2) This program is supported by an educational grant from Sanofi and is intended for healthcare professionals. Statement of accreditation and disclosures are listed at https://t.co/PHlIpplEO4. See prior programs and earn 🆓credit at https://t.co/L4qK6GpsLH.
— @CKD_ce (@ckd_ce) February 7, 2023
3b) Also on atorvastatin 40 mg/day and losartan/HCTZ 100/12.5 mg day. BMI 33 kg/m2. Physical exam unremarkable except for abdominal obesity.
— @CKD_ce (@ckd_ce) February 7, 2023
Labs ➡️FPG = 123, #HbA1c = 7.9% (63 mmol/mol), LDL-C 44, HDL-C 43, TG 224, #eGFR is 66. Urine albumin/creatinine ratio #UACR = 23.
3d) The correct answer is B. The patient is an older adult with #T2D. Although he has hypertension and dyslipidemia, he has had no major complications and has good cognitive and functional status.
— @CKD_ce (@ckd_ce) February 7, 2023
4) BTW . . . For older adults with multiple comorbidities, or impairment in cognitive function or functional dependence, less stringent goals (such as #HbA1c less than 8.0% [64 mmol/mol]) are recommended.
— @CKD_ce (@ckd_ce) February 7, 2023
5b) He also reports feeling weak and hungry – sometime with sweating and trembling. Typically this happens on the golf course. He treats with a snack bar and his symptoms resolve shortly afterward.
— @CKD_ce (@ckd_ce) February 7, 2023
6) What else should you ask?
— @CKD_ce (@ckd_ce) February 7, 2023
👉Does he eat regularly?
👉Does he skip insulin doses?
👉Does he adjust insulin dose?
👉All of the above?
✔️All are important to ask so that you can better understand his barriers to good #glycemic control.
7b) from 7a:
— @CKD_ce (@ckd_ce) February 7, 2023
a. Continuous glucose monitoring (#CGM) to get a better idea of his glycemic profile throughout 24 hours?
b. Meet with a diabetes educator to discuss diet and insulin dosing?
c. Changing to a long-acting basal insulin (such as #glargine or #degludec)
8) There are two main choices for continuous glucose monitoring #CGM, but the area is evolving rapidly. Both will interface with smartphones. Newer devices are smaller and more discrete, and have improved accuracy. pic.twitter.com/Z2CbGcWAOb
— @CKD_ce (@ckd_ce) February 7, 2023
10a) How do you interpret the CGM report? pic.twitter.com/MGEzyRvlg6
— @CKD_ce (@ckd_ce) February 7, 2023
11a) The Time Above Range (or #TAR) is also important and reflects periods in which #glycemic control is not optimal. In this case, your patient is spending excessive time above range, particularly in the overnight period.
— @CKD_ce (@ckd_ce) February 7, 2023
12a) In the case of our patient, we are interested in #hypoglycemia since he seems to have symptoms on golf days ⛳️. The Time Below Range (or #TBR), usually < 70 mg/dL, assesses this.
— @CKD_ce (@ckd_ce) February 7, 2023
13a) Another useful metric from the #CGM profile is the #coefficient_of_variation or #CV. This reflects the daily and day-to-day variability in #glucose levels.
— @CKD_ce (@ckd_ce) February 7, 2023
14) OK, so we have figured out the problem. He has #hyperglycemia in the overnight period and #hypoglycemia in the mid-afternoon. Why is this happening? RETURN TOMORROW and we'll discuss! pic.twitter.com/8eTYv6fcAk
— @CKD_ce (@ckd_ce) February 7, 2023
16) Welcome back! I am @RpratleyMD & we are talking about Strategies to Minimize Glucose Variability with the Application of Newer Longer-Acting Insulins while YOU earn🆓CE/#CME. Follow @ckd_ce (& @ardiomet_ce) for the ONLY #accredited #tweetorials in #CKD!
— @CKD_ce (@ckd_ce) February 8, 2023
17b) The correct answer is c: Optimally, we want #TIR to be at least 70%, #TAR to be no more than 25%, and #CV to be less than 25%. So now you know the cool #CGM terminology!
— @CKD_ce (@ckd_ce) February 8, 2023
18b) 70/30 #insulin is a fixed ratio combination of a longer acting and shorter acting insulin. It is almost impossible to adequately match meal-time glycemic excursions as a consequence. pic.twitter.com/yGooFbZ6on
— @CKD_ce (@ckd_ce) February 8, 2023
19) We have lots of options! Several classes of #insulin are available, each with a different pharmacokinetic/pharmacodynamic profile. pic.twitter.com/O8GWYTO1x6
— @CKD_ce (@ckd_ce) February 8, 2023
21) For patients with #T2D who require insulin, a #basal_insulin is often a good choice. There are several advantages to basal insulins. pic.twitter.com/waKITi0MEC
— @CKD_ce (@ckd_ce) February 8, 2023
23) Which basal insulin would you select for this patient?
— @CKD_ce (@ckd_ce) February 8, 2023
24b) In our patient who is experiencing hypoglycemia but also has nocturnal hypoglycemia, an ultra-long-acting #basal_insulin (#glargine U-300 or #degludec) would be a great choice.
— @CKD_ce (@ckd_ce) February 8, 2023
25) You decide to start the patient on insulin glargine U-300, but what dose?
— @CKD_ce (@ckd_ce) February 8, 2023
27a) This is a good choice, because the patient’s #insulin requirements are associated with a higher injection volume. The more concentrated U-300 insulin results in lower (and more comfortable) injection volumes.
— @CKD_ce (@ckd_ce) February 8, 2023
28) The patient returns 3 months later. He has titrated the #insulin #glargine U-300 to 72 units a day. His fasting blood glucose levels are in the 100 range. He reports significantly fewer #hypoglycemic episodes and none at night. His most recent #HbA1c was 7.2%. pic.twitter.com/qsFazf0aFL
— @CKD_ce (@ckd_ce) February 8, 2023
30) Thanks for joining this #accredited #tweetorial on Strategies to Minimize Glucose Variability with the Application of Newer Longer-acting Insulins! Key points to remember include: pic.twitter.com/6pfU7a5Rbw
— @CKD_ce (@ckd_ce) February 8, 2023
31) Now go claim what is rightfully yours–a certificate for 0.5h 🆓CE/#CME! Just 🖱️ on https://t.co/Ij73ptOtEP and you're done! I am @RpratleyMD.
— @CKD_ce (@ckd_ce) February 8, 2023