Transcript PowerPoint slides - American Association of Clinical Endocrinologists

American Association
of Clinical Endocrinologists (AACE)
American College of Endocrinology (ACE)
2016 Outpatient Glucose
Monitoring Consensus Statement
Task Force Co-Chairs
Timothy S. Bailey, MD, FACP, FACE, ECNU
George Grunberger, MD, FACP, FACE
ENDOCRINE PRACTICE Vol. 21 No. 2 February 2016 Pages 231-261.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
2016 Outpatient Glucose Monitoring Consensus
Statement Task Force Members
 Timothy S. Bailey, MD, FACP, FACE, ECNU (Co-Chair)
 George Grunberger, MD, FACP, FACE (Co-Chair)
 Bruce W. Bode, MD, FACE
 Yehuda Handelsman, MD, FACP, FACE, FNLA
 Irl B. Hirsch, MD
 Lois Jovanovič, MD, MACE
 Victor Lawrence Roberts, MD, MBA, FACP, FACE
 David Rodbard, MD
 William V. Tamborlane, MD
 John Walsh, PA, CDTC
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
AACE/ACE Glucose Monitoring Consensus
Statement Objectives and Structure
This consensus statement provides recommendations to clinicians
regarding the type and frequency of GM technology to be employed in
the management of:
T1DM
(pediatric or adult)
T2DM (with and
without insulin
therapy)
Pregnancy
complicated by
preexisting
diabetes or GDM
 This statement also
 Provides a primer on GM accuracy
 Reviews measures of glycemic control (glucometrics)
 Presents graphical methods to display glycemic data
GDM = gestational diabetes mellitus; GM = glucose monitoring; T1DM = type 1 diabetes mellitus; T2DM = type 2 diabetes
mellitus.
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May not be reprinted in any form without express written permission from AACE.
Benefits and Drawbacks of CGM
Pros
Cons
Alerts patients to
• Episodes of hypoglycemia
and hyperglycemia
• Predicted episodes of
hypoglycemia and
hyperglycemia
Issues related to
• Accuracy
• Comfort
• Convenience
• Patient acceptance
• Expense
Device displays help patients
with clinical decision making
CGM = continuous glucose monitoring.
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May not be reprinted in any form without express written permission from AACE.
Most devices require
frequent calibration
Adult Patients With T1DM
 Frequent BGM is an essential element in effective T1DM
management because it:
Detects glycemic
variability and
hypoglycemia
Informs treatment
modifications and
reflects the impact
of food intake and
physical activity1-3
Provides important
information on
treatment efficacy1,4
 All major clinical practice guidelines recommend
individualized, frequent BGM for patients with T1DM1,3-6
 CGM is particularly important for patients with a history of
severe hypoglycemia or hypoglycemia unawareness1,3,7-8
BGM = blood glucose monitoring; CGM = continuous glucose monitoring; T1DM = type 1 diabetes mellitus.
1. Joslin Diabetes Center, 2014. http://www.joslin.org/docs/Adult_guideline_-update_thru_10-23-14_2.pdf; 2. American Diabetes Association. Diabetes Care.
2015;38(Suppl 1):S1-S94; 3. American Association of Diabetes Educators. 2011.
http://www.diabeteseducator.org/export/sites/aade/_resources/pdf/general/PracticeGuidelines2011.pdf; 4. Handelsman Y. Endocr Pract. 2011;17(Suppl 2):S1-S53;
5. International Diabetes Federation. 2009. Available at: http://www.idf.org/guidelines/self-monitoring; 6. Garber AJ. Endocr Pract. 2015;21(4):438-447; 7. Blevins
TC. Endocr Pract. 2010;16(5):730-745; 8. Klonoff DC. J Clin Endocrinol Metab. 2011;96(10):2968-2979.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Pediatric Patients With T1DM
 Challenges of glycemic control in pediatric patients:
 Changing insulin requirements
 Unpredictable food intake and physical activity
 Concerns about hypoglycemic risk
 Close monitoring needed to recognize when the patient outgrows their
insulin dose(s)1
CGM should be considered for regular daily use in pediatric patients with
T1DM who perform frequent blood glucose testing and have:2
•
•
•
•
•
•
Severe hypoglycemic episodes
Hypoglycemic unawareness (especially in young children)
Nocturnal hypoglycemia
Wide glucose excursions, regardless of A1C
Suboptimal glycemic control, with A1C exceeding target range
A1C levels <7%, to maintain target glycemic control while limiting hypoglycemia risk
T1DM = type 1 diabetes mellitus; A1C = glycated hemoglobin; CGM = continuous glucose monitoring.
1. Niedel S. J Health Services Research Policy. 2013; 2. Phillip M. Pediatr Diabetes. 2012;13(3):215-228.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Adult Patients With T2DM
 BGM should be individualized and accessible to all patients
receiving any therapy for T2DM1
Patients receiving non-insulin agents
associated with hypoglycemia:
• Perform BGM at least once daily (fasting)
and periodically at other times
Patients at low risk for increased
hypoglycemia risk and not at goal:
•
Perform structured testing (eg, before
meals and at bedtime) at least weekly
 Limited data on the use of real-time CGM in patients with
T2DM, although available evidence is promising2-3
 Trials are ongoing to evaluate the potential use of CGM
(masked or unmasked) in patients with T2DM
BGM = blood glucose monitoring; CGM = continuous glucose monitoring; T2DM = type 2 diabetes mellitus.
1. International Diabetes Federation. 2009. Available at: http://www.idf.org/guidelines/self-monitoring; 2. Vigersky RA. Diabetes Care.
2012;35(1):32-38; 3. Tildesley HD. Can J Diabetes. 2013;37(5):305-308.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Adult Patients With T2DM
BGM is recommended for patients not taking insulin if1
• Patients and/or caregivers have knowledge, skills, and willingness to
incorporate BGM and therapeutic adjustments into diabetes care plan
• Protocols are individualized to meet patient educational/behavioral/clinical
requirements and have been agreed upon by the patient and clinician
If the patient is on insulin therapy, BGM should be tailored by therapy type
• Patients taking prandial and basal insulin should perform BGM when fasting,
premeal, at bedtime, and periodically during the night
• Patients taking only basal insulin (with or without other diabetes medications)
should perform BGM at minimum when fasting and at bedtime
BGM = blood glucose monitoring; T2DM = type 2 diabetes mellitus.
1. International Diabetes Federation. 2009. Available at: http://www.idf.org/guidelines/self-monitoring; 2. Polonsky WH. Diabetes Care.
2011;34(2):262-267.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Pregnancy Complicated by Diabetes
 BGM is integral to diabetes management in pregnancy1
 Real-time results enable women to make informed daily
self-care decisions regarding diet, exercise, and insulin
 Retrospective analysis of BGM data helps to:

Enable clinicians to develop individualized care plans2

Inform decisions related to insulin initiation and adjustment

Recognize the need for interventions to improve self-monitoring3
 Potential benefit of CGM in pregnant women with preexisting
diabetes is unclear
BGM = blood glucose monitoring; CGM = continuous glucose monitoring.
1. Jovanovic L, Pending publication; 2. Boutati EI. Diabetes Care. 2009;32(Suppl 2):S205-S210; 3. Jovanovic L. Personal communication.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Pregnancy Complicated by Diabetes
GDM managed
with MNT
• Check blood glucose levels 4 times per day:
• Before breakfast (fasting) and after 3
largest meals of the day
Preexisting
diabetes
• Before attempting to become pregnant,
maintain glycemic control as close to normal
as possible for 3 to 6 months1
Diabetes
managed with
insulin
• Monitor glucose both before and after each
meal (ie, at least 6 times per day)
GDM = gestational diabetes mellitus; MNT = medical nutrition therapy.
1. American Diabetes Association. Diabetes Care. 2004;27(Suppl 1):S88-S90.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Glucose Monitoring Accuracy and Precision
 Accuracy is defined as the closeness of agreement between a
glucose test result and an accepted reference value
 Accuracy improves when it has minimal bias and relative error
(%CV, MARD, and minimal absolute error)
 Point accuracy refers to blood glucose values and sensor readings
at single points in time
Bias: systematic error in meter or
sensor measurements
Precision: measurement reproducibility
(irrespective of accuracy)
 Measurements may cluster around
 May be due to improper calibration,
an erroneous value
 It is possible to derive a measure of
precision without knowing the true
value
lack of calibration, or calibration with
an inaccurate BGM
 May vary depending on the glucose
levels being measured
BGM = blood glucose monitoring; CV = coefficient of variation; MARD = mean absolute relative deviation.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Measures of Accuracy for BGM and CGM
Arithmetic deviation
• The difference between true value and measured value
Absolute deviation
• The absolute value of the arithmetic deviation
Absolute relative deviation (ARD)
• The absolute deviation in relation to true value
Mean absolute relative deviation (MARD):
• The mean value of individual absolute relative
deviations
Median absolute relative deviation (MedARD):
• The median value of individual absolute relative
deviations
BGM = blood glucose monitor/monitoring; CGM = continuous glucose monitor.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Measures of Accuracy for BGM and CGM: MARD
 This graph shows an example of accuracy results and how MARD
values for CGM can vary systematically by day (eg, day 1 vs day 3 vs
day 7)1
 Display shows:
 Mean (diamonds)
 Median (horizontal
lines within boxes)
 25th and 75th
percentiles (lower
and upper box edges)
 Minimum and
maximum values
(antennae)
BGM = blood glucose monitor; CGM = continuous glucose monitor; MARD = mean absolute relative deviation.
1. Pleus S. J Diabetes Sci Technol. 2013;7(4):833-841.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Understanding Clinical Standards for Accuracy of
Current BGMs and CGMs: Error Grids
 The Parkes Error Grid (2000)1 is
one way to measure accuracy
 Grid regions reflect the potential
risk severity of incorrect
treatment triggered by the
measurement error
 Device performance typically
reported as percentage of glucose
values in zone A or zones A + B
(higher percentages indicate
better performance)
BGM = blood glucose monitor; CGM = continuous glucose monitor.
1. Parkes JL. Diabetes Care. 2000;23(8):1143-1148.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Understanding Clinical Standards for Accuracy of
Current BGMs and CGMs
ISO Meter Approval Standards
ISO 15197 20131 <100 mg/dL
(<5.55 mmol/L)
≥100 mg/dL
(≥5.55 mmol/L)
±15 mg/dL
(±0.83 mmol/L)
95%
±15%
 Both FDA and ISO standards allow 5% of meter values to be outside limits
 99% of values must be within Consensus Error Grid zones A or B
BGM = blood glucose monitor; CGM = continuous glucose monitor; FDA = US Food and Drug Administration; ISO = International
Organization for Standardization.
1. International Organization for Standardization. 2013. Available at: http://www.iso.org/iso/catalogue_detail?csnumber=54976.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Understanding Clinical Standards for Accuracy of
Current BGMs and CGMs
FDA Draft Guidance
(2014)1
50-400 mg/dL
±15%
(2.8-22.2 mmol/L)
95%
±20%
errors in the hypoglycemic
range and fewer outliers
 Testing should be performed
by non-trained people2
 If devices are only tested by
and
50-400 mg/dL
(2.8-22.2 mmol/l)
 The draft proposes smaller
99%
trained technicians, greater
accuracy might be seen than
when used by untrained
people
BGM = blood glucose monitor; CGM = continuous glucose monitor; FDA = US Food and Drug Administration.
1. US Food and Drug Administration. 2014. Available at:
http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM380327.pdf; 2. Freckmann G,
Schmid C. J Diabetes Sci Technol. 2015;9(4):885-894.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Clinical Situations Requiring Increased Accuracy
Patients Requiring the Highest Possible
Accuracy in Glucose Monitoring
History of severe hypoglycemia
Hypoglycemia unawareness
Pregnancy
Infants and children receiving insulin therapy
Patients at risk for hypoglycemia, including:
• Patients receiving basal insulin
• Patients receiving basal bolus insulin therapy with multiple daily injections
• Patients receiving sulfonylureas or glinides (insulin secretagogues)
• Patients with irregular schedules, skipped or small meals, vigorous
exercise, travel between time zones, disrupted sleep schedules, shift work
People with occupational risks that enhance possible risks from hypoglycemia (for
example, driving or operating hazardous machinery)
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May not be reprinted in any form without express written permission from AACE.
What Impacts BGM Accuracy?
 Manufacturing defects and test-strip lot-to-lot variations
impact BGM accuracy and introduce bias with differences
up to 11%1-3
 Underfilling the test strip can introduce errors >20%4
 Use of alternate sites (sampling from palm, upper arm,
forearm, thigh, or calf) can generate inaccurate results
 Particularly true when glucose levels are changing rapidly



after meals or exercise
when the patient is ill or under stress
shortly after insulin administration5,6
BGM = blood glucose monitor.
1. Baumstark A. J Diabetes Sci Technol. 2012;6(5):1076-1086; 2. Kristensen GB. Clin Chem. 2005;51(9):1632-1636; 3. Brazg R. J Diabetes Sci
Technol. 2013;7(1):144-152; 4. Pfutzner A. J Diabetes Sci Technol. 2013;7(6):1522-1529; 5. US Food and Drug Administration. 2014. Available
at: http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM380327.pdf; 6. Riddle MC.
Diabetes Care. 2010;33(5):983-990.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Other Factors Affecting Test Results
 Factors that interfere with glucose oxidase or glucose-1-
dehydrogenase enzyme or BGM degrade overall accuracy:
 Competing blood substrates (eg, maltose, vitamin C)1,2
 Environmental issues (eg, cold temperature, high altitude)
 Contaminants on the skin from food sources and lotions3
 Acetaminophen use
 Physical compression of the CGM sensor during sleep4,5
 Reduced accuracy and precision in tests performed by
patients/other lay users compared with trained health
professionals6
BGM = blood glucose monitor; CGM = continuous glucose monitor.
1. Dungan K. Diabetes Care. 2007;30(2):403-409; 2. Vasudevan S. Diabetes Care. 2014;37(5):e93-e94; 3. Ginsberg BH. J Diabetes Sci Technol.
2009;3(4):903-913; 4. Freckmann G. Diabetes Technol Ther. 2014;16(2):113-122; 5. Helton KL. J Diabetes Sci Technol. 2011;5(3):647-656; 6.
Kilo C. Diabetes Technol Ther. 2005;7(2):283-294.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Communicating BGM Device Accuracy Data
Sample label information for meter and test-strip boxes
 Recent FDA proposed
guidance document
suggests labeling each
BGM device and its
test strips or sensors
with specific
performance
characteristics2
 This allows clinicians
and patients to make
informed choices
Your ABC meter result may vary slightly from your actual blood glucose value. This may
be due to slight differences in technique and natural variation in the testing technology.
The chart below shows the results of a study where 350 typical users used the ABC
meter to test their blood glucose levels. For example, in this study, the ABC meter gave
results within 15% of their true blood glucose level 340 out of 350 times.
Difference in range between the
true blood glucose level and the
ABC meter result
The percent (and number) of
meter results that match true
blood glucose level with x%
Accuracy levels
Within
Within
Within
Within
5%
10%
15%
20%
57%
94%
97%
100%
(200/350)
(330/350)
(340/350)
(350/350)
Meter results meeting
standard
Percentage of meter values
compared to laboratory values
Accurate
350 out of 350
±15%
More Accurate
262 out of 350
±10%
Most Accurate
175 out of 350
±5%
BGM = blood glucose monitor; FDA = US Food and Drug Administration.
1. US Food and Drug Administration. 2014. Available at:
http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM380327.pdf.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Improving the Quality of Glycemic Control:
More Than Measurement Accuracy Is Needed
 Features that provide additional information and give context to raw
glucose numbers include:
 Weekly or monthly glucose averages to highlight glycemic variability patterns
 On-screen analysis capabilities display glucose trend lines over time, and
arrows reflect magnitude of current glucose rate-of-change
 BGM clock setting must be accurate, clearly visible, easy to adjust, and
maintained during battery change1
 Clocks in meter, CGM, and insulin pump should be synchronized (automatically
if possible), with accommodation for travel across time zones
 To effectively use these informative features, many users will require
guidance
 Clinicians should consider ease and speed of BGM data downloading
BGM = blood glucose monitor; CGM = continuous glucose monitor.
1. Crowe DJ. Diabetes Technol Ther. 2005;7(5):663-664.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Post-approval Meter Accuracy
 Independent laboratories should confirm ongoing routine
quality assurance verification of test-strip lots using a
standardized methodology1
 Studies confirm:
 Review of post-approval accuracy of 27 meters under 2003 ISO
15197 standard; >40% of meters failed to meet standard by which
they had received approval2
 2014 study found only 12 (44.4%) of 27 available BGMs met most
recent 2013 ISO 15197 standard3
 FDA approval does not mean a BGM will continue to meet
FDA accuracy requirements
BGM = blood glucose monitor; FDA = US Food and Drug Administration; ISO = International Organization for Standardization.
1. Klonoff DC. J Diabetes Sci Technol. 2013;7(4):1071-1083; 2. Freckmann G. Diabetes Technol Ther. 2010;12(3):221-231; 3. Hasslacher C.
J Diabetes Sci Technol. 2014;8(3):466-472.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Glucometrics: Downloading and Interpreting
GM Data
 Glucometrics is the analysis and display of glucose data1 and can
provide insights into how medications, diet, stress, and activity
contribute to diabetes control2,3
 Patient-to-health care team communication methods can include:
 Logbook during office visit
 Computer outputs
 Periodic phone calls, faxes, or emails to office
 Automated transfer from meter or sensor to Internet for review
 Automated interpretation by glucose monitoring device
 Glucose and related data should be integrated with an electronic
health record
GM = glucose monitoring.
1. Rodbard D. Diabetes Technol Ther. 2009;11(Suppl 1):S55-S67; 2. Bailey TS. Diabetes Technol & Ther. 2007;9(3):203-210; 3. Rodbard D.
J Diabetes Sci Technol. 2007;1(1):62-71.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Representing Glucometric Data
 Mean, median, and %CV metrics describe overall
glycemia
 Average glucose level may represent the mean or median
 The SD of glucose is highly correlated with mean glucose

%CV is usually the best method to characterize variability1-6
 Other methods describe actionable patterns to help
clinicians optimize diabetes therapy
 In graphical presentation, “standard day,” “modal day,”7,8 or AGP
displays individual glucose measurements (pooled over multiple
days) by time of day on a single 24-hour scale
AGP = ambulatory glucose profile; CV = coefficient of variation; SD = standard deviation.
1. Kaufman FR. Diabetes Care. 2001;24(12):2030-2034; 2. Potts RO. Diabetes Metab Res Rev. 2002;18(Suppl 1):S49-S53; 3. JDRF. Diabetes
Tech & Ther. 2008;10(4):310-321; 4. Rodbard D. Postgrad Med. 2011;123(4):107-118; 5. DeVries JH. Diabetes. 2013;62(5):1405-1408; 6.
Rodbard D. J Diabetes Sci Technol. 2015;9(1):56-62; 7. Mazze RS. Diabetes Care. 1987;10(1):111-117; 8. Rodbard D. Diabetes Care.
1988;11(Suppl 1):S54-S61.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Standard or Modal Day
 The “Standard Day” or “Modal Day” graph indicates both glucose
values and times of day when monitoring occurs
 Facilitates detection of consistent patterns in glucose excursions
 Provides assessment of glucose monitoring adequacy
 Generally shows glucose values by time of day but can show them in
relation to meals
Glucose Profile by Time of Day1
Glucose in Relation to Meals2
1. Rodbard D. J Diab Sci Technol. 2009;3(6):1388-1394; 2. Pernick N. Diabetes Care. 1986;9(1):61-69.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Ambulatory Glucose Profile
 To generate AGP:
 Blood glucose levels are measured via BGM or CGM
 All glucose data pooled and analyzed as if it had been collected during a single
24-hour period
 Result is a standardized software report that can be displayed graphically
 AGP provides an excellent starting point for a standardized computerized
display of BGM and/or CGM data by time of day1-3
Patient With Normal Glucose Tolerance
Patient With T1DM
AGP display for
multiple days of
CGM data with
estimates of 10th,
25th, 50th, 75th,
and 90th
percentiles
AGP = ambulatory glucose profile; BGM = blood glucose monitor; CGM = continuous glucose monitor; T1DM = type 1
diabetes mellitus
1. Bergenstal RM. J Diabetes Sci Technol. 2013;7(2):562-578; 2. Rodbard D. J Diabetes Sci Technol. 2015;9(1):56-62; 3. Mazze RS.
Diabetes Care. 1987;10(1):111-117.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Graphic AGP Display: T2DM
Patient With T2DM
 The solid curve in the
middle represents the
smoothed median
glucose (50th
percentile) values for
a 24-hour period
 The striped, shaded
area shows the
presumptive target
range (70-180 mg/dL
or 3.9-10 mmol/l)
AGP = ambulatory glucose profile; CGM = continuous glucose monitor; IQR = interquartile range; T2DM = type 2
diabetes mellitus.
Bergenstal R. J Diab Sci Technol. 2013;7(2):562-578.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Other Graphical Displays of Glucometric Data
 Other ways that graphic
data related to glucose
changes over time can be
displayed
 Pie graphs
 Simple bar charts
 Box plots
 Scattergrams
 Stacked bar charts
 Histograms
 The purpose of these displays is to help clinicians identify and
prioritize clinical problems and educate and motivate the
patient to achieve improved glycemic control
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Recommendations
 Patients should be educated to interpret and use GM data to:
 Enhance their ability to self-adjust therapy
 Decide when to seek medical assistance
 To assess glucometrics, physicians should first examine:
 Overall statistics (mean, SD, %CV)
 Distribution of glucose values
 Glucose by date, by time of day and in relationship to meals, and by
day of the week
 The most helpful glucometric graphical displays show:
 Graphs of glucose by date
 AGP by time of day
 Stacked bar charts and/or box plots by time of day, in relation to
meals, and by day of the week
AGP = ambulatory glucose profile; CV = coefficient of variation; GM = glucose monitoring; SD = standard deviation.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.
Glucose Monitoring, Looking Forward
 Improvements in progress
 Data-sharing via the Internet
 Use of additional displays
 Improved usability
 Comprehensive and standardized integration of multiple
data inputs
 Several mobile health applications have been developed,
enabling patients to monitor and adjust their lifestyle and
therapy on a real-time basis
 CGM developments may broaden the appeal and
applicability of CGM in T1DM and T2DM
CGM = continuous glucose monitoring; T1DM = type 1 diabetes mellitus; T2DM = type 2 diabetes mellitus.
Copyright © 2016 AACE.
May not be reprinted in any form without express written permission from AACE.