To Normoglycemia & Beyond: Updates in Diabetes Therapy - Utah Academy of Family ...
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To Normoglycemia & Beyond:
Updates in Diabetes Therapy
Hanna Raber, PharmD, BCPS, BCACP Elizabeth Bald, PharmD, BCACP
Assistant Professor (Clinical) Assistant Professor (Clinical)
University of Utah College of Pharmacy University of Utah College of Pharmacy
Utah Academy of Family Physicians
OBJECTIVES
• Compare & contrast the benefits of SGLT2 inhibitors & GLP-1 agonists
as add-on therapies for the treatment of type 2 diabetes mellitus
(T2DM)
• Review available higher concentration insulin products & determine
which patients may benefit from use of higher concentration insulin
• Identify patients with T2DM that would benefit from personal
continuous glucose monitoring (P-CGM) & those that are most likely to
be eligible for insurance coverage of P-CGM
• Utilize P-CGM data to make treatment modifications for patients
with T2DM
Utah Academy of Family Physicians
Presentation Overview
Clinical Updates CGM Overview
• SGLT2 Inhibitors • Patient Identification
• GLP-1 Agonists • Data Interpretation
• Concentrated Insulin
Utah Academy of Family Physicians
DM Clinical Updates
Utah Academy of Family Physicians
MEET RL
CC: RL is a 56-year-old male who presents to clinic for a follow-up appointment to discuss
type 2 diabetes management. RL was recently diagnosed 3 months ago and started on
Metformin (titrated to max dose).
Current DM Medications Vitals: Labs
• Metformin 1g BID • BP: 132/88mmHg • HbA1c
• HR: 72 bpm • 4/11/21: 7.8%
Past Medical History • RR: 16 rpm • 1/13/20: 8.5%
• T2DM • Temp: 98ºF • SCr
• HTN • BMI: 36 • 0.9
• HLD
• CAD
• GAD
Utah Academy of Family Physicians
T2DM THERAPY OVERVIEW
Step 1 Metformin + Comprehensive Lifestyle
Step 2 ASCVD GLP-1 RA* or SGLT2I*
CKD SGLT2I*
HF** SGLT2I*
*Choose an agent with proven benefit in this population
**Particularly HFrEF (LVEF
T2DM THERAPY OVERVIEW
Step 2 Hypoglycemia DPP-4, GLP-1 RA, SGLT2I,
TZD
Weight GLP-RA, SGLTI
Cost SU, TZD
Utah Academy of Family Physicians
American Diabetes Association. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2021. Diabetes Care.
SGLT2 Inhibitors &
GLP-1 Agonists
Utah Academy of Family Physicians
SGLT2 INHIBITORS
Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors
MOA: inhibits transporter in proximal renal tubules which reduces reabsorption of
filtered glucose & increases urinary excretion
Generic: Brand: Starting Dose: Max Dose:
Canagliflozin Invokana 100mg daily 300mg daily
Dapagliflozin Farxiga 5mg daily 10mg daily
Empagliflozin Jardiance 10mg daily 25mg daily
Ertugliflozin Steglatro 5mg daily 15mg daily
Utah Academy of Family Physicians
Lexicomp Online Database
American Diabetes Association. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2021. Diabetes Care.
SGLT2 INHIBITORS: CLINICAL CONSIDERATIONS
Efficacy: Safety:
• A1c lowering: • Genital yeast infection/UTI
• 0.5-1% • Rare: Fournier’s gangrene
• Weight loss: • Increased urination,
• ~2kg dizziness, hypotension
• CV Benefit:
• Empagliflozin, Canagliflozin,
• Hypoglycemia (rare)
(Dapagliflozin) • Rare: DKA
• HF Benefit: • Increased LDL cholesterol
• Dapagliflozin, Empagliflozin • Bone fractures/amputations
• Renal Benefit:
• Canagliflozin, Dapagliflozin
Utah Academy of Family Physicians
American Diabetes Association. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2021. Diabetes Care.GLP-1 AGONISTS
Glucagon-Like,Peptide-1 (GLP-1) Agonists
MOA: increases insulin secretion in response to elevated blood glucose, decreases
glucagon secretion
Generic: Brand: Starting Dose: Max Dose:
Liraglutide Victoza 0.6mg SQ daily 1.8mg SQ daily
Lixisenatide Adlyxin 10mcg SQ daily 20mcg SQ daily
Exenatide Byetta 5mcg SQ twice daily 10mcg SQ twice daily
Exenatide XR Bydureon 2mg SQ weekly 2mg SQ weekly
Dulaglutide Trulicity 0.75mg weekly 4.5mg weekly
Semaglutide Ozempic 0.25mg SQ weekly 1mg SQ weekly
Rybelsus 3mg PO daily 14mg PO daily
Utah Academy of Family Physicians
Lexicomp Online Database
American Diabetes Association. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2021. Diabetes Care.GLP-1 AGONISTS: CLINICAL CONSIDERATIONS
Efficacy: Safety:
• A1c lowering: • GI side effects (~8-20%)
• 0.5-1% • Nausea, vomiting, diarrhea
• Weight loss: • Injection site reactions
• ~1.6kg – ~5.5kg • Up to 23% w/ Bydureon
(Semaglutide)
• Hypoglycemia (rare)
• CV/Renal Benefit:
• Thyroid C-cell tumors
• Liraglutide, Semaglutide,
Dulaglutide
(rodents)
• Pancreatitis/Gallbladder
disease
Utah Academy of Family Physicians
American Diabetes Association. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2021. Diabetes Care.MEDICATION ACCESS
Patient
Uninsured Assistance
Programs
Commercial
Insurance Manufacturer
Discount Cards
Medicaid
Low Income
Medicare Subsidy
Utah Academy of Family PhysiciansMEET RL
CC: RL is a 56-year-old male who presents to clinic for a follow-up appointment to discuss
type 2 diabetes management. RL was recently diagnosed 3 months ago and started on
Metformin (titrated to max dose).
Current DM Medications Vitals: Labs
• Metformin 1g BID • BP: 132/88mmHg • HbA1c
• HR: 72 bpm • 4/11/21: 7.8%
Past Medical History • RR: 16 rpm • 1/13/20: 8.5%
• T2DM • Temp: 98ºF • SCr
• HTN • BMI: 36 • 0.9
• HLD
• CAD Options include:
• GAD • Initiating GLP-1 (Semaglutide 0.25mg weekly x 4 weeks)
• Initiating SGLT2 Inhibitor (Empagliflozin 10mg or Canagliflozin 100mg)
Utah Academy of Family PhysiciansConcentrated Insulin
Utah Academy of Family PhysiciansINITIATING INSULIN IN T2DM
“In patients with T2DM, a GLP-1 is preferred
Step 1
to insulin when possible”
Step 2 Add basal insulin
Step 3 Add prandial insulin once daily
Step 4 Add additional prandial insulin
Step 5 Consider concentrated insulin
Utah Academy of Family Physicians
American Diabetes Association. 9. Pharmacologic Approaches to Glycemic Treatment: Standards of Medical Care in Diabetes-2021. Diabetes Care.MEET SR
CC: SR is a 52-year-old female who presents to clinic for a follow-up appointment to
discuss type 2 diabetes management.
Current DM Regimen Labs SMBG
• Metformin 1g BID • HbA1c • Fasting BG
• Semaglutide (Ozempic) 1mg once weekly • 4/11/21: 8.9% • 135-185 mg/dL
• Empagliflozin (Jardiance) 25mg daily • 1/13/20: 9.1% • Post Prandial BG
• Insulin Glargine (Lantus) U-100 Pen 80 • >200 mg/dL
units daily at bedtime
• Insulin Lispro (Humalog) U-100 Pen 26
units three times daily with meals
Utah Academy of Family PhysiciansCONCENTRATED INSULIN OVERVIEW
PRODUCTS
WHO?
• Patients who require higher insulin doses due to insulin
resistance
• Patients who require multiple injections/dose
• Patients who require frequent pen changes
WHY?
• Less volume= less pain
• Less injections= better adherence?
• Less pens= less cost?
Diabetes Research and Clinical Practice 2019; 148: 93-101
Utah Academy of Family Physicians
Diabetes Obes Metab 2014; 16(10):971-6.
Images obtained from: https://www.humulin.com/what-is-humulinCONCENTRATED INSULIN PRODUCTS
Bolus Insulin Basal Insulin Basal/Bolus Hybrid
Generic Lispro Lispro-aabc U- Glargine Degludec Regular U-500
U-200 200 U-300 U-200
Brand Humalog Lyumjev Toujeo Tresiba Humulin R 500u/mL
200u/mL 200u/mL 300u/mL 200u/mL
Onset 15-30 mins 15-17 mins Up to 360 mins 30-90 mins 30 mins
Peak 0.5-2.5 hrs 2-2.9 hrs N/A 12 hrs 1-3 hrs
(minimal)
Duration 3-6.5 hrs 4.6-7.3 hrs >24 hrs 42 hrs Up to 24 hrs
Preparation KwikPen KwikPen SoloStar Pen FlexTouch Pen Vial & KwikPen
(60 units per (60 units per (80 units per (160 units per (300 units per
injection) injection) injection) injection) injection)
Max SoloStar
Pen (160 units
per injection
Utah Academy of Family Physicians
Lexicomp Online DatabaseBOLUS CONCENTRATED INSULIN
ü INTERCHANGEABLE W/ U-100
Humalog
U-200 ü CONVERT UNIT-PER-UNIT
ü SAME MAXIMUM DOSE/INJECTION, 60 UNITS
ü “ULTRA-FAST ACTING”
Lyumjev
ü CONVERT UNIT-PER-UNIT FROM OTHER BOLUS INSULIN
U-200
ü CAN INJECT UP TO 20 MINS POST MEALS
Utah Academy of Family Physicians
Humalog Kwikpen U-200 [Package Insert]. Eli Lilly and Company; 2019
Lyumjev [Package Insert]. Eli Lilly and Company; 2020BASAL CONCENTRATED INSULIN
ü IF CONVERTING TO TOUJEO, CONVERT UNIT-PER-UNIT,
Toujeo
U-300
ü IF CONVERTING FROM TOUJEO, ADMINISTER 80% OF DOSE
ü ADJUST DOSE IN 2-UNIT INCREMENTS (MAX SOLOSTAR)
ü
AVAILABLE IN U-100 AND U-200 CONCENTRATIONS
Tresiba
ü CONVERT UNIT-PER-UNIT
U-200
ü CONSIDER FOR PATIENTS W/ HX OR RISK OF HYPOGLYCEMIA
Toujeo [Package Insert]. Sanofi-Aventis; 2015
Utah Academy of Family Physicians
Tresiba [Package Insert]. Novo Nordisk A/S; 2015
JAMA 2017;318(1):45-56U-500 INSULIN
ü
CONSIDER FOR PATIENT WITH INSULIN TDD> 200
ü UNUSUAL KINETICS! REPLACES BASAL + BOLUS INSULIN
ü DOSED BID OR TID 30 MINUTES BEFORE MEALS
Utah Academy of Family Physicians
Humulin R U-500 [Package Insert]. Eli Lilly and Company: 2019.
Images obtained from: https://www.humulin.com/what-is-humulinMEET SR CC: SR is a 52-year-old female who presents to clinic for a follow-up appointment to discuss type 2 diabetes management. Current DM Regimen Labs SMBG • Metformin 1g BID • HbA1c • Fasting BG • Semaglutide (Ozempic) 1mg once weekly • 4/11/21: 8.9% • 135-185 mg/dL • Empagliflozin (Jardiance) 25mg daily • 1/13/20: 9.1% • Post Prandial BG • Insulin Glargine (Lantus) U-100 Pen 80 • >200 mg/dL units daily at bedtime • Insulin Lispro (Humalog) U-100 Pen 26 units three times daily with meals ü Switch Lantus 80 units daily to Toujeo 80 units daily or Tresiba 80 units daily ü Max for Humalog U-100 is 60 units/injection Utah Academy of Family Physicians
CGM Device Overview
Utah Academy of Family PhysiciansDEVICE COMPARISON
Personal CGM Professional CGM
CGM owned by user that is worn CGM owned by clinic that is worn
long-term & used to make real VS vs short-term & used for pattern
time treatment decisions identification
Real-Time CGM Intermittently Scanned CGM
measures glucose continuously
measures & displays glucose VS vs but only displays values when
values continuously
swiped by reader/smartphone
Therapeutic CGM Non-Therapeutic CGM
approved by the FDA to replace
SMBG and make diabetes VS vs approved by the FDA as an
adjunct to SMBG
treatment decisions
Utah Academy of Family Physicians
American Diabetes Association. 7. Diabetes Technology: Standards of Medical Care in Diabetes-2021. Diabetes Care. 2021 Jan;44(Suppl 1):S85-S99. doi: 10.2337/dc21-S007. PMID: 33298418.
Longo R, Sperling S. Personal Versus Professional Continuous Glucose Monitoring: When to Use Which on Whom. Diabetes Spectr. 2019;32(3):183-193. doi:10.2337/ds18-009
Therapeutic Continuous Glucose Monitors. Medicare.gov. https://www.medicare.gov/coverage/therapeutic-continuous-glucose-monitors-cgms. Accessed April; 8, 2021.DEVICE COMPARISON
Freestyle Libre: 14-day therapeutic intermittently scanned
CGM system consisting of a sensor/ transmitter worn on the
back of the arm & a handheld reader or phone app
Freestyle Libre 2: 14-day therapeutic intermittently scanned
CGM system consisting of a sensor/ transmitter worn on the
back of the arm & a handheld reader
Dexcom G6: 10-day therapeutic real-time CGM system
consisting of a sensor/transmitter worn on the abdomen
and a handheld reader or phone app
Utah Academy of Family Physicians
Scalzo PL, Brock KA, Isaacs D. Personal Continuous Glucose Monitoring Implementation Playbook. 2020 Association of Diabetes Care & Education Specialists. Accessed April 8, 2021.DEVICE COMPARISON
FDA Sensor Warmup Display Interfering
Alarms
Approval Duration Time Options Substances
Freestyle reader or vitamin C &
age 18+ 14 days 1 hour none
Libre 14 day smartphone salicylic acid
Freestyle age 4+ 14 days 1 hour real-time reader vitamin C
Libre 2
Dexcom reader or hydroxyurea
age 2+ 10 days 2 hours real-time
G6® smartphone & APAP
Utah Academy of Family Physicians
Scalzo PL, Brock KA, Isaacs D. Personal Continuous Glucose Monitoring Implementation Playbook. 2020 Association of Diabetes Care & Education Specialists. Accessed April 8, 2021.DEVICE COMPARISON
LIBRE 14 DAY
FREESTYLE
Reader: $83 for 1 reader
Sensor: $126.36 for 2 (28 day supply)
FREESTYLE
Reader: $83 for 1 reader
LIBRE 2
Sensor: $126.36 for 2 (28 day supply)
Reader: $425 for 1 reader
DEXCOM
Sensor: $129.17 for 3 (30 day supply)
G6
Transmitter: $272.50 for 1 (90 day supply)
Utah Academy of Family Physicians
Get a Sensor. Diabetes Wise. https://diabeteswise.org/how-to-get-a-sensor. Accessed April 15, 2021.Patient Identification
& Insurance Coverage
Utah Academy of Family PhysiciansMEET HS
CC: HS is a 69-year-old female who presents to clinic for T2DM follow-up.
Current DM Regimen SMBG
• Metformin XR 2000 mg daily • Fasting: ~120 mg/dL
• Lantus 60 units every morning • Dinner 2-hour Postprandial: 150-180 mg/dL
• Humalog
• 10-15 units with brunch
• 20-30 units with dinner Insurance HbA1c
• 15-30 units at bedtime • Medicare • 1/20/2021: 6.1%
Utah Academy of Family PhysiciansPATIENT IDENTIFICATION
2019 Association of
Diabetes Care & • diabetes care & education specialist can help identify those
Education Specialists who would benefit from professional or personal CGM
Practice Paper
• CGM in conjunction with multiple daily injections &
2021 American Diabetes continuous subcutaneous insulin infusion & other forms of
Association Standards insulin therapy is a useful tool to lower &/or maintain A1C
of Care in Diabetes levels &/or reduce hypoglycemia in adults & youth with
diabetes
• T1DM: real-time CGM recommended for adults who are
2016 Endocrine Society willing & able to use device on a nearly daily basis
Guideline on Diabetes
Technology • T2DM: short-term, intermittent, real-time CGM recommended
for adults not on prandial insulin who have A1c ≥ 7%
Utah Academy of Family Physicians
American Diabetes Association. 7. Diabetes Technology: Standards of Medical Care in Diabetes-2021. Diabetes Care. 2021 Jan;44(Suppl 1):S85-S99. doi: 10.2337/dc21-S007. PMID: 33298418.
Isaacs D, Cox C, Schwab K, et al. Technology Integration: The Role of the Diabetes Care and Education Specialist in Practice. Diabetes Educ. 2020;46(4):323-334. doi:10.1177/0145721720935123
Peters AL, Ahmann AJ, Battelino T, et al. Diabetes Technology-Continuous Subcutaneous Insulin Infusion Therapy and Continuous Glucose Monitoring in Adults: An Endocrine Society Clinical Practice Guideline. J Clin Endocrinol Metab. 2016;101(11):3922-3937.
doi:10.1210/jc.2016-2534PATIENT IDENTIFICATION
2020 American
Association of Clinical • CGM preferred over SMBG
Endocrinologists & • P-CGM should be considered for patients on intensive insulin
American College of therapy, those with history of hypoglycemia unawareness, or
Endocrinology Executive those with recurrent hypoglycemia
Summary
2017 International • T1DM: CGM recommended for all adults with type 1 diabetes
Consensus on Use of
Continuous Glucose • T2DM: CGM recommended for patients treated with intensive
Monitoring insulin therapy who are not achieving glucose targets
Utah Academy of Family Physicians
Danne T, Nimri R, Battelino T, et al. International Consensus on Use of Continuous Glucose Monitoring. Diabetes Care. 2017;40(12):1631-1640. doi:10.2337/dc17-1600
Garber AJ, Handelsman Y, Grunberger G, et al. CONSENSUS STATEMENT BY THE AMERICAN ASSOCIATION OF CLINICAL ENDOCRINOLOGISTS AND AMERICAN COLLEGE OF ENDOCRINOLOGY ON THE COMPREHENSIVE TYPE 2 DIABETES MANAGEMENT ALGORITHM -
2020 EXECUTIVE SUMMARY. Endocr Pract. 2020;26(1):107-139. doi:10.4158/CS-2019-0472PATIENT IDENTIFICATION
CANDIDATE SELECTION CHARACTERISTICS
• Taking multiple daily insulin injections
• Using an insulin pump
• Frequent hypoglycemia
• Hypoglycemia unawareness
• High degree of glycemic variability
• Not achieving glucose targets
Utah Academy of Family Physicians
Scalzo PL, Brock KA, Isaacs D. Personal Continuous Glucose Monitoring Implementation Playbook. 2020 Association of Diabetes Care & Education Specialists. Accessed April 8, 2021.INSURANCE COVERAGE
MEDICAID MEDICARE COMMERCIAL
varies by state;
covered for
covered for
certain patients varies by plan
certain patients
with T1DM &
with T1DM &
T2DM
T2DM in Utah
Abbott Laboratories. FreeStyle Libre System.
Utah Academy of Family Physicians
Dexcom, Inc. Dexcom G6 Continuous Glucose Monitoring (CGM) System.
Centers for Medicare and Medicaid Services. Ruling No.: [CMS-1682-R].INSURANCE COVERAGE
UTAH MEDICAID CRITERIA
Utah Academy of Family Physicians
https://medicaid.utah.gov/pharmacy/priorauthorization/pdf/Continuous%20Glucose%20Monitor.pdfINSURANCE COVERAGE
MEDICARE PART B CRITERIA
• diagnosis of type 1 or type 2 diabetes
• ≥ 4 daily blood glucose checks
• ≥ 3 daily injections of insulin or a
continuous insulin infusion pump
• insulin regimen requiring frequent
adjustments made possible by CGM
• in-person visit with treating provider
in past 6 months
Utah Academy of Family Physicians
Centers for Medicare and Medicaid Services. Ruling No.: [CMS-1682-R].
Image obtained from https://provider.myfreestyle.com/INSURANCE COVERAGE
[Patient Name] checks blood glucose 4 times
per day, uses ≥3 insulin injections per day, and
has a treatment regimen that requires frequent
adjustments based on glucose readings. They
are indicated for a personal continuous glucose
monitoring system in order to prevent
diabetes-related complications.
Utah Academy of Family PhysiciansINSURANCE COVERAGE
PRODUCT QUANTITY REFILL
DEXCOM G6
Dexcom G6 Receiver 1 once a year
Dexcom G6 Transmitter 1 every 90 days
Dexcom G6 Sensor 3 every 30 days
PRODUCT QUANTITY REFILL
FRESTYLE
FreeStyle Libre Reader OR
LBRE
1 once a year
FreeStyle Libre 2 Reader
FreeStyle Libre Sensor OR
2 every 28 days
FreeStyle Libre 2 Sensor
Utah Academy of Family Physicians
Abbott Laboratories. FreeStyle Libre System.
Dexcom, Inc. Dexcom G6 Continuous Glucose Monitoring (CGM) System.MEET HS
CANDIDATE SELECTION CHARACTERISTICS MEDICARE PART B CRITERIA
• diagnosis of type 1 or type 2 diabetes
• taking multiple daily insulin injections
• ≥ 4 daily blood glucose checks
• using an insulin pump
• ≥ 3 daily injections of insulin or a
• frequent hypoglycemia? continuous insulin infusion pump
• hypoglycemia unawareness • insulin regimen requiring frequent
• high degree of glycemic variability adjustments made possible by CGM
• not achieving glucose targets • in-person visit with treating provider
in past 6 months
Patient would be eligible for personal CGM
if she increases SMBG to 4 times daily Utah Academy of Family PhysiciansData Interpretation
Utah Academy of Family PhysiciansDATA INTERPRETATION
• Key metrics, ambulatory glucose profile (AGP), day-by-day graph
Download Data • Start with global overview & describe what key metrics mean
• Ask what person learned & what is going well
• Identify times below range, % time in hypoglycemia, # of
Assess Safety hypoglycemic events
• Interactive discussion about possible causes & solutions
• Focus on the positive – identify days or times when time in
Time in Range range is highest
• Interactive discussion about how to replicate what is working
well
• Identify times above range, % time in hyperglycemia, # of
Areas to Improve hyperglycemic events
• Interactive discussion: possible causes, solutions, events
Action Plan • Develop collaboratively with patient
Utah Academy of Family Physicians
Scalzo PL, Brock KA, Isaacs D. Personal Continuous Glucose Monitoring Implementation Playbook. 2020 Association of Diabetes Care & Education Specialists. Accessed April 8, 2021.DATA INTERPRETATION
LIBREVIEW DEXCOM CLARITY
KEY METRICS
AMBULATORY
GLUCOSE
PROFILE
DAY-BY-DAY
GRAPH
Utah Academy of Family Physicians
Images obtained from LibreView and Dexcom Clarity
Scalzo PL, Brock KA, Isaacs D. Personal Continuous Glucose Monitoring Implementation Playbook. 2020 Association of Diabetes Care & Education Specialists.DATA INTERPRETATION
14+ days recommended
≥70% recommended
estimate of current A1c
≤36% recommended
Utah Academy of Family Physicians
Images obtained from LibreView
Scalzo PL, Brock KA, Isaacs D. Personal Continuous Glucose Monitoring Implementation Playbook. 2020 Association of Diabetes Care & Education Specialists. Accessed April 8, 2021.DATA INTERPRETATION
10% ↑ time in range = 0.5-0.8% ↓ HbA1c
Utah Academy of Family Physicians
Battelino T, Danne T, Bergenstal RM, et al. Clinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations From the International Consensus on Time in Range. Diabetes Care. 2019;42(8):1593-1603. doi:10.2337/dci19-0028
Scalzo PL, Brock KA, Isaacs D. Personal Continuous Glucose Monitoring Implementation Playbook. 2020 Association of Diabetes Care & Education Specialists. Accessed April 8, 2021.MEET CT
CC: CT is a 62-year-old male who presents to clinic for a follow-up appointment to discuss
type 1 diabetes management.
PMH Current Regimen Labs
• BPH • Insulin glargine U-300 (Toujeo) 35 • HbA1c
• Hypertension units daily at bedtime • 3/11/21: 8.1%
• Major depression • Insulin lispro (Humalog) three times • 12/3/20: 8.1%
• Seborrheic dermatitis daily with meals 5 units plus 3 units • 8/14/20: 7.8%
• T1DM for every 50 mg/dL >150 mg/dL
Utah Academy of Family PhysiciansDownload Data
too too
high high
wide
variability
below goal too too
of ≥70% low low
above goal ofAssess Safety
Possible Causes of Hypoglycemia
• Frequently administers a dose of Humalog before
bedtime to correct high readings
• Rarely feels any symptoms when glucose is low
and typically corrects with 1 glucose tablet
• Increased physical activity due to helping
daughter move
Utah Academy of Family Physicians
Images obtained from LibreViewTime in Range
Factors that Contributed to Best Glucose Day
• Did not drink any soda
• Remembered to administer all Humalog doses
with meals
Utah Academy of Family Physicians
Images obtained from LibreViewAreas to Improve
Possible Causes of Hyperglycemia
• Typically drinks three 16 oz bottles of regular soda
daily
• Frequently forgets to take Humalog
Utah Academy of Family Physicians
Images obtained from LibreViewAction Plan
• Stop giving Humalog at bedtime
• Provide education about signs/symptoms of hypoglycemia
and the rule of 15
• Consider switching to Freestyle Libre 2 CGM as the patient
may benefit from the predictive low alarms
• Set goal to switch to diet soda
• Increase adherence to Humalog mealtime dosing
• Follow up in 2-3 weeks
Utah Academy of Family PhysiciansBilling
Utah Academy of Family PhysiciansBILLING
Utah Academy of Family Physicians
Scalzo PL, Brock KA, Isaacs D. Personal Continuous Glucose Monitoring Implementation Playbook. 2020 Association of Diabetes Care & Education Specialists. Accessed April 8, 2021.KEY POINTS
• Consider adding a GLP-1 agonist or SGLT2 inhibitor to metformin for
patients with T2DM and comorbid ASCVD.
• Consider adding a SGLT2 inhibitor to metformin for patients with T2DM
and comorbid kidney dysfunction or HF.
• Utilize concentrated insulin for patients who would benefit from less
insulin volume or reduced injections per day.
• Patients who are using intensive insulin regimens, have frequent
hypoglycemia or hypoglycemia unawareness, have a high degree of
glycemia variability, and/or who are not achieving glucose targets may
benefit from personal CGM.
• The DATAA Method is recommended for evaluating CGM data.
• The time in range metric better captures glucose variability than HbA1c.
Utah Academy of Family PhysiciansQUESTIONS
Hanna Raber | hanna.raber@pharm.utah.edu
Elizabeth Bald | elizabeth.bald@pharm.utah.edu
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