Case 1: Diagnosis of Diabetes
This patient had a Random sugar test done on a glucometer after a heavy meal, which showed a glucose reading of 165 mg/dl. This represents a pre-diabetic state. He was keen to know whether he developed pre-diabetes. Instead of the standard FBS/PLBS/Hba1c, a CGM was applied for this patient.
The AGP in pic 1a shows that this patient’s blood sugars were in fact never high, with most the readings well within the target range. The daily glucose summary in pic 1b also reflects the same, with only 1 or 2 occasions of high sugar when the patient had a heavy lunch. With a healthy diet and exercise, the patient was convinced that he could maintain his blood sugars within target. He will have a repeat AGP in a year’s time to recheck his diabetic status,
Case 2: Fluctuant Blood sugar Values
This is a common complaint in a lot of Type 1 and Type 2 insulin treated Diabetic patients. These patients have both high and low blood sugars during any given day, leading to confusion in the amount of insulin that needs to be taken. One such patient came for consultation and a CGM was applied.
The AGP in pic 2a reveals that this patient’s blood sugars were very high after lunch but near normal at other times. An extra insulin dose was added before lunch and a consequent AGP taken at a later date (pic 2b) shows good control in the late afternoon readings.
Case 3: Diabetes in Pregnancy
Diabetes in pregnancy is a special situation where the blood sugars have to be really tightly controlled to prevent any complications for the foetus. Generally pregnant women are asked to regularly check their sugars on a glucometer upto 4 times daily. CGM provides an excellent alternative to this painful testing, giving precise values to guide treatment.
CGM was applied on one pregnant woman, whose sugar values as seen in pic 3a were rising beyond target after breakfast and dinner. With good dietary advice and some insulin before breakfast and dinner, the glucose targets were achieved (pic 3b)
Case 4: Hypoglycaemia
CGM has a crucial role in revealing hidden hypoglycemia patterns in an apparently well controlled diabetic. A Type 2 diabetic patient had good control on FBS/PLBS and Hba1c but was complaining of weakness and headaches on waking up. Suspecting hypoglycemia overnight, she was put on CGMS.
Pic 4a shows the AGP of this patient which shows that there is significant low sugars overnight, which would otherwise not have been picked up on routine testing. The daily glucose patterns in pic 4b also confirm night time low sugars. His medications were changed accordingly and a subsequent AGP (pic 4c) showed no hypoglycaemias.
Case 5: Insulin titration
Most type 2 Diabetic patients will need to switch to insulin treatment at some point due to failure of insulin production of pancreas. This switch from oral medication to insulin requires close monitoring of blood sugars and how they are responding to the uptitration of insulin doses.
An example of CGM use in one such patient is shown in pic 5a. The daily glucose patterns show values were >350 to start with. She was started on regular insulin doses with uptitration of doses every 3-4 days. By the end of 14 days, we see that >90% target values could be achieved. In conventional system of regular glucose checking and follow ups, it is difficult to achieve such precision control
Case 6: New Type 1 Diabetics
Type 1 Diabetes mainly affects the children, and it is a traumatic time for both the children and their parents when it is first diagnosed. Firstly the child has to start regular insulin injections 3-4 times daily. In addition, it is also important to monitor blood sugars by regular skin pricks 3-4 times daily. The whole process can be emotionally, mentally and physically tiring for both the child and the parents. CGM (and insulin pumps) are an efficient way of easing the adaptability of this new life change for the child. Entirely painless, the CGM records sugar values every 15 min and gives important information about the insulin doses required for that particular child.
One such example of a newly diagnosed child is shown in the daily glucose patterns in pic 6a and 6b. Through regular visits every 3-4 days, I was able to titrate the insulin doses to the desired target values for glucose.
Case 7: Elderly patients
The new guidelines for the treatment of diabetes does not follow a “one size fits all policy”. The younger the patient, the tighter the control. A much more lenient approach is advised in older patients, patients with established co-morbidities and patients with high risk of complications from tighter control of Diabetes. CGM is extremely useful in this scenario to ensure that we are not treating Diabetes too tightly.
One such example of a 70 year old man with a history of seizures is shown in pic 7a. He had many episodes of hypoglycaemia which triggered his seizures. The AGP in 7a and the daily glucose patterns in pic 7b suggests that the glycemic control is too tight. After relaxing his glucose control with lighter medications, I could bring the readings in to an acceptable range of sugars for his age and risk factors.
