Optimizing Therapy and Clinical Outcomes Using Real-Time Continuous Glucose Monitoring (AADE PRODUCT THEATRE) August 7, 2014 Orlando, FL

Transcription

1 Optimizing Therapy and Clinical Outcomes Using Real-Time Continuous Glucose Monitoring (AADE PRODUCT THEATRE) August 7, 2014 Orlando, FL

2 Welcome and Introduction Orlando, FL August 7 th, 2014 Keri Weindel, MS, RD, CDE Director, Professional Education Dexcom, Inc.

3 Agenda 2:15 PM Doors Open and Refreshments Served 2:15 PM Hands-on Demonstrations of Dexcom G4 Platinum CGM System and Dexcom Studio Software Demonstration Booths 2:45 PM Welcome and Introductions Program Objectives Keri Weindel, MS, RD, CDE 2:50 PM Optimizing Diabetes Management Using Professional Real-Time Continuous Glucose Monitoring Audience Response Gary Scheiner, MS, CDE 3:15 PM Getting Your Patients to Goal Efficiently and Effectively with Real-Time Continuous Glucose Monitoring Audience Response Patricia Knutsen, MSN 3:45 PM Questions and Adjourn

4 Optimizing Diabetes Management Using Professional Real-Time CGM Gary Scheiner MS, CDE 2014 AADE Diabetes Educator of the Year Owner & Clinical Director Integrated Diabetes Services LLC Wynnewood, PA

5 Optimizing Diabetes Management Using Professional Real-Time CGM Borrowed System Worn temporarily Data analyzed for fine-tuning purposes

6 Why Real Time (vs. blinded)? Cause / Effect Learning Better Calibration Safety Likelihood to Obtain & Use

7 Reimbursement for Real-Time Professional CGM Medicare & >90% of Commercial Plans CGM Startup $157 (Medicare) Any staff member (under supervision) CGM Interpretation $44 (Medicare) Physician, MD, PA

8 Reimbursement for Real-Time Professional CGM May Bill for Professional or Personal CGM Medicare Professional Only May be Done Remotely No more than 1x/month Minimum 72 hrs data required

9 Startup Tips Remote Training Considerations Provide toll-free 24/7 hotline Materials Manuals, shortcut guides Logsheets Chargers Extra Tape Transmitter Power Guarantee Set Clock & Date Minimize Alarms!

10 Startup Tips User Instructions Optimal Calibration To trust, or not to trust? Written logging, event markers Basal testing & experimentation Sensor reuse? When to call it quits* * don t throw anything away!!!

11 CGM Data Analysis

12 Why Is It So COMPLICATED???

13

14 Objectives-Based Analysis 1. What s happening between fingersticks? 2. Are meal & correction doses correct? 3. Is basal insulin doing its job? 4. How long do boluses work? 5. What is happening after meals? 6. Is basal insulin holding BG steady? 7. Frequency & Response to hypoglycemia? 8. Effects of lifestyle events?

15 Before You Analyze, Qualify. Were sufficient calibrations performed? Did the calibrations match the CGM data reasonably well?

16 Inaccurate data - disregard Reliable data

17 These Are a Few of My Favorite Stats Mean (avg) glucose % Of Time Above / Below / Within Target Range Standard Deviation (coeffecient of variance)

18 Patterns Report (short-term stats) Success Report (long-term stats)

19 Objective: Uncover What s Missing Type-2 on glargine only; Checking fasting BG daily BGs avg 120, HbA1c is 8.5% May need mealtime insulin. Consider glargine or lunch carbs

20 Objective: Evaluate Meal Insulin Doses 34-y.o. pump user Breakfast dose may be too high Lunch dose appears to be too low Night-snack dose insufficient

21 Objective: Evaluate Meal Insulin Doses 5-year-old on MDI; levemir BID. Dropping low 2-3 hours after dinner. Consider decreasing dinner bolus.

22 Objective: Fine-Tune Correction Boluses Pump user, dropping low after correcting at bedtime and during the night Consider increasing nighttime correction factor / insulin sensitivity

23 Teenager on MDI. Objective: Postprandial Analysis Tired and lethargic in the afternoon. Dosing with, sometimes after meals Significant spikes after lunch, sometimes after dinner. Educate on proper dosage timing.

24 Objective: Postprandial Analysis T1 Pump user, 6 months pregnant Pre-bolusing (15-20 min) at most meals. Consider splitting meals, post-meal walks.

25 Objective: Basal Insulin Adjustment Type 1 diabetes; using glargine & MDI History of morning lows Snacking at night and not covering w/bolus Basal dose is likely too high. Consider reducing.

26 Objective: Basal Insulin Adjustment Pump user. Nothing to eat after 10pm. Breakfast & bolus at 7, skipped lunch. BG rising 2-6 am. Consider raising basal 12a-4a. BG falling 11a-3p. Consider lowering basal 9a-1p.

27 Objective: Determine Insulin Action Duration 12am 3am 6am 3-Hour Duration 4-Hour Duration 4.5-Hour Duration

28 Objective: Detection of Hypoglycemia College student; on pump BGs rising in the morning. Wants to raise basal. Dropping & rebounding during the night. Consider decreasing basal in early part of night.

29 Objective: Evaluate Treatment of Hypoglycemia Over-treating lows. Education on proper hypo treatment indicated.

30 Objective: Reveal Lifestyle Influences Pump user, basal rates confirmed overnight yellow night: light cardio workout prior evening Red night: Lifting & cardio workout prior evening Experiencing delayed-onset hypoglycemia from heavy workouts. Consider temp basal reduction.

31 Objective: Reveal Lifestyle Influences Mondays & Tuesdays Stressful Job Saturdays & Sundays Off-Days: Reduced daytime doses Refer for stress-management training?

32 Objective: Reveal Lifestyle Influences Type 1 diabetes; pump user 40 years old; athletic Handsome, excellent speaker Late for meeting Gets flat tire; eats 15g carbs to prepare for tire change Spare is flat too!! Glucose (mg/dl) AM 12 PM 3 PM 6 PM 9 PM STRESS CAN RAISE BLOOD GLUCOSE A LOT!!!

33 I Patricia Gaye Knutsen, M.S.N. Program Coordinator Washington University Diabetes Center

34

35

36 Iatrogenic hypoglycemia is the limiting factor in the glycemic management of diabetes -Phil Cryer, M.D

37 So why aren t patients charging our doors for new technology?

38 Basal settings: correction carb target Time of day: 00:00 Rate: Time of day: 03:00 Rate: 1.60 chg Time of day: 09:00 Rate: Time of day: 11:00 Rate: Time of day: 16:00 Rate: Time of day: 20:00 Rate: Retrospective Data

39 Real time data allows one to be proactive rather than reactive Courtesy of Tomas C. Walker, MSN, APRN, BC-ADM, CDE.

40 CGM Supports Patients in Proactive vs Reactive Self-Management Warns of impending hypoglycemia and/or hyperglycemia Alerts and alarms help patient stay between the lines Helps detect nocturnal events Provides immediate feedback on how changes in diet, exercise, and insulin affect glucose levels May help avoid overinsulinization and weight gain by alerting of impending high and low glucose values Supports pattern management Tracking and trending provides a series of multiple sequential glucose readings over time that can aid in diabetes selfmanagement decisions Empowers patients to optimize control and allow for a more meaningful conversation with their HCP.

41 CGM Supports Patients in Proactive vs Reactive Self-Management Warns of impending hypoglycemia and/or hyperglycemia Alerts and alarms help patient stay between the lines

42 CGM Supports Patients in Proactive vs Reactive Self-Management Warns of impending hypoglycemia and/or hyperglycemia Alerts and alarms help patient stay between the lines Helps detect nocturnal events Provides immediate feedback on how changes in diet, exercise, and insulin affect glucose levels Promotes Behavior change Cobry et al, Diab Tech Therapy 2010; 12:

43 CGM Supports Patients in Proactive vs Reactive Self-Management Warns of impending hypoglycemia and/or hyperglycemia Alerts and alarms help patient stay between the lines Helps detect nocturnal events Provides immediate feedback on how changes in diet, exercise, and insulin affect glucose levels May help avoid overinsulinization and weight gain by alerting of impending high and low glucose values

44 Every one should be aware that it is an option We are getting some through now on Medicare supplemental

45 IT IS A MATTER OF TIME so here are a few tips I talk about issues that the person sitting in front of me deals with Do you sleep alone? Driving? Work? I don t want to wear/ carry another device

46 Have supplies in the room We have an unbranded brochure in the exam room

47

48 Above 210 mg/dl for 4.8 hours

49

50 Have supplies in the room We have an unbranded brochure in the exam room I keep a transmitter on a card in the room

51

52 Have supplies in the room We have an unbranded brochure in the exam room I keep a transmitter on a card in the room CGMS brochure and initiate insurance

53 If interested, I initiate the process. Part of the decision is based on cost

54 Outpatient Diabetes Center affiliated with a university We have five endocrinologists, two advanced practice nurses, and five C.D.E. s The patients that I follow are 80% Type 1 DM, it is rare for me to see someone not on insulin I have >1500 visits per year

55 Once patients order a sensor, I encourage them to schedule an apt. with our educator for startup. We individualize our settings but we initially set our alarms very generously Anticipatory alarms are off The educators follow-up on day 2 or 3 We bill the visit as DSMT and CPT 95250

56 When patients arrive at the front desk, they are asked for meter, pump, and sensor These are downloaded and hard copies are placed in the room with the patient In our EMR, we have templates for pump settings and for sensor s My Success Report At each visit, they are asked to do 3-4 days of intensive monitoring and bring the records to the visit We bill as a provider visit but also CPT 95251

57 To get the most out of your visit

58

59 H.S. is a 52 year old gentleman who has had Type 1 Diabetes since age 5 We reviewed the last three days. I asked several times, what was different last night Exercise? No Change in diet? No High fat dinner? No I see a large bolus at 9 pm last night. What did you eat?

60 My Note Trends noted Varying patterns overnight, last night trended up, other nights he is relatively flat overnight Reviewed what he had for dinner last night and he had had fast food, double bacon cheese burger with fries and did not treat the fat. Reviewed how to treat high fat meals Any meal >20 gms of fat Bolus now for carbs and correction Square an additional 1 unit over 4 hours

61

62 Some is easy look at the sensor At the moment, recall cause and effect And what we always say: give some insulin with coffee bolus minutes before a meal go into meals with a good bld glucose treat any meal with more than 20 gms of fat

63 Slide by Dr. Steve Edelman

64 One arrow up; Add enough insulin to bring the bld glu down 25 points Example; target is 100; Sensitivity is 25 blood glucose is 175 with one arrow up. Use 200 for calculation Give 4 units Two arrows up Add 50 points to blood glucose and use insulin sensitivity Example; target is 100 sensitivity is 25 blood glucose is 175 with two arrows up. Use 225 for Calculation. Give 5 units

65 The good news. rare to have two arrows up Address the curve one hour after a meal, if the curve hasn t broken.. nudge it. Or put in the actual bld glucose and override insulin on board one hour after correction, if the curve hasn t broken.. nudge it. Or put in the actual bld glucose and override insulin on board

66