Insulin dose adjustment policy for certified diabetes care and education specialists: Safe and effective

In 4T Study 1, youth with new-onset type 1 diabetes started a continuous glucose monitor (CGM) soon after diagnosis and received remote CGM data review and dose changes by a Certified Diabetes Care and Education Specialist (CDCES) via secure portal messaging. We describe the CDCES policy to make incremental dose adjustments and report its safety and effectiveness, which facilitated patients' reaching and maintaining targets. We aim to publish this data-supported CDCES protocol to facilitate use at other diabetes centers who may restrict CDCES from adjusting insulin doses. The CDCESs and Pediatric Endocrinologists agreed on criteria for making dose changes. CDCESs made insulin dose adjustments and consulted with Pediatric Endocrinologists per protocol and as needed. CDCES sent messages with suggested dose adjustments and behavior changes via secure portal messaging. In the first year, a total of 1564 remote patient monitoring messages were sent to 133 participants. Most messages were triggered by low time-in-range (TIR, 70-180 mg/dl [63 %]), hypoglycemia (39 %), decline in TIR (13 %), or insufficient CGM wear time (7 %). There were 3 episodes of severe hypoglycemia, none adjudicated related to the CDCES dosing protocol. At one year, the mean time <70 mg/dl was <2 %, and the A1C target of <7 % was met by 64 %. We created a policy for CDCESs to adjust insulin doses and increase patient interaction between visits. The results demonstrate that CDCES can work at the top of their certification to adjust insulin doses to achieve target goals without decreasing safety.