CGM: Continuous Glucose Monitoring Making Sense of It All AW: ANCO/GEND/1016/0117

Transcription

1 CGM: Continuous Glucose Monitoring Making Sense of It All

2 Objectives Review how to do a time effective interpretation of CGM and insulin pump download data Review how medications, lifestyle, and current insulin pumping techniques impact glucose Demonstrate interpretation of CGM data and discuss potential causes

3 Factors to Consider before Interpreting CGM Data Before reviewing data, be sure to keep some of the following factors in mind Stress New meds Change in physical activity/season Acetaminophen Times are set correctly Type of Meter used for calibration Growth spurts/puberty Alcohol Menses Bolus Adherence Sleep position

4 Pattern Management The spaghetti report (AKA Standard Day)

5 Pattern Management Identify episodes of hypoglycemia Initially, the very first thing to assess is where the patient is having lows Is there a pattern to them as far as time of day, day of the week, following boluses, activity Eliminate the lows first adjust the basal or bolus settings accordingly Can fine-tune or tweak them after the danger is past

6 Pattern Management: Basal Rate Look at basal insulin levels first Goal: keep the BG stable without the need for extra food or insulin If basal rates are not accurate, it is hard to evaluate other pump settings Basal rates usually vary throughout the day and should be individualized

7 Pattern Management : Basal Rate If basal rates are set correctly, blood glucose will stay within a range of about 30 mg/dl over a period of several hours, in the absence of food, exercise, or additional (bolus) insulin BG changes of more than 30 mg/dl indicate the need to adjust

8 Pattern Management : Basal Rate Review overnight period and assess for patterns According to Ly et al, 2016: A large factor in achieving overall glycemic control for a patient starts with first controlling the overnight period Could improve the enormous burden of care of children with type 1 diabetes. They also relate that according to Davis, Keating & Byrne (1997) When having a significant, prolonged low with a seizure, 75% happened overnight

9 Pattern Management: Overnight Eat a dinner that is low in fat and with a known amount of carbs Test BG 4hrs after dinner and if under 150, test BGs at 12a, 3a, 6a Need several nights of data to determine a pattern

10 Pattern Management : Basal Rate Things to keep in mind when reviewing the data: Coffee drinkers Workdays/school days vs off days Change mode of transportation to/from work/school Higher protein meals Shift workers

11 Pattern Management: Basal Rate

12 Standard Day Box Plot

13 Pattern Management: Bolus doses After basal rates are confirmed, it s time to evaluate bolus doses and related pump settings: I:C (Insulin: Carbohydrate) Ratio: Food bolus ISF (Insulin Sensitivity Factor): Correction bolus

14 Pattern Management: Bolus Doses IC Ratio If BG consistently returns to target range about 4 hours after meals, I:C ratio is working well If BG does not return to target range about 4 hours after meals, you should evaluate your I:C ratio

15 Pattern Management: Bolus Doses IC Ratio Pre-meal BG must be in target range Allows specific evaluation of I:C ratio without interference from other factors, such as extra insulin for high BG Evaluate each mealtime separately, as needed Repeat evaluation 2-3 times before making changes, then recheck

16 Pattern Management: Bolus Doses

17 Pattern Management: Bolus Doses Insulin Sensitivity Factor/ Correction Factor When to start evaluation: BG is high, usually 180 mg/dl, but at least mg/dl over target Last bolus was at least 3-4 hours earlier You can go without food for about 4 hours after giving the bolus You are not ill or under unusual stress You haven t participated in unusual exercise within the past 24 hrs

18 Pattern Management: Bolus Doses Insulin Sensitivity Factor/ Correction Factor If BG is over 250 mg/dl troubleshoot pump/infusion set Postpone evaluation if ketones are present If BG drops too low, discontinue evaluation and treat BG

19 Pattern Management: Bolus Doses

20 Pattern Management: Bolus Doses Insulin on Board/Duration of Action Tracks how much bolus is still working Based on action/duration of fast-acting insulin Does not track basal insulin This feature is intended for use with U100 insulin only

21 Comparison Logbook Table

22 Bolus Adherence Report

23 Compilation Report

24 Compilation Report

25

26 Comparison: Day by Day Overview

27 Standard Day Box Plot Chart

28 CGM Standard Day

29 CGM Standard Day

30 References Bailey, T.S., Grunberger, G., Bode, B.W., Handelsman, Y., Hirsch, I.B., Jovanovic, L., Roberts, V.L., Rodbard, D., Tamborlance, W.V. and Walsh, J. (2016). American Association of Clinical Endocrinologists and American College of Endocrinology 2016 Outpatient Glucose Monitoring Consensus Statement. Endocrine Practice. 22 (2), Basu, A., Veettil, S., Dyer, R., Peyser, T., and Basu, R. (2016). Direct evidence of acetaminophen interference with subcutaneous glucose sensing in humans: A pilot study. Diabetes Technology and Therapeutics. 18 (2), S Ly, T., Keenan, D.B., Roy, A., Han, J., Grosman, B., Cantwell, M., Kurtz, N., von Eyben, R., Clinton, P., Wilson, D.M., and Buckingham, B.A. (2016). Automated overnight closed-loop control using a proportional-integral-derivative algorithm with insulin feedback in children and adolescents with type 1 diabetes at diabetes camp. Diabetes Technology and Therapeutics. 18 (6),

31 References Scheiner, G. (2016). CGM retrospective data analysis. Diabetes Technology & Therapeutics. 18 (2), S2-14. vandam, R.M., Pasman, W.J., Verhoef, P. (2004). Effects of cofee consumption on fasting blood glucose and insulin concentrations. Diabetes Care. 27 (12), Walsh, J., Roberts, R. (2013). Pumping Insulin (5 th Edition). Torrey Pines Press. San Diego, CA.