CEimpact Podcast

Continuous Glucose Monitors

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This week's GameChangers explores the transformative impact of continuous glucose monitors (CGMs) on diabetes care. Discover the latest advancements in CGM technology, current ADA recommendations, and practical tips for patient education.
 
The GameChanger
CGM technology is constantly changing. The devices are smaller, more user-friendly, and easier to integrate into daily life, thereby improving patient adherence and outcomes.
 
Guest
Jennifer Clements, PharmD, FCCP, FADCES, BCPS, CDCES, BCACP, BC-ADM
Clinical Professor and Director of Pharmacy Education
University of South Carolina College of Pharmacy

Reference
ADA Info on CGMs
AACE Guidelines Update on CGMs


Interested in additional Diabetes and CGM pharmacy education?
Enroll in Guardian of the Glucose Galaxy: The Rise of CGMs
During this 1-hour CE, we will cover hot topics such as:

  • The evolution of Continuous Glucose Monitors (CGMs)
  • The impact of CGMs in improving health, clinical outcomes, and quality of life for persons with diabetes
  • The use of CGMs to manage diabetes across patient populations
  • The role of pharmacy teams in managing people with diabetes
  • The opportunity to integrate CGM devices into practice

Pharmacists Enroll Here



Pharmacist Members, REDEEM YOUR CPE HERE!

Not a member? Get a Pharmacist Membership & earn CE for GameChangers Podcast episodes! (30 mins/episode)

CPE Information

Learning Objectives
Upon successful completion of this knowledge-based activity, participants should be able to:
1. Explain the principles and applications of continuous glucose monitors (CGMs) and summarize current recommendations for their use in diabetes management.
2. Discuss how to educate patients on CGM use, including device placement, data interpretation, and troubleshooting common issues.

0.05 CEU/0.5 Hr
UAN: 0107-0000-24-189-H01-P
Initial release date: 06/10/2024
Expiration date: 06/10/2025
Additional CPE details can be found here.

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Speaker 1:

Are you looking for free CE? Learn more about CGMs by joining us for a free live webinar this Thursday, June 13th. Guardians of the Glucose Galaxy, the Rise of CGMs starts at 7 pm Central on June 13th and you'll earn one hour of live drug therapy. Ce credit Register via the link in the show notes. We'll see you Thursday. Hey CE plan members from CE Impact, this is Game Changers. I am so excited today to talk about a topic that we have lots of education on actually at CE Impact, and so we are really excited to get into this this morning and talk about continuous glucose monitors. They are very popular now in people with diabetes and also not with diabetes, although we're not going to really talk about that today, and so with me today I have Dr Jennifer Clements. Welcome, Jennifer, Thanks for having me.

Speaker 1:

Yeah, I'm so excited. Before we get into it today, can you tell us a little bit about yourself and your practice?

Speaker 2:

Sure, Well, currently I am clinical professor and director of pharmacy education with the University of South Carolina College of Pharmacy. Pharmacy education with the University of South Carolina College of Pharmacy. But with my background I've been a pharmacist now for 18 years and that includes one year of residency training after I graduated and this was in a primary care setting within the VA. But my practice experience has expanded over the years, about six within a federal system like the VA and also seven in a rural health family medicine clinic, and I wanted to mention that because that particular experience is where I started to use CGM. So at that time Freestyle Libre came out with the intermittent scanned CGM and I just remember talking to the providers and getting them on board to initiate that into practice.

Speaker 2:

But after those 12 years I went into the hospital and actually worked for nursing administration where I gained additional experience with CGMs, particularly for people that came into the hospital with them maybe also needed to be initiated on them during their hospitalization, particularly during the initial months of the COVID pandemic and beyond, and then a transition of care type of service to get people on them at discharge, get people on them at discharge and then more recently I would say that with CGMs it's been a lot of education with healthcare professions. So, for example, here at the College of Pharmacy we've been able to implement a program where we educate individuals such as pharmacy students and medical students on CGMs so they get that practical experience before going on rotation, so they learn about them. They actually get the place one on themselves and then wear them for about 10 to 14 days, depending on the product, so again they can feel comfortable educating individuals or people with diabetes in practice.

Speaker 1:

Oh, that's so great. Nothing better than experiencing it yourself to know what people are dealing with. Yeah, that's great. Well, thank you for being with us today. I know you have such a wealth of experience that you just talked about, and you're one of the faculty members for our advanced training course, for our expert course, so that is awesome, and I know you were actually at a conference that we had this year as well, so we've worked with you quite a bit. My team loves working with you, and they were so happy to know that we're going to do this podcast today, so I'm excited to get into it. So, as we get started, I guess can you talk a little bit about the recommendations for CGM, because I think that that has changed in the recent past, and so where do we sit right now in terms of the recommendations?

Speaker 2:

Yeah, so we kind of look at maybe the American Diabetes Association as well as the American Association of Clinical Endocrinology and between those two organizations there's, of course, similarities and then, I think, some slight differences in how they state certain recommendations, again within both standards or their clinical practice guidelines. But if we focus on American Diabetes Association and I state that one just because probably a lot of people refer to it as it's pretty general and and really wanting to be utilized by multiple healthcare professions or professionals they, you know, provide strong support for CGMs across different populations. So the first one I would say is definitely adults with diabetes that are on multiple daily injections or even on pumps, and with that they've kind of changed, based on the evidence that's become available, to be adults with diabetes on basal insulin, and so with each of those recommendations I just mentioned, you could use a real-time or an intermittent scanned CGM. We have more real-time CGMs available currently than intermittent scanned CGMs, but this does then expand into other populations like the youth, meaning younger individuals that have type 1 diabetes on multiple daily injections or also utilizing a pump. But you could also use a real-time CGM in younger individuals that have type 2 diabetes, and then of course there's evidence and so leading to changes in recommendations for pregnancy. You can't use any CGM in pregnancy, it depends on which ones are approved, but that's always an option to be kind of.

Speaker 2:

In addition to that self-monitoring that would be done with a glucometer. And then I think more recently we've seen some evidence with hospitalized patients. Cgms are not FDA approved to be utilized in the hospital, but this of course, is if they've been on a CGM prior or maybe there's a reason to utilize it in the hospital. However, they have to be kind of clinically stable, so you know, maybe out of the ICU hemodynamically stable in order to utilize it. So those from the American Diabetes Association are pretty much the recommendations that are mentioned in the 2024 standards With the endocrinology group. Just because they're specialized, they provide a little bit more language like what does MDI mean? Meaning multiple daily injections, so usually three or more. They also have language in there about hypoglycemia. So anytime someone has severe hypoglycemia or they're unaware that they're going low, those could be individuals that could benefit from a CGM. But otherwise there's some consistency in terms of type one diabetes, type two diabetes, basal insulin for type two diabetes and then the pregnant population as well.

Speaker 1:

So so that's kind of everybody, I mean really. So I mean so is that, should all patients with diabetes be offered a CGM, like it sounds like from the recommendations you're? I mean at least in an outpatient, you know in an ambulatory care setting?

Speaker 2:

Right. So I mean definitely it does sound like CGMs for all, and that's often what a lot of us say in practice is that we do want CGMs for everybody with diabetes, and those recommendations are really based on personal CGMs, so ones that the individual would be utilizing at home. There's also professional CGMs, so that's more of the in-office CGMs, where they would be placed and then the patient would come back, you know so, 10 days, 14 days later, and then it would be removed and then you would interpret the data. We don't have as many professional CGMs and, of course, I think that the professional CGMs could be valuable for someone maybe newly diagnosed.

Speaker 2:

It could be, very overwhelming to somebody right at the beginning of a diagnosis of diabetes to have all this information and now have to be utilizing this device personally. So maybe something more short-term like a professional CGM would be valuable. Or the professional CGM could be used for someone that doesn't get insurance coverage or maybe has a difference in their glucometer readings and their A1C. It's not matching up. So perhaps we just put that CGM on them short term in the office and they come back and get it. So it does seem like it's for everybody, but it's probably more of the personal. There are instances where the individual may not get coverage for that personal CGM and the office may have their own professional ones that could still be utilized.

Speaker 1:

Yeah, that's what I was going to ask. So, if you know, oftentimes we want those recommendations because then they lead to coverage. So I mean, is the insurance coverage pretty good? For I feel like it's getting better and better, but are there instances where insurance maybe doesn't cover a CGM yet Feels like they kind of follow the guidelines typically, but yeah, I mean I think that we've seen changes.

Speaker 2:

You know there's obviously been changes too on a state level, depending on Medicare. Medicare was probably the one that caused a lot of, I would say maybe barriers or challenges initially with CGMs, just because of the kind of regulations they put on it, meaning, you know, clearly defining that this individual had to be on three or more insulin injections and they had to be checking three to four times a day and that had to be clearly documented in a note in order to get coverage. But a lot of that has been lifted to where again they can. All you know you could get coverage through Medicare and they just be on basal insulin for type two diabetes and I think that's because you just have more evidence come out. And with evidence we know it does take time to then see changes in coverage regulations, less restrictions, that sort of stuff, particularly with Medicare.

Speaker 2:

I will say that it depends on where somebody practices. For instance, in my rural health family medicine clinic experience, health family medicine clinic experience, you know I would say 75% of our patients were Medicare, medicaid, and then probably 20% had pretty good insurance, but that 5% left was no insurance, so cash only, and that depending on someone's financial you know budget, they may not be able to afford, and so we would say up to $75 could be the cost and you would have to get it maybe this often and so it could really then put a barrier on that person, additional burden, I would say. And the same for my hospital experience. We could talk to people and say we want to give you a CGM at discharge for whatever reason. You're newly diagnosed or now you're going on insulin, you've had hypoglycemia and not had this technology. But if they didn't have cash, you know, or they didn't have insurance, that cash price is just an additional burden, as I mentioned to them that they may not be able to afford.

Speaker 1:

Yeah, yeah, I want to go back to one thing you talked about a little bit with, you know, maybe providing a professional one in the beginning for someone who's newly diagnosed, and you know some of that maybe information overload. Can you talk a little bit about that from a technology perspective? Because I think you know younger people, obviously, you know, have technology and you know they've grown up with that. But, for example, I have a situation in my family, someone who is a little bit older, who does not want to touch it because they're not a technological person and they're like I don't want all the information and it's like, well, wouldn't you want information about your health? Like that's not how my brain works. But I know that there are people that just you know whether it's alarm, fatigue, and they get worried and you know, and so then that sense of of worry is there or it's just too much information and they don't want to look at it anymore. Can you talk a little bit about the technology piece and maybe how to talk to patients about some?

Speaker 2:

of those concerns. Yeah, I think if someone is kind of hesitant and the clinic has a professional CGM, that could be one way to maybe get them a little bit more open. You know, some of those, like the Freestyle Libre Pro is blinded information, so once that CGM goes on they're not going to know anything until they come back 14 days later, Whereas the Dexcom Pro can be blinded or unblinded, so they just come back a little bit sooner, in 10 days. So I think if the clinic has a professional CGM and you can go down that route bringing them back and showing them this is what we got over this short term may start to make them feel comfortable, maybe down the road Can't say initially, because everybody's different, but it could just then have, I think, a little bit more confidence or maybe show that it's not that scary. You know, to have this sort of data.

Speaker 2:

I think with personal CGMs a lot of them you could hook up your family members so they can monitor you remotely. So, for instance, it doesn't necessarily have to be that person that's always looking at their data. That could seem very overwhelming, but it could be the daughter or the son or the husband or another caregiver having access based on the app and setting up an account linking them to that person's account, to them being able to access the data, and maybe that would be less burden or overwhelming for that individual burden or overwhelming for that individual. But I would say that a way to maybe a key strategy to maybe open up the door of conversation and make them feel comfortable is letting them know why it would benefit them.

Speaker 2:

Technology is great, but let's really identify the main reason why it would be valuable for that person and an instance is really with hypoglycemia, for example is you know, there's some people that are just unaware. They're out there doing their thing and they really don't feel bad until it's 40. But we really need to catch it way sooner than that and telling them that this sort of technology is really to pick up the trends, you know, the trends of where they're going and where they're heading and how. That's different than checking their levels with a glucometer or even checking their A1C every three months. And I think relating it to that person rather than that technology is great and it's very beneficial and we should give it to all. When it's personalized, I feel like they'll have a better connection with it and then be more likely or more open to utilizing it.

Speaker 1:

Yeah, yeah, that's a great point, and it feels like the technology is constantly changing and so it's getting easier too. I mean, I remember when we first had that conversation, it was, you know, years ago. It's like it's a little bit clunky and now it's pretty streamlined.

Speaker 2:

Yeah, I mean, I think too. I mean the devices are also getting smaller. I mean, even the application is getting better. So an instance is you know, if I think back to Dexcom G6, where you would have to have the applicator and then the transmitter is separate, so it's like a two step process. But now at Dexcom G7, it's a one step, it's all together transmitter and sensor are all together, and it's just bam real easy. I think even that and the fact that they're getting smaller I mean, some of them are like the size of two stacked pennies and I think with that too, it's not this clunky device on someone's arm as how it used to be and that could, I think, make somebody feel like they're still able to move or function or they're not tied to it. There's still concerns, though, if it falls, function or they're not tied to it. There's still concerns, though, if it falls off or they have reactions.

Speaker 1:

But I think it's getting more sophisticated, where we should feel more confident and, you know, allow individuals to feel more comfortable with them as well, yeah, that was one of the takeaways that I had from I've reviewed our course that we're launching this month and you know, there's just so much technology and you know it's just interesting, kind of from a global perspective. I feel like, as pharmacists, we were always focused on medication, and now there's a technology component to you know, and there's a pharmacogenomic component, and you know there's all these other things that we need to think about as pharmacists. So it's, you know, this is a perfect example of one of those technological advances that it's so important to stay up to date, and I think helping other providers to do that as well. You know, that could really be our role.

Speaker 2:

Yeah, I think you know they're very much. You know the CGMs or technology in general for diabetes, historically, POMs or software that could be used in the hospital, or the connected insulin pens that are available, and so things are just becoming more sophisticated as technology advances and we know that's probably always going to be the case and I think it's very important for us as pharmacists that we are the medication experts, important for us as pharmacists that we are the medication experts yes, so we can interpret the CGM data and probably be able to say this is the medication change that we need to shoot for, particularly as we have targets with the reports as far as time and range and time above range and time below range. We love those numbers as pharmacists, so it makes it easier for us to recommend a change. But it's going to be very important for us to stay up to date because with technology, it's like your iPhone it could be updated at night and then the next morning you're wondering how do I use this? That's why they have the tips type of yes that I often need.

Speaker 2:

Yeah, that automatically like opens or shows up on your screen whenever there's an update, so you know what to do. But that's, that's like technology for diabetes is that there's going to be something new that comes out, and we need to also know how to use that, because it helps us better educate individuals. So even if you have the opportunity to wear one, it's going to make that counseling easier, because you're going to go through what the patient goes through. Even using the app, you have to set up an account in order to then place it on yourself, and I think it just makes it easier and more relatable. You may experience some of the things those individuals will also experience once they go home and start using the CGM device.

Speaker 1:

Yeah, it's such a good point to stay up to date on the technology, because technology is changing so fast. I mean, you talk about the iPhone. I usually have to go to my kids and say, okay, what's new, what, what should I do, what? Because technology is changing so fast. I mean, you talk about the iPhone. I usually have to go to my kids and say, okay, what's new, what should I do, what should I not do? And they're always like, oh, don't do this. Or you know, I'm like, how do you know this stuff? So I don't know if they're going to TikTok and finding it or what, but it is. It's such a good point that you know. You know we're always thinking, I think as pharmacists, on staying up to date with the medications, but that technology in this space in particular is so important and then being able to help patients through that Such a great point that it's so good to wear that so that you know what.

Speaker 1:

You know what patients are seeing and dealing with. And I think it brings up a really good point too in terms of you know, depending on where your practice is, the pharmacist is going to get involved at different points. You know they may be the one to initiate that therapy, or that may be happening in the physician office or in a diabetes education center. If you're in, you know, a bigger community, if you're in a rural area, you may be the person you know you may be the person doing that, and so it's so important to know that. But I think, no matter what area you're in, you're always going to be working with patients after the fact, so you know. So what are those important points of you know somebody who's already wearing one? You know, what do we need to stay up to date on so that we can help patients, you know, through the technology issues or the medications that interfere with things, or I?

Speaker 1:

mean I just feel like there's a whole host of those things that we need to be always asking patients when they come in. You know how's it going, are you experiencing any issues? Or you know what are the things that we need to stay up to date on as pharmacists so that we can help patients who are wearing them, you know what are the things that we need to stay up to date on as pharmacists so that we can help patients who are wearing them?

Speaker 2:

Yeah, I mean, I think, just as you mentioned, our role as pharmacists will vary depending on where we practice. It may also depend on the resources that are available to refer someone to different types of programs or other specialists, and so we may have shared responsibilities, which is fine because the patient will probably hear it more than once. But our responsibilities may differ depending on community based practice, ambulatory care or even for those in the hospital, if they're doing diabetes management, or even transition of care. But I think, you know, for someone that's already wearing a CGM, we just need to continue to build, I think, on their knowledge. They may not have gotten every bit of information on what to do when the CGM was placed, and so I think, going over calibrations for instance, have they needed to calibrate? Do they know if their device requires it or not? Most now, like that we would see in practice, like Freestyle Libre 3 or Dexcom G7, it's none or it's optional, right, but if they have a pump, maybe they have to, like a Medtronic, so it just is going to vary like a Medtronic, so it just is going to vary. Maximum sensor wear would be good to kind of remember and be up to date on, because they do need to change it out. Assessing the skin reactions on where they're placing it would be good, and making sure that they're rotating so often. Having six to 10 sites already identified so they can rotate would be good to go over.

Speaker 2:

I think other things would be, you know, their apps, their ability to share the data remotely. They may not know that they can share that with their primary care provider or their other specialists. They may not, you know, have other people remote in if they needed to, like I mentioned, with family members. But I think as pharmacists we need to always be asking about medications to make sure that there's nothing interfering with the levels. There's several medications that can actually falsely elevate blood glucose, and some of these can do it anywhere from 60 milligrams per deciliter to 100 milligrams per deciliter, and some can be more immediate after ingesting, maybe, an interfering substance, whereas some can affect the blood glucose level, you know, up to 10 hours.

Speaker 2:

The main thing is that as pharmacists, we have to be up to date on the interfering substances and which ones those are, but how they vary for each CGM.

Speaker 2:

It's not the same across the board and to me that's important regardless of the setting, because I can think back to my hospital experience and during the COVID pandemic, when we're giving high doses of vitamin C and that interfered with just the self-monitoring, the point of care that's done, but also with those wearing CGMs.

Speaker 2:

We had to keep that in mind and maybe other hospitals had to do the same as they utilize CGMs, you know, to kind of preserve PPE or nurse exposure during that time. So I think that there's a lot of things to kind of build on someone's knowledge when they come in and after having worn it maybe once or a couple of times. It could also be how to change the alarms, if that is the option, depending on the CGM, how to maybe make adjustments at home. That's not going to be for everybody based on CGM data, but some individuals may be more advanced and have had diabetes for a longer period of time that they're going to be able to do that make some more adjustments depending on their trends. So there could be a list and there's some definite resources out there through multiple organizations. There's diabetes organizations that have resources on CGMs that may have patient-friendly handouts that could be utilized as well no-transcript.

Speaker 1:

So, like I mean, are there kind of a list of questions that you would recommend a pharmacist ask? You know, maybe every time somebody comes in to get their you know medications refilled, you know, are you experiencing any sensor issues? Or you know, have medications changed? Or you know what are those most important points to ask?

Speaker 2:

Yeah, I mean I think the list of questions could be useful, but I think you probably, depending on the time in your role and what else you have going on, kind of limiting but leaving them open you could be a way to go. So, like you mentioned, what, um, what issues are you currently experiencing with your cgm device could open the door for anything to be received from that individual? And then maybe asking some pointer questions regarding the sensor. Um, if they're still using Dexcom G6, like their transmitter, because the transmitter has to be kept for 90 days, if they're on a pump, right, any issues between the pump and the CGM you know that could bring up, then, I think, other questions to be asked. So I think you could have main ones, just like the medications Are you still taking these medications, anything new? But also the doses. Like we can't just focus on that. There was a medication, it could be. Were there any dose changes as well with that?

Speaker 2:

But then you know, I think it really depends on what happens, like if someone says their CGM has been falling off. That could lead to a spiral questions like have you had to go through? Did you try to replace another one? What sites are you going to. Can you show me how to do it? Because you can get demo, some demo products of the CGMs to walk somebody through it and maybe they have to show you. So probably some general questions would be good, but then of course it's going to be individualized depending on what that patient reports or responds back to you.

Speaker 1:

Regarding some broader questions initially, yeah, yeah, so much to know and some of those things you talked about. I think it's a great way to get technicians involved as well and, you know, providing some some information and education to the technicians about the questions to ask and the things maybe to look for, to then pull the pharmacist in for some more education. So that's a really great opportunity for the whole team to participate in that. Yeah, well, this, I think, if nothing else, this has left me with a lot of questions, and we could go on and on, I think, and talk about CGMs forever.

Speaker 1:

There's so much to know and I think it's such an important area to be pharmacists to be up to date in this, and I know we've got a lot of resources as well, um, with CE Impact, that that people can get more education on CGMs. Um, we actually have a free um webinar coming up, um next week. So, uh, I'll talk a little bit more about that at the end and how people can register for that, but, um, there's just so much information and and I think it's really important, no matter what your practice, to know the basics at least about CGMs and if your patients are on them and the things to look for. So thank you so much for being with us today. I really appreciate it, and I don't know if there's any like parting last words, like what's your most important takeaway for pharmacists in this space?

Speaker 2:

words like what's your most important takeaway for pharmacists in this space? I think that you know when I think about it. It's we emphasize, it's important to stay up to date. But I think, depending on where you practice, you probably will get comfortable with like one or two personal CGMs and I think knowing as much as you can to educate individuals on those devices would be great, because you know we could talk for hours about how to optimize alarms for each of these devices between glucometer and CGMs, the directional arrows for interpretation, even like when they fall off what to do, and the skin reaction. So I think, again, knowing that knowing the general information about CGMs is very valuable, but then building upon that, as you may utilize just one or two in your practice, I think will then give you the confidence as a pharmacist to provide that thorough information to the person new to the device or has been using it consistently.

Speaker 1:

Yeah, I think that's a really good point, and I think this is one of those areas where there's so much that sometimes people aren't, you know, wanting to delve in, because there are, like you said, every device has its own nuances. So really good point to you know, find a couple that you're comfortable with and stick with that. So thank you, thanks for sharing that. Well, thank you again for being with us today and sharing your expertise. Like I said, we only scratched barely of the surface of this topic, so so much more to know. So, you know, stay tuned for more information and education. And thank you for for working with us on all of that other content that we have, if people really want to become an expert in this area, which I think we all should be truly, because there are so many people that it impacts. So thank you again, dr Clements, for really want to become an expert in this area, which I think we all should be truly, because there are so many people that it impacts. So, thank you again, dr Clements, for being with us today. Really appreciate it. And that is it for this week. If you are a CE plan member, be sure to claim your CE credit for this episode by logging into CEimpactcom and, as always, have a great week and keep learning. We'll talk to you next week. Hi, this is Jen. Thanks again for listening in.

Speaker 1:

I wanted to let you know that, if this content intrigued you, you should really think about becoming a CGM expert. Whether you want to help your patients get the best outcomes and triage their CGM issues, or you want to get reimbursed for providing CGM services or you want to do both, you'll learn all of it by earning a CGM services. Or you want to do both, you'll learn all of it by earning a CGM badge. With our six and a half hour course. You can buy the CGM badge on its own or you can buy an elite annual CE plan to get this course, all of our expert badge courses and unlimited CE, including this podcast. It's really the best deal around. Buy it today and start earning your CGM badge. I've taken the course already and I guarantee you won't be disappointed. Buy it through the show notes today and let me know what you think. Happy learning.