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Advanced concepts for applying continuous glucose monitoring data in daily diabetes self care decision making. This deck is for ADVANCED USERS ONLY. I will be delivered whole (or in part) on April 26, 2014 at the Texas Lions Camp in Kerrville Texas by Stephen W Ponder MD, FAAP, CDE
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Sugar Surfing with a CGMStephen W. Ponder MD, FAAP, CDE
Managing “d” well requires…
• Comprehending a system with basic principles/concepts
• Adjusting to changing or shifting conditions/situations
• Frequent assessments and re-assessments
LIKE….• Driving a car• Flying an airplane• Walking a tightrope• Surfing
#01-01Sensor*/HemoCue Data
(29%)
50
100
150
200
27 TueMar 2001
28 Wed 29 Thu 30 Fri 31 Sat 1 Apr 2 Mon 3 Tue
Sensor Vs. HemoCue (Finger) Glucose --- Sensor # 6989 hCDP Output
Glu
cose
(mg/
dL)
Average Blood Glucose = 98 mg/dl
* Note: Investigational device. Device not approved by FDA
Appreciate the flux of sugar levels in non-d persons
Remember: Sugar Surfing is all about managing…
FLUXdrift
exercise insulin
“incoming” blood sugar
External Internal
metabolism
“outgoing”
Diabetes is best approached 1 day at a time
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
*
*
*
**
*
**
Don’t pass up an opportunity to assess a trending BG
• Choose what you consider “actionable”
• Set personal action thresholds• Use situational thinking: consider
recent, current and impending actions• Check your BG results over time• “treat to target” (repeat as needed, but don’t
“overstack” your insulin)
(Glucose production – Glucose disposal) = FLUX
Here is a picture of FLUX and DRIFT
How much sugar is in the bloodstream for a 100 mg/dl BG level?
Human circulatory system
165 pound (75 kg) man(5.1 grams)
55 pound (25 kg) girl(1.75 grams)
110 pound (50 kg) boy(3.45 grams)
= 4 gram glucose tabaka “glucose transit system”
static vs. dynamic diabetes carestatic• Actions predetermined• Minimal 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 constantly influence
subsequent actions• Training needed, plus ongoing
reinforcement• More time intensive• Favors problem-solving• Requires ongoing motivation
present
past future
REACTIVE PROACTIVE
Actions
Omissions
Actions
Omissions
A pancreas can’t predict the future
• It acts so fast it doesn’t need to.• Can shut off insulin immediately• Can release premade insulin• Insulin it releases can start
working in minutes• Can rapidly respond to shifts in
sugar levels
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
Traits of effective CGM usersWear it most of the timeCheck trend line oftenThey “work the lag” times
FOOD lagINSULIN lagSENSOR lag
Not afraid to experimentNot expecting perfection
Principles of Sugar Surfing1. A CGM is no better or
worse than the person responding to 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. Pre-empt when you can
“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
Turnaround Time : glycemic inertiaCorrections may need to be adjusted 10-20% to compensate
Goal: Try to stay between the lines
As your skills improve, lower the glucose for the upper alert
Timing 101 – 20 min. match
Insulin
Food
Timing 101 – 45 min. mismatch
Insulin
Food
Be realisticAccept that the first 6-12 months
are on a “learning curve”Set higher and wider targetsHave low expectations to startIt’s still a finicky technologyPLEASE BE PATIENT
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
Cal-i-bra-tion (noun \ˌka-lə-ˈbrā-shən\)• Comparing the sensor to an
accepted “standard” value• The accepted “standard” value is
a fingerstick BG level• So the sensor itself can be no
more accurate than the BG meter it’s compared to…or how well the BG meter was used
Calibration tips
• The first sensor day can be erratic as it “settles in”
• Don’t over calibrate!• Try to calibrate on a steady trend • Try to calibrate when in your
target range
CGM calibration tip…
steady
2 hours
Whenever possible: calibrate the CGM system when on a “steady” sugar trendline
2 hr “wait” time between “turning on” sensor and providing 2 calibration BG readings to start session
steady baseline
Daily calibrating on a steady baseline
Steady trend2 hours
Calibrate your CGM…On a steady trend when you can…
In the BG range you want to be most accurate in…
Steady trend
4 hours post start up calibration (extra)
Settling in at 6 hours: wobble
Sensors are not always right
Or is it the meter that’s off?
Morning madness?
After 14 hours after new CGM sensor insertion…
After calibrating with 112 mg/dl, the sensor immediately reads this
Take home message: a new CGM sensor site might take a day or so to properly “settle in” or “read” properly. Take this under consideration and don’t give up on a session too soon.
But BG meter calibration shows THIS…
Overnight basal testing
Overnight basal in range (glargine)
Overnight in range!
Overnight control in range
Basal testing…
Overnight basal control - Lantus
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
Why timing is everything
3 units @6:10 28 gm @ 6:50
Timing…waiting for the bend
“window”
3 U lispro @ 6:22AM
28 GM CHO @ 6:52AM
Timing insulin and meals to prevent a spike
Wait for the bend!!
6U @146 mg/dl Eat here @132
mg/dl
45 minutes
Wait for the “bend”!
Stopping sugar spikes
3 units (5:32AM)
Meal(5:48 AM)
?
Point “A” Point “B”
sugar trend
sugar trend
sugar t
rend
Insulin “correction”
Carb “correction”
~ 2 hours for insulin~ 15-30 minutes for carbs
Range of possible BG outcomes
“the trend is your friend”
Blood glucose level
Noticed rising trend at 1:43 PM: 165 mg/dl
Took 5 units lispro @ 1:45 PM
4 hours
Late BG rise after the morning: no lunch eaten 135 mg/dl @ 2 hours
“Direction affects correction ”
Although subtle, this can be “felt”
BG = 157 mg/dlInj 4 U lispro @3:15
2-3 hours
20-30 minA
B
C
Correction tips (on a steady trend)
A. Remember the lag time before insulin starts to effectively lower BG
B. Remember the length of time it takes to accomplish the desired task
C. Patience and practice make these kinds of results possible
Micro-bolusing (dosing)
Steady baseline BG trend
BG 136 mg/dl
2 units lisproWait 2 hours
Target zone
• Very advanced • CGM needed!• Note flat BG
“baseline” trend• Calibration good• Not “correction”
per se• More of an
“adjustment”
BG 137 mg/dl and rising slowly
3 units lispro
“Micro-bolusing”
BG 124 mg/dl injected 1.5 units lispro
@3:56AM
2 hours
Microbolus experimentation
Lag time
112 mg/dl to 78 mg/dl after 1.5 units by injection on a “steady” BG baseline
1.5 units
~ 2 hours
3U lispro@ 3:40AM
4 unit lispro “push”
“Course correcting for smooth sailing”
Well balanced basal insulin
6 unit “shove” at 133 mg/dl
2 hour correction
Mealtime insulin @ 8:30PM 7 units lispro
Duration of insulin 3hr
Slow BG rise fro
m fried meal
Insulin correction dose @ 2:53AM 6 units lispro
lag
2 hours to correct
Teaching points…
a. Know your insulin “umbrella”
b. Slow carbs cause unexpected highs
c. Insulin onset of action = lag time
d. Rise in BG levels has vector qualities
e. It takes time to correct a high
a
b
c
d
ea
b
6:53PM BG 108 inj 6 units
7:15-7:359:52PM BG 125↑ inj 4 units
“Effective duration” of insulin action: 3 hrs
“Active insulin” • Example: Slow carb
meal (fried food) • e.g., Chicken fried steak,
cream gravy and 3 onion rings and 8 French fries
• Estimated 60 grams: 6 units: inject 6 units lispro
• NO rise in BG for 3 hours, then rapid ascent
• Time until rise reflects “active insulin” effect
• Must do this many times and take the average
Duration of insulin effect can be determined here
~ 4 hours
IOB after 6 units and fried meal
6 units
3.5-4 hours 2 units
WalkFried Meal
Rising BG trend (132 mg/dl) @ 2:06AM
5 units lispro @ 2:12
Fried Chicken
2.5 hours
8 U 6 U 5 U 5 U3 U Lispro
20 Lantus
“Inflections”
calibration
Tex-Mex Dinner
calibration
“Remember the Alamo”
Correction and meal
6 units (161 mg/dl)
Meal(26 gm CHO)
~ 45m126 mg/dl
5 units @ 5:43AM; 25 gm CHO @ 6:23AM
5 units
Meal(25 gm CHO)
40 minutes
Correction with 20 grams carbs
20 gm CHO
121 mg/dl: 3 units @ 10:04PM
80 mg/dl: 7 units lispro @ 6:36PM
Meter: 55 mg/dl @ 7:56PM
My estimated duration of insulin action: 3.5 hours
Slow carbs
• Experimented here:• Ate a pasta meal at the
Olive Garden• Took a single insulin shot
(70 gm = 7 units)• Sugar dropped at time
of usual peak insulin action: ~60-90 minutes
• BG recovered without treatment
• Late rise in BG required second injection
Leveling off
Olive Garden2 salad
servings, 1 breadstick
and Lasagna
Slow BG rise
lispro
121 mg/dl: 3 units @ 10:04PM
80 mg/dl: 7 units lispro @ 6:36PM
Meter: 55 mg/dl @ 7:56PM
My estimated duration of insulin action: 3.5 hours
Fast insulin + slow carbs =
low BG• Ate a pasta meal at the
Olive Garden• Took a single insulin
shot (70 gm = 7 units)• Sugar dropped at time
of usual peak insulin action: ~60-90 minutes
• BG recovered without treatment
• Late rise in BG required second injection
• Notice the insulin-food “balance” and how it effects BG levels
Leveling off
Olive Garden2 salad
servings, 1 breadstick
and Lasagna
Slow BG rise
lispro
Insulin effect
Food effect
“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
Slow overnight rise and early AM correction
Correction at 2:45 AM after slow post dinner rise with 5 units
5 units
~ 2 hours
3 units lispro
Breakfast
BG 173 mg/dl 5 units lispro
Meeting
A “random rise” in BG during a routine day.
2-3 hours
Working it…(i.e., glucose control exists “in the moment”)
~ 2 hoursOops! I Ate an EXTRA breakfast
taco!
BG 142 ↑ : took 5 units
hypothetical
real
And thirdly, the correction and carb ratios is more what you’d call ‘guidelines’ than
actual rules
“Most of our assumptions have outlived their usefulness”
Marshall McLuhan
8 U @ 9:30AM
7 U @ 10:54AM
6 U @ 12:29PM
60 grams carbs
Ultimately 21 U lispro
Insulin to carb ratios are only a start
7
5
4
5
Large bowl turkey soup and 2 small pieces cornbread @ 6:30
…flux?”
“What the…
Duration of insulin P
iz
za
9 units lispro for 90 gm Mexican food lunch @3:30
6 units lispro @ 6:30PM for rising BG after 3 hr IOB
Stabilization
Two gulps of juice (15-20g CHO)
5 gram CHO “nudge” @ 66 m/dl
Dropping < 1 mg/dl/min
“The nudge” (aka microcarbing)
5 gram CHO “nudge” @ 66 m/dl
Glucose counter-regulationGlucagonEpinephrineCortisolGrowth hormone
Leisurely walk from 7:00 to 8:30: straight line
Exercise “bump up”Moderate intensity75 minute durationGlycogen Glucose
2 units
1 hr walk
“Walking down” a trend
Blood sugar correction 160 mg/dl to 100 mg/dl in 2 hours with 4 units insulin lispro by injection
4 units
~ 2 hours
Correction: 151 mg/dl to 103 mg/dl with 2 units insulin lispro after walk
2 units
~ 2 hours
127 mg/dl @4:47AMInjected 3 units lispro
1.5 hours
“Pushing sugar”
BG 137 mg/dl : dose 5 U lispro
Lag time
Eat breakfast here
Timing insulin and food is like shooting clay pigeons
6 U lispro @ 1:45AM @ 170 mg/dl
30 min lag
3 hour wait
Taking the drop…
“Taking the drop”
BG 160 mg/dl @ 1:47AMInjected 5 units lispro
Lag time
Drop time 2-3 hrs
perfect bottom turn
froth
Woke up at 3:55AM at 184 mg/dl
Took 4 units lispro
Wait (slept) about 3 hours
Bingo!
Tamale Soup at dinner (slow carbs, slow rise)
“Livin’ la vida Gluco”
182 mg/dl : 7 units lispro
Insulin lag time 30-40 min
Eat breakfast here
Food lag time
124 mg/dl
Timing is everything…do you have the patience or the time?
Slow BG rise overnight from
fried meal
BG drop time20-30 min
Missed 9PM basal dose (glargine)
Normal timeLantus taken (9PM)
Detected rising sugar level @ 2AM
Humalog dose (7U) AND usual Lantus taken (20U)
Sensor “gap”!!
dinner
Fell asleep!
All back in range by morning!
What happens when a basal insulin dose is missed
Usual time Lantus dose is taken: 9PM
Rising BG discovered here
Insulin correction given
If not treated: high BG and ketones
Treated: In range BG and NO ketones
Stress effect
Endocrinology Board Exam taken every 10 years
Stress and Sugar• Strong emotional stress
triggers release of a several hormones
• These hormones act on liver and muscle to cause the release of internal sugar from depots inside the body
• Stress hormones also make the liver produce sugar from substances like protein and fat
• This can overwhelm the ability of basal insulin to dispose of sugar faster than it can build up in the blood
• CGM allows for more aggressive anti-stress treatment of rising sugars
Crossing 140 mg/dl @ 3AM and a 2.5 U lispro correction
~ 2 hours
Lag time
Why act?• Slow upward BG trend
(red arrow)
• Crossed personal “action consideration” threshold: 140 mg/dl in my case (yellow line)
• Knew the CGM would alert me to a rapidly dropping BG later if I over treated
• Have done this many times before: practice, practice, practice
Slow gradual overnight rise in blood sugar
Microbolus at 7:55AM when BG was 151 mg/dl took 2 units (after surgery)
Awakened by CGM alarm to a BG below 60 mg/dl
Slow gradual overnight fall in blood sugar
Lag time
20gm
Rationale• Slow downward BG trend
(red arrow)
• Crossed personal “action consideration” threshold: 60 mg/dl in my case (yellow bottom line)
• Drank 20 gm grape juice and went back to sleep
• Knew the CGM would alert me to a rapidly rising BG later if I over treated
• Have done this many times before: practice, practice, practice
This can be “felt”
This can be “sensed too”
CHO
A steady trend
The body’s defenses against low blood sugar
include the brainDownward shifts, even small, can be sensed by
the conscious brain Once sugar levels off, the brain senses
stability
Rationale• Blood sugar control is
complex, it includes the brain and nervous system
• Long term damage to the autonomic nervous system can result in loss of classic signs/symptoms of low blood sugar
• But, the brain itself might still retain the ability to sense downward sugar shifts before severe low BG kicks in (e.g., < 50 mg/dl)
• A CGM device can serve as a “biofeedback” device of sorts in adults willing to develop the ability over time.
Feel the drop and level off
Subtle correction• BG 125 and rising• Took 4 units lispro• 2 for the slow rise• 2 for the
correction• Waited almost 2
hours (yellow arrow)
• Notice lag time before BG “turns” (red arrow)
This rise can be sensed
This feels stable This also “feels” stable
> 1-2 mg/dl/min
~ 1 mg/dl/min
“Working down” a rising BG
4 units @ 173 mg/dl
2 units @ 167 mg/dl
7 units @ 2PM for Whataburger and rings
Rise
4 units Humalog @ 11:07PM
BG rising after insulin effect is“waning”. BG = 146 mg/dl
Dinner (soft tacos, refried bean and
chips/salsa); 7 units lispro taken 20 minutes
premeal at 7PM
My “DIA” = 3-4 hours
Slow drop over 6 hours
Notice the obligatory “lag time”!
Anatomy of a preemptive correction
Anatomy of a nighttime low
A) 4 hour window
B) 24 hour window
C) 6 hour window
D) Resolution
34 mg/dl
36 grams CHO
2.5 hours
6 month CGM data summary
Average BG = 103 mg/dlStandard deviation = 34 mg/dl
Aim to keep the average BG in range and the standard deviation AT LEAST HALF the average BG value
Day vs. Night: any thoughts about why?
Interpret these two images
Hint: sensor is over two weeks old
What is it a good time for and why?
Straight line trend
Straight line trend
= 10 grams carbs
60 mg/dl
90 mg/dl + 30 mg/dl
6 U
4 U
4 U 4 U
5 U
6 U
28 GM
90+ GM
1. Stacked insulin + delayed eating2. “Hyper-treated” severe low3. Fought “rebound” high BG all night4. Took the drop and timed meal
Dislodged insulin pump site…Picked up early by CGM
Pump site changed, insulin dose given, carb correction taken…$13,000 saved
Penny stock day trading strategyCGM is “sugar surfing”
board
©
“Kickin’ D’s Butt”