Basic Sugar SurfingStephen W. Ponder MD, FAAP, CDE

What can a CGM help with?

• Prevent after meal BG spikes• Correct low & high BG more accurately• Prevent severe low blood sugars• Reveal subtle shifts in BG• Reduce the fear of lows, especially at night• Lower the A1C levels• Feel more “normal” (even self-confident)

What I will not be discussing…• Costs of different CGM devices

– That depends on your insurance– There is a cash price too

• How to purchase a CGM device– Operators probably standing by now– Need Rx to get insurance to consider

paying

• How to insert or start up a CGM– There are trainers and apps for that

• Estimates sugar level from interstitial fluid

• Calibrated with fingerstick blood sugar levels at least twice daily

• Readings provided every 1 to 5 minutes

• Drift and imprecision are possible

24 hour glucose plot – A1c 5.7%

1st Rule of CGM:Your blood sugar levels are unique.Trends and patterns are what’s important

Diabetes control exists largely in the momentNo two days are ever the same…

Each day is unique…

“You can never step into the same river; for new waters are always flowing on to you.” Heraclitus of Ephesus

8 versus 1440 “decision points”

7:03 115

9:33 129

12:15 95

3:34 131

6:12 168

9:49 107

11:53 114

3:05 132

*

*

*

*

*

*

*

*

One goal of diabetes care is managing glucose…

FLUXdrift

Hint: It takes TIME and PATIENCE!

Non-diabetic persons

Sugarlevel

In Out

Why do blood sugar levels shift all the time?

static vs. dynamic diabetes carestatic• Actions predetermined• Minimal to no flexibility:

RIGID• Outcomes don’t

immediately affect subsequent actions

• Easy to teach/learn• Less time-intensive• Favors concrete thinking• Less motivation needed

dynamic• Actions are dependent on

situation/circumstance• Flexible and adaptable• Outcomes influence

subsequent actions• Training needed, plus

ongoing reinforcement• More time intensive• Favors problem-solving• Requires motivation

Ways to use RT-CGM technology

“Burglar alarm” “Surveillance system ”

Principles of advanced CGM use1. A CGM is no better or

worse than the person wearing it.

2. If you can measure it, you can predict it.

3. Flux and drift happen… manipulate them!

4. Keep your eye on your line.5. The trend is your friend6. Learn lag limits; be patient

7. Zero in on your zone8. Master micro-dosing9. Factor in glycemic inertia

and insulin momentum10. Don’t let “good enough”

be the enemy11. Calibrate carefully12. CGM as “sugar surfing”

or “day trading”

Set “actionable” thresholds• Upper/Lower limits

– 80 mg/dl and 140 mg/dl– 90 mg/dl and 180 mg/dl

• Rates of change– Up or down arrows

• Factor in recent/current/future events as you are able

• Test your skills, experiment a little within reason

A pancreas can’t predict the future

• It just can act very fast so it doesn’t have to.

• Can shut off insulin immediately

• Can release preformed insulin

• Insulin released can start working in minutes

• Can respond to rates of change in sugar levels

Traits of effective CGM users• Wear it all the time• Check trend line often• Work the “lag” times

– FOOD– INSULIN– SENSOR

• Not afraid to experiment• Not expecting perfection

Penny stock day trading strategyCGM - glycemic day trading tool

“sugar surfing”

BG awareness vs. alarm fatigue• Set reasonable alarm

thresholds– Depends on your goals

• Avoid high spikes?• Avoid lows?• Toddler? Child? Teen? Adult?

• Make sure you can hear/sense the alarm

• Anticipatory action can minimize alarms

Living with a CGM

• Keeping up with receiver (if not part of pump)• Keeping up with meter/strips/lancing device• Sensor unit size and longevity (recycling)• Showering/bathing/changing clothes• Taping and securing• Air travel (security and seating)• Acetaminophen can cause “headaches” (Dex)• Charging up/downloading• Logging events

Human hair

CGM sensor

under skin(not in a vein)

• LCD Display.

• 20 feet range between Transmitter and Receiver.• Rate-of-change arrows tell you where your glucose is

headed and how fast, to help you avoid the highs and lows before they happen.

• Approved by the FDA for up to 7 days of use in patients

2 and older.

Taping tips

“Fried-food revenge” and correction

Fried food earlier in evening @ 8PM

BG = 1946 unit correction @ 7AM

BG = 115 in 3 hours

“Revenge of the Ribeye” and “The Insulin Strikes Back”

SLOW RISE

BG 167: 4 units

CORRECTION

LAG

2-3h

Slow BG rise from protein-fat laden meal

Basal testing…

Time to correct

> 2 hours

Fine tuning a correction…

62 mg/dl

8gm

Timing 101 – 20 min. match

Insulin

Food

Timing 101 – 45 min. mismatch

Insulin

Food

Overnight in range!

Day in the life…

Overnight rise, correction and meal

Slow overnight rise and early AM correction

“THE TREND IS YOUR FRIEND”CHECKING INSULIN BOLUSES WITH CGM

6 pm 8 pm 10 pm

300

200

100

60

Carb bolus Correction bolus

6 pm 8 pm 10 pm

Goal: green lines

Learning from the Line Graph – Effect of Exercise

2p 4p

70140

210

350

280 Bike ride – 60 minutes

E

2p 4p

70140

210

350

280

E

No insulin adjustment w/ basal rate reduction

CHO

Learning from the Line Graph – Correction dose

70140

210

350

280

8a 10a

“Stacked” insulin

I I 70

140

210

350

280

Blood glucose: 212 mg/dl

Correction dose: 5.5 units

I

Proper correction

Blood glucose: 212 mg/dl

Correction dose: 5.5 units

Correction dose: 3.5 units

12p 8a 10a 12pCHO CHO

Learning from the Line Graph – Insulin Timing

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Insulin bolus: 7:30 AM

Breakfast: 7:30 AM

Insulin bolus: 7:10 AM

Breakfast: 7:30 AM

MI MI

Learning from the Line Graph – Effect of Food

8a 10a

70140

210

350

280

8a 10a

70140

210

350

280

TodayYesterday

Bagel Breakfast Oatmeal breakfast

M I M I

Don’t Stack your Insulin!

Slide courtesy of Jen Block RN, CDE and Stephen Ponder MD CDE

Learning from the Line Graph – What would you do?

4:30 pm 6:30 pm

70

140

210

350

280

1. What did I do?

2. What am I doing?

3. What will I be doing?

4. What do I need to do?

Learning from the Line Graph – What would you do?

12:30 pm 2:30 am

70

140

210

350

280

1. What did I do?

2. What am I doing?

3. What will I be doing?

4. What do I need to do?

Learning from the Line Graph – What would you do?

12:30 pm 2:30 pm

70

140

210

350

280

1. What did I do?

2. What am I doing?

3. What will I be doing?

4. What do I need to do?

Turnaround Time : glycemic inertia

Corrections may need to be adjusted 10-20% to compensate

Goal: Try to stay between the lines

As readings improve, lower the glucose for the upper alert

Don’t pass up an opportunity to correct a high (or low) BG

• Choose what you consider “actionable”?

• BG above or below chosen thresholds

• Consider recent and impending actions

• Check your results with BG levels

• Repeat as necessary

Curb your liver!

• The liver makes as well as stores sugar

• A proper insulin level “calms down” the liver

• Aim for an in-range sugar level (<120 mg/dl)

upon waking up each day

Principles of advanced CGM use1. A CGM is no better or

worse than the person wearing it.

2. If you can measure it, you can predict it.

3. Flux and drift happen… manipulate them!

4. Keep your eye on your line.5. The trend is your friend6. Learn lag limits; be patient

7. Zero in on your zone8. Master micro-dosing9. Factor in glycemic inertia

and insulin momentum10. Don’t let “good enough”

be the enemy11. Calibrate carefully12. CGM as “sugar surfing”

or “day trading”

Questions?