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CONTINUOUS GLUCOSE MONITORING

PART 2

Veronica Brady, PhD, FNP- C, BC-ADM, CDEUniversity of Nevada, Reno School of MedicineAugust 3, 2017

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COURSE OUTLINE(4- 40 MINUTE SEGMENTS)

1. What is CGM professional personal

2. Identification of appropriate candidates for CGMpre-DM, T1 or T2DMpatients not at goalhypoglycemia unawareness

3. Interpretation of data review downloads from 3 available devices

4. Billing and coding cost of professional device ROI billing codes

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OBJECTIVES1. Define continuous glucose monitoring

(CGM)2. Identify the different types of CGM devices3. Identify appropriate candidates for the use

of CGM4. Verbalize understanding of data

interpretation5. Have a beginning knowledge of billing for

CGM insertion and interpretation

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RECOMMENDATIONS FOR CGM USE

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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.

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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.

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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.

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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.

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CHOOSING THE APPROPRIATE DEVICE

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PROFESSIONAL DEVICES

BlindedMedtronic/Libre/Dexcom

Provider information to make medication adjustments

Patient unwilling be involved

UnblindedDexcom

Attempting to change behaviors

Patient willingness to be involved (test BG)

Prevention of hypoglycemia

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PLACEMENT OF DEVICE

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SITE SELECTION

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SITE SELECTION 2

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PATIENT EDUCATION

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CASES

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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: 150-200 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 55-

563mg/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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CHANGES IN REGIMEN BASED ON CGM

Pat ie n t Ins t ruc t io ns : 1) 1 ) C he c k b lo o d s u g ar s b e fo re me a ls and a t b e d t ime and re co rd . B r ing re co rd to a l l

End o c r ino lo g y ap p o in tme nts . 2) 2 ) In je c t L eve mi r 15 un i t s in t the mo rn ing and 10 un i t s a t b e d t ime 3) 3 ) In je c t Novo lo g u n i t s b e fo re me a ls 4) 4 ) b lo o d s ug ar un i t s o f novo lo g 5) 5 ) le s s than 70 no ne 6) 6 ) 70 -100 2 un i t s 7) 7 ) 101 -150 3 un i t s 8) 8 ) 151 -200 4 un i t s 9) 9 ) 201 -250 5 un i t s 10) 10) 251 -300 6 un i t s 11) 11) 301 - -350 7 un i t s 1 2) 1 2) 351 -400 8 un i t s 1 3) 1 3) 401 -450 9 un i t s 14) 14) >450 10 un i t s 15) 15) IF YO U A R E NOT EAT ING A ND BLO O D SUG A R S A R E H IGH TA K E INSUL IN A S FO L LOWS: 16) 16) 250 -300 1 un i t s 17) 17) 300 -350 2 un i t s 1 8) 1 8) 351 -400 3 un i t s 19) 19) >400 4 un i t s 20) 20) I f g lu co s e le s s than 70mg / d L e at/ d r ink 15g ms o f fas t ing ac t ing ca rb o hyd ra te 21) C a l l me o n Fr id ay

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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 cl inic today to establish care with endocrinology in the Reno area.

The patient repor ts that since his diagnosis of type 1 diabetes he has been on insul in therapy and most recently he has been on Levemir insul in 46 units twice daily and Humalog meals 1 unit for each 10 g of carbohydrate at breakfast and dinner. He repor ts he normally does not take any insul in with lunch.

The patient repor ts concerned at this t ime due to the fact that over the last 6 months he has been experiencing severe episodes of hypoglycemia. He repor ts in the last 6 months he has used glucagon 6 t imes. 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 br ings with him his glucometer which reveals blood glucoses ranging between 46 to greater than 300 mg/dL. He repor ts that he is currently test ing 8-10 t imes per day.

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CHANGES TO REGIMEN BASED ON CGMRESULTS

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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EG is a 79 year o ld female wi th a >35 year h/o T2DM.

She exper ienced adverse ef fects f rom the Bydureon. She can not to lerate more than 500mg BID of Metformin.

She is current ly taking Lantus 40 uni ts BID and Novolog 20 with breakfast and 15 with d inner. She forgets the af ternoon dose fa i r ly of ten.

She is test ing 3 t imes a day, wi th BG ranging 70-293mg/dL (avg 193) .

Dietar y Intake: Breakfast :eggs , bacon, toast (1) or engl ish muf f in Lunch: f rench dip (1/2) Dinner : lef tovers Snacks:sees candy, cupcakes ,sweets Beverages: water, tea

Weight - up 4# Last A1c-8 .7%

OLDER PATIENT WITH T2DM

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CHANGES TO REGIMEN BASED ON CGMRESULTS 2

Your thoughts???

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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

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NEXT 2 COURSES1. Interpretation of data2. Billing and coding

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