Optimizing Continuous Glucose Monitoring (CGM)
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Optimizing Continuous Glucose Monitoring (CGM)

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This presentation was given to attendees at the 2013 Advanced Diabetes Management Retreat held at Texas Lions Camp.

This presentation was given to attendees at the 2013 Advanced Diabetes Management Retreat held at Texas Lions Camp.

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  • Requirements of Penny Stock InvestorsYou should not get involved with day trading unless you are able to effectively monitor your holdings and can commit with the proper mind set and outlook. This strategy takes time, research, and a good deal of money (I suggest at least $4,000). Otherwise, you may not be able to benefit from such a trading methodology.You need to be able to check the prices of stocks on a moment's notice, and get an accurate and up-to-the-minute quote. Having internet access or a computer connection to your broker from work or home is generally best. When day trading, you may need to check stock prices frequently, possibly watching their prices all day. Using a computer it takes only a few minutes each time, you can get current prices, and can alter or submit new orders on-line after checking the penny stock's activity.Most of all, you need patience. Although day trading in penny stocks is probably the quickest profit and loss method in the financial world, patience still comes into play. The best day trading strategies involve often going a week or so without a trade, because you must wait to get the best prices. Impatience immediately negates the effectiveness of the day trading strategy.Finally, you need a strong stomach. You should understand that day trading in penny stocks can result in one week gains that are monumental, or can set you up for a loss. Whether making a big profit or taking an ugly loss, you should be able to handle both the good and bad stress that will come with this method of trading. Otherwise, you may make moves for the wrong reasons and compromise your objectives.What Day Trading IsDay trading is simply an attempt to capitalize on short term fluctuations in stocks. For example, with penny stocks it is possible to buy an issue at $0.12 and sell it the next week, day, or even a few hours later at $0.15, giving you a 25% short-term profit on your investment.If a profit of more than 20% to 25% presents itself, you often take it. Do this a few times and you are looking at a highly successful investment strategy.The downside of day trading comes into play when you buy an issue and it drops in value. At that point you either take a quick loss to keep your money available, or you sit and wait for a profit opportunity that may arise later, in which case your money is tied up until that time. This becomes less of a concern for traders who have more assets at their disposal, because while only a portion of their money is temporarily tied up in a stock that has fallen in value, the rest of their portfolio could be actively used.Now, let me tell you how to take advantage of day trading without significant risk, and with maximum profit potential. If you are going to begin day trading, read this section a few times through and adjust your own investment style accordingly.Goals of Day TradingThis is very important if you intend to be successful at day trading. Your overall goal is to make several hundred of percent on your investments on a year by year basis. However, this is to be done 40% and 30%, even sometimes 10% at a time. That is where most day trading strategies fall apart - investors don’t understand that taking the smaller gains more frequently will actually be more effective than the larger gains less frequently!Your goals for an effective day trading strategy should be as follows:•Keep on top of your open buy and sell orders, and the trading activity of the underlying stocks so that you are rarely surprised by a penny stock’s action.•To take small profits when they present themselves. You will find that you have the opportunity for small 15-25% profits very frequently.You won’t often be in a position to be taking the larger 30%-50% profits, because you already would have sold when your shares first began to rise. Therefore, as backwards as it sounds, if you find that you are taking 50% profits more often than 25% gains, you are probably doing something wrong. In the long run, you would likely make more money by grabbing the 25% gains again and again, instead of holding out for the larger returns.Effective Strategies and ConsiderationsThe first consideration of this trading method compared to others is that you will be taking commissions more frequently. If you are not already with a discount broker, or are paying more than $20 per trade, you probably should switch to a cheaper broker. You can read all about penny stock brokers, and get my list of the top ones earlier in this site.With penny stocks, you may often find that a buy or sell order goes partially filled. For example, you may only get $200 worth of shares and be stuck with a $20 commission. To avoid this, keep track of your orders during the trading day - you may pick up a portion of your order at the price you want, then have to adjust the purchase or sell price to make sure you get the rest of the order filled. Changing an existing order to get all the shares you want on one day, instead of over two or three days, means that you will only be subject to one commission.The beauty of day trading is that company fundamentals and overall market action become less significant. You are playing the day by day fluctuations instead of hoping the market will rise or the company will increase its earnings. Buying at the low end of volatility and selling at the high end equals success, despite monthly trends, company fundamentals, or the market outlook.Therefore, it doesn’t matter if the companies you invest in have a positive future or are bad long-term purchases. What’s important is that you keep an eye on the trading activity of the issue in question, try to pick its higher and lower trading ranges, then execute buy and sell orders accordingly.With day trading you need to realize that most of your buy orders should go unfilled, because your bid price needs to be lower than the going trading price of the stock. Buy on the dips and you will have success - put in orders to acquire shares at or below the current bid price. If you put in ten buy orders over the course of a month, you may wind up only getting one of the buys you had wanted, but those shares will be yours at a great price, making it easier to unload them for a quick profit.When tigers hunt, they only catch a meal one out of ten attempts.Deciding on appropriate buy and sell prices at which to submit your orders is relatively simple. Look at a stock that has both high volume of bid lots, and high volume of ask lots. Many people are trying to buy at one price and many people are attempting to sell at another. Look at the spread between the bid and ask prices. If it is about 15% or more, you may want to put in a buy order at the bid price, and if it gets filled immediately put in a sell order at the ask price.Of great importance is the number of bid lots compared to the number of ask lots. There is a very different stock price outlook if the number of bid shares vastly outnumber the ask shares, or vice-versa. The more bid lots, the greater the buying pressure and price strength at that level. In other words, if there is a large level of demand, the price will likely solidify at that level and begin to climb, unless there are enough shares for sale to meet the demand.When getting a stock price quote, look at the number of bid lots and ask lots to get an idea of the demand and supply. This will give you a relatively accurate indicator of the direction the penny stock price will travel in the day, and perhaps throughout the following few days. Use the bid lot and ask lot volumes to help you come up with a price range that the penny stock will trade within.Day trading will prove most effective when you trade in penny stocks that you have been watching for a long time. You will be able to produce better results since you have developed a feel for the upper and lower price ranges. This is not a requirement for success, but rather an advantage.Hedging and Averaging DownAs a more advanced strategy, you may want to incorporate hedging into your day trading practices. When buying, this involves putting in buy orders for the same stock at different prices.Let's use an example: You put in an order to buy 4000 shares of OCN @ $0.23 and a separate order to buy 4000 shares of OCN @ $0.17. Now consult the chart below to see the possible outcomes of your strategy.Possible Hedging Outcomes•Outcome #1: If the price falls to or below $0.23, your first order gets filled. Now if the price drops further, you may get your second order filled at a lower price, averaging the price of your 8000 shares to $0.20. Profits could be realized now by selling at $0.22 or greater. If the price climbs, you will make a profit. If it continues to fall you will take a paper loss. This becomes an actual loss if you sell the shares, or if the shares never return to their $0.22 levels. However, in all likelihood the price will bounce around and will present an opportunity to profit or at least break even at some point in the future.•Outcome #2: The price falls to or below $0.23 and your first order gets filled. The price then rises, leaving your second order unfilled, but providing you with the ability to profit on the 4000 shares you did buy.•Outcome #3: The price does not fall low enough to fill your buy order. You don’t get the shares, but you are no worse off. You can extend your order, adjust your prices, or move on to a different penny stock. Again we must stress that an unfilled buy order means that you probably have the right idea. It is better to have an unfilled buy order than to get shares at too high of a price.These hedging strategies can also apply in the same manner when selling penny stocks.Of course, you are also getting exposed to extra commissions with this strategy.Day Trading SummaryDay trading penny stocks is as straight forward as it sounds. However, you will need a little luck, a lot of patience, and the ability to take the profits that present themselves. By keeping a close eye on the markets and following a simple strategy such as the one outlined above, day trading becomes a straight-forward technical process that requires little thought, yet can provide impressive penny stock returns.
  • TitleThe carbohydrate counting in adolescents with type 1 diabetes (CCAT) study.AuthorsBishop, F. K.; Maahs, D. M.; Spiegel, G.; Owen, D.; Klingensmith, G. J.; Bortsov, A.; Thomas, J.; Mayer-Davis, E. J.Journal Diabetes Spectrum 2009 Vol. 22 No. 1 pp. 56-62 ISSN1944-7353DOI10.2337/diaspect.22.1.56URLhttp://spectrum.diabetesjournals.org/cgi/content/a...This article reports pilot study results evaluating the accuracy of carbohydrate counting among adolescents with type 1 diabetes. This cross-sectional observational study included 48 adolescents ages 12-18 years (mean 15.2±1.8 years) with type 1 diabetes of >1 year in duration (mean A1C 8.0±1.0%) who used insulin:carbohydrate (I:C) ratios for at least one meal per day. The adolescents were asked to assess the amount of carbohydrate in 32 foods commonly consumed by youths. Foods were presented either as food models or as actual food, with some items presented as standard serving sizes and some self-served by study participants. T-tests were used to assess the significance of over- or underestimation of carbohydrate content. For each meal, accuracy was categorized as accurate (within 10 grams), overestimated (by >10 grams), or underestimated (by >10 grams) based on the commonly used I:C ratio of 1 unit of insulin per 10 grams of carbohydrate. Only 23% of adolescents estimated daily carbohydrate within 10 grams of the true amount despite selection of common meals. For dinner meals, individuals with accurate estimation of carbohydrate grams had the lowest A1C values (7.69±0.82%, P=0.04). The pilot study provides preliminary evidence that adolescents with type 1 diabetes do not accurately count carbohydrates. Further data are needed on carbohydrate counting accuracy and other factors that affect glycemic control.

Optimizing Continuous Glucose Monitoring (CGM) Optimizing Continuous Glucose Monitoring (CGM) Presentation Transcript

  • Utilizing your CGMS to the Max Stephen W. Ponder MD, FAAP, CDE
  • What can a CGMS help you do? Continuous Glucose Monitoring System • • • • • • • • Prevent after meal BG spikes Correct low & high BG more accurately Prevent/minimize severe low blood sugars Teach you how to sense subtle shifts in BG Reduce the fear of lows, especially at night Lower the A1C levels Help to make diabetes work for YOU Feel more “normal” (perhaps even confident)
  • What I will not be discussing… • Costs of different CGM devices – That depends on your insurance – There is a cash price too • How to purchase a CGM device – Operators probably standing by now – Need Rx to get insurance to consider paying • How to insert or start up a CGM – There are trainers and apps for that
  • Principles of advanced CGM use 1. A CGM is no better or worse than the person wearing it. 2. If you can measure it, you can predict it. 3. Flux and drift happen… manipulate them! 4. Keep your eye on your line. 5. The trend is your friend 6. Learn lag limits; be patient 7. Zero in on your zone 8. Master micro-dosing 9. Factor in glycemic inertia and insulin momentum 10. Don’t let “good enough” be the enemy 11. Calibrate carefully 12. CGM as “sugar surfing” or “day trading”
  • “Chance favors the prepared mind” Louis Pasteur
  • 24 hour glucose plot – A1c 5.7% • Estimates sugar level from interstitial fluid • Calibrated with fingerstick blood sugar levels at least twice daily • Readings provided every 1 to 5 minutes • Drift and imprecision are possible
  • Diabetes control exists largely the same… No two days are ever in the moment 1st Rule of CGM: Your blood sugar levels are unique. Trends and patterns are what’s important
  • Each day is unique…
  • “You can never step into the same river; for new waters are always flowing on to you.” Heraclitus of Ephesus
  • 8 versus 1440 “decision points” 7:03 115 * 9:33 129 * 12:15 95 * 3:34 131 * 6:12 168 * 9:49 107 11:53 114 * 3:05 132 * *
  • CGM is like shining a flashlight in a dark room of moving objects
  • Meters are commodity items “a commodity is the generic term for any marketable item produced to satisfy wants or needs” • The best BG meter is the one you’ll use • $10.41 for 50 strips (Medicare 2013 rate) • Lancing devices (avoid the nerves) • Ketone meter (get one!)
  • ISO and FDA allowable errors “Glycemic Roulette”? Diabetes Spectrum Volume 25, Number 3, 2012 ISO 15197 Standards for SMBG
  • 223 mg/dl Oops! 5% 114 mg/dl 95 mg/dl 95% of the time 76 mg/dl 52 mg/dl Oops! 5%
  • Calibration advice • • • • A CGM’s accuracy is no better than its calibration. So…minimize variance whenever possible Calibrate (if possible) when things are steady Wash hands; get proper sized blood sample (repeat if needed) • If you calibrate when high or low, do some more later when back “in your zone” • You can over-calibrate too.
  • Remember: D-care is about managing sugar…
  • (Glucose production – Glucose disposal) = FLUX Here is a picture of FLUX
  • Non-diabetic persons
  • Why do blood sugar levels shift all the time?
  • How much sugar is in the bloodstream for a 100 mg/dl BG level? 50 kg boy (3.45 grams) 25 kg girl (1.75 grams) 75 kg man (5.1 grams) Human circulatory system = 4 gram glucose tab
  • present Actions Actions past future
  • static vs. dynamic diabetes care static • Actions predetermined • Minimal to no flexibility: RIGID • Outcomes don’t immediately affect subsequent actions • Easy to teach/learn • Less time-intensive • Favors concrete thinking • Less motivation needed dynamic • Actions are dependent on situation/circumstance • Flexible and adaptable • Outcomes influence subsequent actions • Training needed, plus ongoing reinforcement • More time intensive • Favors problem-solving • Requires motivation
  • Ways to use RT-CGM technology “Burglar alarm” “Surveillance system ”
  • Set “actionable” thresholds • Upper/Lower limits – 80 mg/dl and 140 mg/dl – 90 mg/dl and 180 mg/dl • Rates of change – Up or down arrows • Factor in recent/current/future events as you are able • Test your skills, experiment a little within reason
  • A pancreas can’t predict the future • It just can act very fast so it doesn’t have to. • Can shut off insulin immediately • Can release preformed insulin • Insulin released can start working in minutes • Can respond to rates of change in sugar levels
  • Soldier: Come on. Let me show you. Soldier: The secret to this game is no matter what happens, Soldier: never, ever take your eye off the ball. Gump: All right. Gump: For some reason, ping-pong came very natural to me.
  • Traits of effective CGM users • Wear it all the time • Check trend line often • Work the “lag” times – FOOD – INSULIN – SENSOR • Not afraid to experiment • Not expecting perfection
  • CGM - glycemic “day trading” tool Penny stock day trading strategy “sugar surfing”
  • BG awareness vs. alarm fatigue • Set reasonable alarm thresholds – Depends on your goals • Avoid high spikes? • Avoid lows? • Toddler? Child? Teen? Adult? • Make sure you can hear/sense the alarm • Anticipatory action can minimize alarms
  • Living with a CGM • • • • • • • • • Keeping up with receiver (if not part of pump) Keeping up with meter/strips/lancing device Sensor unit size and longevity (recycling) Showering/bathing/changing clothes Taping and securing Air travel (security and seating) Acetaminophen can cause “headaches” (Dex) Charging up/downloading Logging events
  • Taping tips
  • Two week site before taping
  • Site after 32 days
  • Bruise from CGM sensor
  • Sensor depths Medtronic Abbott
  • Sensor after 32 days Dexcom G4
  • Day in the life…
  • Another in range day
  • A nice day…
  • A nice day…BUT… Pasta 5 units 7 units J 3 units
  • “Fried-food revenge” and correction BG = 194 6 unit correction @ 7AM Fried food earlier in evening @ 8PM BG = 115 in 3 hours
  • “Revenge of the Ribeye” and “The Insulin Strikes Back” BG 167: 4 units LAG 2-3h
  • Slow BG rise from protein-fat laden meal
  • Slow overnight rise and early AM correction
  • Correction at 2:45 AM after slow post dinner rise with 5 units 5 units ~ 2 hours
  • Overnight rise, correction and meal
  • Steady in-range BG trend
  • Overnight basal testing
  • Overnight basal in range (glargine)
  • Overnight in range!
  • Overnight control in range
  • Basal testing…
  • Overnight basal control - Lantus
  • Time to correct > 2 hours
  • Corrections take time
  • Time to reach 100 mg/dl (at ~ 4 mg/dl/min) Blood sugar 420 340 260 180 minutes
  • Fine tuning a correction… 62 mg/dl 8gm
  • Timing 101 – 20 min. match Insulin Food
  • Timing 101 – 45 min. mismatch Insulin Food
  • “THE TREND IS YOUR FRIEND” CHECKING INSULIN BOLUSES WITH CGM Correction bolus Carb bolus 300 200 100 60 6 pm 8 pm 10 pm 6 pm Goal: green lines 8 pm 10 pm
  • Learning from the Line Graph – Effect of Exercise 350 No insulin adjustment Bike ride – 60 minutes 280 350 w/ basal rate reduction 280 210 210 140 70 140 70 E 2p CHO 4p E 2p 4p
  • Learning from the Line Graph – Correction dose “Stacked” insulin Proper correction 350 350 280 280 210 210 140 70 140 70 I I 8a CHO 10a CHO 12p Blood glucose: 212 mg/dl Correction dose: 5.5 units Correction dose: 3.5 units I 8a 10a 12p Blood glucose: 212 mg/dl Correction dose: 5.5 units
  • Learning from the Line Graph – Insulin Timing Yesterday Today 350 350 280 280 210 210 140 M 70 I 8a 140 70 10a IM 8a 10a Insulin bolus: 7:30 AM Insulin bolus: 7:10 AM Breakfast: 7:30 AM Breakfast: 7:30 AM
  • Learning from the Line Graph – Effect of Food Yesterday Today 350 350 280 280 210 210 140 70 140 70 MI 8a 10a Bagel Breakfast MI 8a 10a Oatmeal breakfast
  • Don’t Stack your Insulin! Slide courtesy of Jen Block RN, CDE and Stephen Ponder MD CDE
  • Learning from the Line Graph – What would you do? 350 280 210 1. 2. 3. 4. What did I do? What am I doing? What will I be doing? What do I need to do? 140 70 4:30 pm 6:30 pm
  • Learning from the Line Graph – What would you do? 350 280 1. 2. 3. 4. What did I do? What am I doing? What will I be doing? What do I need to do? 210 140 70 12:30 pm 2:30 am
  • Learning from the Line Graph – What would you do? 1. 2. 3. 4. 350 280 What did I do? What am I doing? What will I be doing? What do I need to do? 210 140 70 12:30 pm 2:30 pm
  • What would you do next?
  • How would you categorize this?
  • 4 day non-diabetic CGM plot
  • Turnaround Time : glycemic inertia Corrections may need to be adjusted 10-20% to compensate
  • Goal: Try to stay between the lines As readings improve, lower the glucose for the upper alert
  • 112 mg/dl to 78 mg/dl after 1.5 units by injection on a “steady” BG baseline 1.5 units ~ 2 hours
  • Correction ~ 25m ~ 80m
  • 5 units @ 5:43AM; 25 gm CHO @ 6:23AM 40 minutes 5 units Meal (25 gm CHO)
  • Calibrate during a steady baseline Calibrating with extreme BG levels can distort accuracy. Try to calibrate within your desired target zone range.
  • “Microcarbing” with CGM monitoring 2 gm CHO Before 2 grams CHO After 2 grams CHO
  • Blood sugar correction 160 mg/dl to 100 mg/dl in 2 hours with 4 units insulin lispro by injection 4 units ~ 2 hours
  • Correction: 151 mg/dl to 103 mg/dl with 2 units insulin lispro after walk 2 units ~ 2 hours
  • Optimal lunch coverage 5 units
  • Stopping sugar spikes 3 units (5:32AM) Meal (5:48 AM)
  • Calibrate during a steady trend
  • Calibrate on a steady line whenever possible 103 mg/dl 97 mg/dl Steady
  • Calibrate during a steady trend
  • Correction and meal 6 units (161 mg/dl) Meal (26 gm CHO) 126 mg/dl ~ 45m
  • Correction with 20 grams carbs 20 gm CHO
  • Skipped data (out of range?)
  • Sensor starting to lose integrity at 32 days 32 days of use 14 days of use
  • Sensor confusion?
  • Sensor confusion?
  • Duration of insulin effect can be determined here ~ 4 hours
  • IOB after 6 units and fried meal 3.5-4 hours 2 units 6 units Fried Meal Walk
  • Walking down a trend 2 units 1 hr walk
  • Wait for the bend!! Wait for the “bend”! 6U @146 mg/dl Eat here @132 mg/dl 45 minutes
  • Stress effect
  • Microbolus at 7:55AM when BG was 151 mg/dl took 2 units (after surgery)
  • Although subtle, this can be “felt”
  • First…figure out your favorite foods
  • Why do lows happen at night? • • • • • Hormonal patterns Lower insulin need Insulin peaks? Post-exercise effect Snacking stacking? Lower overnight insulin/add snack
  • Don’t pass up an opportunity to correct a high (or low) BG • Choose what you consider “actionable”? • BG above or below chosen thresholds • Consider recent and impending actions • Check your results with BG levels • Repeat as necessary
  • Curb your liver! • The liver makes as well as stores sugar • A proper insulin level “calms down” the liver • Aim for an in-range sugar level (<120 mg/dl) upon waking up each day
  • Check your targets often • Make sure you hit your target “zone” sugar ( 30 mg/dl) • Rapid-acting insulin results are best examined at 2-3 hours • Results should feedback to the next attempt “Practice makes better”
  • D-teens count carbs POORLY 23%
  • clinical dietitian (n.) 1. A person specializing in medical nutrition therapy. 2. An underappreciated and underpaid member of the diabetes team. 3. Someone who can help your left brain
  • We have > 60,000 thoughts daily Eat at home “What are we doing for dinner, dear?” • Groups of thoughts comprise decisions • The typical non-D person makes ~ 250 decisions a day about food • How many more food choices does a PWD/CWD make?
  • “You can delegate authority but you can’t delegate responsibility”
  • Do 2 RN’s = 1 kid? Ok? Ok to me! =
  • Concrete thinkers* can’t… 1. Consider a hypothesis 2. Consider multiple possibilities in a scenario 3. Systematically solve a problem 4. Use combinatorial logic *Lasts until 15-17 years of age *25% of adults are concrete thinkers.
  • Diabetes CONTROL results as much (if not more) from what you choose NOT TO DO as it results from what you choose TO DO
  • Principles of advanced CGM use 1. A CGM is no better or worse than the person wearing it. 2. If you can measure it, you can predict it. 3. Flux and drift happen… manipulate them! 4. Keep your eye on your line. 5. The trend is your friend 6. Learn lag limits; be patient 7. Zero in on your zone 8. Master micro-dosing 9. Factor in glycemic inertia and insulin momentum 10. Don’t let “good enough” be the enemy 11. Calibrate carefully 12. CGM as “sugar surfing” or “day trading” Questions?