The smartest way to manage diabetes in pregnancy.

ADCES Conference Overview 

The Association of Diabetes Care and Education Specialists (ADCES) annual conference was in Phoenix this year, and I had the pleasure of attending many great presentations. 

There were six learning tracks available at the conference, including equitable care, innovations in care delivery, and technology integration. While gestational diabetes (GDM) and remote patient monitoring (RPM) didn’t have their own dedicated category, these subjects were woven through a few of the presentations. 

Below are some key takeaways from the ACDES sessions for gestational diabetes.

Using CGM to Predict Gestational Diabetes and Pregnancy Outcomes

Dr. Anders Carlson from the International Diabetes Center in Minneapolis had a very interesting presentation this year: “Using CGM to Predict Gestational Diabetes and Pregnancy Outcomes: GLAM Study Implications”.

As Dr. Carlson reminded us, the oral glucose tolerance test (OGTT) is dreaded by patients and interpretation varies from provider to provider. 

The Glucose Levels Across Pregnancy (GLAM) study was a prospective observational cohort study where patients wore blinded Dexcom G6 Pro devices and completed an OGTT. Almost 800 women were included in the study, with 58 developing GDM. The glucose patterns were studied between the two groups and it was found that glucose differences start to appear as early as 13 to 14 weeks gestation. Using the predictive performance, AUROC, second trimester mean glucose showed similar results compared to the OGTT (0.73 vs 0.7 to 0.8, respectively). 

Dr. Carlson went on to discuss normal continuous glucose monitoring (CGM) levels throughout uncomplicated pregnancies, and found that glucose levels remained pretty evenly distributed throughout the entire pregnancy. The CGM reports also showed a mean glucose of 98, a time in range (TIR) of 94%, a mean fasting glucose of 88, a mean one-hour post-prandial glucose of 108, and a mean two-hour post-prandial glucose of 102. These are tighter targets than we currently see in the guidelines. 

This information brings up some key questions around what the right glucose targets should be, when the best screening time for GDM is, whether we should consider replacing OGTT with CGM, and what would be the impact on outcomes for mom and baby.

To help answer some of these questions, the CGM for the Early Detection and Management of Hyperglycemia in Pregnancy (IMAGINE) study is ongoing. There are several clinical sites in the United States and United Kingdom enrolling a goal of 6,000 patients without diabetes that have uncomplicated pregnancies and are prior to 14 weeks gestation. They will wear a blinded CGM for screening and will eventually complete an OGTT. The primary outcome of the study is a composite outcome of large for gestational age (LGA), shoulder dystocia, elevated bilirubin requiring phototherapy, neonatal intensive care unit (NICU) admission, and maternal hypertensive disorder in pregnancy (HDP). 

Tips and Tricks for Using CGM in Pregnancy Recap

Another GDM-focused session was “Tips and Tricks for Using CGM in Pregnancy” presented by Diana Isaacs, PharmD and Logan Hunkus, PharmD from the Cleveland Clinic in Ohio. 

This presentation gave an in-depth review on GDM complications, CGM options, and glycemic targets during pregnancy, followed by an exploration of the clinical evidence for use of CGM in type 1 and type 2 diabetes during pregnancy and GDM. The presenters also shared what the guidelines say in regards to using CGM during pregnancy and the targets. 

Best practices were also discussed, including

• Providing CGM training to patients
• Changing CGM reports to have the appropriate TIR thresholds
• Turning on appropriate alerts and alarms
• Connecting the patient information to the provider portal
• Having data-driven conversations with patients with shared decision making

While most CGM reports will default to 70 to 180 for TIR, it’s important to update it to 63 to 140. Some CGMs may only give an option of 60 or 65 for the lower limit. Alerts should be actionable and individualized. Having the patients use the notes feature within the CGM app can be very helpful, and guide patient discussions and regimen changes.

RPM to Support Diabetes Care

While not specific to gestational diabetes, there was a great presentation from Stacey Cutrell, PharmD and Zachary Powers, PharmD: “Remote Patient Monitoring to Support Interprofessional Diabetes Care and Decrease Clinical Inertia”. 

The presentation started with the basics of remote patient monitoring (RPM): what it is, key components, and how billing works. The presenters implemented RPM at their workplace and discussed the implementation process and what the patient outcomes were for the RPM program. They also shared important lessons learned and next steps.

One of the key takeaways was the role of diabetes care and education specialists (DCES) in RPM. DCES have a broad set of responsibilities in their program, which include device teaching and education, reviewing and interpreting CGM data, and providing recommendations for lifestyle and medication changes, and helping to implement the care plan. 

Conclusion

While there were countless quality and insightful presentations, I was happy to see that a few were focused on improving patient care around gestational diabetes, which is the same goal we share here at LilyLink. There are several studies in the pipeline that are re-examining CGM targets in GDM, not to mention the possibility of a CGM replacing the dreaded OGTT. 

The presentations at the ADCES conference ultimately highlighted how important it is to continue researching and improving patient care for gestational diabetes and maternal health at large. We look forward to more research coming soon for this historically underserved group of patients. 

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