Postgraduate Medicine

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Stepwise approach to continuous glucose

monitoring interpretation for internists and family
physicians

Emily D. Szmuilowicz & Grazia Aleppo

To cite this article: Emily D. Szmuilowicz & Grazia Aleppo (2022) Stepwise approach to
continuous glucose monitoring interpretation for internists and family physicians, Postgraduate
Medicine, 134:8, 743-751, DOI: 10.1080/00325481.2022.2110507

To link to this article: https://doi.org/10.1080/00325481.2022.2110507

Published online: 18 Aug 2022.

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POSTGRADUATE MEDICINE
2022, VOL. 134, NO. 8, 743–751
https://doi.org/10.1080/00325481.2022.2110507

CLINICAL FEATURE
REVIEW

Stepwise approach to continuous glucose monitoring interpretation for internists

and family physicians
Emily D. Szmuilowicz and Grazia Aleppo
Division of Endocrinology, Metabolism and Molecular Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine,
Chicago, Illinois, USA

ABSTRACT ARTICLE HISTORY

Continuous glucose monitoring (CGM) use has expanded rapidly in recent years among people with both Received 13 April 2022
type 1 and type 2 diabetes. In concert with the globally increasing prevalence of type 2 diabetes, the Accepted 3 August 2022
majority of whom receive diabetes care from internists or family physicians rather than specialists, it is
KEYWORDS
becoming increasingly incumbent upon physicians within internal medicine and family practice to
Continuous glucose
interpret and utilize CGM data in real-world clinical practice. It is therefore of paramount importance monitoring; CGM
that internists and family physicians have access to the tools which will enable them to (1) interpret CGM interpretation; diabetes
data, and (2) utilize CGM data to guide therapeutic modifications for their patients with type 2 diabetes. mellitus; type 2; diabetes
Given the limited amount of time available to internists and family physicians to address multiple technology; time in range;
complex topics in a typical office visit, a pragmatic, simple, and systematic approach to CGM interpreta­ internists; family physicians
tion is crucial. This article aims to provide internists and family physicians with a simplified and systematic
approach to CGM interpretation that can be easily and efficiently implemented in a brief office visit.
Plain Language Summary
Continuous glucose monitoring (CGM) allows people with diabetes to automatically monitor glucose
levels throughout the day and night, helps them to make informed decisions about food choices and
physical activity, and assists people with diabetes and their healthcare providers in adjusting diabetes
medications. CGM use has increased greatly in recent years among people with both type 1 and type 2
diabetes. As the number of people with type 2 diabetes increases around the world, internists and
family physicians increasingly need to understand CGM data and guide their patients who use CGM. As
a result, internists and family physicians need to have the tools which will enable them to (1) interpret
CGM data, and (2) use CGM data to help their patients adjust their diabetes therapies. Since internists
and family physicians have limited time to address many medical issues in a typical office visit, a simple
and systematic approach to CGM interpretation is needed. This article aims to provide internists and
family physicians with a simple and orderly approach to CGM interpretation that can be easily and
efficiently used in a brief office visit.

1. Introduction
Continuous glucose monitoring (CGM) use has expanded
rapidly in recent years [1] and imparts well-established bene­
fits in terms of glycemia and well-being among people with
both type 1 and type 2 diabetes [2–7]. Hemoglobin A1c
(HbA1c), which reflects average glycemia over the preceding
8–12 weeks, remains a cornerstone of diabetes diagnosis and
treatment monitoring, enables cross-sectional comparison of
glycemia across populations, and correlates with risk for
microvascular diabetes complications in clinical studies [8].
However, this measure of average glycemia does not provide
information about individual glycemic patterns, glucose
trends, the presence or absence of hypoglycemia, or glycemic
variability. Thus, while an elevated HbA1c does indicate that
therapeutic action is needed, it does not provide actionable
information that can be harnessed to guide therapeutic
adjustments. Furthermore, HbA1c measurements are com­
monly discordant from average glucose measurements due
to non-glycemic factors such as hemoglobinopathies or com­
monly encountered conditions in which red-cell turnover is
altered, such as iron-deficiency anemia, chronic hemolysis, and
chronic kidney disease [9].
In contrast, CGM data provide direct information about
personalized glucose trends which enable tailored thera­
peutic adjustments, as well as critical information regard­
ing the timing and degree of hypoglycemia,
hyperglycemia, and glucose variability in an individual.
Real-time CGM data alert the user immediately to poten­
tially dangerous impending hypo- or hyperglycemia, allow­
ing interventions in real-time to prevent their occurrence
or mitigate their severity. In addition, retrospective analysis
of either blinded or real-time CGM data enables the

CONTACT Emily D. Szmuilowicz edszmuilowicz@northwestern.edu Division of Endocrinology, Metabolism and Molecular Medicine, Northwestern
University Feinberg School of Medicine, 645 N. Michigan Avenue, Suite 530, Chicago, IL 60611
Social media username: Twitter handle: @NMEndocrinology
© 2022 Informa UK Limited, trading as Taylor & Francis Group
744 E. D. SZMUILOWICZ AND G. ALEPPO
recognition, by both people with diabetes and their provi­
ders, of important glycemic patterns critical to tailored
diabetes management strategies. Common glycemic pat­
terns easily detected by CGM use, but not apparent via
HbA1c measurement or periodic capillary blood glucose
measurements, include nocturnal hypoglycemia, postpran­
dial hyperglycemia, reactive hyperglycemia following
hypoglycemia, and dawn phenomenon.
With the widespread adoption of CGM use, coupled with the
continually increasing global prevalence of type 2 diabetes [10]
and projected shortages of and disparate geographic access to
endocrinologists [11], internists and family practice providers
are increasingly being called upon to interpret CGM data in
real-world clinical practice. It is therefore of paramount impor­
tance that primary care providers have access to the tools
which will enable them to (1) interpret CGM data, and (2) utilize
CGM data to guide therapeutic modification for their patients
with type 2 diabetes. A significant obstacle in the widespread
use of CGM in primary care is the lack of familiarity with CGM
interpretation and the overwhelming amount of data gener­
ated by these devices. Given the limited amount of time avail­
able to internists and family physicians to address often
multiple complex topics in a typical office visit [12], it is essen­
tial for internists and family physicians to have a pragmatic,
simple, and systematic approach to CGM interpretation. This
article aims to provide physicians within internal medicine and
family practice with a simplified and systematic approach to
CGM interpretation that can be easily and efficiently implemen­
ted in a brief office visit.
2. Systematic approach to CGM interpretation
A systematic and stepwise approach to CGM interpretation
enables efficient extraction of the key data needed to guide
therapeutic modifications without becoming overwhelmed
Table 1. Stepwise approach to CGM interpretation.
Question
Before starting Is there enough data to be analyzed?
Step 1 What is the problem?
Step 2 Where is the problem?
Step 3 How to adjust therapy?
CGM: continuous glucose monitoring.
Table 2. Standardized CGM metrics.
Target for adults with type 1 or 2
CGM metric
Time above range (TAR): % of readings and time >250 mg/dL
(>13.9 mmol/L)
Time above range (TAR): % of readings and time >180 mg/dL
(>10.0 mmol/L)*
Time in range (TIR): % of readings and time 70–180 mg/dL (3.9–
10.0 mmol/L)
Time below range (TBR): % of readings and time <70 mg/dL
(<3.9 mmol/L)**
Time below range (TBR): % of readings and time <54 mg/dL
(<3.0 mmol/L)
Glycemic variability (%CV) target
DM: diabetes mellitus; TAR: time above range; TIR: time in range; TBR: time below range; CV: coefficient of variation.
*Includes percentage of values >250 mg/dL (13.9 mmol/L)
**Includes percentage of values <54 mg/dL (3.0 mmol/L)
†non-pregnant
and/or distracted by excessive data. Table 1 summarizes our
suggested stepwise approach.
2.1 Before starting: is there enough data to be
analyzed?
Before starting, one must first assess if there are enough data
available in the analysis period to enable meaningful interpre­
tation and to guide therapeutic decision-making. That is, one
must first determine if the test is valid for interpretation. In
defining data sufficiency, the International Consensus on Time
in Range recommends that the percentage of time CGM is
active be at least 70% of data from 14 days [13]. Analysis
periods with less data than the above should generally not
be used, as lower values may signify an unrepresentative data
sample or selective inclusion of days or times of day when
glucose values are either higher or lower than usual. In the
case of intermittently scanned CGM (isCGM) systems, this
could reflect disproportionate selective scanning by the user
at times of concern for either hypo- or hyperglycemia, or
conversely disproportionate selective omission of scans during
times of concern for abnormal glucose levels (for instance,
after high-carbohydrate meals or desserts).
2.2 Step 1: what is the problem?
Once data sufficiency is established as above, the next step is
defining what challenges exist: (1) excessive hypoglycemia, (2)
excessive hyperglycemia, or (3) both. This is determined by
assessment of standardized CGM metrics that are easily gleaned
from all commonly used CGM software systems. Standardized
CGM metrics with corresponding target ranges are shown in
Table 2 [13]. More conservative targets, with a priority placed
on avoidance of hypoglycemia and severe hyperglycemia,
should be used for elderly patients and/or those at high risk of
hypoglycemia or its complications, with hypoglycemia
Where to find the answer
% time CGM is active
CGM metrics
Ambulatory Glucose Profile
Daily glucose data
Target for older/high-risk adults with type 1 or 2
DM† DM†
<5% (<1 h, 12 min) <10% (<2 h, 24 min)
<25% (<6 h) <50% (<12 h)
>70% (>16 h, 48 min) >50% (>12 h)
<4% (<1 h) <1% (<15 min)
<1% (<15 min) 0%
≤36%
 POSTGRADUATE MEDICINE 745

unawareness, or with cognitive/physical impairments, comorbid­
ities, or assisted care requirements which complicate the treat­
ment regimen and increase risk of adverse treatment effects
(Table 2).
Time in Range (TIR) has been shown in multiple studies to
correlate well with HbA1c, as well as with risk of diabetes
complications. In many ways, TIR provides a more meaningful
metric of overall glycemia than HbA1c, since measures of
average glycemia such as HbA1c can be well within target,
even in the setting of alternating, sometimes severe and
potentially dangerous, hypoglycemia and hyperglycemia. TIR
is emerging as an intuitive indicator of current glycemia that is
easily understood by both patients and providers. TIR of 70%
corresponds to HbA1c of ~7.0% [14,15]. TIR has been shown to
correlate well with HbA1c, and each 10% increase in TIR (that
is, 2.4 more hours per day within the target range) corre­
sponds to a decrease of 0.6–0.8% in HbA1c on average
[14,15]. Even seemingly minor (for example 5%) increases in
TIR may signify clinically relevant progress [13]. In addition,
a growing body of literature has demonstrated that TIR is
associated with risk of microvascular [16–18] and macrovascu­
lar [19] complications in people with diabetes. Thus, TIR is
increasingly emerging as not only a meaningful diagnostic
and therapeutic tool in clinical practice, but also a seemingly
powerful predictor of diabetes complications.
2.3 Step 2: where is the problem?
The ambulatory glucose profile (AGP) provides a visual sum­
mary of glucose values measured during the specified analysis
period (typically the most recent 14 days), and as such provides
a straightforward means of visually identifying the times of day
during which episodes of hypoglycemia or hyperglycemia
requiring clinical action occur (Figure 1). The ‘modal day’ display
of glucose values, in which the glucose data collected over
a specified time period (typically 14 days) is aggregated into
a single 24-hour period, allows one to visually pinpoint the

Figure 1. Ambulatory Glucose Profile (AGP) examples from two different continuous glucose monitor (CGM) manufacturers. (a) The interquartile range (IQR) is
represented by the blue ribbon surrounding the median line and is indicated by the blue arrows. The dashed outer lines (10th and 90th percentiles) are indicated by
the green arrows. (b) The IQR is represented by the blue ribbon surrounding the median line and is indicated by the blue arrows. The dashed outer lines (5th and
95th percentiles) are indicated by the green arrows.
746 E. D. SZMUILOWICZ AND G. ALEPPO
time(s) of the day when specific glycemic patterns exist and
when glucose levels repeatedly deviate from the target range.
Indicating typical mealtimes on the AGP can be helpful in
determining whether hypoglycemia and/or hyperglycemia
patterns occur fasting, postprandially, or both. The interquar­
tile range (IQR; represented by the dark ribbon surrounding
the median line, indicated by blue arrows in Figure 1(a,b)
represents the 25th to 75th percentile range. Stated another
way, 25% of glucose values fall below the lower boundary of
the IQR, 25% of glucose values fall above the upper boundary
of the IQR, and the majority (50%) lie within the IQR. The
dashed outer lines (5–10th percentile curves and 90–95th per­
centile curves depending on the software brand, indicated by
green arrows in Figure 1(a,b) represent the more extreme
values; for example, 5% of glucose values fall below the 5th
percentile curve and 5% of glucose values fall above the 95th
percentile curve.
When assessing for patterns of hypoglycemia, look for any
times of day when the lowest percentile curve displayed (5–10th
percentile curve depending on the software, represented by the
dotted line) crosses 70 mg/dL; this is clinically significant because
the goal is to achieve <4% Time Below Range (TBR), and <1% for
older/high-risk patients (Table 2). That is, action is needed even
when only >5–10% of glucose values fall in the hypoglycemia
range. The recommendations (Table 2) to achieve <4% (<1 hour)
of the day below 70 mg/dL and <1% (<15 minutes) of the day
below 54 mg/dL (and <1% [<15 minutes] below 70 mg/dL in
older/high-risk adults) reflects the fact that both the amount and
severity of hypoglycemia should be considered in adjusting
therapy. Accordingly, action is warranted when glucose is
below 54 mg/dL for more than just 15 minutes of the day, or if
Figure 2. Therapeutic modifications based on CGM patterns.
a
Suggested therapeutic modifications are for people with type 2 diabetes only.bMultiple options for GLP-1 RA therapy are clinically available, including daily and weekly formulations. While
some comparative data between agents exist in regards to glycemic efficacy, selection of the specific agent among patients with atherosclerotic cardiovascular disease or with indicators of
high risk is additionally guided by differences in cardiovascular outcome data, and often by patient preference and payer coverage among patients without cardiovascular disease or
indicators of high risk [22]. GLP-1 RA: glucagon-like peptide 1 receptor agonist; SGLT-2: sodium-glucose co-transporter 2; DPP-4: dipeptidyl peptidase 4.
glucose is below 70 mg/dL for more than 1 hour of the day. The
practice of addressing hypoglycemia first is supported by two
important clinical principles: (1) even rare episodes of hypogly­
cemia can be dangerous; and (2) ‘hypoglycemia begets hyper­
glycemia’ when intrinsic counterregulatory mechanisms are
activated in response to hypoglycemia and/or defensive eating
is required to correct hypoglycemia.
In contrast, when assessing for patterns of hyperglycemia,
look for any times of day when the upper boundary of the IQR
(dark ribbon), rather than the extreme percentile curves, crosses
the upper end of the target range (180 mg/dL). Since the goal is
to achieve <25% Time Above Range (TAR), action is needed
when the 75th percentile (the upper boundary of the IQR, which
contains the majority of glucose values) crosses above this
upper target, but not when the more extreme percentile curves
cross into the hyperglycemia range. When only the highest
percentile line (90–95th percentile) crosses the upper target,
and thus the frequency of hyperglycemia is limited to no
more than 5–10% of the day, no immediate action is needed,
since hyperglycemia occurring 5–10% of the time (5–10% TAR)
is acceptable (Table 2). These infrequent episodes of hypergly­
cemia should prompt discussion of potential causes with the
patient, as they may represent unusually high-carbohydrate
meals, day-to-day variation, irregular meal/medication timing,
or other atypical patterns that do not constitute the norm. As
such, they do not warrant immediate therapeutic modification.
2.4 Step 3: how to adjust therapy?
Once the problem is identified in Step 1 (excessive hypoglyce­
mia, hyperglycemia, or both), and the hyperglycemic and/or

hypoglycemic patterns are localized in Step 2 (assessment of
AGP), the final step is determining appropriate therapeutic
modifications. For this, we suggest reviewing the most recent
7–14 days of daily glucose data, which can be found at the
bottom of the AGP profile report or in the daily glucose reports.
Reviewing the daily patterns provides granular details about
glucose trends over the day and thus enables one to assess the
glycemic impact of medication doses, medication timing, and
the impact of behaviors such as physical activity and alcohol
intake. When repeated patterns of hypoglycemia or hypergly­
cemia are identified, one should then suggest therapeutic mod­
ifications that address the specific patterns identified (Figure 2).
Common hypoglycemic and hyperglycemic patterns, and
general suggested therapeutic approaches for people with
type 2 diabetes, are described in Figure 2. One key principle
of therapeutic adjustment is to always address hypoglycemia
first [20]. That is, treatment modifications aimed at reduction
in hypoglycemia should be undertaken prior to interventions
directed at improving hyperglycemia. As described above,
even rare episodes of hypoglycemia can be clinically danger­
ous, and additionally hypoglycemia can be a major contributor
to subsequent hyperglycemia. In these instances, therapeutic
modifications aimed at reduction of hypoglycemia are an
effective therapy for the subsequent hyperglycemia (since
instrinsic counterregulatory responses will be quelled, and
defensive eating will no longer be necessary).
Another key principle, in determining the etiology and treat­
ment of fasting hyperglycemia, is the need to assess the trend
in glucose overnight and between meals. For patients taking
basal insulin, a large decrease in glucose overnight from bed­
time (post-dinner) to morning (before breakfast) generally indi­
cates an adequate or possibly excessive basal insulin dose.
Factors which may signal ‘overbasalization’ include basal insulin
dose more than ~0.5 units/kg/day and/or a large decrease in
glucose level from bedtime to morning or from post-meal to
subsequent pre-meal [7,21]. Further increasing the basal insulin
dose in this situation can lead to nocturnal/fasting hypoglyce­
mia. The intervention that is typically needed to lower the
fasting glucose in this situation (fasting glucose elevated, with
bedtime glucose on night prior even higher) is therapy aimed
at decreasing post-dinner/bedtime hyperglycemia from the
night prior, as decreasing evening postprandial glucose with
a therapy that targets postprandial hyperglycemia will in turn
lower fasting glucose the next morning (Figure 2).
In general, we suggest honing in on the most salient issue
at each visit. Addressing only one CGM pattern at each visit
allows the provider and patient to more clearly assess the
impact of the suggested therapeutic change and avoids over­
whelming the patient. As stated above, hypoglycemia should
always be addressed first. Once hypoglycemia is resolved or if
hypoglycemia is not present, then efforts should turn toward
treatment of hyperglycemia. For cases in which only postpran­
dial (but not fasting) hyperglycemia is present, therapeutic
modifications aimed at treating postprandial hyperglycemia
should be recommended (Figure 2). For cases in which both
fasting and postprandial hyperglycemia are present, we sug­
gest assessment of the trend in glucose overnight (Figure 2) to
help determine next steps in therapy. If there is minimal
POSTGRADUATE MEDICINE 747
decrease in glucose overnight, suggestive of hyperglycemia
throughout the day and night, we suggest adding or increas­
ing a therapeutic agent which either lowers fasting glucose
(basal insulin) or which lowers both fasting and postprandial
glucose (metformin, glucagon-like peptide 1 receptor agonist
[GLP-1 RA], sodium-glucose co-transporter 2 [SGLT-2] inhibitor,
or dipeptidyl peptidase 4 [DPP-4] inhibitor). If there is a large
decrease in glucose overnight and no nocturnal hypoglycemia
is observed, therapeutic modifications aimed at treating post-
dinner hyperglycemia should be recommended (Figure 2),
with the expectation that this intervention will also decrease
fasting glucose on the following day.
3. Case studies
3.1 Case example #1
A 71-year-old man with type 2 diabetes and hyperlipidemia
takes insulin degludec 24 units once daily (basal insulin),
metformin 1000 mg twice daily, dulaglutide 1.5 mg subcuta­
neously once per week (GLP-1 RA), and empagliflozin 25 mg
once daily (SGLT-2 inhibitor). He has no other significant med­
ical history and has intact cognitive and functional status. CGM
data are shown in Figure 3(a).
Before starting: Is there enough data to be analyzed?
Yes, there is >70% of data from 14 days.
Step 1: What is the problem?
● Time above range (TAR); % of readings and time
>250 mg/dL (target <5%; <1 h 12 min): 10%
● Time above range (TAR); % of readings and time
>180 mg/dL (target <25%; <6 h): 25 + 10 = 35%
● Time in range (TIR); % of readings and time 70–180 mg/
dL (target >70%; 16 h 48 min): 65%
● Time below range (TBR); % of readings and time <70 mg/
dL (target <4%; <1 h): 0%
● Time below range (TBR); % of readings and time <54 mg/
dL (target <1%; <15 min): 0%
As shown above, TAR is above target, and TIR is below
target (due to excessive hyperglycemia), so the problem is
that there is excessive hyperglycemia.
Step 2: Where is the problem?
On the AGP, the 5th percentile line (dotted line) does not
cross or even approach 70 mg/dL, so there are no significant
hypoglycemia patterns. The 75th percentile line (dark blue
band representing the IQR) crosses above 180 mg/dL after
meals, suggesting postprandial hyperglycemia (purple arrows).
748 E. D. SZMUILOWICZ AND G. ALEPPO

Figure 3. CGM data for case example #1, before (a) and after (b) therapeutic modification.
 POSTGRADUATE MEDICINE 749

Figure 4. CGM data for case example #2, before (a) and after (b) therapeutic modification.

Step 3: How to adjust therapy?
Review of the daily glucose trends (examples shown in
Figure 3(a)) showed postprandial hyperglycemia following
most but not all meals. Of note, fasting hyperglycemia was
noted on some days (red arrows); however, this followed
elevated postprandial bedtime glucose on the preceding
night, and glucose decreased by ≥50 mg/dL (≥2.8 mmol/L)
overnight from bedtime to fasting the next morning. This
pattern indicates that interventions targeting postprandial
hyperglycemia were needed (Figure 2), and these measures
750 E. D. SZMUILOWICZ AND G. ALEPPO
would be expected to improve the fasting glucose on the
next day as well. Indeed, fasting glucose levels were improved
on days when postprandial hyperglycemia on the night prior
was less severe (green arrows), indicating that the basal insulin
dose was adequate. The therapeutic modification recom­
mended was to increase dulaglutide to 3.0 mg once week to
address the postprandial hyperglycemia. In addition, the daily
glucose trends were reviewed with the patient to identify
which meal choices were associated with larger versus smaller
postprandial glucose increases, in order to guide meal choices.
Following these interventions, there was significant improve­
ment in TIR (increased from 65% to 86%) and TAR (decrease
from 35% to 14%; Figure 3(b)).
3.2 Case example #2
A 73-year-old woman with type 2 diabetes, coronary artery
disease (CAD), history of thrombotic intracerebral stroke
with residual deficits of right leg weakness and poor bal­
ance resulting in increased fall risk, hypertension, and
hyperlipidemia presents for an initial visit. She takes the
following diabetes medications: insulin glargine 17 units
once daily (basal insulin), glimepiride 1 mg daily, and
metformin 1000 mg twice daily. CGM data are shown in
Figure 4(a).
Before starting: Is there enough data to be analyzed?
Yes, there is >70% of data from 14 days.
Step 1: What is the problem?
● Time above range (TAR); % of readings and time
>250 mg/dL (target <10%; <2 h, 24 min): 1%
● Time above range (TAR); % of readings and time
>180 mg/dL (target <50%; <12 h): 1 + 17 = 18%
● Time in range (TIR); % of readings and time 70–180 mg/
dL (target >50%; >12 h): 67%
● Time below range (TBR); % of readings and time <70 mg/
dL (target <1%; <15 min): 9 + 6 = 15%
● Time below range (TBR); % of readings and time <54 mg/
dL (target 0%): 6%
As shown above, TBR is significantly above target, so the
problem is that there is excessive hypoglycemia. Note that
targets for older/high-risk adults are used based on the pre­
sence of multiple coexisting chronic illnesses and increased
fall risk.
Step 2: Where is the problem?
On the AGP, the 5th percentile line (dotted line), and nota­
bly even the 25th percentile line (dark blue band representing
IQR), both cross below 70 mg/dL overnight, indicating signifi­
cant overnight hypoglycemia (red arrow). The 75th percentile
line (dark blue band representing the IQR) crosses above
180 mg/dL after lunch and dinner, suggesting postprandial
hyperglycemia (purple arrows).
Step 3: How to adjust therapy?
The major challenge for this patient is significant hypogly­
cemia, which poses significant safety risks, particularly in the
setting of CAD, increased fall risk, and other comorbidities. Of
note, the hypoglycemia occurred predominantly overnight,
when it would not typically be captured by traditional finger­
stick glucose measurements and when the patient may not
experience symptoms of hypoglycemia. In addition, review of
the daily glucose trends (examples shown in Figure 4(a))
showed instances (yellow arrow showing representative exam­
ple) of hyperglycemia following hypoglycemic episodes (due
to the body’s intrinsic counterregulatory responses which
defend against hypoglycemia, as well as the patient’s practice
of eating exogenous carbohydrate in response to hypoglyce­
mia symptoms). Thus, it is imperative to address the hypogly­
cemia first, both due to the safety risks of hypoglycemia as
well as the fact that hypoglycemia actually contributes to
subsequent hyperglycemia (and treatment of hypoglycemia
typically improves the ensuing hyperglycemia). Therapeutic
modifications recommended were as follows: (1) decrease
insulin glargine to 12 units once daily and stop the glimepiride
(due to excessive hypoglycemia); and (2) continue metformin.
Once hypoglycemia resolved, the GLP-1 RA dulaglutide
0.75 mg subcutaneously once per week was added to treat
postprandial hyperglycemia, with a plan to subsequently
titrate the dose up to 1.5 mg weekly as tolerated (or higher
if needed for persistent hyperglycemia). In addition, the daily
glucose trends, which revealed intermittent postprandial
hyperglycemia following some but not all meals, were
reviewed with the patient to identify meal patterns associated
with improved postprandial glycemia (including pairing pro­
tein with carbohydrate, moderate carbohydrate consumption,
and lower glycemic-index carbohydrate choices). Following
these interventions, there was significant improvement in
TBR (decreased from 15% to 1%) and TIR (increased from
67% to 85%; Figure 4(b)).
4. Conclusion
CGM use has revolutionized modern diabetes care by provid­
ing easily obtained and actionable information regarding gly­
cemic trends that enables targeted and individualized
therapeutic modification. Internists and family physicians are
being increasingly called upon to interpret CGM data within
the time constraints of a primary care office visit, as CGM use
becomes more widespread amidst a growing population with
type 2 diabetes. While the plethora of data provided by CGM
can be overwhelming to providers unfamiliar with its use,
a simple, stepwise, and systematic approach to CGM interpre­
tation enables the efficient identification of glycemic trends
requiring therapeutic action as well as the therapeutic mod­
ifications needed.
 POSTGRADUATE MEDICINE 751

Abbreviations 4. Polonsky WH, Hessler D, Ruedy KJ, et al. The impact of continuous
glucose monitoring on markers of quality of life in adults with type
1 diabetes: further findings from the DIAMOND randomized clinical
AGP ambulatory glucose profile trial. Diabetes Care. 2017 Jun;40(6):736–741.
CAD coronary artery disease 5. Beck RW, Riddlesworth TD, Ruedy K, et al. Continuous glucose
CGM continuous glucose monitoring monitoring versus usual care in patients with type 2 diabetes
CV coefficient of variation receiving multiple daily insulin injections: a randomized trial. Ann
GLP-1 RA glucagon-like peptide 1 receptor agonist Intern Med. 2017 Sep 19;167(6):365–374.
GV glycemic variability 6. Martens T, Beck RW, Bailey R, et al. Effect of continuous glucose
HbA1c hemoglobin A1c monitoring on glycemic control in patients with type 2 diabetes
IQR interquartile range treated with basal insulin: a randomized clinical trial. JAMA. 2021
isCGM intermittently scanned CGM Jun 8;325(22):2262–2272.
SGLT-2 sodium-glucose co-transporter 2 7. American Diabetes Association Professional Practice Committee. 9.
TAR time above range Pharmacologic Approaches to Glycemic Treatment: standards of
TBR time below range Medical Care in Diabetes-2022. Diabetes Care. 2022 Jan 1;45
TIR time in range (Suppl 1):S125–S143.
8. Beck RW, Connor CG, Mullen DM, et al. The fallacy of average: how
using HbA1c alone to assess glycemic control can be misleading.
Acknowledgments Diabetes Care. 2017 Aug;40(8):994–999.
9. Perlman JE, Gooley TA, McNulty B, et al. HbA1c and glucose man­
This article was supported by the Division of Endocrinology, Metabolism
agement indicator discordance: a real-world analysis. Diabetes
and Molecular Medicine at Northwestern University.
Technol Ther. 2021 Apr;23(4):253–258.
10. Centers for Disease Control and Prevention. National diabetes
statistics report website. March 29, 2022. Available from:
Funding https://www.cdc.gov/diabetes/data/statistics-report/index.
This work was supported by the Division of Endocrinology, Metabolism html
and Molecular Medicine at Northwestern University. 11. Lu H, Holt JB, Cheng YJ, et al. Population-based geographic access
to endocrinologists in the United States, 2012. BMC Health Serv
Res. 2015 Dec 7;15(1):541.
Disclosure of any financial/other conflicts of interest 12. Tai-Seale M, McGuire TG, Zhang W. Time allocation in primary care
office visits. Health Serv Res. 2007 Oct;42(5):1871–1894.
E.D.S. has no competing financial interests. G.A. has served as consultant 13. Battelino T, Danne T, Bergenstal RM, et al. Clinical targets for
for Bayer, Dexcom, Inc., and Insulet Corporation and has received research continuous glucose monitoring data interpretation: recommenda­
support from Dexcom, Eli Lilly, Emmes, Fractyl Health and Insulet tions from the international consensus on time in range. Diabetes
Corporation. The authors have no other relevant affiliations or financial Care. 2019 Aug;42(8):1593–1603.
involvement with any organization or entity with a financial interest in or 14. Vigersky RA, McMahon C. The relationship of hemoglobin A1C to
financial conflict with the subject matter or materials discussed in the time-in-range in patients with diabetes. Diabetes Technol Ther.
manuscript apart from those disclosed. 2019 Feb;21(2):81–85.
A reviewer on this manuscript has disclosed ‘I have been an advisor 15. Beck RW, Bergenstal RM, Cheng P, et al. The relationships between
and consultant to Abbott Diabetes Care and advise, consult and speak on time in range, hyperglycemia metrics, and HbA1c. J Diabetes Sci
the use and interpretation of the AGP.’ Peer reviewers on this manuscript Technol. 2019 Jul;13(4):614–626.
have no other relevant financial relationships or otherwise to disclose. 16. Lu J, Ma X, Zhou J, et al. Association of time in range, as
assessed by continuous glucose monitoring, with diabetic reti­
nopathy in type 2 diabetes. Diabetes Care. 2018 Nov;41
ORCID (11):2370–2376.
17. Ranjan AG, Rosenlund SV, Hansen TW, et al. Improved time in
Emily D. Szmuilowicz http://orcid.org/0000-0002-7399-3934 range over 1 year is associated with reduced albuminuria in indi­
Grazia Aleppo http://orcid.org/0000-0003-1644-5947 viduals with sensor-augmented insulin pump-treated type 1
diabetes. Diabetes Care. 2020 Nov;43(11):2882–2885.
18. Beck RW, Bergenstal RM, Riddlesworth TD, et al. Validation of time
References in range as an outcome measure for diabetes clinical trials.
Diabetes Care. 2019 Mar;42(3):400–405.
1. Hood KK, DiMeglio LA, Riddle MC. Putting continuous glucose
19. Lu J, Wang C, Shen Y, et al. Time in range in relation to all-cause
monitoring to work for people with type 1 diabetes. Diabetes
and cardiovascular mortality in patients with type 2 diabetes:
Care. 2020 Jan;43(1):19–21.
a prospective cohort study. Diabetes Care. 2021 Feb;44
2. Beck RW, Riddlesworth T, Ruedy K, et al. Effect of continuous
(2):549–555.
glucose monitoring on glycemic control in adults with type 1
20. Kroger J, Reichel A, Siegmund T, et al. Clinical recommendations for
diabetes using insulin injections: the DIAMOND randomized clinical
the use of the ambulatory glucose profile in diabetes care.
trial. JAMA. 2017 Jan 24;317(4):371–378.
J Diabetes Sci Technol. 2020 May;14(3):586–594.
3. Lind M, Polonsky W, Hirsch IB, et al. Continuous glucose monitor­
21. Zisman A, Morales F, Stewart J, et al. BeAM value: an indicator of
ing vs conventional therapy for glycemic control in adults with
the need to initiate and intensify prandial therapy in patients with
type 1 diabetes treated with multiple daily insulin injections: the
GOLD RANDOMIZED CLINICAL TRIAL. JAMA. 2017 Jan 24;317 type 2 diabetes mellitus receiving basal insulin. BMJ Open Diabetes
(4):379–387. Res Care. 2016;4(1):e000171.