Treating Type 2 Diabetes: Looking Ahead - Episode 8
A discussion on using continuous glucose monitoring systems to improve the management of type 2 diabetes.
Davida Kruger, NP: One of the newer things—it’s not really new for those of us in diabetes—I’ve been utilizing it probably for the better part of 20 years, but different iterations is continuous glucose monitoring [CGM]. And the beauty of continuous glucose monitoring is how accurate it is and the fact that if we place a continuous glucose monitor, and there’s professional and personal meeting on placing it for just a short period of time, 10 of 14 days, patient brings the data back to me, I get to look at it I guess to help me make decisions. And then there’s personal. The patients are utilizing personal. For type 2 diabetes right now...we get coverage, whether it be Medicaid, Medicare, or commercial. For type 2 diabetes, for the most part they need to be on multiple daily injections. And one of the things that we’re really working with Medicare on, because Medicare makes a decision and that’s how the world turns, is to look at all people with diabetes, but mostly to look at people who are on insulin period. If you’re on one injection of insulin, basal insulin you should qualify for continuous glucose monitoring, but the whole concept of CGM is just totally explosive in terms of what it can do in helping us manage people with diabetes. What are your thinking on continuous glucose monitoring? I almost don’t see a patient that is wearing it or using it.
Margo B. Minissian, PhD, ACNP: I can’t imagine that you would, because anything that is going to give more data, and accurate data, especially for those patients that have more aggressive or poorly controlled type 2 diabetes. Knowledge is power. These continuous glucose monitoring data is really, incredibly important, especially as we were just talking about for these the basal dosings. I absolutely was so impressed. We were just talking about the article that was in JAMA [Journal of the American Medical Association] that just very recently came out. And a very large meta-analysis that was going over how you can significantly reduce hemoglobin A1C in as little as 8 months just with the improved monitoring in and of itself. That awareness is essential.
Davida Kruger, NP: What was interesting about the JAMA article, it came out in June 2021, was first of all, we were trying to complete it in the middle of COVID-19. That was one interesting thing. But the other thing is that it wasn’t managed by endocrinology. The patients had to come out of primary care. They could never have owned or worn CGM. They were on programs with just basal insulin. And we would upload it for the primary care provider, and we would tell them what we were seeing. But they were having the conversations with the patients. They were making any adjustments. They were the ones that were having the relationships. The fact that we saw such significant A1C lowering. The other thing is that there was another paper that was published in August of 2021. And what we did in that one was we kept one group on CGM, we took CGM away from the other group, and the increase in the A1C, which you and I would expect for those individuals who were now not on CGM was very significant. To show that even just a on basal insulin, when the patient’s getting that kind of feedback on a regular basis of what happens when I walk, what happens when I eat, what happens when I take my medication as prescribed is remarkable in moving that patient ahead.
Margo B. Minissian, PhD, ACNP: Absolutely. You can see how that would help improve their overall quality of life because they have increased self-awareness. And when you have increased self-awareness, I just feel that you start to do other things that are good for you inherently. This monitoring in places where people live gather, whether it’ a Fitbit or it’s a blood pressure monitor that communicates with your phone, your continuous blood sugar monitoring. There’s many different ways that we’re able to use AI [artificial intelligence] and other smart technology to be able to have real-time data and it’s really incredibly powerful for providers today and equally so for our patients that can come in and say, “Look at me. Look what I did. Look what I was able to accomplish.” Because then they can start to also see that their nutrition can make a difference. Just having that improved awareness is significant.
Davida Kruger, NP: The other thing we find too is that if a patient does have low blood sugar that impedes their ability to keep getting their blood sugars under control. Because at that time of day someone will feed them, they’ll omit their insulin. They’ll omit their medications if they’ve had an episode or if they have one episode overnight somebody will feed them before they go to bed to make sure their blood sugars are 2 to 300 so they don’t have an episode during the night. These devices have alarms and alerts on them so that if you’re going low, they can let you know so that you can treat it right away.
Margo B. Minissian, PhD, ACNP: Way before. The yo-yo. The yo-yo phenomenon starts to take place.
Transcript edited for clarity.