Patient CGM Case Studies

Christel O. is a 41-year-old female who has lived with Type 1 diabetes since 1997. Her insulin plan includes Detemir and Lispro. Christel considered getting a CGM for several years and has now used one for about five years. She researched her possibilities before getting it and her endocrinologist ordered it for her. She did not encounter any difficulties with obtaining insurance approval for the device or for the ongoing supplies.

Christel shares that she felt that she had a lot of initial training on the technical part of CGM use but not much on the emotional part of the use of CGM. She found the technology easy to use but felt that she “overreacted to the information initially and ended up chasing my BG.” She states that ongoing CGM training and support has been “limited.” She does use the CGM results and trend arrows to help determine how much mealtime and correction insulin to take.

Christel shares that one thing she really likes about the CGM is that she “hardly ever has a bad low while wearing the CGM since it alerts me before things go wrong. It can help me troubleshoot and make adjustments to my diabetes care more frequently.” She also shares the following CGM dislikes: “It can be stressful to constantly see your BG and the inaccuracy or when it doesn’t work is frustrating. Lastly, it’s costing me a lot of money.” Christel says she plans to continue with her CGM. “I think it’s a complete gamechanger. It not only helps with the daily management but can also help fear of lows.”

She offers the following advice to health care professionals: “Don’t just focus on the mechanical part of using a CGM, that’s the easy part. Focus more on how to use CGM in a mentally safe way. I try to tell myself to only check it when I want to make a management decision and don’t chase my BG but rely on my Smart Insulin Pen calculator (could just as well be a pump calculator or an app).”

CASE INSIGHTS:

Christel’s health care team could have taken the following actions to help increase her comfort level and satisfaction with personal CGM:
• Discuss emotional/human factors involved with device use, at device initiation and ongoing
• Provide ongoing support and education about her personal CGM, at device initiation and ongoing
• Discuss the potential disadvantages of wearing the device, starting at device initiation, and explore solutions together.

Frank O. is a 72-year-old male who was diagnosed with Type 2 diabetes five years ago. Diabetes medications include Glimepiride 2mg every morning, Metformin 500mg twice daily, and basal insulin 12 units every evening.

Cost of medications is a concern for Frank, and he has had difficulties affording other newer, more costly diabetes medications in the past. The regimen that he is currently on is affordable to him due to availability of generics. Frank has not been testing his fingerstick blood glucose consistently due to complaints of pain in his fingertips.

Frank’s HbA1C has been steadily creeping up, despite following a relatively low carbohydrate diet and maintaining a daily walking program. HbA1C is currently 8.4% and his primary care provider decides to refer Frank to a diabetes care and education specialist (DCES) to begin use of a CGM. The DCES shows Frank the CGM choices, and he opts for the lowest cost CGM and does have some coverage for this therapy with his health care plan. He gets started on it at the visit.

Frank returns to see his primary care provider (PCP) four weeks later. His CGM device is downloaded and reviewed by his PCP. He has been scanning before each meal and at bedtime and therefore has consistent data to review. His Ambulatory Glucose Profile shows that average glucose is 194 mg/dl and time in range is 52%. Time below range is 0% and time above range is 48%. Glucose trends show elevated fasting readings and elevated pre-evening meal and bedtime readings.

Frank’s PCP decides to increase the basal insulin to 16 units every evening and to increase his Glimepiride to 4 mg every morning. They follow up by telephone one week later and at that time most of Frank’s glucose results are in desired target range and there has been no hypoglycemia. Frank states that he “loves his CGM” and never wants to return to poking his fingers.

John B. is a 63-year-old gentleman who has been living with Type 2 diabetes for 20 years. BMI is 33 kg/ m². Medications include basal insulin 30 units daily, mealtime insulin analog 8 units before each meal plus a correction scale, a statin, low dose aspirin, ace inhibitor and a once weekly GLP-1 receptor agonist.

John has the following comorbidities: Hyperlipidemia, hypertension, obesity, osteoarthritis and chronic renal insufficiency. Recent A1C 8 .1%. He was maintained on oral diabetes medications for over 15 years and then transitioned to insulin therapy five years ago.

He started to experience more glycemic variability as time went by. He checks his fingerstick blood glucose level four times daily and results are as follows:
Before breakfast: 52-305 mg/dl
Before lunch: 121-298 mg/dl
Before dinner: 58-233 mg/dl
Before bed: 67-402 mg/dl

John feels that he eats relatively carbohydrate-consistent meals and can’t identify reasons for his blood glucose fluctuations. His primary care provider recommends a personal CGM for him with training and follow up with the diabetes care and education specialist (DCES).

After meeting with the DCES, John chose a CGM device. He learned to keep food logs and to aim for 45-60 grams of carbohydrates at meals and to not skip meals, which he had been doing at times. He was instructed to start logging his activity along with his food. Four weeks later, John followed up with his primary care provider.

His CGM device was downloaded and available for review by the PCP. The Ambulatory Glucose Profile (AGP) report showed that John has an average glucose of 164 mg/dl and his time in range is 60%. However, 6% of the time he is in Low Time Below Range, 30% of the time he is in High Time Above Range and 4% of the time he is in Very High Time Above Range. Glucose trends include a pattern of falling overnight and running high post-prandially after the noon and evening meals. John is sometimes running low before the noon meal.

The following adjustments were made to John’s insulin plan: Basal insulin was reduced to 26 units per day. Mealtime insulin was adjusted to 6 units at breakfast meal, 10 units at noon and evening meal. He returned to the PCP six weeks later. A1C 6 .9%. Time in range now 72% and no time spent in low or very low range. 28% of values are in High Time Above Range.

John continues to work with the DCES to learn more about diabetes self-management. 

Keena B. is a 47-year-old female who has lived with Type 1 diabetes since 1974. She uses an insulin pump to manage her diabetes. Keena considered getting a CGM for less than a year and has now used one since 2011. Her endocrinologist prescribed it for her, and she did not experience any difficulties getting it approved by the insurance company. Keena shares that her initial CGM training was “limited, but adequate.”

The training was provided by a diabetes educator and company representative. Her ongoing training and support have been “limited but adequate” and she has “switched CGM providers and asked questions.” She does use the CGM results and trend arrows to make treatment decisions and says, “This is one of the primary drivers for me ever trying a CGM. I wanted more convenience in managing my diabetes.”

Keena shares that one thing she really likes about CGM is “the convenience it provides for making treatment decisions and peace of mind knowing blood sugar readings and trends, especially when I’m alone, traveling, and in the company of friends/family who may not be as aware or knowledgeable about my condition in terms of what CGM or blood sugar readings/ trends mean to my treatment and overall health.”

She also shares some dislikes regarding CGM:
1. Aesthetic qualities, “I don’t know many people who would or do find machinery attached to my body to be particularly flattering to my body type or attire.”

2. “Constant reminder of diabetes, especially on days when my diabetes is more frustrating to treat.”

3. “Not having customization of alarms on my receiver or the iPhone app to the degree I would prefer. Consequently, I am one of the few people I know who prefers to use the CGM receiver over an iPhone app for readings because I feel like I can control the (sometimes) barrage of alarms at inconvenient times, especially when coupled with the (sometimes) barrage of alarms from my pump.”

Keena does plan to continue using a CGM. With her current busy schedule, “I cannot risk a low blood sugar, so I depend on my CGM, all the time!” She “believes that my CGM has eased my diabetes burden as I pursue my goal. I miss it when it is not with me.”

She offers the following advice to health care professionals: “Obviously, HIPAA prevents health care professionals from sharing patient references; however, if they could build a data bank of patients who are willing to speak to other patients about their experience, I think that could be really helpful. Speaking to someone who is already on a particular system provides real-world experience a potential user can rely on.”

CASE INSIGHTS:

Keena’s health care team could have taken the following actions to help increase her comfort level and satisfaction with personal CGM:
• Provide ongoing support and education about her personal CGM, at device initiation and ongoing
• Discuss emotional/human factors involved with device use, at device initiation and ongoing
• Discuss and provide a resource listing of social support/networks for Keena to connect with 

Nikki P. is a 48-year-old female who has lived with Type 1 diabetes for five and a half years. She uses an insulin pump to manage her diabetes. Nikki thought about getting a CGM for about six weeks before deciding to get one. She has used a CGM for about five years.

She did some research online and asked questions in Facebook Diabetes groups to help her with her decision about CGM. Her endocrinologist ordered it for her, and she initially encountered some difficulties with getting it approved by the insurance company, but with use of an appeal process was able to obtain it.

Nikki shares that she received no training on the use of her CGM and watched a video on her own which helped her to learn about it. She did not have any difficulty learning how to use the CGM device. She has not received any ongoing training but will sometimes reach out to the Facebook community to ask questions from others.

She does use the CGM to make treatment decisions. Nikki shares that one thing she really likes about the CGM is that it “gives me a freedom and peace of mind that I don’t have otherwise. I can go about my life, particularly runs or bike rides, without worrying about what my glucose is.” She adds, “Knowing that I will be alerted when I’m out of range makes managing diabetes feel manageable.”

She dislikes that her current CGM device requires 2x daily fingerstick glucose readings to calibrate it. Nikki shares that her overall CGM experience has been positive and that she plans to always have one. “It is a complete gamechanger that makes exercise and sleep possible (if not perfect).”

For ongoing support, she is a member of the Diabetes Sisters virtual pod and several other Facebook groups. Nikki offers the following advice to health care professionals: “I think an emphasis on having the data to make decisions and regain control might appeal to a hesitant user. I also know that the fear of being judged by health care providers exists so again, an emphasis on it just being data being reviewed for trends, not judgment.”

She advises to recommend that people with diabetes who are new to CGM “stick with it for at least a month. It might be hard to adjust to having something attached.” She recommends that the health care professional “Set alerts wide at first and narrow as results improve” (meaning that the low alert should not be set at too high a level and the high alert should not be set at too low of a level initially).

Nikki recommends Facebook groups and others in the diabetes community as good sources of support for answering questions about the real-life challenges of CGM use.

CASE INSIGHTS:

Nikki’s health care team could have taken the following actions to help increase her comfort level and satisfaction with personal CGM:
• Enlist the pharmacist on the team to assist with checking insurance benefits
• Discuss pros and cons of all CGM devices with her before she obtains one so she can choose, although her choice of device may be limited to those covered by her health plan
• Provide ongoing support and education about her personal CGM, at device initiation and ongoing
• Discuss potential disadvantages of wearing the device, starting at device initiation, and explore solutions together.