Q&A: Standards of Care encourages more people with diabetes to use CGM
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Key takeaways:
- The 2024 ADA Standards of Care recommend continuous glucose monitoring for all people with type 1 diabetes.
- CGM and certain insulins help people with diabetes quickly recognize, prevent and treat hypoglycemia.
The 2024 American Diabetes Association Standards of Care put an emphasis on getting continuous glucose monitoring into the hands of more people with diabetes.
Joanne Rinker, MS, RDN, BC-ADM, CDCES, LDN, FADCES, a board-certified advanced diabetes manager, reviewed some of the biggest changes in the 2024 ADA Standards of Care during a poster presentation at the International Conference on Advanced Technologies and Treatments for Diabetes. Many of the changes revolved around the importance of CGM use, including for people with type 2 diabetes who use basal insulin.
“There were three big messages,” Rinker told Healio. “One is that there’s a huge push for CGM use. Any adult on insulin, even if it’s basal insulin, should be offered a CGM. Another message is there was a specific focus on how time in range is directly correlated with microvascular complications. That means if we’re seeing that time in range is not 70% or greater, this is a time for us not only to be talking to [people with diabetes] about management of blood sugar, but we also need to talk to them about screening for complications. The last message was a big focus on hypoglycemia awareness. If there is frequent hypoglycemia in a patient, then there needs to be a discussion at every encounter about hypoglycemia, making sure they understand how to prevent hypoglycemia, and how to treat it.”
Healio spoke with Rinker about technology-related Standards of Care revisions, why CGM access is being recommended for more people with diabetes and how providers should use CGM metrics to enhance care within their practices.
Healio: Why is it crucial to offer CGM right away for people with type 1 diabetes?
Rinker: There’s so much more information from a CGM. When we look at HbA1c, it’s giving us an average glucose, but those people could be having highs of 400 mg/dL and lows of 40 mg/dL. When we can look at CGM data, we can see where the issues are in their day, and we can pinpoint them and focus on that.
CGM use is increasing because we can actually pinpoint those trends and we can work on getting that time in range tighter and decreasing these risks of microvascular complications. I feel like you need to be wearing a CGM to know your time in range, and knowing your time in range will help you to forecast if you’re at risk for complications. All of those things coming together is the reason for the push.
Healio: How should providers assess CGM metrics at a clinic visit, and what actions should they take for someone with a time in range of less than 70%?
Rinker: First, time in range should be looked at. Then, what are the trends? Are they often having low glucose levels 3 to 4 hours after meals? If they are, their insulin tail is too long. The ADA is recommending a regular human insulin, either injected or inhaled, because they have shorter tails.
Hypoglycemia always has to be looked at because that’s an emergency. But you should also look at trends in hyperglycemia. Are they having high blood sugar 2 hours after meals? If they are, what conversations should we have with the patient? Are there things they can do in their meal plan? Are they getting enough exercise? When are they exercising? Are they taking their medication as prescribed?
Healio: Do you foresee barriers providers may face with recommending CGM for more patients?
Rinker: The biggest barrier is time. Providers are not given enough time with their patients. There are so many access gaps in this country as far as diabetes care and education specialists. If patients’ only interaction is with the provider, they are only with them for 8 to 10 minutes if they’re lucky. That is not enough time to talk about new technologies. One of the biggest reasons we have therapeutic inertia is because there’s so little time to have the conversation with the patient about making changes to their care, whether it’s a change in medication or a change in technology.
There’s also the cost and patient willingness. Those are probably our three big barriers. I think providers would be willing to offer CGM if they truly had the time to be able to have those conversations.
Healio: Do the ADA’s new recommendation on therapies for hypoglycemia tie in with the new diabetes technology recommendations?
Rinker: Yes, because now we have this benefit of not only seeing the numbers with CGM, we can also see when glucose trends down. It draws our attention to what percent of the time people are spending in hypoglycemia and how we get them out of it.
Before CGM, one of two things had to happen. A person had to not feel well. We would always tell them to check their blood sugar first, because a lot of the sensations of low blood sugar can be the same as very high blood sugar. So it was either a patient reporting that they’d had a low blood sugar between their current visit and the previous one, or they were actually showing up to the emergency room. Now with CGM, as soon as glucose is dropping and we see the down arrow, there are alarms going off and people are treating it. They’re not getting into a place where they’re having hypoglycemia.
For more information:
Joanne Rinker, MS, RDN, BC-ADM, CDCES, LDN, FADCES, can be reached at jorinker@gmail.com.
Reference:
Rinker J. American Diabetes Association 2024 Standards of Care in diabetes living standards. Presented at: International Conference on Advanced Technologies & Treatments for Diabetes; March 6-9, 2024; Florence, Italy (hybrid meeting).
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