continuous glucose monitoring. diabetes management evolution insulin delivery glucose monitoring...
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Continuous Glucose Monitoring
Diabetes Management Evolution Diabetes Management Evolution
Insulin Delivery
Glucose Monitoring
2000 First CGM system
2006
Paradigm REAL-Time, combining Insulin Pump and CGM
1983 First Minimed
Pump-502
1978First Insulin
Pump1920s
Insulin Injections
2005-2007Real-time CGM
Urine Testing
1977 Blood Glucose
Meter
1999 First AnimasPump-R1000
2012 Dexcom G4
Navigator
NOTE: Only the Medtronic Real-time CGM is approved for use in children and adolescents in the U.S.
Why Continuous Glucose Monitor?
• Prevention of hypoglycemia
• Prevention of hyperglycemia
• Pattern assessment
• Basal Testing
• Assess the impact of food on blood glucose
• Assess the impact of exercise on blood glucose
• Behavior modification tool
• Alerts/Alarms: Safety, peace of mind…
Hypoglycemia in Children and Adolescents
• 657 children followed for 3 years
• 8.5% had severe (seizure/coma) hypoglycemia
• 27% had moderate (required assistance) hypoglycemia
• 75% of seizures occurred at night
• Recent CGM data shows seizure may require prolonged severe hypoglycemia prior to event
Davis EA, et al. “Hypoglycemia: Incidence and clinical predictors in a large population-based sample of children and adolescents with IDDM” Diabetes Care 1997;20:22-25.
17 y.o. Female, A1C 6.2%, in Study 3 Months
17 y.o. Female, A1C 6.2%
Seizure
14 y.o. male A1C 6.6%, Crews (rowing team) in PM
5/16/06
5/27/06
Camp Study: Duration of hypoglycemia with and without remote monitoring in 13 y.o. male on MDI
“Insulin Rx” is glucagon
No Remote Monitoring<70 mg/dl = 350 minutes<50 mg/dl = 305 minutes
Remote Monitoring<70 mg/dl = 110 minutes< 50 mg/dl = 10 minutes
0
50
100
150
200
250
300
350
400
Fingerstick Measurement
Glu
cose
(mg/
dl)
Breakfast8:30 am
Lunch12:00 noon
Dinner6:00 p.m.
Bedtime10:30 p.m.
Insulin Bolus
Target Range
Daily Patient Log
Target Range
Daily Patient Log and Sensor Data
0
50
100
150
200
250
300
350
400
Glu
cose
(mg/
dl)
Breakfast8:30 a.m.
Lunch12:00 noon
Dinner6:00 p.m.
Bedtime10:30 p.m.
Sensor Measurement
Insulin Bolus
Fingerstick Measurement
What’s the Difference??
1. 100 mg/dL
OR
2. 100 mg/dL dropping at rate of >2 mg/dL/min
CGM adds an additional dimension, the rate of change and direction of change.
Practical Application:Real Life Experience
“Paula’s Pearls”
Pearl # 1: Match Device to Patient Needs
Size…real estate issues
Transmitter Range
Transmitter Range:
I can’t find you!!
Pearl # 2 : Match Insertion Approach…Ouch!
◊ Use numbing cream: lidocaine topical
Ela-Max cream
EMLA cream
◊ Use soap and water to wipe off cream
then clean with alcohol
Tape Issues: How do we get this thing to stay on??
• IV 3000, Tegaderm, Hy-Tape
• Coban
• IV prep- avoid at sensor insertion area
• “Sandwich”/layer tape
• Tape Allergies…Ugh!
Pearl # 3: Teach, Teach and Teach Again!
Sensor Lag Time
Calibration
Trend Arrows
Glucose Trends/Patterns
Sensor Lag Time: Why doesn’t the sensor match my fingerstick reading?
• There is a 10-20 minute lag time between interstitial fluid (ISF) glucose and BG
• Lag occurs with ALL subcutaneous sensors
• CGM is a trending device, NOT a treatment device
Sensor Lag
Time (minutes) (0 = start if meal)
-40 -20 0 20 40 60 80 100 120 140
Blo
od G
luco
se (
mg/
dl)
0
100
200
300
400
500
Freestyle Sensor
Sensor Lag
Fingerstick Capillary Glucose (SMBG)
Interstitial Fluid Glucose (CGM)
QUESTION:When will the ISF glucose and the BG value be the most similar/closest?
When BG is stable/not fluctuating rapidly
QUESTION:When using a CGM, when should the patient test their BG with a fingerstick?
1. Before all treatment decisions and insulin
2. To verify symptoms of hypoglycemia
3. Before driving
Calibration: When to calibrate?
• The accuracy of all the CGM’s are dependent on the calibration phase
• Devices calibrate in 1-2 hours
• Must do a fingerstick BG to calibrate
• Do NOT calibrate when the BG is changing rapidly
Calibration: When is the best time to calibrate?
• When BG is not changing rapidly
Trend Arrows:
• Show the direction of change
• Provides information on the rate-of-change
Activity
• Table teams review the CGM downloads
• What do you see?
• What don’t you see?
• Recommendations/Suggestions?
Glucose Trends – CGM Report
Post-breakfastexcursion
Post-breakfastexcursion
Nocturnal lows
Glucose Trends – CGM Report
Pearl # 4: Respond to Data
1. Change behavior!• Pre-bolus
• Less carbs at breakfast
• Assess food impact
2. Check basal rates
3. Use alarms
Pearl # 5: Who should wear a CGM?
• MOTIVATED patients/parents!
• Those willing and able to be educated on the device
• Those who are willing to look at and respond to the data!
• Those with realistic expectations and who can handle a potentially “rocky” start
CGM REPORTS
Report #1: Patience is important!
Report # 2: Missed Meal Bolus
Report # 3: Near perfection! A1C 6.1%
Report # 4: Failure to acknowledge alarms and using pump suspend
Report # 5: Pump site failure
Pump site failure Insulin via syringe Insulin via syringe
“NAKED DIABETES!”