DISCLAIMER: ECHO Nevada emphasizes patient privacy and asks participants to not share ANY Protected Health Information during ECHO clinics.

Transcription

1 DISCLAIMER: Video will be taken at this clinic and potentially used in Project ECHO promotional materials. By attending this clinic, you consent to have your photo taken and allow Project ECHO to use this photo and/or video. If you don t want your photo taken, please let us know. Thank you! ECHO Nevada emphasizes patient privacy and asks participants to not share ANY Protected Health Information during ECHO clinics.

2 CONTINUOUS GLUCOSE MONITORING PART 2 Veronica Brady, PhD, FNP- C, BC-ADM, CDE University of Nevada, Reno School of Medicine August 3, 2017

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4 COURSE OUTLINE (4-40 MINUTE SEGMENTS) 1. What is CGM professional personal 2. Identification of appropriate candidates for CGM pre-dm, T1 or T2DM patients not at goal hypoglycemia unawareness 3. Interpretation of data review downloads from 3 available devices 4. Billing and coding cost of professional device ROI billing codes

5 OBJECTIVES 1. Define continuous glucose monitoring (CGM) 2. Identify the different types of CGM devices 3. Identify appropriate candidates for the use of CGM 4. Verbalize understanding of data interpretation 5. Have a beginning knowledge of billing for CGM insertion and interpretation

6 RECOMMENDATIONS FOR CGM USE

7 AACE & ACE CONSENSUS ON CGM 2015 CGM usage has improved clinical diabetes outcomes by reducing hypoglycemia (1). CGM is recommended in all patients with type 1 diabetes and should be available to all type 2 diabetes on multiple insulin injections, basal insulin, or sulfonylureas. CGM should also be used in all patients who are at risk for hypoglycemia and/or have hypoglycemia unawareness (10). CGM in type 2 diabetes can be useful in identifying and correcting postprandial glycemic excursions (11,12). Intermittent use of CGM (usually 1-2 weeks) in patients with type 2 diabetes might be more effective than daily glucose fasting glucose in guiding the need for medication adjustment or advancing to new medications.

8 AACE & ACE CONSENSUS 2017 CGM is recommended for patients with type 1 diabetes who have a history of severe hypoglycemia, hypoglycemia unawareness, or frequent hyperglycemia. There is insufficient evidence to recommend CGM among patients with type 2 diabetes at this time. Data on CGM during pregnancy are unclear.

9 ADA STANDARDS OF CARE 2017 Continuous glucose monitoring (CGM) in conjunction with intensive insulin regimens is a useful tool to lower A1C in selected adults (aged 25 years) with type 1 diabetes. Although the evidence for A1C lowering is less strong in children, teens, and younger adults, CGM may be helpful in these groups. Success correlates with adherence to ongoing use of the device. CGM may be a useful tool in those with hypoglycemia unawareness and/or frequent hypoglycemic episodes.

10 ADA STANDARDS OF CARE 2017 (CONT) Given the variable adherence to CGM, assess individual readiness for continuing CGM use prior to prescribing. When prescribing CGM, robust diabetes education, training, and support are required for optimal CGM implementation and ongoing use. People who have been successfully using CGM should have continued access after they turn 65 years of age.

11 CHOOSING THE APPROPRIATE DEVICE

12 PROFESSIONAL DEVICES Blinded Medtronic/Libre/Dexcom Unblinded Dexcom Provider information to make medication adjustments Patient unwilling be involved Attempting to change behaviors Patient willingness to be involved (test BG) Prevention of hypoglycemia

13 PLACEMENT OF DEVICE

14 SITE SELECTION

15 SITE SELECTION 2

16 PATIENT EDUCATION

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20 CASES

21 OLDER PATIENT W/T1DM & HYPERGLYCEMIA (MM) MM is a 64 year old female with a 3 year h/o T1DM. She was recently admitted to St Mary's for hypoglycemia followed by DKA. Current A1c >15% Medications currently taking Basal Insulin: Detemir Dosage: 10 units am and 10 units pm Prandial: Novolog Dosage: units + 2/50 How many times a day patient is currently testing: 1-4 Patient brought a record of blood glucose readings to visit today: yes Review of BG log reveal BG readings ranging: Meter mg/dL (avg 322mg/dL) Me Patient required use of glucagon since last visit: no Patient required assistance of REMSA since last visit: no Patient wears MediAlert: yes

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24 CHANGES IN REGIMEN BASED ON CGM Patient Instructions: 1) 1) Check blood sugars before meals and at bedtime and record. Endocrinology appointments. Bring record to all 2) 2) Inject Levemir 15 units int the morning and 10 units at bedtime 3) 3) Inject Novolog units before meals 4) 4) blood sugar units of novolog 5) 5) less than 70 none 6) 6) units 7) 7) units 8) 8) units 9) 9) units 10) 10) units 11) 11) units 12) 12) units 13) 13) units 14) 14) > units 15) 15) IF YOU ARE NOT EATING AND BLOOD SUGARS ARE HIGH TAKE INSULIN AS FOLLOWS: 16) 16) units 17) 17) units 18) 18) units 19) 19) >400 4 units 20) 20) If glucose less than 70mg/dL eat/drink 15gms of fasting acting carbohydrate 21) Call me on Friday

25 YOUNG ADULT WITH SEVERE HYPOGLYCEMIA (NM) NM is a 24-year-old man with a history of type 1 diabetes diagnosed at the age of 9-1/2 years. The patient comes to clinic today to establish care with endocrinology in the Reno area. The patient reports that since his diagnosis of type 1 diabetes he has been on insulin therapy and most recently he has been on Levemir insulin 46 units twice daily and Humalog meals 1 unit for each 10 g of carbohydrate at breakfast and dinner. He reports he normally does not take any insulin with lunch. The patient reports concerned at this time due to the fact that over the last 6 months he has been experiencing severe episodes of hypoglycemia. He reports in the last 6 months he has used glucagon 6 times. He states that while his A1c is usually about 6% it has not been due to the fact that he is having low blood sugars. The patient brings with him his glucometer which reveals blood glucoses ranging between 46 to greater than 300 mg/dl. He reports that he is currently testing 8-10 times per day.

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27 CHANGES TO REGIMEN BASED ON CGM RESULTS Patient Instructions: 1) Check blood sugars before meals and at bedtime and record. Bring record to all Endocrinology appointments. 2) Inject Lantus 26 in the morning and 44 bedtime 3) Inject Humalog/ 1 unit for each 5-7 grams of carb before meals 4) If glucose less than 70mg/dL eat/drink 15gms of fasting acting carbohydrate and recheck in 15 minutes. 5) Contact our office if glucose persistently less than 70mg/dL or greater than 300mg/dL 6) Bring in meter or dexcom for download tomorrow and Monday morning.

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30 OLDER PATIENT WITH T2DM EG is a 79 year old female with a >35 year h/o T2DM. She experienced adverse effects from the Bydureon. than 500mg BID of Metformin. She can not tolerate more She is currently taking Lantus 40 units BID and Novolog 20 with breakfast and 15 with dinner. She forgets the afternoon dose fairly often. She is testing 3 times a day, with BG ranging mg/dL (avg 193). Dietary Intake: Breakfast:eggs, bacon, toast (1) or english muffin Lunch:french dip (1/2) Dinner:leftovers Snacks:sees candy, cupcakes,sweets Beverages: water, tea Weight- up 4# Last A1c-8.7%

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32 CHANGES TO REGIMEN BASED ON CGM RESULTS 2 Your thoughts???

33 TAKE HOME MESSAGES CGM is not for everyone Patient selection should center around: Who-the patient in front of you What- do you want to know about the patients diabetes control When- do you suspect there may be issues with the patients glycemic control (i.e. after exercise, early morning, etc.) Where- is the patient willing to have the device inserted Why- do you want to know about the patients BG readings How- long of a wear period is needed to obtain the desired information Inform the patient that CGM does not replace the need for regular blood glucose monitoring

34 NEXT 2 COURSES 1.Interpretation of data 2.Billing and coding

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