656380
research-article2016
DSTXXX10.1177/1932296816656380Journal of Diabetes Science and TechnologyWallia et al
Commentary
Round Table Discussion on Inpatient Use of Continuous Glucose Monitoring at the International Hospital Diabetes Meeting
Journal of Diabetes Science and Technology 2016, Vol. 10(5) 1174–1181 © 2016 Diabetes Technology Society Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1932296816656380 dst.sagepub.com
Amisha Wallia, MD, MS1, Guillermo E. Umpierrez, MD2, Stanley A. Nasraway, MD3, and David C. Klonoff, MD4, on behalf of PRIDE Investigators
Abstract In May 2015 the Diabetes Technology Society convened a panel of 27 experts in hospital medicine and endocrinology to discuss the current and potential future roles of continuous glucose monitoring (CGM) in delivering optimum health care to hospitalized patients in the United States. The panel focused on 3 potential settings for CGM in the hospital, including (1) the intensive care unit (ICU), (2) non-ICU, and (3) continuation of use of home CGM in the hospital. The group reviewed barriers to use and solutions to overcome the barriers. They concluded that CGM has the potential to improve the quality of patient care and can provide useful information to help health care providers learn more about glucose management. Widespread adoption of CGM by hospitals, however, has been limited by added costs and insufficient outcome data. Keywords inpatient continuous glucose monitor, hospital, hypoglycemia, diabetes, glucose In May 2015, the Diabetes Technology Society (President David C. Klonoff, MD, FACP, FRCP, Burlingame, California) convened a panel of 27 experts in hospital medicine and endocrinology to discuss the current and potential future roles of continuous glucose monitoring (CGM) in delivering optimum health care to patients in the United States. The main objective of the panel was to have a round table discussion on the current state of applicable uses of CGM in the hospital, potential future use, and current gaps in the use of this technology for inpatient glycemic control. Three cochairs, Dr Stanley Nasraway, Dr Guillermo Umpierrez, and Dr Amisha Wallia, each served as a moderator of a discussion on CGM use in (1) intensive care unit (ICU), (2) non-ICU, and (3) continuation of use of home CGM in the hospital. The focus of each discussion was to determine how and when CGM is used in the aforementioned patient populations and to enumerate the real-world pros and cons of CGM use in particular sections of the hospital, in specific patient subgroups, and/or in types of CGM. Experts were asked to identify any barriers to the widespread adoption of CGM as standard of care (ie, to increase patient safety) and provide recommendations for increasing current and future CGM use in hospitals.
Background Continuous Glucose Monitors (CGM) can measure glucose in interstitial fluid (glucose oxidase enzymatic method) or
intravenously (IV; fluorescent chemistry, midinfrared spec, hydrogel methods).1 Today in the United States, CGM is available for use by patients (real-time) and professionals (retrospective), measure subcutaneous glucose in interstitial fluid via the glucose oxidase method with lag times up to 15 minutes.1 This type of technology is currently FDA cleared for adjunctive use to compliment, not replace, information obtained from standard personal glucose monitoring systems 1
Northwestern University, Feinberg School of Medicine, Division of Endocrinology, Metabolism, and Molecular Medicine, Chicago, IL, USA 2 Emory University School of Medicine, Atlanta, GA, USA 3 Tufts Medical Center, Boston, MA, USA 4 Mills-Peninsula Health Services, Diabetes Research Institute, San Mateo, CA, USA PRIDE Investigators/Panel Members: Sara Alexanian, MD, Enrico Cagliero, MD, Curtiss B. Cook, MD, Boris Draznin, MD, PhD, Andjela Drincic, MD, Linda Gaudiani, MD, FACP, FACE, Roma Gianchandani, MD, Janice L. Gilden, MD, FCP, FACE, Mikhail Kosiborod, MD, FACC, FAHA, Kristen Kulasa, MD, Lillian F. Lien, MD, Cecilia C. Low Wang, MD, FACP, Greg Maynard, MD, MSc, SFHM, Carlos E. Mendez, MD, FACP, Thomas Pieber, MD, Gerry Rayman, MB BS, FRCP, MD, Chanhaeng Rhee, MD, MBA, Daniel J. Rubin, MD, MSc, FACE, Robert J. Rushakoff, MD, Stanley Schwartz, MD, Mitchell G. Scott, PhD, Jane Jeffrie Seley, DNP, MPH, BCADM, CDE, CDTC, Garry Tobin, MD, Robert A. Vigersky, MD Corresponding Author: Amisha Wallia, MD, MS, Northwestern University, Feinberg School of Medicine, Division of Endocrinology, Metabolism, and Molecular Medicine, 645 N Michigan Ave, Ste 530, Chicago, IL 60611, USA. Email: [email protected]
Wallia et al in the outpatient setting. CGM aids in the detection of episodes of hyperglycemia and hypoglycemia, facilitating both acute and long-term therapy adjustments. While various CGM devices have been studied in the inpatient setting, there are currently 5 CGMS for intravenous (IV) use approved in Europe: (1) GlucoClear by Edwards Life Sciences, (2) Glysure System by Glysure, (3) ERIUS by Maquet, and (4) Optiscanner 5000 by Optiscan and (5) Subcutaneous system Sentrino by Medtronic. In the United States there are no CGM devices specifically approved for use in the inpatient setting and no IV glucose monitoring systems approved by the Food and Drug Administration. Additional potential use in the hospital setting includes adjunctive therapy for inpatient glycemic control monitoring through the use of real-time or retrospective CGM by either intravenous or subcutaneous placement. Specific technological barriers to use in the inpatient setting include the buildup of tissue deposits (bio-film),2 accuracy (poor circulation, anemia, edema), need for calibration, sensor drift, measurement lag, interference (acetaminophen, maltose, ascorbic acid, dopamine, mannitol), infection and anticoagulation risk.3,4 In addition, the increased number of patients with diabetes mellitus (DM) using subcutaneous CGM in the home setting has resulted in a rise in patient’s requests for continuation of their use in the inpatient setting. A summary of the discussions, the opinions expressed, and the consensus reached for each discussion follows.
ICU: Is There a Role for CGM in the Intensive Care of Patients? Moderator: Stanley Nasraway, MD Director of the Surgical Intensive Care Units and Professor of Surgery, Anesthesiology, and Medicine, Tufts University School of Medicine, Boston, Massachusetts
The majority of evidence on the use of CGM in the inpatient setting comes from the intensive care setting. Previous studies have shown acceptable sensor accuracy, lack of interference in prospective studies, and acceptable safety in high-risk patients (eg, acute coronary syndrome), however minimal change in overall glycemic control.5-10 A large randomized clinical trial in 124 mechanically ventilated ICU patients on IV insulin infusion showed a similar percentage of time at a glucose level
research-article2016
DSTXXX10.1177/1932296816656380Journal of Diabetes Science and TechnologyWallia et al
Commentary
Round Table Discussion on Inpatient Use of Continuous Glucose Monitoring at the International Hospital Diabetes Meeting
Journal of Diabetes Science and Technology 2016, Vol. 10(5) 1174–1181 © 2016 Diabetes Technology Society Reprints and permissions: sagepub.com/journalsPermissions.nav DOI: 10.1177/1932296816656380 dst.sagepub.com
Amisha Wallia, MD, MS1, Guillermo E. Umpierrez, MD2, Stanley A. Nasraway, MD3, and David C. Klonoff, MD4, on behalf of PRIDE Investigators
Abstract In May 2015 the Diabetes Technology Society convened a panel of 27 experts in hospital medicine and endocrinology to discuss the current and potential future roles of continuous glucose monitoring (CGM) in delivering optimum health care to hospitalized patients in the United States. The panel focused on 3 potential settings for CGM in the hospital, including (1) the intensive care unit (ICU), (2) non-ICU, and (3) continuation of use of home CGM in the hospital. The group reviewed barriers to use and solutions to overcome the barriers. They concluded that CGM has the potential to improve the quality of patient care and can provide useful information to help health care providers learn more about glucose management. Widespread adoption of CGM by hospitals, however, has been limited by added costs and insufficient outcome data. Keywords inpatient continuous glucose monitor, hospital, hypoglycemia, diabetes, glucose In May 2015, the Diabetes Technology Society (President David C. Klonoff, MD, FACP, FRCP, Burlingame, California) convened a panel of 27 experts in hospital medicine and endocrinology to discuss the current and potential future roles of continuous glucose monitoring (CGM) in delivering optimum health care to patients in the United States. The main objective of the panel was to have a round table discussion on the current state of applicable uses of CGM in the hospital, potential future use, and current gaps in the use of this technology for inpatient glycemic control. Three cochairs, Dr Stanley Nasraway, Dr Guillermo Umpierrez, and Dr Amisha Wallia, each served as a moderator of a discussion on CGM use in (1) intensive care unit (ICU), (2) non-ICU, and (3) continuation of use of home CGM in the hospital. The focus of each discussion was to determine how and when CGM is used in the aforementioned patient populations and to enumerate the real-world pros and cons of CGM use in particular sections of the hospital, in specific patient subgroups, and/or in types of CGM. Experts were asked to identify any barriers to the widespread adoption of CGM as standard of care (ie, to increase patient safety) and provide recommendations for increasing current and future CGM use in hospitals.
Background Continuous Glucose Monitors (CGM) can measure glucose in interstitial fluid (glucose oxidase enzymatic method) or
intravenously (IV; fluorescent chemistry, midinfrared spec, hydrogel methods).1 Today in the United States, CGM is available for use by patients (real-time) and professionals (retrospective), measure subcutaneous glucose in interstitial fluid via the glucose oxidase method with lag times up to 15 minutes.1 This type of technology is currently FDA cleared for adjunctive use to compliment, not replace, information obtained from standard personal glucose monitoring systems 1
Northwestern University, Feinberg School of Medicine, Division of Endocrinology, Metabolism, and Molecular Medicine, Chicago, IL, USA 2 Emory University School of Medicine, Atlanta, GA, USA 3 Tufts Medical Center, Boston, MA, USA 4 Mills-Peninsula Health Services, Diabetes Research Institute, San Mateo, CA, USA PRIDE Investigators/Panel Members: Sara Alexanian, MD, Enrico Cagliero, MD, Curtiss B. Cook, MD, Boris Draznin, MD, PhD, Andjela Drincic, MD, Linda Gaudiani, MD, FACP, FACE, Roma Gianchandani, MD, Janice L. Gilden, MD, FCP, FACE, Mikhail Kosiborod, MD, FACC, FAHA, Kristen Kulasa, MD, Lillian F. Lien, MD, Cecilia C. Low Wang, MD, FACP, Greg Maynard, MD, MSc, SFHM, Carlos E. Mendez, MD, FACP, Thomas Pieber, MD, Gerry Rayman, MB BS, FRCP, MD, Chanhaeng Rhee, MD, MBA, Daniel J. Rubin, MD, MSc, FACE, Robert J. Rushakoff, MD, Stanley Schwartz, MD, Mitchell G. Scott, PhD, Jane Jeffrie Seley, DNP, MPH, BCADM, CDE, CDTC, Garry Tobin, MD, Robert A. Vigersky, MD Corresponding Author: Amisha Wallia, MD, MS, Northwestern University, Feinberg School of Medicine, Division of Endocrinology, Metabolism, and Molecular Medicine, 645 N Michigan Ave, Ste 530, Chicago, IL 60611, USA. Email: [email protected]
Wallia et al in the outpatient setting. CGM aids in the detection of episodes of hyperglycemia and hypoglycemia, facilitating both acute and long-term therapy adjustments. While various CGM devices have been studied in the inpatient setting, there are currently 5 CGMS for intravenous (IV) use approved in Europe: (1) GlucoClear by Edwards Life Sciences, (2) Glysure System by Glysure, (3) ERIUS by Maquet, and (4) Optiscanner 5000 by Optiscan and (5) Subcutaneous system Sentrino by Medtronic. In the United States there are no CGM devices specifically approved for use in the inpatient setting and no IV glucose monitoring systems approved by the Food and Drug Administration. Additional potential use in the hospital setting includes adjunctive therapy for inpatient glycemic control monitoring through the use of real-time or retrospective CGM by either intravenous or subcutaneous placement. Specific technological barriers to use in the inpatient setting include the buildup of tissue deposits (bio-film),2 accuracy (poor circulation, anemia, edema), need for calibration, sensor drift, measurement lag, interference (acetaminophen, maltose, ascorbic acid, dopamine, mannitol), infection and anticoagulation risk.3,4 In addition, the increased number of patients with diabetes mellitus (DM) using subcutaneous CGM in the home setting has resulted in a rise in patient’s requests for continuation of their use in the inpatient setting. A summary of the discussions, the opinions expressed, and the consensus reached for each discussion follows.
ICU: Is There a Role for CGM in the Intensive Care of Patients? Moderator: Stanley Nasraway, MD Director of the Surgical Intensive Care Units and Professor of Surgery, Anesthesiology, and Medicine, Tufts University School of Medicine, Boston, Massachusetts
The majority of evidence on the use of CGM in the inpatient setting comes from the intensive care setting. Previous studies have shown acceptable sensor accuracy, lack of interference in prospective studies, and acceptable safety in high-risk patients (eg, acute coronary syndrome), however minimal change in overall glycemic control.5-10 A large randomized clinical trial in 124 mechanically ventilated ICU patients on IV insulin infusion showed a similar percentage of time at a glucose level
