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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 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 ® 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 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,

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 (90+ if hypo unaware) HIGH: 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,

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 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%

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… qMean (avg) glucose q% Of Time Above, Below, Within Target Range qStandard Deviation q# 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 Meal doses insufficient; not covering snacks? 3 AM 6 AM Glucose (mg/dL) AM 12 PM 3 PM 6 PM 9 PM

27 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)

28 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

29 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

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

31 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

32 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

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

34 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

35 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

36 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

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

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

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 Wear the CGM at least 90% of the time Look at the monitor 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 Source: Dr. Bruce Bode & Gary Scheiner, personal observation.

46 Think Like A Pancreas!


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