Cecelia Health - Hyperglycemia and the Role of Technology & CGM

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Hypoglycemia and The Role of Technology & CGM Brooke Benton, MS, RD, LDN, CDCES; Amy Bradshaw, RD, CDCES • Cecelia Health • ceceliahealth.com

Introduction  Using a CGM (Continuous Glucose Monitor) device can make it easier to manage Type 1 (T1D) and Type 2 (T2D) diabetes  CGM is a powerful intervention tool that helps identify if an individual is in blood glucose range throughout the day  CGM also helps to identify hypoglycemia as well as hyperglycemia  Identification of people with diabetes and impaired hypoglycemia awareness is important for an improved management of hypoglycemia problems  CGM may be able to help individuals avoid hypoglycemia and support the management of hypoglycemia problems in clinical care  For people with T1D or T2D, experts recommend aiming for: (1) � > 180 mg/dl - Minimize � 70-180 mg/dl - At least 70% of the day � < 70 mg/dl - Less than 4% (58 minutes) � < 54 mg/dl - Less than 1% (14 minutes)

Technology brings improved awareness, collaborative management & results in people with hypoglycemia— decreasing fear of long-term complications & replacing with freedom

How is CGM helpful? CGM provides more personalized care CGM allows the patient to see the bigger picture of how diabetes affects them Patients can have support people follow them, to help with their management CGM has shown to improve glycemic control in people with T1D and T2D on insulin and reduce risk of hypoglycemia in persons with diabetes of all ages (1)  A recent study using retrospective, real-world data from insurance claims showed that the use of CGM was associated with a reduction in acute diabetes-related events and all-cause inpatient hospitalizations  Another study from a large health care delivery system showed the benefit of initiating (vs. not initiating) CGM in insulin-treated patients with diabetes on the reduction in emergency department (ED) visits and hospitalization for hypoglycemia (3)  When used properly, CGM in conjunction with multiple daily injections (MDI) and continuous subcutaneous insulin infusion and other forms of insulin therapy are useful tools to lower and/or maintain A1c levels and/or reduce hypoglycemia in adults and youth with diabetes    

With CGM, patients can always know their glucose numbers:

How to get started on CGM         

Helpful wording when working on insurance coverage CGM has been proven in clinical trials to: Reduce hypoglycemia

Increase time in range Decrease hyperglycemia

Decrease diabetes burden Improve outcomes

Real-world stories Patient: 43 year-old male Diagnosis: T1D, diagnosed at age 12 Medications: Tresiba and Humalog  Prior to CGM, was checking blood glucose ~15 times a day  A1c: 5%  Issues with hypoglycemia unawareness CGM Data – Before

 Patient uses insulin via MDI or insulin pump as well as a personal CGM device  Patient requires therapeutic CGM for best glucose control  Treatment requires frequent adjustments of insulin by the patient on the basis of therapeutic CGM testing  Patient is currently using an insulin pump  Patient is following an MDI regimen taking “X” number of injections daily  CGM therapy will help to achieve glycemic control by alerting people of hyperglycemia and hypoglycemia and allowing modification of insulin dosing based on glucose trends and patterns  Patient demonstrates an understanding of the technology and is motivated to use the device correctly and consistently

CGM helped me see how small decisions I thought weren't a big deal were making a huge impact on blood glucose (BG) numbers, but I often did not see this with just using BG checks. I have been able to act in real time.

Outcomes: After 6 months of wearing CGM, the patient experienced the following changes in hypoglycemia: Start 8.5 hours per day >25% low, 9% very low

After 6 months 3 hours per day (9% low, 3% very low) 1.5 hours per day (5% low, 1% very low)

CGM Data – After

For the first time since diagnosis Iactually feel comfortable managing my diabetes, everyone with diabetes should have a CGM.

Who is a good candidate for CGM? Good candidates for CGM include: (4)  Uncontrolled diabetes  Lack of hypoglycemia awareness  Discordant A1c and finger-stick readings  Dawn phenomenon  Postprandial hyperglycemia  Nocturnal hypoglycemia  Special populations (e.g., chronic kidney disease or pregnancy)  Require uninterrupted monitoring by caregivers  Choose to use advanced insulin delivery technologies  Unable to achieve desired glycemic control CGMs are increasingly accessible and effective for patients not only with T1D but also T2D, and even those with prediabetes, as a means for real-time biofeedback and behavior change. (5)

Set reasonable expectations based on one’s lifestyle Provide comprehensive training when starting a person with diabetes (PWD) Teach that CGMs have high inaccuracy on day one Help patients view CGM as a partner not a burden; the data is a tool not a grade Set alarms at conservative thresholds to avoid alarm fatigue Educate patients to never overreact to high alarms with aggressive bolus dosing Teach patients to understand and use trend arrows Encourage patients to try different site locations to find what works best Be prepared for assistance on insurance coverage � Documentation of blood glucose control, insulin therapy, history of hypoglycemia (severe, nocturnal and recurring)

Patient: 55 year-old female Diagnosis: T1D, diagnosed at age 10  Since diagnosis, patient had 10+ severe hypoglycemic events where someone had to assist in treatment  Patient had been taking too much basal for many years and then eating to fight the lows

Outcomes: After 1 year of wearing CGM, patient was able to understand the role of insulin and adjust appropriately

CGM Data – Before

CGM Data – After

“I don’t have to feed my insulin anymore.”


9.1% A1c

This is the best control I’ve had in 49 years of diabetes.

References After 1 year

7.7% A1c

1. 2.




Time In Range. (n.d.). DiaTribe. Retrieved June 23, 2022, from https://diatribe.org/time-range. Beck RW, Riddlesworth T, Ruedy K, Ahmann A, Bergenstal R, Haller S, et al. Effect of Continuous Glucose Monitoring on Glycemic Control in Adults With Type 1 Diabetes Using Insulin Injections: The DIAMOND Randomized Clinical Trial. JAMA. 2017;317(4):371-8. Karter AJ, Parker MM, Moffet HH, Gilliam LK, Dlott R. Association of Real-time Continuous Glucose Monitoring With Glycemic Control and Acute Metabolic Events Among Patients With Insulin-Treated Diabetes. JAMA. 2021;325(22):2273-84. Add continuous glucose monitoring to your practice: a step-by-step guide. (n.d.). Add Continuous Glucose Monitoring to Your Practice: A Step-by-Step Guide. Retrieved June 23, 2022, from https://www.aafp.org/pubs/fpm/blogs/inpractice/entry/cgm_guide.html Aaron Neinstein, MD, FAMIA, T. K. M. D. (2019). A New Era: Increasing Continuous Glucose Monitoring Use in Type 2 Diabetes. Evidence-Based Diabetes Management, 25(4).

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