Implementation of Continuous Glucose Monitoring for Improving the Level 1 and Level 2 Hypoglycemia in Patients with Type 1 and Type 2 Diabetes Mellitus

Abstract

This chapter demonstrates about using CGM instead of SMBG can improve control of diabetes mellitus type 1 and type 2 not only in specialised facilities but also in general internal medicine residency clinics with active involvement of the medical and transitional year residents. Twenty- five Patients with uncontrolled DM type 1 and type 2 were recruited in our Internal Medicine Residency Clinic by our CGM team. The team consisted of 4- Transitional Year Residents 5- Internal Medicine Residents and Board- Certified Endocrinologist.

The patients were spending while SMBG on average 1 hour and 14 minutes a day having level 1 hypoglycemia- between 69-54 mg/dl. This was 4.75% of the time which was above the American Diabetic Association (ADA) goal of less than 4 %. They were spending with level 2 hypoglycemia - less than 54 mg/dl, 29 min per day while SMBG. This was 3.01% which was again above the ADA goal of less than 1 % per day.

At that point we introduced monitoring of our patients with CGM instead of SMBG four times a day. We had CGM team involved with the project in which participated Internal medicine and Transitional Year Residents under the supervision of Board-certified Endocrinologist who was a member of the clinic. The CGM used in our project was Dexcom G6.

The goal of the study was to show that not only in specialized centers, but in General Internal Medicine Residency clinic with active participation of the medical and transitional year residents can be improved the control of DM type 1 and type 2 but also can be reduced the time the patients spend in hypoglycemia by using CGM compare to SMBG.

The study involved both the Transitional year and Internal Medicine Residents. Before they started using the CGM, they were teaching the patients about their food, exercise routine, and how to regulate their insulin at home using written instructions. A member of the CGM team from the Internal Medicine Clinic called the patients at least once per week with instructions on how to modify their insulin, treat hypoglycemia, and provide them dietary and exercise advice. The patients had scheduled appointment in the clinic once a month.

After monitoring the patients’ blood glucose using CGM and adjusting their Insulin by our CGM team the control of the diabetes was achieved with reduction of HbA1c to 7.04% compare to 11.21% while using SMBG.

With the help of the CGM the time spent by our patients in level 1 hypoglycemia decreased to 11 minutes per day. This was -0.78% well below the ADA goal of less than 4% per day. The time spend in level 2 hypoglycemia per day decreased to 3 minutes. This was 0.25% per day which was also bellow the ADA target of less than 1 %.

Four of the patients – 16% were able to have achieve excellent control of their DM 2 without any low blood glucose by using only oral antidiabetic medications and or injectable GLP1-RAG.

Our experience demonstrated that switching to CGM from SMBG in the General Internal Medicine residency Clinic can benefit a large number of patients with diabetes mellitus type 1 and type 2 who require multiple daily insulin injections by lowering level 1 and level 2 hypoglycemia and enhancing blood sugar management. Our success can be replicated by other Internal Medicine Residency Programs in USA to improve the quality of care of patients with DM on MDI and improve quality of education of Transitional year and Internal Medicine Residents under the supervision of board-certified endocrinologist.