Insulin Dosing off CGM

[Holiday9]

What are your school districts doing with incoming doctors orders to dose insulin based off CGM? Parent does not want student's finger stick before dosing and doctor agrees.

[NurseBeans, BSN, RN, EMT-B]

UGh. My understanding was that the cgm is for blood glucose monitoring, not meant for dosing off of. I always did a fingerstick and they always varied from the cgm. Sometimes enough to change the intervention. It isn't real-time results so you are seeing what their bg was about 10 minutes ago. Also the little guy I had the last few years with a cgm was able to manipulate it to show lower numbers because he always wanted candy and juice.

I mean, I guess you could use it to dose but it will be imprecise at best.

[Windchaser22]

I would call the doc and clarify, at least for the lunch dose.

[halohg, RN]

Agreed, really only used to determine trends if my clinic.

[OyWithThePoodles, RN]

We DO NOT dose off CGM's. Dad tried to tell me that the G5's were the most accurate and even more accurate than a finger stick. I let him know that they can do whatever they want at home, but until I got orders saying otherwise (which I knew the doc wouldn't) I would still have to use a finger stick to dose with. The CGM's are supposed to be changed weekly, but parents, because they are so dang expensive, will try to get as much life out of them as possible, meaning two weeks more. And I can't say I blame them, but it makes them less accurate the longer they've been on.

Once my T1 kiddo said his CGM was alerting, CGM said 55, asymptomatic. I do have orders to treat off of CGM. (Give snack if this number with two arrows down, or this number with one arrow down) but I knew he had had his sensor on for two weeks. Finger stick was 233. Had I treated him without check he would've likely ended up in the 300's.

I would clarify with the doc. If they still say it's okay to treat with the CGM, check with your boss and make sure it follow's your district policy. And let the doc know if there are any large deficits between the finger stick and the CGM that you have seen. Or if you know that parent's go two/three weeks in between changing.

The FDA has approved it, so if we have an order we'd have to follow it I would think. From FDA website:

"The U.S. Food and Drug Administration today expanded the approved use of Dexcom's G5 Mobile Continuous Glucose Monitoring System to allow for replacement of fingerstick blood glucose (sugar) testing for diabetes treatment decisions in people 2 years of age and older with diabetes. This is the first FDA-approved continuous glucose monitoring system that can be used to make diabetes treatment decisions without confirmation with a traditional fingerstick test. The system was previously approved to complement, not replace, fingerstick testing for diabetes treatment decisions.

"The FDA works hard to help ensure that novel technologies, which can reduce the burden of daily disease management, are safe and accurate," said Alberto Gutierrez, Ph.D., director of the Office of In Vitro Diagnostics and Radiological Health in the FDA's Center for Devices and Radiological Health. "Although this system still requires calibration with two daily fingersticks, it eliminates the need for any additional fingerstick blood glucose testing in order to make treatment decisions. This may allow some patients to manage their disease more comfortably and may encourage them to have routine dialogue with their health care providers about the use of real-time continuous glucose monitoring in diabetes management." "

But it still makes me nervous... Not only that but they do have a bit of a lag, so if a kiddo comes in straight from PE/Recess to get dosed for lunch, it's likely their glucose is dropping but their CGM hasn't picked it up yet.

[denstar]

We have had orders from the doctor for dexcom 5 stating that as long as blood sugar was in a certain range, we could go off of the CGM numbers and not do a fingerstick for meal/snacktime dosing. Seemed to work well for the student and her blood sugars were generally well managed. If blood sugars were running low/high, a fingerstick was done before treatment.

[JenTheSchoolRN, BSN, RN]

Ugh. I would hate those orders. Though I've yet to see a T1D student wear one consistently. Usually they only wear it for a week prior to one of their scheduled appointments, so moot point for me thus far.