Make room for continuous glucose monitoring in type 2 diabetes management
Here’s how the various devices can be used to reach an individualized target of glycemic control and what reimbursement to expect from insurers.
PRACTICE RECOMMENDATIONS
› Initiate continuous glucose monitoring early in the disease process, based on a patient’s needs or preferences. C
› Interpret a continuous glucose monitor (CGM) report with the understanding that time within target range is the most important factor to evaluate. Minimizing or eliminating time below range is of paramount importance. B
› Advise patients who use a CGM to continue to have access to a glucometer and instruct them on appropriate times when such confirmation might be necessary. B
Strength of recommendation (SOR)
A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series
In general, patients should be counseled to rotate the location of the sensor and to use only specific barrier products that are recommended on each manufacturer’s website. The use of other barriers that are not specifically recommended might compromise the accuracy of the sensor.
Summing up
As CGM technology improves, it is likely that more and more of your patients will utilize one of these devices. The value of CGMs has been documented, but any endorsement of their use is qualified:
- Data from many older RCTs of patients with T2D who utilize a CGM did not demonstrate a significant reduction in A1C20,24,36; however, real-world observational data do show a greater reduction in A1C.
- From a safety standpoint, contact dermatitis is the primary drawback of CGMs.
- CGMs can provide patients and clinicians with a comprehensive picture of daily glucose trends, which can help patients make lifestyle changes and serve as a positive reinforcement for the effects of diet and exercise. Analysis of glucose trends can also help clinicians confidently make decisions about when to intensify or taper a medication regimen, based on data that is reported more often than 90-day A1C changes.
Health insurance coverage will continue to dictate access to CGM technology for many patients. When a CGM is reimbursable by the patient’s insurance, consider offering it as an option—even for patients who do not require an intensive insulin regimen.
a The US Food and Drug Administration cleared a new Abbott CGM, FreeStyle Libre 3, earlier this year; however, the device is not yet available for purchase. With advances in monitoring technology, several other manufacturers also anticipate introducing novel CGMs. (See “Continuous glucose monitors: The next generation.” )
SIDEBAR
Continuous glucose monitors: The next generation9-13
Expect new continuous glucose monitoring devices to be introduced to US and European health care markets in the near future.
FreeStyle Libre 3 (Abbott) was cleared by the US Food and Drug Administration in May 2022, although it is not yet available for purchase. The manufacturer promotes the device as having the smallest sensor of any continuous glucose monitor (the diameter and thickness of 2 stacked pennies); improved mean absolute relative difference; the ability to provide real-time glucose level readings; and 50% greater range of Bluetooth connectivity (about 10 extra feet).9,10
Dexcom G7 (Dexcom) has a sensor that is 60% smaller than the Dexcom G6 sensor and a 30-minute warm-up time, compared to 120 minutes for the G6.11 The device has received European Union CE mark approval.
Guardian 4 Sensor (Medtronic) does not require fingerstick calibration. The device has also received European Union CE mark approval12 but is available only for investigational use in the United States.
Eversense XL technology is similar to that of the Eversense E3, including a 180-day sensor.13 The device, which has received European Union CE mark approval, includes a removable smart transmitter.
CORRESPONDENCE
Kevin Schleich, PharmD, BCACP, Departments of Pharmaceutical Care and Family Medicine, University of Iowa, 200 Hawkins Drive, 01102-D PFP, Iowa City, IA, 52242; kevin-schleich@uiowa.edu
