Personalized Precision: Continuous Glucose Monitors (CGMs) as a Partner in Every Diabetes Journey

Video Transcript:

Robin Loveday: Hello and welcome, everyone. My name is Robin Loveday. I'm a nurse practitioner, CDCES. And today, we're going to discuss the role of continuous glucose monitoring, or CGM, with managing diabetes. We're going to review benefits, challenges associated with this type of device, barriers to adoption, but also the unique benefits of this device in different subpopulations of patients living with diabetes. If you'll start us off and introduce yourself.

David Doriguzzi: Thanks, Robin. I'm David Doriguzzi. I'm a physician assistant. I've been working as a diabetes specialty PA for about 23 years. I am with a large medical group in Northern Los Angeles County in Lancaster, California. And it's a pleasure to be here today.

Dr Anita Swamy: I'm Dr. Anita Swamy. I'm a pediatric endocrinologist, and I specialize in diabetes. And I'm in the awesome city of Chicago, Illinois, and honored to be here today.

Dr Aaron King: My name is Dr Aaron King. I'm a family medicine physician in San Antonio. I've had an area of interest in diabetes now for about 20 years and enjoy taking care of full scope adults both with and without diabetes and also take care of type 1 diabetes.

Joy Ashby Cornthwaite: I'm Joy Ashby Cornthwaite, and I'm a registered dietitian and a certified diabetes care and education specialist. I lead a group of clinicians taking care of high-risk pregnancies in Houston, Texas.

Robin Loveday: So, let's talk about medications and let's talk about the synergistic effect that you all see there. And, obviously, CGM helps patients to better understand, right? They're making the behavioral changes. They're seeing things, quality, quantity. GLPs is the big trendy medication now, right? Can you guys talk to us a little bit about CGM and how it plays a role there?

Dr Aaron King: I'd like to jump in there, Robin. I think if you had asked me, if you did a study looking at patients going on GLP-1s and you added some of those to CGM as well, would the CGM have an additional benefit? And my honest gut impulse would be, no, I don't think so. These GLP-1s are so powerful. They're really transforming diabetes, as you said, for obvious reasons and good reasons. Maybe we can't add to that with CGM. And yet, our data that we have is surprising and that I would've been wrong. It turns out that actually patients do better on GLP-1 plus CGM.

And I think there's a lot of different potential reasons for that. But a lot of that is that feedback and that constant touchpoints that we get with CGM, or that the patient gets. We forget that we only see them every 3 months. And so, for that 15 minutes that we see them—if we're lucky to see them every 3 months—it's a very concentrated conversation. And then, they're going home and living with this disease for 99% of their life.

And so, the CGM is there basically to walk them through the rest of that life when we're not there to help. And so, it makes perfect sense as somebody motivated to take care of their diabetes, to eat better, to potentially lose weight. And we have these agents that can help with all that. We can then augment that further with CGM. And so, I try to remember that data when I'm prescribing GLP-1s that CGM can still be of great benefit here as well.

David Doriguzzi: I've noticed that there's different reasons that patients won't take medications. If it's making them feel worse, if they're experiencing adverse effects, they're going to stop taking medication. But a patient also won't take a medication if they don't believe that it's actually helping them, even if they feel fine. I mean, how many times have we prescribed a statin to a patient and 3 months later you come back, and they tell you that they stopped taking it because they didn't feel any different? You're like, "Well, that was kind of the point."

But if a patient doesn't get a perception that this drug that I'm taking is actually doing something for me, why would they take it? And I can understand that mentality. Having a CGM gives them that knowledge to see that what we're prescribing them may actually be doing them some good. When they start seeing the difference in their time and range, when they look at their phones and they see that green bar growing, and they see the reds getting less, and they see the yellows becoming more narrow, I mean, that's a really, really encouraging thing. And when a patient is encouraged, they're far more likely to be—and I hate using this word, but compliant, right? They're going to be more part of the team because they feel like they're actually accomplishing something.

Dr Anita Swamy: And I think it's not just specific to GLP-1s but any drug. I don't care what I put you on, whether it's SGLT2, GLP-1, you name it, DPP-4 inhibitors, the point is that you are now having that patient aware of the drug effects. And separately, they can also see the food effects that I know we're going to talk about a little bit more later. But I think marketing is huge and people might not realize what all these products have in them or drinks with sugar.

They might not realize what that sugar actually does to their glucose. And so, you might speak till your blue in the face. I used to say, "No soda. No soda." And then, having someone come in and say, "I drank this, and my sugar went to 400," and it's like they have that eureka moment. And so, they're much less likely to do it. Even if you are having them on other drugs, it's important to have that component of self-awareness.

Dr Aaron King: You know, David, one other scenario that I think of when we talk about GLP-1s and the incretin therapies. In primary care, as you know, the incretin therapies have been out now for about two decades. And yet, it took primary care about 10 to 15 years to really get comfortable. And so, we saw a great uptick in the prescribing habits of incretin therapies in the last five years.

Well, what that amounts to is we have a lot of patients on basal insulin. That was kind of the right approach, if you will, after you failed one or more oral agents 10, 20 years ago. And so, the real question is, how do we now put these patients on these therapies that we know are advantageous and how do we get them off of their basal insulin safely?

And I get that question a lot from primary care doctors that I'm talking to. And the truth is there's no one answer. There's a lot of different strategies and techniques, but it all depends on the individual situation. Well, what better way to see that individual situation than with Dexcom? So, if that Dexcom is in place, now I can make educated recommendations on how to offload the basal while uptitrating the incretin therapy.

David Doriguzzi: And for engaged patients, it really empowers them to be able to be informed enough to make those self-titration adjustments as needed. Whereas before, we might not have really wanted people to make a whole lot of unguided choices on insulin doses, but now they can see every day what their needs might be. And if suddenly they don't need as much insulin, hallelujah, cut back the dose and you're now aware of that.

Dr Aaron King: And in a busy primary care office where you don't want callbacks, I find you're exactly right. Most of the time patients understand this concept. It's not complicated, right? Maybe give them a basic strategy if your blood glucose goes low, decrease your insulin by this much. And I find often they come back in 3 months and say, "Hey, I'm happy to report, I'm no longer taking insulin." I got off of that safely without hypoglycemia.

David Doriguzzi: That's amazing.

Robin Loveday: Yeah, I always call that deputizing my patients when I would tell them to do something. And so, in addition to increasing the medication, can you guys talk a little bit more though, because CGM fits into that equation, because it's allowing people to see their behaviors, what is that like though to deprescribe, and that medication list suddenly becomes that much shorter? I imagine your patients are very excited and—yeah. Can you share any more stories?

Dr Aaron King: Yeah. Well, I mentioned the one earlier, and it's amazing to see the countenance change. When somebody is not to goal, they feel a little bit like a failure. They feel a little bit guilty. They're taking multiple medications. For them to then come off of therapy and still be achieving success, changes their whole perspective on their health, on the outlook of themselves and what they can accomplish. It's so empowering for the patient and it's amazing to think that just a tool that really I was the gatekeeper for, and if I hadn't brought that up or allowed that to happen, maybe it wouldn't have occurred. All it took was me simply saying, "Yes, you can have this technology” to give that patient that power over their own health is really meaningful.

Robin Loveday: So, Dr King, with that being said, how have you and your practice seen CGM impact your patients’ glycemic control? What was that empowerment like for them?

Dr Aaron King: Yeah. Well, I always say that CGM is the single most important thing you can do for your diabetes. And the analogy I like to use is that of when you're on insulin, especially, but even in oral agents that cause hypoglycemia, diabetes is like driving the car. And there are ditches on either side of the road that can be very dangerous.
And what if it's night and you can't see? The way BGM used to work is we would flip the lights on in the car, see where we're going, and then turn the lights off in the darkness and drive down and hope we don't end up in the ditch. Very unsafe, very dangerous. Now that we have CGM technology readily available, it's like the lights on the car are on all the time and you can greatly avoid the ditches and just head right down the road successfully.

David Doriguzzi: Yeah, I agree with everything you just said about enabling a patient to be treated much more safely. And I think patients really want to do well. One thing that I've really noticed about the patient journey is that it really sort of gives patients the motivation to keep working at this, because patients want to be successful. Patients want to be healthy, and patients will do things that allow them to be successful in that goal, right? Patients won't do things if they feel like it is unhelpful.
I mean, just look at the supplement industry. There's an entire industry out there that is giving people the hope of, “This is something that will help your problem, and it's not medication.” And people are, "Yes, thank you." I'm not trying to say anything negative about the supplement industry. There's probably plenty of things out there that are quite helpful. But the concept is that people would like to be better with the least amount of medications possible, and I think we want that for our patients as well.
So, it's important to remember that there is, particularly with type 2 diabetes, there is a whole world of efforts that patients can make—whether it's diet, lifestyle, a combination of the two, decreasing stress, improving sleep quality—that will improve their ultimate outcome. And enabling them to be aware of the cause-and-effect relationship between each of those variables and what it does to their glycemic control is highly motivating.

If a patient puts in all sorts of effort, diet changes—but they don't really have the guidance—exercise, but maybe they don't really know how much or what type to do. And they're trying. They're really legitimately trying. And then, they put all that effort in for 3 months, just to come back to my office and see that their A1C is still above 8. That is profoundly disheartening. That is super discouraging. And I really believe that that's where a lot of our patients give up.
But if they can see in between in real time what works, what doesn't work. "Oh, I thought oatmeal was healthy and good for me, but wow, look what happened." And they don't even need me standing there next to them telling them what to do in every moment. They have that feedback in real time. And what they learn on their own, the conclusions that they draw from their own experiences, are always going to be much more impactful than anything that I tell them.

Dr Aaron King: Yeah, I agree. And I want to add there that even though it—as I always say, “It seems like a good idea.” We know that it is a good idea. Meaning that, we have both real-world and prospective data looking at 1 week, 1 month, 3 month, 6 month, 12 months. Patients not only gain that control, but they also keep it there. And that shows you the value of what you're talking about, that if patients didn't find that value there, they would stop the therapy. But they don't. Over 90% of patients continue that therapy indefinitely. And so, we know that they're getting that feedback, and it continues to work. It's not a temporary motivational factor. It's a lifelong journey that they're walking through with this technology.

Joy Ashby Cornthwaite: So, one of the important tenants of—and the connecting threads of what you just spoke about—is the idea of self-efficacy. So, as a dietitian in this space for a very long time—I won't tell you exactly how many years—having patients come in and, despite the pain, despite the burden, despite the stigma, despite the time-consuming checking their blood sugars, people would continue to do that. And they would do that and adjust whole medication, as well as their food choices for not only themselves but their entire family.

And to come back and only have four finger sticks that said, "I am still not succeeding," that was a huge detriment to all of the gains that had been achieved in the 2 weeks or 4 weeks between visits with them. What CGM allows patients to see is to see how their changes are impacting their glucose.

And that repeated positive reinforcement boosts self-efficacy in ways that we have come to understand through research. So, you've got motivation involved there. You've got repetition and habit-forming involved there. You also have the positive influence of everyone in the family is feeling better and you haven't made these huge changes to your entire family's grocery list and eating habits for nothing to end up being more positive.

Coming in and having a blood glucose value and having someone circle on your piece of paper in red ink to say how terrible you've done is not really a good positive motivator. But if you have an AGP and a compare from before and after that says, "I have done a better job this time—there is more green involved," it's highly motivating. And that self-efficacy is what keeps them going 12 months down the line.

Dr Anita Swamy: I think in diabetes type 1 or type 2 is a feeling of failure and guilt, and there's a lot of blame and judgment. And we were even practicing in that way for decades because that's how it was. And so, I'm so happy we've come a long way. But I feel like CGM has been the tool to help us really understand and get there. So, just to share a personal story, my entire family has type 2 diabetes. And my dad actually passed away from complications of type 2 when I was 12. So, that was the impetus for me to become a diabetes doctor.

And through my training and my fellowship, we had an opportunity to wear a sensor. And I was fairly healthy, and I thought I did a pretty good job. And, lo and behold, I had prediabetes. And I, a medical professional, had no clue. And so, that really was the moment for me where I said, "How can I expect anyone else to understand if I had no idea?" And also, I kept blaming myself or I'd get upset if I ate something I shouldn't.

And so, I think it's more learning over time that there's things in moderation. There's things that are in your control. The whole term, brittle diabetes, I think comes from people's lack of control and lack of understanding. And I tell people it's not brittle, it's just that we were educated and uninformed. And so, this is now informed diabetes. It is empowered diabetes. And I feel like, back to what you were saying, Dr King, about the headlights. I think that is so critical, even for providers, for us to understand. I have every patient on a Dexcom G7 for that reason.

Robin Loveday: Thank you all so much for your time and your expertise. This has been an absolute pleasure, and thank you so much for joining us.