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Continuous Glucose Monitors

Elizabeth Lamos, MD and Paul Simmons, MD
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Are you an expert in continuous glucose monitors and how to use them? Great! Then you can teach us! If not, endocrinologist and friend of the podcast Dr. Beth Lamos is back to walk us through the indications for CGMs and practical ways to use them in our patients.

Pearls:

  • As continuous glucose monitors (CGMs) become more widely available, consider them for primary care patients who check their blood sugar levels multiple times a day, have complex insulin regimens or have a history of hypoglycemia.

 

  • What are continuous glucose monitors (CGMs)?

    • Continuously monitor glucose with a sensor on the body usually the size of a quarter that has a small (couple millimeter) plastic catheter on it sitting underneath the skin in the interstitial space

    • Transmits wirelessly

    • Historically had been used in patients with complex diabetes but as the technology has advanced is more applicable to patients seen in primary care

    • Accurate within about 10% of a fingerstick glucose

    • Lag time of 5 to 10 minutes

  • Good candidates:

    • Type 1 and 2 diabetics that require intensive insulin titration

    • Those with multi-injection daily insulin regimens

    • Those with issues of hypoglycemia regardless of insulin regimen

    • Those struggling with fingersticks

  • Relative Contraindications:

    • Pregnancy

    • Critically ill / hospitalized

    • Dialysis

  • Functions of CGM’s:

    • Catheters last 7-14 days

    • May transmit intermittently to continuously to a device (ie: phone, watch, separate device)

    • Set alarms for different glucose levels

  • Different use cases:

    • Can be used for short-term periods borrowed from the office to monitor a patient who you’re worried about has significant hypoglycemia. Can be checked out from the office.

    • May unblind monitoring so the patient can use the data to change behavior as they see it

    • May blind monitoring to review with the patient to provide feedback retrospectively

  • FreeStyle Libre:

    • Place sensor on the arm every 10-14 days and usually takes 12 hours before its ready to give accurate readings

    • Good for those with Type 1 or 2 diabetes who have to check sugar frequently

    • Does not have hypoglycemia alarm so isn’t good for people who have hypoglycemia unawareness or frequent hypoglycemia

    • Data can be downloaded by provider to show percent time spent at different glucose levels

  • Eversense:

    • The only implanted CGM on the market

    • Implanted in the upper arm under local anesthesia in the office every 90 days

  • Other devices:

    • Dexcom G5 and G6

    • Medtronic Guardian Sensor can pair with insulin pumps

  • Reimbursement:

    • CPT codes (99250) can pay for the review of CGM data

 

REFERENCES:

  1. Chamberlain JJ, Doyle-Delgado K, Peterson L, Skolnik N. Diabetes Technology: Review of the 2019 American Diabetes Association Standards of Medical Care in Diabetes. Ann Intern Med. 2019;171(6):415. doi:10.7326/m19-1638

  2. Carlson AL, Mullen DM, Bergenstal RM. Clinical Use of Continuous Glucose Monitoring in Adults with Type 2 Diabetes. Diabetes Technol Ther. 2017;19(S2):S4–S11. doi:10.1089/dia.2017.0024

  3. Tamborlane W, Beck R, Bode B, et al. Continuous Glucose Monitoring and Intensive Treatment of Type 1 Diabetes. N Engl J Med. 2008;359(14):1464-1476. doi:10.1056/nejmoa0805017

  4. Klonoff DC, Buckingham B, Christiansen JS, et al. Continuous Glucose Monitoring: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2011;96(10):2968-2979. doi:10.1210/jc.2010-2756

  5. Longo R, Sperling S. Personal Versus Professional Continuous Glucose Monitoring: When to Use Which on Whom. Diabetes Spectr. 2019;32(3):183–193. doi:10.2337/ds18-0093

Ian L., Dr -

Very Intriguing MED -Tech .
Would also be good for initiating Insulin in Type2 and also treating Type 2 patients when are ill with moderate illness the "sick days " who do not want to go to hospital
In a Rural setting would help with Hospitilised Patients on Insulin to prevent Hypoglycemia as you correct Hyperglycemia though not yet authorised for this yet .

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