1. Achieving Excellent Control of Hyperglycemia in Critical Care and Surgery, Safely: Continuous Glucose Monitoring: Does it Have a Future in the Hospital
BACK TO THE FUTURE
STAN SCHWARTZ MD Clinical Assoc Professor of Medicine, Emeritus
Univ. Of Pennsylvania
Practice in Diabetes/ Endocrinology , Ardmore, Pa. 1

2. Disclosures re: CGMS
2009: Medtronic
2010- none
2011 none

3. A Solution
ADVERSE OUTCOMES
STRESS
ADVERSE OUTCOMES
EASD 2010

4. Glycemic Control in the Hospital
EPIDEMIOLOGIC / PATHOPHYSIOLOGIC
Rationale for Glycemic Control EXISTS – Adverse outcomes
with increased glucose; Brownlee, variability
2. Benefit of Control Highly Likely- Portland, Leuven. others
3. But, High Risk of, and if, have Hypoglycemia – NICE, others
4. Has Resulted in a ‘push’ for Therapeutic Nihilism; ; ACP, to 200
MUST AVOID
5. Rather , Optimize Glycemia, minimize Hypoglycemia
6. Find Therapies and Processes of Care to
Optimize Benefit/ Risk Ratio
7. Alternate Pharmacotherapy- Incretins , pramlintide, ranolazine
8. ACCURATE CGMS, open/ closed loop

5. Blinded Trial Data with Medtronic Hospital Sensor Demonstrates Need for Continuous Glucose Monitoring
Admitting Diagnosis: Necrotizing Fasciitis
Exposes higher variability, delay in discovering trends ,
Miss hypos and hyperglycemic peaks
29%
46%
The current standard of care, intermittent glucose monitoring, provides a very limited vision to patient glucose
On average 6-12 data points in 24 hour period
Glucose changes quickly, (include anecdotal or cite published rapid rate of change within one hour time period)
Chasing a number, being reactive instead of proactive
Tendency to overshoot targets consequently having hyper and hypo events
Rebound events are common when trying to stabilize glucose levels
This patient, which was in a controlled study, spent less than 50% of the time in the target zone. In the future I predict that once CGM becomes common in the hospital patients will be managed with an eye on “Area Under the Curve”. Future studies will show that its not only important the magnitude of the excursion, but the time spent in the excursion as well.
Once hypo and hyper there are associated morbidities and difficulty getting and staying back in target
25%
Unpublished individual result from Medtronic sponsored study (HF2004P)

6. Glycemic Control in the Hospital
EPIDEMIOLOGIC / PATHOPHYSIOLOGIC
Rationale for Glycemic Control EXISTS – Adverse outcomes
with increased glucose; Brownlee, variability
2. Benefit of Control Highly Likely- Portland, Leuven
3. But, High Risk of, and if, have Hypoglycemia – NICE, others
4. Has Resulted in a ‘push’ for Therapeutic Nihilism; ; ACP, to 200
MUST AVOID
5. Rather , Optimize Glycemia, minimize Hypoglycemia
6. Find Therapies and Processes of Care to
Optimize Benefit/ Risk Ratio
7. Alternate Pharmacotherapy- Incretins , pramlintide, ranolazine
8. ACCURATE CGMS, open/ closed loop

7. Therapeutic Nihilism ACP Evidence –Based With Clinical Judgement
ADA/ AACE
Better Approach
‘Potential for Greater Benefit
at Lower range’
AS LONG AS
NO UNDUE HYPOGLYCEMIA
Recommendation Chosen by 1 Vote

8. Glycemic Control in the Hospital
EPIDEMIOLOGIC / PATHOPHYSIOLOGIC
Rationale for Glycemic Control EXISTS – Adverse outcomes
with increased glucose; Brownlee, variability
2. Benefit of Control Highly Likely- Portland, Leuven
3. But, High Risk of, and if, have Hypoglycemia – NICE, others
4. Has Resulted in a ‘push’ for Therapeutic Nihilism; ; ACP, to 200
MUST AVOID
5. Rather , Optimize Glycemia, minimize Hypoglycemia
6. Find Therapies and Processes of Care to
Optimize Benefit/ Risk Ratio
7. Alternate Pharmacotherapy- Incretins , pramlintide, ranolazine
8. ACCURATE CGMS, open/ closed loop

9. Conclusion: 100,000 Foot Level
We need , Now, as ROI exists
Continuous Glucose Monitoring with Closed-Loop Control of Glycemia
Compensate for Imperfect Sensors, Site Issues, and Human Variability and Fallibility by
Algorithms: Dialing-in Goal that Avoids Hypoglycemia
Adjust DESIGN and USAGE of Imperfect Tools until IDEAL available 9