May 26, 2017
Continuous glucose monitoring (CGM) has an important function in the treatment of diabetes. Pharmacists can play a key role in ensuring this technology is accessible and used correctly in this patient population.
During a breakfast symposium at the recent APhA2017 meeting that was supported by an educational grant from Dexcom, Inc., two pharmacists with expertise in diabetes medication management discussed CGM, its advantages and drawbacks, and how to integrate CGM data and device information into pharmacy practice and management decisions.
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“CGM helps us to navigate. It gives us points and times so we can better understand what interventions need to be taken…so we’re not guessing anymore,” said Nancy J. D’Hondt, RPh, CDE, FAADE, Clinical Pharmacist, St. John Providence Hospital and Medical Center (Detroit, MI). “I am looking at CGM as standard care for medical management of diabetes.”
Although A1c is a marker for complications and progression of disease, it is just an average, she noted. Glycemic variability also causes damage, which can be mitigated with CGM. Ms. D’Hondt, who is also president of the American Association of Diabetes Educators (AADE), said that CGM is recognized by many of the professional societies, citing an AADE white paper (https://www.diabeteseducator.org/docs/default-source/default-document-library/aade-2015-cgm-summit-white-paper-final.pdf?sfvrsn=0) that states personal CGM may be appropriate for any individual with diabetes who is willing to wear it, regardless of their age, type of diabetes, and duration of disease.
Stephanie Smith, PharmD, CDE, Medication Therapy Management Pharmacist, Ridgeview Endocrinology Clinic (Chaska, MN), provided a brief review of three CGM systems, in which the data can be blinded or unblinded, and the pharmacist’s role in CGM management. The Dexcom G5 Mobile system offers both a personal and professional system. The system was recently approved under Medicare for patients with type 1 or type 2 diabetes who meet the criteria for therapeutic CGM. The use of this device “in dosing decisions is really changing the landscape for our senior population,” she said. Freestyle Libre Pro is another device that is only available as a professional system in the clinic or pharmacy setting and the data is blinded. It offers up to 14 days of glucose readings, and requires no finger-stick calibration. Medtronic offers both a professional and personal CGM system. According to Dr. Smith, the personal system can only be used when integrated with insulin pump therapy,.
Patient education is a critical component of CGM, and pharmacists as medication experts can provide this service. Patients with personal CGM systems should be instructed on the importance of calibration, how to properly set and respond to high or low alerts, and how to make adjustments for upward and downward glucose trends. Pharmacists should also make sure patients understand how to take their insulin correctly.
Dr. Smith also touched on how the use of CGM has the potential to expand beyond the endocrinologist’s office. “CGM is rarely used in the primary care setting, with more than 80% of patients with diabetes receiving care in the primary care clinic and at their community pharmacy. Pharmacists can do much more than just dispense CGM,” said Dr. Smith. —Eileen Koutnik-Fotopoulos