Beyond A1C-Standardization of Continuous Glucose Monitoring Reporting: Why It Is Needed and How It Continues to Evolve

Limitations of 14-Day Continuous Glucose Monitoring Sampling for Assessment of Hypoglycemia and Glycemic Variability in Type 1 Diabetes

Continuous glucose monitoring (CGM) has become the standard of care in diabetes management with the recent advances in technology and accessibility in the last decade. An International Consensus was established to define CGM metrics and its goals in diabetes care. The 2019 International Consensus suggested 14 days of CGM sampling for the assessment of CGM metrics stating the limitations that may occur for hypoglycemia and glycemic variability metrics. Since then, several studies assessed the correlation between CGM metrics and duration of the sampling period. This review summarized the studies that investigated the relationship between 14-day CGM sampling to 90-day CGM data in >70% CGM users for all CGM metrics and highlighted possible solutions for more accurate CGM sampling durations in type 1 diabetes (T1D). Accumulating evidence showed that 14-day CGM sampling correlates well with 90-day CGM data for mean glucose, time in 70-180 mg/dL, and hyperglycemia metrics; however, it correlates weakly for hypoglycemia and glycemic variability metrics. In the studies included in this review, in adults with T1D, minimum sampling duration was 14 days for mean glucose, time in 70-180 mg/dL, and time in hyperglycemia (>180 and >250 mg/dL); however, minimum sampling duration varied between 21 to 30 days for time <70 mg/dL, 30 to 35 days for time <54 mg/dL, and 28 to 35 days for coefficient of variation. Longer than 14 days of CGM, sampling was required to properly assess hypoglycemia and glycemic variability in T1D.

Expert Panel Recommendations for a Standardized Ambulatory Glucose Profile Report for Connected Insulin Pens

Background: Connected insulin pens capture data on insulin dosing/timing and can integrate with continuous glucose monitoring (CGM) devices with essential insulin and glucose metrics combined into a single platform. Standardization of connected insulin pen reports is desirable to enhance clinical utility with a single report. Methods: An international expert panel was convened to develop a standardized connected insulin pen report incorporating insulin and glucose metrics into a single report containing clinically useful information. An extensive literature review and identification of examples of current connected insulin pen reports were performed serving as the basis for creation of a draft of a standardized connected insulin pen report. The expert panel participated in three virtual standardization meetings and online surveys. Results: The Ambulatory Glucose Profile (AGP) Report: Connected Insulin Pen brings all clinically relevant CGM-derived glucose and connected insulin pen metrics into a single simplified two-page report. The first page contains the time in ranges bar, summary of key insulin and glucose metrics, the AGP curve, and detailed basal (long-acting) insulin assessment. The second page contains the bolus (mealtime and correction) insulin assessment periods with information on meal timing, insulin-to-carbohydrate ratio, average bolus insulin dose, and number of days with bolus doses recorded. The report's second page contains daily glucose profiles with an overlay of the timing and amount of basal and bolus insulin administered. Conclusion: The AGP Report: Connected Insulin Pen is a standardized clinically useful report that should be considered by companies developing connected pen technology as part of their system reporting/output.

Association between continuous glucose monitoring metrics and clinical outcomes in adults with type 1 diabetes in a real-world setting

AIMS

Continuous glucose monitoring (CGM) metrics can assist diabetes management. Consensus statements recommend > 70 % time in range (TIR) and ≤ 36 % glucose coefficient of variation (CV). However, how these targets perform in clinical practice is unknown. This retrospective, longitudinal cohort study analyzed relationships between TIR, CV, glycated hemoglobin (HbA1c), and hypoglycemia in a real-world setting.

METHODS

Data of 542 adults with type 1 diabetes who used CGM (January 2014-July 2020) were analyzed. Associations between TIR and HbA1c at the same and subsequent visits, incidence rate ratios (IRRs) for hypoglycemia at different CVs, and number of hypoglycemic events at cross-sections of HbA1c and CV were estimated by regression.

RESULTS

TIR was inversely related to HbA1c; for every 10 % increase in TIR, HbA1c was significantly reduced by 0.34 % (4 mmol/mol) and 0.20 % (2 mmol/mol) at the same and subsequent visits, respectively. Level 2 hypoglycemia was significantly reduced at CV < 30 %, 30-33 %, 33.1-36 %, and 36.1-40 %: adjusted IRRs vs CV ≥ 40.1 % of 0.14, 0.28, 0.32, and 0.50, respectively. Hypoglycemic events were reduced at lower CV across HbA1c levels and at higher HbA1c across CV levels.

CONCLUSION

This study quantifies HbA1c improvements with increased TIR and hypoglycemia reductions with improved CV in clinical practice.

Prioritizing Patient Experiences in the Management of Diabetes and Its Complications: An Endocrine Society Position Statement

Diabetes can be an arduous journey both for people with diabetes (PWD) and their caregivers. While the journey of every person with diabetes is unique, common themes emerge in managing this disease. To date, the experiences of PWD have not been fully considered to successfully implement the recommended standards of diabetes care in practice. It is critical for health-care providers (HCPs) to recognize perspectives of PWD to achieve optimal health outcomes. Further, existing tools are available to facilitate patient-centered care but are often underused. This statement summarizes findings from multistakeholder expert roundtable discussions hosted by the Endocrine Society that aimed to identify existing gaps in the management of diabetes and its complications and to identify tools needed to empower HCPs and PWD to address their many challenges. The roundtables included delegates from professional societies, governmental organizations, patient advocacy organizations, and social enterprises committed to making life better for PWD. Each section begins with a clinical scenario that serves as a framework to achieve desired health outcomes and includes a discussion of resources for HCPs to deliver patient-centered care in clinical practice. As diabetes management evolves, achieving this goal will also require the development of new tools to help guide HCPs in supporting PWD, as well as concrete strategies for the efficient uptake of these tools in clinical practice to minimize provider burden. Importantly, coordination among various stakeholders including PWD, HCPs, caregivers, policymakers, and payers is critical at all stages of the patient journey.

Integrated modeling of labile and glycated hemoglobin with glucose for enhanced diabetes detection and short-term monitoring

Metabolic biomarkers, particularly glycated hemoglobin and fasting plasma glucose, are pivotal in the diagnosis and control of diabetes mellitus. Despite their importance, they exhibit limitations in assessing short-term glucose variations. In this study, we propose labile hemoglobin as an additional biomarker, providing insightful perspectives into these fluctuations. By utilizing datasets from 40,652 retrospective general participants and conducting glucose tolerance tests on 60 prospective pediatric subjects, we explored the relationship between plasma glucose and labile hemoglobin. A mathematical model was developed to encapsulate short-term glucose kinetics in the pediatric group. Applying dimensionality reduction techniques, we successfully identified participant subclusters, facilitating the differentiation between diabetic and non-diabetic individuals. Intriguingly, by integrating labile hemoglobin measurements with plasma glucose values, we were able to predict the likelihood of diabetes in pediatric subjects, underscoring the potential of labile hemoglobin as a significant glycemic biomarker for diabetes research.

Time in Range Is Associated with Incident Diabetic Retinopathy in Adults with Type 1 Diabetes: A Longitudinal Study

Abstract Objective: To evaluate the association between continuous glucose monitoring (CGM)-based time in various ranges and the subsequent development of diabetic retinopathy (incident DR) in adults with type 1 diabetes. Methods: Between June 2018 and March 2022, adults with type 1 diabetes with incident DR or no retinopathy (control) were identified. CGM data were collected retrospectively for up to 7 years before the date of eye examination defining incident DR or control. Associations between incident DR and CGM metrics were evaluated using logistic regression models. Results: This analysis included 71 adults with incident DR (mean age 27 years, 52% females, and mean diabetes duration 15 years) and 92 adults without DR (mean age 38 years, 48% females, and mean diabetes duration 20 years). Adjusting for age, diabetes duration, and CGM type, each 0.5% increase in glycated hemoglobin (HbA1c), 10 mg/dL increase in mean glucose, 5% decrease in time in target range 70-180 mg/dL (TIR), 5% decrease in time in tight target range 70-140 mg/dL (TITR), and 5% increase in time above 180 mg/dL (TAR) were associated with 24%, 22%, 18%, 28%, and 20% increase in odds of incident DR, respectively. Spearman correlations of TIR, TITR, TAR, and mean glucose with each other were all ≥0.97. Conclusion: Similar to HbA1c, TIR, TITR, TAR, and mean glucose were associated with increased risk for incident DR in adults with type 1 diabetes. These CGM metrics are highly correlated indicating that they provide similar information on glycemic control and diabetic retinopathy risk.

Decreasing the Burden of Carbohydrate Counting and Meal Announcement with Automated Insulin Delivery, Meal Recognition, and Autocorrection Doses: A Case Study

The use of automated insulin delivery (AID) has led to a decrease in the burden of diabetes, allowing for better sleep, decreased anxiety about hypoglycemia, and automatic corrections doses, and meal recognition algorithms have provided "forgiveness" for imprecise carbohydrate (CHO) entries and missed or late meal boluses. We provide a case report and review of the current literature assessing the effect of AID on the burden of meal bolus. The case also demonstrates how sensor and pump data provide insight into insulin bolus behavior, and access to integrated cloud-based data has allowed for virtual patient visits. Glucose sensor metrics provides time in range and time below range, and the sensor-derived glucose management indicator provides an assessment of the long-term risk of complications when a laboratory glycated hemoglobin is not available.

Roadmap to the Effective Use of Continuous Glucose Monitoring: Innovation, Investigation, and Implementation

For 25 years, continuous glucose monitoring (CGM) has been evolving into what it is now: a key tool to both measure individuals' glycemic status and to help guide their day-to-day management of diabetes. Through a series of engineering innovations, clinical investigations, and efforts to optimize workflow implementation, the use of CGM is helping to transform diabetes care. This article presents a roadmap to the effective use of CGM that outlines past, present, and possible future advances in harnessing the potential of CGM to improve the lives of many people with diabetes, with an emphasis on ensuring that CGM technology is available to all who could benefit from its use.

Pharmacist-driven continuous glucose monitoring in community and ambulatory care pharmacy practice: A scoping review

BACKGROUND

Continuous glucose monitoring (CGM) devices improve clinical outcomes and facilitate achieving patient-specific goals. However, opportunities and barriers to implementation of pharmacist-driven CGM services are not well-described.

OBJECTIVES

This scoping review was conducted to identify opportunities and barriers to implementing pharmacist-driven CGM services in the community and ambulatory care setting. Clinical outcomes resulting from pharmacist-driven CGM were also explored.

METHODS

A health librarian searched Ovid MEDLINE, Cochrane CENTRAL, Embase, Web of Science, Scopus, International Pharmaceutical Abstracts using keywords and subject headings from inception through December 2, 2022 to identify studies describing pharmacist or pharmacy-based CGM programs. No publication type, date limits, language restrictions, or other filters were applied. The database search was supplemented by a search of Google Scholar and a citation search of preselected gold standard articles.

RESULTS

The scoping review initially identified 942 citations of which 249 passed abstract screening and 11 were included in the review. Among studies, the most common design was retrospective, populations varied, control groups were not consistently used, follow-up was primarily short, and sample sizes were small. One study evaluated pharmacist-driven CGM in a community pharmacy setting. Ten studies took place in the ambulatory care setting. Barriers to initiating pharmacist-driven CGM as a clinical service include educational, logistical, workflow, and financial incentive. Beneficial outcomes from pharmacist-driven CGM include improved quality of life, increased empowerment, and improved glycemic control.

CONCLUSION

There is lack of strong evidence to support pharmacist-driven CGM in the community pharmacy setting. However, small studies suggest pharmacist-driven CGM is feasible and beneficial in the ambulatory care setting. Further exploration of how educational, logistical, workflow, and financial barriers can be overcome is warranted, given potential for improved clinical outcomes.

A systematic bibliometric analysis on the clinical practice of CGM in diabetes mellitus from 2012 to 2022

Background

Continuous glucose monitoring (CGM) has revolutionized diabetes management, but a comprehensive analysis of its clinical implementation is lacking. This study aims to explore CGM in diabetes practice over the past decade using bibliometric analysis. It will identify trends, research focal points, and provide a framework for future investigations.

Materials and methods

The Web of Science Core Collection (WOSCC) was utilized to acquire literature pertaining to the employment of continuous glucose monitoring (CGM) in diabetes that was published between the years 2012 and 2022, and to conduct a comprehensive analysis of the associated citation data. To achieve bibliometric visualization and analysis of the collated data, the bibliography package in the Rstudio(v.4.2.2), Citespace 6.2.R4, and VOS viewer were employed.

Results

A total of 3024 eligible publications were extracted from 91 countries, with the United States being the leading country in terms of the number of issued articles. Furthermore, the annual publication rate has shown a gradual increase during the past decade. Among the various journals in this field, DIABETES TECHNOLOGY & THERAPEUTICS was identified as the most highly cited one. Keyword clustering analysis of the extracted publications indicates that the research hotspots in the past decade have primarily focused on "continuous glucose monitoring", "glycemic variability", "type 1 diabetes", "hypoglycemia", and "glycemic control". Moreover, the analysis of keyword emergence reveals that "Time In Range" and "Young Adult" represent the current research frontiers for the years 2012-2022.

Conclusion

The concept of Time in Range (TIR) has garnered considerable attention as a significant area of inquiry and an emerging research trend in the clinical practice of Continuous Glucose Monitoring (CGM) for Diabetes Mellitus. Moreover, recent investigations have demonstrated a growing focus on young adults with type 1 diabetes as the research population of interest. In the foreseeable future, research endeavors will persist in the pursuit of improving glycemic management among young adults through the utilization of continuous glucose monitoring (CGM) technology, while also delving into the examination of the Time in Range metric via supplementary clinical investigations.

Discordance Between Glucose Management Indicator and Glycated Hemoglobin in People Without Diabetes

Background: In recent years, continuous glucose monitor (CGM) use is increasing in people without diabetes to promote healthy lifestyle. CGM metrics such as glucose management indicator (GMI), a statistical formula to estimate glycated hemoglobin (HbA1c) from sensor glucose, is commonly used to approximate HbA1c. This study was aimed to evaluate discordance between GMI and HbA1c in people without diabetes. Methods: Children and nonpregnant adults (age ≥6 years) without diabetes (laboratory HbA1c <5.7% and negative islet antibodies) were invited to participate in a multicenter prospective study aimed to evaluate glycemic profiles in nondiabetic individuals. Each participant wore a blinded Dexcom G6 for up to 10 days. GMI was calculated from mean sensor glucose and discordance between GMI and HbA1c was analyzed. Results: Of 201 screened participants, 153 participants (mean age 31.2 ± 21.0 years, 66.0% female, HbA1c 5.1% ± 0.3%) were included in the analysis. Mean GMI was 0.59% higher than laboratory HbA1c in participants without diabetes. The discordance between GMI and HbA1c of 0.4% or greater was 71% in participants without diabetes compared with 39% in the original GMI development cohort. Conclusion: GMI does not accurately estimate HbA1c in healthy people without diabetes. Clinical trial registration number is: NCT00717977.

The management of type 1 diabetes in adults. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) convened a writing group to develop a consensus statement on the management of type 1 diabetes in adults. The writing group has considered the rapid development of new treatments and technologies and addressed the following topics: diagnosis, aims of management, schedule of care, diabetes self-management education and support, glucose monitoring, insulin therapy, hypoglycaemia, behavioural considerations, psychosocial care, diabetic ketoacidosis, pancreas and islet transplantation, adjunctive therapies, special populations, inpatient management and future perspectives. Although we discuss the schedule for follow-up examinations and testing, we have not included the evaluation and treatment of the chronic microvascular and macrovascular complications of diabetes as these are well-reviewed and discussed elsewhere. The writing group was aware of both national and international guidance on type 1 diabetes and did not seek to replicate this but rather aimed to highlight the major areas that healthcare professionals should consider when managing adults with type 1 diabetes. Though evidence-based where possible, the recommendations in the report represent the consensus opinion of the authors. Graphical abstract.

The Management of Type 1 Diabetes in Adults. A Consensus Report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD)

The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) convened a writing group to develop a consensus statement on the management of type 1 diabetes in adults. The writing group has considered the rapid development of new treatments and technologies and addressed the following topics: diagnosis, aims of management, schedule of care, diabetes self-management education and support, glucose monitoring, insulin therapy, hypoglycemia, behavioral considerations, psychosocial care, diabetic ketoacidosis, pancreas and islet transplantation, adjunctive therapies, special populations, inpatient management, and future perspectives. Although we discuss the schedule for follow-up examinations and testing, we have not included the evaluation and treatment of the chronic microvascular and macrovascular complications of diabetes as these are well-reviewed and discussed elsewhere. The writing group was aware of both national and international guidance on type 1 diabetes and did not seek to replicate this but rather aimed to highlight the major areas that health care professionals should consider when managing adults with type 1 diabetes. Though evidence-based where possible, the recommendations in the report represent the consensus opinion of the authors.