Endocrine News speaks with Vivian A. Fonseca, MD, FRCP, and Pamela Kushner, MD, FAAFP, to learn more about the Endocrine Society’s new CME program, “Continuous Glucose Monitoring: Merging Patient Satisfaction with Data-Driven Glycemic Control.”
As Endocrine News showed in its December 2020 issue, breakthroughs in endocrine science and research continue to take place at a breakneck pace in recent months, despite the lockdowns around the world. This research is vital to improve the health of those patients living with a variety of endocrine disorders, and one of the most prevalent is diabetes.
Since the debut of insulin 100 years ago, treatments for people living with diabetes have been flourishing, from new insulin formulations and care delivery to the types of devices patients can use to monitor their health on a daily, even hourly, basis. Continuous glucose monitoring (CGM) has been at the forefront since the systems were first approved by the U.S. Food and Drug Administration (FDA) in 1999. Since that time, new developments in CGM technology have been rapidly evolving.
Staying on top of these new developments can be a challenge for a busy endocrinologist and is one of the reasons why the Endocrine Society partnered with Clinical Care Options, LLC, to offer a primer program on the latest in CGM technology. Regardless of where clinicians are in their practice levels, they will no doubt find the program, “Continuous Glucose Monitoring: Merging Patient Satisfaction with Data-Driven Glycemic Control” extremely informative while also garnering CME credits.
“Even though most endocrinologists have embraced the use of CGM, learning the nuance of interpretation, particularly from the patient’s perspective, will help your patients obtain the full benefit of this technological advance,” says the program’s director Vivian Fonseca, MD, FRCP, Tullis-Tulane Alumni Chair in Diabetes, professor of medicine, chief, Section of Endocrinology, Tulane University School of Medicine, New Orleans, La.
So far, the program has reached more the 3,000 clinicians of all stripes — physicians, nurses, pharmacists, and certified diabetes educators (CDEs). Endocrine News sat down with Fonseca and faculty member Pamela Kushner, MD, FAAFP, clinical professor, University of California Irvine Medical Center, Irvine; director, Kushner Wellness, Los Alamitos, Calif., for their top tips from the program.
Endocrine News: Who would benefit most from participating in this CME program?
Pamela Kushner: The advances in CGM technology are a condition-changing opportunity for the people living with diabetes and for the clinicians who treat them. But that also means there’s an ever-evolving learning curve for both patients and physicians. This program will help even out that curve and provide clinicians with the most current information. Since it’s online, they can attend and learn the recent advances in CGM technology on their own schedules.
Vivian A. Fonseca: Even though most endocrinologists have embraced the use of CGM, learning the nuance of interpretation, particularly from the patient perspective, will be useful in patients obtaining the full benefit of this technological advance.
“Even though most endocrinologists have embraced the use of CGM, learning the nuance of interpretation, particularly from the patient’s perspective, will help your patients obtain the full benefit of this technological advance.” – Vivian Fonseca, MD, FRCP, Tullis-Tulane Alumni Chair in Diabetes, professor of medicine, chief, Section of Endocrinology, Tulane University School of Medicine, New Orleans, La.
“Even though most endocrinologists have embraced the use of CGM, learning the nuance of interpretation, particularly from the patient’s perspective, will help your patients obtain the full benefit of this technological advance.”EN: Are there certain patients with diabetes who would be better served than other patients by continuous glucose monitoring?
Kushner: CGM is appropriate for all patients receiving diabetes medication. It allows patients to play an active role in their diabetes care, which is so important in shared decision making. CGM teaches patients how their medications, specific foods, exercise, stress, work, and other factors influence their daily glucose results.
CGM can help motivate patients to make positive lifestyle changes. Identifying the individual patient needs will ensure that appropriate expectations for the clinician and patient are met.
EN: What is the evidence that CGM is a benefit to people with diabetes?
Fonseca: Although early trials simply demonstrated a reduction in hypoglycemia and were mainly in type 1 diabetes, more recent randomized trials have demonstrated a range of benefits including improved glycemic control with less hypoglycemia, and some trials have demonstrated benefit in type 2 diabetes.
Recent CGM trials include:
- DIAMOND and GOLD, which showed improved glycemic control in patients with type 1 diabetes receiving multiple daily injections;
- IMPACT and REPLACE, which showed significantly less hypoglycemia in patients with flash (intermittently scanned) glucose monitoring in patients with both type 1 and type 2 diabetes, respectively; and
- CONCEPTT, which showed improved pregnancy outcomes.
EN: How do you teach people with diabetes to use CGM devices and how to react to the various results?
Kushner: Most CGM devices have excellent online patient support videos and other materials from the manufacturers to help with a smooth start. However, clinicians play a key role in patient satisfaction and adherence.
After initial CGM sensor placement, patients should be advised to keep a detailed profile of meals, exercise, medication administration, alcohol, and sleep. They should be given a follow-up appointment to review the data, and they should be advised to continue with any therapy changes until that follow-up.
At the follow-up visit, patients and clinicians can work together to recognize hypoglycemia risk, evaluate patterns of low or high readings, uncover any obstacles to monitoring, and consider potential therapy changes.
For personal-use CGM devices, trend arrows allow patients to see the rate and direction of their glucose changes, allowing patients to adjust the insulin dose as needed to prevent potentially dangerous glycemic events.
EN: How do you efficiently incorporate CGM review into your patient workflow?
Kushner: Particularly in primary care, the clinician needs to schedule adequate time to use CGM effectively, making it clear that the focus of the visit is to review CGM data. This makes it a priority over other issues that often are brought up in a primary care visit.
As an active participant, the patient is urged to scan as much as possible and ideally upload the data to an online portal. Alternatively, the clinician can use professional CGM where there is no patient-initiated scanning. To be most efficient, data can be downloaded prior to the clinician entering the room. This allows the patient to review daily graphs that include AGP and TIR and better understand the concepts.
Having more detailed profile sheets kept by the patient also helps save time by making it simpler to recognize patterns.
“CGM is appropriate for all patients receiving diabetes medication. It allows patients to play an active role in their diabetes care, which is so important in shared decision making.
CGM teaches patients how their medications, specific foods, exercise, stress, work, and other factors influence their daily glucose results.”EN: With the world currently battling the COVID-19 pandemic, and many of these patients requiring care in intensive care units (ICU), can people with diabetes still use the CGM if they are in an ICU?
Fonseca: CGM devices are generally not approved for ICU use. However, the FDA has approved use of one specific flash glucose monitoring system in the hospital setting during the COVID-19 pandemic only, allowing for remote monitoring of glucose levels.
In patients who are hemodynamically unstable or who are on medications that may interfere with measurement, CGM results should be interpreted with caution. In such situations, confirmation of a very abnormal reading with capillary blood glucose monitoring is appropriate.
The Endocrine Society partnered with Clinical Care Options, LLC, for this program. Eli Lilly provided additional support through an educational grant.
To access “Continuous Glucose Monitoring: Merging Patient Satisfaction with Data-Driven Glycemic Control,” go to: www.clinicaloptions.com/cgm.
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