Video Using CGM-Based Glycemic Management and AGP Readouts to Improve Diabetes Management and Outcomes for Persons with T2D in the Primary Care Setting Play Pause Volume Quality 720P 720P 576P Fullscreen Captions Transcript Chapters Slides Using CGM-Based Glycemic Management and AGP Readouts to Improve Diabetes Management and Outcomes for Persons with T2D in the Primary Care Setting Overview Hello everyone. My name is Evita Superman Ian I am an associate professor in the division of metabolism, endocrinology and nutrition at the university of Washington and Seattle the title of my presentation is use how to use continuous glucose monitoring data to improve management of people with diabetes in primary care. Um I work very closely with our primary care providers in my health system. I wear a huge primary care diabetes liaison hat um and I understand um how primary care works uh and um the struggles and the business that primary care comes with. So I'm hoping this presentation will give you an overview of how you can interpret C. G. M. Data in patients who are already utilizing it in your practice. Um This uh talk will not discuss implementation. I'm sure there are other presentations on this but we're gonna look at how to interpret um an data that comes from continue glucose monitoring devices. So with that we'll go ahead and get started. Um So it you're all very familiar with lots of new medications and technologies available for people with diabetes. However despite this availability of lots of new drugs and technologies a large proportion of patients who live with diabetes have suboptimal glycemic control in the United States. People with diabetes who have an A. One c. Greater than nine actually increased from 12 to 15% from 2011 to 2014. A big reason for this suboptimal glycemic control in. People with diabetes is something that's referred to as therapeutic inertia. And what this means is um a failure to initiate or to intensify diabetes therapy when diabetes goals are not met in an individual. There are many reasons for therapeutic inertia. Um This failure to adjust or monitor therapy is limited by patient factors as well as clinician factors. Patient factors could include not checking blood sugars, not bringing the data in, fear of failure, denial, not wanting to take injectable therapies, um etcetera. Provider factors could include um time constraints, not having data to look at because it wasn't provided um And patient factors actually limiting provider um initiating or adjusting therapy. But all of this can be improved by the use of this new technology, continuous glucose monitoring because it can facilitate appropriate and timely therapy adjustments. So let's look at self monitoring of blood glucose. Um SMB G. For short um is fraught with many limitations or drawbacks. People with diabetes are challenged to keep their blood glucose is in a healthy range. But checking finger stick blood glucose is is quite cumbersome and lacks convenience because you need to find time to um test place. You need to carry the supplies including the meter test strips and Lance. It's um privacy may be an issue. Um And then they're also actually financial barriers associated with test strips. The cost of test strips. Um Insurance requires specific brands. Um and limitation in the number of test strips that are provided, especially for patients who have Medicare. Also, patients who do check their blood sugars may not really understand what to do with that number. And then this data unless it's written down in a logbook and provided to the clinician who provides care to the patient. No one actually looks at the data or does anything. Let's look at this picture which shows discrete points. Um Let's say this is a highly motivated patient with diabetes who checks their blood sugars four times a day. You can see there are four spot uh dots which represent um finger stick. Blood glucose is checked before breakfast, lunch before dinner and at bedtime. And uh these are discrete points but you really don't have an idea of what's really happening. Um And the curve could look like this. So self monitoring of blood glucose really misses the extreme glycemic excursions. So this is where continuous glucose monitoring comes into play. So what is continuous glucose monitoring? Or C. G. M. For short. Um So C. G. M. Is automated or automatic tracking of blood glucose levels throughout the day. So day and night. With the help of a sensor device that actually typically is placed on the surface of the skin. It is stuck to the skin. The individual can look at their glucose levels anytime of the day. They can look at their glucose levels. They can adjust medications over appeared a few hours or days and look at trends. Um how does this technology actually work? So um these um continuous glucose measurement actually involves measuring glucose in interstitial fluid. This is fluid surrounding the fat cells. And the sensor actually checks it every 1-5 minutes, depending upon the type of sensor. Uh This is actually quite sophisticated piece of technology. Uh The sensor, as you can see on the screen has a little filament that actually goes into the um skin um into the subcutaneous tissue. It's thinner than a needle in about a half an inch long, It's inserted just under the skin. It remains in place for several days and it detects glucose in the surrounding fluid. Um The center actually uses the same chemical reaction or the enzymatic um reaction that you have in a test strip. So glucose oxidase is what is present in the test strip, similarly also on the center. Um And when the sensor device comes into contact with glucose, it converts the glucose to hydrogen peroxide. That peroxide actually reacts with a pla platinum in with platinum inside the sensor and that generates an electrical signal that goes to the transmitter um That's on the skin and that converts into an electric signal and converts it to a um number, which is the glucose number. So, um it's quite sophisticated and um the sensor remains impact in the skin because it has a coating of several um of um layers of chemical uh that actually protects it from the surrounding tissue. So what happens to that data that all that the center reports. So um the glucose values are actually um calculated and stored for retrieval every 5 to 15 minutes depending upon the device. So there's a lot of data that is generated. So if it's a five minute measurement sensor um like the ducks com um you have 288 readings a day and if it's a 15 minute one um it's about 96 readings a day. That's a lot of data. Um The if you're wondering well does it you mentioned interstitial fluid glucose. How does it correlate with Cavalleri blood glucose? So it actually correlates quite well. Um There is a lag meaning sensor glucose lags by about 54 to 5 minutes. Sometimes at the most 10. Um So it's never actually the exact same number between a finger stick glucose and a sensor reading. Um And this lag can be much more with when blood sugars are highly fluctuate. So when blood sugars are dropping or very rising very rapidly, then what happens to this data is it's actually transmitted in numeric and graphic format so that it can be displayed and it's displayed typically in a handheld receiver that's shown here on top. Um I've got the error there and then the bottom. These are the two different devices there's a handheld receiver or their mobile applications which have um uh the app specific to the particular device that's being used which can be present on a smartphone or smartwatch. And the data can also be seen on an insulin pump in certain situations if an individual is wearing an insulin pump that is compatible and all this data is retrospective data and it can be accessed by the patient through cloud based system as well as the clinician um and can be downloaded and placed in the patient chart and actually reviewed and therapy adjustments can be made. So who will benefit from this kind of technology? Um So the american association of clinical endocrinologists actually put out a consensus statement on C. G. M. Technology who will benefit from this and they strongly recommend C. G. M. For all persons with diabetes who are treated with intensive insulin therapy defined as three or more injections of insulin per day or those who use an insulin pump. Um So the wording is strong recommendation for that for number one and then it is recommended for people who have difficult to treat hypoglycemia, nocturnal hypoglycemia, hypoglycemia unawareness. And then the pediatric population Children and adolescents who have type one diabetes, pregnant women who have type one diabetes or type two diabetes treated with intensive insulin therapy. Women who have gestational diabetes who are on insulin therapy. Um The A. D. A. Wording um is uh somewhat different from what the ace recommends A. D. A. Suggests that you offer see gm therapies to individuals of similar who fit similar criteria and pick the device based on patient circumstances desires. And so um the takeaway from this is C. G. M. Actually can be used in a lot of different types of people who have diabetes including um those who take insulin especially multiple injections of insulin a day. But you know there's now a push for use of C. G. M. In more and more individuals especially type two who are worlds just basal insulin etcetera. So what are the types of C. G. M. That are available? Um There are there's a personal C. G. M. Which in which situation the device is owned and worn continuously by the individual. The individual puts it on themselves at home and these sensors can last anywhere from 10 to 14 days. Uh And depending upon the type C. G. M. Um The it provides the user data in real time meaning as it's checking you can see the readings or after scanning. That's called intermittent scan which we'll discuss in the next few slides. And this data is seen on a receiver or a smartphone that the individual has and they can be the personal systems can be standalone systems or integrated with pumps. Professional or diagnostic. See GM are slightly different in that the C. G. M. Is placed um And in in the office and the it's the devices started in the office are activated in the office. Um I have here where cannot see data with professional C. G. M. And it's blinded. But actually nowadays there are professional devices where the individual if they choose to can actually look at the data. Um This um stores data for about 7 to 14 days. The patient goes back to the clinic and the data can be downloaded and you can actually turn it out and show it to the patient. Um and actually make changes right there. Um And it is very useful for people who do not want to wear a device every day are centered on their skin every day or those who cannot afford it or um you know they do not have appropriate coverage. Um So let's look at the stand alone personal CGs. Um My doctor Day will focus on data from Personal CGM systems today. Um So there are two flavors of personal C. G. M. S. One is the first one is real time C. G. M. Um The most commonly used um product is the decks com, There's also a product from electronic which works primarily with their insulin pump. Um This real time C. G. M. Has three components. The sensor current sensor version is 10 days. Um And there is something called a transmitter that is on top of the bottom panel here. My Arrow is pointing to it. Um that's a transmitter that has a lifespan of 90 days. It has to be changed every 90 days. Um and the sensor itself gets changed every 10 days but this is the transmitter that gets clicked on there. Um and then there's a receiver or the app on the phone. The receiver could be either actual device or smartphone app. Um These sensors monitor every five minutes or 288 readings a day. Um There's no calibration meaning you don't have to check a finger stick glucose and feed that number to the sensor device. Um These devices have alarms which is highly beneficial for people who have who are at risk for hypoglycemia, especially those with type one diabetes. Um The alarms go off if there is um downward trend in the glucose or hyperglycemia, alarms are also present. So this gives the patient um time to respond based on what their glucose ratings are. And these devices now are actually available to prescription through pharmacy depending upon insurance. Uh Some in some situations uh which is primarily Medicare. They come from a durable medical equipment supply company. Um These devices are intuitive for most part but there are some nuances and requires some extra training. And here's a celebrity who um um wears this device. Um And then there's the intermittent scan um um or flash continuous glucose monitor. Um The device that is available in the market in the United States is the freestyle libre. Um There's three versions of this available now the 14 day center that's the older one which will likely be phased out. The current version is the liberal too and the liberal three just got approved and is um to my knowledge not yet available. Um At the time of this recording this intermittent scan. See GM has two components. It has a sensor that's this white circle that is worn on the back of the arm. So specifically this can only be worn at the back of the arms. Um um And there is a reader device that here as you can see this individual is holding or the app can be put on the phone. This sensor stays on for 14 days with a one hour warm up. Um And the the one aspect of this is that it's not real time as the device I showed you showed you in the previous slide. You have to scan to see the glucose um And um you have to hold the smartphone or the reader close to the center and it will give you a reading. Um This also does not require calibration. The labor too has alarms um And so it can alert the patient to hypoglycemia. Um And this is available through prescription um from the clinician and can also be available for individuals with Medicare through the DME supplier. So this is the introduction of what's available and now we're gonna move on to how to interpret the data that you get from the C. G. M. Devices. Um So I want you to get ready for a whole new terminology in diabetes. So almost like a diabetes dictionary or um alphabet soup. Um The um The new definitions for diabetes or things you want to be aware of are called glucose metrics. Um And there's a variety of different terms I will be introducing over the next several slides um All the abbreviations so I will put here on this slide. So there's something called an ambulatory glucose profile or IGP. Um The glucose metrics specifically R. T. IR time in range time below range. That's DVR and time above range. T. A R. G. M. I. R. Glucose management indicator. G. V. Is glucose variability. So we these will become apparent as we go through the next several slides are the next part of this talk. So um when you are able to look at the data from a continuous glucose monitor, you get the data that's presented in something called an A. G. P. Report. Uh A G. P. Stands for ambulatory glucose profile. And what this is is a standardized single page report which gives you a big picture view um A 3 60 if you will um or a bird's eye view of all the glycemic patterns and trends for the duration that download is for um So it helps you interpret the glucose patterns. Um This figure on the right side shows you a typical A G. P. Report from an intermittent scan device. Um And the top panels panel shows glucose metrics and targets and again we will go through all of this in the next several slides in detail. Um The middle panel is called the ambulatory glucose profile and the bottom panel shows you the daily view. So how do you look at an IGP report? So um assuming your office is set up um and you are able to get this data downloaded. Alternatively patients can also download this and bring it to you. Um So this is what you will look at. So what you want to do is I want you to bring your eye to the top left to your screen off this figure and that's where the glucose statistics and targets are. So the first thing you want to know is are there enough number of days uh that the C. G. M. Has been worn. And what is recommended is that at least 14 days of where it's recommended. And um the way you can find this is by looking at the percentage time uh C G. M. Is active. So you see that red box on the right side there um this figure shows for 28 days, 14 days should suffice and you want at least 70% C G. M active um percentage for appropriate interpretation. So that's your first step. So have they warned the center appropriately secondly you can draw your eye down to the average glucose. So this gives you an average for that 14 or 28 days um duration that the center has In this case you can see that it's 142 below that. There's something called glucose management indicator. So this is new terminology and um something you should be aware of um So what the G. M. I. Is um is a new, you could think of it as a new metric. Um It's a calculated for C G. M based formula from a population of mean glucose data. So essentially some in very simple terms. What that means is that it's a software calculated a one C. How did this all come about? So in 2018, a group of clinicians, researchers and patients got together and um figured out how to interpret data from continuous glucose monitoring um that that we get um see GMS have been around since 1999 and there's been plenty of data. They've been um technology has advanced and there was a lot of data that came out of the C. G. M. Um and uh we didn't really know what to do with them. So this consensus was gathered and this group put together um certain parameters for how to interpret and use the data from these um data sets or you know, um information that your patients providing. So the Gm I came from this and it's a new term for estimating a one C from C G. M. Um And what this does is it minimizes the main limitation of a laboratory measured a one C. And that there may be wide variability for any mean glucose. So the data from a c G M. Can minimize that. So the G M. I is essentially a software calculated a one C. And you want to look at that in that top left box below that is something called glucose variability. And what that means is it's um the ups and downs, um the peaks and valleys you will see in the blood glucose is um the lower the value, the lesser the risk of hyperplasia. Tenia in people who take insulin Um or cellphone areas. Um the definition of what a bowl um glucose variability should be is um if you look at this, it's actually less than 36% which is acceptable. Uh sometimes less than 33 is recommended. Um for example, my mentor and colleague Dr. Hirsch uses less than 33%. So which means that the curves are tighter and there's less variability, but third less than 36 is acceptable. Um And it just means less ups and downs and peaks and valleys in the in the glucose is. Um So so that was the top left part. So then there's a lot more to this page here. So the next we're going to look at the top right where the time in ranges are given. So this is the top part of that same figure again um blown up. So the time in range R. T. I. R. Is shown here. Um The target range is typically 70 to 1 80 this is standardized based on that um um consensus statement publication um that's referenced down their diabetes 2019. Um 70 to 1 80 is the target range high is 1 81 to 2 50 very high is um greater than 2 50. Um low blood sugars are in the red 54 to 69 very low is less than 50. For now. There is an alternative definition. Some people will call the highest stage one level one and level two hypo or hyperglycemia, but I'm not showing you that here. Um it's semantics that this should be fine. Um and if you look to the left, there's actually a box which tells you what ranges and targets for each of these um ranges should be. So what it shows here is you want your target range for an individual to be greater than 70% And you want those to be less than 4% and you want the highest to be less than 25%. And I will this um I will clarify for you in the next slide. So the target time and range should be over 70%. So if you go back to this bright panel, you see a lot of green and not much yellow or orange and no red. So you want most you want more red and less yellow and no more green. I'm sorry, Um less yellow and um no red. And this green here in this situation is 86%. Which is well above 70%. So this person is in target. Um so the time in range is what you want to look at and again to reiterate greater than 70%. Um The next step you want to do is look at anything in the red hypoglycemia. Um You wanna make sure it's less than 4% as shown here. Um And I want to point out every 1% hypoglycemia equals about 14 to 15 minutes low. So you want less than one hour low per day. Um And highs you want less than 25%. So where did this all come from? Um So again this is from all the data that was put together by that group. And the correlation between time and range and a one C. Is quite good. Yes it's a correlation but still it's uh quite acceptable. And there's also data that there's correlation between time and range and development of complications. So time and range of 70%. Where did that come from? This appears to correlate to an A one c. Of about 7% and a time and range of 50% is about a one C. Of 8%. So what that means is for every 10% change in time and range there's about a half a percent change in a one C. So as long as you remember a one c. 7% for time and range of 70. Um that's a good start. So here's a table on the clinical targets for C. G. M. Data and population. So what's recommended? So if you look um here on the top line um people with type one diabetes and type two diabetes. Um You want time and range greater than 70%. Less than 4% time below range and time above range. Um You want to minimize hyperglycemia so less than 25% as I stated in the last slide If it's an older individual or higher risk 50% is should suffice. Um and greater than 90% of time below 250. And so this is a good um table to look at. And um when you're looking at the ADP report. So then you wanna move your eyes to the next panel which is below the um time and range which shows you something called the ambulatory glucose profile or a G. P. What this is is essentially a box which goes from midnight to midnight. And this is an amalgamation of all the numbers that are present in that. And so if you look here the dark blue line shows you 50% or median Interpol median for all the blood glucose is the blue shading shows you the inter portal ranges between 25 and 75% blood glucose is and this light blue you could think of it as the cloud tells you what the highest and the lowest numbers are. So this can help you identify where the problem is in this individual. Again, this is this box goes from midnight to midnight. Um This um slight peak. You can see the trend upwards towards the latter half of the day, um maybe even a later dinner. And then hyperglycemia with dinner. And so the problem is over here is shown by a yellow circle below that you get daily glucose profiles where you can see individual days and what you want to look at here is to see if there's any yellows if if they're um curves are above range. You will see yellow if there are any lows, there will be read this individual. This report does not have any lows, but there are yellows and that shows the highest. And then you can also get a daily view which is um individual days. As you can see here, there's two weeks worth of individual days here. You can get a sense of patterns when there are blood glucose spikes. And again each box goes from midnight to midnight. They also give you an average glucose for each day. Um And so um it gives you a lot of information um and an individual patterns based on what what they're doing. So that was the um A G. P. For intermittent scan. C. G. M. Um The real time C. G. M. Um A G. P looks slightly different. It has the same information just visually it looks a little different and I've showed it to you here uh to walk through this quickly um Move your eye to the top panel. Um It'll show you whether the C. G. M. Has been worn enough so data sufficiency 97%. So it's excellent. Greater than 7 70% as I told you earlier. And then you want to look at the average, there's 1 58. Um You want to look at the coefficient of variation which is that up and down value and you want that to be less than 36%. Or if you want them to be very tight less than 33. This individual has 28%. So um coefficient of variation which is excellent. And then you look at the time and range here um It's 68.6%. About 69%. Close to 70. So not too bad. Um And you can look at the age GP here to get a general sense. You can see the color here is an orange, that's the median uh 50% range. Um just the general pattern suggests that um there again this box goes from midnight to midnight and you can see some hyperglycemia in the night time is what um what it shows and you can see the individual dates at the bottom. So pretty similar. Just visually looks a little different. So with that um introduction to heart interpreted. Um An A. G. P. Report will move on to cases I have four or five cases here which we can walk through. Um So let's look at um the first um scenario. So this is a 57 year old woman with type two diabetes and she's only on oral agents. Um She was very interested in C. G. M. And she um um gets it through her providers through prescription and she um it's partly covered by her insurance and so she continues to wear it. So let's walk through this um A. G. P. And uh look at it. Um So first thing as I do if you want to recall you want to look at the top left and again this is intermittent scan. C. G. M. Um You want to make sure that they are wearing there's enough C. G. M. Data and you've got 35% for 28 days. That is not adequate. Uh Refresh your memory 70% at least. Um You want to see that the C. G. M. Is active. Um And then if you look on the right um This is inadequate data but you can see the target range is 86%. So what's going on here um If you look at the bottom um that box again for the A. G. P. Goes from midnight to midnight you see there's a big patch of white there. Um And that means there's miss data. So what this means is she's not scanning. As I said that was intermittent scan C. G. M. Um A. G. P. Download um scanning frequency actually um predicts a success with views with this technology for um for intermittent scan C. G. M. So um there are people so the recommended scanning frequencies 3 to 4 times a day. There are people who scan 20 times a day. I have people who scan 50 times a day and then there are people who put it on and forget to scan. So at the very minimum you want to scan every eight hours because that center only holds eight hours worth of data. And if you don't scan every eight hours you will miss data. So this woman um um So before we talk about the patient. So the figure here shows you a calendar. Um So you can actually get this from that A. G. P. Download. You can actually see how many times an individual is scanning. So this individual who have shown scans 89 10 multiple times a day. Um This obviously is not the calendar for the patient I just showed you because there's miss data. And so this woman is not scanning and that's why she was scanning once maybe twice a day. Um And this results in MS data and this is lack of scanning. So patients should to use this technology efficiently. If it's an intermittent scan see Gm you want to encourage them to scan. A typical way to do it is um I usually tell patients to scan and first thing in the morning and at bedtime and most people have the app on their phone uh And we all are on our phones all the time. Um a couple of times when they're you know holding their phone or going to the bathroom, just remember to um scan. You can also set alarms on your phone um you know in separate from the phone up for the C. G. M. To set reminders. Um um And you can also set it on the reader device if they have a reader device for reminding them to scan. Um So this is not really interpret herbal because there's not enough data. So how do you interpret an ambulatory glucose profile? So here are a few steps so you want to first look and see if there's enough data to review. And again I've already told you this but then once you can print out that first page um and you can actually share it with the patient because a picture is worth worth 1000 words. Uh And you can mark the page as you talk and you can actually identify patterns around meals activities, sleep medications, when are they taking their medications? All of these can be marked off. Um And I will show you how that's done. Um You can look for patterns then and you can see if they're in target as we talked about. Are there the after the target range. You want to see if there are any lows. So make sure there are no lows and then look at the height, so high post first, then hyper and then look at the shape of the curve. Come up with an action plan and then documented in the chart. So we're gonna go through this in different scenarios. So let's talk about our patient here. So 74 year old male, he's had longstanding type two diabetes. He also has non ischemic cardiomyopathy. He comes to you for diabetes focused visit and his most recent A one C. Is 8.5%. Um He um complex regimen um or he's on basal insulin Large in 25 units. He's on Metformin 1000 mg twice daily. So maximized uh 10 mg and maximum dose of tight the GLP one block. So let's look at his ADP. So here's his ADP and we'll walk through this. Look at this and there you go. So first thing is there adequate data is the first question. At least 14 days. Yes, there's 28 days. Their percentage time. See gms active 87%. So quite good there. And then um next step would be, you know, you've already printed this out. So now let's look at the um you know, different patterns. So he eats breakfast around seven o'clock. Um he's lunch around 12 and then dinner. So you can mark it off. You can also mark off when he takes his medication. So if he takes metformin with breakfast and his lodging at breakfast and as guardians when he's taking his type he was taking most of them um in the morning around breakfast time the a little bit after breakfast. But I didn't put that here. It got too cluttered. But you can write all this down as you talk to your patient. So then look at the metrics. Um You can, the average glucose here is 200. So obviously high. And the G. M. I. The glucose management indicator. The software calculated A one C. Is 8.1% and glucose variability. So the peaks and valleys. The goal being less than 36% or less than 33. Um is about 33, right at 33% here. Um and then you can look to the right and look at the time and range. So the amount of green here is not as much as we saw in previous ones. So 43 and a lot of time um in highs so about 57%. So you want more green, last yellow and orange um more green less orange. Um So then let's look at the pattern. So he's got no hypoglycemia as you can see here. There's no red and there's also nothing touching the bottom line of 70 here in the A. G. P. In the middle section. So there's no hypoglycemia. That's the first thing you want to eliminate. But there is a lot of hyperglycemia as you can see that blue line is that medium. Uh And you can see as the day progresses, there is a rise in the blue. And so this means he lives in the high range post likely related to his eating patterns um for most of the waking hours. And then if you look at the bottom at the daily glucose profiles as I told you, look at how much yellow and how much red red is for hypo there's no hypo here mostly all in the yellow range. So he is hyperglycemia. So now we gotta come up with an action plan to remind you his this is his diabetes regimen. He's got lodging. Um He's got my foreman emperor to frozen um arugula tied his um nighttime. So 12 to 6 a.m. And when he wakes up at breakfast is quite okay for now. But most of his numbers run high through the rest of the day after he starts eating. And so this would be a situation where he likely needs Crandall insulin with the largest meal of the day. And for him it was dinner and that's what we did. We initiated Crandall insulin before dinner. I don't have a follow up. But um he started taking Um Neil Diamond's land before dinner and there was improvement in his a. one c. So let's look at the next patient. So this is an individual who is not on insulin and this isn't this will be um um a good uh example of how you can use these um sensor devices for people who do not take insulin also. So is a 49 year old meal type two diabetes on Metformin maximized and also on a cell phone area. So a little bit of an older president. His most recent A one C. Is 9.7%. His recent numbers when you look back have actually been trending up words gradually. And so um you know, this is an indication for therapy advancement but he's quite hesitant to add new medications. Um So um let's say you have sensor samples in your office. Uh I understand many do not but if you do. Um And this is what happened in this individual's case. Um He was given sample sensors and he put it on and let's look through this uh top left again. Let's look at the glucose stats. His C. G. M. Activity 93% greater than 70%. So excellent. Um And then if you move your eye to the bottom of that red box average glucose is 2 26. His G. M. I. Or that software catholic today, once he is 8.7% and his glucose variability is 33.5. And then as you can eyeball this uh there's less green and more yellow and orange and you want and target rate time and target is 28%. So very suboptimal glacial mia. And we already knew this, but we don't know the patterns. So when you look move your eye to the middle of this figure, you can see the So this box goes from midnight to midnight and you can see that blue median line is always above 180. So he is running by all the way through. And then if you look in the bottom, the individual days also, um quite a pretty much all in yellow, so significant hyperglycemia. So he so discussion was had, so we um to come up with an action plan. Um He endorsed that he was eating a lot more um through the pandemic, he had some weight gain and he was interested in losing weight. And so he was given um weekly um GLP one analog which and also referred to diabetes education because he endorsed large meals. And you can see the spikes and the individual days. If you move your eye to the bottom right, you can see all the hot hyperglycemia through the day and all related to likely larger meals and waking. And so this resulted in weight loss. And um his whole curve got pushed down and his a one c actually dropped nicely through about mid sevens in this situation. So, so this is how even in someone who's not on insulin how um information um his power. and so he was able to make the changes and he's actually going quite well um on this combination therapy. Um So let's look at another patient. So here's another one who's on quite a complex regimen. So 56 year old male with type two diabetes. Um He his diabetes regimen includes Metformin. Um He's on the regulatory side. He's on basal insulin and he's also on premium insulin. And his A one sees on this combination always running the 73 to 7.7% fridge. Um Never really lower than that. He has no other comorbidities but um you know attempts had been made to get his numbers lower but really um he has struggled to get his A. One C. Um well under seven which is what his personal goal also is. Um So um he was able to get a sensor because he's on three um injections a day. Um And this a G. P. Looks a little different because it's from 2019. Um I think because the this changed after 2020. So um the newer ones um look the way you've you're used to seeing it in the last few slides but still the information is the same if you look on top time Time and target is 58% and his average glucose was 1 77. And if you move your eye to the bottom and you can see um he's had a trend upwards of that blue line. So as the day progresses he has some significant hyperglycemia with his um dinner time. So um what we opted to do rather than increasing. So you might wanna you might think that you wanted to increase his um dinnertime list bro. But what we opted to do was actually start him on an SDR two inhibitor. And after he was started on it this is what happened. Um It was quite remarkable and you can see here um that his um, oops yeah he his C. G. M. Is worn pretty well 77% for 14 days and his average view goes came down to 1 21 G. M. I. 6.2% with GVg glucose variability of 28% and time and target is 92%. So you can see how that whole curve got shifted down. He still has some excursions with dinner. Um But overall this is quite acceptable and it would probably be helpful for him to um refresh his diabetes education um carbohydrate counting principles um in this situation especially with those mealtime expressions. Um So this is how you know the C. G. M. Actually gives you more information. So um here's another one. So um this is a 65 year old male um who I just saw actually he has 15 years of type two diabetes. Um He's on Metformin be Ziggler and less pro um he had been his B. M. I was quite low so and he didn't want to lose any further late await. And so we did not try um GLP one. Uh And I think he had intolerance to S. C. L. T. Two inhibitors. So this was the regimen um that he has been on in the day once. He was 7.3%. Um He has a sensor that he wears. Um you can see here um um If you look at a C. G. M. Activity it's only 63%. So not that great. But uh if you move your eye down 1 66 on the glucose average and his G. M. I. Is quite concordant with his lab one C. Of 7.3. Um and his time in target um is 65%. Um and he's got some highs and if you move your eyes to the ambulatory glucose profile you can see that kind of trends upwards beginning of the day and then drifts down the blue line, the median line. And in the bottom you can see the um daily glucose profiles. You can see some miss data because he's not scanning as enough which is which explains the C. G. M. Activity being only 63%. So he wasn't really scanning as well. So this sensor could be used a little bit more efficiently nevertheless this was his A. G. P. Not too bad. And then recently um this happened so this is um um what A. C. G. M. Or a G. P. Should not be like um here his he's only 33% active on the C. G. M. And his average glucose is 4 39 G. M. I. Is 13.8%. So his A. One C. Is very high and you can see his time and range is nothing zero. And what happened was he got covid and he has severe insulin resistance and he's still recovering and you can see how there's significant um um insulin resistance and hyperglycemia. And his insulin doses have tripled and quadrupled in the last several weeks after Covid infection. Um So hopefully this will come down but you can see he's not scanning as much as he's very disappointed in looking at his blood glucose is. But his insulin doses being adjusted actively and he's being monitored. Um So um now with all of this how do you put all this in the charts? So you want to document um that you have looked at the C. G. M. So that you can get paid for it. So the support billing um You there's a few key words that you can put in so that the C. G. M. Was reviewed with the patient what the pattern you identified was. Um what action steps or plan that you took. Um And then you can if you you should put the print um scanned into the EMR or the electronic pdf off the download has to go into the chart. So how do you do this? So here's an example um you can say we reviewed so and so C. G. M. Data um What pattern did you identify? Um This download reveals um average glucose of 1 80 with 53% of readings in range. Um And the pattern is that there's significant post dinner hyperglycemia if you look down there due to snacking. And so what we discussed, so what was the action step? We discussed addition of GLP one receptor analog such as laura appetite to curb appetite. And she agrees and you know as I mentioned you should have a copy of this um in the electronic medical record and this can be made into a smart phrase that's appropriate for your EMR and can be pulled in at the time of the um note and it's pretty straightforward and easy to do. Um However I want to point out that just wearing a C. G. M. Is just not enough. Um You really should um incorporate your team um make sure there's robust diabetes education. Um So that diabetes educators are a wealth of uh of information. They can train the patient make sure they're wearing their center okay? Um And you need good support for device and implementation and ongoing use. Um You really wanna set the patient up for success um and then you want to make sure the patient is engaged to look at the readings that they're getting. Um and you know education and empowering them to make um to how to use their data. And in the end I want to show you a C. G. M. Um success story. So this was a gentleman who is actually a baker for a large warehouse store who has had diabetes for 10 years and had been on Mac foreman for um um for quite a while. And um his A one C. Has always been in the low sevens. And with the pandemic um there was significant weight gain and um he was not checking his blood sugars. And so his primary care provider prescribed an intermittent scan C. G. M. Um And he had heard about it and he was very um interested in it. And in addition because of the weight gain and wanting to drive the onesie down some magnetite was also prescribed. So what happened after that? I don't have the previous or pre treatment. It went um um sensor download. But this is what we hope for in our patients. Um A time and target here in this gentleman was is 98% and A G. P. Shows you almost all numbers well in range. Um with and this is a success story. His Gm is 5.8 and his average glucose is um 105 lab measured a one C. Was 6.1%. That's fairly concordant. Um And so um we hope for this in all our patients but diabetes is hard. Uh and this is how C. G. M. Can help us help our patients. Um So to conclude um technology has become a very integral part of diabetes management and primary care practices can tremendously benefit from using CGM devices to help their patients. Um you know the the type of practice setting and the CGM system that the practice fix can actually influence strategy and implementation. But flash systems are quite intuitive um They're very simple and can be used in a variety of patients and it allows um clinicians and patients to work together. Um And the data that you get offers patients knowledge and feedback to enable behavior change and self knowledge. And with that here are some resources. Um These are all very simple and easy to read articles and the two links in the bottom has a lot of resources and um um uh PDFs as well as videos on um how to interpret C. G. M. A G. P. S again um Similar to what I just presented and um with that good luck. Um and I hope you use more technology in your practice. Thank you very much for listening Published August 8, 2022 Created by Related Presenters Savitha Subramanian M.D. Associate Professor of MedicineDivision of Metabolism, Endocrinology and NutritionUniversity of Washington, Seattle
