CGM & Pump Integration

Rapid Data Collection Using CGM Integrated With Insulin Pumps

CGM provides invaluable information that is unattainable using finger stick blood glucose measurements. The ability to display rate of change, alarm the user with impending low blood glucose, and collect data every five minutes can help to inform, motivate and alert people with diabetes (PWD) to enhance management.

Sensor Integrated Pumps

Technology is changing rapidly, and several options are now available for reading sensor data on the pump screen and responding to the data; Tandem X2 Basal IQ and Control IQ, Medtronic 670, 770G with Guardian sensor, non-FDA approved open-source systems. These systems can alter basal rates and/or correctional insulin determined from sensor data and more systems are presently with the FDA for approval.

It is the role of the diabetes care and education specialist who works with PWD on multiple daily injections and/or an insulin pump to remain updated on the options. By providing PWD the knowledge of their availability in the marketplace, the individual can share in the decision-making about tools that can be utilized to enhance their diabetes care, in addition to standard pump therapy.

Data supports the impact of sensor augmented pump therapy for A1C reduction in the Start 3 study.²⁵ In addition, most research suggests that even if A1C is not reduced, there is a reduction in hypoglycemia while retaining A1C, suggesting a reduction in glucose variability which is in itself a success.²⁶

In a recent study on predictive hyperglycemia and hypoglycemia minimization, the predictive hyperglycemia and hypoglycemia systems optimized overnight glucose management and increased the time in range in children 6-14 years of age.²⁷

Breton et. al.²⁸ reported improved glycemic management and a reduction in hypoglycemia during intensive winter cold and high-altitude activity with a closed-loop control system (the artificial pancreas), which is still in the research phase. This again demonstrates the value of sensor integrated insulin pump therapy. Tauschmann et al.²⁹ 

It is important for the specialist to be aware of options being utilized by individuals that are not FDA approved but are being used by over 2,200 individuals worldwide such as Do It Yourself (DIY) and Night Scout.³⁰ This may be a particular challenge to the specialist in recognizing the concern over non-FDA approved devices and the individual’s successful utilization of these systems. The role of the diabetes care and education specialist is more of acceptance and promoting safety, rather than education in regard to these devices at this time.

The most recent Standards of Medical Care in Diabetes – 2021 states the following: When prescribing CGM “robust diabetes education, training, and support are required for optimal CGM implementation and ongoing use”.³¹ This is supported by the International Consensus on the use of CGM,³² which states “patient education should utilize standardized programs with the follow-up to improve adherence and facilitate appropriate use of data and diabetes therapies”.

The sensor augmented insulin pumps are more complex than sensor add-on technology without augmentation and require more in-depth education to the pump trainer and PWD. Pump training will often occur over multiple days, with an initial visit for pump training, another visit for CGM training and a subsequent visit to go into auto mode.

It is the role of the diabetes care and education specialist in sensor augmented insulin pump therapy to educate the PWD and caregivers on:

• Options available for sensor added or integrated insulin pump therapy
• Differentiating interstitial glucose and blood glucose results
• Timing of sensor calibration if required and technique
• Placement of the sensor for most accurate readings
• Insertion of the sensor
• Problem-solving taping and securing the sensor
• Skin care
• Limitation to sensor readings
• Appropriate use of the suspend feature
• How to stay in or return to auto mode delivery in the 670G Medtronic insulin pump (largely eliminated in the 770G)

The specialist should also be able to download data from the integrated insulin pump, review the information with the individual and make recommendations based on sensor data that can enhance glucose goals. They should have an ongoing relationship with the prescriber and communicate these changes.

Education is ongoing and pump upgrades as they become available should be reviewed and discussed as appropriate. In addition, it is important for the diabetes care and education specialist to work with school nurses and support persons to enhance the understanding of sensor integrated pump therapy while children are at school. Employees may also want to integrate education within their workplace.

Sensors at this time are not approved for dosing in the hospital setting, but the specialist can (and should) be involved in creating hospital policy to allow sensor wear when appropriate and to augment POC data with sensor data in understanding individual BG variability during their hospital stay.³⁴ It is important to note there has been some concern about the consistency of the accuracy of sensor data³⁵ which cannot be ignored. Sensor integrated insulin pumps are becoming more common and will continue to improve over time with more options slated to come on the market in the near future. This may include dual hormone systems (glucagon and insulin) with sensor integration, implantable sensors and pumps and fully integrated sensor and pump systems (the artificial pancreas). And pumps that can be initiated with just the weight of the PWD, making it easier for primary care practices to initiate pump therapy.

The diabetes care and education specialist who chooses to work with individuals on sensor augmented insulin pumps must be aware of the options, keep up with the technology, understand the benefits and limitations, be able to download the technology and help direct the interpretation of the data.

References:

^{American Diabetes Association. Standards of Medical Care in Diabetes—2024. Diabetes Care. ADCES Insulin Pump Therapy Guidelines, ISPAD Clinical Practice Consensus Guidelines 2022: Insulin Pump Therapy. Endocrine Society. Management of Continuous Subcutaneous Insulin Infusion (CSII) and Continuous Glucose Monitoring (CGM). Clinical Research on Insulin Pumps & Automated Insulin Delivery (AID) Systems: Beck RW, Riddlesworth T, et al. Effect of Continuous Glucose Monitoring on Glycemic Control in Adults With Type 1 Diabetes Using Insulin Injections: The DIAMOND Randomized Clinical Trial. JAMA, 2017.}