On this accredited episode of NP Pulse: The Voice of the Nurse Practitioner, hear from experts Kathryn Evans-Kreider and Debbie Hinnen, who will be discussing the latest evidence and practical strategies for using continuous glucose monitoring (CGM) to improve outcomes, prevent complications and empower patients. NPs will learn how to apply current guidelines and expand CGM access across diverse patient populations.
A participation code will be provided at the end of the podcast — make sure to write this code down. Once you have listened to the podcast and have the participation code, return to this activity in the AANP CE Center. Click on the "Next Steps" button of the activity and:
- Enter the participation code that was provided.
- Complete the posttest.
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This will award your continuing education (CE) credit and certificate of completion.
CE will be available through Oct. 31, 2026.
Podcast Resource: ClinicalBrief_TacklingTherapeuticInertia.pdf
This activity is supported by an independent medical educational grant from Abbott Diabetes.
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Transcript
Episode Transcript
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(00:13):
From the American Associationof Nurse Practitioners,
I'm the host of today's special editionepisode nurse practitioner and education
specialist Patty Scalzo,and this is NP Pulse,
the voice of the nurse practitioner.
Welcome to NP Pulse, AANP's podcast,
(00:36):
bringing you unique nurse practitionervoices and expertise on issues that
matter to NPs and our patients. As always,
be sure to subscribe to thispodcast, share with your colleagues,
and check back often for newconversations with nurse practitioners and
healthcare leaders from across the nation.
NP Pulse podcast listeners may claimCE credit for this program through
(00:59):
October, 2026. After youlisten to the podcast,
visit AANP.org/cecenter.
Register for this activity.
Enter the participation codeprovided at the end of the podcast,
and then complete the post-testand evaluation. On today's episode,
we are joined by experts KathrynEvans Kreider and Debbie Hinnan,
(01:21):
who will discuss key clinicaltrials, guideline updates,
practical implementation strategies,
and real world patient experiencesthat highlight the impact of CGM on
A1C reduction, hyperglycemia prevention,
and quality of life. Listeners willgain insights into current evidence,
device options,
and how nurse practitioners can lead inexpanding access and empowering patients
(01:46):
through CGM use.
Dr. Kathryn Kreider is a professorof nursing at Duke University and the
director of the EndocrinologySpecialty Program for NPs.
She has an active clinicalpractice in endocrinology.
She's a nationally recognized speakerin topics of diabetes and endocrinology,
and was appointed to the AmericanDiabetes Association Professional Practice
(02:08):
Committee, which writes the standardsof medical care and diabetes.
Deborah Hinnan has been a clinicianand diabetes educator for over 40 years
and is an advanced practice nurse whoconsults at the University of Colorado
Health in Colorado Springs.
She also provides diabetesservices at Tri Lakes Cares.
Debbie is involved extensively withthe American Association of Diabetes
(02:31):
Educators, having served as theirnational president. Currently,
Debbie serves on the American DiabetesAssociation Board for Colorado and the
Mountain states.
It is my pleasure to welcomethis panel of experts.
Hi everyone, and welcometo Empowering NPs,
Overcoming Therapeutic Inertiawith Continuous Glucose Monitoring.
(02:54):
My name is Kathryn Kreider and I'm sothrilled to be here today on this podcast
to talk with Debbie Hennin about oneof our favorite topics, right, Debbie?
Yeah.
CGM therapy.
That's right.
CGM has really begun toexplode and not just here in
Colorado Springs, I meaneverywhere. The technology,
(03:14):
particularly in the last fiveyears and rapid expansion.
That's right.
I think when I talk about with patientsand also to colleagues about the
developments that I've seen in diabetesmanagement since my time in practice,
which is now almost 18 years,
I think that CGMs andGLP1s have been the biggest
(03:36):
game changers as far as our ability tohelp patients make really incredible
improvements in theirlife and their wellbeing.
And so it's exciting to see all of thesenew changes that continue to come out
and continue to impact patientsin such a positive way.
Indeed.
And the CGMs that talk throughBluetooth to the insulin pumps,
(03:57):
oh my gosh. Well, if it's all right,
I'll jump right in withsome discussion about our
utility for use with type 1 and
CGM. We,
I think particularly appreciatethe ability to visualize a
consolidated amount of glucose data.
(04:19):
And when you compare that to thefinger sticks we used to have, I mean,
not just that we would get 'em on a nicechart or that we could even download
them,
we would get them on the envelope thatthe electric bill came in and there was
no way to analyze the trends.It was just impossible.
Hyperglycemia though is much morecommon, particularly at night,
(04:42):
and CGM has allowed us to seethat as well as document the
dawn phenomena,
but the real time alertsfor hyperglycemia,
that is I think a powerful benefit,
especially for patientswith type 1 and reduction in
A1C reducing glycemic variability.
(05:04):
Those things are really going to havean enormous impact on the long-term
complications of diabetes. Kathryn,
what evidence are weseeing around this now?
Yeah, I think it's great, Debbie,
to kind of kick off talking about patientswith type 1 diabetes and then those
who have insulindependent type 2 diabetes.
So we'll talk a little bit about some ofthe evidence around CGM and how it can
(05:28):
improve the lives ofpatients who use insulin,
but also point out that as we kindof go through this podcast today,
we're going to talk about theexpanded role of CGMs too.
So we'll talk a bit more laterabout prevention and wellness.
We'll talk some about the over-the-countersensors that are coming out.
So we hope to provide kindof a comprehensive viewpoint of where we are in the
(05:50):
landscape of CGMs rightnow. But to your point,
I think it's helpful to start withsome of the key trials in type 1
diabetes because this isreally where CGMs sort of were
initially placed,
right? Because we know that patients whouse insulin are going to be at higher
risk for hyperglycemia.
There are more challenges with theirmanagement from a complexity standpoint.
(06:14):
And so this is really where CGM started,
and there's amazing datashowing really wonderful
improvements in A1C and likeyou said, glycemic variability.
And so one of the first studies thatcame out was called the STAR 3 trial,
and in this trial the patientsused a sensor augmented pump.
(06:35):
And what that means, of course, isthat the pump is connected to the CGM,
and that's as you mentioned as well,
kind of where we start to see some ofthis really awesome advancement that's
happening now with patients.
We call them also automatedinsulin delivery devices now.
And in this particular trial with STAR 3,
the study showed that A1C decreasedsignificantly more than self-monitoring of
(06:58):
blood glucose levels. This was one ofthe earlier trials that was published.
And of course, this makesintuitive sense, doesn't it?
We always want to see the data andwe want to see the trial outcomes.
And so it really is important tosee some of this concrete evidence,
some of the other important trialsspecifically in type 1 diabetes.
There was one called the IN CONTROLtrial that was published in 2016,
(07:21):
and it looked at this concept ofdiabetes distress and patients who
used CGMs had lowerdiabetes distress and higher
satisfaction compared to those whodid self-monitoring of blood glucose.
I love this trial becauseI'm really passionate about mental health and diabetes
management.
And so the fact that we can see patientshave better quality of life and lower
(07:45):
diabetes distress is really, reallyimpactful. A couple other trials,
there was one called theHypoDE trial published in 2018,
in The Lancet Journal,
which showed a 72% reductionin hyperglycemia events with
real time CGM.And this is amazing, right?
And one of the key benefits Ialways talk to about with patients,
(08:07):
particularly with insulin dependentdiabetes, is that it really,
really helps improveand reduce hypo events.
And that really speaks to patientsbecause everyone has that in the back of
their mind, right? Debbie,where they're like,
they have this anxiety that this couldhappen when they're sleeping or when it's
not expected.
And so one of the most powerful tools wehave is the reduction of hyperglycemia.
(08:30):
We always love a good meta-analysis whenwe're looking at multiple studies and
all of the impact of the studies combined.
And I think this is interestingbecause patients will ask you,
and it's also a helpful kind of thingto bring up if they don't ask you,
how much is this going to impact my A1C?
And the studies have shownthat overall A1C is reduced
(08:54):
typically between 0.2 and0.4% and sometimes up to
0.5% reduction in a A1C.And that's just from using the
CGM. But that makes sense becausepatients are seeing this data,
they're able to respond to the data,they're reducing hyperglycemia,
which then reduces the spikesthat can happen after hypos.
(09:17):
So there's all of these factors that canhelp lower the A1C just by having this
increased awareness.
So this meta-analysis showedreduction in A1C by 0.23%
overall, which is a small amount,
but it's still a clinically relevantand clinically significant amount for
patients.
And then one other study I'll sharewas looking at the difference between
(09:40):
real-time CGM versusintermittently scanned. CGM.
Really the intermittently scannedCGM systems are phasing out.
And so these are the systems that patientshave to scan in order to activate or
to ask what the glucose is.
And I think there's pros and consto these devices, but in general,
it really helps when patients don't haveto think about it. It takes the onus
(10:05):
away from the patient to have toremember to check or to ask what the
glucose is.
And so the real time systems I think aremuch more of the wave of the future and
where we're heading from now on.
But this particular study publishedin 2024 showed that the real-time
sensors improved time in range by 7%
(10:26):
versus the intermittentlyscanned CGM systems and the
time in hyperglycemia or timebelow range was significantly
less for the real-time system.
So both of those were betterwith a system that is constantly
reporting out what the data is.
So I think that's really helpful becauseit kind of proves what we already see
(10:49):
in clinical practice,
which is it's really nice for patientsto have the real time systems.
For those of you that might see children,
there's a lot of dataabout CGMs and children and
the impact on daily lives of patientsthat have children with diabetes and
children who have diabetesis both just is really,
really wonderful improvements that wesee across the board in those kiddos.
(11:13):
So that is kind of a briefoverview of the type 1 diabetes
data. And there's also a lot of datanow about type 2 diabetes and CGMs,
which is the next wave thathappened where we're looking at use
across patient populations andnot just with type 1. So Debbie,
do you want to share some of thekey trial data from type 2 patients?
(11:35):
Thank you, Kathryn. I so appreciateyour comments about pediatrics,
the to share that glucosedata with parents,
teachers,
caregivers is just sucha reassuring kind of
technology boon. So Kathryn,
let me start with some studiesfocused on insulin dependent
(11:57):
type 2 diabetes.
The MOBILE trial with Martenset al in JAMA from 2021
showed us that CGM group spent 15%
more time and range 16% less
time above 250 milligrams and a lower mean
(12:17):
glucose by nearly 30 points.
We also see reduction timespent in hyperglycemia.
And that study from diabetes therapy in
2017 and a study inFebruary of that same year
showed us that people withtype 2 diabetes on insulin had
(12:38):
reduced the hyperglycemiatime by about half.
And that's not justglucose levels below 70,
that's glucose levels below 55.
And that kind of data fromthe CGM I think is the
safety, the very reassuring piece,wouldn't you agree? We also,
(12:59):
I think,
have trials to share that arerelated to all people with type 2
diabetes, whether they'reon insulin or not.
And a narrative review from2018 of 11 studies with
over 5,500 patients showed that glucose
monitoring compared to CGM,
(13:20):
the CGM reduced the A1C,reduced the body weight,
reduced caloric intake,
and had greater than 90% compliance with
CGM wear time.
A meta-analysis from 2024 of 14 trials
with over 1600 patientsshowed that A1C reduction of
(13:43):
0.32. And as you mentioned in type 1,
that is similar. However,
another study by Millerin 2022 showed that the
A1C reduction,
whether people were on the FreestyleLibre Flash or the Dexcom G5
or G6 had A1C reductions that were even
(14:06):
greater 0.7 0.8 2.80.
And I think particularly noteworthyhere is there weren't any differences
between the devices. So each cohort group,
regardless of which CGM they were using,
had comparable reductions in the A1Cs.
(14:26):
Kathryn, what are theguidelines advising us?
Yeah, so first of all,
we hope that you appreciatelistening to some of the statistics.
I know it can be hard a little bit tolisten to that and put context around it.
But before we wrap up that section too,
I just wanted to highlight thatthe A1C reductions are clinically
meaningful and the hypo reductionsare clinically meaningful.
(14:49):
And so I think those are two of thekey discussion points I think to bring
forward to patients when we're talkingabout pros and cons of these devices is
that the vast majority of patientsreally have wonderful benefits and
that's backed up by the clinicaltrials. So from a clinician standpoint,
we always want to make sure that we'repracticing evidence-based medicine and
(15:11):
the American DiabetesAssociation publishes the standards of care every year.
And if you're not familiar with that,
I always recommend thatpeople take a look at it,
you can easily find it on their website.And one of the key points that has
continued to emerge year over year isthis highlighting of technology and
how it can really help patients.
(15:31):
And so I want to highlight a coupleof the guideline recommendations,
and Debbie,
get your take on these two or maybe theones that you think are the most helpful
or impactful for your practice. Firstof all, we start with something simple,
which is diabetes devicesshould be offered to people with diabetes. Definitely,
right? When we think aboutpatients with type 1 diabetes,
(15:52):
the recommendation at a level A ofevidence is that CGM should be offered to
people early, even atthe time of diagnosis.
And this is something I do andI think is pretty well received,
which is you try to get someoneon a CGM immediately if possible,
when they have type 1.
And that can really help just with allthe things we talked about already. But
(16:12):
it also as a framework for this is howwe want to help you manage your diabetes,
let's get this started now becauseit will make such a big difference.
We always want to individualizetechnology recommendations.
And so this is where having some fluencywith this as a provider is really
helpful when we can kind of understandthe differences between devices and who
(16:34):
might be a better fit for a certaintype of device, for example.
And that can help us have patient-centeredcare and individualized care where
we're able to tailor our recommendationsmore readily to someone's specific
needs. And the ADA uses thisframework of specific needs,
preferences and skill level,
and those are all things that weshould be taking into consideration.
(16:55):
So a couple other things, and we cankind of go through these quickly,
but if someone has been on aCGM or an automated insulin
delivery system,
we need to make sure that they havecontinued access to this device. This is
speaking to payers, right?
We want insurance companiesto be making sure that these
patients continue to access their devices.
(17:16):
And I know that we have all had situationswhere people can no longer afford or
their copays go up dramatically.
And that American Diabetes Associationputs language like this into the
standards of care becauseit's an advocacy piece.
And I think this is important for us asNPs to know what's going on behind the
scenes and understand why theywould say something like that,
(17:37):
because it's a huge part for us ashealthcare providers to make sure we're
advocating for our patientsto have access to devices.
So one of the newer thingsthat's happened, Debbie,
and I'll have you speak to this one,
is that adults with diabeteswho are on basal insulin
only should be offered CGMs.
And this is awesome, right? I mean,we all recognize the benefit of this,
(18:01):
but this is more recentthat Medicare, for example,
would cover patients who arejust on one injection a day,
and this is a very firm recommendationthat we should be considering this.
So Debbie,
have you seen that change or practiceat all with Medicare coverage or sort of
this shift to offering to more patients?
Absolutely. And I think thatclinically it's a very powerful tool,
(18:24):
not just for the person withdiabetes, but for us as clinicians,
because people lose firstphase insulin release first.
And so if they're just on basal insulin,
we need to monitor thatpostprandial and that
opportunity,
particularly for Medicarepatients is a huge opportunity.
(18:45):
Yeah, that's a really good point.
And now that we have moreand more patients on GLP1s plus basal insulin and all
these different combinations of therapies,
it is really helpful to be able to seechanges over time. So that's right.
So a couple other things I want tohighlight. From the ADA standards of care,
we should definitely be offeringCGMs to youth with type 1 diabetes,
(19:06):
youth with type 2 diabetes whoare on insulin should have CGMs.
This is all kind of intuitive.
I think we want patients to usethese devices as close to daily as
possible. If they can't do that or theycan't necessarily afford ongoing use,
then intermittent use is reasonable.
And that can still bereally helpful in many ways,
but we want to make sure that they'reusing it often in order to maximize the
(19:30):
benefit. And then thefinal thing I'll mention,
which we'll talk a little bitmore about in just a few minutes,
is you want to make sure that and thatyour patients know about potential
interfering substances and otherfactors that could impact the accuracy.
Maybe you've had patients say,
this is rating really high orthis doesn't really seem right.
And that's the opportunity for us topause and to make sure we're checking for
(19:54):
accuracy in anything that couldbe impacting those values.
I guess it's also important to mentionhere that the ADA I think is really the
premier voice in many ways of thestandards for diabetes management.
But the other organizations thatare really important and impactful,
both nationally and internationallyagree on this importance of CGM
(20:15):
therapy for patients with diabetes.
And so I think it's nice when we canall kind of come together and all the
organizations agree because that doesn'talways happen when we're thinking about
how to position these therapiesfor diabetes management.
And then another recent development,which we're going to talk more about,
and also in patients that don'tuse insulin at all is considering
(20:37):
CGM when hyperglycemiais a risk factor or when
glycemic variability is aconcern or something that is impacting someone's care.
So that starts to get into these differentnuances of other things and other
opportunities to consider CGM therapy.
AACE is the American Associationof Clinical Endocrinology.
(20:58):
They usually release guidelinesfor diabetes every couple of years,
and they say CGM highly recommended toall patients with diabetes to assist
in reaching goals safely. I love that.
That's very broad reachingfor everyone to consider.
And then ADCES is 2021practice paper recognizes
CGM as an essential tool forimproving outcomes in both type 1 and
(21:22):
type 2 diabetes to reduce hyperglycemia,
lower A1C and improve quality of life.
And we can't forget that component becauseI think sometimes when we think about
diabetes management, wefocus on numbers, right?
And time and range andtime below range and A1C.
And ultimately those are important,
but it's so much more importantin some ways, in many ways, right?
(21:43):
That someone has a really good qualityof life and that they can live a healthy
life with diabetes. So I mentionedbefore about interfering substances,
and I'll just briefly mention this hereis actually this has gotten a lot better
in recent years where there's not quiteas many things to think about as far as
interfering substances.
The two things to rememberare acetaminophen and vitamin
(22:06):
C. And so let me explain acetaminophen.
If it is over four grams per day,
that will affect theDexcom G6 and G7 device.
If your patients happen to usea Medtronic Guardian sensor,
then any dose of acetaminophen willaffect the accuracy of the device.
So what this looks like is patientshave higher sensor readings
(22:31):
than their actual glucose,and this is Tylenol,
acetaminophen super common.
And we need to make sure we're asking ifthings are not adding up or if patients
are reporting that it seemslike they're elevated.
The other one would be vitamin C.If it's over 500 milligrams a day,
that will affect theFreestyle Libre devices.
(22:52):
So that's the 14 day theFreestyle Libre 2 and the 3.
And again, that will make the sensorreadings higher than the actual glucose.
So those are two really common ones.
The other things to consider wouldbe hydroxyurea, mannitol or sorbitol.
The latter two are inperitoneal dialysis solutions.
So they're certainly not as common.
(23:14):
But if you start running into thesesituations where you see a difference,
the first thing to have patientsdo is to calibrate their device.
They still should havean actual glucometer,
a very old fashioned glucometer wherethey can compare the data so they can see
if it looks like it is lining up or not.And then you can start investigating.
And I've had actually several patientsin the last couple of weeks that have had
(23:37):
the acetaminophen interference, soit's important to remember that one.
So those are just somepractical tips, but Debbie,
when we think about nursepractitioners and our role in
helping patients implement CGMs inboth type 1 and type 2 diabetes,
what are your thoughts on how to framethat or how to get started with these
devices?
(23:58):
It's an enormous opportunity, Kathryn,
and nurse practitioners do,
primary care does 90% of diabetes and our
patients are walkingin asking for sensors.
So the awareness that our nursepractitioner colleagues have about
CGMs is very important.
(24:20):
So they will of coursebe initiating protocols,
initiating sensors,
but interpreting that glucose datathrough the ambulatory glucose
profile is really critical.
And I know you're going to talk tous about that a little bit more,
but it consolidates a couple ofweeks worth of data and gives
(24:42):
you that tool to huddlewith the patient and begin
to have the conversation.
I like to start the conversationwith what have you learned
from wearing the CGM?
What have you discoveredabout your glucoses that
lets us look for opportunitiesin lifestyle adjustments?
(25:05):
I think we always want to startwith talking about the meal plan,
the diet, the exercise,
and what have you learned is anopportunity for the person with diabetes
to say, well,
I sure can't have Cheerios at breakfast.And that's powerful.
That's more powerful thanus saying that by far.
(25:28):
But it's also really important, I think,
to have this tool as aresource when insulin is
initiated. And I thinkof the ultra long basals,
particularly in this case,
because they don't reach steadystate for three or four days.
So we've been used to for years,
helping people initiate insulinand increase one unit a day
(25:51):
or something more frequentlythan every three or four days.
And so if we can have thisglucose monitoring tool when
people are startinginsulin and titrating it,
it's very beneficial. And Iwould say the same for GLPs.
So we've got the GLPGIP class of medications
(26:15):
that begin to have an impact onboth fasting and postprandial within
72 hours.
So if people can see that andlook at their lifestyle changes,
it is a huge benefit.
And as we look at our in healthcare,
the interdisciplinary team is powerful.You and I are focused a
(26:38):
lot in diabetes and endocrinology.
We're speaking to a lot ofour primary care colleagues,
but dieticians andpharmacists have a large role.
A lot of dieticians are startingpumps and sensors of course with
that sometimes.
And so that initiation andtitration may be handled by
(27:00):
dieticians and or pharmacists.
The clinical role of pharmacists hasreally expanded in the last few years.
And when I think aboutall of this and our role,
I think how powerful it isfor patients to have that
data, have that opportunity.
I'm doing a lot of diabetes workat our local Tri Lakes Cares,
(27:24):
our food bank with lots ofother community services.
But when I did a recent diabetes workshop,
we offered CGMs and Istarted CGMs on everyone.
And at the two week follow-up,one of those patients said to me,
Debbie, I can see these blood sugarsall the time. And you know what?
(27:45):
It's an accountability tool for me.
And now cake is anexperiment, not a habit.
And I thought, what a greatcomment. I mean, that's a headline.
She was empowered, she learned data,
she made changes in her behavior.
What kinds of things areyou seeing with patients?
(28:06):
Yeah, I love that story. I mean,
I think it's so similar tomany patients that I see,
but I have one example of a guythat I saw a couple of weeks ago,
and when he first came to see me,
he's had type 2 diabetes oninsulin for 15 years or more.
And today when, see when he came tosee me, I think was nine and a half.
He was checking hisglucoses a few times a day.
(28:27):
He had never been offered a CGM before.And so that's the first thing I do.
I know what a powerful tool it is.
And so he agreed to try itand he came back to see me.
I think he came in six weeks, but bythree months his A1C was 6.5. Wow.
And I had not made any changes to hisinsulin because I was kind of waiting to
see what the data looked like, and thenwe'll make adjustments. And of course,
(28:50):
I was just telling him how wonderfulthis was and commending him on this,
and he said, I know what I need to do.Right? It's like knowledge is power,
and when you have the datathat you've never had before,
it can really be transformative.
So I know you all probablyhave your own experiences too,
but it's awesome to see how muchit really can transform someone's
experience. So I lovethat. And then Debbie,
(29:12):
I know one of the things we wantedto talk about too was using CGM
devices and people whodo not require insulin,
and then we'll also talk later aboutpeople who don't even have diabetes.
So there's all these coolimplications now that are coming up.
Tell us about your thoughts onusing them and patients who do have
type 2 but are not on insulin yet.
(29:34):
Well, Kathryn, I think it's, asyou say, a very powerful tool.
People who are not on insulinmay be looking at an over the
counter glucose sensor. Theirinsurance may not cover it.
And so just within the last year or so,
there are now three over thecounter glucose sensors that are
available, Abbott Lingo, Abbott Rio,
(29:57):
and the Dexcom Stello.
And the devices since they're over thecounter are typically paid out pocket,
but they last for 14 days.So when we talk about,
maybe it's not covered by insurance,
this is where your comments aboutthe intermittent use may become very
helpful because people mayuse one sensor a month,
(30:20):
but we've talked a lot aboutpeople that are on insulin.
And so the prescription sensors wouldbe the ones that are patients on
insulin, on insulin pumpswould certainly be using,
and their insurance is likely goingto cover that. We have the Eversense
365 now that is approved to
(30:43):
use this implantable sensor up to a year,
but we have Medtronics Guardian 4,
the Libre 3, 3 plus Dexcom's G7.
There's still Libre 2 and G6 out there,
even though the newer ones are available.
But the accuracy is the other thingthat I think has dramatically improved.
(31:05):
And the accuracy, the mard,
that monitor of accuracy is less than 10%
in most all of these.
I think having these availableis that first step in
being able to see them usedin our patients and over
the counter,
(31:26):
particularly in our patientswho are on oral agents.
And as we've discussed, when youput that data in somebody's hands,
they see what happensafter they eat a meal.
And it's always, I think,
eye opening to see what happensafter you eat french fries and
(31:46):
the size of the french fries servingis maybe going to cause an enormous
post meal glucose spike. And thenthat gives that information to people
for monitoring or adjustingwhat amount of french fries,
what amount of pizzashould I try, because boy,
that's really important and my lifecan't be happy without a piece of
(32:09):
pizza on occasion.
So we're empowering peoplethrough this data visibility.
And I think pattern recognition issomething that's probably been most
passionate for me over thedecades of my practice.
I've written about this and spoken aboutthis back in the days when we had to
do urine testing to measure whetherthere was glucose in the urine or not.
(32:33):
And now of course,
advancing through BGM finger stick to CGM,
we have the ability forpattern recognition,
not just a single spike, an outlier,
but what is happening over several weeks.
I particularly appreciateMedicare's changes and within the
(32:56):
last year and a half,
CMS has broadened their coverage for CGMs,
and people with diabeteswith type 2 diabetes can
use sensors now be eligible forsensors if they have a history of
hyperglycemia. Now, this may be theperson who's not even on insulin,
(33:17):
maybe they're on a sulfonylurea,
but if we can document that glucoseof 54 according to the guidelines,
make them eligible for a CGMand our patients on insulin have
seen those guidelines relaxas well if they're on insulin,
not three injections a day,
so maybe just bibasilar ifthey're doing glucose monitoring,
(33:40):
not necessarily four timesa day, it used to be,
that would be the new guideline thatwould allow them to be eligible.
And of course we have to have afollow-up with them in six months.
Kathryn, what would you add?
Yeah, those are awesome thoughts.
My first thought is that thecoverage has gotten so much
(34:01):
better, I think universally forpatients on all types of insurance,
private and Medicare and Medicaid.
I very rarely have trouble getting access.
Sometimes the copay can bea little bit of an issue,
but I've been so encouraged by theincreased availability across the board.
I would say another example of apatient type that I've been able to get
(34:24):
CGMs for are patients who havetype 2 diabetes who had metabolic
surgery and now they have hyperglycemia,
which can happen after bariatric surgery.
And that's been a really good opportunityfor safety and kind of helping with
dietary adjustments andso forth after surgery.
So the expanded option when you'readding in the history of hypo without
(34:45):
insulin is really helpful I think. Sothat's been a good benefit I've seen.
That's a great comment.
The Medicare changes remind me ofone of my patients at the food bank
who's on basal insulin and a GLP.
He has a CGM and has foundit very useful for day-to-day
(35:05):
changes and weekly pattern management.
But this week at the foodbank, when I saw him,
he told me he wasn't able to get his GLP,
he couldn't afford it. And I said,
so tell me what's happening toyour glucose levels. He said,
my blood sugars are reallyhigh after meals. Well,
(35:26):
if he had not had the CGM,
he wouldn't know that was happening.When he had his next visit,
he would have an A1C andit would be elevated,
but he still wouldn't know when thatwas happening or why that was happening.
So I really appreciatethe Medicare changes and
(35:46):
relaxation particularly. But Kathryn,
I think we should really delveinto some of the discussion
beyond people with diabetes.We're seeing CGM
now used in preventionand wellness and there's
growing interest and some controversy,
(36:06):
but CGM is used formetabolic optimization.
It's used in weight loss, it'sused for athletic performance.
People are finding this tobe valuable information,
even if they don't havediabetes athletes particularly,
I think we see them carb load, Ithink we see them run a marathon,
(36:28):
and it's reassuring and saferto have this data for them.
So we are seeing the CGMs now
in many other areas besides just our
folks with diabetes.
The other areas I think thatwe've seen some benefit is
(36:48):
pre-diabetes and metabolicsyndrome management.
This is a tool I think whenpeople have that elevated
A1C and are trying to begin some lifestyle
changes,
this is that extra boost togive them information and
stress related diseases.
(37:08):
Clinically driven aspectshere are powerful.
I've used it in potspatients who have stress
spike, blood pressure spike,and when they have a CGM on,
they realize that that correlateswith also that spike in glucose.
You and I know that thestress hormones, the cortisol,
(37:29):
the glucocorticoids allcause an increase in glucose,
but I think people who don't havediabetes or aren't tuned in on this
pathophysiology don't realize that.
So there are other areas thatpeople are gaining a lot of
information.
The biofeedback that people get isreally there to help support their
(37:52):
health goals.
Are you seeing it used Kathrynin some other areas besides
diabetes?
Since I'm in an endocrine clinic,most of my patients have diabetes,
pre-diabetes or obesity.
And so I have definitely had moreexperience with patients with obesity that
are super interested inpreventing diabetes in the future,
(38:15):
for example, or reducing insulinresistance, that kind of thing.
And so this can be,
I think a really powerful toolto help with weight management,
and that's most of my experiences inthat space. When you were talking,
I was thinking of the term biohacking.Have you heard that term before?
Yes.
Yeah. So biohacking, whichI'm not an expert at all,
(38:37):
but it's essentially people that areusing their own data from their body to
optimize their health.
And so this is an example of people weremonitoring sleep or menstrual cycles
and now it's glucoses and all theseother things that can be assessed with
technology and in order to tweak itand adjust it and make improvements to
optimize their health.
So it's definitely an important additionto that when you think about glucose
(39:01):
regulation. So I guess Debbie,
one of the other things to mention aboutthe over-the-counter sensors is that
right now we do not haverandomized control trial data.
And so that's definitelya piece that's lacking.
There's more and more evidence aboutobservational use and user reported
data.
And then there's specific studies lookingat different types of people that do
(39:24):
not have diabetes for example.But I definitely think that the evidence
base for this will grow.
We just don't have a lot of firmdata right now for people without
diabetes.
But there's a couple ofpatient populations that I think would be helpful to
mention. So these are all, again,
people without diabetes and howCGM can help improve their health.
(39:47):
So one example is patients whohave had a kidney transplant,
and I see a lot of these patients becauseI'm in an academic medical center,
and essentially we always monitor thesepeople after surgery because they're on
prednisone usually inthis particular study,
this was published wayback in 2013, actually,
it showed that early CGM detectedhyperglycemia and predicted a
(40:11):
higher risk of post-transplantdiabetes and graft failure.
So clearly hyperglycemia islikely to predict eventual
diabetes,
but the graft failure partis pretty profound because obviously that's the worst
case scenario when you'vehad a transplant. So the thought here would be even in
people that do not have diabetes,
(40:32):
they could benefit from this moreintensive monitoring to help protect and
preserve their outcomes in the future.
Another interesting study published in2023 looked at over 7,000 people who did
not have diabetes.
And this study showed thatmean glucose levels correlated
with health metrics like sleeppatterns. That's a fascinating one.
(40:55):
We talked about the biohackers andthey're always trying to put together the
pieces of if I do this, then thiswill improve this or affect this.
And it makes sense that if youhave glucose dysregulation,
then your body is going to have otherthings that likely are affected by that.
And so sleep is one of those,
and I think that's pretty fascinatingfor patients with chronic kidney disease.
(41:15):
Glycated albumin andfructosamine are more reliable
glycemic markers than A1C in this group.I've been saying this for a long time
because I mentioned that I have apopulation of patients in my practice.
They have a lot of medicalcomplexity. Many of them have CKD,
they have other comorbidities. Wehave a lot of transplant patients.
(41:36):
When you have someone on a CGM and youcan actually compare that data to the
A1C,
I estimate that up to 40%of my patients have an A1C.
That is not accurate.
And I don't think that's something thatwe talk about a lot actually because A1C
is still considered the goldstandard and that's good.
(41:56):
But I think now that we have moreand more and more patients on CGMs,
we're seeing these differences.
And I'm talking about the 90day CGM trends, not the 14 day.
When you actually compare 90 days to theA1C, there's often a vast difference.
And that's because we know that A1Chas a lot of reasons that it can
be falsely high or low. And so thisparticular study just proved that
(42:21):
glycated albumin and fructosamineare more helpful than A1C.
So when you've got patients with CKD,even if they don't have diabetes,
for example,
this might be an interesting thing inthe future we can use to predict future
risk. And then we've mentioned kids acouple times throughout this episode,
and when we think about kidsthat have hyperglycemia,
(42:42):
and this is independent of diabetes,
then CGM in this particularstudy published in 2023
really,
really was helpful as far as preventionand management of hyperglycemia and
these children withoutdiabetes. And so again,
so much help to parents when they'rethinking about optimal management of their
kids and protection of them.
(43:04):
I could talk about this forever that Ihope we'll get to a place where we will
get CGMs covered for pre-diabetesbecause this is such a missed
opportunity,
right? We've got a lot of patientsthat are very motivated to improve
and to prevent diabetes,
but they don't have good monitoring rightnow unless they're able to do out of
(43:25):
pocket for a CGM. But if we wereable to capture these people earlier,
we could really, really helpthem to prevent diabetes I think.
So there was a study published lastyear in 2024 looking at glycemic
variability and that ahigher degree of glycemic
variability, which is of course theups and downs or the roller coaster,
we call it detected by CGM,
(43:48):
was linked to coronaryatherosclerosis and event risk,
and of course the progression to type2. So that's a really interesting one.
Remember, these arepeople with pre-diabetes,
so really interesting datalooking at overall risks and
cardiovascular riskreduction possibilities.
And then finally the last one I'llmention is in people who did not have
(44:10):
diabetes CGMs in this studyshowed that if they had, again,
higher variability, theyhad worse stroke outcomes,
and we didn't understand the impactof glycemic variability before. I
actually used to tell patientsthis was like 18 years ago,
that as long as your average is okay,
(44:30):
it's likely that's what we aim forbecause we didn't really understand the
overall impact as long asthey're not getting low.
But now we have much more firmdata about trying to reduce
that rollercoaster and keep peoplenice and even and nice and smooth,
and that really can improvelots of outcomes. Debbie,
those are just some examples of datathat's coming out in patients that don't
(44:52):
have diabetes, and I think it's reallyinteresting to hear about those.
Do you have any particularthoughts about any of those groups?
Well,
I especially appreciate youfocusing on glycemic variability
because that has been asurprise for me as well,
and a powerful kind of thingto help smooth out people's
(45:12):
symptoms and people's feelings.
That spike of course may increasethe risk of all the cardiovascular
issues,
but that drop then may alsotrigger hyperglycemia symptoms.
And so in finger stick days wemight or might not catch that
glycemic variabilitypieces is really powerful.
(45:33):
And I think that leads tohow important the patient
education is.
And we have to really be educating people,
not just about lookingat their glucose values,
but what they may be ableto do to make changes.
But people may misinterpretdata or they may have
(45:54):
increased anxiety because it's there,
it's in front of them all the time.
And we've talked a lot today aboutpeople who don't have diabetes.
It's fairly common I think forpeople to realize, my gosh,
my blood sugar goes up after Ieat a lot of carbs, or my gosh,
my blood sugar dips after Ihave intense exercise. And so
(46:18):
people may be concerned abouthyperglycemia and we need to help
people understand normalphysiology does not look like
I 70 through Kansas.
There's some elevations and some drops.
We don't want it to look like Pikes Peak,
but it may look like the FlintHills or the Black Forest,
(46:40):
and that is normal variability.
So I may move on to talkingabout some of our patient
barriers that we face. And I know you'llhave a lot to share here, Kathryn,
but cost of course and insurancecoverage are top of mind for
all of us.
And I think it is important forus to not make that decision
(47:03):
for people with diabetes aboutaccessing a CGM because people
may choose to pay out of pocket.
They may choose to use one sensora month if they have type 2
diabetes and their insurance doesn'tcover it. So while cost and insurance
are issues, prior auths may be needed.
(47:23):
I think it's incumbent on us toempower our patients in a shared
decision-making model to beable to make those decisions.
Alarm fatigue is a real thing,
and that barrier I thinkimpacts family members.
It impacts spouses becausea low glucose alert is
(47:45):
going to turn into a siren ifsomeone doesn't stop and take care of
it. And if that happens during thenight when people are sleeping,
they may not hear it as quickly.
And alarm fatigue issometimes a real issue,
but data overload andmisinterpretation might be yet
another barrier. And we do see, of course,
(48:07):
that people have glucose readingthat may be three or 400,
and in fact they say, I feel fine.
And so if they can pull out thatglucose meter and do an old fashioned
finger stick that wouldconfirm that indeed it is an
error of the CGM,
a device error.So that wouldn't necessarily
(48:30):
be them interpreting the data.
It maybe is just a mechanicalproblem. And stigma, body images.
Last week I offered CGMs to threedifferent people at the food
bank and two of them said, no, I don'twant to know. And one person said,
you mean I have to wear it? Like itgoes in the skin and it would be there,
(48:52):
someone might see it. So there is stigma,
there are concerns about body image.
I know role of clinicians,particularly NPs,
is patient-centered andwhether it's pre-diabetes or
diabetes,
we want to have the patient at the centerand meet them where they are with what
(49:14):
information they need. If wecan normalize the trial periods,
we may have a greater reuptake.Those people that told me, no,
I don't want to try it,
I had talked to them aboutit then and it's a sample,
there's not a charge,
so let's consider it next week.So I see people at the food bank every
(49:35):
week.
It's not like the clinic where I'm doingvirtual patient work and seeing people
every three months or once a month.If I'm doing a lot of intensive work,
I'll be able, I think,
to help them get a trialand then begin to interpret.
And I've heard you say 99% of thepeople love it and they want to keep
(49:57):
it and they want to do it more often,but that's what gives them the patterns,
the trends, and to realize whatthey've got in their hands.
Kathryn, talk about the AGPjust a little bit, would you?
Yes, absolutely.
And I'll just add to that too that Ihave for patients that feel hesitant,
then I will often say, you don't haveto use this forever, let's try it.
(50:19):
And especially if they're not purchasinga reader and they're using their phone,
then there's not much of a costinvestment and then it's always their
decision.
But I think it helps them kind ofunload that burden a little bit to think
they're not necessarily signing up forsomething forever if they're not sure.
But absolutely, I would say99% of patients love it,
which is awesome. So froma clinician standpoint,
(50:43):
I want to mention about interpretationof the data that we get.
And not only is this amazing forpatients as far as improving health and
outcomes, but it is soincredible for us as a powerful
individualizing tool thatwe can really help make
precise recommendations for patientsthat we were not able to make before.
(51:05):
And so one of the nice things abouthaving different devices on the market
is that there is a standardizedreport that comes out when you
download the data in your clinic,
and it's called the AmbulatoryGlucose Profile, AGP,
and it has the samemetrics on every report.
They look slightly different,but they are the same data.
(51:28):
And so it helps as you gainfluency in downloading and
interpreting data tomake clinical decisions,
knowing which things are mosthelpful for you to look at.
So for me, when I get a download report,
the first thing I'll look at isaverage glucose and you can change the
timeframe that you're lookingat. So it's usually 7, 14,
(51:51):
30 and 90 days.
So whichever of those wouldbe most helpful for you.
You can adjust it averageglucose over that timeframe.
You also want to look out how often thepatient is wearing the device. That's
really important because if they'reonly wearing it 7% of the time,
that should influence yourinterpretation of the data.
(52:11):
You hear a lot about thisconcept of time in range or TIR,
and our goal for timein range is over 70%.
And what that means is that70% of the time or more a
patient is between 70and 180 milligrams per
deciliter. And so we obviously want themto be in that range more of the time,
(52:34):
which would mean the A1C islower, right? So time in range.
And then immediately after I look at that,
I look at time below range or TBR,
and we want that to be as low as possible.
We do not want patients to have a largedegree of time below range because that
reflects hyperglycemia timeabove range time very high.
(52:58):
There's all these different nuancesto that bar graph that you see,
but those are kind of the key things tolook at. And once you start doing this,
it becomes really quick. You do it,
your mind just kind of flowsthrough this really easily.
The other thing we talked about quitea bit in this podcast was variability,
glycemic variability.
We want that to be lessthan 36% of the time.
(53:21):
That means they're less of the time,
they're on the rollercoasterand more of their time.
They're driving on a straighthighway, as Debbie said.
And so those are all thekind of important aspects.
It also has this beautiful graph thatshows exactly the variability and times of
day and all of that,
but it's a really amazing tool from aclinical perspective that will give you so
(53:41):
much confidence in makingadjustments and also adding
medication based on glucoseprofiles, adjusting medication.
Those are all reallyhelpful parts of that.
There's going to be a resource added tothis podcast that you can look at later,
which will provide more inputon interpreting the AGP,
but that's a key part of this that wewould encourage you to look back on if you
(54:03):
are not yet familiar with that. So onelast thing I'll mention before we move on
to some practical aspects of this isthe emotional and behavioral aspects
of CGM and always thinkingabout individualizing this,
but I think it's important to acknowledgethat this can create anxiety for some
patients. And having a lot of datacan sometimes feel overwhelming.
(54:26):
Debbie's patient said, Idon't want to know what it is.
Maybe because they're afraid it's highor they know that it's going to be high.
And so us recognizing thatthe incorporation of this can
bring out different emotionsand different behaviors,
and taking the time to ask questionsof how are you doing with this?
How do you like it? How doesit affect you on a daily basis?
(54:46):
And the vast majority offeedback will be positive,
but also kind of understandingthat sometimes it can bring about things that can
create new challenges in some ways. Andwe definitely have ways to help patients
when that happens, but it'simportant to take a note of that.
So let's move on just to a coupleof practical aspects of this.
We can bill for these services,which is awesome, right?
(55:09):
I feel like a lot of the time we'rebeing asked to do more things,
but we can't necessarily have a higherbilling code or we have to figure out how
to make it work.
But these tools are one thing that wedefinitely can bill for and include in our
chart notes and in our billing codes.
So I believe this will also beattached to resources afterwards,
but there are several CPT codesthat you should know about,
(55:30):
and you don't have to memorizethese, you can easily Google them,
but CGM interpretation. Sothe first one would be 95249,
which is used for patient educationand personal use of a CGM focusing
on the placement of the sensor trainingand then the printout of recordings. And
these are things that are going to be,
that's a regular thing you'll be doingwith patients when they're wearing this
(55:52):
95250 would cover the startup training,
sensor placement and data printout ofa professional CGM that you provide in
your office. We didn'ttalk about that today,
but that's also a really nice tool thatyou can consider having for patients
that are not otherwise goingto be on a device long-term.
Sometimes that's called a diagnosticsensor. So professional or diagnostic,
(56:15):
you might want to look into that as wellif you're thinking about getting your
clinic up and running. And then95251 is used for the analysis,
interpretation and report of aminimum of 72 hours of data. Again,
that's something you're going to beusing regularly for patients that are
wearing the device. So a coupleof other practical things,
coverage criteria, again,
(56:36):
I don't know that we have to getinto this in too much detail today,
but I do think this wholeprocess has gotten a lot better.
What I have found for the most part isthat my regular clinic notes will allow
patients to qualify for these deviceswithout me having to do a lot of extra
paperwork. And so I reallyhave appreciated that. Debbie,
I know that you work quite a bitwith patients that are underserved.
(56:57):
Do you have any other thoughtsabout expanding access for devices?
Yes, I do. And one comment forhealth providers. Danatech,
ADCES has a very powerful tool
to help look at coverage.
But when we think aboutpatient access as well,
there are a number of programs available.
(57:19):
The companies Abbott offers through the My
Freestyle program, one free sensor,
and the Dexcom offers coveragefor people that have high
copays. There's also apharmacy savings program,
CR3Diabetes Blue Circle Health is in some
(57:41):
states that's a Helmsley funded program.
Insulin Pumpers Foundation mayhelp with financial resources to
help purchase an insulin pump. Insulinfor Life has been around for a while,
and pharmacy discountcards, GoodRx, Single Care.
So I think we'll have these availableto you at the end of the program.
(58:03):
So do indeed check some of thoseout because I think that would be
beneficial,
especially for people that have a bigcopay or their insurance isn't covering
it. Kathryn, how do we getthis going in the clinic?
So just a couple thoughts aboutpractical implementation. First of all,
this is probably intuitive,
but if you do not have any ofthis set up in your clinic,
(58:26):
the reps for the main companies wouldlove to help you get this set up.
And they will come. They'llhelp you with the software.
There's cloud-based systems for each ofthese that will allow you to see data of
patients when they're sharingit on their phones. For example,
you need a cord for patients thatstill have a reader that they're using.
And that way you can download it fromthere. There's advanced things you can do,
(58:50):
like learn how to clip and addthe graphs and charts to your
EMR that's more advanced. Youdon't have to do that right away.
It's more important that you can accesstheir data and use it to make clinical
decisions and use it for yourconversation. So contacting the reps would be the
easy thing to do.
There's also healthcare provider resourcesthat you can access on the websites
(59:11):
and they will walk you through exactlywhat you need to do. And honestly,
it doesn't take much time. So if thisfeels like a big hurdle to cross,
it's well worth your time to spend alittle bit of time kind of onboarding and
ramping up your clinic for this,
and it will pay off in spades as faras the effects that will have on both
patients and the practice.
(59:32):
So let's wrap up here andthink about key takeaways
that we want you to leave with today.
And the first is that we really wantyou to think about the evolution of
CGM and how it has evolved frompeople who are on insulin to
well beyond that.
Now we're talking about people that donot have diabetes and how it can possibly
(59:55):
improve metabolic healthoptimization, wellness,
sleep. Think about maybe yourpatients with pre-diabetes,
if they're able to accessan over the counter sensor,
how that might impact theirprevention of diabetes in the future.
But really CGMs and the utilityof these devices spans treatment
(01:00:16):
prevention and optimization. I'mso excited for the future of this.
I think it's a really,
really just bright horizon that wehave with diabetes management and the
prevention of diabetes.As nurse practitioners,
we are so pivotal in,
we could call it democratizing CGMuse. How do we bring it to the masses?
How do we encourage morepatients to use these devices?
(01:00:39):
How do we help them translate thisdata? It's not just about wearing it,
it's about how it affects your lifeand your diabetes and your wellness
and empowering them to usethis information for good.
And I love because this fitsso well into what we do as NPs,
and I think it's an awesome opportunityfor us. And this is no matter what type
(01:01:00):
of practice setting that you are in.
So think about how you can incorporateit no matter what your patient population
is, and really think about offeringit and recommending it more broadly.
The clinical evidence for patientson insulin and with diabetes is
robust and it continues to build.
And I know AANP is committed tocontinuing to deliver best practice and
(01:01:23):
update these as soon asmore evidence comes out.
And it's a very fastly developing field.
It's hard for all of usto keep up with, honestly,
but I think that's a really good thingbecause it means that we're having more
and more opportunities for patients.
So I guess our final callto action would be this.
Think about how you can explore CGMimplementation with your patients.
(01:01:46):
And I bet Debbie would agree.I want you to weigh in Debbie,
but it is one of the most impactfulthings that you can do for patients with
diabetes, and I truly believeit will change their life.
And that's such a wonderful thingto see when we can make a concrete
recommendation that has thatlevel of impact. So Debbie,
any final thoughts from you?
(01:02:07):
I couldn't agree more.CGM is a game changer,
and I have patientstell me that every week,
but I would offer oneother call to action.
If you haven't worn a sensor yourself,
I would encourage you to wearone. It's very enlightening.
(01:02:28):
There's a lot of information,
and you may be surprised whatyou discover about yourself.
I love that. Yes.
And it's always helpful when we can giveour own experience with something and
share how that affected us. And so Ithink that's a very powerful tool as well.
Well, with that, we appreciate youtaking the time to spend with us,
and we hope that this can impact andchange your practice in really positive ways.
(01:02:53):
Well, thank you so much,Debbie and Kathryn.
It's been an absolute pleasure listeningto you and gaining your perspectives
and insights on this extremelyimportant topic to our listeners.
I hope you found this episode educationaland can apply some of what was
discussed to your practice.
Join your national professionalassociation and add your voice to over
120,000 of your NP colleagues nationwide.
(01:03:16):
I urge you to become an AANP member today.
Membership gives youaccess to so many benefits,
including tools and resources foryour practice, and the AANP CE Center,
which offers a comprehensivelibrary of CE activities for NPs of
all specialties and experiencelevels, exclusive discounts,
and many free activities are yoursas an AANP member to help you
(01:03:41):
complete state licensure requirementsand earn the credits needed for
recertification. Remember, you mayclaim CE credit for this program through
October, 2026, by logginginto the CE center at
AANP.org/cecenter.
Register for this program.Enter the participation code
(01:04:02):
2526CGM. Again,
that's 2526CGM,
and then complete thepost-test and evaluation.
Be sure to subscribe to this podcast,
share with your colleagues andcheck back often for new episodes.
Thank you for listening.
From the American Associationof Nurse Practitioners,
I'm the host of today's special editionepisode nurse practitioner and education
specialist Patty Scalzo,and this is NP Pulse,
the voice of the nurse practitioner.
Welcome to NP Pulse, AANP's podcast,
(00:36):
bringing you unique nurse practitionervoices and expertise on issues that
matter to NPs and our patients. As always,
be sure to subscribe to thispodcast, share with your colleagues,
and check back often for newconversations with nurse practitioners and
healthcare leaders from across the nation.
NP Pulse podcast listeners may claimCE credit for this program through
(00:59):
October, 2026. After youlisten to the podcast,
visit AANP.org/cecenter.
Register for this activity.
Enter the participation codeprovided at the end of the podcast,
and then complete the post-testand evaluation. On today's episode,
we are joined by experts KathrynEvans Kreider and Debbie Hinnan,
(01:21):
who will discuss key clinicaltrials, guideline updates,
practical implementation strategies,
and real world patient experiencesthat highlight the impact of CGM on
A1C reduction, hyperglycemia prevention,
and quality of life. Listeners willgain insights into current evidence,
device options,
and how nurse practitioners can lead inexpanding access and empowering patients
(01:46):
through CGM use.
Dr. Kathryn Kreider is a professorof nursing at Duke University and the
director of the EndocrinologySpecialty Program for NPs.
She has an active clinicalpractice in endocrinology.
She's a nationally recognized speakerin topics of diabetes and endocrinology,
and was appointed to the AmericanDiabetes Association Professional Practice
(02:08):
Committee, which writes the standardsof medical care and diabetes.
Deborah Hinnan has been a clinicianand diabetes educator for over 40 years
and is an advanced practice nurse whoconsults at the University of Colorado
Health in Colorado Springs.
She also provides diabetesservices at Tri Lakes Cares.
Debbie is involved extensively withthe American Association of Diabetes
(02:31):
Educators, having served as theirnational president. Currently,
Debbie serves on the American DiabetesAssociation Board for Colorado and the
Mountain states.
It is my pleasure to welcomethis panel of experts.
Hi everyone, and welcometo Empowering NPs,
Overcoming Therapeutic Inertiawith Continuous Glucose Monitoring.
(02:54):
My name is Kathryn Kreider and I'm sothrilled to be here today on this podcast
to talk with Debbie Hennin about oneof our favorite topics, right, Debbie?
Yeah.
CGM therapy.
That's right.
CGM has really begun toexplode and not just here in
Colorado Springs, I meaneverywhere. The technology,
(03:14):
particularly in the last fiveyears and rapid expansion.
That's right.
I think when I talk about with patientsand also to colleagues about the
developments that I've seen in diabetesmanagement since my time in practice,
which is now almost 18 years,
I think that CGMs andGLP1s have been the biggest
(03:36):
game changers as far as our ability tohelp patients make really incredible
improvements in theirlife and their wellbeing.
And so it's exciting to see all of thesenew changes that continue to come out
and continue to impact patientsin such a positive way.
Indeed.
And the CGMs that talk throughBluetooth to the insulin pumps,
(03:57):
oh my gosh. Well, if it's all right,
I'll jump right in withsome discussion about our
utility for use with type 1 and
CGM. We,
I think particularly appreciatethe ability to visualize a
consolidated amount of glucose data.
(04:19):
And when you compare that to thefinger sticks we used to have, I mean,
not just that we would get 'em on a nicechart or that we could even download
them,
we would get them on the envelope thatthe electric bill came in and there was
no way to analyze the trends.It was just impossible.
Hyperglycemia though is much morecommon, particularly at night,
(04:42):
and CGM has allowed us to seethat as well as document the
dawn phenomena,
but the real time alertsfor hyperglycemia,
that is I think a powerful benefit,
especially for patientswith type 1 and reduction in
A1C reducing glycemic variability.
(05:04):
Those things are really going to havean enormous impact on the long-term
complications of diabetes. Kathryn,
what evidence are weseeing around this now?
Yeah, I think it's great, Debbie,
to kind of kick off talking about patientswith type 1 diabetes and then those
who have insulindependent type 2 diabetes.
So we'll talk a little bit about some ofthe evidence around CGM and how it can
(05:28):
improve the lives ofpatients who use insulin,
but also point out that as we kindof go through this podcast today,
we're going to talk about theexpanded role of CGMs too.
So we'll talk a bit more laterabout prevention and wellness.
We'll talk some about the over-the-countersensors that are coming out.
So we hope to provide kindof a comprehensive viewpoint of where we are in the
(05:50):
landscape of CGMs rightnow. But to your point,
I think it's helpful to start withsome of the key trials in type 1
diabetes because this isreally where CGMs sort of were
initially placed,
right? Because we know that patients whouse insulin are going to be at higher
risk for hyperglycemia.
There are more challenges with theirmanagement from a complexity standpoint.
(06:14):
And so this is really where CGM started,
and there's amazing datashowing really wonderful
improvements in A1C and likeyou said, glycemic variability.
And so one of the first studies thatcame out was called the STAR 3 trial,
and in this trial the patientsused a sensor augmented pump.
(06:35):
And what that means, of course, isthat the pump is connected to the CGM,
and that's as you mentioned as well,
kind of where we start to see some ofthis really awesome advancement that's
happening now with patients.
We call them also automatedinsulin delivery devices now.
And in this particular trial with STAR 3,
the study showed that A1C decreasedsignificantly more than self-monitoring of
(06:58):
blood glucose levels. This was one ofthe earlier trials that was published.
And of course, this makesintuitive sense, doesn't it?
We always want to see the data andwe want to see the trial outcomes.
And so it really is important tosee some of this concrete evidence,
some of the other important trialsspecifically in type 1 diabetes.
There was one called the IN CONTROLtrial that was published in 2016,
(07:21):
and it looked at this concept ofdiabetes distress and patients who
used CGMs had lowerdiabetes distress and higher
satisfaction compared to those whodid self-monitoring of blood glucose.
I love this trial becauseI'm really passionate about mental health and diabetes
management.
And so the fact that we can see patientshave better quality of life and lower
(07:45):
diabetes distress is really, reallyimpactful. A couple other trials,
there was one called theHypoDE trial published in 2018,
in The Lancet Journal,
which showed a 72% reductionin hyperglycemia events with
real time CGM.And this is amazing, right?
And one of the key benefits Ialways talk to about with patients,
(08:07):
particularly with insulin dependentdiabetes, is that it really,
really helps improveand reduce hypo events.
And that really speaks to patientsbecause everyone has that in the back of
their mind, right? Debbie,where they're like,
they have this anxiety that this couldhappen when they're sleeping or when it's
not expected.
And so one of the most powerful tools wehave is the reduction of hyperglycemia.
(08:30):
We always love a good meta-analysis whenwe're looking at multiple studies and
all of the impact of the studies combined.
And I think this is interestingbecause patients will ask you,
and it's also a helpful kind of thingto bring up if they don't ask you,
how much is this going to impact my A1C?
And the studies have shownthat overall A1C is reduced
(08:54):
typically between 0.2 and0.4% and sometimes up to
0.5% reduction in a A1C.And that's just from using the
CGM. But that makes sense becausepatients are seeing this data,
they're able to respond to the data,they're reducing hyperglycemia,
which then reduces the spikesthat can happen after hypos.
(09:17):
So there's all of these factors that canhelp lower the A1C just by having this
increased awareness.
So this meta-analysis showedreduction in A1C by 0.23%
overall, which is a small amount,
but it's still a clinically relevantand clinically significant amount for
patients.
And then one other study I'll sharewas looking at the difference between
(09:40):
real-time CGM versusintermittently scanned. CGM.
Really the intermittently scannedCGM systems are phasing out.
And so these are the systems that patientshave to scan in order to activate or
to ask what the glucose is.
And I think there's pros and consto these devices, but in general,
it really helps when patients don't haveto think about it. It takes the onus
(10:05):
away from the patient to have toremember to check or to ask what the
glucose is.
And so the real time systems I think aremuch more of the wave of the future and
where we're heading from now on.
But this particular study publishedin 2024 showed that the real-time
sensors improved time in range by 7%
(10:26):
versus the intermittentlyscanned CGM systems and the
time in hyperglycemia or timebelow range was significantly
less for the real-time system.
So both of those were betterwith a system that is constantly
reporting out what the data is.
So I think that's really helpful becauseit kind of proves what we already see
(10:49):
in clinical practice,
which is it's really nice for patientsto have the real time systems.
For those of you that might see children,
there's a lot of dataabout CGMs and children and
the impact on daily lives of patientsthat have children with diabetes and
children who have diabetesis both just is really,
really wonderful improvements that wesee across the board in those kiddos.
(11:13):
So that is kind of a briefoverview of the type 1 diabetes
data. And there's also a lot of datanow about type 2 diabetes and CGMs,
which is the next wave thathappened where we're looking at use
across patient populations andnot just with type 1. So Debbie,
do you want to share some of thekey trial data from type 2 patients?
(11:35):
Thank you, Kathryn. I so appreciateyour comments about pediatrics,
the to share that glucosedata with parents,
teachers,
caregivers is just sucha reassuring kind of
technology boon. So Kathryn,
let me start with some studiesfocused on insulin dependent
(11:57):
type 2 diabetes.
The MOBILE trial with Martenset al in JAMA from 2021
showed us that CGM group spent 15%
more time and range 16% less
time above 250 milligrams and a lower mean
(12:17):
glucose by nearly 30 points.
We also see reduction timespent in hyperglycemia.
And that study from diabetes therapy in
2017 and a study inFebruary of that same year
showed us that people withtype 2 diabetes on insulin had
(12:38):
reduced the hyperglycemiatime by about half.
And that's not justglucose levels below 70,
that's glucose levels below 55.
And that kind of data fromthe CGM I think is the
safety, the very reassuring piece,wouldn't you agree? We also,
(12:59):
I think,
have trials to share that arerelated to all people with type 2
diabetes, whether they'reon insulin or not.
And a narrative review from2018 of 11 studies with
over 5,500 patients showed that glucose
monitoring compared to CGM,
(13:20):
the CGM reduced the A1C,reduced the body weight,
reduced caloric intake,
and had greater than 90% compliance with
CGM wear time.
A meta-analysis from 2024 of 14 trials
with over 1600 patientsshowed that A1C reduction of
(13:43):
0.32. And as you mentioned in type 1,
that is similar. However,
another study by Millerin 2022 showed that the
A1C reduction,
whether people were on the FreestyleLibre Flash or the Dexcom G5
or G6 had A1C reductions that were even
(14:06):
greater 0.7 0.8 2.80.
And I think particularly noteworthyhere is there weren't any differences
between the devices. So each cohort group,
regardless of which CGM they were using,
had comparable reductions in the A1Cs.
(14:26):
Kathryn, what are theguidelines advising us?
Yeah, so first of all,
we hope that you appreciatelistening to some of the statistics.
I know it can be hard a little bit tolisten to that and put context around it.
But before we wrap up that section too,
I just wanted to highlight thatthe A1C reductions are clinically
meaningful and the hypo reductionsare clinically meaningful.
(14:49):
And so I think those are two of thekey discussion points I think to bring
forward to patients when we're talkingabout pros and cons of these devices is
that the vast majority of patientsreally have wonderful benefits and
that's backed up by the clinicaltrials. So from a clinician standpoint,
we always want to make sure that we'repracticing evidence-based medicine and
(15:11):
the American DiabetesAssociation publishes the standards of care every year.
And if you're not familiar with that,
I always recommend thatpeople take a look at it,
you can easily find it on their website.And one of the key points that has
continued to emerge year over year isthis highlighting of technology and
how it can really help patients.
(15:31):
And so I want to highlight a coupleof the guideline recommendations,
and Debbie,
get your take on these two or maybe theones that you think are the most helpful
or impactful for your practice. Firstof all, we start with something simple,
which is diabetes devicesshould be offered to people with diabetes. Definitely,
right? When we think aboutpatients with type 1 diabetes,
(15:52):
the recommendation at a level A ofevidence is that CGM should be offered to
people early, even atthe time of diagnosis.
And this is something I do andI think is pretty well received,
which is you try to get someoneon a CGM immediately if possible,
when they have type 1.
And that can really help just with allthe things we talked about already. But
(16:12):
it also as a framework for this is howwe want to help you manage your diabetes,
let's get this started now becauseit will make such a big difference.
We always want to individualizetechnology recommendations.
And so this is where having some fluencywith this as a provider is really
helpful when we can kind of understandthe differences between devices and who
(16:34):
might be a better fit for a certaintype of device, for example.
And that can help us have patient-centeredcare and individualized care where
we're able to tailor our recommendationsmore readily to someone's specific
needs. And the ADA uses thisframework of specific needs,
preferences and skill level,
and those are all things that weshould be taking into consideration.
(16:55):
So a couple other things, and we cankind of go through these quickly,
but if someone has been on aCGM or an automated insulin
delivery system,
we need to make sure that they havecontinued access to this device. This is
speaking to payers, right?
We want insurance companiesto be making sure that these
patients continue to access their devices.
(17:16):
And I know that we have all had situationswhere people can no longer afford or
their copays go up dramatically.
And that American Diabetes Associationputs language like this into the
standards of care becauseit's an advocacy piece.
And I think this is important for us asNPs to know what's going on behind the
scenes and understand why theywould say something like that,
(17:37):
because it's a huge part for us ashealthcare providers to make sure we're
advocating for our patientsto have access to devices.
So one of the newer thingsthat's happened, Debbie,
and I'll have you speak to this one,
is that adults with diabeteswho are on basal insulin
only should be offered CGMs.
And this is awesome, right? I mean,we all recognize the benefit of this,
(18:01):
but this is more recentthat Medicare, for example,
would cover patients who arejust on one injection a day,
and this is a very firm recommendationthat we should be considering this.
So Debbie,
have you seen that change or practiceat all with Medicare coverage or sort of
this shift to offering to more patients?
Absolutely. And I think thatclinically it's a very powerful tool,
(18:24):
not just for the person withdiabetes, but for us as clinicians,
because people lose firstphase insulin release first.
And so if they're just on basal insulin,
we need to monitor thatpostprandial and that
opportunity,
particularly for Medicarepatients is a huge opportunity.
(18:45):
Yeah, that's a really good point.
And now that we have moreand more patients on GLP1s plus basal insulin and all
these different combinations of therapies,
it is really helpful to be able to seechanges over time. So that's right.
So a couple other things I want tohighlight. From the ADA standards of care,
we should definitely be offeringCGMs to youth with type 1 diabetes,
(19:06):
youth with type 2 diabetes whoare on insulin should have CGMs.
This is all kind of intuitive.
I think we want patients to usethese devices as close to daily as
possible. If they can't do that or theycan't necessarily afford ongoing use,
then intermittent use is reasonable.
And that can still bereally helpful in many ways,
but we want to make sure that they'reusing it often in order to maximize the
(19:30):
benefit. And then thefinal thing I'll mention,
which we'll talk a little bitmore about in just a few minutes,
is you want to make sure that and thatyour patients know about potential
interfering substances and otherfactors that could impact the accuracy.
Maybe you've had patients say,
this is rating really high orthis doesn't really seem right.
And that's the opportunity for us topause and to make sure we're checking for
(19:54):
accuracy in anything that couldbe impacting those values.
I guess it's also important to mentionhere that the ADA I think is really the
premier voice in many ways of thestandards for diabetes management.
But the other organizations thatare really important and impactful,
both nationally and internationallyagree on this importance of CGM
(20:15):
therapy for patients with diabetes.
And so I think it's nice when we canall kind of come together and all the
organizations agree because that doesn'talways happen when we're thinking about
how to position these therapiesfor diabetes management.
And then another recent development,which we're going to talk more about,
and also in patients that don'tuse insulin at all is considering
(20:37):
CGM when hyperglycemiais a risk factor or when
glycemic variability is aconcern or something that is impacting someone's care.
So that starts to get into these differentnuances of other things and other
opportunities to consider CGM therapy.
AACE is the American Associationof Clinical Endocrinology.
(20:58):
They usually release guidelinesfor diabetes every couple of years,
and they say CGM highly recommended toall patients with diabetes to assist
in reaching goals safely. I love that.
That's very broad reachingfor everyone to consider.
And then ADCES is 2021practice paper recognizes
CGM as an essential tool forimproving outcomes in both type 1 and
(21:22):
type 2 diabetes to reduce hyperglycemia,
lower A1C and improve quality of life.
And we can't forget that component becauseI think sometimes when we think about
diabetes management, wefocus on numbers, right?
And time and range andtime below range and A1C.
And ultimately those are important,
but it's so much more importantin some ways, in many ways, right?
(21:43):
That someone has a really good qualityof life and that they can live a healthy
life with diabetes. So I mentionedbefore about interfering substances,
and I'll just briefly mention this hereis actually this has gotten a lot better
in recent years where there's not quiteas many things to think about as far as
interfering substances.
The two things to rememberare acetaminophen and vitamin
(22:06):
C. And so let me explain acetaminophen.
If it is over four grams per day,
that will affect theDexcom G6 and G7 device.
If your patients happen to usea Medtronic Guardian sensor,
then any dose of acetaminophen willaffect the accuracy of the device.
So what this looks like is patientshave higher sensor readings
(22:31):
than their actual glucose,and this is Tylenol,
acetaminophen super common.
And we need to make sure we're asking ifthings are not adding up or if patients
are reporting that it seemslike they're elevated.
The other one would be vitamin C.If it's over 500 milligrams a day,
that will affect theFreestyle Libre devices.
(22:52):
So that's the 14 day theFreestyle Libre 2 and the 3.
And again, that will make the sensorreadings higher than the actual glucose.
So those are two really common ones.
The other things to consider wouldbe hydroxyurea, mannitol or sorbitol.
The latter two are inperitoneal dialysis solutions.
So they're certainly not as common.
(23:14):
But if you start running into thesesituations where you see a difference,
the first thing to have patientsdo is to calibrate their device.
They still should havean actual glucometer,
a very old fashioned glucometer wherethey can compare the data so they can see
if it looks like it is lining up or not.And then you can start investigating.
And I've had actually several patientsin the last couple of weeks that have had
(23:37):
the acetaminophen interference, soit's important to remember that one.
So those are just somepractical tips, but Debbie,
when we think about nursepractitioners and our role in
helping patients implement CGMs inboth type 1 and type 2 diabetes,
what are your thoughts on how to framethat or how to get started with these
devices?
(23:58):
It's an enormous opportunity, Kathryn,
and nurse practitioners do,
primary care does 90% of diabetes and our
patients are walkingin asking for sensors.
So the awareness that our nursepractitioner colleagues have about
CGMs is very important.
(24:20):
So they will of coursebe initiating protocols,
initiating sensors,
but interpreting that glucose datathrough the ambulatory glucose
profile is really critical.
And I know you're going to talk tous about that a little bit more,
but it consolidates a couple ofweeks worth of data and gives
(24:42):
you that tool to huddlewith the patient and begin
to have the conversation.
I like to start the conversationwith what have you learned
from wearing the CGM?
What have you discoveredabout your glucoses that
lets us look for opportunitiesin lifestyle adjustments?
(25:05):
I think we always want to startwith talking about the meal plan,
the diet, the exercise,
and what have you learned is anopportunity for the person with diabetes
to say, well,
I sure can't have Cheerios at breakfast.And that's powerful.
That's more powerful thanus saying that by far.
(25:28):
But it's also really important, I think,
to have this tool as aresource when insulin is
initiated. And I thinkof the ultra long basals,
particularly in this case,
because they don't reach steadystate for three or four days.
So we've been used to for years,
helping people initiate insulinand increase one unit a day
(25:51):
or something more frequentlythan every three or four days.
And so if we can have thisglucose monitoring tool when
people are startinginsulin and titrating it,
it's very beneficial. And Iwould say the same for GLPs.
So we've got the GLPGIP class of medications
(26:15):
that begin to have an impact onboth fasting and postprandial within
72 hours.
So if people can see that andlook at their lifestyle changes,
it is a huge benefit.
And as we look at our in healthcare,
the interdisciplinary team is powerful.You and I are focused a
(26:38):
lot in diabetes and endocrinology.
We're speaking to a lot ofour primary care colleagues,
but dieticians andpharmacists have a large role.
A lot of dieticians are startingpumps and sensors of course with
that sometimes.
And so that initiation andtitration may be handled by
(27:00):
dieticians and or pharmacists.
The clinical role of pharmacists hasreally expanded in the last few years.
And when I think aboutall of this and our role,
I think how powerful it isfor patients to have that
data, have that opportunity.
I'm doing a lot of diabetes workat our local Tri Lakes Cares,
(27:24):
our food bank with lots ofother community services.
But when I did a recent diabetes workshop,
we offered CGMs and Istarted CGMs on everyone.
And at the two week follow-up,one of those patients said to me,
Debbie, I can see these blood sugarsall the time. And you know what?
(27:45):
It's an accountability tool for me.
And now cake is anexperiment, not a habit.
And I thought, what a greatcomment. I mean, that's a headline.
She was empowered, she learned data,
she made changes in her behavior.
What kinds of things areyou seeing with patients?
(28:06):
Yeah, I love that story. I mean,
I think it's so similar tomany patients that I see,
but I have one example of a guythat I saw a couple of weeks ago,
and when he first came to see me,
he's had type 2 diabetes oninsulin for 15 years or more.
And today when, see when he came tosee me, I think was nine and a half.
He was checking hisglucoses a few times a day.
(28:27):
He had never been offered a CGM before.And so that's the first thing I do.
I know what a powerful tool it is.
And so he agreed to try itand he came back to see me.
I think he came in six weeks, but bythree months his A1C was 6.5. Wow.
And I had not made any changes to hisinsulin because I was kind of waiting to
see what the data looked like, and thenwe'll make adjustments. And of course,
(28:50):
I was just telling him how wonderfulthis was and commending him on this,
and he said, I know what I need to do.Right? It's like knowledge is power,
and when you have the datathat you've never had before,
it can really be transformative.
So I know you all probablyhave your own experiences too,
but it's awesome to see how muchit really can transform someone's
experience. So I lovethat. And then Debbie,
(29:12):
I know one of the things we wantedto talk about too was using CGM
devices and people whodo not require insulin,
and then we'll also talk later aboutpeople who don't even have diabetes.
So there's all these coolimplications now that are coming up.
Tell us about your thoughts onusing them and patients who do have
type 2 but are not on insulin yet.
(29:34):
Well, Kathryn, I think it's, asyou say, a very powerful tool.
People who are not on insulinmay be looking at an over the
counter glucose sensor. Theirinsurance may not cover it.
And so just within the last year or so,
there are now three over thecounter glucose sensors that are
available, Abbott Lingo, Abbott Rio,
(29:57):
and the Dexcom Stello.
And the devices since they're over thecounter are typically paid out pocket,
but they last for 14 days.So when we talk about,
maybe it's not covered by insurance,
this is where your comments aboutthe intermittent use may become very
helpful because people mayuse one sensor a month,
(30:20):
but we've talked a lot aboutpeople that are on insulin.
And so the prescription sensors wouldbe the ones that are patients on
insulin, on insulin pumpswould certainly be using,
and their insurance is likely goingto cover that. We have the Eversense
365 now that is approved to
(30:43):
use this implantable sensor up to a year,
but we have Medtronics Guardian 4,
the Libre 3, 3 plus Dexcom's G7.
There's still Libre 2 and G6 out there,
even though the newer ones are available.
But the accuracy is the other thingthat I think has dramatically improved.
(31:05):
And the accuracy, the mard,
that monitor of accuracy is less than 10%
in most all of these.
I think having these availableis that first step in
being able to see them usedin our patients and over
the counter,
(31:26):
particularly in our patientswho are on oral agents.
And as we've discussed, when youput that data in somebody's hands,
they see what happensafter they eat a meal.
And it's always, I think,
eye opening to see what happensafter you eat french fries and
(31:46):
the size of the french fries servingis maybe going to cause an enormous
post meal glucose spike. And thenthat gives that information to people
for monitoring or adjustingwhat amount of french fries,
what amount of pizzashould I try, because boy,
that's really important and my lifecan't be happy without a piece of
(32:09):
pizza on occasion.
So we're empowering peoplethrough this data visibility.
And I think pattern recognition issomething that's probably been most
passionate for me over thedecades of my practice.
I've written about this and spoken aboutthis back in the days when we had to
do urine testing to measure whetherthere was glucose in the urine or not.
(32:33):
And now of course,
advancing through BGM finger stick to CGM,
we have the ability forpattern recognition,
not just a single spike, an outlier,
but what is happening over several weeks.
I particularly appreciateMedicare's changes and within the
(32:56):
last year and a half,
CMS has broadened their coverage for CGMs,
and people with diabeteswith type 2 diabetes can
use sensors now be eligible forsensors if they have a history of
hyperglycemia. Now, this may be theperson who's not even on insulin,
(33:17):
maybe they're on a sulfonylurea,
but if we can document that glucoseof 54 according to the guidelines,
make them eligible for a CGMand our patients on insulin have
seen those guidelines relaxas well if they're on insulin,
not three injections a day,
so maybe just bibasilar ifthey're doing glucose monitoring,
(33:40):
not necessarily four timesa day, it used to be,
that would be the new guideline thatwould allow them to be eligible.
And of course we have to have afollow-up with them in six months.
Kathryn, what would you add?
Yeah, those are awesome thoughts.
My first thought is that thecoverage has gotten so much
(34:01):
better, I think universally forpatients on all types of insurance,
private and Medicare and Medicaid.
I very rarely have trouble getting access.
Sometimes the copay can bea little bit of an issue,
but I've been so encouraged by theincreased availability across the board.
I would say another example of apatient type that I've been able to get
(34:24):
CGMs for are patients who havetype 2 diabetes who had metabolic
surgery and now they have hyperglycemia,
which can happen after bariatric surgery.
And that's been a really good opportunityfor safety and kind of helping with
dietary adjustments andso forth after surgery.
So the expanded option when you'readding in the history of hypo without
(34:45):
insulin is really helpful I think. Sothat's been a good benefit I've seen.
That's a great comment.
The Medicare changes remind me ofone of my patients at the food bank
who's on basal insulin and a GLP.
He has a CGM and has foundit very useful for day-to-day
(35:05):
changes and weekly pattern management.
But this week at the foodbank, when I saw him,
he told me he wasn't able to get his GLP,
he couldn't afford it. And I said,
so tell me what's happening toyour glucose levels. He said,
my blood sugars are reallyhigh after meals. Well,
(35:26):
if he had not had the CGM,
he wouldn't know that was happening.When he had his next visit,
he would have an A1C andit would be elevated,
but he still wouldn't know when thatwas happening or why that was happening.
So I really appreciatethe Medicare changes and
(35:46):
relaxation particularly. But Kathryn,
I think we should really delveinto some of the discussion
beyond people with diabetes.We're seeing CGM
now used in preventionand wellness and there's
growing interest and some controversy,
(36:06):
but CGM is used formetabolic optimization.
It's used in weight loss, it'sused for athletic performance.
People are finding this tobe valuable information,
even if they don't havediabetes athletes particularly,
I think we see them carb load, Ithink we see them run a marathon,
(36:28):
and it's reassuring and saferto have this data for them.
So we are seeing the CGMs now
in many other areas besides just our
folks with diabetes.
The other areas I think thatwe've seen some benefit is
(36:48):
pre-diabetes and metabolicsyndrome management.
This is a tool I think whenpeople have that elevated
A1C and are trying to begin some lifestyle
changes,
this is that extra boost togive them information and
stress related diseases.
(37:08):
Clinically driven aspectshere are powerful.
I've used it in potspatients who have stress
spike, blood pressure spike,and when they have a CGM on,
they realize that that correlateswith also that spike in glucose.
You and I know that thestress hormones, the cortisol,
(37:29):
the glucocorticoids allcause an increase in glucose,
but I think people who don't havediabetes or aren't tuned in on this
pathophysiology don't realize that.
So there are other areas thatpeople are gaining a lot of
information.
The biofeedback that people get isreally there to help support their
(37:52):
health goals.
Are you seeing it used Kathrynin some other areas besides
diabetes?
Since I'm in an endocrine clinic,most of my patients have diabetes,
pre-diabetes or obesity.
And so I have definitely had moreexperience with patients with obesity that
are super interested inpreventing diabetes in the future,
(38:15):
for example, or reducing insulinresistance, that kind of thing.
And so this can be,
I think a really powerful toolto help with weight management,
and that's most of my experiences inthat space. When you were talking,
I was thinking of the term biohacking.Have you heard that term before?
Yes.
Yeah. So biohacking, whichI'm not an expert at all,
(38:37):
but it's essentially people that areusing their own data from their body to
optimize their health.
And so this is an example of people weremonitoring sleep or menstrual cycles
and now it's glucoses and all theseother things that can be assessed with
technology and in order to tweak itand adjust it and make improvements to
optimize their health.
So it's definitely an important additionto that when you think about glucose
(39:01):
regulation. So I guess Debbie,
one of the other things to mention aboutthe over-the-counter sensors is that
right now we do not haverandomized control trial data.
And so that's definitelya piece that's lacking.
There's more and more evidence aboutobservational use and user reported
data.
And then there's specific studies lookingat different types of people that do
(39:24):
not have diabetes for example.But I definitely think that the evidence
base for this will grow.
We just don't have a lot of firmdata right now for people without
diabetes.
But there's a couple ofpatient populations that I think would be helpful to
mention. So these are all, again,
people without diabetes and howCGM can help improve their health.
(39:47):
So one example is patients whohave had a kidney transplant,
and I see a lot of these patients becauseI'm in an academic medical center,
and essentially we always monitor thesepeople after surgery because they're on
prednisone usually inthis particular study,
this was published wayback in 2013, actually,
it showed that early CGM detectedhyperglycemia and predicted a
(40:11):
higher risk of post-transplantdiabetes and graft failure.
So clearly hyperglycemia islikely to predict eventual
diabetes,
but the graft failure partis pretty profound because obviously that's the worst
case scenario when you'vehad a transplant. So the thought here would be even in
people that do not have diabetes,
(40:32):
they could benefit from this moreintensive monitoring to help protect and
preserve their outcomes in the future.
Another interesting study published in2023 looked at over 7,000 people who did
not have diabetes.
And this study showed thatmean glucose levels correlated
with health metrics like sleeppatterns. That's a fascinating one.
(40:55):
We talked about the biohackers andthey're always trying to put together the
pieces of if I do this, then thiswill improve this or affect this.
And it makes sense that if youhave glucose dysregulation,
then your body is going to have otherthings that likely are affected by that.
And so sleep is one of those,
and I think that's pretty fascinatingfor patients with chronic kidney disease.
(41:15):
Glycated albumin andfructosamine are more reliable
glycemic markers than A1C in this group.I've been saying this for a long time
because I mentioned that I have apopulation of patients in my practice.
They have a lot of medicalcomplexity. Many of them have CKD,
they have other comorbidities. Wehave a lot of transplant patients.
(41:36):
When you have someone on a CGM and youcan actually compare that data to the
A1C,
I estimate that up to 40%of my patients have an A1C.
That is not accurate.
And I don't think that's something thatwe talk about a lot actually because A1C
is still considered the goldstandard and that's good.
(41:56):
But I think now that we have moreand more and more patients on CGMs,
we're seeing these differences.
And I'm talking about the 90day CGM trends, not the 14 day.
When you actually compare 90 days to theA1C, there's often a vast difference.
And that's because we know that A1Chas a lot of reasons that it can
be falsely high or low. And so thisparticular study just proved that
(42:21):
glycated albumin and fructosamineare more helpful than A1C.
So when you've got patients with CKD,even if they don't have diabetes,
for example,
this might be an interesting thing inthe future we can use to predict future
risk. And then we've mentioned kids acouple times throughout this episode,
and when we think about kidsthat have hyperglycemia,
(42:42):
and this is independent of diabetes,
then CGM in this particularstudy published in 2023
really,
really was helpful as far as preventionand management of hyperglycemia and
these children withoutdiabetes. And so again,
so much help to parents when they'rethinking about optimal management of their
kids and protection of them.
(43:04):
I could talk about this forever that Ihope we'll get to a place where we will
get CGMs covered for pre-diabetesbecause this is such a missed
opportunity,
right? We've got a lot of patientsthat are very motivated to improve
and to prevent diabetes,
but they don't have good monitoring rightnow unless they're able to do out of
(43:25):
pocket for a CGM. But if we wereable to capture these people earlier,
we could really, really helpthem to prevent diabetes I think.
So there was a study published lastyear in 2024 looking at glycemic
variability and that ahigher degree of glycemic
variability, which is of course theups and downs or the roller coaster,
we call it detected by CGM,
(43:48):
was linked to coronaryatherosclerosis and event risk,
and of course the progression to type2. So that's a really interesting one.
Remember, these arepeople with pre-diabetes,
so really interesting datalooking at overall risks and
cardiovascular riskreduction possibilities.
And then finally the last one I'llmention is in people who did not have
(44:10):
diabetes CGMs in this studyshowed that if they had, again,
higher variability, theyhad worse stroke outcomes,
and we didn't understand the impactof glycemic variability before. I
actually used to tell patientsthis was like 18 years ago,
that as long as your average is okay,
(44:30):
it's likely that's what we aim forbecause we didn't really understand the
overall impact as long asthey're not getting low.
But now we have much more firmdata about trying to reduce
that rollercoaster and keep peoplenice and even and nice and smooth,
and that really can improvelots of outcomes. Debbie,
those are just some examples of datathat's coming out in patients that don't
(44:52):
have diabetes, and I think it's reallyinteresting to hear about those.
Do you have any particularthoughts about any of those groups?
Well,
I especially appreciate youfocusing on glycemic variability
because that has been asurprise for me as well,
and a powerful kind of thingto help smooth out people's
(45:12):
symptoms and people's feelings.
That spike of course may increasethe risk of all the cardiovascular
issues,
but that drop then may alsotrigger hyperglycemia symptoms.
And so in finger stick days wemight or might not catch that
glycemic variabilitypieces is really powerful.
(45:33):
And I think that leads tohow important the patient
education is.
And we have to really be educating people,
not just about lookingat their glucose values,
but what they may be ableto do to make changes.
But people may misinterpretdata or they may have
(45:54):
increased anxiety because it's there,
it's in front of them all the time.
And we've talked a lot today aboutpeople who don't have diabetes.
It's fairly common I think forpeople to realize, my gosh,
my blood sugar goes up after Ieat a lot of carbs, or my gosh,
my blood sugar dips after Ihave intense exercise. And so
(46:18):
people may be concerned abouthyperglycemia and we need to help
people understand normalphysiology does not look like
I 70 through Kansas.
There's some elevations and some drops.
We don't want it to look like Pikes Peak,
but it may look like the FlintHills or the Black Forest,
(46:40):
and that is normal variability.
So I may move on to talkingabout some of our patient
barriers that we face. And I know you'llhave a lot to share here, Kathryn,
but cost of course and insurancecoverage are top of mind for
all of us.
And I think it is important forus to not make that decision
(47:03):
for people with diabetes aboutaccessing a CGM because people
may choose to pay out of pocket.
They may choose to use one sensora month if they have type 2
diabetes and their insurance doesn'tcover it. So while cost and insurance
are issues, prior auths may be needed.
(47:23):
I think it's incumbent on us toempower our patients in a shared
decision-making model to beable to make those decisions.
Alarm fatigue is a real thing,
and that barrier I thinkimpacts family members.
It impacts spouses becausea low glucose alert is
(47:45):
going to turn into a siren ifsomeone doesn't stop and take care of
it. And if that happens during thenight when people are sleeping,
they may not hear it as quickly.
And alarm fatigue issometimes a real issue,
but data overload andmisinterpretation might be yet
another barrier. And we do see, of course,
(48:07):
that people have glucose readingthat may be three or 400,
and in fact they say, I feel fine.
And so if they can pull out thatglucose meter and do an old fashioned
finger stick that wouldconfirm that indeed it is an
error of the CGM,
a device error.So that wouldn't necessarily
(48:30):
be them interpreting the data.
It maybe is just a mechanicalproblem. And stigma, body images.
Last week I offered CGMs to threedifferent people at the food
bank and two of them said, no, I don'twant to know. And one person said,
you mean I have to wear it? Like itgoes in the skin and it would be there,
(48:52):
someone might see it. So there is stigma,
there are concerns about body image.
I know role of clinicians,particularly NPs,
is patient-centered andwhether it's pre-diabetes or
diabetes,
we want to have the patient at the centerand meet them where they are with what
(49:14):
information they need. If wecan normalize the trial periods,
we may have a greater reuptake.Those people that told me, no,
I don't want to try it,
I had talked to them aboutit then and it's a sample,
there's not a charge,
so let's consider it next week.So I see people at the food bank every
(49:35):
week.
It's not like the clinic where I'm doingvirtual patient work and seeing people
every three months or once a month.If I'm doing a lot of intensive work,
I'll be able, I think,
to help them get a trialand then begin to interpret.
And I've heard you say 99% of thepeople love it and they want to keep
(49:57):
it and they want to do it more often,but that's what gives them the patterns,
the trends, and to realize whatthey've got in their hands.
Kathryn, talk about the AGPjust a little bit, would you?
Yes, absolutely.
And I'll just add to that too that Ihave for patients that feel hesitant,
then I will often say, you don't haveto use this forever, let's try it.
(50:19):
And especially if they're not purchasinga reader and they're using their phone,
then there's not much of a costinvestment and then it's always their
decision.
But I think it helps them kind ofunload that burden a little bit to think
they're not necessarily signing up forsomething forever if they're not sure.
But absolutely, I would say99% of patients love it,
which is awesome. So froma clinician standpoint,
(50:43):
I want to mention about interpretationof the data that we get.
And not only is this amazing forpatients as far as improving health and
outcomes, but it is soincredible for us as a powerful
individualizing tool thatwe can really help make
precise recommendations for patientsthat we were not able to make before.
(51:05):
And so one of the nice things abouthaving different devices on the market
is that there is a standardizedreport that comes out when you
download the data in your clinic,
and it's called the AmbulatoryGlucose Profile, AGP,
and it has the samemetrics on every report.
They look slightly different,but they are the same data.
(51:28):
And so it helps as you gainfluency in downloading and
interpreting data tomake clinical decisions,
knowing which things are mosthelpful for you to look at.
So for me, when I get a download report,
the first thing I'll look at isaverage glucose and you can change the
timeframe that you're lookingat. So it's usually 7, 14,
(51:51):
30 and 90 days.
So whichever of those wouldbe most helpful for you.
You can adjust it averageglucose over that timeframe.
You also want to look out how often thepatient is wearing the device. That's
really important because if they'reonly wearing it 7% of the time,
that should influence yourinterpretation of the data.
(52:11):
You hear a lot about thisconcept of time in range or TIR,
and our goal for timein range is over 70%.
And what that means is that70% of the time or more a
patient is between 70and 180 milligrams per
deciliter. And so we obviously want themto be in that range more of the time,
(52:34):
which would mean the A1C islower, right? So time in range.
And then immediately after I look at that,
I look at time below range or TBR,
and we want that to be as low as possible.
We do not want patients to have a largedegree of time below range because that
reflects hyperglycemia timeabove range time very high.
(52:58):
There's all these different nuancesto that bar graph that you see,
but those are kind of the key things tolook at. And once you start doing this,
it becomes really quick. You do it,
your mind just kind of flowsthrough this really easily.
The other thing we talked about quitea bit in this podcast was variability,
glycemic variability.
We want that to be lessthan 36% of the time.
(53:21):
That means they're less of the time,
they're on the rollercoasterand more of their time.
They're driving on a straighthighway, as Debbie said.
And so those are all thekind of important aspects.
It also has this beautiful graph thatshows exactly the variability and times of
day and all of that,
but it's a really amazing tool from aclinical perspective that will give you so
(53:41):
much confidence in makingadjustments and also adding
medication based on glucoseprofiles, adjusting medication.
Those are all reallyhelpful parts of that.
There's going to be a resource added tothis podcast that you can look at later,
which will provide more inputon interpreting the AGP,
but that's a key part of this that wewould encourage you to look back on if you
(54:03):
are not yet familiar with that. So onelast thing I'll mention before we move on
to some practical aspects of this isthe emotional and behavioral aspects
of CGM and always thinkingabout individualizing this,
but I think it's important to acknowledgethat this can create anxiety for some
patients. And having a lot of datacan sometimes feel overwhelming.
(54:26):
Debbie's patient said, Idon't want to know what it is.
Maybe because they're afraid it's highor they know that it's going to be high.
And so us recognizing thatthe incorporation of this can
bring out different emotionsand different behaviors,
and taking the time to ask questionsof how are you doing with this?
How do you like it? How doesit affect you on a daily basis?
(54:46):
And the vast majority offeedback will be positive,
but also kind of understandingthat sometimes it can bring about things that can
create new challenges in some ways. Andwe definitely have ways to help patients
when that happens, but it'simportant to take a note of that.
So let's move on just to a coupleof practical aspects of this.
We can bill for these services,which is awesome, right?
(55:09):
I feel like a lot of the time we'rebeing asked to do more things,
but we can't necessarily have a higherbilling code or we have to figure out how
to make it work.
But these tools are one thing that wedefinitely can bill for and include in our
chart notes and in our billing codes.
So I believe this will also beattached to resources afterwards,
but there are several CPT codesthat you should know about,
(55:30):
and you don't have to memorizethese, you can easily Google them,
but CGM interpretation. Sothe first one would be 95249,
which is used for patient educationand personal use of a CGM focusing
on the placement of the sensor trainingand then the printout of recordings. And
these are things that are going to be,
that's a regular thing you'll be doingwith patients when they're wearing this
(55:52):
95250 would cover the startup training,
sensor placement and data printout ofa professional CGM that you provide in
your office. We didn'ttalk about that today,
but that's also a really nice tool thatyou can consider having for patients
that are not otherwise goingto be on a device long-term.
Sometimes that's called a diagnosticsensor. So professional or diagnostic,
(56:15):
you might want to look into that as wellif you're thinking about getting your
clinic up and running. And then95251 is used for the analysis,
interpretation and report of aminimum of 72 hours of data. Again,
that's something you're going to beusing regularly for patients that are
wearing the device. So a coupleof other practical things,
coverage criteria, again,
(56:36):
I don't know that we have to getinto this in too much detail today,
but I do think this wholeprocess has gotten a lot better.
What I have found for the most part isthat my regular clinic notes will allow
patients to qualify for these deviceswithout me having to do a lot of extra
paperwork. And so I reallyhave appreciated that. Debbie,
I know that you work quite a bitwith patients that are underserved.
(56:57):
Do you have any other thoughtsabout expanding access for devices?
Yes, I do. And one comment forhealth providers. Danatech,
ADCES has a very powerful tool
to help look at coverage.
But when we think aboutpatient access as well,
there are a number of programs available.
(57:19):
The companies Abbott offers through the My
Freestyle program, one free sensor,
and the Dexcom offers coveragefor people that have high
copays. There's also apharmacy savings program,
CR3Diabetes Blue Circle Health is in some
(57:41):
states that's a Helmsley funded program.
Insulin Pumpers Foundation mayhelp with financial resources to
help purchase an insulin pump. Insulinfor Life has been around for a while,
and pharmacy discountcards, GoodRx, Single Care.
So I think we'll have these availableto you at the end of the program.
(58:03):
So do indeed check some of thoseout because I think that would be
beneficial,
especially for people that have a bigcopay or their insurance isn't covering
it. Kathryn, how do we getthis going in the clinic?
So just a couple thoughts aboutpractical implementation. First of all,
this is probably intuitive,
but if you do not have any ofthis set up in your clinic,
(58:26):
the reps for the main companies wouldlove to help you get this set up.
And they will come. They'llhelp you with the software.
There's cloud-based systems for each ofthese that will allow you to see data of
patients when they're sharingit on their phones. For example,
you need a cord for patients thatstill have a reader that they're using.
And that way you can download it fromthere. There's advanced things you can do,
(58:50):
like learn how to clip and addthe graphs and charts to your
EMR that's more advanced. Youdon't have to do that right away.
It's more important that you can accesstheir data and use it to make clinical
decisions and use it for yourconversation. So contacting the reps would be the
easy thing to do.
There's also healthcare provider resourcesthat you can access on the websites
(59:11):
and they will walk you through exactlywhat you need to do. And honestly,
it doesn't take much time. So if thisfeels like a big hurdle to cross,
it's well worth your time to spend alittle bit of time kind of onboarding and
ramping up your clinic for this,
and it will pay off in spades as faras the effects that will have on both
patients and the practice.
(59:32):
So let's wrap up here andthink about key takeaways
that we want you to leave with today.
And the first is that we really wantyou to think about the evolution of
CGM and how it has evolved frompeople who are on insulin to
well beyond that.
Now we're talking about people that donot have diabetes and how it can possibly
(59:55):
improve metabolic healthoptimization, wellness,
sleep. Think about maybe yourpatients with pre-diabetes,
if they're able to accessan over the counter sensor,
how that might impact theirprevention of diabetes in the future.
But really CGMs and the utilityof these devices spans treatment
(01:00:16):
prevention and optimization. I'mso excited for the future of this.
I think it's a really,
really just bright horizon that wehave with diabetes management and the
prevention of diabetes.As nurse practitioners,
we are so pivotal in,
we could call it democratizing CGMuse. How do we bring it to the masses?
How do we encourage morepatients to use these devices?
(01:00:39):
How do we help them translate thisdata? It's not just about wearing it,
it's about how it affects your lifeand your diabetes and your wellness
and empowering them to usethis information for good.
And I love because this fitsso well into what we do as NPs,
and I think it's an awesome opportunityfor us. And this is no matter what type
(01:01:00):
of practice setting that you are in.
So think about how you can incorporateit no matter what your patient population
is, and really think about offeringit and recommending it more broadly.
The clinical evidence for patientson insulin and with diabetes is
robust and it continues to build.
And I know AANP is committed tocontinuing to deliver best practice and
(01:01:23):
update these as soon asmore evidence comes out.
And it's a very fastly developing field.
It's hard for all of usto keep up with, honestly,
but I think that's a really good thingbecause it means that we're having more
and more opportunities for patients.
So I guess our final callto action would be this.
Think about how you can explore CGMimplementation with your patients.
(01:01:46):
And I bet Debbie would agree.I want you to weigh in Debbie,
but it is one of the most impactfulthings that you can do for patients with
diabetes, and I truly believeit will change their life.
And that's such a wonderful thingto see when we can make a concrete
recommendation that has thatlevel of impact. So Debbie,
any final thoughts from you?
(01:02:07):
I couldn't agree more.CGM is a game changer,
and I have patientstell me that every week,
but I would offer oneother call to action.
If you haven't worn a sensor yourself,
I would encourage you to wearone. It's very enlightening.
(01:02:28):
There's a lot of information,
and you may be surprised whatyou discover about yourself.
I love that. Yes.
And it's always helpful when we can giveour own experience with something and
share how that affected us. And so Ithink that's a very powerful tool as well.
Well, with that, we appreciate youtaking the time to spend with us,
and we hope that this can impact andchange your practice in really positive ways.
(01:02:53):
Well, thank you so much,Debbie and Kathryn.
It's been an absolute pleasure listeningto you and gaining your perspectives
and insights on this extremelyimportant topic to our listeners.
I hope you found this episode educationaland can apply some of what was
discussed to your practice.
Join your national professionalassociation and add your voice to over
120,000 of your NP colleagues nationwide.
(01:03:16):
I urge you to become an AANP member today.
Membership gives youaccess to so many benefits,
including tools and resources foryour practice, and the AANP CE Center,
which offers a comprehensivelibrary of CE activities for NPs of
all specialties and experiencelevels, exclusive discounts,
and many free activities are yoursas an AANP member to help you
(01:03:41):
complete state licensure requirementsand earn the credits needed for
recertification. Remember, you mayclaim CE credit for this program through
October, 2026, by logginginto the CE center at
AANP.org/cecenter.
Register for this program.Enter the participation code
(01:04:02):
2526CGM. Again,
that's 2526CGM,
and then complete thepost-test and evaluation.
Be sure to subscribe to this podcast,
share with your colleagues andcheck back often for new episodes.
Thank you for listening.
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