By Diana Isaacs, PharmD, BCPS, BCACP, BC-ADM, CDCES, FADCES
Bill is a 23-year-old man that was diagnosed with diabetes through a routine employee screening. His random glucose was 400 and A1C was 12%. Upon reflection, he realized that he was thirsty, fatigued and had lost 25lbs over the last several months.
He came to our comprehensive diabetes clinic at the Cleveland Clinic and was diagnosed with type 1 diabetes. This was the first week of March right before everything in Ohio shut down due to the COVID-19 pandemic. He was prescribed basal and bolus insulin and advised on the glucose targets and treatment of hypoglycemia. We started him that day on an intermittently scanned CGM. He met with the pharmacist (me), endocrinologist, remote monitoring coordinator and diabetes care and education specialist in one visit. We connected his CGM to our account for remote monitoring.
I followed up with Bill one week later through a virtual visit. He really liked having the CGM. I accessed his data and shared my screen so that we could review together. I used the DATAA (Download data, Assess safety, Time in range, Areas for improvement, Action plan) model for a data driven discussion. Using this model, I oriented Bill to the CGM metrics and what they mean. I stressed that this is just information, not good or bad, and the data is being used to help him achieve the glucose targets. We discovered he was going low after breakfast and high over night. In our action plan, through shared decision making, we agreed to decrease a unit of his prandial insulin at breakfast and increase the basal insulin.
He had a follow-up a week later with the dietitian to learn carbohydrate counting. He followed up again with me 2 weeks later. We reviewed his CGM report where he entered his carbohydrates and we came up with a carbohydrate ratio. He was going to start carbohydrate counting for more precise insulin dosing.
Two weeks later, we met again to discuss technology. After hearing about all of the options, he decided he was interested in switching to a real time CGM and a smart pen. These were both ordered to his pharmacy and he picked them up. We did the training virtually. I had my demo supplies to walk him through the process and together we configured his settings. The smart pen is great because we were able to customize it with his carbohydrate ratio, correction factor and glucose target. It keeps track of active insulin to avoid stacking insulin doses. We were able to continue virtual follow up where he sent me his InPen reports that included his smart pen and CGM data.
Despite a new diagnosis of type 1 diabetes during the pandemic, all of Bill’s care was virtual from March until October. We had him come to the office in early October for a physical exam and we checked A1C which was 6.3% with minimal hypoglycemia. He reports feeling great, lifting weights every day and was able to gain back all of the weight he had lost before diagnosis. He was grateful for the team-based and individualized virtual follow-up.
*Name and other key identifiers were changed to protect the patient’s identify