Selected Podcast
Continuous Glucose Monitoring in Clinical Practice
Julio Leey, MD, MsC. Discusses continuous glucose monitoring in clinical practice. He gives us an overview of diabetes technology, the clinical Indications of CGM and insulin pumps, and what’s important to note during the interpretation of CGM data.
Featuring:
Dr Leey focuses in all clinical aspects of diabetes mellitus. He has clinical expertise in diabetes technology, type 1 and type 2 diabetes, Cystic Fibrosis-related diabetes. He participates in clinical studies related to the previously mentioned areas.
Julio A Leey
Julio Leey, MD, MsC. assistant professor in the College of Medicine at University of Florida and he practices at UF Health Shands Hospital.Dr Leey focuses in all clinical aspects of diabetes mellitus. He has clinical expertise in diabetes technology, type 1 and type 2 diabetes, Cystic Fibrosis-related diabetes. He participates in clinical studies related to the previously mentioned areas.
Transcription:
Melanie Cole (Host): Welcome to USF Health Med Ed Cast with USF Health Shands Hospital. I'm Melanie Cole and I invite you to listen as we discuss continuous glucose monitoring in clinical practice. Joining me is Dr. Julio Leey. He's assistant professor in the College of Medicine at University of Florida and he practices at UF Health Shands Hospital.
Dr. Leey, it's a pleasure to have you with us today. There's so much technology happening in the world of endocrinology and diabetes. How is this technology useful and how are you finding it very exciting in your clinical practice?
Julio A Leey (Guest): Thank you for having me here. Yes, there is a lot of progress in diabetes technology. Essentially diabetes technology describes all the hardware and software that is used to manage blood sugar levels, to minimize complications of diabetes and to improve the quality of life of our patients. In a sense we can group diabetes technology in four groups.
One group will be all the advances made in insulin delivery, like insulin pumps, insulin pens. The second group will be all the progress made in sensing blood sugars like regular meters or with continuous glucose monitors. The third group is the combination of the first two, which is the glucose responsive insulin delivery.
And that includes the artificial pancreas or pressure suspend systems that can decrease the dose of insulin when the blood sugar trends down and the fourth group is the so-called data management progress. And that includes all the apps, all the wearables, devices that patients can wear. And also the programs and the software that many, many providers use to help patients in managing their diabetes.
Host: Well, then tell us about the Endocrine Society Guidelines for continuous glucose monitoring. Speak a little bit about the clinical indications for CGM and insulin pumps and what you're seeing right now.
Dr. Leey: The Endocrine Society released guidelines for diabetes technology in 2016 and it specifically, and they address the insulin pumps and continuous glucose monitor systems. At that time, they described in the guidelines that essentially the majority of patients with Type 1 diabetes would benefit from continuous glucose monitoring systems those that are called real time. There are two different types of CGMs or continuous glucose monitor systems. And one is the so-called real time or personal CGM. And the other one is the professional or retrospective CGM. What they are referring here is the first one that real-time CGM that patients can wear this device all the time and seeing their glucose level changing over time and that can helps preventing hypoglycemic events. And that can also help patients understand what type of food or what type of physical activity can have the greatest effect on their blood sugar level.
And something similar happening also in patients with Type 2 diabetes more so if they are using insulin injections and those are the two main groups. More recently, the American Diabetes Association has also released guidelines about the use of CGM systems and essentially adults and youth population with diabetes can benefit similarly in their statements. And whether they are using the CGM for personal use in real-time or intermittently due to some limitations in COVID as perhaps. They are still able to recognize the patterns and they are still able to change their treatment if needed, looking at the downloads of their CGM systems.
Host: Well, what do you feel it's important for other endocrinologists and indeed other providers that are helping their patients with diabetes that may be using CGM or insulin pumps? What do you feel it's important to note when you're interpretating this real-time data as it comes in?
Dr. Leey: Yes. Essentially when the blood sugar is measured constantly, we're able to see subtle patterns that typically we don't see just pricking the finger and getting blood sugar intermittently. When we have a continuous glucose monitor or a real-time glucose monitor the thing the patient can see their blood sugar changing over time and over the office visit with their provider. They can download the device and see the pattern over weeks and can tackle a particular issue with either a dose of insulin that is insufficient or a dose of the insulin that is too high and they can also address a particular food pattern if they are eating maybe too much or too little, or if this is associated to exercise. Exercise can also play a big role in hypoglycemia and having a continuous glucose monitor on board can help prevent the many of those events as well.
Host: Well, it certainly can. Speak about some of the significant barriers that you've seen to the use of self-monitored blood glucose, and as far as the from the patient's perspective and for the clinician that is helping the patient to learn to use this and adapt to this new lifestyle. What have you seen as some of the challenges?
Dr. Leey: Well, some of the, the main challenge is the financial barrier. This system, obviously involves an additional cost. And when patients are monitoring or checking their blood sugar frequently, the approach of doing finger pricks equals or gets closer to the cost of using or wearing a continuous glucose monitor system. In that sense, the Medicare has released guidelines as to when they are going to cover a continuous glucose monitor. And one of those situations is when patients are using insulin in multiple injections, when they are checking their blood sugar four times or more per day? And in that setting, Medicare has decided that this is a cost effective approach and that they are going to pay for that service.
Now, for people who doesn't have that criteria, or for people who is only using insulin once a day, even though they might not qualify for the personal CGM or real-time CGM, they can still have intermittent measurement pattern with the CGM. It's called the professional CGM. And once in a while, they can get that data and identify a pattern that can be fixed and can be improved with additional therapy or maybe lowering the dose of insulin. So, those are the two, the two approaches.
Host: Do you have the ability Doctor to download and share a lot of this data electronically and keeping the current pandemic in mind, how can sharing this data remotely make a Telehealth visit, maybe more meaningful? Have you implemented modules to help your staff upload tools to look at that insulin pump data and the CGM? Tell us how you're using all of this information with your staff and possibly other providers.
Dr. Leey: Well because patients with diabetes have a lot of information in blood sugar levels if they are using fingerprick or from the continuous glucose monitoring systems that are being downloaded, our practice has assigned a clinic that specializes in these issues. And with the current pandemic, we now have developed and expanded the Tele-medicine clinics. And in that setting, we have now the capability of accessing the glucose monitors and the CGMs, as long as the patient also has access has access to internet and can upload their information and then via Telemedicine, our clinic can download that information and see that patient via video conference and then address also the glycemic patterns and propose the changes to the patient that are needed to prevent hypoglycemia events. And also attention needed to improve the glucose control in case they are feeling weak, unusual dietary patterns that are now more common in pandemic.
Host: Well they certainly are and isn't it amazing the technology today? Dr. Leey, what final thoughts do you have for endocrinologists, other providers? What would you like them to know about the topic we're discussing here today, continuous glucose monitoring in clinical practice? What are some points we may have missed that you feel are really important to point out to other providers?
Dr. Leey: Well, CGMs are extremely useful for the management of diabetes, not only the Type1 diabetes, but also Type 2 diabetes. And the amount of information that these systems can provide is very, very and we need a particular pattern to analyze the data. And most of the systems now have a standardized report that allow us to do the interpretation. But these systems that now we have available, over time will continue improving and the cost will go down over time. And it will become more accessible to more and more people. So, they all can enjoy the benefits of assessing their blood sugar especially if they are using insulin where it is celebrate its benefit.
Host: It's really great information and what a fascinating topic and an exciting time to be in your field. Dr. Leey, thank you so much for joining us today. To refer your patient or to listen to more podcasts from our experts, please visit USFhealth.org/medmatters for more information and to get connected with one of our providers.
That concludes today's episode of USF Health Med Ed Cast with USF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other USF Health Shands Hospital podcasts. I'm Melanie Cole.
Melanie Cole (Host): Welcome to USF Health Med Ed Cast with USF Health Shands Hospital. I'm Melanie Cole and I invite you to listen as we discuss continuous glucose monitoring in clinical practice. Joining me is Dr. Julio Leey. He's assistant professor in the College of Medicine at University of Florida and he practices at UF Health Shands Hospital.
Dr. Leey, it's a pleasure to have you with us today. There's so much technology happening in the world of endocrinology and diabetes. How is this technology useful and how are you finding it very exciting in your clinical practice?
Julio A Leey (Guest): Thank you for having me here. Yes, there is a lot of progress in diabetes technology. Essentially diabetes technology describes all the hardware and software that is used to manage blood sugar levels, to minimize complications of diabetes and to improve the quality of life of our patients. In a sense we can group diabetes technology in four groups.
One group will be all the advances made in insulin delivery, like insulin pumps, insulin pens. The second group will be all the progress made in sensing blood sugars like regular meters or with continuous glucose monitors. The third group is the combination of the first two, which is the glucose responsive insulin delivery.
And that includes the artificial pancreas or pressure suspend systems that can decrease the dose of insulin when the blood sugar trends down and the fourth group is the so-called data management progress. And that includes all the apps, all the wearables, devices that patients can wear. And also the programs and the software that many, many providers use to help patients in managing their diabetes.
Host: Well, then tell us about the Endocrine Society Guidelines for continuous glucose monitoring. Speak a little bit about the clinical indications for CGM and insulin pumps and what you're seeing right now.
Dr. Leey: The Endocrine Society released guidelines for diabetes technology in 2016 and it specifically, and they address the insulin pumps and continuous glucose monitor systems. At that time, they described in the guidelines that essentially the majority of patients with Type 1 diabetes would benefit from continuous glucose monitoring systems those that are called real time. There are two different types of CGMs or continuous glucose monitor systems. And one is the so-called real time or personal CGM. And the other one is the professional or retrospective CGM. What they are referring here is the first one that real-time CGM that patients can wear this device all the time and seeing their glucose level changing over time and that can helps preventing hypoglycemic events. And that can also help patients understand what type of food or what type of physical activity can have the greatest effect on their blood sugar level.
And something similar happening also in patients with Type 2 diabetes more so if they are using insulin injections and those are the two main groups. More recently, the American Diabetes Association has also released guidelines about the use of CGM systems and essentially adults and youth population with diabetes can benefit similarly in their statements. And whether they are using the CGM for personal use in real-time or intermittently due to some limitations in COVID as perhaps. They are still able to recognize the patterns and they are still able to change their treatment if needed, looking at the downloads of their CGM systems.
Host: Well, what do you feel it's important for other endocrinologists and indeed other providers that are helping their patients with diabetes that may be using CGM or insulin pumps? What do you feel it's important to note when you're interpretating this real-time data as it comes in?
Dr. Leey: Yes. Essentially when the blood sugar is measured constantly, we're able to see subtle patterns that typically we don't see just pricking the finger and getting blood sugar intermittently. When we have a continuous glucose monitor or a real-time glucose monitor the thing the patient can see their blood sugar changing over time and over the office visit with their provider. They can download the device and see the pattern over weeks and can tackle a particular issue with either a dose of insulin that is insufficient or a dose of the insulin that is too high and they can also address a particular food pattern if they are eating maybe too much or too little, or if this is associated to exercise. Exercise can also play a big role in hypoglycemia and having a continuous glucose monitor on board can help prevent the many of those events as well.
Host: Well, it certainly can. Speak about some of the significant barriers that you've seen to the use of self-monitored blood glucose, and as far as the from the patient's perspective and for the clinician that is helping the patient to learn to use this and adapt to this new lifestyle. What have you seen as some of the challenges?
Dr. Leey: Well, some of the, the main challenge is the financial barrier. This system, obviously involves an additional cost. And when patients are monitoring or checking their blood sugar frequently, the approach of doing finger pricks equals or gets closer to the cost of using or wearing a continuous glucose monitor system. In that sense, the Medicare has released guidelines as to when they are going to cover a continuous glucose monitor. And one of those situations is when patients are using insulin in multiple injections, when they are checking their blood sugar four times or more per day? And in that setting, Medicare has decided that this is a cost effective approach and that they are going to pay for that service.
Now, for people who doesn't have that criteria, or for people who is only using insulin once a day, even though they might not qualify for the personal CGM or real-time CGM, they can still have intermittent measurement pattern with the CGM. It's called the professional CGM. And once in a while, they can get that data and identify a pattern that can be fixed and can be improved with additional therapy or maybe lowering the dose of insulin. So, those are the two, the two approaches.
Host: Do you have the ability Doctor to download and share a lot of this data electronically and keeping the current pandemic in mind, how can sharing this data remotely make a Telehealth visit, maybe more meaningful? Have you implemented modules to help your staff upload tools to look at that insulin pump data and the CGM? Tell us how you're using all of this information with your staff and possibly other providers.
Dr. Leey: Well because patients with diabetes have a lot of information in blood sugar levels if they are using fingerprick or from the continuous glucose monitoring systems that are being downloaded, our practice has assigned a clinic that specializes in these issues. And with the current pandemic, we now have developed and expanded the Tele-medicine clinics. And in that setting, we have now the capability of accessing the glucose monitors and the CGMs, as long as the patient also has access has access to internet and can upload their information and then via Telemedicine, our clinic can download that information and see that patient via video conference and then address also the glycemic patterns and propose the changes to the patient that are needed to prevent hypoglycemia events. And also attention needed to improve the glucose control in case they are feeling weak, unusual dietary patterns that are now more common in pandemic.
Host: Well they certainly are and isn't it amazing the technology today? Dr. Leey, what final thoughts do you have for endocrinologists, other providers? What would you like them to know about the topic we're discussing here today, continuous glucose monitoring in clinical practice? What are some points we may have missed that you feel are really important to point out to other providers?
Dr. Leey: Well, CGMs are extremely useful for the management of diabetes, not only the Type1 diabetes, but also Type 2 diabetes. And the amount of information that these systems can provide is very, very and we need a particular pattern to analyze the data. And most of the systems now have a standardized report that allow us to do the interpretation. But these systems that now we have available, over time will continue improving and the cost will go down over time. And it will become more accessible to more and more people. So, they all can enjoy the benefits of assessing their blood sugar especially if they are using insulin where it is celebrate its benefit.
Host: It's really great information and what a fascinating topic and an exciting time to be in your field. Dr. Leey, thank you so much for joining us today. To refer your patient or to listen to more podcasts from our experts, please visit USFhealth.org/medmatters for more information and to get connected with one of our providers.
That concludes today's episode of USF Health Med Ed Cast with USF Health Shands Hospital. Please remember to subscribe, rate and review this podcast and all the other USF Health Shands Hospital podcasts. I'm Melanie Cole.