The use of personal continuous glucose monitoring (CGM) has expanded dramatically among individuals with diabetes. CGM systems provide retrospective data, as well as the current glucose value and trend arrow data, which indicate the direction and velocity of changing glucose. In 2017, Aleppo and colleagues developed a simplified approach for adults with diabetes to safely adjust rapid-acting insulin doses using trend arrow information in the Dexcom G5 CGM system. Since then, the FreeStyle Libre and FreeStyle Libre 14-day CGM systems have become available in the United States; however, guidance on using trend arrow data that take the unique features of these systems into consideration is lacking. Specifically, the FreeStyle Libre systems do not have automatic alarms, which impact how the system and trend arrow data are used. The Endocrine Society convened an expert panel to address this gap and develop an approach to adjusting rapid-acting insulin doses for adults using trend arrows in the FreeStyle Libre systems. We based our approach on previous work and expanded upon engagement and scanning recommendations, and we incorporated pre-exercise planning specific to these systems. Our approach provides insulin dose adjustments as discrete insulin units based on an individual’s insulin sensitivity and directionality of the trend arrow. We focus on the needs of patients treated with multiple daily injections because these individuals currently make up a greater proportion of individuals on intensive insulin therapy. Our recommendations are intended to provide a safe, practical approach to using trend arrows in the FreeStyle Libre systems.
Research has shown that getting to glycemic targets early on leads to better outcomes in people with type 2 diabetes; yet, there has been no improvement in the attainment of A1C targets in the past decade. One reason is therapeutic inertia: the lack of timely adjustment to the treatment regimen when a person’s therapeutic targets are not met. This article describes the scope and priorities of the American Diabetes Association’s 3-year Overcoming Therapeutic Inertia Initiative. Its planned activities include publishing a systematic review and meta-analysis of approaches to reducing therapeutic inertia, developing a registry of effective strategies, launching clinician awareness and education campaigns, leveraging electronic health record and clinical decision-support tools, influencing payer policies, and potentially executing pragmatic research to test promising interventions.
BACKGROUND | Glycemic control is suboptimal in many individuals with type 2 diabetes. Although use of flash continuous glucose monitoring (CGM) has demonstrated A1C reductions in patients with type 2 diabetes treated with a multiple daily injection or insulin pump therapy regimen, the glycemic benefit of this technology in patients with type 2 diabetes using nonintensive treatment regimens has not been well studied.METHODS | This retrospective, observational study used the IBM Explorys database to assess changes in A1C after flash CGM prescription in a large population with suboptimally controlled type 2 diabetes treated with nonintensive therapy. Inclusion criteria were diagnosis of type 2 diabetes, age ,65 years, treatment with basal insulin or noninsulin therapy, naive to any CGM, baseline A1C $8%, and a prescription for the FreeStyle Libre flash CGM system during the period between October 2017 and February 2020. Patients served as their own control subject.RESULTS | A total of 1,034 adults with type 2 diabetes (mean age 51.6 6 9.2 years, 50.9% male, baseline A1C 10.1 6 1.7%) were assessed. More patients received noninsulin treatments (n 5 728) than basal insulin therapy (n 5 306). We observed a significant reduction in A1C within the full cohort: from 10.1 6 1.7 to 8.6 6 1.8%; D 21.5 6 2.2% (P ,0.001). The largest reductions were seen in patients with a baseline A1C $12.0% (n 5 181, A1C reduction 23.7%, P ,0.001). Significant reductions were seen in both treatment groups (basal insulin 21.1%, noninsulin 21.6%, both P ,0.001).CONCLUSION | Prescription of the flash CGM system was associated with significant reductions in A1C in patients with type 2 diabetes treated with basal insulin or noninsulin therapy. These findings provide evidence for expanding access to flash CGM within the broader population of people with type 2 diabetes.
Continuous glucose monitoring is poised to radically change the treatment of diabetes and patient engagement of those afflicted with this disease. This article will provide an overview of CGM and equip health care providers to begin integrating this technology into their clinical practice.Continuous glucose monitoring (CGM) systems are more than just glucose monitors. Recent CGM systems have moved beyond mere blood glucose monitoring (BGM) by providing both real-time and predictive glycemic data. The robust data garnered from CGM can also be used for detection of trends, identification of asymptomatic events, and review of glycemic variability over a range of time.
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