Melanie Cole, MS (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Grazia Alepoh. She's a professor of medicine and associate chief for clinical affairs in the division of endocrinology at Northwestern Medicine, where she also serves as medical director of the Diabetes Education and Training Program.

She's here to discuss the clinical impact of continuous glucose monitoring in adults with non-insulin treated type 2 diabetes, drawing from her recent review published in Diabetes Technology and Therapeutics, examining evolving evidence and real-world implications for patient care. Dr. Alepoh, thank you so much for joining us today.

It's always such a pleasure to have you join us. And before we delve into the details, can you start by giving us a little bit of a brief overview of your recent review and what motivated you to take that closer look at the role of CGM in adults with type 2 diabetes that are not being treated with insulin?

Grazia Aleppo, MD: Thank you, Melanie. It's always a pleasure to be with you in this wonderful presentation. So, the American Diabetes Association in 2026, in the standard of care guidelines, states that CGM should be recommended for everybody with diabetes on insulin, but also in some people who are not on insulin, if this can help.

So I thought, okay, does it help? So I look at a lot of data, 10, um, randomized clinical trials and 15 random-randomized clinical trials, thousands of patients to say, is there evidence to support the fact that we should consider using CGM in people with Type 2 diabetes not on insulin? The important thing is that right now there is no coverage from insurance.

Some of them are, but the majority are not, for people who are us- who have Type 2 diabetes who are not using insulin for CGM coverage. So I wanted to see what can we do to A, review what's available and maybe, um, shift the needle and say, yeah, patients with Type 2 not on insulin should be on CGM

When people use blood glucose meter, what I wrote in the review, they only see a point in time. And in fact, the literature shows that blood glucose meters in people with type 2 diabetes, whether they are on insulin or not, has not shown many benefits because the patient has no idea what the, where the glucose levels were, where they are, and where they're going to trend in the future.

CGM gives you this. It makes the invisible visible

Melanie Cole, MS (Host): What do you see as the most important shift in evidence that now supports CGM use in adults with type 2 diabetes that are not on insulin? Tell us a lo- a little bit about how this has shifted and evolved

Grazia Aleppo, MD: In the past, we used to use CGM because of concern for hypoglycemia. And of course, you know, the w- these were very helpful. But now we know that treating diabetes early really can minimize the future long-term complication. And one of the way to do this is not just to give a medication to a patient, rather is to engage the patient with their own health management.

So when the patient sees their glucose levels, they see where their glucose levels are, and that is a huge motivator. So we should think about shifting from just giving medication and being really slow in adjusting medication, but also think about why am I-- what am I adjusting the medication to? The A1C alone is no longer sufficient.

Yes, it is a great tool for population-based, for long-term complication sort of prediction, but the person with diabetes in the day-to-day life with this condition, they want to see the changes that their lifestyles are making or the medications are making. As a provider, as a clinician, if I just give a patient a different medication dose, what am I actually fixing without knowing what the glucose levels behind these medications are?

Melanie Cole, MS (Host): That makes so much sense as patients can see in real time what's going on. And your review highlights the value of CGM beyond A1C, as you were just saying. So why are metrics like time and range increasingly important for clinicians to consider?

Grazia Aleppo, MD: Excellent question. So in our review, we both-- we look at both the A1C results, of course, as they were reported, and the time in range changes. So just to give a bit of a background, the A1C has been for many years the gold standard for glycemic, um, status to, to also evaluate populations and the risk for c- for a long-term complication.

However, just like a blood glucose measurement is a point in time, it's a percentage. But that percentage doesn't tell me much other than if it's elevated, we have a major issue. But what if it's a normal A1C in the six or seven percent? Does the patient, in fact, have flat glucose, no fluctuations? I don't know that.

And that's where the CGM metrics have become so important. So we use mainly time in range, which is the, the range between seventy and one eighty milligram per deciliter. And we try to establish the highest possible time in range because that correlates positively with reduction of complication. So the consensus statement says seventy percent or more.

But why not more? Why do we limit ourself to seventy percent? Because there is still thirty percent outside the range, and it can be high glucose. So particularly in type two patients who are whether on or not on insulin, their hyperglycemia is really important, the time above range. So when we see a increase in time in range, we definitely see a shrinking of time above range, and therefore, these glucose levels are much more smooth.

The patients feel better. They're less glucotoxic. There is less concern for long-term complications. And sometimes we can actually reduce medication that increase. But without that time in range that gives you more granularity, you can't make those decisions or encourage the patient because the A1C is an average.

Thirty to three hundred is still one sixty-five, but it's not a good average. Makes sense? Because you don't know there are ups and downs. So we're trying to use together A1C, but also to be with the patient in the moment. We want to see and use more the time in range.

Melanie Cole, MS (Host): So which non-insulin treated patients appear, Dr. Aleppo, to benefit most from CGM based on both trials and that real world data?

Grazia Aleppo, MD: Okay. My answer is simple, everyone, but I have to be more specific . So if you think about even metformin, okay, we use this early, or other medication that don't cause hypoglycemia. A person with diabetes, when they present to us, they do have hyperglycemia, and they are not aware very often of these fluctuations post-meal.

And when we put a CGM on these patients, they say, "Oh, aha, I never thought this, whatever that is, meal would make my glucose go so high." Or they're doing this activity, I will flatten my sugar in much better level, in range. And so whether it is a metformin GLP-1, so GLP-1 become this fantastic... They are fantastic drugs, don't get me wrong.

They've got so much fame and fortune right now, and people are using them a lot for many reasons. But even with GLP, the data shows clearly that when you CGM on top of GLP, patients does better

Usually, I call CGM a therapy more than just a tool or a device because when you have results such as an improvement, the decrease of the A1C by 0.3, 0.5%, therefore the FDA or other, um, agency is considered clinically significant. With CGM plus GLP, you have one point, sometimes more than one point A1C reduction, more than 10 to 15% increase in time and range.

So that to me is the power of this therapy. So yes, you have early medication, metformin, GLP, SGLT2, but you want to see how these patients actually interact with their condition and how they can do improvement, and very often they can reduce their medication dose, which is their desire. And why not?

Melanie Cole, MS (Host): So why not? And that's so interesting that you say having them interact with their condition because that's really an important point that you just made. So why might it have the greatest impact? And I think I know what you're gonna say. But when introduced earlier in the course of type 2 diabetes rather than later, getting them started right off the bat

Grazia Aleppo, MD: First of all, when patients become-- they develop diabetes, their A1C goes over six point five percent, they've had this glycemia for many years. So a diagnosis is even too late. There are data showing that if you do prediabetes, you do a very good job with that. But let's say you have diabetes, you're just diagnosed six point five A1C or above that, and then the patient needs to be engaged.

It's a difficult diagnosis to accept, and the patient says, "So what do I do now?" Well, if you told them just to look at the A1C in three months, the patient's gonna do nothing. Yeah, they can take the pill, whatever you're gonna do with them, the GLP, but they don't have engagement with their own condition.

They have no idea what's going on. With an A-- with, um, a CGM done early, they become engaged. They have actionable things, like actionable things that they can do. They see the number, they see the fluctuation post-meal, for example, and they are-- they ask themselves what happened, and they can modify together with the provider, the educator, how to approach their med-- their condition.

Without that information that is crucial, the patient is passive, and there is nothing worse than a passive person with type II diabetes who has no idea why they are taking a pill or an injection that it says, "Oh, I'm gonna look at the glucose in three months." They're not gonna do well. They're gonna be disengaged.

They're not gonna be motivated. And they understand that it's a burden. For me, it's a concern because I know that the sooner I get these patients in tight glycemic status with a very high time in range, so flat glucose corresponding with the, you know, target A1C obviously, the better chance that this patient will not developed a long-term complication.

You know, there is a major, um, sort of correlation between duration of diabetes, of course, glucose levels and complication, but there's also something called metabolic memory. If a patient is in target early in their condition, they-- the body remembers that, and there are fewer chances to develop complications later in life, even though the glucose levels might increase somewhat.

This has been shown by many studies, and it's very proven by just about really rigorously done many years ago. And so that is important. Think about diabetes is a forever disease for now, unfortunately. It's a long-term condition. It's also an everyday burden. So why not make the patient engage? Actionable items, hyperglycemia, you do the physical activity, goes down, you see it right away.

It's that feedback the patient has with themselves, where there is no judgment, no provider comments. It's the CGM and the patient, and they actually end up getting along pretty well. I have examples of patients who were so successful in improving their glucose levels, they were off of insulin. So I said, "Well, do you wanna give up your CG?"

They say, "Never. I would never give up my CGM because it has kept me well for all this time."

Melanie Cole, MS (Host): That's amazing. And as you're telling us how patient engagement has changed from back in the day when it was just the traditional self-monitoring of blood glucose and how this is changing, as you say, the actionable items for patients so that they can see what's going on with their own care. Because if we do not really keep our own care in check, how are we gonna take care of those that we love?

And you and I both know, and especially for women, that's so important. But how is this helping clinicians such as yourself for practical insights? What is this doing for your profession when patients are more involved, engaged, and take those actionable items?

Grazia Aleppo, MD: First of all, it makes the visit so much more meaningful. The patient comes in, very often they say, "Can you please take a look at this data? I have some challenges. Can we talk about it?" So the visit becomes more, um, focused. I know what they want. I can see what the trouble spots were in the previous two weeks, previous month.

We go with the patient and say, "What you wanna take a look at?" And they of course guide me to-- into viewing the data that they prefer to be evaluated and reviewed. So one, there is focus, so there is engagement, there is shared medical decision. I don't just say, "Good morning. This is what I want to see. This is the prescription."

I say, "No, no, no. What brings you today? How have you been? How is the CGM? What is it showing to you?" And they say, "Oh, this one I want to talk about." Sure. So we look, and we have made... The patient is satisfied. I know the patient has got something out of it, but I also know they're getting better. Also remember, in the study that I-- that I published, we show that this is actually cost-saving.

It doesn't cost-- It actually saves a lot of money because when you make a person healthier earlier, less expense later, and some of these expenses are really high. Think about open heart surgery, amputations, uh, dialysis. These are huge expenses for a healthcare system. So the patient is engaged. For me, I can see where the patients are.

For example, if a patient is taking GLP, I can see whether they have hypoglycemia, hyperglycemia. I can see what the s- fluctuations are. I can see the, I call the green area, which is what I prefer, of course, of the time and range and say, "This is fantastic. Your sugars are flat." I like to show them, you know, their 24-hour fluctuation.

And of course, there always gonna be time when there is hyperglycemia, but that's the time to en-engage and say, "What do you think this could have been caused by?" Whether it is, whatever, a celebration or, um, the food, what about the, the Super Bowl. I don't care what it is, a special event. And you guide the patient to make better choices the next time this happens because there's always something happening in patients' lives.

But also, when I see a patient with CGM, I know that what I've seen that day, I've done a very meaningful visit. It's just not just, "Here is the prescription. You go home." I built something more for the patient and myself. And so we have this conversation going on. They know that. Sometimes they even check with me in between visits and say, "I'm having a challenge.

Can you please take a look?" How could I do it with the blood glucose measurement? There's only one value, maybe two a day, but not in between. With a CGM, I can.

Melanie Cole, MS (Host): Wow. Your passion just comes through so brightly when you and I have these discussions, Dr. Aleppo. I mean, really. So if you had to leave clinicians with one key takeaway from this body of evidence and about patient engagement with CGM and what you've learned over your years doing this, what would you like to tell them?

Grazia Aleppo, MD: Support your patients. work with them, fight for them. Many times, if there is no approval of CGM in, uh, by the insurance company, now there are over-the-counter option that patients can use. And if you think about their cost and you compare them to glucose strips, it's almost comparable, and the results are much, much better than just the blood glucose measurement by finger stick.

So it's don't hold back your patient. CGM is a therapy. It has been shown to be very effective. It is shown in thousands of patients, whether they're on insulin or without insulin, that the data is actually stronger for people not on insulin because they don't have the concerns or the constraints of insulin therapy that can cause hypoglycemia.

So you can really make those glucose target much faster and much safer. So it's just support your patient, think about CGM as a therapy, not just a device

Melanie Cole, MS (Host): What a great discussion. Thank you so much, Dr. Aleppo, as always, for joining today and really sharing that passion and your incredible expertise for patients and for clinicians today. Thank you again. And to refer your patient or for more information, please head over to our website at breakthroughsforphysicians.nm.org/endocrinology to get connected with one of our providers.

That concludes this episode of Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole.