1. The Dexcom G4 PLATINUM Continuous Glucose Monitoring System is designed with convenience, performance, and simplicity in mind. You are already using the basic features of the System, such as:
• High/low alerts
• Glucose trend screens (1-, 3-, 6-, 12-, and 24-hour views)
• Unique hypoglycemic alarm at 55 mg/dL
Many people who are already using the basic features of the Dexcom G4 PLATINUM want additional information and features that go beyond the basics. In an effort to give you just that, today’s presentation will cover the following topics:
Setting Expectations
Using Trend Information
Calibration
Sensor Site Selection and Placement
Advanced Features
Troubleshooting
Using Dexcom STUDIO

2. Ice Breaker- Ask class: What do these numbers mean to you?.
Dexcom G4 PLATINUM gives a reading once every 5 minutes
Dexcom G4 PLATINUM is indicated for up to 7 days of use.
Dexcom G4 PLATINUM needs to be calibrated a minimum of once every 12 hours.

3. This is YOUR Journey. To ask class: Is there anything you would like to focus on tonight?

4. One important thing to note: Your Dexcom G4 System Sensor and blood glucose meter measure glucose from two different
types of body fluids: interstitial fluid and blood. Therefore, readings from your blood glucose meter and Sensor may not match. This is normal. Readings can be different and still be considered accurate. In this example, the difference between the sensor glucose reading and blood glucose meter reading is 17%; this can still be considered accurate.
I recommend to my patients that they focus on the trend information from their Dexcom G4 system, not the glucose value.

5. As you know, your Receiver displays trend graphs (graphs are available for 1-, 3-, 6-, 12-, and 24-hour time periods). These graphs provide information regarding the direction and speed of glucose changes. Trend Arrows are also present and can be found in the upper right corner of your trend graph screen. Trend Arrows provide additional information about the speed and direction of the change in your glucose. They cannot be turned off.
Let’s talk about what each Trend Arrow means:
Constant: Glucose steady (not increasing/decreasing more than 1 mg/dL/min)
Slowly Rising: Glucose rising 1-2 mg/dL/min
Rising: Glucose rising 2-3 mg/dL/min
Rapidly Rising: Glucose rising more than 3 mg/dL/min
Slowly Falling: Glucose falling 1-2 mg/dL/min
Falling: Glucose falling 2-3 mg/dL/min
Rapidly Falling: Glucose falling more than 3 mg/dL/min
No Rate of Change Information: Receiver not currently calculating how fast glucose is rising/falling. If you are concerned that your glucose level may be rising or falling, take a fingerstick to check your readings.
Some notes about using Trend Arrows:
They show the direction and rate of change and should be used IN ADDITION TO trend graphs to help you make informed decisions about managing your glucose levels
In the absence of a Trend Arrow or if there is a “constant” Trend Arrow, your glucose still could be going up or down from your current glucose reading. In the case where there is a “constant” Trend Arrow, your glucose could be going up or down up to 60 mg/dL each hour (changing up to 1 mg/dL each minute).

6. Ask class: How would you handle this situation with your glucose going up at 250mg/dL?
Remember: an appropriate response to a glucose level of 250 mg/dL depends on the direction of the trend. You would treat a 250 going up differently than you would treat a 250 going down.

7. Ask class: Now, if you were 250mg/dL going down, how would you handle this situation? Would you react differently with a 250mg/dL glucose value going up vs. a 250 mg/dL glucose value going down? This example shows the benefit of trend information. A glucose value along does not give you the complete picture of your glucose.
Remember: an appropriate response to a glucose level of 250 mg/dL depends on the direction of the trend. You would treat a 250 going up differently than you would treat a 250 going down.

8. After lunch John’s glucose is too high
After lunch John’s glucose is too high. What should John do in this situation?
Watch and Wait
Give a small amount of mealtime insulin, to lower glucose
Exercise

9. John decides to watch and wait
John decides to watch and wait. This action puts him over his post meal glucose goal of 160 mg/dL as well as his target range. Watching and waiting when the glucose level is rising fairly steeply after a meal usually may mean that not enough insulin was given with that meal.

10. John decides to give a small amount of mealtime insulin
John decides to give a small amount of mealtime insulin. This action puts his meal time glucose level at target.

11. John decides to exercise
John decides to exercise. This action puts his post-mealtime glucose level within his target glucose range but still higher than his post meal goal of 160mg/dL. Aerobic exercise in most cases will help to lower your glucose levels.

12. Why calibrate?
You have to “teach” your new Sensor your bloodglucose values by entering in a KNOWN glucose VALUE from your blood glucose meter—just as you would adjust a new watch to the current time. This is how you calibrate your sensor.
Calibration is a VERY important part of making sure your DexCom G4 System is working its best. So be sure to make every calibration count. And, calibrate smart by using the best fingerstick technique with your blood glucose meter (wash your hands, use your fingertips, etc).
UNLIKE a new watch, where you generally just set the time once, your Sensor needs to be calibrated throughout its life. This is because its readings can change over time…like a watch over time running a little too fast or too slow. You’ll need to calibrate your Sensor to make sure that it is providing you with the most accurate sensor glucose readings over the whole time that you are using it.

13. Which are calibration do’s and don'ts?
Day 1 Hint: Calibrating at various glucose ranges may help improve day one performance (Dexcom, Data on File).

14. Day 1 Hint: Data indicates calibrating at various glucose ranges may help improve day one performance.
Calibration “Do’s”
A at least once every 12 hours
Using fingerstick blood glucose only
Whenever the glucose is < 3 mg/dL/min
Calibration “Don’ts”
When there are straight up or down arrows - ROC (3 or more mg/dL/min ROC
When there is “???” in status bar
When there is out of range simple in the status bar
When your glucose is <40mg/dL or above 400 mg/dL

15. After using the Dexcom G4 PLATINUM for some period of time, people often have questions about site selection and preparation. Let’s review some tips:
Wash and dry your hands thoroughly
Find a fatty, “pinchable” area on your belly.
Clean the area with alcohol and let dry
Avoid areas with scarring, tattoos, or rough patches of skin.
If you wear an insulin pump, make sure the Sensor is placed at least 3 inches away from your pump infusion set.
If you use injections, you need to inject at least 3 inches away from the Sensor site
The site you select should also be out of the way of your waistband or areas where you put pressure while sleeping
Discuss the need for adhesives (i.e. tape over the adhesive of the sensor) if needed

17. Place the Sensor horizontally on the placement site on your body, NOT vertically.
Rotate your fingers around the adhesive to secure the adhesive tape to the body.
Remove the Safety Lock by pulling straight out. Save the Safety Lock, as you’ll be using it to remove your Transmitter from your Sensor after your Sensor session is done.
Using the thumb and forefinger on your non-dominant hand, you may want to pinch up on the tips of white adhesive on your skin at the base of the Sensor Pod.
With your dominant hand, place 2 fingers above the Sensor Applicator collar.
Put your thumb on the plunger and push down completely. You should hear 2 clicks.
Using your thumb as a base, move your fingers from above the collar to below the collar, and pull the collar up completely towards your thumb.
Make sure the Transmitter Latch is flush against the skin.
While still holding the Sensor Applicator, use your other hand to squeeze the ribbed tabs on the sides of the Sensor Pod. Rock the Sensor Applicator forward and out, away from your body.
Once your Sensor has been inserted, it’s time to attach the Transmitter.
First, if you haven’t already done so, clean your Transmitter with an alcohol wipe and let it dry.
Once it’s dry, place your Transmitter into the Sensor Pod (flat side down, thinner side away from the Transmitter Latch).
With one hand, you may want to pinch up on your skin at the front tips of the white adhesive. Use a finger to hold the Transmitter in place. With your other hand, move the Transmitter Latch forward until you hear 2 clicks. This may take some force.
To remove the Transmitter Latch, hold the sides of the Sensor Pod with one hand and the Transmitter Latch with the other. Twist off the Latch.

18. The snooze feature adds a second level of awareness to your glucose alerts. You can program your High and Low Alerts to “snooze” or re-alert you if your glucose levels continue to be outside target range. The snooze feature can be set in 15 minute increments..
Examples of when you might want to set your Alerts to Snooze are:
• After eating a high fat or a high protein meal
• After exercising
Additional tips:
• If you are going to bed and your glucose is too high or too low
• After correcting for a high blood glucose value
• After treating a low blood glucose value
• After you have changed your insulin pump infusion set
To set this feature:
Press the SELECT button to turn on the receiver.
Press the SELECT button to enter the main menu.
Press the UP or DOWN button to highlight “Alerts,” and press the SELECT button.
From the alerts menu, press the UP or DOWN button to select “Advanced,” and press the SELECT button.
Press the UP or DOWN button to highlight “High Snooze” or “Low Snooze,” and press the SELECT button.
Press the UP or DOWN button to select the amount of time (in 15 minute steps) between the first alert and re-alerts. Press the SELECT button.
• If you set the amount of time to zero there will be no re-alerts.
Press the LEFT button to return to the alerts menu when you finish.

19. The Dexcom G4 PLATINUM lets you program Rise and Fall Alerts to support your basic High and Low Alerts. Rise and Fall Alerts can help to provide an additional level of glucose awareness when your glucose is rising or falling, and may help in avoiding hypoglycemic or hyperglycemic events.
You can set the Receiver to alert you when your glucose is rising high or falling low at the rate of ≥2 mg/dL/min or ≥3 mg/dL/min. Rise and Fall Alerts can be set to vibrate then beep or vibrate only, and can also be turned off. Press C to confirm the alert.
Examples of when it might be beneficial to set your Rise and Fall Alerts:
After eating a meal when you are unsure of the carbohydrate content of the meal and you “guesstimated”
After giving a correction dose of insulin
Additional tips:
Overnight
When you are testing your basal rate
When you are trying to achieve the ADA guidelines for peak after-meal glucose of 180 mg/dL
During and after exercise
During stressful or emotional times
On sick days
See the User’s Guide for more information about this feature.

20. The Out-of-Range Alert lets you know when your Dexcom G4 PLATINUM Receiver and Transmitter are not communicating and thus your Receiver is not receiving Sensor glucose readings. When this happens, the Out-of-Range symbol will appear in the Status Box of your Receiver, and then the Out-of-Range screen will appear. The Out-of-Range screen will also show you the amount of time your Dexcom G4 PLATINUM system has not received glucose readings.
You can set the amount of time you can be out of range before you are alerted—between 20 and 200 minutes. The Alert notification can be set to vibrate only, vibrate then beep, or it can be turned off.
An example of when you might want to use the Out-of-Range feature is when you go to bed, so you are alerted if your Dexcom G4 PLATINUM is not tracking your glucose readings overnight.
Additional tips:
When exercising.
See the User’s Guide for more information about this feature.

21. The Dexcom G4 PLATINUM lets you enter information about activities or events that may affect your diabetes so that you can review their effect on your glucose levels.
• Meals—grams of carbohydrate (0-200 grams)
• Insulin dose—0-250 units, in increments of 0.05 units
Exercise—light, medium or heavy intensity; minutes
• Health-related events—including illness, stress, high symptoms, low symptoms, menstrual cycle, and alcohol
Not only do Event Markers help you see how certain events affect your glucose levels, but they also are an important tool to give your health care team the additional information they need to better help you manage your diabetes. Event Markers will not be seen on the Receiver but may be viewed when you download your Receiver data into the Dexcom STUDIO data management software in the Glucose Trend Report.

22. Now let’s talk about troubleshooting
Now let’s talk about troubleshooting. Shown on this slide are some screens you might see at some point when using your Dexcom G4 PLATINUM. Instructions for handling them are available on the back of your Quick Start Guide. You can also call at any time for troubleshooting support.
Here is some information about each screen:
Blood Drop in Status Box
Calibration needed; perform calibration.
Unknown Sensor Glucose Readings ??? in Status Box
Wait. This usually resolves itself within several minutes or up to several hours. Do not calibrate. Make sure Sensor Pod is sticking well to your body and nothing is rubbing against it. Check that Transmitter is snapped in on both sides. When you see a single blood drop or glucose reading in Status Box, enter fingerstick reading.
Out of Range/No Antenna
The Receiver and Transmitter are not communicating. Make sure the Receiver is within 20 feet of the Transmitter/Sensor Pod. Wait 5 to 10 minutes. If no glucose reading appears, contact Technical Support.
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23. Here are some additional screens that you may see:
Sensor Failed
Sensor has shut off before end of 7-day session. The Status Box will appear grayed out. Contact Technical Support. Remove failed Sensor and insert new Sensor; contact Technical Support.
Receiver Error Code
Receiver is not working properly; contact Technical Support.
System Recovery Check
The Receiver had a problem but the system corrected itself. Press SELECT and your Sensor session will continue.

24. One component that can be key to making the Dexcom G4 PLATINUM part of your life is the utilization of the Dexcom STUDIO software. This software is an accessory software program intended to allow for the transfer of glucose data stored by the Dexcom G4 PLATINUM System into a personal computer (PC). After downloading glucose data stored in the Dexcom G4 PLATINUM Receiver, the software displays information in both charts and tables to help analyze trends/patterns in glucose levels.

25. CGM data and interpretation can be overwhelming
CGM data and interpretation can be overwhelming. Dexcom PORTRAIT identifies critical patterns in glucose control, highlighting areas of both patterned hyper- and hypoglycemia and can be used a summary report for patient’s to focus on before their next visit.
Dexcom PORTRAIT is a one page report that easily and quickly identifies critical patterns:
1. Identify clinically significant patterns with the Pattern Map
2. Prioritize clinical patterns to address with the Pattern Map
3. Focus on critical patterns with Insight Summary
4. Provide possible solutions to improve glucose management with Possible Considerations and Interpretation section
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26. Hourly Stats- All-in-one report to easily assess glycemic patterns and variability at the same time.

27. Daily Trends- Overlapping days to assess glycemic patterns
Daily Trends- Overlapping days to assess glycemic patterns. Everyday is a different color.

28. Glucose Distribution - Shows percent time high, low and in target glucose ranges and overall glucose distribution.
Assess pre- and post-prandial control by comparing pie chart distribution.
Reminder: Use Quick Pick feature for both pre-meal and post-meal glucose target ranges to assess how well your insulin dosing is covering your meals.

29. Glucose Trends - Report to review daily glucose trends, event markers and correlation between SMBG and CGM.

30. Glucose Trends – Print Daily Strips
This feature allows you to print out your glucose trends day by day, as well as see the detailed information of every event mark entered.

31. Daily Stats- Review percent time spent high, low and in target glucose ranges by day.

32. Success Report - Compares glycemic control weekly, monthly or quarterly.
This report helps see your progress overtime with obtaining your glycemic control goals.

33. Ask class: What problem areas do you see with this glucose pattern download report? Which of the problem areas would you fix first and why?

34. The problem area that would need to be addressed first is always hypoglycemia, since it is considered to be the most clinically significant event. Nighttime hypoglycemia is the priority to fix first and then any additional events of hypoglycemia throughout the day.
Glucose Pattern Management and General Guide to CGM Interpretation:
Assess patterns of hypoglycemia and address first
Assess patterns of overnight glucose control
Assess pre-prandial glucose control
Assess post-prandial glucose control
In some cases based on interviewing the patient, the above steps and prioritization may need to be modified based on the individual patient need. With the case above, due to the significance of the post-dinner hyperglycemia, this may be more important to address than the issues with the pre/post-lunch hyperglycemia and post-breakfast hyperglycemia.

35. The Pattern Insight Summary reports the one most significant clinical event of nighttime lows, daytime lows, nighttime highs and daytime highs and some possible considerations to help resolve the problem.