May 15, 2018, Dr Chee L Khoo
You probably think that insulin pump (so-called continuous subcutaneous insulin infusion or CSII) and continuous glucose monitoring (CGM) are all to do with Type 1 diabetes (T1D) in diabetes centres and you probably don’t need to know about it, you are probably right. Well, almost. I mean, how often do you come across CGM and CSII in general practice? Well, that’s about to all change and we better be ready for those changes. I need to declare my interests in here. I, too, know very little about pumps and glucose sensors.
So, what are we trying to achieve in the management of glucose in our patients with T1D? Good glycaemic control, minimal or no hypoglycaemia (especially nocturnal hypos), patient satisfaction and patient engagement. Patient satisfaction and engagement is particularly important because they are critical to patient adherence. When you think about it, the glucose objectives for out T1D are exactly the same for our patients with type 2 diabetes (T2D)!
I hear you say, but T1D is a totally different beast from T2D. T1D has literally no beta cells while T2D has IR and some beta cells left. Well, at least 10-15% of our patients with T2D will need insulin therapy as their beta cells are also literally gone. So, the same issue of hypoglycaemia vs tight glucose control is present.
To achieve that balance, we need more than HbA1c to assess glycaemic control and safety of our therapy. That’s why we need fairly frequent SMBG. Is that enough though we need to assess for nocturnal hypoglycaemia? This is where CGM comes in.
We have ample data telling us that CGM +/- CSII achieve improvement in HbA1c in T1D. CGM also inform us on the frequency of hypoglycaemic episodes and our management can be tailored to minimise that precisely. Studies have also shown that CGM reduce time in hypoglycaemia. Do we have data on T2D then. Yes, we do. In the REPLACE trial 224 patients with T2D were randomised to either monitor their glucose with SMBG or Flash Glucose Monitoring over 12 months. They reported 50% less hypoglycaemia and 52% less nocturnal hypoglycaemia. In the Diamond study, 43 patients with T2D were managed with CGM and CSII (so called closed loop) and they reported significant reduction in HbA1c, hyperglycaemia, glycaemic variability, increased time within target range
With the ready availability of Flash Glucose Monitoring, CGM is already in general practice. The question is are you ready for it? The Tech & Talk Symposium this Friday and Saturday (May 18-19, 2018) has a segment on CGM in general practice. It’s free and it’s not too late to register.
This week we also look at the issue of hypoglycaemia and insulin glargine 300 which has finally made it to the PBS. It’s another tool in our attempt to keep those hypoglycaemic episodes to the minimum.
Haak T, Hanaire, H, Ajjan R, et al. Use of Flash Glucose-Sensing Technology for 12months as a Replacement for Blood Glucose Monitoring in Insulin-treated Type 2 Diabetes. Diabetes Ther (2017) 8:573–586.
Katrina J. Ruedy, MSPH, Christopher G. Parkin, et al. Continuous Glucose Monitoring in Older Adults With Type 1 and Type 2 Diabetes Using Multiple Daily Injections of Insulin: Results From the DIAMOND Trial. Journal of Diabetes Science and Technology 2017, Vol. 11(6) 1138–1146