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endo-assess-cgm-trend-info-adjust-insulin

Evaluates patient’s ability to use CGM trend information (arrows, rate of change) to make insulin dose adjustments. Triggers include reviewing patient’s response to CGM trends and checking if patient adjusts bolus based on glucose direction.

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dromlakhani/MD2SKILL

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Assess use of trend information to adjust insulin doses

STEP 1 — Gather Information

Collect patient’s self‑report on how they use CGM trend arrows (e.g., single, double, or triple arrows) to guide insulin decisions; review recent CGM logs paired with insulin bolus records to see if adjustments align with direction and rate of change; assess frequency of SMBG calibrations; ask about understanding that CGM trend data differ from SMBG spot checks; note any barriers such as vision/dexterity issues, alarm fatigue, or lack of confidence.

STEP 2 — Rule In / Rule Out

Does the patient demonstrate appropriate insulin adjustments based on CGM trend information? (Yes/No)

STEP 3 — Classify or Stratify

If Yes: stratify proficiency as consistent (adjusts for most trends), occasional (adjusts only for obvious extremes), or inconsistent (adjusts unpredictably).
If No: classify barrier type—knowledge deficit (does not know how to interpret arrows), technical (cannot operate device or calibrate), behavioral (relies solely on SMBG or fears over‑correction), or systemic (alarm fatigue, insurance/access issues).

STEP 4 — Decide

If proficient (consistent/occasional): reinforce correct behavior, schedule routine follow‑up, and encourage continued trend‑based adjustments.
If deficient: provide targeted education on trend interpretation and insulin adjustment algorithms, troubleshoot technical issues, adjust alarm settings to reduce fatigue, and arrange a follow‑up visit within 2–4 weeks to reassess.

Clinical Guardrails / Mimics / Pitfalls

Do not assume CGM replaces SMBG for insulin dosing; avoid making large bolus corrections based solely on a single arrow without confirming with SMBG when symptoms disagree; do not ignore calibration requirements, as uncalibrated trend data can be misleading; prevent alarm fatigue by customizing low/high alerts to individual patterns; never adjust insulin based on trend arrows alone if the patient cannot reliably operate the CGM system.

Concrete Clinical Example

A patient with type 1 diabetes sees a double upward arrow (↑↑) indicating a glucose rise >2 mg/dL/min on their CGM, administers an extra 2 units of rapid‑acting insulin to blunt the anticipated hyperglycemia, and rechecks the CGM trend 30 minutes later to confirm stabilization.

Source: Diabetes Technology—Continuous Subcutaneous Insulin Infusion Therapy and Continuous Glucose Monitoring in Adults: An Endocrine Society Clinical Practice Guideline, Endocrine Society, 2016, DOI:10.1210/jc.2016-2534

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