LOS ANGELES – Cardiology patients can strap on a Holter monitor for a day or two to track their heart activity and get a brief but helpful glimpse at their cardiac health. Could patients with type 2 diabetes benefit by monitoring their blood sugar for a short period? Absolutely, according to an endocrinologist who says he’s had tremendous success with the temporary use of continuous glucose monitors (CGMs) in appropriate patients.
Dr. Daniel Einhorn
“There’s an actionable surprise with almost every patient,” said Daniel Einhorn, MD, FACP, FACE, medical director of Scripps Whittier Diabetes Institute and clinical professor of medicine at the University of California, San Diego.
The key is to use CGM data to pinpoint glucose spikes and then quickly make adjustments, typically over a period of 2 weeks. “This is about pattern recognition. We can do [CGM] over a week, see what the pattern is, and then try to fix something. Then they come back after the second week or send [the monitor] in, and they have the problem fixed. You have a happy patient and a happy family,” said Dr. Einhorn, who spoke in a presentation at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.
He highlighted how CGM data allow patients to track their blood sugar over extended periods of time and detect patterns. The data can uncover hidden hypoglycemia and hyperglycemia, he said, and is much more useful to patients than the self-monitoring of glucose levels or hemoglobin A1c (HbA1c) data.
Reading the patterns, adjusting behavior
Dr. Einhorn discussed several specific cases of patients who had changed their behavior in regard to food or medicine after CGM data disclosed certain blood sugar patterns.
Often, he said, patients say they’re surprised to find their well-being improves after they make adjustments, saying something along the lines of “I didn’t feel badly, but I feel better now.” According to Dr. Einhorn, “You hear that all the time.”
For example, he said, one patient knew his blood sugar occasionally topped 200 mg/dL, but he felt all right and didn’t want to take insulin. CGM monitoring over 6 days showed the patient had continuous glucose levels well over 200 mg/dL, especially at night. The patient accepted insulin, and a few months later his HbA1c dropped from 10.4% to 6.6%, and his blood sugar level stayed near or below the target range of 154 mg/dL.
Dr. Einhorn said the CGM data can reveal a range of problems, including:
- The “breakfast bump” after carbohydrate-heavy breakfasts of cereal, toast, and juice. “Breakfast cereal is diabolical,” he said.
- Hypoglycemia hours after exercise.
- Nocturnal hypoglycemia.
- Hypoglycemia unawareness.
Insurance coverage of the CGM device varies widely, he said, and insurers may not cover it at all in type 2 diabetes or only pay if the patient takes insulin. Fortunately, he said, the devices can be inexpensive.
Temporary use is not for everyone
Dr. Einhorn cautioned that temporary use of CGM is not appropriate for every patient with type 2 diabetes. “There’s absolutely a place for [permanent] monitoring for those people who have to make decisions throughout the day, especially if they are taking insulin,” he said.
And anyone with type 1 diabetes should use CGM on an ongoing basis, he emphasized. “Type 1 is a different world, a different universe,” he said.
He also noted that some patients don’t fare well on CGM, even on a temporary basis. That would include patients who hate to wear devices (possibly out of embarrassment), those who can’t manage to switch over from self-monitoring, and those who can’t manage to understand the data.
Dr. Einhorn disclosed various types of relationships with a number of drug makers, including Abbott, Boehringer Ingelheim, Novo, Sanofi, Janssen, and others.