Flash CONtinous Glucose Monitoring in TRansition to Outpatient: Libre for Type 2 Diabetes Mellitus (CONTROL-DM)

This is a pilot study of the use of flash glucose monitoring (FGM) to assess glycemic control, behavioural, quality of life benefits and manpower utilization in poorly controlled T2DM patients on insulin in the transitional care period after discharge from hospital.

Background:

Hospitalization often provides an opportunity to optimise the care of patients with diabetes, however, there could be destabilisation of dietary habits and diabetes therapy during admission. During transition from hospital to home, diabetes treatment may be intensified to control hyperglycemia, such as starting insulin therapy, or, de-escalated, due to risks of hypoglycaemia secondary to variable oral intake and physical activity levels peri-hospitalization.

Achieving optimal glycemic control necessitates frequent blood glucose monitoring. However, patients may perceive repeated self-monitoring of blood glucose (SMBG) as inconvenient, intrusive and laborious as it requires pricking their fingers multiple times, resulting in reduced compliance and poorer glycemic outcomes. Ambulatory flash glucose monitoring (FGM) may overcome this and facilitate more rapid achievement of euglycemia due to the benefit of immediate feedback of glucose levels with changes in diet, medication and activity.

As the transitional care period is a period of stress for patients and an opportunity to encourage behavioural change, we propose that the use of intermittent short term FGM in the first two weeks post discharge, and for another two weeks at a 6-week interval may promote behavioural change resulting in improvements in glycemic control.

Objectives:

1. To explore the use of FGM in patients with T2DM with baseline HbA1c \>9% and requiring insulin who at risk of hypoglycemia or hyperglycemia, in facilitating the transition care from inpatient to the ambulatory setting.
2. This pilot study is exploratory to determine the logistics and feasibility of the protocol, and to collect preliminary information that will lead to a larger grant application for a larger clinical trial in the future.

Hypotheses:

1. FGM use in patients with T2DM with baseline HbA1c \>9% and requiring insulin would facilitate the transition of care from inpatient to the ambulatory setting, resulting in improved glycemic control, as measured by HbA1c at 12 weeks.
2. FGM use in the transitional care period would lead to improved time in range (TIR), reduced time in hypoglycaemia and hyperglycaemia, reduced readmission rates for hypo or hyperglycaemia, improved quality of life, reduced loss to follow-up and encourage individual lifestyle modification, without a significant increase in costs and manpower utilization.

Eligibility Criteria:
Inclusion Criteria:

* Age between 21-80 inclusive
* HbA1c\>9% on insulin
* Requiring inpatient adjustment of DM medication if meets any of the following:
* A) Hypoglycemia (defined as glucose \< 4 mmol/l occurring 2 or more times at least 3 hours apart in the last 72 hours or any glucose \<2.5 mmol/l in the last 24 hours)
* B) Hyperglycemia (defined as glucose \> 14 mmol/l occurring 2 or more times in the last 36 hours, or any glucose \> 24 mmol/l in the last 24 hours)
* Desire to lower HbA1c to a target of 7%
* Willing to wear FGM device
* Willing and able to use FreeStyle Librelink app on personal device
* Willing to avoid use of ascorbic acid throughout the study
* Willing to perform SMBG (by history) of an average of at least 4 times a day, 3 days a week

Exclusion Criteria:

* T1DM
* Pregnant or planning pregnancy during duration of study
* Unable to use or unwilling to comply with study requirements
* Use of personal FGM within 3 months of screening or plan to use personal FGM during the course of the study
* On ascorbic acid
* Extensive skin changes that preclude wearing the sensor on normal skin (e.g. extensive psoriasis, extensive eczema, recent burns or severe sunburn, extensive tattoos, dermatitis herpetiformis)
* Known allergy to medical-grade adhesives
* Renal insufficiency (eGFR\<30)
* Pancreatic insufficiency or history of pancreatitis
* Patients on any structured weight reduction interventions such as prescription weight loss medications, bariatric surgery, or protein sparing modified fast during the course of the study.
* Current or anticipated short term uses of glucocorticoids (oral, injectable, or intravenous. Long-term stable glucocorticoid doses are allowed, such as for treatment of rheumatoid arthritis or Addison's disease.
* Any medical condition that would make it inappropriate to target an HbA1c of \<7%
* Currently abusing illicit drugs, alcohol or prescription drugs
* Any condition per investigator assessment, that could impact reliability of the HbA1c measurement, such as but not limited to hemoglobinopathy, haemolytic anaemia, chronic liver disease, chronic GI blood loss, recent red blood cell transfusion or erythropoietin administration within 3 months prior to screening
* Current participation in another investigational study (must have completed any prior studies at least 30 days prior to being enrolled in this study)