Professional Continuous Glucose Monitoring Research Articles

Time in range prediction using the experimental mobile application in type 1 diabetes

BACKGROUND: Time in range (TIR) is a promising indicator of glycemic control used for evaluation of continuous glucose monitoring (CGM) for patients with diabetes mellitus (DM). The current problem is the assessment and prediction of TIR for patients who use self-monitoring of blood glucose (SМBG) corresponding low CGM availability for the majority of diabetic patients.AIM: To develop a predictive model of TIR for patients with T1DM based on data of the experimental mobile application.MATERIALS AND METHODS: An analysis of 1253 professional CGM profiles of patients with T1DM was performed. On the base of included records, TIR(CGM) was calculated and training models of 7-point SMBG profiles were generated. SMBG profiles’re loaded into the developed experimental mobile application that calculated standard glycemic control parameters. The dataset was divided into main and test samples (80 and 20%). For the main sample, the following methods’re used to develop predictive models: simple linear regression (SLR), multiple linear regression (MLR), artificial neural network (ANN). The effectiveness of the developed models was assessed on the test sample with the calculation of the mean absolute error (MAE), the root mean square error (RMSE).RESULTS: The 568 CGM profiles’re included in the study. TIR in the main group (n=454) — 45 [33; 65]%, in the test group (n=114) — 43 [33; 58]%. The most significant predictors of the regression models were the derived TIR (dTIR), p<0,001; derived time below range level 1 (dTBR1), p<0,001; standard deviation of blood glucose (SD), p=0,007. Determination coefficient for SLR (predictor: dTIR) — 0,844; for MLR (predictors: dTIR, dTBR1, SD) — 0,907. ANN multilayer perceptron models with two and one hidden layers’re developed, with the RMSE on the validation set 4,617 and 6,639%, respectively. The results of the forecast efficiency on the test sample were: dTIR: MAE — 6,82%, RMSE — 8,60%; SLR: MAE — 5,66%, RMSE — 7,34%; MLR: MAE — 4,18%, RMSE — 5,28%; ANN (2 layers): MAE — 4,14%, RMSE — 5,19%; ANN (1 layer): MAE — 4,44%, RMSE — 5,52%.CONCLUSION: ANN with two hidden layers and MLR demonstrated the best ability for TIR prediction. Further studies are required for clinical validation of developed prognostic models.

Beyond HbA1c: Identifying Gaps in Glycemic Control Among Children and Young People with Type 1 Diabetes Using Continuous Glucose Monitoring.

To describe continuous glucose monitoring (CGM) derived glycemic variables, and study their association with HbA1c and socio-economic factors in young people with Type 1 diabetes mellitus (T1DM). Ninety-two participants [age 15.7 ± 5.0 y (mean ± SD), HbA1c 8.0 ± 1.5% (mean ± SD)] wore a professional CGM sensor for 14 d. Median (IQR) time in range (TIR) was 41 (18)%. Participants spent 41 ± 20% of their day in hyperglycemia (>180mg/dl), and 14 (13)% in hypoglycemia (<70mg/dl). High glycemic variability (percent CV >36%) was seen in 92% participants. Older age at diagnosis was associated with higher TIR (β = 0.267, p = 0.01), lower time above range (TAR) (β = -0.352, p <0.001), but higher time below range (TBR) (β = 0.274, p = 0.006). The use of NPH vs. glargine basal insulin was associated with higher TBR (β = -0.262, p = 0.009) but lower TAR (β = 0.202, p = 0.041). HbA1c showed negative correlation with TIR (r= -0.449, p <0.001) and TBR (r= -0.466, p <0.001) and positive correlation with TAR (r = 0.580, p <0.001) and mean glucose (r = 0.589, p <0.001). These data demonstrate wide gaps between the recommended vs. real world glycemic variables in patients with T1DM in thisregionon multiple daily insulin injections. CGM identifies glycemic variability and complements HbA1c in improving glycemic control.

Comparison of efficacy and safety of insulin degludec/liraglutide and insulin glargine U-100/lixisenatide in individuals with type 2 diabetes mellitus using professional continuous glucose monitoring.

Insulin glargine U100/lixisenatide and insulin degludec/liraglutide are fixed-ratio combinations containing basal insulin and a glucagon-like peptide-1 receptor agonist capable of reducing both fasting and postprandial blood glucose levels with a single formulation. This study aimed to compare the time in range (TIR) and the time below range (TBR) level 1 using professional continuous glucose monitoring and to establish criteria for the differential use of the fixed-ratio combinations. Thirty-six outpatients with type 2 diabetes mellitus (24 men and 12 women; average age, 62.1 years) were randomly assigned to the groups. At 0 and 18 weeks, a device was worn to compare the TIR and TBR level 1. Thecorrelation between the C-peptide index at baseline and TIR at 18 weeks was assessed. The TIR and TBR level 1 showed no significant differences between the two groups. Both groups showed significant positive correlations between the C-peptide index and the TIR (P = 0.002, r = 0.679; P = 0.002, r = 0.681, respectively). The changes in glycemic variability, therapeutic indices, and body mass index were not significantly different among the groups (P > 0.05). The receiver operating curve analysis revealed that the cut-off values of the C-peptide index to achieve TIR of >70% at 18 weeks were 1.258 (sensitivity, 77.8%; specificity, 100%) and 1.099 (sensitivity, 57.1%; specificity, 90.9%) in the insulin glargine U100/lixisenatide and insulin degludec/liraglutide groups, respectively. A TIR of >70% was achieved for both fixed-ratio combinations without significant differences.

Development of a Continuous Glucose Monitoring Service by Clinical Pharmacists in a Medically Underserved Population.

Background: Continuous glucose monitoring (CGM) is an evolving technology that provides a wealth of information to aid in managing diabetes. Professional CGM (ProCGM) is recommended when personal CGM is not desired or available. Patients in medically underserved areas may have limited access to personal CGM devices, thus ProCGM devices can be used for short-term monitoring and medication adjustment. Clinical pharmacists are well-positioned to help set up and establish personal and professional CGM management services. Objectives: To determine the effect of ProCGM in patients with persistently uncontrolled type 2 diabetes in a medically underserved population (MUP). Methods: Pre-post intervention analysis of a single cohort of patients in a public health center. Patients with persistently uncontrolled (A1c > 9%) and taking at least one daily dose of insulin were included. Included participants wore a ProCGM sensor and met with the clinical pharmacist at least once for ProCGM data interpretation and education. The primary analysis evaluated patients who achieved an A1c <9% 1-6 months after intervention. The change in A1c was also evaluated. Participants completed a pre- and post-survey about their experience. Results: Twenty-two patients were included in the final analysis. Ten patients achieved an A1c <9% (45%). The mean A1c pre- and post-ProCGM was 11.0% and 9.8% respectively, with a decrease of -1.2% (p=0.055) overall and a decrease of -1.7% for patients who wore the sensor for at least 10 days (p=0.012; n=15). Using the CGM data 91% of participants had a change to their medication regimen and 45% achieved an A1c <9%. Six participants experienced hypoglycemia per the CGM report, but only two were aware of it. After reviewing their glucose report with the pharmacist, 95% of the respondents agreed or strongly agreed to feeling more knowledgeable about blood sugar patterns after reviewing the report with a pharmacist. Conclusion: Almost half of the patients in the study achieved an A1c <9%. This study demonstrated glycemic benefit in patients in a MUP who wore a ProCGM for at least 10 days and met with a clinical pharmacist. Data from ProCGM enabled patients to better understand glucose patterns in those with persistently uncontrolled type 2 diabetes.

Continuous glucose monitoring metrics following sub-Tenon’s injection of triamcinolone acetonide for diabetic macular edema

PurposeThis pilot study aims to comprehensively evaluate the effects of sub-Tenon’s injection of triamcinolone acetonide (STTA) on glycemic control in patients with diabetic macular edema (DME) using professional continuous glucose monitoring (CGM).MethodsThis retrospective study analyzed changes in glycemic control in 20 patients with type 2 mellitus and DME following single STTA (20 mg/0.5 mL) using The FreeStyle Libre Pro system. Professional CGM provides core CGM metrics such as the percentage of time that glucose levels fall within a target range and include the time in range (TIR) (70–180 mg/dL), time above range (TAR) (> 180 mg/dL), and time below range (TBR) (< 70 mg/dL). Outcome measures were the changes in CGM metrics (TIR, TAR and TBR) and the percentage of patients in whom TAR increased by at least 10 percentage points (ppt) 4 days before to 4 days after STTA administration.ResultsThe mean CGM metrics (TIR/TAR/TBR) were 75.5%/19.9%/4.4% 4 days before STTA and 73.7%/22.4%/3.5% 4 days after STTA; the metrics 4 days before and 4 days after STTA were not significantly different (P = 0.625 for TIR, P = 0.250 for TAR, and P = 0.375 for TBR). TAR increased by more than 10 ppt in four (20%) patients treated with sulfonylurea and/or insulin.ConclusionAlthough there were no significant changes in the CGM metrics, four patients developed CGM-measured hyperglycemia after STTA for DME.

SAT142 Utilization Of Continuous Glucose Monitoring In Diagnosis And Management Of Insulinoma

Abstract Disclosure: V. Phan: None. P. kretschmer: None. A.G. Pittas: None. Background: Insulinoma is a rare condition that can cause life-threatening hypoglycemia. Its diagnosis and management are challenging due to the requirement of a prolonged fasting test and frequent blood glucose testing. Continuous glucose monitoring (CGM) is widely available in diabetes management; however, its usage in people without diabetes is limited due to lack of evidence. Here, we report an acutely ill patient where we used professional CGM to streamline and expedite the diagnosis of insulinoma, and personal CGM to titrate medical management with diazoxide. Clinical Case: An 81-year-old woman with complex past medical history was admitted for chest pain and shortness of breath, found to have non-ST-elevation myocardial infarction. During inpatient work up, she experienced several hypoglycemia episodes that resolved with oral glucose intake. She had a history of recurrent hypoglycemia and prior MRI showing pancreatic tumor; however, outside records did not reveal biochemical work-up for insulinoma. Her symptoms were unpredictable, so a professional CGM (Freestyle Libre) was placed. CGM data revealed persistent nocturnal hypoglycemia, and occasional postprandial hypoglycemia. Patient-recorded symptoms were present in less than half of the hypoglycemic periods detected by CGM, indicating hypoglycemia unawareness. Given her acute cardiac condition and knowing her nocturnal hypoglycemia pattern from CGM, we performed a modified 72-hour fasting test that started at midnight and was able to capture a hypoglycemia episode within only 2.5 hours of initiation. Her plasma glucose was 57 mg/dL, insulin was 13 uIU/mL, C-peptide was 1.33 uIU/mL, and proinsulin was 9.5 pmol/L. She had a negative screen for sulfonylurea and there was no evidence of antibodies to insulin, suggesting a diagnosis of insulinoma. While awaiting localization studies, the patient was started on diazoxide. We used the personal CGM connected to our clinic portal to monitor glycemia at home and titrate diazoxide dose and frequency. CGM data showed nocturnal hypoglycemia and minimal daytime hypoglycemia, therefore, we recommended diazoxide only at bedtime to minimize daytime side effects and hyperglycemia. On one occasion, the patient was on as short course of prednisone which typically causes hyperglycemia during the day and hypoglycemia in early morning. CGM allowed us to monitor patterns of steroid-induced hyperglycemia, and we moved the prednisone dose to bedtime which resulted in euglycemia overnight. Conclusion: CGM can be a valuable tool in diagnosing and managing people with insulinomas. The CGM provides information about hypoglycemia frequency and pattern. It also helps detect hypoglycemia unawareness. With CGM, we can choose the right timing for 72-hour fasting test to minimize the length of the procedure. As outpatient, CGM also makes monitoring response to diazoxide a seamless process. Presentation: Saturday, June 17, 2023

Association Between Continuous Glucose Monitoring-Derived Glycemia Risk Index and Albuminuria in Type 2 Diabetes.

The glycemia risk index (GRI) is a new composite metric derived from continuous glucose monitoring (CGM) data to assess the quality of glycemia. This study investigates the association between the GRI and albuminuria. Professional CGM and urinary albumin-to-creatinine ratio (UACR) data from 866 individuals with type 2 diabetes were retrospectively reviewed. Albuminuria and macroalbuminuria were defined as one or more UACR measurements ≥30 mg/g and ≥300 mg/g, respectively. The overall prevalence of albuminuria and macroalbuminuria was 36.6% and 13.9%, respectively. Participants with a higher UACR had a significantly higher hyperglycemia component and GRI score than those with a lower UACR (all p <0.001), although the hypoglycemia component did not differ among the groups. Multiple logistic regression analyses that adjusted for various factors affecting albuminuria revealed that the OR of albuminuria was 1.13 (95% CI: 1.02-1.27, p = 0.039) per increase in the GRI zone. The results were similar for the risk of macroalbuminuria (OR: 1.42 [95% CI: 1.20-1.69], p <0.001), and that association remained after adjusting for HbA1c (OR: 1.31 [95% CI: 1.10-1.58], p = 0.004). GRI is strongly associated with albuminuria, especially macroalbuminuria, in type 2 diabetes.

Improving glucose control in patients with type 2 diabetes using retrospective continuous glucose monitoring.

The prevalence and cost of type 2 diabetes mellitus (T2DM) is rising. Diabetes care should be individualized based on patient risk factors and goals. Professional continuous glucose monitoring (CGM) is a tool for primary care providers to assist patients with diabetes management. Nurse practitioners at an outpatient primary care practice began using CGM in patients with T2DM in 2019 to guide treatment due to the high number of patients not reaching glucose targets. There was no policy in place to guide patient selection for CGM. This quality improvement (QI) project, conducted in an outpatient primary care clinic, evaluated the effect of retrospective CGM use in patients with T2DM through a retrospective chart review to create a policy for use. Hemoglobin A1c (HbA1c) measurements pre-CGM and post-CGM use were compared. CGM reports were evaluated for the presence of hypoglycemia. Additionally, number of times a patient used CGM between HbA1c laboratory examinations as well as insulin status were determined by reviewing the electronic health record. Patients using CGM for HbA1c higher than goal (n = 60) noted a 1.01% decrease in HbA1c (p < .01). The decrease was similar regardless of exogenous insulin status. Hypoglycemia was detected in 54.3% of patients (n = 44), including 45% (n = 27) of those with elevated HbA1c levels. Retrospective CGM is a cost-effective tool to individualize management of patients with T2DM in primary care. A policy was created to guide CGM use in patients not reaching glucose goals and those with concern for hypoglycemia.

1050-P: Implementation of Professional Continuous Glucose Monitoring in VA Primary Care Clinics

Background: Professional continuous glucose monitoring (proCGM) can be used sporadically for patients who do not meet criteria for Personal CGM. The interdisciplinary nature of primary care teams from Veterans Affairs Community Based Outpatient Clinics (CBOCs) represents a good opportunity for implementation of proCGM technology to improve glycemic control. Objectives: To assess treatment changes prompted by proCGM implementation. Methods: Veterans with suboptimal glycemic control (A1c &amp;gt;7.5% or hypoglycemia) who did not qualify for a personal CGM had a proCGM placed during office visit. Two weeks later, the proCGM was downloaded during a follow-up visit and changes were implemented as needed. Results: Thirty-eight sensors were placed in 36 patients (two patients repeat after sensor fell off) seen by clinical pharmacists from 5 CBOCs from North Florida/South Georgia VA Health System. Baseline A1c was 8.1% (SD 1.3), proCGM data was available in 91% of patients. Mean duration of sensors was 13 days (SD 3.3). In 36% of patients, there was insulin de-intensification, mainly because of hypoglycemic events. In 6% of patients, an oral agent was discontinued because their time in range was above 90% and side effect profile (weight gain). About 18% of veterans needed insulin intensification, either adding short acting insulin or increasing basal insulin. Overall, significant treatments changes were implemented in 60% of patients, thus, avoiding clinical inertia. High glucose variability (% coefficient of variation &amp;gt;33%) was present in 45% of veterans and two thirds of them required de-intensification of their insulin regimen due to hypoglycemia. Conclusions: Implementation of proCGM in primary care clinics led to treatment changes in 60% of patients. This improvement project demonstrated feasibility of deploying new diabetes technologies in primary care setting. Disclosure K.Saren: None. A.L.Raulerson: None. S.Finch: None. J.A.Leey: None. Funding U.S. Department of Veterans Affairs Office of Rural Health

1345-P: Proinsulin–to–C-Peptide Ratio Is Associated with the Time above the Target Glucose Range and the Duration of Type 2 Diabetes

Background: The proinsulin-to-C-peptide (PI:C) ratio is thought to be an index of pancreatic β-cell dysfunction, and in subjects with prediabetes and type 2 diabetes (T2DM), abnormally high PI:C ratios have been identified. In the present study, we investigated the relationships of the duration of diabetes and glucose variability in subjects with T2DM with the PI:C ratio. Methods: We performed a prospective observational study of 272 Japanese outpatients with T2DM who underwent blinded professional continuous glucose monitoring (CGM) and fasting blood sample collection. Their fasting PI:C ratio and CGM-related indices were calculated. After placing all the participants into four groups on the basis of quartile (Q) of diabetes duration (Q1 &amp;lt;8 years, Q2 8-13 years, Q3 14-21 years, Q4 ≥22 years), the characteristics associated with PI:C ratio were identified. All of the statistical tests were two-sided and P&amp;lt;0.05 was considered to indicate statistical significance. Results: The mean age of the cohort was 68.0 years, their mean HbA1c 7.1%, and their mean body mass index (BMI) 24.9 kg/m2. High PI:C ratio was associated with a short duration of diabetes (P&amp;lt;0.001). In each group, there was a positive correlation between PI:C ratio and the time above the target glucose range (TAR; &amp;gt;180 mg/dL) in Q1, Q2, and Q3. The closest correlation between PI:C ratio and TAR was found for Q1 but there was no significant correlation for Q4 (Q1: ρ=0.38, P=0.003; Q2: ρ=0.28, P=0.019; Q3: ρ=0.24, P=0.045; Q4: ρ=0.03, P=0.811). Conclusions: We have shown that the PI:C ratio was positively associated with TAR in subjects with a short duration of T2DM. Given that insufficient pancreatic β-cell function and hyperglycemia is closely related, the PI:C ratio may play a role as the index of pancreatic β-cell dysfunction in subjects with a short duration of T2DM, but not in those with long-standing T2DM. Disclosure A.Miya: None. A.Nakamura: Research Support; Abbott Japan Co., Ltd., Boehringer Ingelheim Japan, Inc., Daiichi Sankyo, Taisho Pharmaceutical Holdings Co., Ltd., Teijin Pharma Limited, Kowa Company, Ltd., Mitsubishi Tanabe Pharma Corporation. H.Nomoto: Speaker's Bureau; Novo Nordisk, Sumitomo Pharma, Co., Ltd. H.Kameda: None. T.Atsumi: Speaker's Bureau; Eli Lilly Japan K.K., Kowa Company, Ltd. Funding Japan Society for the Promotion of Science (22K17766)

950-P: Factors Associated with Hyper-/Hypoglycemia Unawareness in People with Type 2 Diabetes

Background: Hyper-/hypoglycemia unawareness harvours one of the major issues to hamper good clinical practice in people with type 2 diabetes (T2DM). To unveil risk factors of hyper-/hypoglycemia unawareness, we investigated its relationship with actual glucose variability in people with T2DM using continuous glucose monitoring (CGM). Methods: Data were obtained from our prospective observational study comprising Japanese people with T2DM who underwent blinded professional CGM and the Diabetes Treatment Satisfaction Questionnaire (DTSQ). People with a time above range (TAR; &amp;gt;180 mg/dL) ≥25% and those who answered 0 (“never”) or +1 (“almost never”) for the frequency of hyperglycemia in the DTSQ were defined as having hyperglycemia unawareness. People with a time below range (TBR; &amp;lt;70 mg/dL) ≥4% with an answer of 0 or +1 for the frequency of hypoglycemia were labelled as having hypoglycemia unawareness. We extracted various clinical characteristics associated with the discrepancies between hyper-/hypoglycemia unawareness and TAR ≥25% / TBR ≥4% on a multivariate logistic regression analysis. Results: This analysis included 284 subjects. In subjects with a TAR ≥25% (n=115), 27 had hyperglycemia unawareness. The analysis showed that each of no insulin use, older age, and a history of stroke was correlated with hyperglycemia unawareness. Among subjects with a TBR ≥4% (n=45), 28 were unaware of their hypoglycemia. A low eGFR was an independent risk of hypoglycemia unawareness. Conclusions: We newly identified some clinical characteristics that were significantly associated with hyper-/hypoglycemia unawareness. In people with those characteristics, careful and intensive information sharing regarding asymptomatic hyper-/hypoglycemia using CGM may lead to better glucose management. Disclosure Y.Suzuki: None.

Glucose-lowering effects of semaglutide compared with dulaglutide using professional continuous glucose monitoring in outpatients with type 2 diabetes mellitus: a pilot study.

Currently, the most frequently prescribed once weekly glucagon-like peptide-1 receptor agonists (GLP-1RA) in Japan are dulaglutide (DG) and semaglutide (SG). However, little is known about the differences between these two compounds in clinical practice in Japan. This study compared the efficacy and safety of DG and SG using professional CGM in 12 patients attending our outpatient with poorly controlled type 2 diabetes mellitus (T2DM) while using GLP-1RA. The study subjects were 12 T2DM patients with HbA1c ≥ 7.0% on treatment with 0.75mg/week DG for at least 24weeks. All patients wore the professional CGM twice, once while receiving DG and once when the SG dose was increased to 0.5mg/week. Time inrange was significantly better with SG than with DG, which was the main outcome measure. Regarding the secondary outcome measures, standard deviation of glucose, average sensor glucose, time above range, maximum sensor glucose, interquartile range, SD of glucose during the nocturnal period (0000-0559), and average nocturnal sensor glucose (0000-0559) were significantly better with SG than DG. In contrast, SG had no effect on the time below range and minimum sensor glucose compared to DG. Switching from 0.75mg DG to 0.5mg SG in patients with T2DM improved glycemic variability, mean glycemic index, and daily variability without increasing the hypoglycemic index. The results suggest that switching to SG may be a useful option in patients experiencing inadequate glycemic control with DG. The online version contains supplementary material available at 10.1007/s13340-023-00640-2.

Professional continuous glucose monitoring in patients with diabetes mellitus: A systematic review and meta-analysis.

To evaluate the effect on glucose control of professional continuous glucose monitoring (p-CGM)-based care as compared with standard care in the management of patients with type 1 and type 2 diabetes. The PubMed database was searched comprehensively to identify prospective or retrospective studies evaluating p-CGM as a diagnostic tool for subsequent implementation of lifestyle and/or medication changes and reporting glycated haemoglobin (HbA1c) as an outcome measure. We found 872 articles, 22 of which were included in the meta-analysis. Overall, the use of p-CGM was associated with greater HbA1c reduction from baseline (-0.28%, 95% confidence interval [CI] -0.36% to -0.21%, I2 =0%, P< 0.00001) than usual care, irrespective of type of diabetes, length of follow-up, frequency of continuous glucose monitoring (CGM) use and duration of CGM recording. In the few studies describing CGM-derived glucose metrics, p-CGM showed a beneficial effect on change in time in range from baseline (5.59%, 95% CI 0.12 to 11.06, I2 =0%, P=0.05) and a neutral effect on change in time below the target range from baseline (-0.11%, 95% CI -1.76% to 1.55%, I2 =33%, P=0.90). In patients with type 1 and type 2 diabetes, p-CGM-driven care is superior to usual care in improving glucose control without increasing hypoglycaemia.

Association Between Change in A1C and Use of Professional Continuous Glucose Monitoring in Adults With Type 2 Diabetes on Noninsulin Therapies: A Real-World Evidence Study.

This retrospective analysis examined the association between change in A1C and professional continuous glucose monitoring (p-CGM) use in patients with type 2 diabetes and poor glycemic control who were not using insulin. Data from 15,481 eligible patients (p-CGM users n = 707 and p-CGM nonusers n = 14,774) showed a greater decrease in A1C from baseline to the end of follow-up for p-CGM users, and differences favored p-CGM users regardless of whether they started insulin therapy during the follow-up period. These findings suggest that people with type 2 diabetes who have poor glycemic control using multiple noninsulin therapies may benefit from p-CGM, which can reduce A1C over a 6-month period compared with usual care.

GLYCEMIC VARIABILITY INDICATORS BY CONTINUOUS GLUCOSE MONITORING AND HYPOGLYCEMIA RISK IN CHILDREN AND YOUNG ADULTS WITH TYPE 1 DIABETES

Background: Hypoglycemia is the main barrier to optimizing insulin treatment in people with type 1 diabetes, different risk factors have been studied and one of the mechanisms involved is glycemic variability. Aims: To assess hypoglycemia risk showed by the glycemic variability metrics: coefficient of variation (CV), continuous overlapping net glycemic action (CONGA), low blood glucose index (LBGI) and lability index (LI) in a group of children, adolescents, and young adults with type 1 diabetes. Methods: A group of 31 subjects with type 1 diabetes under 25 years were evaluated, data from professional continuous glucose monitoring records were studied, glycemic variability metrics, including CV, CONGA24, LBGI, and LI, were calculated. Correlation with percentage time of hypoglycemia under 54mg% was assessed. Multiple linear regression models were generated, univariate and multivariate analysis was also performed, area under curve of glycemic variability metrics was obtain from ROC curves analysis, the optimal cutoff points were calculated. Results: The average age was 14.5 years with a range of 5 to 24 years. The mean duration of diabetes was 6.6 ± 3.7 years, and the glycated hemoglobin mean value was 8.2% ± 2.1%. The average percentage of time for hypoglycemia alert was 4.23% (0.2 to 13%), while for clinically significant hypoglycemia was 4.55% (0 to 17.1%). LBGI with R= 0.913 and CV with R= 0.735 (p &lt; 0.0001) expressed the highest degree of correlation with percentage of time in hypoglycemia, furthermore, after multivariate analysis, they showed the highest predictive load. CV expressed an AUC of 0.97, while LBGI was 0.95, both statistically significant (p&lt;0.0005). The cut-off point for CV of 38% had sensitivity of 93% and specificity of 74% in detection of time in hypoglycemia under 54mg/dl, and the cut-off point for LBGI of 5.4 expressed sensitivity of 87% and specificity of 94%. Conclusions: Glycemic variability metrics studied outperformed the clinical variables as indicators of risk of hypoglycemia, and those with the greatest predictive power of hypoglycemia risk were LBGI and CV above 38%.

Safety and Accuracy of Professional Continuous Glucose Monitoring in Patients Undergoing Allogeneic Hematopoietic Stem Cell Transplantation.

Hyperglycemia in the early days following allogeneic hematopoietic stem cell transplantation (allo-HSCT) is a well-known risk factor for acute graft-versus-host disease (GVHD) and non-relapse mortality. The FreeStyle Libre Pro, a factory calibrated continuous glucose monitoring (CGM) device, has been used for the retrospective analysis of glucose testing in patients with diabetes. We assessed the safety and accuracy of the device in patients undergoing allo-HSCT. We recruited eight patients who underwent allo-HSCT between August 2017 and March 2020. They wore the FreeStyle Libre Pro on the day before or on the day of transplantation until 28 days after transplantation. Adverse events, especially bleeding and infection, were monitored to assess safety, and blood glucose levels were measured and compared with the device values. None of the eight participants experienced bleeding that was difficult to stop from the sensor site or local infection that required antimicrobial administration. The device value was well correlated with blood glucose (correlation coefficient r=0.795, P<0.01); however, the overall mean absolute relative difference was 32.1%±16.0%. Our study demonstrated the safety of FreeStyle Libre Pro in allo-HSCT patients. However, the sensor results tended to be lower than the blood glucose levels.

Regimen comprising GLP-1 receptor agonist and basal insulin can decrease the effect of food on glycemic variability compared to a pre-mixed insulin regimen

BackgroundIncreasing evidence suggests that glucagon-like peptide 1 (GLP-1) receptor agonists (RA) can stabilize glycemic variability (GV) and interfere with eating behavior. This study compared the impact of insulin, GLP-1 RA, and dietary components on GV using professional continuous glucose monitoring (CGM).MethodsPatients with type 2 diabetes underwent CGM before and after switching from a twice-daily pre-mixed insulin treatment regimen to a GLP-1 RA (liraglutide) plus basal insulin regimen. The dietary components were recorded and analyzed by a certified dietitian. The interactions between the medical regimen, GV indices, and nutrient components were analyzed.ResultsSixteen patients with type 2 diabetes were enrolled in this study. No significant differences in the diet components and total calorie intake between the two regimens were found. Under the pre-mixed insulin regimen, for increase in carbohydrate intake ratio, mean amplitude of glucose excursion (MAGE) and standard deviation (SD) increased; in contrast, under the new regimen, for increase in fat intake ratio, MAGE and SD decreased, while when the protein intake ratio increased, the coefficient of variation (CV) decreased. The impact of the food intake ratio on GV indices disappeared under the GLP-1 RA regimen. After switching to the GLP-1 RA regimen, the median MAGE, SD, and CV values decreased significantly. However, the significant difference in GV between the two regimens decreased during the daytime.ConclusionA GLP-1 RA plus basal insulin regimen can stabilize GV better than a regimen of twice-daily pre-mixed insulin, especially in the daytime, and can diminish the effect of food components on GV.

Difference on Glucose Profile From Continuous Glucose Monitoring in People With Prediabetes vs. Normoglycemic Individuals: A Matched-Pair Analysis.

Comprehensive characteristics of the glycemic profile for prediabetes derived by continuous glucose monitoring (CGM) are unknown. We evaluate the difference of CGM profiles between individuals with prediabetes and normoglycemic individuals, including the response to oral glucose tolerance test (OGTT). Individuals with prediabetes matched for age, sex, and BMI with normoglycemic individuals were instructed to use professional CGM for 1 week. OGTT was performed on the second day. The primary outcomes were percentages of glucose readings time below range (TBR): <54 or <70 mg/dL, time in range (TIR): 70 to 180 mg/dL, and time above range (TAR): >180 or >250 mg/dL. Area under the curve (AUC) was calculated following the OGTT. Glucose variability was depicted by coefficient of variation (CV), SD, and mean amplitude of glucose excursion (MAGE). Wilcoxon sign-ranked test, McNemar mid P-test and linear regression models were employed. In all, 36 participants (median age 51 years; median body mass index [BMI] = 26.4 kg/m2) formed 18 matched pairs. Statistically significant differences were observed for 24-hour time in range (TIR; median 98.5% vs. 99.9%, P = .013), time above range (TAR) >180 mg/dl (0.4% vs. 0%, P = .0062), and 24-hour mean interstitial glucose (113.8 vs. 108.8 mg/dL, P = .0038) between people with prediabetes compared to normoglycemic participants. Statistically significant differences favoring the normoglycemic group were found for glycemic variability indexes (median CV 15.2% vs. 11.9%, P = .0156; median MAGE 44.3 vs. 33.3 mg/dL, P = 0.0043). Following OGTT, the AUC was significantly lower in normoglycemic compared to the prediabetes group (median 18615.3 vs. 16370.0, P = .0347 for total and 4666.5 vs. 2792.7, P = .0429 for incremental 2-hour post OGTT). Individuals with prediabetes have different glucose profiles compared to normoglycemic individuals. CGM might be helpful in individuals with borderline glucose values for a more accurate reclassification.

What Nephrologists Should Know about the Use of Continuous Glucose Monitoring in Type 2 Diabetes Mellitus Patients on Chronic Hemodialysis

Patients with type 2 diabetes (T2D) and end-stage kidney disease (ESKD) on renal replacement therapy represent a specific population with high morbidity and mortality, an increased risk of hypoglycemic episodes and large intra- and interdialysis glycemic variability. Antidiabetic treatment adjustment is therefore challenging, especially in insulin-treated patients. Continuous glucose monitoring (CGM) is increasingly proposed to T2D patients on hemodialysis (HD), although data regarding flash monitoring systems (FMSs) and real-time CGM (rtCGM) in HD patients are limited. Small CGM pilot studies of a short duration demonstrated improvements in glycemic control and decreased hypoglycemic events, despite a lower accuracy of CGM as compared to capillary blood glucose. Moreover, CGM–drug interactions with vitamin C, mannitol and paracetamol can occur in HD diabetic patients and need further study. Despite these shortcomings, professional CGM has the potential to become an integral part of glucose monitoring of HD patients treated with insulin. Personal CGM prescriptions can especially be useful in highly selected, motivated T2D HD patients on multiple daily insulin injections or experiencing frequent hypoglycemia with preserved diabetes self-management abilities or in whom diabetes is fully managed by medical providers. A close collaboration between the clinical staff working on HD units and diabetology teams, and ongoing patient education, are mandatory for optimal use of CGM.

Patient Satisfaction with Professional Continuous Glucose Monitoring in a Diverse Family Medicine Clinic: A Pilot Study.

Primary care providers (PCPs) manage a large portion of patients with diabetes. Continuous glucose monitoring (CGM) can give detailed information about glucose trends to improve treatment and safety. We conducted a prospective cohort pilot study to understand patient experience with the use of professional CGM in a primary care practice with a high volume of diverse, non-English speakers. Eligible patients were on an insulin regimen and either had an A1c above goal or whose PCPs had concerns for hypoglycemia. Surveys were collected prior to the intervention to assess the acceptability of the patient's self-monitoring blood glucose efforts and after the intervention to assess their experience of using the CGM. Participants at baseline had a mean A1c of 10.6% and a high amount of emotional distress as measured on the Problem Areas in Diabetes (PAID) scale. Post-intervention, patients reported their experience with professional CGM was positive and, overall, as acceptable of an intervention as their previous self-monitoring blood glucose practice. Professional CGM can serve as an additional, acceptable tool for PCPs to better understand how to help patients achieve diabetes blood glucose goals. Ambulatory care pharmacists are well positioned to lead this effort in clinics.