The Use of Continuous Glucose Monitoring for Medication Adjustments, Lifestyle Interventions for Patients With Diabetes
In this podcast, Diana Isaacs, PharmD, CDCES, talks about continuous glucose monitoring (CGM) technology and how it can be used for medicine adjustments and lifestyle interventions for patients with diabetes. Dr Isaacs discusses how this technology has evolved over time, how clinicians can strategically use CGM technology in their practice, and more.
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TRANSCRIPTION:
Jessica Ganga: Hello everyone and welcome to another installment of Podcast360, your go-to resource for medical education and clinical updates. I'm your moderator, Jessica Ganga with Consultant360, a multidisciplinary medical information network.
Dr Diana Isaacs is joining us today to discuss the use of continuous glucose monitoring (CGM) technology for medication adjustments and lifestyle interventions for patients with diabetes. Welcome to the podcast, Dr Isaacs. Please introduce yourself to the audience.
Dr Diana Isaacs: Hello, everyone. My name is Diana Isaacs. I'm an endocrine clinical pharmacist and a certified diabetes care and education specialist and also the director of education and training in diabetes technology at the Cleveland Clinic in Cleveland, Ohio.
Jessica Ganga: Well, welcome again, Dr Isaacs. Thank you for being on the podcast. How has CGM technology evoloved to what it is now?
Dr Isaacs: Well, CGM is very exciting, And, you know, even before CGM, when we think about how far we’ve come, believe it or not, we started off with urine glucose testing, which was really not very specific because glucose isn’t detected in urine until hit hits 180. So when we got our first blood glucose monitors in the 1970s, that was really exciting at the time. Of course, continuous glucose monitors offer so many advantages over blood glucose monitoring in that it's measuring close every 1 to 5 minutes. It's recording that data every 5 to 15 minutes. And in 1999, we had our first FDA-approved device. However, that device was very limited in that it was a 3-day wear. It was actually a professional blinded device, meaning a person did not see their glucose readings while they wore it. It wasn't until it was downloaded that they were able to see their readings. So, in the early 2000s, when we got our first personal CGM devices and people could actually see in real time their glucose values, that was super exciting.
However, our first personal CGMs were limited in terms of accuracy. They were much less accurate. They were good for capturing trends, but they lagged way behind what a finger stick or a venous lab draw would be. They were also much bigger, much bulkier. And initially, they required confirmatory finger sticks to make dosing decisions. You compare that to where we are today, where now we have devices that are disposable. So, we take them off, change them out, not have to save different pieces and cards. We even have an implantable CGM that could be worn for 6 months. All of our devices now are approved to make dosing decisions without needing to confirm with finger sticks.
There's still a couple that require some finger stick calibrations, but all of them are approved to make dosing decisions. And when you look at accuracy, just so spot on accurate and the ability now to have high alerts and low alerts and more customization with alerts, we have just really come such a long way.
Jessica Ganga: With this technology, how can clinicians use CGM devices to adjust medications for their patients? What should they look for?
Dr Isaacs: So with CGM, in addition to all the benefits for the person with diabetes and the alerts and everything, we get this beautiful data, which has been standardized in the ambulatory glucose profile report.
And this is a one-page report that really shows us at the top of it, the key metrics and those are things like the percentage of time a person is in their target range. For most people we're aiming for 70% of the time between 70 and 180 milligrams per deciliter while trying to minimize time in hypoglycemia to less than 4% below 70 and less than 25% of the time over 180. In addition to that, we get other metrics like the estimate of A1C, which is called the glucose management indicator (GMI), and can really provide current information—like with an A1C, you're only checking that every 3 months. With this GMI, it can be recalculated every 14 days. So, it's a much more current assessment of how somebody is doing.
And then in addition to that, in the middle of the report, you have what's called the ambulatory profile itself, which is this visual image of the patterns. And this is where it really comes to these medications, where you can see, okay, are there glaring patterns? Like is the person dropping overnight? And maybe we need to decrease their insulin or other medications, or are they having spikes at certain heels and they need to make adjustments there. In addition to that, at the bottom of the report, you get the last 14 days of daily information. And there's also additional reports that you can deep dive into as well, but this one pager really provides a lot of valuable information where you can quickly assess it and see, okay, are there glaring patterns where we would need to increase, decrease the medication or is the person meeting their goals and we continue things as is?
Jessica Ganga: How can this technology be used for lifestyle interventions in patients? And do the interventions differ between patients with, say, type 1 diabetes vs patients with type 2 diabetes?
Dr Isaacs: Well, yes, absolutely. So CGM is great for medication adjustments, but also fantastic for lifestyle interventions. And there's some data that shows that wearing CGM can improve someone's time and range, lower their A1C to the point where that may replace the need for a medication adjustment. I think when people first start wearing it, inherently they're able to see real time the kind of the effects of some of their food choices, some of their physical activity.
And so it can be really motivating to see, oh, “that food, the cereals spiked my blood sugar at breakfast. But when I had a hard boiled egg, it was like a flat line.” So that really reinforces some positive healthy food choices. Also things like the benefits of exercise. If, you know, going for a walk after eating a meal can really prevent glucose from spiking up as high. So absolutely, it's great for that.
There's also many mobile apps that can work with the CGM data that can help reinforce lifestyle choices, like for example, pairing up taking pictures of food and being able to pair that up with the CGM data to really see patterns and trends of how foods are affecting glucose levels and then the devices also have the option with the mobile apps to enter in different comments and things. And I find this really helpful, before I meet with a patient, I encourage them a few days before to enter in different comments about their week if they notice their glucose spiked or it went low or just something different in their usual pattern to enter that in. And that can really help facilitate this discussion and recommend certain lifestyle changes based on what is discovered through wearing a CGM and having this data.
Jessica Ganga: And then the second part of the question, do the interventions differ between patients with type 1 diabetes vs patients with type 2 diabetes?
Dr Diana Isaacs: Oh, yes, sorry, I forgot to address that.
Jessica Ganga: That's okay.
Dr Diana Isaacs: They absolutely can for sure. Type 1 is always going to need insulin. Type 2 doesn't need and doesn't always need insulin. And so that can be a difference in terms of hypoglycemia or low blood sugars. And so that with type 1 diabetes, there's a little bit more nuance around exercise, I would say, in terms of having to figure out, do we need to add some additional carbohydrates before exercise to prevent going low? Or do we need to subtract some insulin at the meal or snack prior to the exercise? So, CGM is very helpful for learning individualized patterns of how to address that.
For other areas, there's a lot of similarities. I mean, we want both people with type 1 and type 2 needs to eat healthy to try to incorporate non-starchy vegetables and have protein paired with their carbohydrates when possible. So, a lot of it can be similar, but I would say there's nuance certainly around anyone who's taking a medication that can cause hypoglycemia.
Jessica Ganga: Thank you for that, Dr Isaacs. What are some strategies clinicians can implement for using CGM in in their practice?
Dr Isaacs: So, it can definitely feel overwhelming, I think, especially in a primary care setting where you—like I'm in endocrinology, so we've been using this now for several years, but this is kind of like all of a sudden, now everyone with diabetes is on a CGM or has access or wants a CGM. And it's like, wow, how do you add this to your workflow? And it's already a super busy clinic.
And so I think one thing is utilizing who you have on your team. And this is different for different clinics and settings, but who are the ancillary staff? Who's around? Are there medical assistants that are checking patients in and can they be involved in making sure patients get connected to the mobile platform? Because for those using mobile apps, or even if they're using, let's say a reader or receiver to see their gross, we can either download that data in the clinic or we can get them connected to the Cloud where their data will stream to our clinic account. So, if you can have people help get that set up, then the data will be there.
And it's just a question of, okay, who's going to access it? Then who's going to look at it and what are we going to do with it? And I would say the companies for all these respective CGM devices are great about providing support. So, if your clinic isn't already set up with a clinic account or isn't sure where to begin with how to access the data, they're an absolutely great resource. Now, once you have access to the data, the next question is, what's the workflow going to look like? And I think this is where there's different ways to do it.
Someone can print it out in advance of the clinic day. Someone could copy and paste it into the electronic health records into the chart notes. We are hopefully getting closer—some places have direct electronic health record integration and this would ultimately be the gold standard where the data seamlessly goes directly into the [electronic health record] and it's already there. I believe we will get there one day, but right now it's a little bit of a convoluted process and some systems have that set up, but others—many—most don't yet.
Dr Isaacs: So anyway, all of that to say getting the data into there and then just having the time to review it. One thing is that once you get more experience with looking at these reports, it becomes pretty quick where within a couple of minutes, you can really look at it and identify patterns and trends. It may seem overwhelming at first because it's a new way of looking at data.
In the past, we relied so much just on A1C, which is just one number, so that's so easy. But it really does get easier as you get used to looking at these reports, and it also can really help facilitate discussion with the person. The other thing is if you have other people on your team, like diabetes care and education specialists, pharmacists, dietitians that you also can send people to, to do maybe a deeper dive or talk about that data, that can help a ton as well.
So those are, I guess, some, yeah, some basic strategies. We could talk all day about that though.
Jessica Ganga: What do you believe the future looks like for the use of CGM devices to help manage diabetes in patients?
Dr Isaacs: Well, I think this is going to become the standard of care. We're expecting in the near future, there's going to be over the counter versions of CGM, which I think is only going to further the access. One thing I didn't mention in the beginning with the whole future of CGM and how it's evolved is the cost has come way down to the point where often it's as cheap as buying test strips. And so, we're getting to a place where this really is going to be the standard of care for all people with diabetes, certainly insulin users right now it is, but I think we're headed to where everyone's going to find benefit in utilizing devices and some capacity.
So, I think that is really exciting. Also, I think we expect to see there’s probably going to be more artificial intelligence embedded with this. And I know a lot of efforts are underway to— what can be done to simplify it for the health care team, like how can we maybe use AI or different strategies to basically look at that data and say, “Okay, this is probably what we should do. This is the medication change that needs to be done” or “this is the lifestyle change that we should recommend.”
So, oh, and one other thing, too. So, right now, all of our devices are, you know, there's a needle essentially that goes in under your skin, it comes right out and then there's a sensor that's under the skin. There's one implantable, but all the others work that way.
Well, something that's in research that I think is coming soon is non-invasive CGM, where it would just go on the skin and there would be no needle at all. So that would be really interesting as well. So yeah, we'll see how that goes.
Jessica Ganga: Well, thank you again, Dr Isaacs, for your time. Is there anything else you would like to add?
Dr Isaacs: Just this is an exciting area. I encourage people to stay up to date, to talk with their different respective CGM companies. Wear one, if you haven't worn one before, that's the best way to learn. But CGM is here. We need all hands on deck. We need everyone involved. So, I encourage you to stay up to date on this topic.
Jessica Ganga: Well, I think that was a perfect closing in itself. Thank you again, Dr Isaacs.
Dr Isaacs: Thank you so much for having me.