Welcome to the ATTD 2023 Interactive Program

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Today’s Headlines for CGM use in T1D:

“CGM-First,” “CGM-Standard of Care,” “CGM- Most significant advance in diabetes management since the discovery of insulin!”

Today’s Headlines for CGM use in T2D non-insulin users:

Amer. Board Internal Med- Choosing Wisely campaign promotes clinician-patient conversations about avoiding unnecessary care … like this example, “Don’t routinely recommend daily home glucose monitoring for patients who have Type 2 diabetes and are not using insulin.”

What is the nature of the data we have today on CGM use in T2D non-insulin users?

Intriguing - survey data; “they say it helps…

Interesting - pilot data; "I think" it might help…

Innovative - technology programs; CGM "seems to" help patients…

Incomplete - registry data, hints at populations of PwD who do better, so "maybe it does" help...

Informative - trials using CGM in T2D patients on insulin resulted in glycemic improvement

compared to using SMBG, but minimal insulin dose changes were made, with

the concluding summary, “It must have been CGM guided lIfestlye changes.”

Insistent - powerful anecdotes, and voices of people with diabetes not on insulin, saying “FOR SURE IT HELPS!” “Please - Listen to me.”

What do we need to do for CGM to become a standard of care in T2D non-insulin users?

Determine - how A1C and CGM data align/coexist in the management of diabetes

Define - the outcome(s) we are trying to achieve with the help of CGM

Decide - if CGM data and profiles can facilitate healthy lifestyle choices

Deliberate - on the role of CGM in helping the selection of high value diabetes drugs

Decipher - CGM user registry data by separating out and evaluating T2D non-insulin users

Design - RCT’s and robust real-word evaluations to demonstrate the value of CMG in

non-insulin users

My prediction is that after we Investigate and Discuss the “I_s” and “D_s” above we will want to rewrite a headline for people with T2D not using insulin that reads something like: “Of Course CGM Should Be Part of Diabetes Education, Management and Support for All People Living with Diabetes.”

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Glucose monitoring is central to safe and effective management for individuals with type 2 diabetes using insulin. It is estimated that approximately 30% of people living with type 2 diabetes in the USA are treated with insulin, with about two-thirds using basal insulin without prandial insulin. However, only about one-third of those individuals using insulin achieved HbA1c of less than 7.0%. Recent data also suggest there had not been much improvement in glycaemic outcomes in the USA between 2005 and 2016. Real-time (rtCGM) and intermittently scanned continuous glucose monitoring (isCGM), by providing frequent glucose measurements, low and high glucose alerts, and glucose trend information can better inform diabetes management decisions compared with episodic self-monitoring with fingerstick glucose. Studies have demonstrated that CGM improved glycaemic control in individuals with type 1 diabetes and with type 2 diabetes using insulin regimens with basal plus prandial insulin. However, the role of CGM in individuals with type 2 diabetes using less-intensive insulin regimens is not well defined.

Key Objectives of this lecture include:

Understand the status of current glycaemic control in people with type 2 diabetes

Glycaemic profiles of patients with type 2 diabetes using basal insulin

HbA1c, sensor-based and other outcomes from studies investigating the efficacy and safety of continuous glucose monitoring in people with T2DM only on basal insulin

Impact of CGM on patient-reported outcomes and quality of life

Use of SGLT2 inhibitors and GLP-1 in studies investigating CGM

Mechanisms underpinning the improved outcomes

Cost-effectiveness

Gaps in evidence-based and future studies

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Cystic fibrosis related diabetes (CFRD) affects up to 20% of adolescents and 50% of adults with cystic fibrosis (CF). Although CFRD shares some characteristics of type 1 and type 2 diabetes, it is a unique form of diabetes caused primarily by insulin deficiency from progressive islet cell dysfunction and destruction related to underlying pancreatic exocrine disease and fibrosis. At present, the oral glucose tolerance test (OGTT) is recommended annually in adolescents and adults with CF to screen for CFRD, but screening rates have historically been suboptimal, particularly among adults. Insulin is the only recommended treatment for CFRD, but this can add substantial treatment burden to an already medically complex patient population. Continuous glucose monitoring (CGM) has been validated in people with CF, and CGM measures have been correlated with important clinical outcomes such as pulmonary function and nutritional status. Emerging data suggest that CGM may identify people at risk for the future development of CFRD and may be a promising approach for the diagnosis of CFRD, but prospective longitudinal studies investigating this as a tool for CFRD screening are greatly needed. Although data are very limited, CGM may also have a beneficial effect on the management of CFRD, including in combination with hybrid closed loop insulin pumps, offering the potential for improved glycemic control and decreased diabetes treatment burden. In summary, CGM technology may be particularly useful for addressing current challenges unique to CF, but further studies are needed to investigate the use of this tool in the screening, diagnosis, and management of CFRD.

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Vision of Future of CGM in Type 2 Diabetes: CGM Use in Prediabetes and Managing T2D

Satish K. Garg, MD

Abstract:

With the increasing number of people diagnosed with both type 1 and type 2 diabetes and related healthcare costs, it is imperative that we find easier ways to manage diabetes remotely and empower self-diabetes management. Recently, the JDRF launched Type 1 Diabetes (T1D) Index where they revealed stark disparities in T1D life expectancy by countries. They also project a 66-116% increase in the prevalence of T1D by 2040.

Over the last three years, many new continuous glucose monitors (CGMs) have been approved in Western Europe and the USA. We have come a long way in the past 28 years from the first CGM being iPro, developed and launched by MiniMed (now Medtronic MiniMed, Northridge, CA, USA). Many CGM terminologies have been used, such as retrospective vs real-time, real-time vs isCGM, and adjunctive vs non-adjunctive. Now most CGMs are standalone factory-calibrated devices lasting for 10-14 days.

At the time of this writing, about 8 million people are using a CGM for their diabetes management, and this number is likely to exponentially grow to more than 15-20 million in the next 5-10 years. Also, in the near future, we might see another electrolyte or a ketone measurement being measured continuously through the same device (CGM + CKM, etc.). The majority of the available CGMs have a MARD of <10%; and thus, are pretty accurate for their interoperability with other devices like insulin pumps.

Just like many years ago, Louis Monnier, et al. had shown that fasting blood glucose (FBG) values relate better in individuals with higher A1c and post-prandial blood glucose (PPBG) values correlate better with individuals with lower A1c values. Similarly now, Time In Range (TIR) correlates to the contributions by FBG and PPBG.

The research data has clearly documented that use of CGM improves glucose control, TIR, reduces hypo- and hyperglycemia, and a higher TIR reduces the risk of micro- and macrovascular complications. Since the insulin need in patients with T2D has continued to increase, it is likely that the use of CGM will become the standard of care for people with both T1D and T2D. It is also likely that many people with pre-diabetes (T1D and T2D) could be detected before overt deterioration of glucose control and the risk of diabetic ketoacidosis (DKA). One wonders if glucose could be considered a vital sign just like blood pressure and heart rate.