Continuous Glucose Monitors (recent reports) Video
(Top Posts - Science - 060509, updated 071409)

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Summary of posts I made from April 30, 2009
-to- June 5, 2009, pertaining to Continuous
Glucose Monitors and how a recent (April 26,
2009) event + the accumulation of almost 50
years of treatment for type 1 diabetes have
impacted yours truly:

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Some optimistic views, along with a skeptical
view, on where this technology currently stands
and where it may be going regarding reducing
A1c levels -and- reducing  incidents of hypo-
glycemia:

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First, a skeptical view:

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Continuous Glucose Monitoring Technology: Promising
New Tool For Maintaining Optimal Glucose Control
ScienceDaily (June 2, 2009)
  http://www.sciencedaily.com/releases/2009/05/090529112532.htm
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Excerpt:

...

"Do We Really Need Continuous Glucose Monitoring?"
Anne Peters, MD, from the University of Southern
California Keck School of Medicine (Los Angeles),
points out some of the drawbacks of current CGM
technology: for example, the devices are "finicky and
require care and calibration leading patients to use
them infrequently"; "few physicians know how to
interpret the data"; and "CGM devices have not
been shown to reduce rates of severe hypoglycemia."

[that statement is in contradiction with the following
report that offered a much more optimistic view on
the current positive impact of Continuous Glucose
Monitors]
    http://www.sciencedaily.com/releases/2009/05/090527151140.htm

...

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An upbeat view:

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DIABETES TECHNOLOGY & THERAPEUTICS
Volume 11, Supplement 1, 2009
Mary Ann Liebert, Inc.
DOI: 10.1089=dia.2008.0105

Editorial
The Future of Continuous Glucose Monitoring
  http://www.liebertonline.com/doi/pdfplus/10.1089/dia.2008.0105
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Excerpt:

...

Many subjects with diabetes are likely to benefit from this
technological advance. Patients with higher A1c levels will
likely see a drop in A1c values because of altered behavior in
response to constant information of higher glucose values.
However, subjects with lower A1c levels will notice value in
decreasing time spent in hypoglycemia by using CGM. Of
course, not all patients will benefit from early adoption of this
technology, which is still clearly in its early phases. However,
as CGM matures it is hoped to have greater penetration into
the world of type 1 diabetes.

...

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An exciting optimistic view:

A comprehensive history on the development of Continuous
Glucose Monitors which ends with an exiting optimistic view
of where all this will (in the near future?) eventually end up:

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DIABETES TECHNOLOGY & THERAPEUTICS
Volume 11, Supplement 1, 2009
Mary Ann Liebert, Inc.
DOI: 10.1089=dia.2009.0045

Editorial
Continuous Glucose Monitoring: An Overview
of Its Development
  http://www.liebertonline.com/doi/pdfplus/10.1089/dia.2009.0045
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Ending excerpt:

...

Even though today all CGM devices are approved as
adjunctive (must cross-check with fingerstick glucose
values), it is my hope and sincere belief that these
devices will become available as stand-alone in the
near future. It is a non-stop evolution that eventually
will result in a cure for this disease.

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Continuous Glucose Monitoring Devices
Benefit People With Type 1 Diabetes
  http://www.sciencedaily.com/releases/2009/05/090527151140.htm
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Complete article:

ScienceDaily (May 27, 2009) - People with type 1 diabetes
who have already been successful in achieving recommended
blood sugar goals can further benefit from using continuous
glucose monitoring (CGM) devices, according to results of
a major multi-center clinical trial by the Juvenile Diabetes
Research Foundation.

According to the JDRF study, using CGM devices enables
people who have achieved excellent control (with HbA1c
levels below 7 percent) to continue to tightly manage their
diabetes while cutting down on the frequency of low blood
sugars, called hypoglycemia. 

Research has shown that good blood sugar control is a key
factor in reducing the risk of the devastating long-term com-
plications of the disease, such as blindness and kidney disease
 -- but that the fear of low blood sugar emergencies often pre-
vents many people from achieving tight control, and remains
a constant concern for those who manage their diabetes well. 

The landmark Diabetes Control and Complications Trial (DCCT)
showed that with intensive insulin therapy, excellent blood glu-
cose control was obtained, but at the expense of a considerable
increase in hypoglycemia.  Today, the JDRF study has shown
that, with CGM, hypoglycemia can be reduced while maintaining
excellent blood sugar control.

...

Participants all had good diabetes control when they enrolled in
the trial, and were randomly assigned to either a group that used
CGM devices or one using standard finger-stick glucose testing
for 26 weeks. Findings of the study were published online by the
journal Diabetes Care.

"The research suggests that CGM devices helped people who
were already doing an excellent job of managing their diabetes
continue to do so, while lowering the risk of pushing their blood
sugar so low it causes hypoglycemia, which can be life threatening,"
said Dr. Bruce Bode, Atlanta Diabetes Associates and one of the
lead authors of the Diabetes Care paper. 

"These trials are showing that CGM not only helps people get into
control, which can have a significant positive impact on lowering
the risk of complications, but it enables them to stay in control
without increasing the near-term risk of hypoglycemia.  That's ter-
rific news for people with diabetes and their families."

(People with diabetes try to maintain their blood sugar levels be-
tween 70 mg/dL and 180 mg/dL.  When blood sugar becomes
very low, people can become confused, lethargic, and even slip
into a coma or die.  Very high blood sugars can also be dangerous. 
And long term, lack of control increases the risk of developing
devastating complications, including eye, kidney, nerve, and heart
disease. HbA1c is a measure of long term blood sugar control;
standards of good control are generally below 7% for adults, and
below 7.5% to 8% for children, depending on age.  According to
the DCCT findings, every one point reduction in HbA1c reduces
the risk of long-term complications by approximately 40%.)

According to the study, for the people using CGM devices the
time the blood sugar level was below 70 mg/dL decreased by 37
minutes a day.  This compared with a decrease in the control
group of only 5 minutes a day.  In other words, people in the
CGM group spent almost two hours more time per day in the
target blood sugar range of 71 to 180 mg/dL compared with
the control group, and about half an hour less time per day with
glucose values in the potentially dangerous hypoglycemia range. 

...

Encouragingly, similar beneficial results were seen in children,
adolescents, and adults spanning the ages of 8 to 69 years.

...

The study is the second major publication resulting from JDRF's
groundbreaking CGM trials, established to clinically document the
benefits of CGM devices in helping people with type 1 diabetes
manage their disease more effectively. 

In results published last fall in The New England Journal of Medicine,
the JDRF Continuous Glucose  Monitoring Study Group reported
that CGM substantially improved blood sugar levels without increasing
the frequency of hypoglycemia in adults over 25 years of age in a ran-
domized trial of 322 adults and children with type 1 diabetes and
HbA1c levels above 7 percent. 

(Like virtually every other study of a new drug or device in the treat-
ment of type 1 diabetes, because lowering of HbA1c was the primary
outcome of interest, that study excluded individuals already reaching
target HbA1c levels lower than 7 percent.  As a result, the study group
also conducted a separate, concurrent randomized trial to evaluate the
efficacy and safety of CGM in adults and children with type 1 diabetes
who already had successfully achieved HbA1c levels less than 7 per-
cent with intensive insulin therapy.) 

Dr. Kowalski noted that over the past 15 years, the use of rapid and
long-acting insulin analogs, improvements in insulin pumps, and more
frequent home blood glucose monitoring have had a positive impact
on the ability of people with type 1 diabetes to achieve blood sugar
control targets.  However, the rates of severe hypoglycemia remain
too high and the occurrence of such events is often followed by a
decline in glycemic control due to fears of further hypoglycemic epi-
sodes. 

Hypoglycemia remains the major limiting factor for people with type 1
diabetes in trying to achieve and maintain good blood sugar control. 

These study results are extremely encouraging in showing that hypo-
glycemia can be reduced without sacrificing glycemic control.

About Type 1 Diabetes

Type 1 diabetes is an autoimmune disease that affects children, adoles-
cents, and adults, in which the immune system attacks cells in the pan-
creas that produce insulin, a hormone that enables people to convert
food into energy.  People with type 1 diabetes are dependent on insulin
for the rest of their life. 

But insulin is not a cure, and people with diabetes are at significant risk
for a wide range of serious complications, including heart disease, blind-
ness and kidney disease. 

As many as 3 million people in the U.S. have type 1 diabetes.   

About CGM Devices

CGM devices, manufactured by several companies and approved by
the FDA as an adjunctive therapeutic for diabetes, provide both a real-
time snapshot of the glucose levels of a person with diabetes, as well
as trend information on whether glucose is moving upwards or down-
wards, and how fast. 

Devices also provide warnings when the glucose is becoming too high
or too low.

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Post I made on May 6, 2009:

Continuous Glucose Monitor / Hypoglycemia / Insulin / Glucagon

Update 2 -- Continuous Glucose Monitor (CGM) /
Hypoglycemic Status

After a visit to a doctor, major changes to my insulin
therapy are going to be embarked on, with the goal
being 100% avoidance of hypoglycemia, while main-
taining or reducing my excellent HbA1C levels.

This is the first time I'd gotten an HbA1C level since
1995 or so, and then, the doctor was surprised my
level was so good being that I didn't fit the normal
model of how to manage the disease. I don't recall
what that level was, but yesterday, it was 6.7, indicat-
ing good diabetic control (at least as pertains to
HbA1C) over a long period of time (also explains
why I've had no complications after almost 50 years
of having type 1 diabetes, since the age of 5).

I'm switching to new insulins (I've been using NPH
and Regular since 1960) to both attempt better con-
trol and to maintain or reduce HbA1C while at the
same time avoiding hypoglycemia. That's the goal,
anyway, and in that regard, it appears that a Contin-
uous Glucose Monitor is well-advised.

Here's an interesting article on a type 1 diabetic race
car driver who's using Levemir & Novolog flex pens
in a manner similar to what I'm about to embark on:
  http://sev.prnewswire.com/null/20090414/NY9837314042009-1.html

Here's a quick run-down on 4 continuous glucose
monitors. The DexCom Seven is now the DexCom
Seven Plus, with more features than those that are
listed.
  http://www.diabetesnet.com/diabetes_technology/continuous_monitoring.php

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Interesting 29 minute video on Continuous
Glucose Monitors:
  http://www.youtube.com/watch?v=q_mZPpCKKH0

Taking Control of Your Diabetes
Continuous Glucose Monitoring




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For "All You Ever Wanted to Know About Continuous
Glucose Monitors, but Were Afraid to Ask", the follow-
ing 1 hour video tells the tale. A thorough discussion of
the JDRF study which recommends Continuous Glucose
Monitors for type 1 diabetics to both lower HbA1C levels
and reduce incidents of hypoglycemia, as well as some
helpful insight into how to use the CGM device (of note,
acetiminophen is verboten):
  http://www.researchchannel.org/mov/uw_lab_glumon_1300k_qt.mov

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Update (071409)

The next step in type 1 diabetes management, the artificial
pancreas, currently in test trials:

Artificial Pancreas May Free Diabetics
From Constant Glucose Monitoring




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The JDRF Artificial Pancreas Project  >
Continuous Glucose Monitor (CGM)
  http://tinyurl.com/JDRF-ContinuousGlucoseMonitors

Continuous Glucose Monitor (CGM)

Continuous glucose monitor (CGM) is a device for people
with diabetes that provides continuous "real-time" readings
and data about trends in glucose levels.

This can allow people with diabetes to understand the level
of their glucose and whether it is rising or falling, and to
intervene by eating food or taking insulin to prevent it from
going too high or too low.

To date, continuous glucose monitors from three companies
have been approved by the FDA, and a major clinical trial
funded by JDRF has found that people with type 1 diabetes
who use CGM experience significant improvements in blood
sugar control.

Additional information:

    * Results of JDRF's CGM Human Clinical Trial
       http://tinyurl.com/JDRF-CGMsHumanClinicalTrial

    * Join JDRF's CGM Coverage Campaign
       http://www.jdrf.org/cgmcoverage

    * Read JDRF's Position Statement on CGM Coverage by
       Health Insurers
       http://www.jdrf.org/index.cfm?page_id=111283

    * Read an article about CGM in the American Association
       of Clinical Endocrinology publication, First Messenger.
       http://www.aace.com/pub/fm/JanFeb09fm.pdf

    * JDRF CGM Trial Named One of Top Medical Break-
       throughs of 2008
       http://www.jdrf.org/index.cfm?page_id=111318

For more information about specific continuous glucose moni-
toring (CGM) devices, click on the links below:

    * Abbott FreeStyle Navigator® Continuous Glucose Monitoring
       System
       http://www.freestylenavigator.com/en_US/application/html/freestyle-navigator.htm

    * DexCom SEVEN® Plus
       http://www.dexcom.com/

    * Medtronic MiniMed Paradigm® REAL-Time Insulin Pump
       and Continuous Glucose Monitoring System
       http://www.minimed.com/products/insulinpumps/index.html

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Brief Explanation of Hypoglycemic Unawareness Causality

Caused by the liver shutting down its administration of glucagon,
which raises blood sugar, if it experiences too much in the way
of highs and lows. I've already found that this may be a result
of having the disease for a long time, but in any case, with this
new intensive therapy, 4 shots per day + either manual testing
every two hours or automatic testing all day, verifying that blood
sugars are within acceptable ranges, if it is reducable, the hypo-
glycemic unawareness, we'll see if that improves.

Needless to say, a Continuous Glucose Monitor would be ex-
tremely well-advised, medically speaking, in my case, having had
at least 7 instances of emergency care caused by hypoglycemia
in the past four years.

That, of course, doesn't include the multiple night-time hypos
when emergency care wasn't solicited, one in which a scar on
my forehead was the noticable result, or the daytime hypos when
co-workers interceded without requiring intervention from emer-
gency care.

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Study Pinpoints Role of Insulin on Glucagon Levels

An interesting article I was working on back on
April 7, 2009, which addresses why my type 1
diabetes, having it for so long, has lowered my
ability to sense low blood sugar:

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April 7, 2009

Summary of research results:

Insulin -- blood sugar reducer.

Glucagon -- blood sugar increaser.

Type 1 diabetes -- impact of insulin injec-
tions over many years suppresses the re-
lease of glucagon, thereby increasing the
chances of hypoglycemia.

So, a side impact of long-term type 1
diabetes (a condition I've had for over
48 years) is that my risk of hypoglycemia
has increased, and the following article
explains why that has occurred:

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Study Pinpoints Role of Insulin on Glucagon Levels
  http://www.newswise.com/articles/view/550742/
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Excerpt:

Researchers at the Joslin Diabetes Center
have shown for the first time that insulin
plays a key role in suppressing levels of
glucagon, a hormone involved in carbo-
hydrate metabolism and regulating blood
glucose levels.

The study helps in the understanding of
why those with diabetes have high blood
glucose levels and could lead to develop-
ment of a drug aimed at targeting glucagon
levels.

Produced by the alpha cells in the pancreas,
glucagon acts on the liver to help raise blood
glucose when it becomes low.

It has the opposite effect on the liver as insulin,
which is released from pancreatic beta cells to
lower blood glucose when it is high.

In a healthy individual, the two counter each
other to keep blood glucose levels balanced.

...

In addition, the research may also help in the
understanding of why patients with type 1
diabetes in particular, who are required to
inject insulin on a regular basis, are at risk
for hypoglycemia. It was thought that this
increased risk was linked in some way to
insulin receptors in the alpha cells, an idea
that today's study suggests is in fact the
case, Dr. Kulkarni explained.

"This gives us some insight into the cause
of hypoglycemia, the most common com-
plication in patients with type 1 diabetes,"
he said. "Injecting insulin leads to a decrease
in blood glucose. If it starts to go too low,
glucagon normally kicks in to prevent hypo-
glycemia.

But, what happens in diabetes is the alpha
cells become desensitized by repeated
insulin injections over many years and
they start to behave abnormally. We
believe this is linked to insulin receptor
function."

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Excerpt from post I made on May 2, 2009:

Update -- Continuous Glucose Monitor (CGM) / Hypoglycemic Status

Still in the early stages of ascertaining how to go
about getting a CGM. Don't know if or how much
of it would be covered under my health care plan.

For my European friends, in America, health care
for most isn't covered by national health insurance,
so for those who have health care, it's a matter of
satisfying individual health care providers require-
ments to ascertain what is/is not covered and how
much (if any) is provided for any health care treat-
ment.

Any way, the biking thing, my stamina is beginning
to build up, and no hypoglycemia since the one that
caused the cop to dissuade me from driving (i.e.,
saying my drivers license was revoked, though I
have yet to receive a letter confirming that, but I
suspect it's on the way).

If the CGM is the answer, in my case, it would be-
hoove society to facilitate getting one of those, but
it is America I live in, after all, and I'm doubtful that
much, if any, of that will be covered under the health
plan. In any case, unless someone has testimony that
they experienced disappointment with a CGM, I'm
optimistic that that (along with a change in my insulin
treatment, along with any medication or treatment
that I'm unaware of that might increase my hypo-
glycemic awareness to levels I used to have, and it
doesn't appear there is any that would work in my
case, being that I've had the disease for almost 50
years) is the ideal solution.

I suppose, I'm discovering something about the long-
term consequences of having type 1 diabetes since
age 5 that I didn't expect, that being the decrease in
hypoglycemic awareness, and the fact that society
reacts with a stick rather than a helping hand regarding
such matters, but whatever, since I'm before forced
to deal with the stick, I'll do so by trying to submit to
their will (although, there is that option of dropping out,
and I'm unsure, right now, if I even have it in me, the
submission thing, but I'm trying to do it), and looking
for any helping hands that may be extended.

As for the despair I mentioned recently, I think that's
lifting, but it is a very stressful time, and I admit I'm
at risk until these major league life-impacting events
are resolved in some positive way. I did have a spark
of optimism this morning, so that's welcome, even
if it's unjustified based on my present status.

Once again, anyone having any helpful suggestions,
please share. Thanks in advance.

...

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Excerpts from two posts I made on April 30, 2009:

How many blood sugar tests do you do per day?

For those who 'depend' on blood sugar testing for so-
called control, some information from a video I recently
viewed might give you pause to reconsider your reliance
or confidence in that.

A blood sugar test is a photograph of an instance in time.
An instance. Your blood sugar varies over a 1,440 minute
day, from minute to minute.

For 'normal' non-diabetic people, every second of every
minute of every hour of every day, their pancreas is mon-
itoring and responding to blood sugar levels. For diabetics
who supposedly depend on blood sugar tests for so-called
control, your information reflects photographs of blood
sugar which may deviate, dramatically, from what your blood
sugar is doing in all the moments you're not testing.

In essence, if you blood sugar test 3 times per day, you're
getting a blood sugar picture that equates to 3/1440 (or 2/10ths
of one percent) of what your blood sugar is up to during that
day.

For further details, see the following for details on the futility
of relying on a few photographs for so-called 'control', and
also, for an understanding of why many type 1 diabetics look
at blood sugar testing as a farcical joke, providing naught but
the pretense of the appearance of 'control', nothing more:
    www.drblumervideo.com

As for a better way, can't know 'til I've tried it, and as such,
I hesitate to recommend it, so I'll leave it at that, for now, and
will get back to you on such matters after I've gone through
the process of getting a doctor to 'prescribe' a continuous
glucose monitor, and actually used it to assess how much it
really helps to 'control' this damnable disease we, who are
type 1, are forced to deal with for every moment of every
day until a cure is found.

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(another post on April 30, 2009)

... I wrote to a doctor who is type 1, and here's some helpful
advice he had to offer regarding my current situation:

"We have similar medical histories. The severe hypoglycemia
is the most disconcerting aspect of my long term diabetes (there
are others but they are less likely to acutely impact me).

That said, I would strongly suggest you consider a continuous
glucose monitor (CGM). Dexcom makes a good one. They
are well worth the cost and can literally save your life. I use
a Navigator.

My severe lows have gone away and I have advanced warning
if they are coming, even if I'm asleep. ..."

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For a reference on what caused my switch in insulin
regimen and my switch to active blood glucose
testing, refer to the following posts I made on from
April 28 to 30, 2009:

Personal Note -- Drivers License Revocation
  http://prohuman.net/social_legal/drivers_license_revocation.htm

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