3rd Place Poster Winner

CGMs (Continuous Glucose Monitors) are devices that measure blood glucose on a continuous basis using a sensor device placed in the interstitial space using an enzymatic technology which reacts with glucose molecules, generating an electric current proportional to glucose concentration. Because it takes time for blood glucose to travel from the blood stream to the interstitial fluid, there is an inherent lag time of 5-20 minutes between actual blood glucose and the level measured by the CGM.

This is an exciting time for providers caring for persons with diabetes. The first 5 months of this year, I had the opportunity to care for older adults with diabetes in a PACE (Program for All Inclusive Care for Elders) program where I was serving as the Interim Medical Director. Our participants may be homebound, fail to keep medical appointments, and may live with poor glycemic control and multiple complications of diabetes. In a brief period, I saw the benefits of comprehensive supportive healthcare using a team approach that parsed identified problems to members of our team with expertise in each area. As a provider, I was able to prescribe newer effective medications (some given subcutaneously weekly at our center) with less hypoglycemic risk than insulin or sulfonylureas. At team conferences we were able to simplify the care and help their families and caregivers provide supportive care that was beyond the capacity of the participant alone. When appropriate, we provided CGMs (Continuous Glucose Monitors) for about 2-4 weeks to better understand the effectiveness and safety of our medical interventions. In the brief time I was there, I saw safer and more effective care with hemoglobin A1c’s dropping from the 13-16 range into the 8-9 range. As that happened, I saw dramatic improvements in the participants’ cognition and quality of life.

As a general internist, I appreciate the work of the ADA (American Diabetes Association) that identifies advances in diabetes care and adds these new developments to their comprehensive guidance called “Standards of Care''.  The SOC is published in Diabetes Care as a supplement every January.  The 2023 full version, abridged version, primary care, and other versions are all available online for free.  For providers, a free app is now available (ADA SOC) which allows real time access on your smartphone for quick guidance on specific patient care issues.  

For many reasons, our education committee chose to focus this year on reducing the risk of hypoglycemia in persons with diabetes.  CMS has data from April 2016-March 2017 showing this is a major reason for a higher first 30 day all-cause SNF Readmissions rate. As of Jan 1, 2019, the CMS “SNF Readmission Measure” (SNF-RM) adjusts payments to facilities based on this measure. From multiple randomized controlled studies, we know that serious hypoglycemia increases mortality. For this reason, in high risk patients, AGS and ADA have recommended higher A1C targets in those with higher hypoglycemic risk.  

Let’s face it: sliding scale insulin (or “rescue dose”) is still very common. This is in spite of the practice being actively discouraged for years, and being listed in the “Beers Criteria” (for years) as a treatment modality to “avoid.” The reasons for this are many, but the main reasons are:

 

1.    Prescribers want an “intervention” for high blood glucose readings (>150) that doesn’t involve a phone call.

In the October 4, 2018 issue of Diabetes Care, the ADA and EASD (European Association for the Study of Diabetes) published their consensus report for Management of Type 2 Diabetes, 2018.  Both organizations now favor the use of Incretin Receptor Agonists or SLG2 Inhibitors for persons with established macrovascular disease (or high risk for Cardiovascular Disease), for improving glycemic control, if metformin alone isn’t adequate or not appropriate.