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Making The Most of Continuous Glucose Monitoring Gary Scheiner MS, CDE Owner/Director, Integrated Diabetes Services 333

Making The Most of Continuous Glucose Monitoring Gary Scheiner MS, CDE Owner/Director, Integrated Diabetes Services 333 E. Lancaster Ave., Suite 204 Wynnewood, PA 19096 (877) 735-3648 www.integrateddiabetes.com Gary@integrateddiabetes.com.

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Making The Most of Continuous Glucose Monitoring Gary Scheiner MS, CDE Owner/Director, Integrated Diabetes Services 333

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  1. Making The Most of Continuous Glucose Monitoring Gary Scheiner MS, CDE Owner/Director, Integrated Diabetes Services 333 E. Lancaster Ave., Suite 204 Wynnewood, PA 19096 (877) 735-3648 www.integrateddiabetes.com Gary@integrateddiabetes.com

  2. Making the Most of Continuous Glucose Monitoring • What Information Is Available? • How to Use Immediate Data? • How to Use Intermediate Data? • What Can Be Learned from Retrospective Analysis? • Optimizing CGM System Performance

  3. MiniMed Paradigm® & Guardian® REAL-Time CGM Systems On-Screen Reports • 3-hr and 24-hr graphs (pump); 3 / 6 / 12 / 24-hr graphs (Guardian) • Can scroll back for specific data points •  “direction” indicators • Updates every 5 minutes • Hi/Low Alerts • Predictive Alerts (Guardian)

  4. CareLink™ Personal: Online Reports MiniMed Paradigm® & Guardian® REAL-Time CGM Systems • Sensor daily overlay • Sensor overlay by meal

  5. MiniMed Paradigm® & Guardian® REAL-Time CGM Systems CareLink™ Personal Online Reports Daily summaries & layered reports, including… • Sensor tracing • Basal & bolus delivery • Carbohydrate & logbook entries

  6. DexCom™ Seven Plus® On-Screen Reports • 1, 3, 6, 12, 24-hr graphs • Updates every 5 minutes • Hi/Low alerts • Rate of Change alerts

  7. DexCom™ 7 STS® Dexcom DM2 Download Reports Glucose Trend Hourly Stats

  8. DexCom™ 7 STS® Dexcom DM2 Download Reports Trend Analysis BG Distribution

  9. Freestyle Navigator™ On-Screen Reports • 2/4/6/12/24-hr line graphs • Predictive alerts •  “direction” indicators • Can scroll back to data points • Customizable time range: • Highest, Lowest, Avg, SD • % Time High, Low, In-Range • # Hypo, Hyper events • Updates every minute

  10. Freestyle Navigator™ Download to CoPilot Software Modal Day Report Glucose Line Report Statistics Report

  11. Practical Benefits of Real-Time CGM Rumble strips (avoid serious extremes) Peace of mind Basal & bolus fine tuning Postprandial analysis Insulin action curve determination Short-term Forecasting Learning tool & immediate feedback Eliminates some blood glucose checks??? Partially derived from: Hirsch, et al. Clinical Application of Emerging Sensor Technologies in Diabetes Management: Consensus Guidelines for Continuous Glucose Monitoring (CGM). Diabetes Technology & Therapeutics, 10:4, 2008, 232-244.

  12. How to Look at the Information Immediate Intermediate Retrospective

  13. Immediate Info: Alerts Customizable settings Vibrate and/or beep Alert the user of glucose levels that have crossed specified high or low thresholds (predictive) Alert of anticipated crossing of high or low thresholds

  14. Setting Alerts Hi/Low alarm thresholds are not BG target ranges Balance need for alerts against “nuisance factor”

  15. LOW: 80 mg/dl (4.5 mmol) 90 (5) + if hypo unaware HIGH: 300 mg/dl (16 mmol) lower progressively toward 180 (10) Initial Alert Settings Recommendation NOT RECOMMENDED: Low 70 (3.9) NOT RECOMMENDED: High 140 (7.8) Derived from: Hirsch, et al. Clinical Application of Emerging Sensor Technologies in Diabetes Management: Consensus Guidelines for Continuous Glucose Monitoring (CGM). Diabetes Technology & Therapeutics, 10:4, 2008, 232-244.

  16. Special Alert Settings Young children (higher, wider range) Hypoglycemia unawareness, high-risk professions (higher hypo setting) Pregnancy (lower, narrower range) HbA1c of 11.0% (higher initially)

  17. Immediate Info: Glucose and Trend • Prediction/Forecasting • Safety/Performance • Driving • Sports • Tests

  18. Immediate Glucose Info: Can it Replace Fingersticks? • Not during first 1-2 cycles of using the system • Wait at least 12 hrs after sensor replacement • If BG Stable • If Recent calibrations in-line • If No recent alarms

  19. Immediate Info: Potential Bolus AdjustmentBased on BG Direction • BG Stable: Usual Bolus Dose • BG Rising Gradually:  bolus 10% • BG Rising Sharply:  bolus 20% • BG Dropping Gradually:  bolus 10% • BG Dropping Sharply:  bolus 20%

  20. Immediate Info: Hypoglycemia Alerts • Predictive Hypo Alert or Hypo Alert & recovering: Subtle Treatment • 50% of usual carbs • Med-High G.I. food • Hypo Alert & Dropping: Aggressive Treatment • Full or increased carbs • High G.I. food

  21. Intermediate Info:Use of 2/3/4 Hr Trend Graphs Effects of different food types Effectiveness of bolus amt. Reveals postprandial spikes Pramlintide/Exenatide Influence Exercise effects Impact of Stress

  22. Intermediate Info:Use of 9 / 12 / 24 Hr Trend Graphs Facilitates decision-making for basal insulin doses Shows delayed effects of exercise, stress, high-fat foods Reveals overnight patterns Lets user know when bolus action is complete

  23. Specific Insights to Derive (a purely retrospective journey)

  24. Before You Analyze, Qualify. Were sufficient calibrations performed? Did the calibrations match the CGM data reasonably well? Was the data mostly continuous? Was the time/date set correctly?

  25. These Are a Few of My Favorite Stats… Mean (avg) glucose % Of Time Above, Below, Within Target Range Standard Deviation # Of High & Low Excursions Per Week

  26. Case Study 1: Effectiveness of Current Program Type 1 diabetes; using insulin glargine & MDI Overnight readings are OK; HbA1c levels are elevated 400 Glucose (mg/dL) 300 200 100 0 3 AM 6 AM 9 AM 12 PM 3 PM 6 PM 9 PM Meal doses insufficient; not covering snacks?

  27. Case Study 2a: Basal Insulin Regulation Rising 2 AM – 8 AM 400 300 200 100 Glucose (mg/dL) 400 0 300 200 100 0 3 AM 9 AM 3 PM 9 PM 3 AM 9 AM 3 PM 9 PM • Stable 12 AM – 4 AM, then dropping pre-dawn • Dropping late afternoon

  28. Case Study 2b: Basal Insulin Regulation Type 1 diabetes; using insulin glargine & MDI History of morning lows Now not “covering” highs at night 400 Glucose (mg/dL) 300 200 100 0 3 AM 6 AM 9 AM 12 PM 3 PM 6 PM 9 PM BG dropping overnight; insulin dose too high

  29. Case Study 3: Detection of Silent Hypoglycemia Type1 diabetes; on pump Frequent fasting highs (9 AM) 400 Glucose (mg/dL) 300 200 100 0 3 AM 6 AM 9 AM 12 PM 3 PM 6 PM 9 PM Somogyi effect during the night

  30. Case Study 4: Determination of Insulin Action Curve 3-Hour Duration 4-Hour Duration 5-HourDuration

  31. Case Study 5: Fine-Tuning Meal Boluses 400 Glucose (mg/dL) 300 200 100 0 3 AM 6 AM 9 AM 12 PM 3 PM 6 PM 9 PM Night-snack dose clearly insufficient Breakfast and lunch doses may be too low Dinner dose appears OK

  32. Case Study 6: Fine-Tuning Correction Boluses 400 Glucose (mg/dL) 300 200 100 0 • Dropping low after correcting for highs at bedtime and wake-up time 3 AM 6 AM 9 AM 12 PM 3 PM 6 PM 9 PM Need to change correction factor & insulin sensitivity during AM hours

  33. Case Study 7: Postprandial Analysis Pre-meal BG levels are usually in target range HbA1c are higher than expected based on SMBG Tired and lethargic after meals 400 Glucose (mg/dL) 300 Meal 200 Meal Meal 100 Meal Significant postprandial spikes (300s)

  34. Case Study 8: Impact of Physical Activity Type 1 diabetes; pump user Basal rates confirmed overnight Exercises in the evening (9 PM) 400 Glucose (mg/dL) 300 200 100 0 Exercise 3 PM 6 PM 9 PM 12 AM 3 AM 6 AM 9 AM 12 PM Experiencing delayed-onset hypoglycemia

  35. Case Study 9: Impact of Stress Type 1 diabetes; pump user 40 years old; athletic Handsome, excellent speaker 400 Glucose (mg/dL) 300 200 100 0 • Late for meeting • Gets flat tire; eats 15g carbs to prepare for tire change 9 AM 12 PM 3 PM 6 PM 9 PM • Spare is flat too!! STRESS CAN RAISE BLOOD GLUCOSE… A LOT!!!

  36. Case Study 10: Impact of Various Food Types Cereal Pasta Meal Oatmeal Stir-Fry Over Rice Yogurt BG peaks later with pasta than rice Postprandial peak: cereal > oatmeal > yogurt

  37. Case Study 11: Impact of Hi-Fat Meals Saturday Nights, Dinner Out Temp basal increase following hi-fat meals

  38. CGM “Homework” Assignments Verify basal doses See effect of dietary fat Study effects of specific exercises Evaluate impact of different food types Measure insulin sensitivity Determine insulin action curve Download (if poss.) prior to appointments!

  39. Optimizing CGM System Performance • Calibration • Site selection/care • Signal reception • Ingredients for success

  40. Calibrate at times when blood glucose (BG) is stable (fasting, pre-meals)* Avoid calibrations during times of rapid glucose change* Post meal UP or DOWN arrows are displayed In the period following a correction with food or insulin During exercise * Not required w/Dexcom system Optimal Calibration

  41. Calibrate before bedtime to avoid alarms during the night Use good technique when performing BG checks for calibration Proper coding Clean hands USE FINGERSTICKS Enter the calibration immediately after the fingerstick (Dexcom, Medtronic systems) Optimal Calibration

  42. Sensor Sites Site Selection “Fleshy” areas At least 3” Away from insulin infusion Avoid tight clothing areas, scars, bruises, lipoatrophy Rotate sites Bleeding/Irritation Slight bleeding OK Profuse bleeding: remove Remove introducer needle at proper angle

  43. Sensor Sites Adhesive Completely cover the Transmitter & Sensor (Navigator & Medtronic systems) Check sensor daily for loose tape Apply extra tape over sensor & transmitter if tape patch begins to “curl” around edges Site Irritation Watch for redness, swelling, tenderness Remove sensor with prolonged irritation (>1 hour)

  44. Signal Reception Heed transmitter ranges Medtronic: 6 ft. Dexcom: 5 ft. Navigator: 10 ft. Signals do not travel well through water Wear receiver on same side of body as sensor Keep receiver very close while charging (Dexcom) Charge transmitter fully every 6 days (Medtronic)

  45. Ingredients For Success Have the right expectations Wear the CGM at least 90% of the time Look at the monitor 10-20 times per day Do not over-react to the data; take IOB into account Adjust your therapy based on trends/patterns Calibrate appropriately Minimize “nuisance” alarms

  46. Think Like A Pancreas!

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