Case 2 T1D

PATIENT DETAILS

• Demographics: 57-year-old female, with 23 years duration of T1D

• Glucose monitoring and glycated hemoglobin (HbA1c) levels:
       – Previous HbA1c had ranged from 7.6% to 8.4% over the past 2 years
       – She had been followed by another endocrinologist for several years and treated with metered dose insulin (MDI) therapy
       – Patient was already using a rtCGM device

• Medical history: Moderate nonproliferative retinopathy and she was overweight with her initial weight at 83.5 kg (body mass index = 29.7)

• Glycemic management: Insulin glargine (30 units per day/0.36 units/kg/day) and insulin aspart (10–12 units at each meal)

• Initial rtCGM from past 90 days:
       – Time in range (70–180 mg/dL) = 48% (i.e., below the established target of >70%)

• Glucose profile:
       – Persistent hyperglycemia seen throughout the day and night
       – A separate download report indicated that patient’s high glucose alert was set at 280 mg/dL and the alert ‘repeat’ feature was turned off
       – Patient often ignored the alert and seldom looked at the CGM data

• Patient’s need to improve her glycemic status in order to prevent progression of her retinopathy was discussed and patient agreed to: (1) lower her high alert threshold to 200 mg/dL;(2) turn on the alert repeat feature; (3) transition from metered dose insulin (MDI) to insulin pump therapy with an older insulin patch device, interfacing with her rtCGM

• Patient’s infusion rate for basal insulin coverage was set at 1.2 units/hour

• During the next month, weekly phone consults were carried out to discuss her progress, increase her basal dosage (as needed), and address any problems or questions with her new therapy.

• At one-month follow-up visit: Patient’s basal infusion had been increased to 1.5 units/hour; notable improvement in her overall glycemic management was observed, with 79% of glucose values within target, significant reductions in %TAR without an increase in hypoglycemia, and a relatively flat glucose profile with most glucose values within target range

• Patient reviewed her data several times a day and always responded to her high glucose alerts

• Patient was living with poor glycemic control over several months; this clearly illustrated the impact of therapeutic inertia on glycemic management.

• Patient’s previous clinician (responsible for lack of appropriate goal-setting and timely intensification of therapy) and patient’s lack of engagement with her diabetes self-management contributed to her suboptimal management.

• Patient’s daily use of rtCGM data and the retrospective analyses allowed rapid identification of the most significant glycemic pattern (e.g. ‘nighttime highs’) and addressal of her hyperglycemia in a step-wise approach, and also improved her understanding about the impact of her adherence to treatment (e.g. use of alarms/alerts) ultimately impacting her glycemic control.