Continuous Glucose Monitoring News For Pharmacists
We are in the midst of the CGM (continuous glucose monitoring) revolution. The leaders in diabetes no longer see CGM as being an unaffordable and technologically challenging option but now the standard of care for guiding diabetes treatment decisions for any person using multiple daily dosing or basal insulin. CGM can be helpful for virtually every person with diabetes and even prediabetes in managing lifestyle decisions. CGM can eliminate the need for routine fingerstick blood glucose monitoring (BGM), with some exceptions.
How do they work?
The currently available systems measure glucose in the interstitial fluid, rather than capillary blood used by traditional fingerstick BGM. The Freestyle, Dexcom, and Medtronic systems use a tiny sensor inserted into the interstitial fluid via an applicator, whereas the Eversense 3 uses a surgically implanted sensor. The sensor generates an electrical current when in contact with interstitial glucose, the transmitter then sends the values to a reader (smartphone or a supplied reader) every 1-5 minutes. Using a smartphone app or the reader, one can see the current BG as well as trend arrows, several hours of history, and depending on the device, receive high and low blood sugar alarms. An Integrated CGM (iCGM) can communicate with other devices such as smart insulin pens and insulin pumps.
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Three types of CGMs
Real time: automatically sends values to the reader about every 1-5 minutes.
- Dexcom G6 and G7
- Freestyle Libre 3
- Eversense E3 (180-day sensor surgically implanted)
- Medtronic Guardian Connect
Flash or scan: must pass the reader over the transmitter (scan it) to see the values.
- Freestyle Libre 14 day
- Freestyle Libre 2
Professional: CGM devices owned by the medical clinic and used for short term blinded or unblinded assessment of diabetes control or to show the person how CGM might work for them before purchasing the device. Dexcom, Abbot, and Medtronic have professional models.
The AGP (Ambulatory Glucose Profile) report:
This is a standard report that every CGM uses. There are some differences between devices in the way information is displayed but they all consist of three sections.
- Targets and statistics
- The Ambulatory Glucose Profile (AGP)
- Daily glucose profile
 Time in Range vs A1c:
The A1c represents the average of blood glucose levels over a 3-month period and does not identify variability. Person A with an A1c of 7% can be in adequate control with few excursions into hypoglycemia or hyperglycemia whereas person B with the same A1c of 7% can be experiencing wide variability with frequent dangerous hypoglycemia or hyperglycemia. Time In Range (TIR)uses the 300-1500 glucose data points generated daily by CGM and shows the percentage of those between 70 and 180 mg/dL as TIR, below 70 mg/dL as Time Below Range, and above 180 mg/dL as Time Above Range.
The Value of CGM: from bewilderment to epiphany
CGM has been shown to improve A1c, reduce frequency of hypoglycemia, hyperglycemia, and glucose variability. That having been said, arguably the greatest value in CGM is that it produces those aha moments where a person sees the effect of food, exercise activity, stress, or medication choices on their diabetes control. The informed person will be able to act on this information to live healthier with diabetes.
3MinuteExtraMile suggested action steps:
CGM users will need ongoing support to get the most benefit and pharmacists should be proactive in starting conversations with CGM users, especially new ones. This Community Pharmacist Study is not encouraging but demonstrates the need for pharmacists to find a place in facilitating patient success with CGM. Examples of conversation starters:
- How often do you scan your Freestyle Libre? Both 14 day and Libre 2 require scanning every 8 hours to prevent data gaps.
- How do you use the numbers and lines you see on the screen? Is this information helpful for you?
- Have you ever tried looking at the screen to see how high your blood sugar goes up after having your (pick a meal)? What does that tell you? What can you do about it?
- Do you know that some nonprescription medicines can cause incorrect CGM readings? (vitamin C with Freestyle and acetaminophen with Dexcom)
Resources:
Danatech (educator’s site)
Diabetes Wise Pro (all the diabetes technology here)
CGM professional education (good info for clinicians)
DiaTribe (for PWD and professionals)
CGM and food newsletter (patient directed diabetes management with CGM)
Freestyle
Dexcom
Eversense 3
Medtronic
James Bennett BsPharm, BCGP, CDCES
Bozeman, MT
Do you have someone you would like to recognize for going above and beyond in their care a patients with diabetes? Nominate them for an award!
Awards will be given at the Annual Diabetes Professional Conference. Please register and plan to join us.
Medications with the Potential to Increase Asthma Symptoms
Many patients rely on over the counter and prescription medications to manage a variety of disease states. However, in patients with asthma, it is important to watch out for specific medication classes. Some have the ability to worsen or mimic symptoms of asthma.
Beta Blockers:
Beta blockers are medications used to treat disease states like heart failure, atrial fibrillation, and hypertension. They can also help with migraine prevention and symptoms of overactive thyroid. These medications block beta receptors in the heart to help with heart rate and rhythm. Simultaneously, they can block beta receptors in the lungs causing bronchoconstriction. Some beta blockers are more selective to the heart (metoprolol and atenolol) and do not pose as great of a risk for exacerbating asthma symptoms.
NSAIDs and Aspirin:
NSAIDs are used to treat pain and inflammatory conditions. Most of these medications are available over the counter. These medications work by blocking cyclo-oxygenase (COX), an enzyme involved in arachidonic acid metabolism. By blocking this enzyme, cysteinyl leukotrienes are produced which stimulate the production of inflammatory mediators. In patients with asthma, this can lead to further inflammation in the lungs, tightening of the airways and increased mucus production. Aspirin is the most common NSAID that can lead to asthma exacerbations. Some patients with asthma can experience a triad of rhinitis, sinusitis, and worsened asthma symptoms when they take aspirin.
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Angiotensin Converting Enzyme Inhibitors (ACE Inhibitors):
ACE inhibitors are a class of medication that work in the kidneys to treat high blood pressure. They specifically target the renin-angiotensin-aldosterone system, which is responsible for maintaining blood volume, electrolyte balance, and systemic vascular resistance. ACE is an enzyme that blocks the formation of angiotensin II. This is a hormone that causes vasoconstriction, leading to an increase in blood pressure. As a result, a molecule called bradykinin is produced. This can cause some patients to experience a dry, nonproductive cough. Frequent coughing can mimic the symptoms of asthma or even cause symptoms of asthma to worsen.
Pharmacist Action Steps:
- Understand the mechanism of action of medications at risk of causing asthma exacerbations so you can recommend an alternative to the patient or provider.
- Counsel the patient on safe and effective over the counter medications that will not have an impact on their asthma.
- If patients must take an at-risk medication, counsel the patient on correct inhaler use and when it is an appropriate time to seek medical care.
- Ensure your asthma patients have a rescue inhaler and assess their inhaler technique.
- Remind your patient to let their doctor or pharmacist know if they start a new medication.
Written by Kenna Stensrud, PharmD Candidate. Reviewed by Rachael Zins, PharmD, AE-C.
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