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Making The Most of Continuous Glucose Monitoring Gary Scheiner MS, CDE Owner/Director, Integrated Diabetes Services 333 PowerPoint Presentation
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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, PA 19096 (877) 735-3648 www.integrateddiabetes.com Gary@integrateddiabetes.com.

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slide1

Making The Most

of Continuous Glucose Monitoring

Gary Scheiner MS, CDE

Owner/Director, Integrated Diabetes Services

333 E. Lancaster Ave., Suite 204

Wynnewood, PA 19096

(877) 735-3648

www.integrateddiabetes.com

Gary@integrateddiabetes.com

making the most of continuous glucose monitoring
Making the Most of Continuous Glucose Monitoring
  • What Information Is Available?
  • How to Use Immediate Data?
  • How to Use Intermediate Data?
  • What Can Be Learned from Retrospective Analysis?
  • Optimizing CGM System Performance
minimed paradigm guardian real time cgm systems
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)
slide4
CareLink™ Personal:

Online Reports

MiniMed Paradigm® & Guardian® REAL-Time CGM Systems

  • Sensor daily overlay
  • Sensor overlay by meal
slide5

MiniMed Paradigm® & Guardian® REAL-Time CGM Systems

CareLink™ Personal Online Reports

Daily summaries & layered reports, including…

  • Sensor tracing
  • Basal & bolus delivery
  • Carbohydrate & logbook entries
dexcom seven plus
DexCom™ Seven Plus®

On-Screen Reports

  • 1, 3, 6, 12, 24-hr graphs
  • Updates every 5 minutes
  • Hi/Low alerts
  • Rate of Change alerts
dexcom 7 sts
DexCom™ 7 STS®

Dexcom DM2 Download Reports

Glucose Trend

Hourly Stats

dexcom 7 sts1
DexCom™ 7 STS®

Dexcom DM2 Download Reports

Trend Analysis

BG

Distribution

freestyle navigator
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
freestyle navigator1
Freestyle Navigator™

Download to CoPilot Software

Modal Day Report

Glucose Line Report

Statistics Report

practical benefits of real time cgm
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, 232-244.

how to look at the information
How to Look at the Information

Immediate

Intermediate

Retrospective

immediate info alerts
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

setting alerts
Setting Alerts

Hi/Low alarm thresholds are not BG target ranges

Balance need for alerts against “nuisance factor”

initial alert settings recommendation
LOW: 80 mg/dl (4.5 mmol)

90 (5) + if hypo unaware

HIGH: 300 mg/dl (16 mmol)

lower progressively toward 180 (10)

Initial Alert Settings Recommendation

NOT RECOMMENDED: Low 70 (3.9)

NOT RECOMMENDED: High 140 (7.8)

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, 232-244.

special alert settings
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)

immediate info glucose and trend
Immediate Info: Glucose and Trend
  • Prediction/Forecasting
  • Safety/Performance
    • Driving
    • Sports
    • Tests
immediate glucose info
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
immediate info potential bolus adjustment based on bg direction
Immediate Info: Potential Bolus AdjustmentBased 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%

immediate info hypoglycemia alerts
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
intermediate info use of 2 3 4 hr trend graphs
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

intermediate info use of 9 12 24 hr trend graphs
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

specific insights to derive
Specific Insights to Derive

(a purely retrospective journey)

before you analyze qualify
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?

these are a few of my favorite stats
These Are a Few of My Favorite Stats…

Mean (avg) glucose

% Of Time Above, Below, Within Target Range

Standard Deviation

# Of High & Low Excursions Per Week

case study 1 effectiveness of current program
Case Study 1: Effectiveness of Current Program

Type 1 diabetes; using insulin glargine & MDI

Overnight readings are OK; HbA1c levels are elevated

400

Glucose (mg/dL)

300

200

100

0

3 AM 6 AM

9 AM 12 PM 3 PM 6 PM 9 PM

Meal doses insufficient; not covering snacks?

case study 2a basal insulin regulation
Case Study 2a: Basal Insulin Regulation

Rising 2 AM – 8 AM

400

300

200

100

Glucose (mg/dL)

400

0

300

200

100

0

3 AM 9 AM 3 PM 9 PM

3 AM 9 AM 3 PM 9 PM

  • Stable 12 AM – 4 AM, then dropping pre-dawn
  • Dropping late afternoon
case study 2b basal insulin regulation
Case Study 2b: Basal Insulin Regulation

Type 1 diabetes; using insulin glargine & MDI

History of morning lows

Now not “covering” highs at night

400

Glucose (mg/dL)

300

200

100

0

3 AM 6 AM 9 AM 12 PM 3 PM 6 PM 9 PM

BG dropping overnight; insulin dose too high

case study 3 detection of silent hypoglycemia
Case Study 3: Detection of Silent Hypoglycemia

Type1 diabetes; on pump

Frequent fasting highs (9 AM)

400

Glucose (mg/dL)

300

200

100

0

3 AM 6 AM 9 AM 12 PM 3 PM 6 PM 9 PM

Somogyi effect during the night

case study 4 determination of insulin action curve
Case Study 4: Determination of Insulin Action Curve

3-Hour Duration

4-Hour Duration

5-HourDuration

case study 5 fine tuning meal boluses
Case Study 5: Fine-Tuning Meal Boluses

400

Glucose (mg/dL)

300

200

100

0

3 AM 6 AM 9 AM 12 PM 3 PM 6 PM 9 PM

Night-snack dose clearly insufficient

Breakfast and lunch doses may be too low

Dinner dose appears OK

case study 6 fine tuning correction boluses
Case Study 6: Fine-Tuning Correction Boluses

400

Glucose (mg/dL)

300

200

100

0

  • Dropping low after correcting for highs at bedtime and wake-up time

3 AM 6 AM 9 AM 12 PM 3 PM 6 PM 9 PM

Need to change correction factor & insulin sensitivity during AM hours

case study 7 postprandial analysis
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

400

Glucose (mg/dL)

300

Meal

200

Meal

Meal

100

Meal

Significant postprandial spikes (300s)

case study 8 impact of physical activity
Case Study 8: Impact of Physical Activity

Type 1 diabetes; pump user

Basal rates confirmed overnight

Exercises in the evening (9 PM)

400

Glucose (mg/dL)

300

200

100

0

Exercise

3 PM 6 PM 9 PM 12 AM 3 AM 6 AM 9 AM 12 PM

Experiencing delayed-onset hypoglycemia

case study 9 impact of stress
Case Study 9: Impact of Stress

Type 1 diabetes; pump user

40 years old; athletic

Handsome, excellent speaker

400

Glucose (mg/dL)

300

200

100

0

  • Late for meeting
  • Gets flat tire; eats 15g carbs to prepare for tire change

9 AM 12 PM 3 PM 6 PM 9 PM

  • Spare is flat too!!

STRESS CAN RAISE BLOOD GLUCOSE… A LOT!!!

case study 10 impact of various food types
Case Study 10: Impact of Various Food Types

Cereal

Pasta Meal

Oatmeal

Stir-Fry Over Rice

Yogurt

BG peaks later with pasta than rice

Postprandial peak: cereal > oatmeal > yogurt

case study 11 impact of hi fat meals
Case Study 11: Impact of Hi-Fat Meals

Saturday Nights, Dinner Out

Temp basal increase following hi-fat meals

cgm homework assignments
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

Download (if poss.) prior to appointments!

slide39

Optimizing CGM

System Performance

  • Calibration
  • Site selection/care
  • Signal reception
  • Ingredients for success
optimal calibration
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
optimal calibration1
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
sensor sites
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

sensor sites1
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)

signal reception
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)

ingredients for success
Ingredients For Success

Have the right expectations

Wear the CGM at least 90% of the time

Look at the monitor 10-20 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