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Klonoff DC, Wang J, Rodbard D, Kohn MA, Li C, Liepmann D, Kerr D, Ahn D, Peters AL, Umpierrez GE, Seley JJ, Xu NY, Nguyen KT, Simonson G, Agus MSD, Al-Sofiani ME, Armaiz-Pena G, Bailey TS, Basu A, Battelino T, Bekele SY, Benhamou PY, Bequette BW, Blevins T, Breton MD, Castle JR, Chase JG, Chen KY, Choudhary P, Clements MA, Close KL, Cook CB, Danne T, Doyle FJ, Drincic A, Dungan KM, Edelman SV, Ejskjaer N, Espinoza JC, Fleming GA, Forlenza GP, Freckmann G, Galindo RJ, Gomez AM, Gutow HA, Heinemann L, Hirsch IB, Hoang TD, Hovorka R, Jendle JH, Ji L, Joshi SR, Joubert M, Koliwad SK, Lal RA, Lansang MC, Lee WA(A, Leelarathna L, Leiter LA, Lind M, Litchman ML, Mader JK, Mahoney KM, Mankovsky B, Masharani U, Mathioudakis NN, Mayorov A, Messler J, Miller JD, Mohan V, Nichols JH, Nørgaard K, O’Neal DN, Pasquel FJ, Philis-Tsimikas A, Pieber T, Phillip M, Polonsky WH, Pop-Busui R, Rayman G, Rhee EJ, Russell SJ, Shah VN, Sherr JL, Sode K, Spanakis EK, Wake DJ, Waki K, Wallia A, Weinberg ME, Wolpert H, Wright EE, Zilbermint M, Kovatchev B. A Glycemia Risk Index (GRI) of Hypoglycemia and Hyperglycemia for Continuous Glucose Monitoring Validated by Clinician Ratings. J Diabetes Sci Technol 2023; 17:1226-1242. [PMID: 35348391 PMCID: PMC10563532 DOI: 10.1177/19322968221085273] [Citation(s) in RCA: 53] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND A composite metric for the quality of glycemia from continuous glucose monitor (CGM) tracings could be useful for assisting with basic clinical interpretation of CGM data. METHODS We assembled a data set of 14-day CGM tracings from 225 insulin-treated adults with diabetes. Using a balanced incomplete block design, 330 clinicians who were highly experienced with CGM analysis and interpretation ranked the CGM tracings from best to worst quality of glycemia. We used principal component analysis and multiple regressions to develop a model to predict the clinician ranking based on seven standard metrics in an Ambulatory Glucose Profile: very low-glucose and low-glucose hypoglycemia; very high-glucose and high-glucose hyperglycemia; time in range; mean glucose; and coefficient of variation. RESULTS The analysis showed that clinician rankings depend on two components, one related to hypoglycemia that gives more weight to very low-glucose than to low-glucose and the other related to hyperglycemia that likewise gives greater weight to very high-glucose than to high-glucose. These two components should be calculated and displayed separately, but they can also be combined into a single Glycemia Risk Index (GRI) that corresponds closely to the clinician rankings of the overall quality of glycemia (r = 0.95). The GRI can be displayed graphically on a GRI Grid with the hypoglycemia component on the horizontal axis and the hyperglycemia component on the vertical axis. Diagonal lines divide the graph into five zones (quintiles) corresponding to the best (0th to 20th percentile) to worst (81st to 100th percentile) overall quality of glycemia. The GRI Grid enables users to track sequential changes within an individual over time and compare groups of individuals. CONCLUSION The GRI is a single-number summary of the quality of glycemia. Its hypoglycemia and hyperglycemia components provide actionable scores and a graphical display (the GRI Grid) that can be used by clinicians and researchers to determine the glycemic effects of prescribed and investigational treatments.
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Affiliation(s)
- David C. Klonoff
- Diabetes Research Institute, Mills-Peninsula Medical Center, San Mateo, CA, USA
| | - Jing Wang
- Florida State University College of Nursing, Tallahassee, FL, USA
| | - David Rodbard
- Biomedical Informatics Consultants LLC, Potomac, MD, USA
| | - Michael A. Kohn
- University of California, San Francisco, San Francisco, CA, USA
| | - Chengdong Li
- Florida State University College of Nursing, Tallahassee, FL, USA
| | | | - David Kerr
- Sansum Diabetes Research Institute, Santa Barbara, CA, USA
| | - David Ahn
- Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | | | | | | | - Nicole Y. Xu
- Diabetes Technology Society, Burlingame, CA, USA
| | | | | | | | | | | | | | - Ananda Basu
- University of Virginia, Charlottesville, VA, USA
| | - Tadej Battelino
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | | | | | | | | | | | | | - Kong Y. Chen
- National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, MD, USA
| | | | | | | | | | - Thomas Danne
- Diabetes Center Auf der Bult, Hannover Medical School, Hannover, Germany
| | | | | | | | | | - Niels Ejskjaer
- Steno Diabetes Center North Denmark, Aalborg University Hospital, Aalborg, Denmark
| | - Juan C. Espinoza
- Children’s Hospital Los Angeles, University of Southern California, Los Angeles, CA, USA
| | | | | | | | | | | | | | | | | | - Thanh D. Hoang
- Walter Reed National Military Medical Center, Bethesda, MD, USA
| | | | | | - Linong Ji
- Peking University People’s Hospital, Peking University Diabetes Center, Beijing, China
| | | | | | | | | | - M. Cecilia Lansang
- Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Wei-An (Andy) Lee
- LAC + USC Medical Center, Los Angeles County Department of Health Service, Los Angeles, CA, USA
| | - Lalantha Leelarathna
- Manchester University NHS Foundation Trust and The University of Manchester, Manchester, UK
| | - Lawrence A. Leiter
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital and University of Toronto, Toronto, ON, Canada
| | - Marcus Lind
- University of Gothenburg, Gothenburg, Sweden
| | | | | | | | | | - Umesh Masharani
- University of California, San Francisco, San Francisco, CA, USA
| | | | | | | | | | - Viswanathan Mohan
- Dr. Mohan’s Diabetes Specialities Centre, Chennai, India
- Madras Diabetes Research Foundation, Chennai, India
| | | | | | | | | | | | | | - Moshe Phillip
- Institute for Endocrinology and Diabetes, Schneider Children’s Medical Center of Israel and Sackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, Israel
| | | | | | - Gerry Rayman
- Ipswich Hospital, East Suffolk and North Essex Foundation Trust and University of East Anglia, Ipswich, UK
| | - Eun-Jung Rhee
- Kangbuk Samsung Hospital, Sungkyunkwan University, Seoul, Korea
| | - Steven J. Russell
- Massachusetts General Hospital Diabetes Research Center, Boston, MA, USA
| | - Viral N. Shah
- Barbara Davis Center for Diabetes, University of Colorado, Aurora, CO, USA
| | | | - Koji Sode
- The University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- North Carolina State University, Raleigh, NC, USA
| | | | | | - Kayo Waki
- The University of Tokyo, Tokyo, Japan
| | | | | | | | | | - Mihail Zilbermint
- Johns Hopkins University, Baltimore, MD, USA
- Johns Hopkins Community Physicians, Bethesda, MD, USA
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Bellido V, Aguilera E, Cardona-Hernandez R, Diaz-Soto G, González Pérez de Villar N, Picón-César MJ, Ampudia-Blasco FJ. Expert Recommendations for Using Time-in-Range and Other Continuous Glucose Monitoring Metrics to Achieve Patient-Centered Glycemic Control in People With Diabetes. J Diabetes Sci Technol 2023; 17:1326-1336. [PMID: 35470692 PMCID: PMC10563535 DOI: 10.1177/19322968221088601] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
New metrics for assessing glycemic control beyond HbA1c have recently emerged due to the increasing use of continuous glucose monitoring (CGM) in diabetes clinical practice. Among them, time in range (TIR) has appeared as a simple and intuitive metric that correlates inversely with HbA1c and has also been newly linked to the risk of long-term diabetes complications. The International Consensus on Time in Range established a series of target glucose ranges (TIR, time below range and time above range) and recommendations for time spent within these ranges for different diabetes populations. These parameters should be evaluated together with the ambulatory glucose profile (AGP). Using standardized visual reporting may help people with diabetes and healthcare professionals in the evaluation of glucose control in frequent clinical situations. The objective of the present review is to provide practical insights to quick interpretation of patient-centered metrics based on flash glucose monitoring data, as well as showing some visual examples of common clinical situations and giving practical recommendations for their management.
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Affiliation(s)
- Virginia Bellido
- Unidad de Gestión Clínica de Endocrinología y Nutrición, Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Eva Aguilera
- Endocrinology and Nutrition Department, Health Sciences Research Institute and University, Hospital Germans Trias i Pujol, Badalona, Spain
| | | | - Gonzalo Diaz-Soto
- Endocrinology and Nutrition Department, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
- Universidad de Valladolid, Valladolid, Spain
| | | | - María J. Picón-César
- Endocrinology and Nutrition Department, Hospital Universitario Virgen de la Victoria, Málaga, Spain
- Instituto de Investigación Biomédica de Málaga, Málaga, Spain
- Centro de Investigación Biomédica en Red de Fisiopatología de la Obesidad y Nutrición, Instituto de Salud Carlos III, Madrid, Spain
| | - Francisco Javier Ampudia-Blasco
- Endocrinology and Nutrition Department, Hospital Clínico Universitario de Valencia, Valencia, Spain
- INCLIVA Research Foundation, Valencia, Spain
- CIBERDEM, Madrid, Spain
- Universitat de Valencia, Valencia, Spain
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3
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Mackett K, Gerstein H, Santesso N. Patient Perspectives on the Ambulatory Glucose Profile Report for Type 1 Diabetes Management in Adults: A National Online Survey. Can J Diabetes 2023:S1499-2671(23)00002-3. [PMID: 36863949 DOI: 10.1016/j.jcjd.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/21/2022] [Accepted: 01/03/2023] [Indexed: 01/09/2023]
Abstract
OBJECTIVES Continuous and flash glucose monitoring devices produce data reports (e.g. ambulatory glucose profile [AGP]) that can be used by people with diabetes and health-care providers (HCPs). Clinical benefits of these reports have been published, but the patient perspective is underreported. METHODS We conducted an online survey for adults with type 1 diabetes (T1D) using continuous/flash glucose monitoring to understand their use and attitudes toward the AGP report. Barriers and facilitators related to digital health technology were explored. RESULTS The survey included 291 respondents: 63% were <40 years of age, and 65% had been living with T1D for >15 years. Nearly 80% reviewed their AGP report, with 50% often discussing it with their HCP. Support from family and HCPs was positively associated with the use of the AGP report, and there was a positive relationship between motivation and better understanding of the AGP report (odds ratio=2.61; 95% confidence interval, 1.45 to 4.71). Nearly all respondents (92%) indicated that the AGP report is important for their diabetes management, but most indicated dissatisfaction with the cost of the device. Open-ended responses suggested some concern with the complexity of information from the AGP report. CONCLUSIONS The online survey showed that there may be few barriers to the use of the AGP report by people with T1D, with the main barrier being its cost of the devices. Facilitators for the use of the AGP report included motivation and support from both family and the HCP. Facilitating discussion between HCPs and patients may be a strategy to improve the use and potential benefit of the AGP.
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Tokutsu A, Okada Y, Mita T, Torimoto K, Wakasugi S, Katakami N, Yoshii H, Uryu K, Nishida K, Arao T, Tanaka Y, Gosho M, Shimomura I, Watada H. Relationship between blood glucose variability in ambulatory glucose profile and standardized continuous glucose monitoring metrics: Subanalysis of a prospective cohort study. Diabetes Obes Metab 2022; 24:82-93. [PMID: 34498346 DOI: 10.1111/dom.14550] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 09/01/2021] [Accepted: 09/07/2021] [Indexed: 12/22/2022]
Abstract
AIM To clarify the relationship between ambulatory glucose profile (AGP) indexes and standardized continuous glucose monitoring (CGM) metrics in patients with type 2 diabetes (T2D). METHODS This is an exploratory, cross-sectional analysis of baseline data collected from a prospective, multicentre, 5-year follow-up observational study conducted and published previously by our group. The study participants were 999 outpatients with T2D who used CGM at baseline, and had no apparent history of cardiovascular disease. We investigated the relationship between average interquartile range (IQR) and time in range (TIR). We also calculated, for the first time, the cutoff values to achieve the TIR target values. RESULTS In both the TIR more than 70% and TIR more than 90% achievement groups, the average IQR was notably small compared with the non-achievement groups. Particularly in comparison of the TIR quartiles, the average IQR became significantly smaller as the TIR became larger. The average IQR correlated negatively with TIR, and the cutoff values for TIR of more than 70% achievement and TIR of more than 90% achievement were an average IQR (>70%/>90%) of 2.13/1.85 mmol/L. CONCLUSION Our results showed a negative correlation between TIR and the range of blood glucose variations visually represented in AGP. The results also showed that the range of blood glucose variations in AGP is associated with indices of intraday and interday blood glucose variations and also with hypoglycaemia. Our results may provide new perspectives in the assessment and application of AGP in the clinical setting.
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Affiliation(s)
- Akemi Tokutsu
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Yosuke Okada
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Tomoya Mita
- Department of Metabolism & Endocrinology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Keiichi Torimoto
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Satomi Wakasugi
- Department of Metabolism & Endocrinology, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Naoto Katakami
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
- Department of Metabolism and Atherosclerosis, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hidenori Yoshii
- Department of Medicine, Diabetology & Endocrinology, Juntendo Tokyo Koto Geriatric Medical Center, Tokyo, Japan
| | - Kohei Uryu
- Department of Internal Medicine, Ashiya Central Hospital, Ongagun, Fukuoka, Japan
| | | | - Tadashi Arao
- Department of Internal Medicine, Division of Diabetes, Metabolism and Endocrinology, Japan Labour Health and Safety Organization Kyushu Rosai Hospital, Moji Medical Center, Kitakyushu, Japan
| | - Yoshiya Tanaka
- First Department of Internal Medicine, School of Medicine, University of Occupational and Environmental Health, Japan, Kitakyushu, Japan
| | - Masahiko Gosho
- Department of Biostatistics, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Iichiro Shimomura
- Department of Metabolic Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hirotaka Watada
- Department of Metabolism & Endocrinology, Juntendo University Graduate School of Medicine, Tokyo, Japan
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5
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Dagdelen S, Deyneli O, Dinccag N, Ilkova H, Osar Siva Z, Yetkin I, Yilmaz T. Expert Panel Recommendations for Use of Standardized Glucose Reporting System Based on Standardized Glucometrics Plus Visual Ambulatory Glucose Profile (AGP) Data in Clinical Practice. Front Endocrinol (Lausanne) 2021; 12:663222. [PMID: 35140679 PMCID: PMC8819142 DOI: 10.3389/fendo.2021.663222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 11/25/2021] [Indexed: 11/30/2022] Open
Abstract
This expert panel of diabetes specialists aimed to provide guidance to healthcare providers on the best practice in the use of innovative continuous glucose monitoring (CGM) techniques through a practical and implementable document that specifically addresses the rationale for and also analysis and interpretation of the new standardized glucose reporting system based on standardized CGM metrics and visual ambulatory glucose profile (AGP) data. This guidance document presents recommendations and a useful algorithm for the use of a standardized glucose reporting system in the routine diabetes care setting.
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Affiliation(s)
- Selcuk Dagdelen
- Department of Endocrinology and Metabolism, Hacettepe University Faculty of Medicine, Ankara, Turkey
- *Correspondence: Selcuk Dagdelen,
| | - Oguzhan Deyneli
- Department of Endocrinology and Metabolism, Koc University Faculty of Medicine, Istanbul, Turkey
| | - Nevin Dinccag
- Department of Endocrinology and Metabolism, Istanbul University Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Hasan Ilkova
- Department of Endocrinology and Metabolism, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Zeynep Osar Siva
- Department of Endocrinology and Metabolism, Istanbul University Cerrahpasa Faculty of Medicine, Istanbul, Turkey
| | - Ilhan Yetkin
- Department of Endocrinology and Metabolism, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Temel Yilmaz
- Department of Endocrinology and Metabolism, Florence Nightingale Hospital, Istanbul, Turkey
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6
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Pla B, Arranz A, Knott C, Sampedro M, Jiménez S, Hernando I, Marazuela M. Impact of COVID-19 Lockdown on Glycemic Control in Adults with Type 1 Diabetes Mellitus. J Endocr Soc 2020; 4:bvaa149. [PMID: 33173841 PMCID: PMC7641317 DOI: 10.1210/jendso/bvaa149] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 10/08/2020] [Indexed: 01/08/2023] Open
Abstract
Aim To examine the impact of the lockdown caused by the COVID-19 pandemic on both the glycemic control and the daily habits of a group of patients with type 1 diabetes mellitus (T1DM) using flash continuous glucose monitoring devices (flash CGMs). Methods Retrospective analysis based on all the information gathered in virtual consultations from a cohort of 50 adult patients with T1DM with follow-up at our site. We compared their CGM metrics during lockdown with their own previous data before the pandemic occurred, as well as the potential psychological and therapeutic changes. Results We observed a reduction of average glucose values: 160.26 ± 22.55 mg/dL vs 150 ± 20.96 mg/dL, P = .0009; estimated glycosylated hemoglobin: 7.21 ± 0.78% vs 6.83 ± 0.71%, P = .0005; glucose management indicator 7.15 ± 0.57% vs 6.88 ± 0.49%; P = .0003, and glycemic variability: 40.74 ± 6.66 vs 36.43 ± 6.09 P < .0001. Time in range showed an improvement: 57.46 ± 11.85% vs a 65.76 ± 12.09%, P < .0001, without an increase in percentage of time in hypoglycemia. Conclusions COVID-19 lockdown was associated with an improvement in glycemic control in patients with T1DM using CGMs.
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Affiliation(s)
- Begoña Pla
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Alfonso Arranz
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Carolina Knott
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Miguel Sampedro
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Sara Jiménez
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Iñigo Hernando
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, Madrid, Spain
| | - Monica Marazuela
- Department of Endocrinology and Nutrition, Hospital Universitario de La Princesa, Instituto de Investigación Princesa, Universidad Autónoma de Madrid, Madrid, Spain
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Abstract
The HbA1c value is a well-established parameter used to characterize glucose control. Continuous glucose monitoring (CGM)-derived parameters calculated using daily glucose profiles such as Time-in-Range (TiR) have increasingly been gaining interest for assessing a patient's current therapy. The question has arisen as to whether TiR could replace HbA1c? Because TiR focuses on the current quality of glucose control during a minimum of 10 to 14 days of CGM use and reflects the variability of glucose concentrations. Time-in-Range could be considered an attractive option for improving diabetes control in patients with diabetes. Due to the lack of established standards for glucose measurements with CGM systems, results from different CGM systems can deviate from each other. Time-in-Range should not be viewed as a replacement for HbA1c, but should be used to deliver valuable additional information.
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Affiliation(s)
- Lutz Heinemann
- Science & Co, Dusseldorf, Germany
- Lutz Heinemann, PhD, Science Consulting in Diabetes GmbH, Schwerinstr. 50, Neuss 41462, Germany.
| | | | - Dirk Müller-Wieland
- Klinik für Kardiologie, Angiologie und Internistische Intensivmedizin (Med. Klinik 1), Uniklinik RWTH Aachen, Germany
| | - Monika Kellerer
- Klinik für Innere Medizin 1, Marienhospital Stuttgart, Germany
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8
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Abstract
BACKGROUND The ambulatory glucose profile (AGP) uses the wealth of data that are generated by continuous glucose monitoring, including flash glucose monitoring technologies, to provide a visual representation of glucose levels over a typical standard day of usually the most recent two weeks for a person with diabetes and helps to identify patterns and trends in glucose control. The AGP allows certain patterns of glucose levels to be identified and analyzed, such that treatment adjustments can be made, and new individual treatment goals can be defined. This helps to ensure increased treatment satisfaction and adherence, quality of life, and an improvement in metabolic management for people with diabetes. OBJECTIVE To date, a range of approaches exists for interpreting the information contained in an AGP, with different priorities given to identifying and targeting patterns of hypoglycemia and the degree of variability and stability underlying the glucose levels. The objective of the present recommendation is to describe the steps for assessing an AGP in detail and to illustrate these steps using visual examples. CONCLUSION This paper describes the consensus recommendations from a group of German expert diabetologists on the necessary steps for assessing an AGP in a structured and detailed way and to explain these steps using practical clinical examples.
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Affiliation(s)
- Jens Kröger
- Centre for Diabetology, Hamburg Bergedorf, Germany
- Jens Kröger, MD, Centre for Diabetology, Hamburg Bergedorf, Glindersweg 80, 21029 Hamburg, Germany.
| | - Andreas Reichel
- Medical Clinic and Outpatient Clinic 3, University Hospital of Carl-Gustav-Carus, Dresden, Germany
| | - Thorsten Siegmund
- Department for Endocrinology, Diabetes and Metabolism, ISAR Klinikum, Munich, Germany
| | - Ralph Ziegler
- Diabetes Clinic for Children and Adolescents, Munster, Germany
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9
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Chico A, Aguilera E, Ampudia-Blasco FJ, Bellido V, Cardona-Hernández R, Escalada FJ, Fernández D, Gómez-Peralta F, González Pérez de Villar N, Gorgojo JJ, Mezquita-Raya P, Morales C, de Pablos Velasco P, Palomares R, Parra J, Rivero MT, González-Blanco C. Clinical Approach to Flash Glucose Monitoring: An Expert Recommendation. J Diabetes Sci Technol 2020; 14:155-164. [PMID: 31081362 PMCID: PMC7189166 DOI: 10.1177/1932296819841911] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The flash glucose monitoring (FGM) system FreeStyle Libre® is a device that measures interstitial glucose in a very simple way and indicates direction and speed of glucose change. This allows persons with diabetes to prevent hypoglycemic and hyperglycemic events. Scientific evidence indicates that the system can improve glycemic control and quality of life. To obtain the maximum benefit, it is necessary to properly handle glucose values and trends. Due to the generalization of the system use, the purpose of the document is to provide recommendations for the optimal use of the device, not only in the management of glucose values and trends but also in the prevention of hypoglycemia, actuation in exercise, special situations, and retrospective analysis of the glucose data, among others.
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Affiliation(s)
- Ana Chico
- Endocrinology Department, Hospital Santa
Creu i Sant Pau, CIBER-BBN, Universitat Autònoma de Barcelona, Barcelona,
Spain
- Ana Isabel Chico, MD, PhD, Endocrinology
Department, Hospital Santa Creu i Sant Pau, Av Pare Claret 167, 08025
Barcelona,, Spain.
| | - Eva Aguilera
- Endocrinology Department, Hospital
Germans Trias i Pujol, Badalona, Spain
| | | | - Virgina Bellido
- Endocrinology Department, Hospital
Universitario Central de Asturias, Oviedo, Spain
| | - Roque Cardona-Hernández
- Division of Pediatric Endocrinology,
Diabetes Unit, Hospital Sant Joan de Déu, Esplugues de Llobregat, Barcelona,
Spain
| | | | - Diego Fernández
- Endocrinology Department, Hospital
Universitario Virgen de la Victoria, Málaga, Spain
| | | | | | - Juan José Gorgojo
- Endocrinology Department, Hospital
Universitario Fundación Alcorcón, Alcorcón, Madrid, Spain
| | - Pedro Mezquita-Raya
- Endocrinology Department, Hospital
Universitario Torrecárdenas, Almería, Spain
| | - Cristóbal Morales
- Endocrinology Department, Hospital
Universitario Virgen de la Macarena, Sevilla, Spain
| | | | - Rafael Palomares
- Endocrinologist, Hospital
Universitario Reina Sofía, Córdoba, Spain
| | - Juan Parra
- Endocrinology Department, Hospital de
Mérida, Mérida, Badajoz, Spain
| | - María Teresa Rivero
- Endocrinology Department, Complexo
Hospitalario Universitario de Ourense, Orense, Spain
| | - Cintia González-Blanco
- Endocrinology Department, Hospital Santa
Creu i Sant Pau, CIBER-BBN, Universitat Autònoma de Barcelona, Barcelona,
Spain
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10
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Abstract
BACKGROUND The advent of continuous glucose monitoring (CGM) technology has transformed the approach to diabetes care. Multiple CGM systems are commercially available and increased accuracy has allowed development of hybrid and automated insulin delivery systems. Evidence of CGM clinical benefits has also increased exponentially in the last decade. METHODS Literature search, review of professional guidelines, and consensus statements were used to guide the preparation of this article. The clinical benefits of both professional and personal CGM in clinical practice as well as barriers to wider adotpion were explored. A stepped approach to review and interpretation of CGM data is suggested for use in the clinician's office regardless of the software used. RESULTS Although increasing, the use of CGM in patients with diabetes is still not widespread; multiple barriers are still in place, despite the approval of CGM systems for patients above the age of 2 years old, the extension of coverage for Medicare beneficiaries and the integration of CGM with multiple insulin pump systems. Integration of CGM technology in clinical practice presents various challenges, from concerns relative to time constraints during office visits to lack of systematic approach to interpretation of the data. CONCLUSIONS Understanding the usefulness of personal and professional CGM, appropriate patient selection as well as patient and provider training are crucial for the expansion of CGM therapy use in clinical practice. Utilizing the proposed stepped approach to CGM review and interpretation may allow wider adoption of CGM with more effective and efficient office visits.
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Affiliation(s)
- Grazia Aleppo
- Division of Endocrinology, Metabolism
and Molecular Medicine, Feinberg School of Medicine, Northwestern University,
Chicago, IL, USA
- Northwestern Medicine Diabetes Training
and Education Program, Division of Endocrinology, Metabolism and Molecular Medicine,
Northwestern Medical Group, Chicago, IL, USA
- Grazia Aleppo, MD, FACE, FACP, Division of
Endocrinology, Northwestern University, 645 N Michigan Ave, Ste 530, Chicago, IL
60611, USA.
| | - Kimberly Webb
- Northwestern Medicine Diabetes Training
and Education Program, Division of Endocrinology, Metabolism and Molecular Medicine,
Northwestern Medical Group, Chicago, IL, USA
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11
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Ogawa Y, Shimizu S, Takenoshita N, Kaneko Y, Satoto T, Hanyu H. Ambulatory glucose profile in diabetes-related dementia. Geriatr Gerontol Int 2019; 19:282-286. [PMID: 30665263 DOI: 10.1111/ggi.13612] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 10/29/2018] [Accepted: 12/14/2018] [Indexed: 01/21/2023]
Abstract
AIM Diabetes-related dementia (DrD), a dementia subgroup associated with specific diabetes mellitus (DM)-related metabolic abnormalities rather than Alzheimer's disease (AD) pathology or cerebrovascular disease, is characterized by less well-controlled glycemia. We investigated the glucose level, variability and stability, and risk of hypoglycemia in DrD to determine characteristic ambulatory glucose profiles (AGP). METHODS We obtained AGP for 14 days of 40 patients with AD associated with DM and 19 patients with DrD using a novel sensor-based flash glucose monitoring system (FreeStyle Libre Pro). RESULTS Despite similar mean glucose and estimated A1c values, the DrD group showed significantly greater glucose variability and higher percentage of time spent in hypoglycemia than the AD associated with DM group. Glucose level and variability correlated significantly and negatively with Mini-Mental State Examination in DrD, but not in AD associated with DM The estimated A1c levels calculated from the 14 days of AGP data significantly correlated with the HbA1c levels measured within 2 months of the insertion of the sensor. CONCLUSIONS DrD has a distinctively different AGP from that of AD associated with DM. Glucose variability and hypoglycemia are more involved in the pathophysiology of DrD than in that of AD associated with DM. The AGP analysis using the flash glucose monitoring system might provide useful information undetected by HbA1c values. Geriatr Gerontol Int 2019; 19: 282-286.
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Affiliation(s)
- Yusuke Ogawa
- Department of Geriatric Medicine, Tokyo Medical University, Tokyo, Japan
| | - Soichiro Shimizu
- Department of Geriatric Medicine, Tokyo Medical University, Tokyo, Japan
| | | | - Yoshitsugu Kaneko
- Department of Geriatric Medicine, Tokyo Medical University, Tokyo, Japan
| | - Tomohiko Satoto
- Department of Geriatric Medicine, Tokyo Medical University, Tokyo, Japan
| | - Haruo Hanyu
- Department of Geriatric Medicine, Tokyo Medical University, Tokyo, Japan
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12
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Forlenza GP, Pyle LL, Maahs DM, Dunn TC. Ambulatory glucose profile analysis of the juvenile diabetes research foundation continuous glucose monitoring dataset-Applications to the pediatric diabetes population. Pediatr Diabetes 2017; 18:622-628. [PMID: 27878929 PMCID: PMC7162536 DOI: 10.1111/pedi.12474] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Revised: 10/18/2016] [Accepted: 10/20/2016] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Increased continuous glucose monitor (CGM) use presents both the benefit and burden of increased data for clinicians to rapidly analyze. The ambulatory glucose profile (AGP) is an evolving a universal software report for CGM data analysis. OBJECTIVES/HYPOTHESES We utilized the Juvenile Diabetes Research Foundation-CGM dataset to evaluate the AGP across a broad spectrum of patients to show how AGP can be used clinically to assist with CGM-related decision making. We hypothesized that AGP metrics would be different across age and HbA1c strata. SUBJECTS AGPs were generated from the JDRF-CGM trial dataset for all periods during which there were ≥10 days of CGM coverage in the 2 weeks adjacent to an HbA1c measurement yielding 1101 AGPs for 393 unique subjects. METHODS AGPs were stratified by age group (8-14, 15-24, and ≥25 years) and HbA1c (within or above target for age) and compared for between group differences in AGP metrics via two-factor ANOVA. Glycemic differences between time periods were analyzed via segmented regression analysis. RESULTS Glucose exposure (average and estimated A1c) and variability (standard deviation and interquartile range) were different between the low and high HbA1c levels. Within a given HbA1c level all age groups were significantly different from each other with older patients having lower averages with less variability than younger patients. CONCLUSIONS AGP analysis of the JDRF-CGM data highlights significant differences in glycemic profiles between pediatric and adult age groups and between well and less well-controlled patient populations.
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Affiliation(s)
| | - Laura L. Pyle
- Department of Pediatrics, University of Colorado Denver, Denver, Colorado,Department of Biostatistics and Informatics, University of Colorado Denver, Denver, Colorado
| | - David M. Maahs
- Barbara Davis Center, University of Colorado Denver, Denver, Colorado
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13
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Affiliation(s)
- Alberto Maran
- Department of Medicine, Division of Metabolic Diseases, University of Padova, Padova, Italy
| | - Katherine Esposito
- Diabetes Unit, Department of Clinical and Experimental Medicine, Second University of Naples, Naples, Italy
| | - Sofia Toni
- Pediatric Diabetology Unit, Meyer Children’s Hospital, Florence, Italy
| | - Carla Giordano
- Section of Endocrinology, Diabetology and Metabolism, University of Palermo, Palermo, Italy
- Carla Giordano, MD, Biomedical Department of Internal and Specialized Medicine, Section of Cardio-Respiratory and Endocrine-Metabolic Diseases University of Palermo, Piazza delle Cliniche 2, 90127 Palermo, Italy.
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14
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Distiller LA, Cranston I, Mazze R. First Clinical Experience with Retrospective Flash Glucose Monitoring (FGM) Analysis in South Africa: Characterizing Glycemic Control with Ambulatory Glucose Profile. J Diabetes Sci Technol 2016; 10:1294-1302. [PMID: 27154973 PMCID: PMC5094324 DOI: 10.1177/1932296816648165] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND In 2014, an innovative blinded continuous glucose monitoring system was introduced with automated ambulatory glucose profile (AGP) reporting. The clinical use and interpretation of this new technology has not previously been described. Therefore we wanted to understand its use in characterizing key factors related to glycemic control: glucose exposure, variability, and stability, and risk of hypoglycemia in clinical practice. METHODS Clinicians representing affiliated diabetes centers throughout South Africa were trained and subsequently were given flash glucose monitoring readers and 2-week glucose sensors to use at their discretion. After patient use, sensor data were collected and uploaded for AGP reporting. RESULTS Complete data (sensor AGP with corresponding clinical information) were obtained for 50 patients with type 1 (70%) and type 2 diabetes (30%), irrespective of therapy. Aggregated analysis of AGP data comparing patients with type 1 versus type 2 diabetes, revealed that despite similar HbA1c values between both groups (8.4 ± 2 vs 8.6 ± 1.7%, respectively), those with type 2 diabetes had lower mean glucose levels (9.2 ± 3 vs 10.3 mmol/l [166 ± 54 vs 185 mg/dl]) and lower indices of glucose variability (3.0 ± 1.5 vs 5.0 ± 1.9 mmol/l [54 ± 27 vs 90 ± 34.2 mg/dl]). This highlights key areas for future focus. CONCLUSIONS Using AGP, the characteristics of glucose exposure, variability, stability, and hypoglycemia risk and occurrence were obtained within a short time and with minimal provider and patient input. In a survey at the time of the follow-up visit, clinicians indicated that aggregated AGP data analysis provided important new clinical information and insights.
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Affiliation(s)
| | - Iain Cranston
- AGP Clinical Academy, Portsmouth Hospitals, NHST, Portsmouth, UK
| | - Roger Mazze
- AGP Clinical Academy, Portsmouth Hospitals, NHST, Portsmouth, UK
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15
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Ish-Shalom M, Wainstein J, Raz I, Mosenzon O. Improvement in Glucose Control in Difficult-to-Control Patients With Diabetes Using a Novel Flash Glucose Monitoring Device. J Diabetes Sci Technol 2016; 10:1412-1413. [PMID: 27277660 PMCID: PMC5094332 DOI: 10.1177/1932296816653412] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
| | | | - Itamar Raz
- Diabetes Unit, Hadassah Hebrew University, Jerusalem, Israel
| | - Ofri Mosenzon
- Diabetes Unit, Hadassah University Hospital, Jerusalem, Israel
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16
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Abstract
BACKGROUND In children with type 1 diabetes, intensive diabetes management has been demonstrated to reduce long-term microvascular complications. At present, self-monitoring of blood glucose (SMBG) by patients at home and glycated hemoglobin estimation every 3 months are used to monitor glycemic control in children. Recently, ambulatory glucose profile (AGP) is increasingly being used to study the glycemic patterns in adults. However, accuracy and reliability of AGP in children have not been evaluated yet. OBJECTIVES To assess the accuracy of AGP data in children with type 1 diabetes mellitus when compared with laboratory random blood sugar (RBS) levels, capillary blood glucose (CBG) measured by glucometer in the hospital, and SMBG monitored at home. METHODS Paired RBS, CBG, and AGP data were analyzed for 51 patients who wore AGP sensors for 2 weeks. Simultaneous venous and CBG samples were collected on day 1 and day 14. SMBG at home was checked and recorded by the patients for optimizing insulin doses. Accuracy measures (mean absolute deviation, mean absolute relative difference (MARD), and coefficient of linear regression of AGP on RBS, CBG, and home-monitored SMBG were calculated. RESULTS Seventy paired RBS, CBG, and AGP data and 362 paired home-monitored SMBG and AGP data were available. The MARD was 9.56% for AGP over RBS and 15.07% for AGP over CBG. The linear regression coefficient of AGP over RBS was 0.93 and that of AGP over CBG was 0.89 (P < 0.001). The accuracy of AGP over SMBG was evaluated over four ranges: <75, 76-140, 141-200, and >200 mg/dl. CONCLUSION In this study, AGP data significantly correlate with RBS and CBG data in children with type 1 diabetes. However, a large number of samples in a research setting would help to document reproducibility of our results.
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Affiliation(s)
- Anjana Hulse
- Department of Diabetes and Endocrinology, Bangalore Diabetes Hospital, Bangalore, Karnataka, India
| | - Suahma Rai
- Department of Diabetes and Endocrinology, Bangalore Diabetes Hospital, Bangalore, Karnataka, India
- Department of Paediatrics, P.E.S. Institute of Medical Sciences and Research, Kuppam, Andhra Pradesh, India
| | - K. M. Prasanna Kumar
- Department of Diabetes and Endocrinology, Bangalore Diabetes Hospital, Bangalore, Karnataka, India
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17
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Dunn TC, Hayter GA, Doniger KJ, Wolpert HA. Development of the Likelihood of Low Glucose (LLG) algorithm for evaluating risk of hypoglycemia: a new approach for using continuous glucose data to guide therapeutic decision making. J Diabetes Sci Technol 2014; 8:720-30. [PMID: 24876422 PMCID: PMC4764240 DOI: 10.1177/1932296814532200] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The objective was to develop an analysis methodology for generating diabetes therapy decision guidance using continuous glucose (CG) data. The novel Likelihood of Low Glucose (LLG) methodology, which exploits the relationship between glucose median, glucose variability, and hypoglycemia risk, is mathematically based and can be implemented in computer software. Using JDRF Continuous Glucose Monitoring Clinical Trial data, CG values for all participants were divided into 4-week periods starting at the first available sensor reading. The safety and sensitivity performance regarding hypoglycemia guidance "stoplights" were compared between the LLG method and one based on 10th percentile (P10) values. Examining 13 932 hypoglycemia guidance outputs, the safety performance of the LLG method ranged from 0.5% to 5.4% incorrect "green" indicators, compared with 0.9% to 6.0% for P10 value of 110 mg/dL. Guidance with lower P10 values yielded higher rates of incorrect indicators, such as 11.7% to 38% at 80 mg/dL. When evaluated only for periods of higher glucose (median above 155 mg/dL), the safety performance of the LLG method was superior to the P10 method. Sensitivity performance of correct "red" indicators of the LLG method had an in sample rate of 88.3% and an out of sample rate of 59.6%, comparable with the P10 method up to about 80 mg/dL. To aid in therapeutic decision making, we developed an algorithm-supported report that graphically highlights low glucose risk and increased variability. When tested with clinical data, the proposed method demonstrated equivalent or superior safety and sensitivity performance.
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Bergenstal RM, Ahmann AJ, Bailey T, Beck RW, Bissen J, Buckingham B, Deeb L, Dolin RH, Garg SK, Goland R, Hirsch IB, Klonoff DC, Kruger DF, Matfin G, Mazze RS, Olson BA, Parkin C, Peters A, Powers MA, Rodriguez H, Southerland P, Strock ES, Tamborlane W, Wesley DM. Recommendations for standardizing glucose reporting and analysis to optimize clinical decision making in diabetes: the ambulatory glucose profile. J Diabetes Sci Technol 2013; 7:562-78. [PMID: 23567014 PMCID: PMC3737658 DOI: 10.1177/193229681300700234] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Underutilization of glucose data and lack of easy and standardized glucose data collection, analysis, visualization, and guided clinical decision making are key contributors to poor glycemic control among individuals with type 1 diabetes mellitus. An expert panel of diabetes specialists, facilitated by the International Diabetes Center and sponsored by the Helmsley Charitable Trust, met in 2012 to discuss recommendations for standardizing the analysis and presentation of glucose monitoring data, with the initial focus on data derived from continuous glucose monitoring systems. The panel members were introduced to a universal software report, the Ambulatory Glucose Profile, and asked to provide feedback on its content and functionality, both as a research tool and in clinical settings. This article provides a summary of the topics and issues discussed during the meeting and presents recommendations from the expert panel regarding the need to standardize glucose profile summary metrics and the value of a uniform glucose report to aid clinicians, researchers, and patients.
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Affiliation(s)
- Richard M Bergenstal
- International Diabetes Center at Park Nicollet, 3800 Park Nicollet Blvd., Minneapolis, MN 55416-2699, USA.
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