Improvement of time in range and glucose management indicator in Type 1 and Type 2 Diabetes Mellitus patients after introduction of continuous Glucose monitoring in internal medicine residency clinic

Abstract

Continuous glucose monitoring (CGM)-derived time in range (TIR) correlates with Glucose management indicator(GMI) which correlates with hemoglobin A1c (HbA1c) among patients with type 1 and type 2 diabetes mellitus. Compare to HbA1c it has better correlation with glucose control, because HbA1c can be influenced by conditions like anemia, Chronic kidney disease, Cirrhosis of the liver etc. With our current project we wanted to introduce CGM not in specialized endocrine clinic, but in Internal medicine Residency clinic. The CGM team had 12 Internal Medicine and Transitional year Residents who were functioning under the supervision of Board Certified Endocrinologist who was a member of the clinic also. Twenty Five patients -85% with type 2 DM and 15% with type 1 DM on multiple injections of Insulin per day-3-4, self-monitored their blood Glucose(SMBG). They were given CGM- Dexcom G6 in the clinic. In the first 2- weeks after the switch the TIR of the blood glucose of the patients-70-180 mg/dl was 18%. Their average blood glucose was 286 mg/dl, GMI was 11.21%. During then first 2- weeks after initiation of CGM the patients were educated in length by our CGM team about their diet, physical activity, how to adjust their Insulin based on their blood glucose levels as well as how to treat the hypoglycemia. Members of the CGM team were contacting the patients twice a week to adjust patients treatment with Insulin and other per oral antidiabetic medications and or injectable – GLP1-RAG if needed after consultation with the Endocrinologist in the clinic based on the shared information between the clinic and the patients. Once a month the patients were seen in the clinic by member of the CGM team as well. The patients were followed for 2- years. After 3- months on CGM and followed for the 2 years thereafter the patients TIR improved from 18 % to 74%, GMI decreased from 11.21% to 7.04% and the average blood glucose decreased from 286 mg/dl to 158 mg/dl. There was also significant reduction of the hypoglycemia. Twenty percent of the patients were able to discontinue their Insulin and be treated only with oral antidiabetic medications plus/minus GLP1-RAG and have GMI less than 7%. We have showed that targeted TIR – above 70% which has been associated recently with diabetic micro and macrovascular complications in diabetic patients can be achieved not only in specialized endocrine clinics , but in Internal Medicine residency clinic and can be adopted by other Internal Medicine Residency programs in USA.