Sunday, September 20, 2020

Part two of a Three Part Series on Continuous Glucose Monitoring

by David Kliff

How many times does it happen something new comes out, you here good things about it, you take the time to learn about it so you can tell your patients about it and you actually get them to use it. However after all this this great new device which was supposed to be a tool to help the patient has turned into a toy rarely played with.

Here we are again as you’ve likely heard very good things about continuous glucose monitors (CGM), you are taking the time to educate yourself about the various systems but the last thing you want is this fantastic piece of technology to become another toy the patient doesn’t play with. As an experienced CGM user and highly engaged Type 1 patient who has been covering this technology since its invention allow us to pass along a few tips.

First the very good news you can tell your patients that the days of pricking their fingers are gone forever. No more finger sticks. Next you can also tell them no more logbooks nothing to carry around but their smartphone. CGM is not just ground breaking technology it’s a technology that actually makes the patients life easier. Put simply once the sensor is inserted or attached to the patients body, a very simple and nearly pain free experience, for the 10 to 14 days the patient really doesn’t do all that much.

It’s also important to be prepared and prepare your patient for a few things.

1. Data, data and more data – Remember this is a CONTINUOUS monitor so the patient is moving from a point to point system that gathered maybe 4 data points per day to a CONTINUOUS system which gathers over 250 data points per day. In the beginning this avalanche of data can be overwhelming creating lots of Wow and Why moments. Wow as for the first time the patient will see what their levels do all day and all night long. This in turn creates lots of Why moment as Why is   this happening, which creates phone calls for you. (More on this in a moment)
2. Medical devices can and do fail or malfunction- While we would say that the majority of CGM systems are accurate and reliable they are medical devices and as such they can and sometimes do fail or malfunction. Hey this happens and honestly there is not much you or your patient can do about it but it does help to talk about this before the patients starts using the CGM.
3. CGM is NOT real time information and will differ from finger stick data- although the two most popular CGM systems do not require any finger stick calibrations there is a group of patients new to CGM who check anyway to see how their CGM system matches up with their BGM system. While it can happen it’s a rare occurrence when the two systems match up exactly and there are times when they provide dramatically different readings. This obviously creates more questions for you so just be prepared for the which is right question my new system or my old system.  

To be very clear here the two most popular CGM systems the Dexcom G6 and Abbott FreeStyle Libre have proven to be very accurate and very reliable.Neither system requires finger stick calibrations and neither requires a patient confirm readings before they dose insulin.  While no system works perfectly 100% of the time you and your patient should feel very confident that the data being seen is accurate.

1. Connectivity – one of the best features of CGM is they send readings to an app on the patients smartphone which then can be shared with you, a family member, friend or care giver. This is the good news, the bad news is just as sometimes there is no cell service the app and sensor don’t communicate. This of course creates lots of calls to tech support.
2. Reports – another great feature of these apps are all the great reports they generate. Reports which create lots of Wow and Why moments. Now before we go any further you should be seeing a pattern as that’s one of the greatest things about CGM as it does create lots of Wow and Why moments. Perhaps the best way to think about the difference between CGM and BGM is BGM data is like looking at a still picture while looking at CGM data is like watching a movie, that’s how dramatic the difference is.
3. Trend Management – In the old days before CGM diabetes management was pretty much point to point as data was only available when the patient tested. With CGM diabetes management changes to managing trends rather than managing moments. CGM data allows you to see things that were only guessed at before things like time to action or duration of action. As we noted in the first part of this series CGM data provides a comprehensive overview a complete picture of what’s happening.
4. Social Media – whether its Facebook, Twitter or Instagram social media is now part of diabetes management and CGM technology has spawned lots of chatter (some of it white noise) on social media. Having reviewed many of the diabetes dedicated web sites and blogs we’d say for the ,most part the information posted is helpful, the same goes for the various posts on Facebook. Yes there is a fair amount of ranting however for the most part we’d say social media is a net positive. However like most things related to CGM social media does create questions so be prepared. Like almost everything else in diabetes what happens with one patient does not necessarily transform to all patients.
5. Alarms. Alerts – These are two of the most maddening features of CGM. In one respect these alarms and alerts can be a life saver helping the patient avoid a severe hypoglycemic event or deal with a possible hyperglycemic event. They can also be very annoying and not just to the patient but anyone who happens to be around when they go off. The good news here is this feature does NOT have to be enabled and second the patient can adjust the settings as to when these alarms and alerts happen.
6. Skin issues – although we have never had any issues with rashes or skin irritations it does occur with some patients. Some CGM users and we are among them use skin prep pads which provide stronger adhesive so that sensor stays attached during exercise, etc. This is one area where we have found social media to be very helpful with patients sharing information as to what and what hasn’t worked for their situation.
7. Expectations- this is THE most important aspect transitioning a patient from BGM to CGM, managing expectations. CGM creates lots of Wows and Why’s which in turn creates lots of questions. What should discussed UP FRONT is who will answer these questions. While we understand that your time is valuable and that you are not compensated to analyze and interrupt all this data most patients do not understand this. Understandably as their trusted advisor they will reach out to with questions so it’s imperative they have a clear understanding of what you will and will not do.

While it is true that CGM apps can share data/reports with you or your team there are certain things these reports do not tell you. They do not collect insulin dosing data nor do they collect meal data nor do they tell you if the patient was exercising, etc. Yes there are patients who will track such things and you likely know who they are already but the majority of patients don’t track these things. We mention this as lots of why questions can be more easily answered with this information.

As to which system is right for your patients that like almost everything you deal with has a lot to do with who their insurance provider is and what type of patient they are. The two most popular systems are the FreeStyle Libre from Abbott and the G6 from Dexcom. Although we have had no personal experience with the Libre the patients we have spoken with who have or are using the LIbre seem very pleased.

Our personal experience with the G6 has been nothing short of outstanding. The sensor is very easy to insert and yes is pretty much pain free. The sensor data has been reliable and accurate. Yes we have dealt with some connectivity issues, as have Libre users, but for the most part the G6 has matched and exceeded our expectations. We can say without question that CGM is the most transformational technology we have ever used.

We understand that adding CGM to your practice is not an easy decision which is why you need to be aware of how CGM works in the real world. However we can state unequivocally that this technology can be enlightening and transformational.