Broadening Access to Continuous Glucose Monitoring for Patients With Type 2 Diabetes

Abstract

Persons from racial and ethnic minority populations, those in low-income groups, and other socially marginalized groups are disproportionately affected by type 2 diabetes and experience higher disease prevalence, poorer glycemic control, higher rates of diabetes complications, and higher prevalence of comorbid conditions. 1,2 Achieving glucose targets that will reduce the risk of diabetes complications, particularly among high-risk groups, is critical to improve the health and well-being of those with diabetes and to reduce health care utilization and expenditures. Yet, diabetes control remains elusive. Self-monitoring of blood glucose, while still a standard part of diabetes self-management, has not been shown to result in self-adjustments to insulin in primary care settings. This represents a significant opportunity gap because 30% of patients with type 2 diabetes are treated with some form of insulin. 3 Real-time continuous glucose monitoring (CGM), which measures glucose levels in subcutaneous interstitial fluid as frequently as every 5 minutes, has been shown to improve diabetes control, reduce hypoglycemia, and be cost-effective for patients with type 1 diabetes. 4,5 Less research has been conducted among patients with type 2 diabetes, but clinical trials involving patients using intensive insulin regimens (eg, basal/ bolus insulin) have shown reductions in hemoglobin A 1c (HbA 1c ) levels and shorter intervals of hypoglycemia. 6,7 Several questions remain: Can the results of clinical trials of patients with type 2 diabetes be translated into usual care settings? Can patients with type 2 diabetes who use less intensive insulin regimens benefit from CGM? Can CGM be feasibly implemented in primary care settings, where most of type 2 diabetes management occurs? In this issue of JAMA, the randomized clinical trial (RCT) reported by Martens et al 8 and the observational study reported by Karter et al 9 provide new data that help provide answers to these questions.Martens et al 8 conducted an RCT of CGM (n = 116) vs blood glucose meter (BGM) monitoring (n = 59) among adults with type 2 diabetes who were taking basal insulin without prandial insulin and were recruited from primary care practices. At 8 months, the mean HbA 1c level improved from 9.1% to 8.0% in the CGM group and from 9.0% to 8.4% in the control group (adjusted difference, −0.4% [95% CI, −0.8% to −0.1%]). This effect size may have been greater if the control group had received usual care rather than instructions on how to self-titrate insulin based on BGM data. Compared with the BGM group, the time in range, or the amount of time spent in the target blood glucose range (70-180 mg/dL), was 3.6 hours per day higher, the mean glucose level was

Continuous Glucose Monitoring and Glycemic Control in Patients With Type 2 Diabetes Treated With Basal Insulin

“…Although the study included a diverse group of patients, the authors did not present some important information that may have affected glycemic control (eg, adherence to insulin and other diabetes medications, dietary changes, physical activity). As the accompanying Editorial suggests, patient engagement is critical to enhance outcomes in diabetes. In support of this assertion, we note that patients with a baseline hemoglobin A 1c (HbA 1c ) of at least 10% had a 2.1% decrease in HbA 1c with CGM vs a 0.1% decrease with blood glucose monitoring (BGM), despite little change in insulin dose or medication class (eTables 8, 11, and 12 in Supplement 2 of the article).…”

What accounts for the high mortality of anorexia nervosa?

“…(b) For those patients with low A1c levels or for those who present with a serum glucose <35 mg/dl, utilize the useful technology of continuous glucose monitoring (CGM) devices to detect hypoglycemia which will provide the most proximate serum glucose level before a potentially catastrophic event. CGMs are increasingly being utilized to improve diabetic outcomes (Peek & Thomas, 2021) and advances in biomedical technology have made them smaller, more comfortable and easier to use (Presseler, Parker, Lin, Weimer & Juarascio, 2020). (c) As part of a rigorous research study, insert long‐term cardiac monitoring devices in the chest walls of patients with moderately severe AN and continuously monitor their heart rhythm to try to further correlate marked bradycardia or lethal arrythmias as the proximate adverse event causing sudden death.…”

“…(b) For those patients with low A1c levels or for those who present with a serum glucose <35 mg/dl, utilize the useful technology of continuous glucose monitoring (CGM) devices to detect hypoglycemia which will provide the most proximate serum glucose level before a potentially catastrophic event. CGMs are increasingly being utilized to improve diabetic outcomes (Peek & Thomas, 2021) (Tseng et al, 2021). Perhaps more frequent autopsy F I G U R E 1 Conceptual model: cardiovascular complications of eating disorders and mortality risk.…”

Differences in Glucose Levels Between Arms Using Continuous Glucose Monitors

“…Use of continuous glucose monitoring (CGM) devices is on the rise. 1,2 Interestingly, in an analysis of the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database, more than 25 000 complaints of CGM device inaccuracy have been filed. 3 We sought to determine whether glucose levels differ between the left and right arms.…”