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Making The Most of Continuous Glucose Monitoring Gary Scheiner MS, CDE Owner/Director, Integrated Diabetes Services 333 E. Lancaster Ave., Suite 204 Wynnewood,

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Presentation on theme: "Making The Most of Continuous Glucose Monitoring Gary Scheiner MS, CDE Owner/Director, Integrated Diabetes Services 333 E. Lancaster Ave., Suite 204 Wynnewood,"— Presentation transcript:

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 (877)

2 Making the Most of Continuous Glucose Monitoring 1.What Information Is Available? 2.How to Use Immediate Data? 3.How to Use Intermediate Data? 4.What Can Be Learned from Retrospective Analysis? 5.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 Sensor daily overlay Sensor overlay by meal MiniMed Paradigm ® & Guardian ® REAL-Time CGM Systems

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

6 DexCom 7 STS ® On-Screen Reports 1, 3, 9-hr graphs Updates every 5 minutes Hi/Low alerts

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

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

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 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,

11 How to Look at the Information Immediate Intermediate Retrospective

12 Immediate Info: Alerts Alert the user of glucose levels that have crossed specified thresholds, either high or low Visual cues on-screen Vibrations, audible tones

13 Setting Alerts Individualize settings Alarm thresholds are not BG targets Balance need for alerts against nuisance factor

14 LOW:80 mg/dl (90+ if hypo unaware) HIGH:240 mg/dL (lower progressively toward 180) NOT RECOMMENDED: Low 70 mg/dL NOT RECOMMENDED: High 140 mg/dL Alert Settings Recommendation 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,

15 Special Alert Settings Young children (higher, wider range) Hypoglycemia unawareness (higher) Pregnancy (lower, narrower range) HbA1c of 11.0% (higher initially)

16 Immediate Info: Real-Time Adjustments Prediction/Forecasting Safety/Performance Driving Sports Tests

17 Immediate Info: Real-Time Adjustments Replace Fingersticks? Not during first 3-7 days of system use Wait until hrs after sensor replacement If BG Stable If Recent calibrations in-line If No recent alarms

18 Immediate Info: Potential Bolus Adjustment Based 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%

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

20 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

21 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

22 Specific Insights to Derive (a purely retrospective journey)

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

24 Case Study 2a: Basal Insulin Regulation Rising 2 AM – 8 AM Stable 12 AM – 4 AM, then dropping pre-dawn Dropping late afternoon Stable 12 AM – 4 AM, then dropping pre-dawn Dropping late afternoon 3 AM 9 AM 3 PM 9 PM Glucose (mg/dL)

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

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

27 Case Study 4: Determination of Insulin Action Curve 3-Hour Duration 5-Hour Duration 4-Hour Duration

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

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

30 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 Significant postprandial spikes (300s) Glucose (mg/dL) Meal

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

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

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

34 Optimizing CGM System Performance Calibration Site selection/care Signal reception Ingredients for success

35 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 Optimal Calibration

36 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

37 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

38 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)

39 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)

40 Ingredients For Success Wear the CGM at least 90% of the time Look at the monitor times per day Do not over-react to the data Adjust your therapy based on trends/patterns Take IOB into account when using CGM values Minimize nuisance alarms Source: Dr. Bruce Bode, personal observation.

41 Think Like A Pancreas!


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