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CGM Will Change The Way We Treat Type 1 And Type 2 Diabetes

Feb 11, 2017

Let’s start off with what is in the pipeline.

Can CGM benefit not only type 1 diabetes — if so, what will it mean for those with type 2 diabetes?

Let’s look at the history of blood glucose monitors. At first it was who had the best software, smallest drop of blood and accuracy. They used to cost 75 cents a strip and the monitor companies where in a fierce competition, with all of them making millions if not billions of dollars. Then last year the government opened up bidding for the business and the price of 100 strips for most brands went from $75 per box to $10 for one hundred strips.  So now all the major companies are trying to sell their diabetes divisions that make blood glucose strips and monitors and they are losing money, but it will get worse.

Now let’s look at the CGM market. Dexcom has gotten their CGM approved by Medicare to pay for managing type 1 diabetes under specific circumstances.  People with type 2 diabetes and on insulin will be next to be approved. Right now, the sensors are expensive, which can make it difficult to get insurance companies to pay for it. They would rather pay $10 per month for blood glucose strips than a couple hundred dollars for sensors every month.

Now Dexcom and Google are working on a new CGM that is called the Band-Aid CGM that you will be able to wear for weeks at a time with wifi capabilities to send your results to your doctor or your care provider, and that will be cost effective. Then the blood glucose monitors will go the way of the Model-T or the landline phone.

If you think about it, knowing what your blood sugars are every three minutes, which will let you see how everything you eat and your physical activity affects your blood sugars, would not provide better results than sticking your finger 2-5 times daily.

Let’s look at the benefits of using CGM in the control of diabetes.

Start with the premise that the majority of individuals with type 1 and type 2 diabetes do not meet recommended glycemic targets. In a new study they looked at CGM vs Conventional Therapy for Type 1 Patients to evaluate the effects of continuous glucose monitoring in adults with type 1 diabetes treated with multiple daily insulin injections.

Open-label crossover randomized clinical trial conducted in 15 diabetes outpatient clinics in Sweden between February 24, 2014, and June 1, 2016 that included 161 individuals with type 1 diabetes and hemoglobin A1c (HbA1c) of at least 7.5% (58 mmol/mol) treated with multiple daily insulin injections.

Participants were randomized to receive treatment using a continuous glucose monitoring system or conventional treatment for 26 weeks, separated by a washout period of 17 weeks.

Difference in HbA1c between weeks 26 and 69 for the 2 treatments. Adverse events including severe hypoglycemia were also studied.

The results showed that among 161 randomized participants, mean age was 43.7 years, 45.3% were women, and mean HbA1c was 8.6% (70 mmol/mol). A total of 142 participants had follow-up data in both treatment periods. Mean HbA1c was 7.92% (63 mmol/mol) during continuous glucose monitoring use and 8.35% (68 mmol/mol) during conventional treatment (mean difference, -0.43% or -4.7; P < .001). Of 19 secondary end points comprising psychosocial and various glycemic measures, six met the hierarchical testing criteria of statistical significance, favoring continuous glucose monitoring compared with conventional treatment. Five patients in the conventional treatment group and one patient in the continuous glucose monitoring group had severe hypoglycemia. During washout when patients used conventional therapy, seven patients had severe hypoglycemia.

From the results, it was concluded that among patients with inadequately controlled type 1 diabetes treated with multiple daily insulin injections, the use of continuous glucose monitoring compared with conventional treatment for 26 weeks resulted in lower HbA1c. Further research is needed to assess clinical outcomes and longer-term adverse effects.

In another study, adult patients with type 1 diabetes who use multiple daily insulin injections had a significant reduction in HbA1c levels with continuous glucose monitor (CGM) versus usual care, according to researchers. There was a -0.6% mean change in A1c levels after 24 weeks of using a CGM compared with usual care (95% CI, -0.8% to -0.3%, P<0.001).  Usual care was defined as self-monitored blood glucose testing for a minimum of four times per day, they reported in the Journal of the American Medical Association.

A separate Swedish study, also in JAMA, also reported benefits with CGM in a similar patient population but at 26 weeks.

The Future is Near!

Practice Pearls:

  • This open-label, crossover trial examined two different glucose monitoring approaches in 161 adults with type 1 diabetes treated with insulin injections. Participants received 26 weeks of treatment with a continuous glucose monitoring system or conventional treatment, followed by a washout period, and then the opposite intervention.
  • During the continuous glucose monitoring phase, mean HbA1c was 7.92%; during conventional treatment, it was 8.35% (P  <  .001). Patients also experienced fewer episodes of severe hypoglycemia during the continuous glucose monitoring phase compared with the conventional treatment phase (one vs five events, respectively).
  • Continuous glucose monitoring was more effective for lowering HbA1c and reducing instances of hypoglycemia than conventional treatment in type 1 diabetics using insulin injections. Additional research on continuous glucose monitoring systems will be needed to determine the impact of these devices on long-term patient outcomes.

JAMA; 2017 Jan 24; 317 (4)379-387; M Lind, W Polonsky, IB Hirsch, et al : also Published in Diabetes