Big Changes! Centers for Medicare & Medicaid Services (CMS) Loosen Requirements for Obtaining a Continuous Glucose Monitor (CGM) During COVID-19

This content originally appeared on diaTribe. Republished with permission.

By Karena Yan and Kelly Close

In-person visits, lab tests, and finger stick documentation are no longer required at present to get a CGM

Editor’s note: This article was updated on May 21, 2020 to reflect that lab testing is still required for an insulin pump and pump supplies.

High blood sugar levels leave the body vulnerable to infections, meaning those individuals with poorly controlled diabetes are at greater risk of contracting COVID-19. To properly monitor and respond to glucose levels and to strengthen the immune system to fight off infections, a continuous glucose monitor (CGM) can be very helpful.

If you are on Medicare, obtaining a CGM through your healthcare professional is a relatively involved process, requiring an in-person clinic visit, lab tests, documentation of frequent finger sticks (four or more times a day), and a lot of paperwork. At present, only those on insulin have an opportunity for approval. However, due to COVID-19 and the increased risks it poses for people with diabetes, the Centers for Medicare & Medicaid Services (CMS) announced that it will not enforce the following criteria for receiving a CGM:

  • In-person clinic visits
  • “Clinical criteria,” including lab tests for C-peptide or auto-antibodies, or demonstration of frequent finger sticks

This means that people with diabetes do not have to go to the doctor’s office or undergo lab tests to receive a CGM. Importantly, these loosened restrictions also reduce the amount of paperwork and bureaucracy for healthcare providers and give them greater flexibility in providing CGMs. Lab testing is still required for insulin pumps and pump supplies.

This increased access to CGMs is a huge win for the many people with diabetes on insulin who would not otherwise be able to get a CGM. Because CGMs provide real-time data for blood sugar levels, users are able to monitor their glucose and proactively adjust their insulin doses. Not only do CGMs help increase time in range, and thus have the opportunity to increase productivity and quality of life, but they can also improve overall diabetes management and can help keep patients out of the hospital.

We hope that in the future, at least those on SFUs will be able to get CGM, as SFUs can prompt hypoglycemia, which is especially dangerous right now, given the importance of staying out of the hospital.

Every person with diabetes can benefit from either a professional CGM used regularly (at least yearly) or a 24/7 CGM. While these new CMS guidelines are temporary in response to COVID-19, we are hoping and advocating for making the changes permanent. With the rise of the Beyond A1C movement and increased awareness of time in range, CGM (24/7 or professional) is an essential tool for people with diabetes to live happy and healthy lives, both during and after COVID-19.

This article is part of a series on time in range maybe possible by support from the Time in Range Coalition. The diaTribe Foundation retains strict editorial independence for all content.

Source: diabetesdaily.com

Working with Your Healthcare Team to Achieve Your Time in Range Goals: An Interview with Cleveland Clinic’s Dr. Diana Isaacs

This content originally appeared on diaTribe. Republished with permission.

By Frida Velcani

Dr. Diana Isaacs on improving time in range, making the most of your data, and the barriers facing people with diabetes and their healthcare teams

Dr. Diana Isaacs is a Clinical Pharmacist and Diabetes Care and Education Specialist at the Cleveland Clinic. She works with people with diabetes on a range of issues, including medications, technology, and lifestyle changes. She also educates people every day about the benefits of time in range.

In addition, Dr. Isaacs is the coordinator for the Cleveland Clinic’s continuous glucose monitor (CGM) program. You can find more information on how to choose a CGM here. We continue to think that CGM is of the utmost importance for helping people keep their blood glucose levels in-range, assuming they have access. Dr. Isaacs meets with 200 people every month, through individual appointments, classes, phone follow-ups, and virtual visits. She also works with other healthcare providers, including nurses, nurse practitioners, dietitians, and physicians.

For this article, we spoke with her to better understand her views on the importance of time in range for people with diabetes. Here are her insights on how we can shift away from using A1C and move everyone toward better health.

Dr. Isaacs on Ways to Improve Time in Range, Setting Target Goals, and Celebrating the “Wins” 

We asked Dr. Isaacs to pinpoint the most important things that people can do to improve their time in range. “Work with your diabetes care and education specialist and healthcare team to interpret CGM data, understand patterns, and optimize medication doses,” she said. When reviewing data, it’s important to keep a positive attitude and focus on the successes. Repeat what worked well on the days when your time in range was the highest. Figure out what is causing the lows (which often lead to rebound highs) and work to prevent them.

Dr. Isaacs wants people to know that having high glucose variability is completely normal. Many people have the misconception that they should be spending 100% time in range. In reality, time-in-range goals are different for each individual depending on factors such as medication, age, and type of diabetes. Experts recommend that people with type 1 and type 2 diabetes aim to spend at least 70% of the day within 70 to 180 mg/dl, less than 4% of the day below 70 mg/dl, and less than 25% above 180 mg/dl. However, experts emphasize that even a 5% change in time in range – for example, going from 60% to 65% – is meaningful, as that translates to one more hour per day spent in-range.

“I’ve seen everything from 0% to 100% time in range,” she said. “There are differences when comparing someone who is new to our clinic compared to someone working with us for a year. It’s so individualized, and people have different challenges. The goal is to improve your personal time in range, and any increase in time in range is a win.”

Measuring Time in Range using Blood Glucose Meters, CGM, and Professional CGM

If you are using a blood glucose meter (BGM) or CGM, talk with your healthcare team about your glucose targets. The data will be more meaningful if you are working toward a specific goal.

For BGM users, paired testing can help you see the direct impact of food on your blood glucose – all you have to do is check your glucose before a meal and again two hours after the meal. To check that your basal insulin is working well, check your glucose levels before bed and first thing in the morning.

At the Cleveland Clinic, people are required to attend a two-part shared appointment to get access to professional CGM. The classes are usually two diabetes care and education specialists (pharmacist and dietitian or nurse) and 4-6 people with diabetes.

In part one, you go over glucose targets, time in range, and how to treat high and low blood sugars. In part two, you download the data and review it with your diabetes care and education specialists. You discuss what it means, find patterns, and make medication adjustments as needed. This class is offered five times per month. Dr. Isaacs says that this program has helped many people improve their A1C (an average 0.8% reduction) and diabetes self-management.

How can we make time in range accessible to people with diabetes and their healthcare teams?

Dr. Isaacs believes that everyone should have access to affordable medications, affordable technology, and a great support system. She says, “I’ve seen so much rationing of insulin and medications, especially in the Medicare and uninsured populations.” There are many people that have diabetes and haven’t connected with their healthcare team in years. We need to do a better job to help these people.

According to Dr. Isaacs, the average healthcare professional is not prepared to talk about time in range. A1C has been and continues to be widely used by most healthcare teams. While she is excited about the growing use of CGM, there are “still some hurdles to get all practices up to speed with how to download the devices and interpret the data.”

Her advice is to tackle these barriers from multiple angles:

  • In research, we need to make sure that time in range is an outcome in all clinical trials that measure glycemic management, so that we can directly measure the effect of time in range on clinical outcomes.
  • We need targeted education for busy healthcare professionals, including podcasts, webinars, and continuing education.
  • We need targeted education for people with diabetes who are often the ones bringing information to their healthcare team.
  • In practice, healthcare professionals should discuss time in range with every person with diabetes that is using CGM.
  • People with diabetes using CGM should be encouraged to bring their reports to their healthcare provider and discuss time in range.
  • Instead of only marketing CGM as a convenient way to reduce finger sticks (which is true), the real benefit is that it lets the person with diabetes be the driver, and time in range is their roadmap.

Dr. Isaacs recently spoke on a panel at the ADA post-graduate sessions about the power of time in range and CGM for all people with diabetes. She was joined by diaTribe’s medical advisory board member, Dr. Irl Hirsch, our editor-in-chief, Kelly Close, and Jane Kadohiro as the moderator, who herself has had diabetes for over 50 years. If you or your healthcare provider are interested in learning more about time in range and downloading CGM data, you can make an account and watch the session here!

Source: diabetesdaily.com

Celebrating a Diaversary in Quarantine

The whole world has seemingly halted operations, due to the novel coronavirus. With over 1/3 of the world’s population on lockdown, shops, restaurants, coffee shops, tattoo parlors, bars, and gyms (any non-essential business) are closed, it’s almost impossible to find something (anything!?) to celebrate these days.

But as we all know, diabetes doesn’t stop, not even for a global pandemic. Those of us with diabetes are still counting, measuring, and injecting multiple times every day, and with that, come diaversaries, or celebrating the anniversary of our diagnosis date. For some people, this can be very emotional, and I’ve previously talked about celebrating my diaversary here. So, how exactly do you celebrate a diaversary while in quarantine? Whether you’re celebrating for yourself or a loved one, check out our top ideas:

Still Mark the Occasion

You may be wondering if celebrating your diaversary is even worth it during this time of international grief and suffering, and I say, if you feel like celebrating, then by all means, celebrate! There is a heaviness in the air, and many people are suffering, but if you can acknowledge the hard work, time, and dedication you’ve given yourself to be healthy this past year, it’s good not only for your self-esteem but also for your mental health.

Treat Yourself

You may not be able to take a lavish vacation, or go out to a fancy dinner, but you can still treat yourself by baking a cake, creating an elaborate meal at home, or toasting to good health in your backyard. Make the evening special by lighting candles, dressing up, and playing some music while you take in the occasion.

Involve Friends and Family

You can zoom or video chat with your closest friends and family who may live far away, for a party without all the clean up! Touching base with those close to you on such a momentous day to reminisce, laugh (or cry!), and connecting will be totally worth it.

Set Goals

A diaversary is an excellent time to look back on your year with diabetes, review what worked for you and what hasn’t (maybe ice cream for breakfast three times a week wasn’t such a good idea?), and set some goals for your upcoming year with diabetes. Maybe you want to try out a new kind of CGM, or get your HbA1c to a lower (or even higher) level. Maybe you’re trying to take a pump break or give insulin pens a try. Set some goals to get your year started off right!

Indulge

Whether that’s by skipping dish-duty for a long, leisurely walk around your neighborhood, or having an extra piece of cake, or even by ordering a fun diabetes bag, make sure you enjoy a no-guilt treat on this day- after all, you deserve it!

Celebrating your diaversary during quarantine and shelter-in-place rules is definitely different, but it doesn’t have to be sad or lonely. Have you celebrated your diaversary during the COVID quarantine, or are you planning to? What strategies or ideas have you used or do you plan on using in order to celebrate? Share this post and share your stories below; we love hearing from our readers!

Source: diabetesdaily.com

How to Navigate Blood Sugars During a Pandemic

Diabetes management is challenging enough as it is. It takes a daily and consistent effort, around the clock, to check your blood sugar levels, pay close attention to your diet and a multitude of other variables, all while making medication adjustments to stay in your target range. The constant management tasks already take a substantial amount of effort and headspace. It’s no wonder that when a particularly high-stress situation arises, it can make diabetes management especially tricky.

Right now, we are all living through a very stressful time, globally. As the COVID-19 pandemic continues, we are all doing our part in trying to slow the spread of the infection. Between school and university closings, bars and restaurants and stores being shut down, and the constant effort of social distancing, the changes to our daily routines are paramount. Not being able to go to the gym, socialize as we are used to, and the added stresses of childcare, not to mention unemployment concerns, are skyrocketing our stress levels.

We know that stress levels can cause higher than normal blood glucose levels. As a result, many of us may be struggling with our diabetes management more than usual.

Jennifer Smith RD, LD, CDCES, Director of Lifestyle and Nutrition and Registered Dietitian, Certified Diabetes Care and Education Specialist at Integrated Diabetes Services explains:

“Stress comes in all forms and can effect each person a bit differently. Stress at work, from a presentation, a big project for school, studying, a terrifying experience like a car accident, a big game against the top opposing team, a performance in gymnastics, or even a scary movie – these can stimulate the “fight or flight” response in the body. The main hormones that are released in a time of stress are adrenaline and cortisol. The release of these hormones encourages the liver to dump glucose into the blood stream in order to provide a quick supply of energy to “get out of the situation”…our body still responds to stress as if we were running away from a Saber tooth tiger ages ago. This extra glucose can and will raise blood glucose levels. It won’t be the same for each person and different types of stress will cause a different rise in blood glucose, but this is the main reason for the typical rise from stress.”

In these unprecedented times, it is perhaps more than ever important to continue to care for our physical and mental health, and in particular, our diabetes. Optimizing our blood glucose levels can help promote optimal immune system function, which helps us fight off all kinds of infections more effectively. Also, keeping blood glucose levels in range as much as possible can go a long way in helping us to feel our best on a day to day basis, physically and mentally.

Here are some tips for optimizing our diabetes self-care during these high-stress times.

Check Your Basal Insulin Dose

For the many of us who are on a basal/bolus insulin regimen, whether using a pump or multiple daily injections, basal insulin doses (or rates) are the cornerstone of blood glucose management. If the basal insulin dose is too high, we might find ourselves with unexpectedly low blood sugar levels throughout the day or night, while if the dose is too low, we may be constantly chasing higher than desired blood sugar levels.

Jennifer Smith RD, LD, CDCES, explains:

“This the foundation of your diabetes management. Think of it like the foundation of a house – if you build it sturdy and strong then everything placed on top of it will hold stable. If you have a foundation that has holes in it, or it put together with shoddy materials, you are like to have to patch and fix it along with everything you build on top of it or it will all fall apart. Basal insulin is what we use to manage blood glucose without food in the picture. In a body without diabetes there is a fine coordination between insulin released by the pancreas in the fasting state and the livers release of glucose into the blood stream to maintain normal glucose levels. This happens whether or not there is food eaten. Getting the basal rates tested is the baseline of management to ensure that if you skip a meal, or for overnight when you aren’t eating, glucose levels stay stable without falling or rising more than 30mg/dl (1.6mmol). Having this set well will ensure that the bolus insulin you take to cover food or to correct blood glucose when it is too high is working optimally. It may need to be adjusted as you move through life, as hormones for growth, menstruation, stress and illness can change insulin needs. But, if you have your base basal set well, then adjusting for these variables is a bit easier to navigate.”

For most people, stress tends to increase insulin resistance, resulting in higher blood glucose levels. This means that many need more insulin during times of stress to stay in range. However, your response to stress may vary, so it is important to carry out basal testing to determine if your dose is appropriately set.

Photo by iStock

Below, you can find a previously published description of how to determine if your basal insulin doses or rates are working well for you. Once that cornerstone of insulin therapy is properly set, it will be much easier to troubleshoot other areas, like bolus and exercise adjustments. (*Note: always consult with your healthcare provider prior to making any changes to your medication doses).

To determine if the basal insulin dose is set correctly, one can fast for a specific number of hours without bolus (fast-acting) insulin onboard and monitor blood glucose levels to see if they remain steady. Importantly, the test should be performed in the absence of other complicating variables, like exercise, stress, or illness. The test should not be performed if your blood glucose level is low or high.

Many people prefer to perform basal testing in 8-12-hour spurts, so as not to fast for an entire 24 hours. For example, it can be quite easy to check the overnight basal dose by not eating after 6 pm and assessing the blood glucose trend from 10 pm to 6 am (in the absence of food or bolus insulin). To determine the basal dose efficacy for morning or evening hours, one would skip a meal and monitor blood glucose levels to determine whether the basal dose is well-set.

The basal insulin requirement may be very similar throughout the day, or it may vary. In particular, many individuals experience “dawn phenomenon,” whereby hormones stimulate glucose release by the liver in the early morning hours. When using an insulin pump, it is quite easy to adjust the basal insulin rate of delivery to accommodate any variations. For those on insulin injection therapy, it may be worthwhile to split the basal insulin injections into several doses throughout the day, to best match the requirements. These individuals may also benefit from taking a small amount of short-acting insulin upon waking to account for dawn phenomenon.

Accurate basal insulin dosing is the first step to achieve the best blood glucose control possible. Once the optimal doses or rates are determined, one should not need to worry about hyper- or hypoglycemia in the absence of food or other variables (like exercise). This will make it a lot easier to systematically start addressing other variables that affect blood glucose levels.

Reduce Stress

It may be easier said than done, but there are several, proven ways that we can reduce our stress levels. Whether it’s taking ten minutes to meditate every morning, making sure you get your exercise in, or connecting with loved ones through phone or video chats, taking time to care for our physical and emotional health can in itself help us to de-stress. In turn, our blood sugar levels will (hopefully) become more predictable and easier to manage. Check out some of these articles to help you get started:

Mindfulness and Meditation Apps

Staying Active at Home

Taking Care of Your Mental Health

And, as the weather finally improves for many of us, don’t forget about the benefits of time spent in nature. Between the vitamin D exposure and the exercise, you can gain a boost for your immune system and mental state by making it a priority to get outdoors as much as possible.

Create (and Stick to) a Routine

Maintaining some degree of normalcy by having a regular schedule can help us feel more in control and help keep us on track when it comes to our meal planning and exercise goals, which in turn, can have a tremendously positive effect on our diabetes management. A routine can be especially helpful when we find ourselves in a rut or experiencing burnout.

For example, if you’re struggling to check your blood sugar level on a regular basis, you can make a concrete plan of when exactly you will check each day. Next, keep yourself accountable by setting an alarm to do so. Moreover, consider trying out a diabetes management app, to help you stay on track.

If you find that your diet has suffered, try to plan your meals ahead for the week. Focus on nutrient-dense foods and get your family involved. Try out a new vegetable recipe or even a low-carb desert! Similarly, with exercise consider engaging all together at a set time, at least a few times per week.

Make Use of Technology

We are so fortunate to have the advanced technology we have today, diabetes-related and not. If you have found yourself in a rut, not wearing your continuous glucose monitor (CGM), or not utilizing the features on your insulin pump to their fullest extent, this is a great time to lean into the technology that can help us thrive during these difficult times.

Moreover, we can data share with our healthcare providers, providing them with detailed information about what’s working and what’s not. Ask your healthcare providers about telehealth appointments, if you haven’t yet!

Photo credit: geralt (Pixabay)

On another note, just using video conferencing to keep up with family and friends, or even just chatting about diabetes in a forum, is a gift that did not exist even 50 years ago! Making use of the internet to strengthen existing connections and make new ones is critical to our emotional health during these times, and can even help with diabetes management and emotional support.

Lean On Others

If you need help, reach out. If you are having a bad day, reach out to a friend for support. If you’re struggling with your diabetes management, reach out to the online community, as well as your diabetes provider. Don’t underestimate the power of social support, as well as having another pair of eyes to review your data to help you identify where you can make some changes to get back on track.

We may be socially distancing, but we are not alone! Lean into your community and make use of your provider’s expertise, remotely.

Also, be aware of the following mental health hotlines and be sure to share them with anyone who may benefit:

  • National Suicide Prevention Lifeline: 1-800-273-TALK (8255)
  • Crisis Counselor Hotline: Text HOME to 741741 to connect with a counselor

Also, you can visit this website for hotlines that are tailored to more specific mental health issues.

***

How has your diabetes management been affected by the COVID-19 pandemic? What are you doing to stay healthy? Please share your experiences with us in the comments below.

Source: diabetesdaily.com

The FAA Continues to Ground Commercial Pilots with Insulin-Dependent Diabetes

This content originally appeared on Beyond Type 1. Republished with permission.

By Lala Jackson

On November 7, 2019, the Federal Aviation Administration (FAA) lifted their previous ban on certifying insulin-dependent people with diabetes as commercial pilots. The statement followed a 2015 announcement that the FAA would begin considering certification for insulin-dependent people with diabetes.

Private pilot Chris Hanrahan initially applied for his commercial pilot medical clearance in 2015, when the FAA originally announced they would be considering clearance for insulin-dependent people with diabetes. According to Chris, he has since learned that his original application was used to “acquire data to develop protocols. They were never intending to use our data to admit us, but to develop their guidelines.”

Chris filed his second commercial pilot medical clearance application on December 3rd, 2019 and has been told by the FAA multiple times that he would hear back within three weeks. Now, at the start of March 2020, the FAA has told Chris he will hear back by the end of the month. For Chris and other pilots waiting to hear back, lack of clear expectations and an honored review timeline from the FAA creates confusion and frustration.

The FAA has extensive guidelines around medical certifications for a variety of disease states that have the potential to impact the safety of flights. With insulin-dependent diabetes, the FAA has expressed concern about the “risk of subtle or sudden incapacitation due to hypoglycemia.” Because of this, they have created an extensive set of steps for pilots with diabetes to receive medical clearance.

For those seeking medical clearance to fly commercially a continuous glucose monitor (CGM) is required, as well as a significant amount of documentation including:

  • a minimum of 6 months (or 12 months, depending on which guideline document is being referenced) of CGM data that shows percentages of time in range
  • additional blood glucose check by fingerstick data
  • a detailed Excel spreadsheet that notes glucose levels during past flights and any actions taken to correct levels
  • reports on episodes of blood sugar <70 mg/dL or higher than 250 mg/dL for the past year
  • HbA1c data from the past year
  • eye and cardiac evaluations
  • a detailed diabetes and medical history
  • and comprehensive lab work including thyroid and B12 levels

Additional reports for recertification are required every three months. Despite the extensive application data required, the FAA reports they’ve received ten applications from insulin-dependent pilots since their statement in November. However, none have yet been approved. The FAA says they’re working on reviewing applications within 90 days on a case by case basis.

“They keep changing the time frame,” Chris told the Beyond Type 1 team. “There’s no explanation or logic at to why they’re doing this. They’ve told me they’ve had my stuff looked at by their endocrinology team and they told me everything is fine, they’re just waiting on signatures.”

For Chris and pilots like him who have followed every guideline to apply, a clear decision from the FAA is what they deserve.

Source: diabetesdaily.com

Imagine 288 Fingersticks a Day: The Power of CGM

This content originally appeared on diaTribe. Republished with permission.

By Michael Hattori

Michael writes about his diagnosis with type 2 diabetes, and how he used a CGM to put his type 2 diabetes into remission

My name is Michael, and I have type 2 diabetes. In remission. This means that my body no longer experiences unusually high blood sugar levels, and I don’t have to take diabetes medications.

Diabetes remission would not have been possible for me without the help of a miraculous tool called a continuous glucose monitor (CGM). Let me tell you how and why.

I have been a nurse for almost 22 years. Although most of my time has been in the operating room, I started my career taking care of people with diabetes, most of whom were faced with complications from diabetes. I realized early on how immensely complex and challenging diabetes is – I never imagined that I would be diagnosed with type 2 diabetes.

Well! About six months ago, my weight had reached 200 pounds (I’m 5’3”), my appetite was growing, I began experiencing extreme thirst. The huge amounts of water I was drinking seemed to do nothing but drive me to the bathroom seemingly every five minutes. Now, as a nurse, I knew exactly what was happening. But it couldn’t be happening to me!

At first I thought, “Oh, this will go away. It’s temporary.” But after several weeks of symptoms, I realized I needed to do something. I asked one of my colleagues at work to check my blood sugar, and it was 298 mg/dl. I could not believe it. We checked again, and it was 300 mg/dl. Lab tests a few day later showed a fasting glucose of 305 mg/dl and A1C of 10.5%. I had diabetes.

Now, you may be thinking, “You’re a nurse, for crying out loud! How could this happen to you?” But the fact is, I’m also a human being, just like you. Having worked outside of diabetes care for over 18 years, I was as uninformed as most people, and just as frightened.

One of the general surgeons I work with was standing next to me, and I asked him what he thought I should do. He was genuinely shocked, and said, “I think we need to get you on metformin, an SGLT-2 inhibitor, and a DPP-4 inhibitor.” Fortunately, my friend and colleague, Jennifer, immediately interjected, “No! You have to try this CGM first!”

I had no idea what a CGM was, but I soon found out. And it changed my life – saved my life, really.

Jennifer said, “This [CGM] is the greatest thing ever! It measures your blood sugar every five minutes, 24 hours a day, and you don’t have to stick your finger to see the results!” I was intrigued, as I had heard rumors of such devices (and also hated sticking my finger). She said that it had become her “best friend” and that it helped her mother, who had type 2 diabetes for 20 years, to manage her blood glucose. The next day I spoke with my primary care provider, and one day later I had a Freestyle Libre CGM sensor on my arm and the determination to manage my type 2 diabetes with diet and exercise alone.

Over the next six weeks, I came to rely on my CGM as my personal blood sugar “GPS.” It allowed me to see how every single thing I did affected my blood sugar, and not only during waking hours, but also while I was asleep. I kept a log of everything I ate; the CGM helped me to see how it affected my blood sugar, both immediately and over many hours. Can you imagine how powerful a tool that is for people with diabetes? To see in real time what effect food has? And not for just one point in time, like a fingerstick, but every five minutes after you eat. Imagine, if you are taking insulin, how valuable that information would be to help with dosing. No more guessing – incredible!

I had also heard about intermittent fasting but was skeptical until I started reading and found agreement that it is not only effective in helping to manage blood sugars and lose weight, but that there are other long-term health benefits. Jennifer had been doing intermittent fasting for over a month and was very positive about it, so I decided to give it a try. One of the main reasons I was willing to try it was because I had my friend, the CGM, as my guide. Being able to check my blood sugar at any time provided me with the safety net I needed to try something as radical (to my mind, at least) as fasting. And guess what, it worked!

I am now a huge advocate of intermittent fasting. But– and this is a big but – it is not for everyone. Anyone using insulin or medications that might cause low blood sugar (hypoglycemia) must consult with their healthcare professional, and also preferably a diabetes care and education specialist, before starting any kind of fasting program.

Along with helping me with my diet, the CGM gave me immediate feedback on exercise. I knew that exercise would help manage my diabetes, but I had no idea just how big a difference it could make. I’m not talking about hours of hard, furious sweating and exhaustion; all I did at the beginning was walk. The diabetes care and education specialist who led my class told us that even a 10-15 minute walk after a meal can bring your blood sugar down significantly. Many of the people in the class were skeptical, but she made us promise to walk at least ten minutes after every meal, and to check our blood glucose before and after the walk. Everyone was amazed at how much it really did bring down blood sugars.

For those of us with CGM, we could monitor our blood glucose throughout the walk, without any fingersticks. For me, a 20-minute brisk walk after dinner would often bring my blood sugar down 60 points or more. It was so gratifying to be able to watch my blood sugar go down and down. It motived me to make walking part of my daily routine – I still try to walk at least ten minutes after every meal, especially dinner.

Having so much CGM knowledge at my fingertips 24 hours a day gave me the power to make informed decisions about exactly what and how much to eat, to experiment with favorite foods, and to see, in real time, the benefits of exercise. How could you ask for a better tool? Within a month, I was able to get my fasting blood sugar down from over 300 mg/dl to less than 150 mg/dl. After three months it was under 120 mg/dl, and after four months under 100 mg/dl, with an A1C of 5.2%. I lost 35 pounds and still plan to lose 20 more.

I don’t think I could have achieved this without a CGM. My CGM gave me the equivalent of 288 fingersticks a day! A CGM puts that huge amount of information right at your (now not sore) fingertips. Of course, it’s up to you to use that information. But as they say, knowledge is power, and this gives you the power to manage your diabetes, and not the other way around. The CGM is the ultimate tool to show you just how your behavior affects your blood sugar, all day long.

Michael Hattori

Image source: diaTribe

Diabetes was a wake-up call for me to improve my lifestyle, and the CGM was the tool that allowed me to do so quickly and effectively. I am now in remission and intend to stay that way.

I am now on the path to becoming a certified diabetes care and education specialist, so that I can share my story and help others understand and manage their diabetes. Surprisingly, the CGM is not available to all people with diabetes. I can’t imagine a single person with diabetes who wouldn’t benefit from this amazing technology: it is like going from seeing through a tiny pinhole to having a full 360-degree view. And the view is incredible!

Source: diabetesdaily.com

Traveling Abroad with Diabetes: Have Your Dolce and Eat It Too!

This content originally appeared on diaTribe. Republished with permission.

By Maria Horner

Maria shares her experiences and strategies for managing blood sugar levels while studying abroad

Like many young adults, I love to travel and will take any excuse to do so. Going into college, I knew that I wanted to study abroad; the moment I learned about my university’s semester program at their Rome campus, I was ready to go. However, traveling with diabetes isn’t always easy. The longer the trip, the more complicated it can be, and especially a trip to Italy, a country known for all of its carbohydrates!

What’s someone with diabetes to do about managing their diabetes while living in Italy?

Preparation is key!

One of the most important things I did to ensure my trip went well was put a lot of time into preparation. This means figuring out the quantity of diabetes supplies you’ll need, ordering them in advance, and finding space to pack it all. On my blog, I created a handy spreadsheet that helps you calculate exactly how much of each item you’ll need. You should start refilling your prescriptions as frequently as possible months before you travel, to make sure you stockpile enough supplies to last the whole trip. When I was preparing to go to Italy, my insurance only allowed me to order three months of supplies at one time, so I had to wait a few weeks before refilling my prescription. If you’re short on time, ask your healthcare professional if they can help you order extra supplies.

Preparation also means making back-up plans in case anything goes wrong, like talking through solutions to possible challenges. I have a great team of people that support me at home, including my parents, friends, and healthcare professionals, so before I left, I made sure I had several ways to contact them while abroad. Once I arrived in Rome, my host family, my friends, and the staff at my school became the people who could help me if I needed assistance.

Here are some things to talk about with your support team before you travel:

  • If I run out of a diabetes supply, what will I do? Can I get this supply abroad? Is having it shipped to me an option, considering what can be sent through the mail, what is allowed through customs, and the reliability of the mail system?
  • If I need to see a doctor or go to the hospital, can I find English-speaking doctors? Where is the closest hospital?
  • How does insurance work? Do I need to get special insurance while I am abroad?
  • How can I get in contact with my doctor? Can someone from my support team contact my doctor if I can’t?

Here’s a little story about how back-up supplies and my support team saved the day while I was in Rome:

About halfway through my semester, I was returning from Venice on an overnight trip and I arrived back in Rome early in the morning. I must have been sleep deprived, because I left my phone on the train! To anyone else, that would be very frustrating but manageable; most of the things people use their phones for, like email and messages, can be done on a computer. For me, it felt like a disaster, because my Dexcom G5 continuous glucose monitor (CGM) was tied to my phone. I love being able to check my blood sugar with just a glance at my phone, but without my phone, I couldn’t use my CGM. Because I’m used to constantly knowing my blood sugar, not having readings for an extended period of time was hard. Long story short, it was two days before I could get my phone back, and only with help from my support team in Rome. Thankfully, I had plenty of test strips and a blood glucose meter (BGM), so my back-up supplies came to the rescue.

Enjoy new foods, but do so in moderation.

After all my preparation, living in Rome still brought different challenges my way. Even though I wanted to experience all that Rome had to offer, I still had to keep blood sugar management in the back of my mind, especially during mealtime. Italian cuisine is full of carb-heavy foods, from pastries for breakfast to sandwiches, pizza, and pasta for lunch and dinner. Unfortunately, all these unknown carbs can make it hard to keep one’s blood sugar in range.

I didn’t want to deny myself all of the delicious, yet carb-rich, Italian foods. But I also didn’t want to drive my blood sugars out of my target range. I found that my best option was to eat these foods in moderation (just one or two bites), and fill myself up with delicious lower carb options, like vegetables and meat.

To prepare for a meal that may contain many carbs, make sure to dose extra insulin before the meal. If you end up eating more carbs than expected (which can easily happen with Italian food), the sooner you’re able to dose additional insulin – even if it means stopping in the middle of the meal to take insulin – the more quickly your blood sugars will respond.

Do some research and know what to order at restaurants.

When eating out at a restaurant, a good tactic is to order a meat, seafood, or vegetable-based dish as your main entree. Before you’re faced with ordering low-carb food in a foreign country, it’s helpful to know what you can expect from a local menu. Here’s what I learned in Italy:

  • Italian meals consist of several courses, including antipasto (appetizer), primi (the first course, typically pasta), secondi (the second course, usually meat or seafood), contorni (a side dish, usually a vegetable), and dolci (dessert).
  • Most people order either a primi or secondi as their main dish.
  • You can find the best low-carb options in the antipasti, secondi, or contorni sections of the menu.
  • If you have diabetes, ignore the primi section – it won’t be helpful for keeping your blood sugars in range.

One more tip: when you’re not sure what something is on the menu, it never hurts to ask the server or look up a picture online. This was important for me in Italy, since some of the meat dishes are breaded. I’ve included a list of my favorite low-carb Italian orders at the end of this article.

Share food with friends and family!

If you don’t want to miss out on experiencing all the pizza and pasta, get your friends to help you out. If they order a high-carb dish, ask if you can trade a few bites of your food for theirs – that way, you get to taste some pizza or pasta, while still keeping your meal low-carb. The same thing can apply to desserts, like gelato: ask a friend for a few bites, or offer to split one.

No matter what you decide to eat, just make sure you watch your blood sugars carefully, especially when trying new foods and guessing on insulin doses. Don’t let your diabetes stop you from exploring all the wonders of a new cuisine and culture, but also, don’t let impulsive food choices throw your blood sugars off. That balance can be hard to find, but do the best you can and enjoy the experience. Mangia bene (eat well)!

For more details, tips, and advice on studying abroad with diabetes, visit my blog, Winging It.

Here are some of my favorite low-carb Italian food orders, classified by course.

Antipasti (appetizers):

  • Insalata caprese (mozzarella, tomato, basil salad) – if you’re lucky, they’ll use fresh mozzarella di bufala, the most delicious cheese I’ve ever tasted!
  • Verdure grigliate misti (mixed grilled vegetables)
  • Affettato misto or salumi misti (mixed cold cuts)
  • Prosciutto (ham)

Secondi (entrees):

  • Tagliata/bistecca/filetto di manzo (beef)
  • Salsiccia (sausage)
  • Petto di pollo (chicken breast)
  • Vitella (veal)
  • Bollito alla picchiapo (beef stew in tomato sauce)

Contorni (side dishes):

  • Carciofo alla romana (roman artichoke)
  • Peperone (bell peppers)
  • Spinaci (spinach)
  • Insalata (salad)
maria horner

Image source: diaTribe

Maria Horner is a college student from Northern Virginia. She was diagnosed with type 1 diabetes at age seven, but she hasn’t let that hold her back! She had the incredible opportunity to study abroad in Rome during the fall of 2018, and recently started a blog about her experiences, to help and encourage other people with diabetes that are interested in studying abroad. When she’s not in class, you can find her taking a dance course or trying out a new recipe in the kitchen. She also loves travelling and going on adventures, one of her most recent adventures being skydiving!

Source: diabetesdaily.com

Advancements in Treatment: The Use of Adjunctive Therapies in Type 1 Diabetes

This content originally appeared on diaTribe. Republished with permission.

By Paresh Dandona and Megan Johnson

Read on to learn about the research around GLP-1, SGLT-2, and combination therapy use in type 1 diabetes. Dr. Paresh Dandona is a Distinguished Professor and Chief of Endocrinology at the University of Buffalo, and Megan Johnson is a fellow on his team

For people living with type 1 diabetes, new treatments are finally on the horizon. The University at Buffalo (UB) Endocrinology Research Center is helping to revolutionize the treatment of this condition. Among the most promising new therapies are two non-insulin medications currently used in type 2 diabetes, SGLT-2 inhibitors and GLP-1 receptor agonists.

SGLT-2 inhibitors, such as Farxiga, act the kidney to help the body excrete more glucose in the urine. Meanwhile, GLP-1 receptor agonists like Victoza work in several different ways: increasing the body’s natural insulin production, decreasing the release of the glucose-raising hormone glucagon, slowing the emptying of the stomach, and curbing excess appetite. Some people with type 1 diabetes take these medications as an addition to insulin treatment as an “off-label” drug. To learn more about off-label, check out the article: Can “Off Label” Drugs and Technology Help You? Ask Your Doctor.

Why consider these medications?

In people without diabetes, the body is constantly releasing more or less insulin to match the body’s energy needs.  People with type 1 diabetes do not make enough insulin on their own and have to try to mimic this process by taking insulin replacement – but it isn’t easy.

People with type 1 diabetes often have fluctuations in their blood sugars, putting them at risk for both low blood sugars (hypoglycemia) and high blood sugars (hyperglycemia). Many individuals are unable to manage their blood sugars in a healthy glucose range with insulin alone. In fact, less than 30% of people with type 1 diabetes currently have an A1C at the target of less than 7%.

Can GLP-1 agonists be safely used in type 1 diabetes?

Over the past decade, the endocrinologists at the University at Buffalo and other research groups have been conducting studies to see whether GLP-1-receptor agonists can safely be used in type 1 diabetes.

  • The first of these was published in 2011 and showed a decrease in A1C within just four weeks of GLP-1 agonist treatment. Importantly, people given GLP-1 agonists plus insulin also had much less variation in their blood sugars, as measured by continuous glucose monitors (CGM).
  • Another study involved 72 people with type 1 diabetes who took GLP-1 agonist or placebo (a “nothing” pil) in addition to insulin for 12 weeks. The GLP-1 group had decreases in A1C, insulin requirements, blood sugar fluctuations, and body weight. People in this group did report more nausea – a common side effect of GLP-1 agonists.
  • Since then, multiple studies, some involving over 1000 people and lasting up to 52 weeks, have shown that GLP-1 treatment in people with type 1 diabetes can reduce A1C and body weight, along with insulin dosages.

Many of these studies, but not all, have suggested that GLP-1 agonists can do this without increasing the risk for hypoglycemia or diabetic ketoacidosis (DKA). There is also some evidence that GLP-1 agonists can improve quality of life in type 1 diabetes.

Who should consider GLP-1’s?

The effects of GLP-1 agonists seem to be especially strong in individuals who are still able to make some insulin on their own, although it also works in people who do not.

In one notable study, researchers gave a GLP-1 agonist to 11 people with type 1 diabetes who were still able to produce some insulin. To get an estimate of insulin production, they measured levels of a molecule called C-peptide, which is produced at the same time as insulin. In these 11 individuals, C-peptide concentrations increased after GLP-1 treatment. By the 12-week mark, they had decreased their insulin dosage by over 60%. Incredibly, five people were not requiring any insulin at all. Even though the study was very small, the results were exciting, because it was the first study to suggest that some people with type 1 diabetes had sufficient insulin reserve and thus, could – at least temporarily – be treated without insulin.

Can SGLT-2 inhibitors be used in type 1 diabetes?

SGLT-2 inhibitors like Farxiga have also shown tremendous potential. In two large studies called DEPICT-1 and DEPICT-2, adults with type 1 diabetes were randomly assigned to take either placebo or SGLT-2 inhibitor in combination with insulin. Over 700 people from 17 different countries participated in DEPICT-1, and over 800 people with type 1 diabetes participated in DEPICT-2. At the end of 24 weeks, people taking dapaglifozin had a percent A1C that was lower, on average, by 0.4 compared to people who had received placebo, and it was still lower, by over 0.3, at 52 weeks. The number of hypoglycemic events was similar in both groups.

As with GLP-1 agonists, people taking SGLT-2 inhibitors had weight loss and decreased insulin requirements. People taking SGLT-2 inhibitor, however, did have an increased risk of diabetic ketoacidosis (DKA). If individuals consider this therapy, they should be cautious about not missing meals or insulin, and not drinking large amounts of alcohol, as these behaviors can lead to increased ketone production.

Several other research groups, in trials recruiting up to 1000 individuals, have seen similar results when using this class of medications.  Researchers have been conducting additional studies to try to determine how best to minimize the risks associated with them. Farxiga (called Forxiga in Europe) has now been approved as the first oral agent as an adjunct treatment for type 1 diabetes in Europe and Japan.

Promising Combination Therapy

Now, endocrinologists are also looking at whether GLP-1 agonist and SGLT-2 inhibitor combination therapy could increase the benefits of each of these treatments. A study conducted on a small number of people showed that GLP-1 agonists can help prevent ketone production, so it is theoretically possible that this medication could reduce the risk of DKA that was seen with SGLT-2 inhibitors.

In an early study involving 30 people with type 1 diabetes who were already on GLP-agonist and insulin were randomly assigned to take SGLT-2 inhibitor or placebo, as well. People who received both drugs saw an 0.7% reduction in A1C values after 12 weeks, without any additional hypoglycemia. People on the SGLT-2 inhibitor did make more ketones, though, and two individuals in the combination group experienced DKA. Larger studies are now being conducted to expand on these results and learn more about how to give these drugs safely. The hope is that non-insulin therapies will soon be approved for type 1 diabetes. By unlocking the potential of these therapies, we can do more than manage blood glucose levels – we can improve people’s lives.

Source: diabetesdaily.com

Prior Authorization: Getting Diabetes Supplies and Medications Covered by Insurance

This content originally appeared on diaTribe. Republished with permission.

By Divya Gopisetty

What is a prior authorization? Read on to learn more about why diabetes supplies or medications might require a prior authorization and how to go through the process

It can be frustrating to learn that you need a prior authorization when you already have a prescription. Insurance plans sometimes require a prior authorization to cover a diabetes supply, device, or medication, even if your doctor prescribed it to you.

Read on to learn about what a prior authorization is, and how you can make the submission process as smooth as possible.

In this article:

Click to jump to a specific section!

What is a prior authorization?

My pharmacist told me I need a prior authorization. What happens next?

How can I check if I need a prior authorization?

How long do prior authorizations last?

What happens if the prior authorization is denied?

What is a prior authorization?

A prior authorization, also known as a pre-authorization or pre-certification, means that your healthcare provider or device company has to get specific approval from your health insurance company (so that it will pay for it).  The requirements for prior authorization differ between and within insurance plans.

If you need a prior authorization, the pharmacist cannot process your prescription until your healthcare professional has contacted the insurance company. Similarly, a device company may not ship your diabetes device to you until it has prior authorization from the insurance company.

A prior authorization is designed to make sure certain prescription drugs or devices are used correctly and only when medically necessary. Before your insurance plan will cover a certain device or drug, you must show that you meet a set of criteria.

Prior authorizations are most often handled by your healthcare professional’s office, but sometimes are handled by the device company itself (e.g., for CGM).

If you want to see what a prior authorization request form looks like, check out this one for OptumRx.

My pharmacist told me I need a prior authorization. What happens next? 

  1. If your insurance company requires (and has not received prior authorization), your pharmacy will contact your healthcare professional.
  2. The healthcare professional will contact your insurance company and submit a formal authorization request.
  3. Your insurance plan may have you fill out and sign some forms.
  4. Your insurance plan will contact the pharmacy once it has approved or denied the request.

During this process, be sure to communicate with both your healthcare provider and your insurance company to see if they need any additional information. Prior authorizations usually take about a week to process – after that, check with your pharmacy to see if the request was approved. If the request was approved, you should be able to pick up your prescription from the pharmacy.

If it wasn’t approved, your pharmacy should be able to tell you why, and then you can decide to request an appeal.

As someone living with diabetes, you are your best advocate. Be prepared to track down the paperwork to make sure you receive the requested device or medication.

How can I check if I need a prior authorization?

Check your health plan’s policy and formulary (you can normally access these on the insurance company’s website) to see if any of your treatments require a prior authorization. Or, you can call the member services number found on the back of your insurance ID card to speak with someone directly.

How long do prior authorizations last?

Most approved prior authorizations last for a set period of time (usually one year). Once it expires, you’ll have to go through the prior authorization process again.

What happens if the prior authorization is denied?

  • You can request an appeal (which is often successful!)
  • You can pay the full cost for the medication or healthcare supply, without insurance coverage.

Want to learn more?

Check out this easy-to-read resource created by DiabetesSisters on prior authorizations, step therapy, and appeals.

What’s Worked for Other People with Diabetes? Hear from Them!

  • I was denied my first CGM in 2008 by a Blue plan and fought and won by knowing how to Google my payer’s medical policy and prove that I met coverage criteria. It helped that I was given the HCP line phone number by a nurse sympathetic to my cause, but I ended the call with an authorization code. – Melissa
  • My strategy has always been persistence pays (eventually the insurance company will give in, although they may have peculiarities to navigate. The doctor’s office is really key and many have specialists who only deal with insurance company issues [mine does]). I’ve been covered by 4 insurance companies over the past decade while at the same employer if that tells you anything about the evolving insurance market. My experience with Anthem was a hassle but predictable, United Healthcare was easiest to navigate, Aetna was straightforward but a pain and had some weird rules (Why does a precertification inexplicably expire at the end of a calendar year? My chronic illness did not expire at the end of the year.). – Scott
  • Do you have experiences with prior authorizations? Let us know!
diaTribe Series

Image source: diaTribe

This article is part of a series on access that was made possible by support from AstraZeneca. The diaTribe Foundation retains strict editorial independence for all content. 

Source: diabetesdaily.com

Benefits of Time in Range: New Study Shows Cost Savings

This content originally appeared on diaTribe. Republished with permission.

By Eliza Skoler and Albert Cai

A new paper suggests that as people with diabetes increase their time in range, healthcare costs decrease

IQVIA, a healthcare consulting firm, published a 22-page paper describing the limitations of A1C and the potential financial benefits of improving time in range, the time a person spends with blood glucose levels between 70-180 mg/dl. The paper was sponsored by Lilly Diabetes.

The paper predicts that if the average time in range for people with diabetes in the US increases to 70% or 80%, healthcare costs will be reduced. The savings could be up to $9.7 billion for the US healthcare system over ten years if the average time in range for people with diabetes is increased to 80%.

The graphic below shows how much money is saved over ten years just by reducing hypoglycemic (low blood sugar) events in people with type 1 diabetes. Other costs saving would likely come from a reduction in diabetes-related complications. Studies (Diabetes Care 2019, Diabetes Care 2018) have suggested that greater time in range is associated with a lower risk of health complications.

Stat

Image source: diaTribe

Unsurprisingly, the biggest reductions in healthcare costs were seen in people with high baseline A1C. While a 5% increase in time in range for a person with an A1C under 7% would save only $20 over ten years, the same 5% increase in time in range for a person with an A1C over 8% would lead to $1,470 in savings over ten years – mostly due to a greater reduction in the risk of diabetes-related complications. This means that to get the greatest health and cost benefits, it is essential to bring time in range practices to people who are most struggling to manage their blood glucose.

To calculate the effects of improving time in range, the study assumed an average time in range for people in the US of 58% (type 1 and type 2 diabetes). This 58% came from a 2019 review of four major CGM studies. However, these four studies were done at top diabetes centers and the participants had relatively low A1Cs (~7.5%). Additionally, the majority of people with type 1 diabetes and almost everyone with type 2 diabetes still don’t have access to CGMs. In other words, the actual population average is likely much lower than 58% time in range and the $9.7 billion calculated in cost savings would actually be much higher if the population’s time in range reached 80%.

IQVIA provides several reasons why CGM should be used to support blood glucose management in people with diabetes:

  • A person with diabetes can understand how variables like food, exercise, and sleep habits affect blood glucose and can use that information to improve decisions and outcomes.
  • Healthcare professionals can provide more individualized care to support people with diabetes.
  • The healthcare system will save money on diabetes care.

The illustration below outlines how CGM can be used to monitor blood glucose and guide shared decision making for a healthcare professional (HCP) and person with diabetes (PwD).

Stat

Image source: diaTribe

The last eight pages of the paper discuss how time in range can become more commonly used, asking policymakers, healthcare professionals, and people with diabetes to drive the time in range movement forward. IQVIA’s ideas include:

  • promoting CGM to help people measure and understand time in range;
  • educating healthcare professionals and people with diabetes about the health benefits of time in range; and,
  • tackling affordability and access issues to make sure all people with diabetes (or even prediabetes) can use CGM.

This paper not only emphasizes the importance of time in range for well-being but also highlights time in range as a public policy matter. While there is clearly much work to be done, this study is an important step in underscoring the need to bring CGM and time in range to more people.

Source: diabetesdaily.com

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