Results from using a CGM in people without diabetes
A week of CGM tracing in a person without diabetes shows glucose values clustering around 100 mg/dL with short variations above and below.
We asked for our patient's friends and family members who didn't have diabetes to wear a blinded Dexcom G6 and a Fitbit activity monitor to update our current knowledge of what glucose levels are in healthy children and adults without diabetes. The average glucose levels were less than 104 mg/dL with a peak after meals of 129 mg/dL. It was not uncommon to see glucose levels above 120 and below 70 mg/dL across all age groups but sensor values above 180 mg/dL were rarely observed except in participants who were 60 and older. Sensor levels less than 54 mg/dL were rarely seen. Glucose levels improved slightly following exercise, but not enough to be considered significant.
What does this mean for our patients with diabetes? As we start to look beyond using A1c to the amount of time spent in a target range of sensor glucose values, we learned that glucose levels either above 180 and less than 54 mg/dL were uncommon which supports using these limits of high and low glucose levels in patients with diabetes. As diabetes technology and medications develop the target range could be tightened by lower the high range from 180 to 160 mg/dL.
To hear the experience of an "almost normal" person wearing a Dexcom G6. Listen to the Podcast of our patient Craig Stubing as he lends his new G6 to a co-worker who was just diagnosed with prediabetes. It includes a Frappuccino surprise.
Taking a post-meal "Touch-Up Dose" Using Inhaled Insulin— The STAT Study
The fast on and off action of inhaled insulin allowed for a post-meal "touch-up" dose if needed. Use of this technique increased the time-in-range of STAT study participants.
The inhaled insulin Afrezza works much faster than injected insulin and since most of glucose lowering action is finished by the end of an hour there is less concern about insulin stacking. Would it be possible to take a touch-up dose of inhaled insulin and hour or two hours after eating to reduce the post-meal spike?
The answer from the STAT Trial was yes. There were three main findings, the participants who followed the system of taking an additional dose of inhaled insulin after a post-meal spike spent an additional two hours a day in the target range between 70 - 180 mg/dL. Their post-meal excursions were also much flatter than the group who used Novolog as their fast-acting insulin. And then there was less time spent where their glucose less than 60 mg/dL. That occurred 3 minutes a day in the inhaled insulin group compared to 12 minutes a day in the Novolog group.
We were one of five study sites in this pilot trial in patients with type 1 diabetes. All the participants were using a Dexcom continuous glucose monitor that they could use to guide their treatment.
This was a short 4-week study and we discovered that there is a learning curve to using Afrezza. You have to learn how to inhale instead of injecting insulin and the dosing is different. Some participants struggled to change their eating pattern to match the 4, 8 & 12-unit dosing options but it was a great new tool for others. After the trial some wanted to stay on Afrezza, others were happy to go back to injecting and there was a third group who were interested in the occasional use of inhaled insulin for certain meals or corrections.
If you are interested in trying Afrezza, talk with your provider about the option and ask for a sample to see how it works for you.
Early Results from a Tele-Monitoring Study of older T1Ds
Older adults with type 1 diabetes (T1D) are still an understudied population and we know that they are more likely to have episodes of hypoglycemia than younger T1Ds. Would it be possible to monitor a group of older T1D's to see if low glucose levels could be prevented?
We conducted a short 14-week pilot study with a group of ten participants who were using a Dexcom CGM and owned a smartphone capable of transmitting data. A morning review of glucose readings from the prior day could trigger either a technical support call or an educational intervention if a hypo event was noted. Our study was funded by the money given to us by our greatly-appreciated donors.
The trial has just completed, and we are analyzing the data, but we have a few observations. Initially the challenge was simply creating a stable connection to the smartphone followed by testing ways to transmit the data with a three-hour delay. We developed an app with Tidepool that provides an automated alert dashboard to identify participants with connection or low glucose issues. Then we reach out to patients who have an alert with a telemedicine connection and follow troubleshooting protocols to help them improve their care. The data we obtained from our pilot study is being used to apply for an NIH grant to determine if we can make a difference in a larger population. If this is true we will be the first group to show this sort of automated diabetes dashboard can improve the health of our patients. We certainly know that remote monitoring can help people with heart disease, so why not diabetes?
Simple Language Pen & Pump Guides
Work continues on the simple language guides for insulin pumps and pens. They are being updated to include pediatric patients as well. Funding has been secured for additional guides to cover continuous glucose monitoring, preliminary work on those guides has begun.
This work is funded by the Helmsley Trust and the guides are geared to a fifth-grade reading level. The current guides are available now and are free to use by any individual or organization to promote diabetes education and educate patients on the use of insulin pens and pumps.