How to Use Real-Time CGM to Optimize Diabetes Outcomes

NEW ORLEANS — Teaching patients to make decisions based on real-time continuous glucose monitoring (CGM) information is both safe and highly effective. This includes instructing patients on when to trust the numbers, how to properly set and respond to high or low alerts, and adjustments for upward and downward glucose trends, according to Gary Scheiner, MS, CDE.

“It is probably more appropriate to screen patients who are not appropriate for CGM rather than the other way around. Real-time CGM offers considerable value to a very wide array of patients with diabetes. There is a relatively short list of reasons not to use it. Also, it is unacceptable to simply order a CGM and expect patients to benefit from it without proper education as well as a guiding hand in analyzing the data,” said Scheiner, who is the clinical director of Integrated Diabetes Services, LLC in Wynnewood, Pennsylvania.

Scheiner — the 2014 AADE Diabetes Educator of the Year — along with Heather Lien, MSN, FNP-BC, CDE, and Patricia (Gaye) Knutsen, NP-C, RN, MSN, ACNS-BC, CDE, discussed how best to implement educational strategies for enhancing patients’ real-time CGM experience at AADE 2015, the annual meeting of the American Association of Diabetes Educators.

Knutsen, who is the diabetes program coordinator at Barnes Jewish Hospital at Washington University School of Medicine in St. Louis, said diabetes educators play a key role in shaping the discussion regarding CGM by setting appropriate expectations, developing a troubleshooting toolbox and coaching patients on real-time data use. She also explained that diabetes educators should download and analyze CGM data at each visit.

“We also teach a streamlined method for analyzing CGM data,” Scheiner told Endocrinology Advisor. “If you go into sensor data analysis with an open mind, you are doomed to become overwhelmed. Instead, proceed with an agenda of specific objectives such as learning whether or not basal insulin holds glucose levels steady overnight. It is also good to learn the duration of action for bolus insulin, the magnitude of postprandial glucose at each mealtime, patterns that precede and follow hypoglycemia, and when it is necessary to intensify a patient’s medical program.”

Lien, who is a glycemic control service nurse practitioner at the University of Washington Medical Center in Seattle, noted that the goals of diabetes treatment should be to optimize glycemic control, help patients avoid acute complications and set up a plan to prevent long-term complications. However, it is most important to make sure you are enhancing the quality of life for the patient, she said.

She also explained that patients on insulin pumps or MDI appear to have improved glycemic control when CGM is added with no increase in hypoglycemia.¹ In one study, results demonstrated that by using CGM, 50% of the subjects achieved an HbA1c reduction of at least 1.0%, and 26% of the subjects achieved a reduction of at least 2.0%. Most notable was the fact that there was no increase in hypoglycemia.

The study included 81 children and 81 adults who were divided into randomized groups of 54 for each branch of the study.

Lien said the potential benefits of CGM use include the identification and confirmation of glycemic excursions and the ability to detect dawn phenomena. Having insights into the effects of physical activity, food and stress can also help prevent many of the problems associated with hypoglycemia and hyperglycemia.

Additionally, Knutsen noted that patients with uncontrolled diabetes have health care expenditures up to eight times greater than those with controlled diabetes. She said barriers need to come down when it comes to CGM.

Many patients also harbor concerns about accuracy when it comes to CGM. Knutsen said a survey of 102 ex-users of CGM showed that 34% did not trust the numbers, 26% thought there were too many false alarms and 22% thought too often the device stopped working. The survey also showed that 28% did not use CGM due to costs, and 27% reported that it added to how much the patient needed to carry around.

Knutsen said these are all challenges that can easily be overcome. However, the challenges must be approached in a structured manner and in a way that does not overwhelm the patient or the provider.

References

1. Deiss D et al. Diabetes Care. 2006;29(12):2730-2732.
2. Scheiner G, Knutsen P, Lien H. T13 – Optimizing CGM: Best Practices for the Diabetes Educator. Presented at: AADE 2015; Aug. 5-8, 2015; New Orleans.