Key Takeaways
- In this interview, Dr. Lori Laffel explores how Continuous Glucose Monitoring (CGM) revolutionises diabetes care by providing real-time feedback, trend arrows, and retrospective data to optimise patient management. A critical focus is nocturnal hypoglycemia, which lasts approximately 50% longer than daytime episodes because it often goes undetected, severely impacting morning glucose stability. Proactively preventing these nighttime lows is essential for patients to awaken refreshed. Dr. Laffel also urges healthcare professionals to recognise CGM-related challenges, such as alarm fatigue, device stigma, and patients feeling "exposed" by constant data tracking. Providers must offer non-judgmental support to help patients overcome these burdens and maximise CGM's clinical benefits.
How has CGM revolutionised diabetes management? Especially with a focus on sleep.
CGM has been an extraordinary tool for the management of diabetes, especially insulin treated diabetes, but overall for the management of diabetes. And there are three main ways that CGM has helped in diabetes management. Number one, a CGM gives real time feedback with glucose levels and alerts and alarms when glucose levels may be exceeding certain high or low thresholds, thereby reducing fear or reducing worry and also potentially adding to sleep quality.
In addition, CGM trend arrows can allow one to do better diabetes management in the moment by understanding where glucose has been and where is likely to be going, thereby either adjusting medication or adjusting food intake, or even adjusting exercise.
Finally, CGM data can be reviewed in a retrospective manner by people living with diabetes as well as by health care providers to overall guide management changes by looking at patterns that may indicate need to change insulin doses or to consider adjustments to food intake when one can see certain foods that may increase glycaemic excursions that may require greater insulin delivery or foods that may lead to late rises in glucose, for example, meals that may be higher in fat and protein may need a different adjustment to insulin dosing patterns.
How might hypoglycaemia differ during the night, compared to the day?
Fear of hypoglycaemia, whether it’s daytime or nighttime, often leads to over treatment and under dosing of insulin for example. And CGM may allow one to give proper medication treatment because an individual will recognise that CGM device can help alert them when glucose may go out of range and is particularly challenging when there is fear of hypoglycaemia at night.
There are data that have shown that nocturnal hypoglycaemia has about a 50% longer duration than daytime hypoglycaemia. That may be related to many factors, but the most obvious is that the nighttime hypoglycaemia goes undetected, so has a longer duration before there is any active intervention. In addition, the nighttime hypoglycaemia may lead to the potential for morning glucose to be out of range, either leading to hyperglycaemia because of excessive overnight treatment, or potentially morning hypoglycaemia because of that prolonged duration of nocturnal low glucose levels. Morning glucose is the hardest glucose levels to control. If one can awaken with a glucose level in the target range, diabetes management becomes much more easier throughout the duration of the day.
Therefore, in summary, for the multiple reasons that we just discussed, it is important to proactively prevent nocturnal hypoglycaemia, if at all possible. Because if one awakens feeling refreshed, the entire day is like a ray of sunshine.
What are some of the potential pitfalls that HCPs should be aware of?
There’s always a trade off when we are thinking about diabetes management. While there are so many benefits of CGM, it is worth understanding how there may be some challenges related to CGM use. There can be stigma associated with wearing a device, especially when there can be audio alerts and alarms that could be disruptive for an individual, especially when they may be in a work or in a school setting. There can be challenges with ensuring you have a constant supply of devices. That one is taking care of, skin quality because of the need for adhesives on the body. And one can’t forget that when one is wearing CGM, there is an extraordinary wealth of data for CGM devices sharing glucose data at five minute intervals. There are 288 glucose readings every single day. When these data may be shared with a health care provider, an individual may feel entirely exposed, so-called, naked in their diabetes management. So it is important for us as health care providers to be supportive of individuals, use the glucose information just as data and not as any, qualitative assessment of the individual living with diabetes.
The challenge here is diabetes, the people living with diabetes are the heroes. And those who can overcome these challenges of CGM use are really having an opportunity to have tremendous benefit from CGM. Given the recognised benefits of CGM, as well as understanding the potential challenges that individuals may feel using CGM devices. It is important to acknowledge these challenges, understand when there could be fatigue related to device use and the constant 24/7 of managing diabetes, and be supportive of the opportunities that CGM has for both the current daytime treatments as well as the potential future it can bring for potential preservation of health with increased glucose time in range and reduction of severe hyperglycaemia, as well as nocturnal hypoglycaemia.
To summarise, while we recognise the challenges of CGM use related to potential stigma, fatigue over alerts and alarms, and the other issues, we have to remember the extraordinary benefits that can be derived from CGM with respect to improved glycaemic control, more glucose time in range, less hypoglycaemia, especially reduced fear of nocturnal hypoglycaemia, and allow people to be heroes in their diabetes management and not be prisoners of the CGM data. Recognise the benefits, most likely here, overcome those burdens.