Silver Fern Healthcare recently integrated the topic of continuous glucose monitoring (CGM) into its Type 2 Diabetes Program on its Behavior Diagnostic Platform. We felt it was essential that clinicians were covering the topic of CGM with their patients as the technology continues to gain acceptance and is more widely available to people with type 2 diabetes. Here’s a bit more on why we felt this content enhancement was essential and timely.
Type 2 diabetes is a multifaceted, difficult-to-treat, chronic disease. It requires patients to be actively involved in their treatment because of the proven and profound impact of individual behavior and lifestyle choices on achieving glycemic control. One major requirement of diabetes self-management is the ability to collect and interpret blood glucose data to make decisions concerning food intake, exercise, and medication adjustments. Patients need tools that are accurate, easy-to-use, and affordable so that they can appreciate the connection between their blood glucose numbers and their behavior.
Although the majority of people living with type 2 diabetes still use fingerstick blood glucose monitoring to obtain a static snapshot of blood glucose levels, continuous glucose monitors allow for a more nuanced view of glucose patterns over time (7-14 days depending on the product). In 2017, the Centers for Medicare and Medicaid Services (CMS) approved the use of non-adjunctive CGMs for people with diabetes meeting certain conditions, including taking multiple daily injections of insulin and checking at least four times a day, opening the door for these devices to become more available to patients living with type 2 diabetes. Coverage may vary, but many of the top commercial insurers have followed CMS’s lead, removing obstacles to wider adoption of CGMs. But what is continuous glucose monitoring and how can patients integrate these devices into their day-to-day lives?
There are two distinct types of CGMs designed for personal patient use: real-time CGMs and intermittent CGMs, both of which have been shown to lower A1C and reduce the incidence of hypoglycemia. All CGMs are comprised of three major parts: 1. the sensor, which is placed under the skin to measure glucose levels in interstitial fluid; 2. the receiver or monitor, which displays the patient’s glucose reading; and 3. the transmitter, which transmits raw, glycemic data from the sensor to the receiver. According to the American Diabetes Association, real-time CGMs passively send a continuous stream of blood glucose data to a receiver or smartphone, which can alert patients if their blood glucose falls below or rises above a user-determined level (some intermittent systems have also included this feature). Real-time CGMs can predict if blood glucose levels are stable, rising, or falling, giving patients an unprecedented amount of information in real time through these robust devices. Intermittent CGMs provide patients with the same information but require individuals to purposefully scan the sensor to find out their blood glucose levels. These devices tend to be more affordable than most real-time CGMs. Both real-time CGMs and intermittent CGMs come with data management programs that allow patients and healthcare providers to review blood glucose history and identify patterns of fluctuation based on food intake, medication, and exercise records.
Continuous glucose monitoring, especially with affordable intermittent devices, let patients see the results of their self-management actions in real-time, without having to experience the discomfort of fingers pricks or the hassle of using their meter in public. For some patients, these are examples of barriers that can prevent proper blood glucose self-management. These barriers, as well as barriers to the patient’s proper use of the CGM technology, are crucial for healthcare providers to understand as they can ensure patients successfully manage their blood glucose. These barriers, in addition to patient behaviors and goals for blood glucose monitoring are comprehensively assessed by Silver Fern’s Type 2 Diabetes Program.
CGMs can be a powerful tool for behavior change by allowing patients to identify issues and measure the impact of their choices, activities, and medications. For example, a patient using an intermittent glucose monitor can scan their sensor before and two hours after a lunch of pasta and garlic bread to see for themselves the effect of their food choices on their glucose readings. Or an elderly patient can be alerted by their real-time CGM of overnight hypoglycemia – information they would not have known by only using a fingerstick blood glucose monitor. Clinicians also benefit from this data and can better understand their patient’s condition. For instance, a 14-day retrospective review of blood glucose could identify hypoglycemic levels in the late evening corresponding to an early-evening exercise routine. This discovery could lead to a productive conversation about adding a snack before exercising or reducing pre-dinner insulin doses.
As with any technological advancement, there are barriers and drawbacks to continuous glucose monitoring (including potential financial ones that directly impact patients). It is important to understand where each patient is on their journey with type 2 diabetes, and how implementing real-time CGM or intermittent CGM can result in unforeseen consequences. Open discussions with patients and recognizing obstacles could help address misconceptions and improve care. Silver Fern Healthcare added continuous glucose monitoring into its Behavior Diagnostic Platform because it is quickly becoming the standard of care for patients with type 2 who take insulin. As these devices become more readily available and affordable, healthcare front line providers should consider adopting the technology to help patients achieve glycemic control.
Stay tuned for upcoming Practice Points that dive deeper into CGM: Who would be a good candidate? What barriers might prevent patients from using CGM? And how can PCPs adopt this technology into their existing workflow?
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Nora Saul is a Registered Dietitian and Certified Diabetes Care and Education Specialist. Nora has more than 25 years of experience in the field of diabetes education, consulting for the Joslin Diabetes Center and other industry partners. Nora leads content development for Silver Fern’s diabetes products and training.