Why should we monitor glucose? 2 1 2/28/2020 American Diabetes - PDF document

2/28/2020 Type 2 Topics: Monitoring Your Glucose with CGMs: To Poke or Not to Poke? Kevin Kam, RPh, CDCES inControl Diabetes Center WWW.TCOYD.ORG WWW.TCOYD.ORG Taking Control Of Your Diabetes, 501(c)3 is a not-for-profit educational organization. Taking Control Of Your Diabetes, 501(c)3 is a not-for-profit educational organization. 1 Why should we monitor glucose? 2 1

2/28/2020 American Diabetes Association Recommendations for Assessment of Glucose Control • SMBG allows patients to evaluate their individual response to therapy and assess whether glycemic targets are being safely achieved. • Integrating SMBG results into diabetes management can be a useful tool for guiding medical nutrition therapy and physical activity , preventing hypoglycemia , and adjusting medications (particularly prandial insulin doses). • Among patients with type 1 diabetes, there is a correlation between greater SMBG frequency and lower A1C. The patient's specific needs and goals should dictate SMBG frequency and timing. American Diabetes Association Diabetes Care 2019 Jan; 42(Supplement 1): S73 3 Summary of Glycemic Recommendations Summary of Glycemic Targets • American Diabetes Association (ADA)*: • Preprandial: 80 ‐ 130 mg/dL • Peak postprandial ⁺ : <180 mg/dL • Hemoglobin A1c: <7.0% (needs to be individualized) • American Association of Clinical Endocrinologist (AACE): • Fasting plasma glucose: <110 mg/dL • 2 ‐ Hour postprandial glucose: <140 mg/dL • Hemoglobin A1c: <6.5% (needs to be individualized) *Non ‐ pregnant Adults Diab Care, s66 Vol 42 Supplement 1, Jan 2019 ⁺ 1 ‐ 2 hours after the beginning of the meal Endo Practice Vol 24 No. 1 January 2018 4 2

2/28/2020 If glucose monitoring is helpful, how often should we test? 5 Intensive Insulin Regimens Most patients using intensive insulin regimens (multiple ‐ dose insulin or insulin pump therapy) should perform SMBG: • Prior to meals and snacks • At bedtime • Occasionally postprandially • Before exercise • When they suspect low blood glucose and after treating low blood glucose until they are normoglycemic • Prior to critical tasks such as driving (For many patients, this will require testing 6–10 times daily, although individual needs may vary) American Diabetes Association Diabetes Care 2019 Jan; 42(Supplement 1): S73 6 3

2/28/2020 T1D Exchange Registry Assessing the Association between SMBG Frequency and A1c (all T1 patients) 13 ‐ 25 years old 1 ‐ 12 years old 26 ‐ 50 years old > 50 years old Miller K, et al Diab Care, Vol 36, July 2013 7 T2D on Basal Insulin/Oral Agents • The evidence is insufficient regarding when to prescribe SMBG and how often testing is needed for patients with type 2 diabetes using oral agents • For patients using basal insulin, assessing fasting glucose with SMBG to inform dose adjustments to achieve blood glucose targets results in lower A1Cs • Glucose monitoring can provide insight into the impact of diet, physical activity, and medication management on glucose levels. • Assessing hypoglycemia • Medicare Allowance: – Not on insulin: 100 test strips/90 days – Insulin: 100 test strips/30 days American Diabetes Association Diabetes Care 2019 Jan; 42(Supplement 1): S73 ‐ S74 8 4

2/28/2020 1950’s 1980’s 2000’s Home Glucose Monitoring 9 What is a Continuous Glucose Monitor (CGM)? 10 5

2/28/2020 Typical CGM System 1. Glucose sensor inserted under the skin • Measures glucose every 1-15 minutes • CGMs measure interstitial glucose 2. Wireless transmitter • Sends glucose measurements 3. Receiver (or smart phone) • Store, process, and display glucose values and trends 11 Continuous Glucose Monitors (CGMs) Measure Interstitial Glucose Interstitial glucose correlates well with plasma glucose. 12 6

2/28/2020 3 people, all with an A1c of 7% https://diatribe.org/BeyondA1c 13 https://diatribe.org/BeyondA1c 14 7

2/28/2020 Trend Arrows More information is better! 15 Trend Arrows… Where is your glucose going? 16 8

2/28/2020 What to Do? • Go for a walk • Take insulin? 220 mg/dl • Keep an eye on it 17 Alerts and Alarms • Dexcom ✔ • Medtronic ✔ • Eversense ✔ • Not currently available with Freestyle Libre 18 9

2/28/2020 Share your data with friends and family 19 Use your glycemic report to review your glucose data 20 10

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2/28/2020 Benefits of CGM Consistent Use: ■ Empowers you to make healthy decisions ■ Can improve your A1c and “Time in Range” (blood glucose between 70-180 mg/dL) ■ May decrease hypoglycemia 23 Current CGM Options 24 12

2/28/2020 Freestyle Libre 14 Day • Sensor worn for 14 days – Simple insertion – 1 hour “warm up” • Swipe reader or smartphone over sensor to get glucose value – Includes glucose trend arrows • No fingerstick required – Reader is also a glucose meter if needed • No alerts/alarms 25 Medtronic Guardian 3 • Sensor worn for 7 days – Insertion slightly more complex – 2 hour “warm up” period • Sends glucose data to insulin pump or smartphone – Includes glucose trend arrows • Requires 2-4x calibrations (fingersticks) per day • Has alerts/alarms and sharing capability 26 13

2/28/2020 Dexcom G6 • Sensor worn for 10 days – Simple insertion – 2 hour “warm up” • Sends glucose data to receiver or smartphone – Includes glucose trend arrows • No fingerstick required • Has alerts/alarms and sharing capability 27 Senseonics Eversense Implantable Continuous Glucose Monitor Sensor Smart Transmitter Mobile App Removable and rechargeable Sensor lasts up to 90 days iOS and Android platform On-body vibe alerts No weekly sensor insertion Alarm settings & reports Gentle, daily adhesive patch 28 14

2/28/2020 Don’t throw out your home glucose monitor just yet! As a general rule, when the glucose results being displayed by the CGM system does NOT match symptoms, patients should confirm their glucose levels via fingerstick. Additionally, exposure to interfering substances in the blood may cause glucose sensor to inaccurately measure glucose. • Acetaminophen (DexG5-Not G6) • Ascorbic Acid/Salicylic Acid (FS Libre 14d) • Mannitol/Sorbitol (I.V. or PD solution-Eversense) 29 What's on the Horizon? 30 15

2/28/2020 Freestyle Libre 2 • Update to current Freestyle Libre system • Will include optional glucose alarms • Available in Europe • Not yet FDA approved 31 Dexcom G7 (under development) • Factory calibrated • Fully disposable • Simple application • Significant cost reduction 32 16

2/28/2020 Insurance Coverage Medicare and Other Plans • Type 1 or Type 2 diabetes diagnosis • Monitoring blood glucose 4x a day or more • Using 3 or more insulin injections per day or wearing an insulin pump • Adjust your insulin regimen based on your glucose monitoring results • Visit HCP in the past 6 months and will continue to see your HCP every 6 months 33 Copy of my slides: www.incontrolhawaii.net password: TCOYD2020 34 17

2/28/2020 Closing Session & Drawing 4:30PM Ballroom 313 Laugh Your Way to Lower Blood Sugars Frank DeLima, Comedian and Entertainer We will be collecting drawing tickets at 4:30PM. Please place your duplicate ticket(s) into the box on the main-stage just prior to the closing session. WWW.TCOYD.ORG WWW.TCOYD.ORG Taking Control Of Your Diabetes, 501(c)3 is a not-for-profit educational organization. Taking Control Of Your Diabetes, 501(c)3 is a not-for-profit educational organization. 35 18