1b) Hence we welcome2⃣ expert faculty from Canada: Ilana Halperin @ilanajhalperin, academic endocrinologist at @sunnybrook and @uoftmedicine, and Noah Ivers @NoahIvers, #familydoc & researcher at Women's College Hospital @UofT pic.twitter.com/HMiWfxoQtw
— cardio-met (@cardiomet_CE) June 15, 2023
3a) @NoahIvers 👨: I was asked to do a #tweetorial on Time in Range (#TIR) in Primary Care. My initial response was sorry I think you have the wrong doctor in our house
— cardio-met (@cardiomet_CE) June 15, 2023
4) @ilanajhalperin 👩: Actually, there is growing evidence of the benefits of continuous glucose monitoring #CGM to help improve #TIR in Type 2 Diabetes and we know most care for #T2D happens in #PrimaryCare
— cardio-met (@cardiomet_CE) June 15, 2023
See 🔓 https://t.co/qMzctMxVG6 and 🔓 https://t.co/xkuvpn7vKL
6) 👩: A1C is useful for diagnosing #T2D, predicting complications on a population level, but we certainly see patients with the same A1C for the same duration of time & other risk factors optimized, but different burdens of micro- and macrovascular complications. pic.twitter.com/98DduncUje
— cardio-met (@cardiomet_CE) June 15, 2023
8) 👨: So, what exactly do you mean by Time in Range for patients I would see in my #familypractice? Like, let’s talk about a patient who is on 2-3 meds and I am contemplating #basal #insulin because #A1C is above target. I’m usually still thinking about A1c there…
— cardio-met (@cardiomet_CE) June 15, 2023
9b) 👩: Time Below Range (further divided in <3.9 and very low <3.0 mmol/L) Time in Range 3.9-10mmol/l and Time Above Range (subdivided into high 10.1-13.8mmol/L and very high >13.9 mmol/L). See 🔓 https://t.co/TYcHCei4oL
— cardio-met (@cardiomet_CE) June 15, 2023
11)👩: Fair point, I think a picture will really help to make it real.
— cardio-met (@cardiomet_CE) June 15, 2023
For most adults the #TIR goal is 70%, with <4% #TBR and 25% #TAR. The TIR goal is relaxed to 50% for frail adults in an effort to avoid hypoglycemia.
🔓 https://t.co/TYcHCei4oL pic.twitter.com/vZXNKiRjd2
12b) 👩:T his picture allows you to visually pinpoint the time(s) of day when specific glycemic patterns exist and when glucose levels repeatedly deviate from the target range. Having knowledge of the patient's typical mealtimes, sleep, and exercise on the #AGP is helpful
— cardio-met (@cardiomet_CE) June 15, 2023
14) 👩: Now in this picture are 3 #AGP reports for the same “in target” #A1C. What's hiding beneath is glucose variability: expressed as coefficient of variation, when CV <36% glucose are stable and >36% glucose levels are unstable (meaning higher risk for hypoglycemia) pic.twitter.com/VvNliWWsKW
— cardio-met (@cardiomet_CE) June 15, 2023
16a) 👩: When #variability is low you can adjust insulin using the recommendations above. When variability is high you need to discuss the patterns with the patient.
— cardio-met (@cardiomet_CE) June 15, 2023
17a) 👩: Usually I just talk to my patients about how their glucose swings from high to low and back again based on how they respond to highs and lows and they look at me . . .
— cardio-met (@cardiomet_CE) June 15, 2023
18) 👩: The key to improving variability is being patient with both the insulin and glucose sensor. I have a publication that discuss this in more detail (https://t.co/09oJracKRx). Here are my main talking points for helping patients decrease their variability: pic.twitter.com/yJcMYOL3BS
— cardio-met (@cardiomet_CE) June 15, 2023
19b) 👩: . . . the biofeedback your patients will get from using #CGM is really helpful and can have a significant impact on their glycemic outcomes! pic.twitter.com/mZsIVj2eIB
— cardio-met (@cardiomet_CE) June 15, 2023
21) 👩: Excellent question, The Mobile Study (🔓 https://t.co/bFi8R7zzSi) looked at the use of Dexcom G6 a real time #CGM use in patients managed on basal insulin in primary care. pic.twitter.com/gAIWxRDeYh
— cardio-met (@cardiomet_CE) June 15, 2023
22b) 👩: In addition, it’s possible that #PCPs and #PWDs felt safer being more aggressive with basal insulin titration when there were alerts and alarms to protect against #hypoglycemia.
— cardio-met (@cardiomet_CE) June 15, 2023
23b)👩: It may be enough to change their lifestyle and get #A1C to target, but if it is not then you will have the #AGP to help you initiate and adjust #insulin.
— cardio-met (@cardiomet_CE) June 15, 2023
25) So the guidelines are now evolving to recognize this newer evidence. pic.twitter.com/wtHCkmrqAa
— cardio-met (@cardiomet_CE) June 15, 2023
26b)👨: How easy is it for me to prescribe these devices to my patients?
— cardio-met (@cardiomet_CE) June 15, 2023
27b) 👩: For people not on insulin or w/out insurance a single Free Style Libre sensor that lasts 2wk will cost around CAD$90. In that population, periodic use may be very helpful. They can wear for 2wk before the appt with you & then you have useful data to review together.
— cardio-met (@cardiomet_CE) June 15, 2023
28a) So let’s close with a couple knowledge ✔️ questions!
— cardio-met (@cardiomet_CE) June 15, 2023
First, monitoring #PWDs with #A1c alone misses:
a. Extent or timing of hypoglycemia
b. Extent or timing of hyperglycemia
c. Glycemic variability
d. All of the above
28c) It’s c, > 70%, but as per tweets 9a and 9b above, don’t neglect to check #TBR and #TAR as well to effectively monitor glucose management and limit excursions into hypo- and hyperglycemia.
— cardio-met (@cardiomet_CE) June 15, 2023
29) And that’s it! Under the expert tutelage of @ilanajhalperin 👩 & @NoahIvers 👨, you just earned 0.75hr 🆓CE/#CME 🇨🇦🇺🇸🇬🇧🇪🇺. Go to https://t.co/7YiiFwgKxf NOW and claim your credit, and FOLLOW @cardiomet_ce for more expert-delivered #MedEd!#FOAMed #cardiotwitter #nephtwitter
— cardio-met (@cardiomet_CE) June 15, 2023