Okay thank you so much Gene and Eden for your contributions and the discussion that we have had about how to really take apart C. G. M. And put it into practice and include it with your team management approach and jean breaking down those reports for us. I'm gonna take some time now to actually show you how I have used continuous glucose monitoring In patients that I've actually seen. So these are real world case management um sessions that I'm going to review with you today. So our first clinical case is a woman by the name of Lydia. She's 78 years old and has had type two diabetes For over 20 years. Her current a. c. is 7.2%. So not bad. She's performing blood sugar testing at least 3-7 times a day as her schedule permits. So she says she's a librarian. Um and sometimes she's not able to break away from what she's doing. She has a history of chronic kidney disease. Not surprising she's probably got some age related decline in addition to just having diabetes for 20 years and maybe some high blood pressure and so on and so forth. Her diabetes management includes a symphony Arria and basil insulin. She is a widow. She lives alone and independently so she's still in her own home and like I said she works at the local library. So why would I want to be even thinking about C. G. M. And this woman who seemed to be doing fine. She's testing her blood sugars. Well she has described that. She feels like she's having a hard time getting her blood sugar under really good control. And she's looking for a discreet way to actually check her sugars that doesn't interfere with everything else that she's doing. Her words were I don't want bloody fingers when I'm handling books and I wouldn't want blood on a book that I borrowed from the library. So mutual. We also have a desire to minimize the risk for hypoglycemia. And Hypoglycemia begets hypoglycemia and and for someone what type two diabetes for 20 years. Um there's a risk that she's probably been experiencing it and may be unaware of the symptoms the longer they actually have the disease. So this is her blood glucose log and as you can see she is testing quite frequently. Um and she even puts down her comments of what she did during the day or how she felt or what she might have eaten to kind of explain some of those blood sugars. So when I look at this I see one blood sugar that's less than 70, just one out of this whole week's worth of data and it's 59. So it's significant. But it was only one the rest of her days, she's either doing pretty well or she's having some highs depending on how she felt or what she might have eaten. So you know, you know you might be thinking okay all of her morning blood sugars for the most part they're okay but some of them are high. What do we need to do about it? Maybe we need to do some education on what she's eating so on and so forth. Well I asked if she'd be willing to at least try a C. G. M. And she of course was very willing and she was very curious as to what she was going to see because when you look at this data it's kind of skewed high. This does not look like if this was really what she was experiencing day in and day out and a one C. Of 7.2%. So that one low blood sugar that we actually see they're kind of raises a red flag. But again when you look at the all of the blood sugar she's got three hundreds two hundreds four hundreds. That's not an A one c. of 7.2. So this is what her C. G. M. Data actually revealed she has an average glucose of 1 60. So that's an A one C. Of 7.2. But what is the composition of that average glucose of 160 with um an a one c. 7.2. And what we're seeing is that while she's within range about 55% of the time, 10% of the time she's below 70. And of that 5% of the time she was actually dropping below 50 for and she only caught it once and the other report that I like to pull out especially when I see hypoglycemia is the snapshot report and the reason why I like to pull that out because when patients don't feel that they're having lows they don't think that they are significant because you know I felt fine. Yeah my blood sugar was 59 but I felt okay. What this is actually showing you in that second bar where um the information is in red different shades of red, the darker the shade of red, the more frequent a low blood sugar is occurring. Um And as you can see her witching hours are from six PM until about one a.m. Is when she's having the most hypoglycemia And this is also showing you that she is experiencing on average about 20 low glucose events and the average duration of each of those events is about 95 minutes. That's not a little bit of time. And so I really like to use that report to kind of drive home. My goodness, not only are you having lows, this is where you're having them. Um So this is actually a commonly encountered scenario. So a woman with type two diabetes long history chronic kidney disease. Um it makes her a non candidate for some of the other medications that we might traditionally used for diabetes. So matt foreman may not be a good option for her because of the kidney disease. Um the S. G. L. T. Two inhibitors while they may convey some protection to her kidney depending on where her E. G. Fr if it's below probably 40 mls per minute, she's not going to be getting much glycemic benefit from the S. G. L. T. Two inhibitor. So it's not unusual to see a patient like this that would be on basil insulin plus a cell phone area because of the kidney issues. But the problem is is that both sophonie area and exogenous insulin are going to be metabolized by that very same kidney that ain't working too well. And chronic kidney disease will change how that insulin behaves. You actually hold on to it longer. So when we think about endogenous li secreted insulin that insulin that we make goes into our portal system and very little of that insulin is accurate act is actually circulating systemically. But when patients are taking insulin. So in Lydia's case basil insulin That's given exogenous Lee and 70% of that insulin is actually available systemically. Very little of it goes through the portal system. And so now you've got a much larger load of insulin circulating that needs to be processed through the kidneys and so soften a area or insulin in someone with chronic kidney disease can cause a very high risk of hypoglycemia. But when we add insulin and a cell phone area we can make that risk much much higher and as a result we already saw based on just her blood sugar tests When she was showing us her log she's got a lot of movement going on and when we look at her C. G. N. And we see that significance of how high she was, how low she was. That's a lot of variability. So her A one C. Of 7.2 while it sounds great on paper is unreliable and it's gonna be unreliable in someone with chronic kidney disease. We typically see lower A one C's and people that have chronic kidney disease. Um And so we also do know that the heart and the kidneys are very closely related. So any patient that has chronic kidney disease is that much higher at risk for coronary artery disease. So what are the clinical issues? We mentioned them variability? She's not recognizing the hypoglycemia because she only caught it once. Whereas A C. G. M. Was catching it a lot more often. Um She's not doing well after she eats, having pretty high blood sugars after she eats. And like I said, having either one of those medications alone is problematic. But when you add them, were really asking for trouble and then the chronic kidney disease with those types of medications and the increased risk for hypoglycemia. So what do we do about it? Well we could reduce or discontinue herself on area and just leave her on basal insulin. But is that going to do anything for her postprandial rises? No we could reduce her insulin dose. We could um but as you saw, she was having some elevations fasting in between the meals. So I'm not sure if just reducing the dose is going to give her the satisfaction that she's looking for. It might reduce the low, but it may not address the highest that she's so in tune to do we have our increased snacking? Well, most of our patients with diabetes are trying to not gain more weight and a lot of them are actually trying to lose weight. Increasing snacking would cause probably more problems with weight gain. Probably cause more issues with disc glitchy mia. We might start seeing even more hyperglycemia. Or she's gonna have to intensify how she takes her insulin to cover for all those extra meals. So maybe that's not a good idea. I don't like to feed the insulin. I'd rather reduce the hypoglycemia in a different way. So what are some other medication alternatives? We could put her on a long acting GLP one receptor agonists like Victoza or to elicit E or O. Xem pick um Those are all good options because they can be used in any stage of kidney disease. We could do all the things that we mentioned before and just leave her on either a cell phone area or insulin because we don't typically see as much hypoglycemia with mono therapy. And we also know that the long acting GLP ones would probably allow us to do that to reduce and stop those medications. And we don't see hypoglycemia with the GLP one receptor agonist because of their mechanism of action. And in addition they are both cardio and renal fail favorable. So again the C. G. M. Now provides us actionable data. We thought her blood glucose log provided some actionable data but it didn't give us the full story. So now that she's got a C. G. M. I was able to take her off the symphony Arria, we did start her on a GLP one receptor agonist. I don't remember which one at this point, we weren't able to completely stop the basal insulin but we were able to lower the dose and that's just as good. So what's interesting here is that her A one C stayed the same. She still has an A one C. Of 7.2 and her average blood sugar as a result stayed the same 1 60 before 1 59. Now, what is different. Look at her time and range and her time below range. So now with a GLP one receptor agonist and a lower dose of her basal insulin Because we were able to identify things that she wasn't sensing or she wasn't catching when she would check her sugar. We were able to reduce her hypoglycemia from 10 With 5% being less than 54 down to 2% and nothing less than 54. And so her composition of that a one c of 7.2 or that blood glucose average of 160 is much better. And you're seeing less variability as well with her coefficient variation going from almost 48 down to about 40. She feels better. She has a better quality of life and she's doing very well. And and this is just one example. So the next example is another patient with Type two. This one is a male 54 years old. He has had diabetes for a little less um longer. So 11 years as opposed to 20. He's a real interesting character and this is probably more typical of many of my patients that have Type two diabetes. So his current A one C. Is 95. He is got co morbid obesity with A. B. M. I. Of 33. He also has high blood pressure and cholesterol and he has a really good insurance coverage because he's on just about every class of drug that we currently have. He's on basal insulin, on a GLP one receptor agonist on an S. G. L. T. Two inhibitor and on Metformin and has a one C. Is 9.5. He's not testing his blood sugars. He is tired of looking seeing that they're high, sometimes it doesn't seem to matter what I do. My question is is he's taking his medications because medications if they're taken and if they're addressing the right type of diabetes will do the job. He tells me he wants to come off all his meds. This is not an unusual goal for patients that have diabetes. They say I'm gonna come off all my meds and I tell them you will when you die, you won't need a single drug. But my priority is to help you live a long and healthy life with very few complications and with as little medication as possible. So you may not be able to come off the meds. But let's see if we can make more sense of what you're actually taking and make it better for you. He was looking for an option that didn't interfere with his routine. He doesn't like to poke his fingers. He, you know, if there's a way to do it that doesn't involve poking. He's all there. And as his health care provider, anyone that's assisting him with his diabetes needs information to know what the heck to do with an a one c of 95 and he's already on insulin. Do we increase the insulin? Do we add something else? Do we put him on multiple insulin injection today and just stop everything? We need information. What are those clinical issues again? He wants to come off drugs? He's on a lot of them. And those were just as diabetes medications that didn't include blood pressure and cholesterol. He he doesn't want to take his meds. He's already told us that he wants to come off, he's not and he's not always taking them. He's not testing his sugars and he says, you know what, I feel no different. So I guess, you know, if I'm not having symptoms, I should be fine. But you know, three things you don't do based on feelings is one get married to vote and three know where your blood sugar is and what that is doing to your body. That's what I like to tell my patients. So what are some of the solutions that we could do? Well, we could talk about the complications and the risks of having an a one c of 9.5. Unfortunately, talking about the complications and the risks doesn't really motivate people to become engaged with managing their diabetes. So I don't particularly care to go to the scare tactics. Um, it's not something that's tangible to them and they will probably come back with a response saying, well I could get hit by a bus on my way to my crossing the street today. So that's not always a good way to motivate them. Um, reinforce that he must take his medications. Yeah. He's probably been hearing that he knows somewhere that he probably should be taking them and taking them more appropriately. So reinforcing that yes, is important. But is it going to change his behavior? I don't think so can we send him to diabetes support and management education um classes. So self management and education and support classes or medical nutrition therapy. Absolutely. That is cornerstone. So patients should be sent to see a certified diabetes educator. Um uh registered dietitian. That is one that is a certified diabetes educator is excellent. And getting them to classes when they're initially diagnosed any time there's a change in their treatment plan, any time there's a change in glucose management. So their A one C. Is not going in the right direction or they're having more hypo or hyperglycemia, that kind of thing you want to send them and any time there's been a change in a life event, maybe they developed a complication. Maybe he had a heart attack. So there's multiple times that our patients need to be going back to education. Um and getting caught up on reinforcing what they should be trying to incorporate and just getting updated on what's new in the world of diabetes management. We could give up on him. He's pretty much given up, we have him on everything. This you could hit play every time this guy comes into your office. It's the same story. Same excuses you feel like you're saying the same things and you know, okay whatever. I'll give you three months, I'll see you back, you know in three months and none of us are in the world of healthcare because we've given up on anybody. So that's certainly not an option. Or we could ask him if he would be willing to wear a continuous glucose monitor for you know two weeks just to get some idea of what his blood sugars are looking like. And to give him an idea of a way to monitor sugars that doesn't interfere with his routine. And this was his Aha moment. So Michael War, the sensor, we're seeing where that a one C of nine something is coming from. He's got an average glucose of 2 11. You can see that he's going way above 3 50 at least a few times in the evening, but he's above goal, 68% of the time his blood sugars are above 180 mg per deciliter, with almost 20% of them being over 250 mg per deciliter. Where do we want that time? And range to be for people with diabetes, we would like it at least 70%. That's what we're aiming for. And right now he's at 32%. His blood sugars are pretty consistent. He's got a low coefficient of variance of 27 you can see how tight that Blue river is, is what I like to call it, especially in the um, late night and into the early morning. So when do his blood sugars really start to go a little crazy And it's as soon as he starts eating, we start to see the spread of those blue shaded areas start to get a little bit more wide after breakfast and then the rest of the day, it just kind of goes to pot. And then during the night when he's not eating, they seem to be doing a little better. And that is what he picked up. I didn't tell him this. He said oh my God I'm this is what I'm seeing. So he said give me four weeks. That's what he said to me give me four weeks. He's not motivated. He wanted to go to see the diabetes educator and registered dietitian because now he's motivated um he decided to eliminate caloric beverages because he was seeing with his C. G. M. That his blood sugars were spiking really high every time he would have one of those. And his next move was trying to really eliminate the evening snacks. He has also added a walk after breakfast found that he was able to lose £5. You're seeing his time and range is now 72% with only 28 above 180 and that above to 50 which was almost 20% before is now about 4%. His average blood sugar 1 57 much much better. So we're seeing um the time and range of 32% which was rendering an A one C. Of nine something 9.5 down to 72%. And so this average blood sugar actually would be an A one C. Of about 77.1% if he continues to behave this way. But the important thing here is that I was indeed able to make an adjustment in his medications because I also had actionable information. He no longer needed the insulin and the other medications that he's on are either weight neutral or can actually help with weight reduction. And so now he's motivated and he wants to take them. And I may even have the ability to reduce perhaps the Metformin since he's on a GLP one and an STL T two inhibitor because of the lifestyle changes that he's made. So his desire to come off meds is actually starting to happen and I'm able to reduce him to the least amount of medication that he actually needs. So What do these two cases teach us about type two diabetes? That there is a lot of heterogeneity in the disease. Everyone is going to have a different life with diabetes. Um and it's going to be different for that person on a day to day, hour to hour basis and it's going to be different between one person and another. And there are many different factors that will impact glucose patterns as well as what patients are doing that is causing those glucose patterns and their their recognition of what's actually happening, that not taking their medication or, you know, eating this or drinking that. What is that actually doing or take a walk after breakfast? Oh my goodness, my blood sugar is a little lower. So those have considerable impact. But they're only going to see that when they have that data in front of them and that's what the continuous glucose monitor gives us. The patterns are going to vary and glucose management is all about pattern management, knowing what's happening when most of the time and what do we do about it? And we can help our patients identify where those patterns are, where the blood sugars are really running wild and identify what those barriers are. But also give them very approachable ways to overcome those barriers and empower them. And that will improve their adherence, reduce disease burden but also helps us as clinicians to act more quickly and reduce that clinical inertia that seems to plague people that have type two diabetes. And the continuous glucose monitor definitely has been shown at least with my cases and also with the cases that you saw gene present, that it helps to devise a safe effective and personalized treatment strategy that you just cannot get with blood sugar testing alone. At this point I would like to thank you and I would like to thank Eden and jean for their contributions. And um well hope to see you again soon
Related Presenters
