FRESH UPDATES AND NEW DEVELOPMENTS IN DIABETES TECHNOLOGY: INCORPORATING EMERGING KNOWLEDGE FROM NEW EVIDENCE
Jessica Ledwidge
Welcome everyone to tonight's webinar. Tonight in the Rural Health Webinar series, we are going to be talking about fresh updates and new developments in diabetes technology. This session is going to be presented by Dr Gary Deed who is the chair of the RACGP Specific Interests Network.
We would like to begin this session by acknowledging the traditional owners of the lands that we are coming together from and on which this event is being broadcast. I would like to pay my respects to the Elders past, present and emerging. I would also like to acknowledge any Aboriginal or Torres Strait Islander people joining us this evening.
Before we start, there are a couple of housekeeping things to cover. All participants are on mute to ensure the webinar is not disrupted by background noise, but we encourage you all to use the chat function and the Q&A box to ask questions. Please address your questions to all panellists and attendees so that everyone can see your questions and comments. We will be answering the questions at the end of the session, so send them through as we go along and we will have time for Q&A towards the end. Finally, this webinar has been accredited for 2 CPD points and in order to gain these points, you must be present for the duration of the webinar. We also ask that you complete the evaluation activity that will pop up at the conclusion of the session. I will now hand over to our facilitator for the evening. Welcome, Dr Gary Deed.
Dr Gary Deed
Thanks, Jessica, and welcome to everyone here tonight. Let us go through some exciting discussion around technology and the application to type 2 diabetes and my disclosures, conflicts of interest of which I do research as well. Some of the outcomes that we are trying to achieve tonight is really understanding, particularly we call it, continuous glucose monitoring technology and understand the principles and functionality of this CGM we call it, and benefits and limitations in managing type 2 diabetes. I am going to focus on type 2 diabetes, the application of the CGM in your clinical practices, and how to identify appropriate patient populations to improve diabetes management outcomes. In doing that, interpretation of the data that is presented by particular CGM, how to analyse and interpret it and enable yourself to make informed decisions and tailor your diabetes management plans based on what we call real time glucose monitoring insights, as well as the other inputs that we currently use in clinical practice, such as blood pressure, pathology testing but also haemoglobin A1c, for instance, as well, and also promotion of CGM adoption if we can.
We are going to do some cases. Jane is a 60-year-old teacher diagnosed type 2 diabetes about seven years ago. She is a theoretical patient, by the way, but hypertension three years ago. South Asian origin, is married with one child, 15 years old. She works in a regional city and had gestational diabetes. She was informed she had glucose problems, high glucose on recent testing. She is currently on metformin 2 g, semaglutide once weekly injection, telmisartan for blood pressure, does yoga once a week, social drinker on weekends. She is partly active. Blood pressure is 140/80. Is that reasonable? I will leave that up to yourselves to think about that, and whether we need to monitor that BMI. For South Asians, is probably into the obese range. Cholesterol LDL is a little bit elevated there, but is probably in primary prevention ranges. Fasting glucose is elevated and haemoglobin A1c is 8%. When she said she had an elevated glucose before, it was at 7.9% before. I am going to go through this quickly because it is really about talking about technology that she needs to commence insulin, but will technology help someone like Jane? Let us park that question and move to the next case, Matt. Different sort of case. Very active 57-year-old, is a long term insulin user. He has been on co-formulated insulin, Ryzodeg is the trade name, 30 units twice daily, so on um DPP-4 and metformin and also empagliflozin 25 mg, could not tolerate a GLP-1 receptor agonist before shifting on to this new insulin. He is obese. Blood pressure is well maintained. No cardiovascular disease, no chronic kidney disease. He is on insulin, but only intermittently does self-monitoring because he often forgets, too busy. He often says he gets embarrassed to do that in public. He is a FIFO worker at a mining site. There are symptoms of hypoglycaemia emerging in his sleep, but no severe hypo. Definition of severe hypoglycaemia is to needing assistance from another person, with proven hypoglycaemia. Now he wants to join a gym because his new son-in-law is very fit. Will technology assist him in this sort of case? Interesting case. We are going to go through some of the information now and then come back to the cases and answer some of those questions.
What is new technology assisting diabetes management out there. Well, I want to break it down into three different groups just to get our heads around it. There is information technology. There are mobile phone apps, SMS messaging, for instance, wearable technology, fitness trackers, smartwatches. I walked home and I was monitoring my amounts of steps I was doing, etc as part of that and my heart rate. Web based programs and clinic based chronic disease care programs. There is a lot out there. Then there is technological innovation for monitoring of glucose, which is where we are trying to focus a little bit on CGM (continuous glucose monitoring) and also flash glucose monitoring. They overlap. Basically, flash is just a divergent technology having insight into glycaemic patterns, but also touch on technology for medication delivery such as insulin pen devices and a little bit on insulin pumps, which have really been mainly traditionally used for people with type 1 diabetes.
Let us go to information technology. Recent meta-analysis found that mobile phone apps and web based applications, combined with your usual standards of care, resulted in significant reduction in haemoglobin A1c in people with type 2 diabetes. If you want the reference, we can provide that to you. There is emerging evidence that information technology interventions are associated with reduced sedentary behaviour. As I said, like with my smartwatch, it has encouraged me to increase my steps or monitoring how many steps I am doing, etc, increase physical activity but also improvements in diet and exercise, including understanding nutrition. There is a push there. As you know, the push for technology is occurring at a very fast rate in people living with diabetes, let alone people without diabetes. Getting across that is probably a useful thing. Here are some resources of some really good apps that you might find helpful, especially if patients ask you about it. MySugr app, and there is something called Glucose Buddy. I am not endorsing either of those. I am just saying that they are being reviewed and seem to be helpful. Diabetes Victoria has an independent resource there, if you can use your mobile phones. I will leave it up and maybe copy the link down there. Remember, some of these slides will be available after this, so that you can go back and look at those, but you can look for MySugr and Glucose Buddy in the Diabetes Victoria website and look for diabetes management apps on their website. I did not spend a lot of time on those at the present time because they are often patient focused and patient facing, but can assist you, as part of your quality as a diabetes managing GP, knowing a little bit about those.
Let us talk about technological innovations for monitoring glucose. This comes under the whole idea of flash or continuous glucose monitoring where a small sensor is implanted into subcutaneous tissue to monitor and remember it says interstitial glucose. It is not the same as capillary glucose, which remains a standard of care. Real time continuous glucose monitoring continually records and reports glucose levels. Some devices now have alarms to alert you about hypoglycaemia or hypoglycaemia of the person utilising the technology. It is a wonderful clinical tool to detect glycaemic patterns and the quality of glycaemic management, such as how is the glucose varying excessively or only a little bit but also detecting hypoglycaemia including nocturnal hypoglycaemia. The minimal duration of use of such devices, for instance, now is probably about 14 days to get an adequate profile. We will show you the profile so you can interpret it better in a moment. Back to interstitial fluids. We will get back to that in a moment and why that varies and what is the time lag between capillary versus interstitial which comes up here. It is about 10 to 15 minutes. When you are using a CGM or a flash glucose monitor, it is not the glucose at this point in time. It actually lags a little bit. Often, the technology does include some information to allow you to understand what the glucose was doing. Was it going up or going down? There are arrows that appear in the sensor monitors that can help you with that. Just remind yourself about that. Often when there are periods of hypoglycaemia, there is a push to say that we should additionally test through a different measure, such as capillary measuring, to get a more accurate measure of hypoglycaemia at this point in time. If the CGM comes up with hypoglycaemia, maybe you should be additionally telling the patient to have capillary sensor and often sensors can be combined to do both, monitoring the flash, but also can have strips that monitor capillary glucose. However, flash monitors, for instance, do not require calibration. As I said, when there is rapidly changing glucose or lower glucose ranges, just be careful that it is interstitial fluid and use a finger prick assessment. Is there evidence to say this can be applied in type 2 diabetes? Well, the evidence is really expanding very quickly. This is just released late last year and says both CGM and intermittent monitored CGM demonstrate a reduction in haemoglobin A1c, demonstrable glucose lowering effects in people with type 2 diabetes. Intermittent use was associated with improved user satisfaction. People do not have to take it forever. You can use it for blocks of time. We will come back to that in a moment. However, the impact on other phenotypic or risk factors remains unclear and whether it really changes lipid levels.
We have to understand the breadth of the technology and the limitations of the technology. I am trying to put meta analyses and high level evidence. Real time and flash glucose monitoring help moderately, but statistically significant reductions in haemoglobin A1c with little heterogeneity. It is actually getting very strong solid evidence for its use. They are authorised here in Australia under the TGA for application in people with type 2 diabetes. I think the last of these studies, CGM use compared with self-monitoring, which is a finger prick, is associated with improvements in glucose control in people with type 2 diabetes. It was found that people preferred the CGM. Bit of open label, so some of the data still needs to accumulate, especially around some of the risks, such as severe hypoglycaemia. Is there a benefit in macrovascular outcomes? Well, that requires long-term further study. This is just to show you from that last study just here, the study published in Diabetologia just this year in May, which showed if you see down at the bottom, favours CGM versus self-monitoring glucose and the overall diamond favours CGM as the left of the upright. That includes multiple studies as well. It is really quite strong evidence. This is to remind you why CGM varies or is different to haemoglobin A1c. Haemoglobin A1c is very useful still because many of the studies on complications and long-term durability of effective glycaemia have been around haemoglobin A1c. On the right hand side here, you can see here that the haemoglobin A1c is 7% as on the left hand side, but the glycaemic variability of each of those is different. You still get the same haemoglobin A1c. The glycaemic variability may include episodes of hypoglycaemia on the left-hand side, but none on the right hand side. This person has different quality of life and different risk factors versus the person on the right-hand side or the person in the middle. However, they have the same haemoglobin A1c. We need to understand the limitations of haemoglobin A1c and its inaccuracy in some patients, great for long-term glycaemic complication management and a change in prescribing on the PBS, but CGM gives you much more patient focused day to day, week to week variability. Haemoglobin A1c just gives you the collective over the last three months.
Just be careful of acute hypoglycaemic or unstable glycaemic states, posttraumatic pancreatic disease, etc. Rapid onset of glycaemia can cause haemoglobin to appear artificially low. Sepsis and steroid use, of course, destabilises the accuracy of haemoglobin A1c. Postpartum patients, it remains inaccurate even for four months postpartum. Hemoglobinopathies, I think you know that in advance, chronic kidney disease, people with iron deficiency can be artificially elevated haemoglobin A1c. If you have had a recent blood transfusion or iron transfusion, it can affect the accuracy. CGM is not so affected by those particular problems. Let us talk the CGM, which are often little devices placed abdominally or on other parts of the body. Flash monitoring is a particular technology where it is a little device often put on the posterior of the arm. I will show that in a moment. As I said, they are TGA authorised for type 2 diabetes and type 1 diabetes. There are insulin pumps and closed loop systems, which are mainly involved in the type 1 space where insulin is delivered through a little pump device, but communicating with the CGM. Now there are, in fact, we call closed loops delivery systems which even shut down insulin if hypoglycaemia is detected or increases the insulin infusion when there are hyperglycaemic excursions. I do encourage you to monitor the National Diabetes Services Scheme for changes in access to type 1 diabetes availability. Currently, there are no subsidised availability for type 2 diabetes and we just need to advocate for that because I have already shown you the demonstrable evidence that certain patients with type 2 diabetes, which we will get to in a moment, do benefit from it.
This is a graph to show you that from the days, it is very interesting over here on the left-hand side on the lower insulin delivery device, there is this man carrying a backpack delivering insulin, my goodness. Now to almost credit card sized delivery devices that can be utilised for delivery of insulin. Also, the same has occurred with the evolution of blood glucose monitoring. I have been around long enough to have seen different devices, wonderful devices, by the way. Currently, CGM and the improvement in cost effectiveness, comfort and convenience. As I said, flash monitors are a little disc device. That is an older picture. They are much smaller now, often called the Libre 2, and it is applied to the outer part of the arm and that can connect to software on your phone or to a sensor still as well. The software on the phone looks like this, LibreLink. I do not endorse one company over the other, but this is currently the only flash monitor, I think, that is available. I have that on my mobile phone and you can scan it, but now it automatically by Bluetooth is sending data continually to your mobile phone to this app. You get this lovely pattern that emerges and you can actually see daily patterns. You can see the instant glucose readings, but also what is something called time and target, which I think we are going to spend some time on as we speak now.
This is an interesting point. I am very enthusiastic about technology, and we do have to sometimes say to ourselves, put a break on is that will technology set all of your patients free. I have seen patients develop anxiety and even obsessive compulsive disorders related to the sense of giving them information that they get stressed by. Monitoring their glucose, and is their glucose normal and should I check it all the time? This is so important that technology should only be utilised in the space where there is adequate patient information, education and support by qualified health professionals, certainly a GP who might be trained and understand this, is certainly qualified to talk about it. We often have to think about our credentialed, diabetes educated colleagues who are trained in this and can give the patient specific support, answer their questions. Otherwise, the technology may entrap some patients and not necessarily improve their quality of life. If you are going to suggest the technology, I do suggest that you think about a multidisciplinary team approach, care plan where appropriate and the use and referral of a credentialed diabetes educator to support yourself and your patients. Why is it important about education? It is education of yourselves here tonight, but also education of the patients because this technology pulls out a lot of information that can help you and ultimately help your patient live better and manage their diabetes in a healthier way. Something that is produced are these reports called the ambulatory glucose profiles. This is gathering the data from that sensor and the software that is associated with it and giving you a profile that actually you can utilise to help explain what is happening to this variability with your patients, for instance. This one actually tells you just on the left-hand box that how is the CGM active. In the old days, 97% was meaning the person was, well you have to call scanning. You get the mobile phone and apply it to the sensor like that. However, now because of these developments, that is automatically going, but still how often is the CGM assessed is an important thing.
If the patient's not utilising it, it is not helpful information. Average glucose can be expanded from it. You can actually get a really sound understanding what is the average glucose of this person, and the variability of glucose 31%, but also what is their glucose management indicator. It is a calculated haemoglobin A1c, but you get a calculated haemoglobin A1c in this case of 6.7%, very helpful. On the right-hand side is also something that is very useful for you to understand. This is something called time in range. That is something that haemoglobin A1c cannot provide you. This technology does. What it does is that it helps you set the targets and also assess for things like being above target, in target and particularly also below target and concerning below targets which are hypoglycaemia. When you utilise this device, often the credentialed diabetes educator or yourself can help set the software up to set the target range which is by international agreement and national agreement here in Australia, is set between 3.9 to 10.0 mmol/L. The target range is we want people hopefully to stay in target range and certainly above 10, 10.1 or above to 13.9 is high. Very high is above 13.9. Importantly, low glucose or hypoglycaemia is set at um 3 to 3.8 mmol/L and very low less than 2. The ideal target range is something we call time in range. You are trying to get these percentages are telling you what is a time in range this person is actually achieving with this glucose profile. I will show you some of the agreements in a moment around time in range and how it applies to your management of patients. The green zone is what we want to expand as best we can.
When you set up this monitor, as I said, it is giving in the software or the sensor or on your mobile phone through the app, it gives you the glucose at that time, lags, as I said, 10 to 15 minutes, but it gives you some idea. Do not forget it is giving you these arrows. There is an arrow that is rising or rising quickly or changing slowly is when the arrow is horizontal, falling or falling quickly. If that number was say 3.9 and the arrow was rising, that person probably is not going to go into a hypoglycaemic fall following that detection level. If it was falling by the falling arrow falling quickly, you know that look, we better prepare that person for a hypoglycaemic event and utilise some management. That is how you teach the patient. It is not just the number, it is whether the arrows are moving in particular directions at that point. I hope that makes sense.
On the right-hand side, though, now we have got not only that little table and the graphical colour bar code, but we have got a wonderful wave like pattern which actually gives you a 24 hour picture of the person's glucose patterns. The dark centre line is the mean. The dark blue surrounding that is the 75th percentile, and then above that is the 95th percentile. It shows you the excursions the person has been involved in. In fact, this person has had quite elevated glucose at the midnight range there. He has also had lower ranges coming up to breakfast time here. It gives you an idea that is this person struggling for elevated glycaemia, for instance, after the evening meal here at 9 pm or are they at risk of having hypos in the early parts of the evening? These are the information and the detail that you can get that really hones your diabetes management. There are agreements. This is on the Australian Diabetes Society website regarding some of the ideals of time in range. On the left-hand side, it is probably the one that probably applies to all of us here, type 2 diabetes and older or high-risk type 2 diabetes, including type 1. On the right-hand side, there is a pregnancy and gestational diabetes which is probably managed in multidisciplinary specialist team, but I will just quickly go through that. You notice that in pregnancy that we like women to probably stay in a higher percentage of time in range. Going to the left-hand bar column, greater than 70% in the target range of 3.9 to 10 mmol/L is ideal for many patients.
That is what you are trying to target by changing therapy to get them to this sort of time in range and try to reduce certainly hypoglycaemia less than 4% or less than 1% in severe. Time above range, certainly trying to be less than 30% above 10 mmol and certainly above 13.9. Higher risk patients are those patients who might be on complex insulin regimes, etc., may have multi morbidities such as advanced cardiovascular disease. At that stage, there might be ability to allow a little bit of a higher percentage in above target range. Also, notice we are trying to minimise hypoglycaemia because the risk of hypoglycaemia in those people is in fact a little bit of a concern. It is not suggesting that you are letting people get out of range and causing complications, but it is reducing risks. That was a download and a half and a lot of information. Please do not forget to ask questions at the end, if we can help unpack that. I do not apologise by giving this level of information, but we are going to show you at the end of this talk about how you can do further education to support this introduction that I am doing tonight.
Let us move to technology for medication delivery before we go back to those clinical cases and sum up some of that information we have been talking about. Continuous glucose infusion or insulin pumps allow a controlled delivery of insulin compared to injectable insulin, particularly basal insulin. They are programmable and they can release an insulin in the background just continually through the 24 hour period, and then they can be programmed to deliver bolus insulin on top of that background we call basal insulin. Also, correction doses, if the glucose is not appropriately responding to the bolus dose that you gave. It requires a lot of education, expensive technology and some health funds will fund that, but they only will fund for type 1 diabetes.
It is rare probably in your own clinical practices to be utilising this technology at the present point in time, and funding models, as I say, restrict the access type 1 diabetes. You will see it, you will see some patients with that and part of our education process later on we are going to talk about the National Association of Diabetes Centres, and you might be able to do some education around those as well, but really also where technology for medication delivery is moving in type 2 diabetes, new smart pens that electronically allow you to record the insulin dose given in the time. Have you ever been utilising insulin? You can actually have injected and five minutes later, you cannot remember whether you have injected or not, and patients have that as well, and you do not want patients to then double dose because the risk of hypoglycaemia, but also you do not want them to miss a dose because hyperglycaemia can occur. These dosing devices I will show you in a moment have electronic data and Bluetooth that can go into apps, etc. to help you both adhere and medication persistence and prevent risks and complications of dosing and glycaemic variability. There is one pin here called the Novo pin six, which can record not only when the patient gave it, but also the dose given can be seen on the pin but also can be Bluetooth directly to your iPhone or Android phone, and can be integrated into the flash monitoring system. It is starting to now integrate so patients have better self-management skills as well as you have the reassurance that people are optimising the technology and optimising the advice you are using for particularly around insulin use here. When are you going to utilise for instance, I am going back again to glucose monitoring for instance, and the technology, these are the key questions I want in your mind to apply when you are going to advise on utilising this technology. One of which is the back to other glucose levels at target on wakening. So when you have got the data dump and you looked at it, look at the target glucose on waking in that profile, you know, is it in target.
Do we need to consider insulin, for instance, or some other step up to therapy, do level spike above 10 millimoles per Litre two hours after a meal which is considered unstable glucose? Remember that level and that postprandial rise. Are they taking insulin for instance properly if you are utilising insulin I am focusing on insulin here because we are going to talk about why insulin users are probably ideal people to utilise this technology and this might tell you are they taking the insulin before they eat or are they taking it too late? A good educational profile is when you get this profile, it might show that the person is injecting insulin by the time they finish the meal. So, the profile of insulin rising lags the rise of glucose. They are following each other, and they get this postprandial rise which could be improved if you gave the insulin before the meal or right when they start eating. Also, the day to day variability, does exercise affect it? Does stress affect it? Had a person in today when we are analysing the, flash monitoring or continuous glucose monitoring, it was very clear that in periods of stress there was increased glycaemic variability but also increased baseline glucose, and we had to understand how to monitor that. The other thing is that also you can monitor that what we call that morning phenomena that people wake up and that adrenaline and cortisol that occurs when you are on awakening or even just on awakening. You see this without even food, you get a glycaemic rise, and that could be something to look for to assess for sleep apnoea that might be affecting that, and certainly stress management etc, and very importantly, are there hypoglycaemia events that are exceeding recommendations, and as I said sometimes that will might be seen on the haemoglobin A1C particularly nocturnal hypoglycaemia, and the reassurance of these technologies is that they have alarms. So even in the sleep if a person is having hypoglycaemia, they will be reminded and be able to be woken up before it reaches critical levels. So back to the level of Jane. Remember, Jane was a lady who had a unstable haemoglobin A1C of 8% was on oral therapies, etc. and the step up was do you want to commence insulin? And as we know with commencing insulin, if you look at the RACGP handbook on Management of type 2 diabetes in general practice. There are commencing doses of insulin and different insulin choices, but then there is titration that requires and with titration you need to be monitoring glucose, and one of the titrations is to do fasting glucose levels, and also that to our post-meal glucose at times to give you an idea of how to adjust insulin or which insulin to use, and as I said, the evidence in that in that meta-analysis showed that people prefer and have better benefit to haemoglobin A1c by utilising CGM and flash technology. So, Jane not only when commencing insulin, but also adjustment of her dose of insulin might be an ideal candidate. Remember, the devices that are currently used last up to about two weeks before you have to change the device so you can use that as a starting block, but continuing for a little while, and then shifting to other forms of monitoring if you wanted to do finger prick after that, but it really allows you the flexibility to give you and Jane reassurance that she is monitoring her glucose and is safe not getting hypoglycaemia, but also is she on the appropriate dose for her glycaemic variability?
Very applicable to Jane. With Matt, remember he is on a complex insulin regime including both the basal insulin and prandial insulin in a fixed ratio co-formulated insulin. He wants to change his activity, and his diet very possibly is going to get all this advice from his healthy son-in-law, and this is the beauty of this system is that it is not self-monitoring very often because of the inconvenience and privacy issues and etc. whereas these devices can be hidden and are seamlessly tracking his glucose to his mobile phone, which he can safely look at, and it not only gives you an idea of all the issues around dose adjustment of insulin and glycaemic variability that we saw with Jane, for instance, but also can show you the influence of different foods and how different dietary changes can shape the glucose variability profile. Higher protein diets, for instance, can cause and improve glycaemic variability and get people to target maybe even be able to reduce his insulin dose. Also, testing before he does exercise would be a very useful thing and therefore he can look at it and like with driving there in Australia we have got the recommendation do not drive if you are under 5 millimoles per litre, exercise if he is under five millimoles per litre, doing some strenuous exercise may cause a hypoglycaemic event. If he is doing it regularly, you might adjust the insulin dose to allow him to exercise safely, or he might need to have some sort of snack to allow him not to get a hypoglycaemic event. Certainly, with driving, we also recommend patients are testing if they are driving in a glucose is above five, particularly if they are on hypoglycaemic inducing agents such as sulfonylureas and insulin, and lastly but not least, hypoglycaemia the risk of hypoglycaemia post-exercise is a concern. It can even occur in that night, and he is changing his diet and increasing his activity, the risk is higher. So this will give you and him some reassurance in the alarm systems that are available, really provide clinical support, so ideal for Matt. And really to summarise, it probably if you applied this technology initially in people with type 2 diabetes utilising insulin, starting insulin, maintaining insulin, complex insulin ratio regimes, people changing lifestyle activities that could influence hypoglycaemic risks. It is certainly that group of patients that really are the phenotype of those that wear this technology, and type 2 diabetes may make a difference. This was Jane's profile. Remember she was less complex as a starting insulin, and you can see this wide glycaemic variability that was occurring say around 12 mid day, and that might suggest that she is eating foods at times that might have a high glycaemic index, and that would be 1 aspect of how you might say to her, Jane, let us have a look at your dietary intake and adjust that and maybe adjust the carbohydrate content of those meals there. Also notice some on the mean around, say, dinner time 5:36 p.m. is a little bit higher as well.
Again, dietary and lifestyle advice doing a bit more physical activity maybe in the late afternoon there or certainly before lunch might also help her, but also how to adjust the dose etc. There are some periods when she is going very low in the morning, so that suggests that basal insulin dose might need to be adjusted for Jane, this was after she started insulin. The dose might be she might be what we call over basalionised or has too much basal insulin and that we need to back that dose down, improve the dietary advice and intake of glucose in foods around midday and dinner time and also increase physical activity, so a really good profile, good information. Matt's profile is the theoretical case as I mentioned. Notice though highlighted that he is having hypoglycaemic events there, and that is not useful, and that is early in the morning and also late afternoon after he has done his exercise, he has got wide glycaemic variability. So again, a credentialed diabetes educator might be useful to help him understand how to adjust his insulin doses and also support you around that, and also look at inadvertent snacking that he might be doing interesting when he gets that hypoglycaemia in the late afternoon after exercise, he gets these peaks of glycaemia. A lot of information here, but very useful information. Hypoglycaemia risk is very important. You need to adjust his insulin program to avoid that if we can. So summing up, I mean, I have talked a lot here today. I think clinically choose the patient to fit the technology and vice versa. I think, as I said insulin initiations and up titrations, complex insulin regimes. A person who has a risk of hypoglycaemia from any cause that might be useful to do a snapshot of that, and also around lifestyle change in people with complex type 2 diabetes, particularly on insulin, it is very important that this technology would support people, but education of each person is so important and there are whole idea of education involves use of a qualified health professionals such as a CDE.
Risk reduction is really the framework we want to work around. Hypoglycaemia particularly is imperative. A quality of life improvement is very important for patients and how to feel safe both in sleep driving and with their activity, particularly utilising insulin, and do not forget improved time in range has been linked to better long-term complication reduction, with a haemoglobin A1c benefit associated with that timing range and misspelling there, but education of practitioners is imperative. This is the next slide. I want to introduce that around World Diabetes Day this year, my colleagues and friends at the National Association of Diabetes Centres or NADC will have a module designed to supplement education in CGM and type 2 diabetes and will be available for points as well, and there is a QR code there, so register your interest. Please utilise that, and if you do not have your mobile phone on that, these slides will be available to you. Please consider that World Diabetes Day is November 14, and again the highlights will be recommendations for suitable candidates. We will go into greater depth available options which can change even overnight, how to analyse data trends and effectively improve clinical support and how to incorporate CGM into diabetes management. There will be some interactive cases and a module assessment. I think we have done a lot here today, but I encourage you to ask questions and I am going to let Jess now open it up for question and answer. Thanks, Jessica.
Jessica Ledwidge
Great. Thank you so much, Gary. We have had a couple of questions come through, which is really good. So, the first one is from Himali who is asking what is the cost for CGM? Is it covered by private health insurance for type 2 diabetes?
Dr Gary Deed
I think CGM is not subsidised, so there is no government subsidy. The cost of the sensors does vary. Independently, the sensor lasting two weeks may cost up to $90 per person. However, some of the companies have incentive programs that reduce that cost dramatically, and I have had a patient today who reminded me that they were able to get the sensor for $15 through. I cannot say how that happened. I think you have to contact the manufacturers of flash and CGM about what are the support processes there, and get the patients reduced price. If you have a letter from a credentialed diabetes educator, you can apply independently to your private health insurance for funding for extras, but you have to have the appropriate health insurance with the appropriate coverage.
Jessica Ledwidge
Brilliant. Thank you for that. The next question that we have got is where can I see a list of mobile phone applications or glucose monitor brands approved in Australia?
Dr Gary Deed
The National Diabetes Services scheme should have that information. The Apps Diabetes Victoria has, those apps that are patient focused around information technology, but the national diabetes services scheme but do not forget that education module which I will just show you again will be able to show you what are the options available, and I think it is an online learning module too as well, so do not forget to enrol for that.
Jessica Ledwidge
Brilliant. Thank you for answering that one. The next one is how long can the CGM sensor be left? What is the preferred site of application for CGM?
Dr Gary Deed
There are different CGMs and flash monitors. I will go through the flash monitor first, which is that small disc like device. The preferred site is actually on the outer part of the arm for the patients, and it can be moved around. Most of the studies are done on utilisation of that site. It still will work on other sites of the body through subcutaneous insertion of the little cannula that is associated with the device. However, they are not standardised and the evidence is not standardised for the use of alternative sites. That particular flash monitor should last about 14 days before it needs to be replaced. The other CGMs can be applied to different parts of the body and abdominal area, for instance different devices there, and again, they utilised up to 10 to 14 days before needing to be replaced.
Jessica Ledwidge
Thank you for that. The next one says on mats CGM profile slide, could you please explain again what the black line is and what is the light blue shaded area and the dark blue shaded area in the chart?
Dr Gary Deed
Very good question. The black line is the mean, that is the mean for every glucose over the last month at 14 days for that, but the dark blue shaded line is the 75th percentile. That is from that mean how much variability in 75 percentile and the lighter blue is the 95th percentile, so that is the extremes less extreme. And then the mean. We often look at the mean to give us an idea of what the profile is through that average 24 hour period, so the black line shows and is confirmed by that the darker blue and the lighter blue excursions that he is having peaks around midday, for instance, and a lower peak around evening after the meal, but the glycaemic variability, the expansion of those dark blue and light blue lines really occur late in the evening, for instance, so something is happening at times where it is much more variable and that we looked into that and asked him what happens, why is it larger chunk of readings that are outside of the mean at those times and there are times when he would suggest he snacked and there are days when he did not exercise, and that is why that variability occurred. And notice there is a great variability in the early hours of the morning to much higher levels, so on average he is doing well, but at times it is quite high, and again you can explore that by asking particular questions, and some of that was that sometimes he omitted to utilise his insulin on some evening doses and that was the curse. education was able to bring that down, and certainly education and lifestyle changes have to bring the evening thing down. So I hope that helps.
Jessica Ledwidge
Thank you for that, Gary. We have got a question from Judith. Judith is asking what are your thoughts on CGM use in non-diabetics or weight management or wellbeing lifestyle in those that can afford it?
Dr Gary Deed
So interesting fact. I do have patients who want to utilise this for information on the glucose profiles. Interestingly, many of them find that glucose is wonderfully in target, which should be if you do not have diabetes. So, the ability to extract that information around these lovely patterns is reduced because people will have much narrower glycaemic range. In a healthy person you will not necessarily find glycaemic peak after food unless they have prediabetes or have diabetes, and remember, they do not measure insulin. I wish I had shown you another graph, but it shows that glucose rising after meals is matched by insulin, of course, in a graphical fashion, but if you have got obesity or insulin resistance, the level of insulin required to keep that glucose in pattern is way higher. Remember it is the insulin rise that is actually characterising insulin resistance and prediabetes and often overweight, and this technology does not measure that. If you are going to utilise it remember there are limitations to what you are going to be able to present to the patient. Often the profile is very flat and it does not give them the information that you might be needing to motivate or support, weight management or lifestyle changes.
Jessica Ledwidge
Thank you very much, Gary, and we have not had any more questions come through. So if any1 would like to send through another question we still have a bit more time.
Dr Gary Deed
We have certainly gone through this fairly quickly. I have downloaded a lot of information for you. Please ask any questions. We are here to ask that. I think it is a very important aspect of modern management of type 2 diabetes in general practice, and one thing I did not mention, which is very important is that this technology, for instance, some of these profiles actually can be sent to you in your practice. You can actually if you are allowed to, apply the software to your own computer system, and your patient can nominate you to receive their profile. I have diabetes for instance, so my credential diabetes Educator received my profile, and so when she wants and when I need her I can say can you look at my profile and give me some ideas on what is happening here, so you can do that for your patients, and in fact, maybe you know, we often say our patients bring in your glucose monitor so I can see it when you come in for your diabetes health assessment. Patients notoriously never do, but if you set this up and get your CDE to help set it up so that you receive these profiles, you can actually have the profile ready for the patient when they come in for their diabetes review, let alone if they have it on their smartphone on their sensor, but it can be also on your own computer. Wonderful use of technology. Over to you, Jessica.
Jessica Ledwidge
Brilliant. We have had a few more come through. The first one is from Cheryl. Can the CGM be used to assist diagnosis of GDM for our ladies who cannot do GTT, e.g. post bariatric surgery in lieu of the two weeks of home BGLs.
Dr Gary Deed
To the limits of my knowledge, I do not think that technology has been applied in that space yet, and I would really if someone has got a bariatric surgery and of course, which if they have lost weight hopefully reduces some of the risk for the CGM for gestational diabetes. I would be talking to my specialist team and specialist endocrinologist about how to accurately diagnose it. I would not be applying the technology without adequate information. It can be used in pregnancy. I am not saying it is not, but for the diagnostic purposes I do not know whether it is the accuracy would allow you to apply that diagnosis.
Jessica Ledwidge
Thank you for that Gary. Another one has come through that says can you use different type of insulin with CGM?
Dr Gary Deed
You can use any. The insulin is not the matter, it is which insulin, which dose of insulin match to which glucose. That is how we use insulin. Insulin is to help you manage the glucose. You can use any type of insulin with CGM because CGM is just giving you the glucose readings so that you can adjust the type or quantity of insulin that you are utilising in that person.
Jessica Ledwidge
Great. Thank you for that. I have got another question here that says how long does an insulin pump last. What is the price and is it subsidised for type 2 diabetes?
Dr Gary Deed
No subsidies for type 2 diabetes. They can be upwards of thousands of dollars. I do not know whether they are into the tens of thousands of dollars, but significant expenditure is required there, and there are no subsidies available and I do not think your health funds will subsidise it because there is not a consensus that suggests that they can be utilised for type 2 diabetes. You could write a particular letter. A specialist endocrinologist might. I have a patient with type 2 diabetes, we moved to an insulin pump because the injectable multi dosing injections were getting up into the 200 units per injection and the pump just completely flattened the profile and the doses of insulin utilised were way lower, and we successfully applied for a private health insurance refund on that.
Jessica Ledwidge
Fantastic. Thank you. Mustafa is asking what if the patient does not have a smartphone? Will a device be able to read the CGM data?
Dr Gary Deed
Absolutely, there are sensing devices that you can also purchase at a much lower price than a smartphone that actually do sense that do connect by Bluetooth to the sensor, and they also can be utilised for finger prick testing in addition and also keytone testing, so yes, absolutely. You do not have to have a smartphone.
Jessica Ledwidge
Brilliant. And another one has come through that says some patients extend CGM to three weeks. Is this okay?
Dr Gary Deed
I know the technology now is such that say for the flash monitor it will just stop working after 14 days. I think the manufacturers are getting around that, and remember the accuracy of the device reduces the longer it is in. Increased risk of infections occur as well due to the sensor under the skin. I do not recommend it. Stick to the manufacturing advice.
Jessica Ledwidge
Thank you. And the last 1 that we have got or actually we have got two that have just come through. How do we overcome this for those that are allergic to plaster on the CGM?
Dr Gary Deed
I would talk to your credentialed diabetes educator. There are some special creams that are used before and letting them be applied and dried before you apply the sensor to that area. I do know some of my patients I have utilised use of a low dose steroid cream applied before they apply the sensor by letting it for a few days before and then they apply it to that area, but these are some things that your credentialed diabetes educator might be able to help. Ultimately, if there is certainly anaphylaxis to the glue or the adherent chemical, sometimes the technology cannot be utilised for those people.
Jessica Ledwidge
Excellent. We have got 2 more minutes. We have got one more question here. Are there any possibilities of lipo, hyper or hypertrophy with the insulin pump as they are not rotating the injection site?
Dr Gary Deed
Absolutely. That can occur with any type of insulin delivery. Lipohypertrophy is not just from insulin alone. It is also from sometimes the trauma of multiple dosing injections. That is the best thing about a pump is that the delivery cannula can stay in for a longer period of time, whereas if you are using a multiple injections such as on basal bolus or co-formulated multiple daily injections, you are actually penetrating that tissue multiple times. That causes trauma as well as the insulin there, so that lipohypertrophy theoretically is much higher with multiple daily injections of insulin but still can occur.
Jessica Ledwidge
Thank you for answering that. We have got one more. So we will do this 1 as our last question. Thank you everyone.
Dr Gary Deed
Very good. Thank you for asking questions.
Jessica Ledwidge
Do apps have the option of allowing patients to add information including, for example, the circumstances leading to hypoglycaemia?
Dr Gary Deed
Look, there is so much we can cover. That is why I have got that learning activity to follow. Yes, you can actually you can say, remember I said if you are using that insulin pen, you can add the insulin pen will drop in and that will come out in the profile, so it will actually automatically tag to that profile on the smartphone, but they can add in that they had food. They can add in that they are doing physical activity. So the idea is the more information they utilise into that profile, the better you can help support the patient. So yes, of course I did not mention that, but yes, that is one aspect of the software. So you can add in food, exercise, insulin and insulin dose and insulin dose can be automatically applied if you are using those new pens.
Jessica Ledwidge
Brilliant. Thank you for that. That brings us to 8:30 p.m. Thank you everyone for coming along, and thank you Gary for a very informative presentation. Bernard has just come through and said thank you for the information. I think our attendees tonight have found it very useful, which is brilliant, and I just wanted to remind everyone before we do finish tonight that you will be receiving evaluation activity after this webinar and you must complete that in order to get your CPD points. Please do not forget to do that when you receive that this evening, and thank you so much everyone for attending. We have recorded the session and it will become available as well on the RACGP website under the Rural Health Webinar series, and we look forward to seeing you at our next webinar in October.
Dr Gary Deed
Thank you. Stay healthy. Bye.
Jessica Ledwidge
Goodbye everyone.