Use of Advanced Technology in the Management of Persons With Diabetes Mellitus

Patient Guideline Summary

Publication Date: April 30, 2021

Last Updated: November 21, 2023

Objective

This patient summary means to discuss key recommendations from the American Association of Clinical Endocrinology (AACE) for the use of advanced technology in the management of persons with Diabetes Mellitus. It is limited to adults 18 years of age and older and should not be used as a reference for children.

Overview

Advances in glucose monitoring and insulin delivery technologies enable persons with diabetes to enhance their daily self-management and improve the quality of their lives.
We will use multiple abbreviations throughout this summary. We will use “glucose” or “blood glucose” to refer to blood sugar.
Standards for diabetes control include two measures:
- Blood sugar readings: Acceptable blood sugar readings are between 54 mg/dL and 70 mg/dL on the low side and between 180mg/dL and 250 mg/dL on the high side – the exact numbers are set by the patient and the physician depending on the patient’s age, difficulty controlling blood sugar, type of diabetes and other factors.
- Percentage of time a patient is within (TIR), above (TAR) or below (TBR) acceptable blood glucose readings.
This patient summary focuses on continuous glucose monitoring (CGM) and its multiple variations to improve glucose control.

Management

The goal of diabetes management is to keep blood glucose levels as close to normal as possible, it is better to have levels a bit high rather than too low to avoid low blood glucose (hypoglycemia), which is much more immediately dangerous than high blood glucose.
- Standards for quality data include 14 days in a row of records that contain at least 70% of readings. The reason for the 70% goal is that it is understandable if you miss some recommended checks on busy days. But trying to take most of the readings helps ensure you collect enough quality data to make treatment decisions.
- A one-page daily printout known as an ambulatory glucose profile (AGP) is available from CGM devices. It is a way to visualize blood sugar data from a CGM device.
  - Critical measurements from an AGP that summarizes time spent in different glucose ranges include:
    - Time in range (TIR) – The goal is to have a high TIR, ideally above 70% or above 50% for elderly and high-risk patients
    - Time below range (TBR) – The goal is to minimize TBR, ideally below 1%
    - Time above range (TAR) – The goal is below 25% or below 10% for elderly and high-risk patients

CGM is strongly recommended for:
- All persons with diabetes treated with intensive insulin therapy (3 or more injections of insulin per day or the use of an insulin pump)
- Individuals with T2D who are treated with less intensive insulin therapy
- Persons with frequent hypoglycemia or hypoglycemia unawareness
- Children/adolescents with T1D
- Pregnant women
- Older adults to reduce hypoglycemia risk.
Self-monitoring of blood glucose (SMBG) (with fingersticks or the newer no fingerstick gadgets) and insulin injections or insulin pens, the standard method of using insulin prior to the new technologies, is now recommended only for:
- Patients who cannot or will not use CGM.
- Patients who do not have access to their CGM readings.
- Patients who are successfully using SMBG and wish to continue.
- Backup of CGM when it is at risk of failure, such as when using telecommunicated values and instructions.

rtCGM can be combined with automated insulin dosing (AID) from a sensor-augmented pump (SAP).
- Real-time systems are obviously needed since a pre-determined response to low blood sugar must be immediate and available at any time.

CGM Modality Selection: CGM can be either:
- intermittent/flash which requires scanning the sensor to obtain readings or
- continuous/real-time which gives constant access to readings, depending on the difficulty of controlling glucose levels, particularly hypoglycemia. Real-time CGM is preferred for those with hypoglycemia unawareness who need alerts/alarms.
Professional CGM: The healthcare provider's clinic provides the CGM device. The patient wears it for up to two weeks. The patient returns the sensor and equipment to the clinic, and data are downloaded and analyzed. Short-term professional CGM experts can help inform treatment changes in those newly diagnosed, not on CGM, with problematic hypoglycemia, or wanting to try CGM before committing.

Intermittent/Occasional CGM: May suit some patients reluctant or unable to use CGM continuously.

Connected Pens: Connected pens = insulin pens which inject insulin with added connectivity to apps, cloud, etc. to track injections.
- Connected pens can benefit many T1D patients, reducing hypoglycemia.

Diabetes technology can be combined with telemedicine and validated smartphone applications to facilitate more rapid and intense diabetes management.
Safety Considerations: The optimal functioning of these technologies depends upon satisfactory education and frequent review of the skills of those using them. Attention must be paid to possible system failures so that backup is available at an interval determined by the patient’s risk factors.

Insulin Pumps

Insulin pumps without CGM may suit those achieving good control with minimal lows, infrequent symptomatic lows, and regular blood sugar checking.
Pumps with CGM are recommended for all needing intensive insulin management who do not have access to or do not want automated dosing systems.
Advanced pumps with low glucose suspend or predictive low glucose suspend are strongly recommended for those with T1D to reduce hypoglycemia duration and risk.
Automated insulin dosing (AID) pumps are strongly recommended for T1D patients to improve time in range and reduce hypo/hyperglycemia.
AID pumps should be considered for those with suboptimal control, glycemic variability, impaired hypoglycemia awareness, or fear of hypoglycemia leading to hyperglycemia.

Abbreviations

AACE: American Association Of Clinical Endocrinology
AGP: Ambulatory Glucose Profile
AID: Automated Insulin Dosing
CGM: Continuous Glucose Monitoring
CSII: Continuous Subcutaneous Insulin Infusion
GMI: Glucose Management Indicator
LGS: Low-glucose Suspend
MDI: Multiple Daily Injections
PLGS: Predictive Low-glucose Suspend
SAP: Sensor-augmented Pump
SMBG: Self-monitoring Blood Glucose
T1D: Type 1 Diabetes
T2D: Type 2 Diabetes
TAR: Time Above Range
TBR: Time Below Range
TIR: Time In Range
isCGM: Intermittently Scanned CGM
rtCGM: Real-time CGM

Source Citation

Grunberger G, Sherr J, Allende M, Blevins T, Bode B, Handelsman Y, Hellman R, Lajara R, Roberts VL, Rodbard D, Stec C, Unger J. American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons With Diabetes Mellitus. Endocr Pract. 2021 Jun;27(6):505-537. doi: 10.1016/j.eprac.2021.04.008. PMID: 34116789.

Disclaimer

The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.