1. Continuous Glucose Monitoring

2. Diabetes Management Evolution Insulin Delivery Glucose Monitoring 2000 First CGM system 2006 Paradigm REAL- Time, combining Insulin Pump and CGM 1983 First Minimed Pump-502 1978 First Insulin Pump 1920s Insulin Injections 2005-2007 Real-time CGM Urine Testing 1977 Blood Glucose Meter 1999 First Animas Pump-R1000 2012 Dexcom G4 Navigator NOTE: Only the Medtronic Real-time CGM is approved for use in children and adolescents in the U.S.

3. Why Continuous Glucose Monitor? Prevention of hypoglycemia Prevention of hyperglycemia Pattern assessment Basal Testing Assess the impact of food on blood glucose Assess the impact of exercise on blood glucose Behavior modification tool Alerts/Alarms: Safety, peace of mind…

4. Hypoglycemia in Children and Adolescents 657 children followed for 3 years 8.5% had severe (seizure/coma) hypoglycemia 27% had moderate (required assistance) hypoglycemia 75% of seizures occurred at night Recent CGM data shows seizure may require prolonged severe hypoglycemia prior to event Davis EA, et al. “Hypoglycemia: Incidence and clinical predictors in a large population-based sample of children and adolescents with IDDM” Diabetes Care 1997;20:22-25.

5. 17 y.o. Female, A1C 6.2%, in Study 3 Months

6. 17 y.o. Female, A1C 6.2% Seizure

7. 14 y.o. male A1C 6.6%, Crews (rowing team) in PM 5/16/06 5/27/06

8. Camp Study: Duration of hypoglycemia with and without remote monitoring in 13 y.o. male on MDI “Insulin Rx” is glucagon No Remote Monitoring <70 mg/dl = 350 minutes <50 mg/dl = 305 minutes Remote Monitoring <70 mg/dl = 110 minutes < 50 mg/dl = 10 minutes

9. 0 50 100 150 200 250 300 350 400 Fingerstick Measurement Glucose (mg/dl) Breakfast 8:30 am Lunch 12:00 noon Dinner 6:00 p.m. Bedtime 10:30 p.m. Insulin Bolus Target Range Daily Patient Log

10. Target Range Daily Patient Log and Sensor Data 0 50 100 150 200 250 300 350 400 Glucose (mg/dl) Breakfast 8:30 a.m. Lunch 12:00 noon Dinner 6:00 p.m. Bedtime 10:30 p.m. Sensor Measurement Insulin Bolus Fingerstick Measurement

11. What’s the Difference?? 1.100 mg/dL OR 2. 100 mg/dL dropping at rate of >2 mg/dL/min CGM adds an additional dimension, the rate of change and direction of change.

12. Practical Application: Real Life Experience “Paula’s Pearls”

13. Pearl # 1: Match Device to Patient Needs Size…real estate issues Transmitter Range

14. Transmitter Range: I can’t find you!!

15. Pearl # 2 : Match Insertion Approach…Ouch! ◊ Use numbing cream: lidocaine topical Ela-Max cream EMLA cream ◊ Use soap and water to wipe off cream then clean with alcohol

16. Tape Issues: How do we get this thing to stay on?? IV 3000, Tegaderm, Hy-Tape Coban IV prep- avoid at sensor insertion area “Sandwich”/layer tape Tape Allergies…Ugh!

17. Pearl # 3: Teach, Teach and Teach Again! Sensor Lag Time Calibration Trend Arrows Glucose Trends/Patterns

18. Sensor Lag Time: Why doesn’t the sensor match my fingerstick reading? There is a 10-20 minute lag time between interstitial fluid (ISF) glucose and BG Lag occurs with ALL subcutaneous sensors CGM is a trending device, NOT a treatment device

19. Sensor Lag Fingerstick Capillary Glucose (SMBG) Interstitial Fluid Glucose (CGM)

20. QUESTION: When will the ISF glucose and the BG value be the most similar/closest? When BG is stable/not fluctuating rapidly

21. QUESTION: When using a CGM, when should the patient test their BG with a fingerstick? 1.Before all treatment decisions and insulin 2.To verify symptoms of hypoglycemia 3.Before driving

22. Calibration: When to calibrate? The accuracy of all the CGM’s are dependent on the calibration phase Devices calibrate in 1-2 hours Must do a fingerstick BG to calibrate Do NOT calibrate when the BG is changing rapidly

23. Calibration: When is the best time to calibrate? When BG is not changing rapidly

24. Trend Arrows: Show the direction of change Provides information on the rate-of-change

25. Activity Table teams review the CGM downloads What do you see? What don’t you see? Recommendations/Suggestions?

26. Glucose Trends – CGM Report Post-breakfast excursion

27. Post-breakfast excursion Nocturnal lows Glucose Trends – CGM Report

28. Pearl # 4: Respond to Data 1.Change behavior! Pre-bolus Less carbs at breakfast Assess food impact 2.Check basal rates 3.Use alarms

29. Pearl # 5: Who should wear a CGM? MOTIVATED patients/parents! Those willing and able to be educated on the device Those who are willing to look at and respond to the data! Those with realistic expectations and who can handle a potentially “rocky” start

30. CGM REPORTS

31. Report #1: Patience is important!

32. Report # 2: Missed Meal Bolus

33. Report # 3: Near perfection! A1C 6.1%

34. Report # 4: Failure to acknowledge alarms and using pump suspend

35. Report # 5: Pump site failure Pump site failureInsulin via syringe

36. “NAKED DIABETES!”