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Insulin therapy: Surfing the curve
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Diabetes management is much like surfing a wave…

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Continuous glucose monitoring, in my view, is the biggest advance in diabetes management.

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Which is?
Let’s examine the answer.

The extent and prevalence of nocturnal hypoglycaemia has only now been discovered with the use of continuous glucose monitoring (CGM).

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This is because testing four times a day is missing much of the real world of diabetes.

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Early CGM gave complex pictures, spaghetti-like, that were hard to interpret.

The basics of CGM is recording glucose entry into the blood stream via hepatic glucose output and food, to its exit following glucose disposal into the muscle, fat and liver.

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CGM visualises the rate of glucose entry and the rate of glucose exit.

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Patients are coping with insulin inter-day variability, insulin resistance and the complex pathophysiology of diabetes.

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The most important clinical point is that the responsible clinician must use the collected data and teach the patient to interpret the data.

The motto is: Don’t test if you are not going to do something with the data.

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Testing an oral agent is aimed at determining further intensification strategies. Structured testing 3 times a day is recommended for basal therapy. Structured testing is advocated for premix if the clinician is considering changes to therapy.

A short sprint of structured testing should be done to provide enough data to make therapy changes.

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In the evaluation of testing, it is interesting to note that the Clinitest, introduced in 1941, gave measured cumulative exposure data over 8-12 hours – so if you were on target, your blood glucose control was good.

Today, CGM and its sharing of data with mobile phones and clinic computers increases the ability for family and clinicians to intervene.

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Clinicians need adequate data for planned alterations to therapy.

In the real world, patient self-testing can present a biased view, as they may/do tend to test when they feel ‘funny’.

 

 

SMBG: self-monitoring of blood glucose

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In type 2 diabetes, physician-led intervention based on patient’s self-monitoring does work, as this STEP study illustrates, using a 3-day strip of data.

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HbA1c does not help with day-to-day diabetes management as this slide of HbA1c (7.7%) from four type 1 diabetes patients shows.

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The AGP provides profiles against a standardised output that allows reliable and consistent interpretation.

 

 

AGP: ambulatory glucose profile

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Essentially, the median line is the therapeutic effect; the dark blue zone reflects the major medication effect and the shaded 10th and 90th percentile curves represents what the patient is doing e.g. giving his insulin too late, eating more or less.

This is where one looks to see what the patient is doing that is not standard.

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When the AGP was first introduced, it came with a score card encouraging doctors to look at variability, including hypoglycaemia risk.

“It provides a pretty good score card and a useful tool.”

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There are multiple devices available, including the one illustrated.

In addition, it is a good idea for the patient to keep a good diary for the 14-day period so the clinician and patient can get the best out of what the device is indicating.

 

 

FGM: flash glucose monitoring

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Among the many guidelines, the Malaysian Guideline has included a vital step for failure on oral antidiabetics or symptomatic with very high HbA1c and the clinician is considering insulin. The guideline says ‘assess the glycaemic abnormality first before introducing any insulinisation’.

Step 1: Assess the glycaemic abnormality you are trying to fix.

 

Summarised from the “Practical guide to insulin therapy in type 2 diabetes mellitus.” Malaysian Endocrine and Metabolic Society,2011 and NICE, (NG28) 2015, last updated July 2016

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All measurements provide retrospective data. Most patients want to have ‘real-time’ data, empowering them to quicker intervention.

As this listing of devices show, there are different quality variables, including costs, calibration needs, and alarm facility.

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What are we looking for in CGM?
An opportunity to live in the moment – as the surfer does!

CGM offers the opportunity to the patient of managing their disease differently and can reinvigorate the ‘tired unmotivated patient’.

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As this study shows, CGM really makes a difference regardless of injection delivery method.

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In this trial, type 1 diabetes patients were offered real-time CGM with either a sensor-augmented pump (CSII) or multiple daily injection (MDI).

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In this trial, type 1 diabetes patients were offered real-time CGM with either a sensor-augmented pump (CSII) or multiple daily injection (MDI).

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The patient becomes more engaged in his therapy as can be seen by the increased willingness to add further insulin therapy during the day (increases from 4-6 boluses14/day).

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Intermittent use of CGM is not advised for type 1 diabetes patients as the GOLD trial illustrates.

 

 

 

rtCGM: real-time continuous glucose monitoring

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This slide illustrates the maintenance of learned behaviour in type 2 diabetes patients after removal/intermittent use of CGM.

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This study illustrates the point that patients better educated about their condition will do really well on CGM.

This study was undertaken by Dr Edelman, a diabetic using CGM and shows the benefits to type 1 diabetes patients.

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In the main, these patients achieved the results in real-time by looking at the trend arrows.

When the curve is going against the target zone, the patients learn how to return the curve into the required zone.

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CGM is the only device that allows the patient to intervene and manage their goal!

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“In my experience, some patients get it and learn from the curve and others do not.”

It is, however, a chance to reinvigorate your patients.

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The patient needs to be educated on all the variable inputs – so they can experiment on how to turn the curve to target.

 

 

CHO: carbohydrate; GI: glycaemic index

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Tips and tricks on using and interpreting the CGM

Firstly, calibration should be done on a steady baseline and adjusted if needed.

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Secondly, look back every morning and check that there is a straight line – so that at night you are having a steady line with steady and predictable glucose levels.

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On CGM, managing postprandial glucose levels becomes more important.

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A useful resource is a book entitled ‘Sugar surfing’ by Stephan Ponder.

In managing postprandial excursions, timing is essential and taking insulin early in time for a meal/snack/breakfast is vital.

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There is a wave motion and momentum to blood glucose levels so by using CGM, the patient can see the pivoting points as they occur.

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The patient can ‘watch’ and know how his body reacts to different carbohydrate amounts and what their body does with 1 unit of insulin.

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This learning allows the patient to understand ‘his ocean’ better.

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So, engage the most underutilised resource in healthcare – the patient with good tools such as CGM.

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Insulin therapy: Surfing the curve
Insulin therapy: Surfing the curve
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NOTE: This article was made possible by an unrestricted educational grant from Sanofi, which had no control over content.

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