Anne L. Peters, MD, CDE; Howard Wolpert, MD


July 07, 2010

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Anne L. Peters, MD, CDE: Hi, I'm Dr. Anne Peters, Director of the Clinical Diabetes Programs at the University of Southern California, and today I'm joined by Dr. Howard Wolpert, Senior Physician, Section of Adult Diabetes, Director of CGM and Insulin Pump Program, Joslin Diabetes Center, Boston, Massachusetts. Welcome, Howard.

Howard Wolpert, MD: Nice to see you.

Dr. Peters: All right, so today we're going to talk about continuous glucose monitoring, which is an area where I think we're making really interesting strides forward, and I think we're creating interesting tools that can help our patients. I'd like for you to describe, first of all: What is continuous glucose monitoring?

Dr. Wolpert: I think this is going to be the next wave in intensive diabetes management.[1] I think it's going to help many of our patients get to goal much more readily, particularly people who run into problems with hypoglycemia.

These are devices that are actually transcutaneous sensors, ie, sensors that pass through the skin. The sensor actually is measuring the glucose in the interstitial fluid underneath the skin, and that's connected up to a transmitter unit. The patient has a receiver, which gives them a readout of the glucoses every 5 minutes.

In addition to that, I think the key novel aspect of this technology is that because people are getting frequent measurements, they can actually see the trend of the direction that the glucose is going. The devices also have indicator arrows, which will tell a person whether they're heading into the hypoglycemia range and need to take action, like taking carbohydrates, and also show high glucoses. Linked into that is the fact that these devices have alarms, which are adjustable so they can be preset to go off at specific hypoglycemic or hyperglycemic thresholds.

It's a really novel tool, which really takes diabetes management to the next level for the patient with diabetes. Obviously, because it demands quite a lot of the patient, it's a tool for the patient who's really motivated and engaged in their diabetes self-management.

Dr. Peters: What sort of patient do you choose to wear a sensor?

Dr. Wolpert: I think there are different modes for using the sensor. There are people who will use them continuously on a daily basis, and those would be primarily people who are self-managing their diabetes fairly tightly and are using all the extra information from the CGM, particularly for those people who are running into problems with hypoglycemia or as they strive to get their A1c [glycated hemoglobin] down close to the normal range.

I think there's a much larger subset of people where CGM has potential value for intermittent use. I think a lot of people will derive benefit in terms of their eating behavior, for example, because CGM really highlights the postprandial spikes, which often aren't apparent on intermittent finger-stick monitoring.

For many patients, I think it's a bit of an eye-opener in terms of getting a grip on foodstuff that is really problematic. Also, it guides people in terms of foods that they like that they can afford to eat, that aren't having much of an impact on their glucoses.

Dr. Peters: Yes, I find that it really surprises my patients -- and me -- to see sometimes what happens after eating. You can really tell someone has diabetes when you see their sugars go up to 200 and 300 after a meal.

Now, my patients all want an artificial pancreas. They want to be cured in some way or another. Is this an artificial pancreas?

Dr. Wolpert: Well, I think it's a step along the way. It gives the patient all the extra information that they need to titrate to adjust their insulin to get themselves closer to goal, but it's not an automated process. Obviously, it actually demands quite a lot more of the patient, so I think it's a bit of a misnomer to put it in that context.

On the other hand, I think when you look at the long-term outcome for people with type 1 diabetes who are intensively controlled, we've essentially licked a lot of the major microvascular complications that people with type 1 diabetes can potentially run into. I think what CGM really offers here is an answer to the hypoglycemic risk that people who are striving for intensive diabetes management will run into.

Dr. Peters: I know that your group is presenting some data here at these ADA [American Diabetes Association] meetings.[2] Is there anything that you'd like to share with our listeners that you all have found recently in your recent research efforts?

Dr. Wolpert: What we've been looking into is to define the predictors of benefit, and particularly the barriers that people run into. I think that's going to help us not only in terms of patient selection, but also in terms of our educational and treatment programs, so that we can kind of target the types of issues that people will run into that get in the way of them really using the technology to full benefit.

One of the issues that we've discovered -- and this was part of an analysis of patients who were involved in the Juvenile Diabetes Research Foundation CGM trial -- is that we looked at people who derived benefit from CGM vs those who didn't. Interestingly, people who are much more stoic in the way they deal with frustrations and the demands of the technology do a lot better than people who tend to get a bit frustrated and angry.

But even something like that, which in a sense is sort of a personality trait, is something that we can address If people have realistic expectations around what the technology promises and what it's prone to, they won't end up frustrated if they do run into potential problems using the devices.

I think the point that underscores all of this is the fact that we still have first-generation technology. As the technology improves, I think a lot of these sorts of teething problems that people run into using the devices are no longer going to be a problem.

Dr. Peters: Thank you so much for those comments. I really appreciate them, and I know that both of us are very enthused about this field of continuous glucose monitoring. I think it offers a lot to patients. There's a lot of research that's going to come in the next few years, and the tools we have are going to improve over time. Even now, I believe that we have the tools we need to help our patients, and as long as we spend time explaining the technology to our patients -- working with them carefully through the first several weeks and months so they really get the hang of what they're supposed to be doing and helping overcome some of those frustrations -- I think it is really beneficial.

I'm excited about the future of this field, and it'll be fun to talk to you next year and find out what's occurred in the intervening year. This has been Dr. Anne Peters and Dr. Howard Wolpert for Medscape. Thank you.


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