase the risk of, of those adverse effects uh quite significantly. And if we just look at the A one C and the G M I and the time and range, we don't necessarily capture those intermittent hypoglycemic events and we can be lulled into a false sense of security that the time and range is exceeding the goal great. We're even over 70%. So we might say great. Uh You know, I've got an extra 10 minutes to be able to catch up on my charting. You're doing great. But I want to encourage you that if, if you're individual is, is far exceeding the goal that you've set for them, that the age appropriate and risk appropriate goal that you've set, then we, we would want to dig a little bit deeper, you know, some, sometimes I can see times in range of over 80 or over 90% and there is that temptation to say great. You're doing wonderful but that's a good time to dig in a little bit more and make sure that those daily logs are not revealing something else entirely. What we saw with this individual was a pattern of those after afternoon hypoglycemic events. Some of them appeared to be after a normal blood sugar. Some of them appeared to be following hyperglycemia. So here's where that patient engagement really comes in. We need to ask the patient what's going on during those times. And the way that I asked this is uh is there any pattern that you've noticed for these low blood sugars is or anything that seems to trigger the lows? Is that when you need to eat or after you've just eaten, is it after exercise? Is it after there's been a long time since you've eaten? What do you notice that that tends to trigger and usually that they will tell you about what's happening that triggers the low or what they tend to do at that time of day or night. And in this particular individual, he is active in the afternoons, he tends to do his exercise regimen after lunch. So he is having to compensate for impending hypoglycemia because he's getting alarms on his, on his sensor. So he ends up eating either a fig bar or an apple or a banana something when he's active to prevent him from going low. So, in this situation, there are compensatory steps being taken to prevent impending hypoglycemia and in that situation, we need to lower his overall insulin doses to prevent these compensatory steps. So let's break it down the issues that we've talked about. So first that pancre allogenic source of, of diabetes. So we definitely need to do our hypoglycemia safety plan with this individual. We need though, they are technically dealing with type two diabetes. We need to think about this individual like they have type one diabetes and talk to them about hypoglycemia and severe hypoglycemia and the use of Glucagon with that with his age and his history of an M I using agents that are low risk of hypoglycemia if possible. Unfortunately, for him, we can't eliminate that altogether, but really stacking the deck in his favor and using cardio favor favorable medications that's going to be very important when we see that A one C G M I and time range don't necessarily represent what kind of hypoglycemia pattern that we're dealing with. That's when we go down to those daily logs and we can start with that very first page on the bottom. See if there's looks like there's any pattern where we might kind of kiss hypoglycemia and dig into that a little bit more. If he is having afternoon hypoglycemia, when following exercise, we can have him cut his NovoLOG or his aspart dose by into half prior to his exercise or if he's about to eat right afterward, he can cut that aspart dose in half uh when the, for the meal immediately following exercise. So essentially we wanna cut the, the short acting insulin in half for exercise induced hypoglycemia. He is adding extra calories to compensate for hypoglycemia that's impending. So that's going to cause a variety of issues. Of course, that may make the A one C end up going higher because he's having to eat, it may make his weight go up, it may make other metabolic parameters look unfavorable because we're having those extra calories come in. So the best way is to eliminate the hypoglycemia and the impending alarms by reducing the overall, uh, insulin demand or the insulin doses. So that we reduce those excess calories that are coming in. Our second case was graciously shared by Doctor Eden Miller. Again, an actual case that, uh, that she saw, we have a 66 year old female who has type two diabetes. She has a history of renal impairment and she's currently on a suona urea, unfortunately, her A one C does not match her glucose test. So we have this discordance in results. And I, I think I will raise my hand that I saw that today in the clinic and I would wage her to say you've probably seen that too where the A N C doesn't match the glucose reading. So something is amiss. So at first glance, we can look at her for a GP report and I'll, I'll challenge you and think about what are your first impressions when you're looking at this, a GP report and we'll kind of walk through each of those steps. So, are you seeing, uh, are, is she hitting her her time in range? Target? Is her time below range at target? How is the activity? Are, are we seeing that we're wearing the sensor consistently? How's the glycaemic variability? What are her average glucose ratings? This is unfortunately a relatively common scenario where we have folks who have kidney disease. We talked about how diabetes is the leading cause of end stage renal disease in the US. So people who have kidney disease, who can't take Metformin and they're instead put on a Sophon Urea because it's inexpensive and it's been around for a long time. So a lot of clinicians are comfortable with that. But unfortunately, Sophon Aas are excreted renally. So we may see a difference in how the body actually processes the Syphon AA when C K D is present. And that means that we can see an increased risk of hypoglycemia for somebody with diabetes and C K D versus somebody who just has diabetes with normal renal status. When we see some of that variability that we'll talk about on the E GP report, it's, it makes our A one C not as reliable and not as reassuring. So we can see even if our A one C looks good. Overall, if we see those ups and downs, we're not really seeing a, a good indication of how that glycaemic control is. The A one C is not as reassuring. Add to this, that folks that have kidney disease are also at increased risk of developing cardiovascular disease. So we have to be thinking of renal protection, but also cardiovascular protection in those individuals before, ideally, before coronary artery disease or cardiovascular disease develops. So let's dig into her ad P report. And what, what do we see first? Great Pine active, we're at 97% active. So she's wearing it and the technology is cooperating her G M I is showing uh she's at 7.3% but we have relatively high glucose variability. That coefficient of variation is over 36. So we're seeing more of that roller coaster or she's seeing more of that roller coaster on a day to day basis at her age, that time and range. She's hitting that target. She's 66 with a history of renal impairment on the Sophon area. So her time in range would be considered over 50%. But we do see about 2% time below range. And again, that variability is happening. So this um actually demonstrates that variability. So what, what clues us in if we're not sure, what was that coefficient of variation that we're supposed to remember? Was it 36? Was it 30? I don't remember, then we can look for the big spread. So a little bit further down, you'll see all the days laid on top of each other. And we see this huge spread variability. So the wider that uh those clouds get, the more variable we're seeing that, that glycaemic control on a day to day basis. So we have everywhere from overnight hypoglycemia to afternoon hyperglycemia that goes even beyond what the scale is showing. So we have a huge variability going on here. And if we break her day down, all of her daily glucose profiles and see what kind of pattern we're dealing with. We have these episodes of pretty profound hypoglycemia and these are nocturnal hypoglycemia, which is some of the most dangerous hypoglycemia because our body has to go so much lower when we're asleep. In order for the symptoms to be able to wake us up versus when we're up moving around, we're more likely to do to notice those symptoms if we have hypoglycemia awareness. So, nocturnal hypoglycemia, nocturnal hypoglycemia, we consider much more concerning and we need to remedy that uh very quickly. Again, we're really looking at these, these glucose patterns and that wide variability, we see a big spread, uh particularly her titus range is actually when she wakes up in the morning and then from there, we have a huge spread and overnight that spread continues. So let's break down some of the the issues that we've identified for for this patient. Number two, we have a lot of variability. So we have variability within each day from morning to evening and we have day to day variability. Monday doesn't look like Tuesday. We can see this pattern of that nocturnal hypoglycemia and then uh the poor postprandial control. So again, those lows overnight, those highs uh towards the end of the day. And of course, we've identified that Syphon ar use alone in C K D does increase that risk of hypoglycemia. So what are some solutions? What we, we might look for, we could reduce the dose of salon aa, particularly her evening dose. I do see some, some people, some providers who recommend a bedtime snack, that is an option that we can use. Not ideal though, because then we're eating to treat the medicine versus the other way around. So the most ideal situation would be to reduce the medication or change the medication to prevent the hypoglycemia from happening and prevent those excess calories from being needed. We could think about some cardiorenal protective alternatives. We know she already has C K D that does increase her risk of cardiovascular disease as well. So, utilizing our, our diabetes agents that have cardiorenal benefits would be preferred and then we can move to case number three. You're very busy in the clinic today. You're on to your next patient that has a A CD M. And again, real patient, real patient that I saw 57 year old male. He has type two diabetes and he has already established coronary artery disease and chronic kidney disease. He's on a basal insulin and a weekly P O P one. His A one C, I don't think there are any arguments here. A one C is suboptimal. We're at 9.1%. So we take a look at his A GP report and I want you to go through each of those steps that Dr Wright walked you through and see what your, what your impression of this. A GP report is what's going well and what's going not so well. And I will pause here to say it's good to underscore what is happening. That's good. So, in this situation, yes, we have a high A one C and uh we are not seeing as good control as we want to see, but I'm gonna highlight a couple of things in this individual starting with. Thank you for wearing your senses are consistent and I'm glad it, it seems to be working for you 98%. That's excellent. I, I'll, I'll say, you know, gold star um on wearing your C G M consistently. So we always want to make sure that we underscore what's being, what's right and what's healthy as well as what maybe needs improvement and we'll dig into that ad P report. So a couple of things that, that stick out to, to me right away, uh that, that G M I, the glucose management indicator is lower than what that A one C was and they're never going to match. Exactly. But whenever I see this, that an A one C, which is our three month average versus A G M I on that two week pattern. If that's moving in the right direction, that's usually reassuring that we are probably moving in the right direction. So I would underscore that piece as well. Ok. It looks like, like on average, we're doing a bit better for our numbers. But again, that's just on average. I see good glucose variability. We're under that 36 mark. Now he is a bit younger than those first two patients that we dealt with. So our time and range goal is not 50% for him. It's the traditional over 70%. And then we want to see the, the low blood sugar that time below range be less than 4%. Let's break down his, his days. So we're laying all those 14 days over top of each other where we've got that dark blue line as the average, the medium blue is the majority and then the lighter blue is the outliers. But again, that's not 100% of the numbers. It's just the, the, uh the vast majority of them. So what we can see is this, this area here, we start to see this big spread. So he start, he starts off the day, relatively good, relatively tight. Um On average, his numbers are good, but then we see a spike happen and then that's when that variability really starts to happen. So even though his coefficient of variation is good, so on average, he's not too variable this particular time of day, he has a pretty widespread. So we need to figure out why that is. So we break down the bottom of that first page with our daily glucose profiles and see what our problem areas are. And we see here that he is having a spike and then he tends to go either low or almost low after that. So we see that that pattern start to emerge. So if once he ends up going high, then it starts this ripple effect happening again, different way of looking at it, you can pick and choose what page of that A G Q report you like the best when you're looking at at these glycaemic patterns. Uh This is a very simplified approach that snapshot, we don't have the different gradations of blue. We just have that average and the uh the total and then it does highlight those low glucose events. So this is a, a very simplified version that can be quite handy if we're needing a, a quick look at how the glycaemic control is. So in this individual, we have that variability in the afternoon, particularly the afternoon and the evening. So we need to address that. Uh he's high at bedtime, sometimes drops at night, he sometimes drops in the evening. We need to address why that's happening and then he does have or postal control, not 100% of the days, but he does have some days where he has pretty big spikes after meals. So what can we do about this? First? Talk to the patient, ask them about what they're seeing, what kind of triggers they're noticing what situation tends to trigger a high, what situation tends to trigger a low? And a lot of times we can get some, some valuable information that only the patient can give to you by having that conversation by engaging that patient in the discussion. So it might be what they're eating. Are they on and off uh, a diet? Are they eating out frequently? Are they going out to lunch more than they used to? What is, what has changed or what maybe is variable in their diet? Are they comfortable with carb counting? Not so comfortable with carb counting. Are their meals being delayed? So, if their, their meal is delayed, a that could unmask some hypoglycemia or it can cause overeating. So that's an important detail to talk about. Are we over correcting with insulin? So either by what we've told them to do, their correction factor is too aggressive or are they increasing their insulin a little bit more when they see those high numbers, stress is one of the factors that can really cause a blood sugar to spike. And of course exercise depending on the type. But typically we're talking cardiovascular exercise or that, that aerobic exercise, we're going to see that drop in, in blood sugar. If the patient is not readily able to tell you what some of those triggers are a diary with close follow up would be helpful in this situation. Couple of things that we can do with that basal insulin, we could reduce it overall to, to prevent that baseline from being quite so low. We could split the, the basal insulin depending on with our first generation of basals versus our, versus our ultra basal. So that's our, our, uh, glargine U 100 our, our, um, our, our Deere U 100 then we, we are more likely to need to split those to get a little bit flatter profile. But either way, addressing this issue with the, with the basal insulin is going to be important. The reason that this really came to light is because the patient actually identified that he will eat at bedtime is if his blood sugar is under 200 he is, uh, not necessarily, he's not over the age of 65. So he's not somebody I would say at the highest risk of hypoglycemia, but he does have kidney disease and heart disease. So I am concerned about those, but this is something that speaks to me of fear of hypoglycemia that there's something that makes him want to eat or like he needs to eat. If his bed time reading is less than 200. And upon further discussion, when we, we got, uh, discussed that a little bit deeper, uh, it turns out that his libra will actually alarm, uh, for him if he, for impending hypoglycemia overnight at about three AM, if he doesn't eat. So, this is disrupting his sleep, it might be disrupting his, his partner's sleep. It's certainly increasing his overall risk because we have nocturnal hypoglycemia or impending nocturnal hypoglycemia. So, this was such key information that tells me exactly. We need to reduce that basil because it's causing him to drop unless he adds those extra calories coming in. Now, he has kidney disease. He has cardiovascular disease. In the back of our mind, we always need to be thinking about stacking that deck in our patients favor if they have established cardiovascular or coronary artery disease, cardiovascular disease, chronic kidney disease, we need to be thinking about our cardio favorable and are real favorable medications. So utilizing either an S G L T two inhibitor, um he's already on a G LP one. So adding an S G L T 22 inhibitor might not be a bad option for him with of course, further reduction in the insulin if you have decided to add that, so that could help not only to minimize the risk of hypoglycemia, but to add our, our agents with extra glycemic benefits. So, outside of just a one C reduction that they actually can help improve cardiovascular and renal health, putting this all together as our, our kind of final take home thoughts that we know we've known this for a while and we know that our patients experience this is there is quite a bit of a variability in the disease itself. So having diabetes does not necessarily put you in a, a box, that's the same as, as your neighbor. We can see a lot of difference in, in how the disease behaves, how the glycemic control is what triggers we're seeing how the response to medication is from person to person. But even from day to day, something I very commonly see say to my patients is that no, two days living with diabetes are the same because there are so many variables that can impact glycaemic control. So knowing that we have all of these variables at play and there is such heterogeneity in this disease. Then we, we know that we need better tools and and reliable tools to help manage this disease on a day to day basis. Those glycaemic patterns that your individual identifies or that you're able to identify on an A GP report and give valuable insights into how this person's diabetes and this person's specific management, specific triggers are working or maybe not working. So that is an ultimate iteration of individualization of therapy. When we're able to gain that kind of insight into the disease management, this helps reduce our risk of complications, helps reduce our risk of hypoglycemia. We've talked about both the randomized controlled trials and the real world data that supports this. It helps to improve adherence overall and improve the level of disease burden that person who's living with this disease may or may not be experiencing and it helps reduce our clinical inertia. So if we're seeing that variability happen and we have no idea what some of these triggers are or we're seeing that A one C is high and we can't seem to bring it down. We may become frustrated or the patient may become resistant to adding more medications or higher doses. But if we're able to identify their specific glycemic patterns, we can make much more individualized treatment recommendations and the patient can more confidence, accept or, or weigh in about those treatment decisions when they feel more empowered and more control over what may be triggering their, their blood sugar to increase or, or decrease. So overall, this provides valuable insight to specifically individualize that treatment for our folks that are living with diabetes. And in this new paradigm of medicine, that individualization of therapy is so key and we now have great tools to be able to do that.
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