Dexcom CGM in Long-term Care

Randomized Controlled Trial To Assess the Benefits of Dexcom Continuous Glucose Monitoring With Glucose Telemetry System for the Management of Diabetes in Long-term Care Setting: The CGM-GTS in Long-term Care

Diabetes is prevalent in adults admitted to subacute rehab (SAR) and long-term care (LTC) skilled nursing care facilities. Management of diabetes in these facilities is challenging due to number of older adults with higher prevalence of other diseases, functional disability, and altered nutritional intake, which increase the risk of hypoglycemia (low blood sugars). The investigators propose to conduct this randomized controlled trial to determine whether the use of Dexcom CGM with Glucose Telemetry System (CGM-GTS) with hypoglycemia alarm compared to standard of care using capillary POC testing, will facilitate diabetes treatment and reduce the risk of hypoglycemia in patients with T2D in LTC facilities. Participants in the standard of care group will also wear a CGM (blinded one). The results of this study have great potential to impact and facilitate care and to change current clinical guidelines in the management of older adults with diabetes in SAR and LTC facilities.

Diabetes is prevalent in adults admitted to subacute rehab (SAR) and long-term care (LTC) skilled nursing care facilities. Management of diabetes in these facilities is challenging due to number of older adults with higher prevalence of other diseases, functional disability, and altered nutritional intake, which increase the risk of hypoglycemia (low blood sugars). Many Clinical guidelines recommend the use of insulin, as the preferred therapy for glycemic (sugar) control for most patients with type 2 diabetes (T2D). The use of insulin is effective in improving glycemic control, but associated with high rates of hypoglycemia in LTC residents with T2D. This high rate of hypoglycemia is concerning, because hypoglycemia has been associated with many complications and mortality. The bedside capillary point of care (POC) glucose monitoring is the standard of care to assess glycemic control in the hospital and in LTC facilities. POC testing is usually performed before meals and at bedtime. Continuous Glucose Monitoring (CGM) measures glucose every 5-15 minutes, thus provides a more complete glycemic profile during 24-hours when compared to POC testing. The investigators propose to conduct a randomized controlled trial to determine whether the use of Dexcom CGM with Glucose Telemetry System (CGM-GTS) with hypoglycemia alarm compared to standard of care using capillary POC testing, will facilitate diabetes treatment and reduce the risk of hypoglycemia in patients with T2D in LTC facilities. Participants in the standard of care group will also wear a CGM (blinded one). Potential Participants will be identified from electronic medical records and enrolled during admission to subacute rehabilitation (SAR)and long-term care (LTC) skilled nursing care facilities and will be followed up for up to sixty (60) days or discharge (whichever comes sooner). Subjects will be compensated for their participation. The results of this study have great potential to impact and facilitate care and to change current clinical guidelines in the management of older adults with diabetes in SAR and LTC facilities.

Patients in the standard of care group will wear a blinded CGM and receive POC testing before meals and bedtime, with providers adjusting oral agents or insulin dose based on POC results.

Patients in the intervention CGM group will have a single daily fasting POC testing and will wear a real-time Dexcom G6 with GTS, and providers will adjust oral or insulin therapy based on CGM-GTS profile information.

CGM sensor will be placed after consent. Glucose values obtained from the CGM sensor will be sent to the CGM transmitter by Bluetooth technology and DEXCOM Share2 software application to a smart phone that serves as an intermediate-transmitting (routing) device. Glucose values from the smart phone will be transmitted wirelessly to a table computer (I-Pad) using the DEXCOM Follow application. Information on the CGM will activate an alarm in case of hypoglycemia or hyperglycemia events. Hypoglycemia alarm will be set to < 85 mg/dl (for prevention for low blood glucose levels). Nursing staff will be instructed to provide 15 grams of carbohydrates in response to a hypoglycemia alarm.The hyperglycemia alarm will be set at 300 mg/dl. If this occurs, the nursing staff will assess clinical status and perform a POC glucose testing to confirm glucose values. If BG > 300 mg/dl, nursing staff will communicate the high glucose value to the primary care team.

Point of Care (POC) testing before meals and bedtime (standard of care). For the control group, participants will also get a CGM sensor (blinded CGM). CGM alarms are turned off, however if the POC is found to be between <80 mg/dl by POC, 15 grams of carbohydrates will be given as a preventive measurement for hypoglycemia (standard of care).

Number of events of Hypoglycemia <70 mg/dl between POC testing group and CGM-GTS group (safety outcome)

Number of events of clinically significant hypoglycemia <54 mg/dl between POC testing group and CGM-GTS group (safety outcome)

Glycemic control will be measured by time in range (TIR) between 80-180 mg/dl during admission (efficacy outcome)

Number of events of nocturnal hypoglycemia < 70 mg/dL and <54 mg/dL between POC testing group and CGM-GTS group

Number of events of nocturnal hypoglycemic events for BGs < 70 mg/dl and <54 mg/dL will be recorded between 22:00 and 06:00

Number of participants with prolonged hypoglycemia > 1 and 2 hours by CGM between POC testing group and CGM-GTS group

Number of events of hyperglycemia > 240 mg/dl during the day and night between POC testing group and CGM-GTS group

Mean amplitude of glycemic excursions (MAGE), together with mean and SD, is the parameter for assessing glycemic variability and is calculated based on the arithmetic mean of differences between consecutive peaks and nadirs of differences greater than one SD of mean glycemia. It is designated to assess major glucose swings and exclude minor ones.

Inclusion Criteria: Males and females admitted to subacute and long-term skilled nursing care facilities. Known history of T2D treated with insulin (glargine, detemir, degludec, NPH, premixed insulin) or sliding scale regular insulin) or insulin secretagogues (sulfonylureas, repaglinide, nateglinide) with or without additional oral antidiabetic agents (alpha-glucosidase inhibitors, thiazolidinedione, SGLT2- inhibitors, DPP4-inhibitors), short- and long-acting GLP1-RA (exenatide, liraglutide, dulaglutide, semaglutide). Patients with an expected LTC length-of-stay > 1 week. Exclusion Criteria: Patients expected to require MRI procedures during admission. Patients with clinically relevant hepatic disease (diagnosed liver cirrhosis and portal hypertension), corticosteroid therapy, end-stage renal disease (dialysis), or anasarca (massive peripheral edema). Female subjects who are pregnant or breast-feeding at time of enrollment into the study.

Individual participant data that underlie the results reported in the article, after deidentification (text, tables, figures, and appendices) will be shared to Researchers who provide a methodologically sound proposal, to achieve the aims in the approved proposal.

Proposals should be directed to geumpie@emory.edu. To gain access, data requestors will need to sign a data access agreement.