Flash Continuous Glucose Monitoring: Implications for Use of Continuous Data in Daily Diabetes Management.

Full realization of the benefits of continuous glucose monitoring (CGM) depends on addressing barriers such as cost, accuracy, burdens of daily use, and uncertainty about applying the data. Lack of systematic education has also hampered widespread adoption among patients and health care professionals. This article describes the practical application of an affordable and intuitive category of CGM called "flash" that requires users to scan the sensor with a handheld reader for on-demand access to continuous data. The data may be used for in-the-moment therapy adjustment, retrospective review of glucose patterns, and observation of glucose trending in response to behavior. Higher rates of flash CGM scanning have been associated with increased time in the glycemic target range and reduced time in hyper- and hypoglycemia. Growing interest in this technology suggests new opportunities for helping more patients incorporate CGM into their daily self-care.

Improving Patient Experience With Insulin Infusion Sets: Practical Guidelines and Future Directions.

PURPOSE: Insulin infusion sets (IISs) are an essential component of safe and effective insulin pump therapy. Establishing best practices for their use has been impeded by a lack of formal study and limited resources for clinician and patient education. Recent innovations in IIS science promise to change this status quo by increasing awareness of such problems as unexplained hyperglycemia and infusion set occlusion. METHODS: In August 2015, a panel of diabetologists and certified diabetes educators from various disciplines was convened to reconsider IIS-related complications of pump therapy, to better characterize infusion set factors affecting patient experience, and to update priorities for optimizing current technologies. Actionable guidelines were provided for addressing common issues, including skin reactions, site rotation and set changes, dislodgment of the infusion set, and partial or complete blockage of the catheter. These issues may underlie episodes of IIS failure and/or unexplained hyperglycemia. CONCLUSION: Development of practical tools and standardized guidelines for empowering patients to prevent, diagnose, and troubleshoot IIS problems that contribute to unexplained hyperglycemia will be necessary to realize the full benefit of insulin pump therapy along the continuum of diabetes education.

Benefits of short-term professional continuous glucose monitoring in clinical practice.

BACKGROUND: The clinical utility of short-term professional continuous glucose monitoring (CGM) is uncertain. SUBJECTS AND METHODS: This is a retrospective review of 121 consecutive insulin-treated patients seen in a university-based subspecialty clinic who completed a 72-120-h professional CGM study. Based on the indications for the study, patients were divided into three groups: hyperglycemia (Hyper) (n=51), widely fluctuating glycemia (Fluctuating) (n=50), or hypoglycemia (Hypo) (n=20). Hemoglobin A1c (A1c) was compared before and 3-6 months after CGM. Hypoglycemia frequency was recorded by patients' self-report. RESULTS: Among the entire cohort, the A1c level dropped a small amount (0.18%; P=0.04). In the Hyper group, the A1c level fell from 9.0±1.1% to 8.6±1.2% (P<0.02). In the Fluctuating group, there was no change (from 8.0±1.0% to 8.0±0.9%). The A1c level of the Hypo group patients did not change (7.6±1.1% before and after), but 14 of 20 (70%; P<0.01) had a drop in self-reported frequency of hypoglycemia. For the whole cohort, the drop in A1c level was correlated with the initial A1c value (r=0.54, P<0.01). Patients with an initial A1c level of >9.0% saw a drop of 0.7% (from 10.2±1.1% to 9.4±1.1%; P<0.01), and those with an A1c level of >7.5% saw a drop of 0.4% (from 8.9±1.2% to 8.5±1.1%; P=0.01). Subgroup analysis showed that patients with type 1 diabetes had a drop in A1c level that was not statistically significant. However, type 1 diabetes patients in the Hypo group did have a decrease in self-reported hypoglycemia (11 of 16 [68%]; P=0.03). CONCLUSIONS: Professional CGM can lead to a lowering of elevated A1c levels in insulin-treated patients, especially those with type 2 diabetes. There also appears to be benefit in decreasing self-reported hypoglycemia.

Use of insulin pump therapy in patients with type 2 diabetes after failure of multiple daily injections.

OBJECTIVE: To determine the effectiveness of insulin pump use (continuous subcutaneous insulin infusion; CSII) in patients with type 2 diabetes (DM2) who have failed multiple daily injection (MDI) therapy. METHODS: In this retrospective study, charts of patients with DM2 who were started on CSII after failure of MDI were reviewed. Patients were categorized as primarily manual (fixed) bolus users or calculated (using pump software) bolus users. The change in hemoglobin A1c (HbA1c), weight, and basal insulin dose from baseline to 6 months was determined. RESULTS: Fifty-seven patients (20 men and 37 women) ranging in age from 13 to 71 were identified in the study. A significant reduction in HbA1c was observed from 8.75 to 7.69% (P<.001). There was an increase in body mass index (BMI) from a mean of 36.53 to a mean of 37.21. A decrease in basal insulin requirement per kilogram of weight (-0.10 U/kg) was noted (P = .03). Seven patients using U-500 insulin in the pump also had a significant decrease in HbA1C of 1.1 % (P<.001), along with a 0.071 U/kg drop in basal insulin requirements (P<.001). When comparing calculated bolus users to manual bolus users, there was no difference in HbA1C improvement (P = .58). CONCLUSION: We found that CSII improves glucose control in patients with DM2 who have failed MDI despite a decrease in overall insulin requirements. This includes patients with severe insulin resistance using U-500 insulin. Use of frequent bolus adjustment incorporating carbohydrate counting and current glucose level does not appear to be required for this benefit.

Benefits of continuous glucose monitor use in clinical practice.

OBJECTIVE: To determine the benefits of personal continuous glucose monitoring (CGM) outside of a controlled clinical trial in a single ambulatory diabetes clinic. METHODS: In this retrospective study, we reviewed medical records of all patients who began CGM in our university-based clinical practice between July 2006 and October 2008. Data pertaining to 1 year before initiation of CGM through January 2009 were collected. All patient visits were performed by any 1 of 7 board-certified endocrinologists and/or 5 certified diabetes educators. A severe hypoglycemic event was considered to have occurred if the patient reported requiring assistance or losing consciousness, or if there was documentation from another source (eg, an emergency department visit). Analysis of the effect of CGM on hemoglobin A1c and occurrence of severe hypoglycemia was performed. RESULTS: A total of 117 patients initiated CGM between July 2006 and October 2008 and used CGM for at least 2 months (total experience on CGM, 1136 patient-months; average 9.7 months per patient). Mean age was 44.5 +/- 12.8 years (range, 14.3-71.7 years), and average duration of diabetes mellitus was 23.9 years. All patients were using insulin pumps before initiation of CGM, including 10 patients with type 2 diabetes. Sixty-eight patients (58%) had preexisting hypoglycemia unawareness. Average hemoglobin A1c level for 1 year before CGM initiation was 7.6 +/- 1.1%, and with CGM use it dropped to 7.2 +/- 0.8% (P<.001). Forty-two patients had severe hypoglycemic events in the year before CGM use or during CGM use. Overall, CGM use was associated with a significant decrease in the rate of severe hypoglycemic episodes (odds ratio, 0.40; 95% confidence interval, 0.24-0.65). CONCLUSIONS: Personal CGM, in a real-world setting, improves glucose control and reduces the rate of severe hypoglycemic episodes.

Individualizing care for the many: the evolving role of professional continuous glucose monitoring systems in clinical practice.

PURPOSE: A generation of individuals with diabetes has come of age since the Diabetes Control and Complications Trial and the United Kingdom Prospective Diabetes Study, providing demonstrable evidence that optimal glycemic control, achieved early with intensive therapy, yields a durable beneficial effect. Yet realizing the full potential of intensive therapy requires more frequent glucose monitoring and accurate interpretation of data. Because patients typically check no more than 3 or 4 times per day and rarely during the night, glucose variability, including glycemic spikes and asymptomatic hypoglycemia, may be missed. Short-term use of a professional continuous glucose monitoring (CGM) device, worn by patients without access to real-time data, reveals patterns of high and low blood glucose undetectable by self-monitoring of blood glucose (SMBG) alone. Clinicians interpret the continuous profile retrospectively to identify and adjust components of the insulin regimen responsible for nocturnal hypoglycemia, postprandial hyperglycemia, and other glucose excursions. This supplement discusses how professional CGM, used as an adjunct to SMBG, can help patients understand the effects of their behavior on glycemic control and consider the potential utility of diabetes technology in transforming knowledge to action. CONCLUSION: Strategic implementation of professional CGM may improve the time- and cost-effectiveness of diabetes care while advancing more personalized treatment in the course of everyday practice.