Continuous Glucose Monitoring and Its Use Beyond Type 1 Diabetes

March 11, 2021
CGM Use Beyond
Type 1 Diabetes?
Aaron Neinstein, MD
Associate Professor, UCSF
Director of Clinical Informatics
UCSF Center for Digital Health Innovation

Disclosures
Research Support
 Cisco Systems, Inc
 Commonwealth Fund
Writing
 WebMD/Medscape
Advisor (Uncompensated)
 Tidepool
 OPEN (Outcomes of Patients with Novel,
DIY Artificial Pancreas Technology)
Consultant or Advisor (Compensated)
 Steady Health
 Medtronic Diabetes
 Intuity Medical
 Eli Lilly
 Roche
 Nokia Growth Partners
 Grand Rounds

Presentation Title
7
Let’s start with a prediction: By 2025, everyone with
diabetes will be tracking their blood sugar with devices
called continuous glucose monitors, and it will be
common for many people without diabetes to dabble in
tracking, too.
CGM Use Beyond Type 1 Diabetes | Mar 11, 2021 | @aaronneinstein

8
Why are we seeing this?
What is evidence-based?
What is fact?
What is hype?

CGM Use Beyond Type 1 Diabetes | Mar 11 2021 | @aaronneinstein
9
T1D Exchange: US CGM Use Over Time
Foster NC et al. State of Type 1 Diabetes Management and Outcomes from the T1D Exchange in 2016-2018. Diabetes
Technology & Therapeutics. 2019 Feb.
Industry
Estimates
50%

10
T1D Exchange: Mean A1c by Use of Tech (2016-2018)
CGM use associated with larger impact on A1c than Insulin Pumps
Foster NC et al. State of Type 1 Diabetes Management and Outcomes from the T1D Exchange in 2016-2018.
Diabetes Technology & Therapeutics. 2019 Feb.
Pump +
CGM
MDI +
CGM
Pump
Only
MDI
Only
Age <13 Age 13-26 Age >26
Pump +
CGM
MDI +
CGM
Pump
Only
MDI
Only
Pump +
CGM
MDI +
CGM
Pump
Only
MDI
Only

11
“From this review, we conclude that when diabetes duration is over one year,
the overall effect of self-monitoring of blood glucose on glycemic control
in patients with type 2 diabetes who are not using insulin is small up to six
months after initiation and subsides after 12 months. Furthermore, based on
a best-evidence synthesis, there is no evidence that SMBG affects patient
satisfaction, general well-being or general health-related quality of life.”
Jan 18, 2012

12

13

14

15

Fifteen-day glucose traces of two subjects with identical A1c
of 8.0% but different degrees of glycemic variability.
Boris Kovatchev, and Claudio Cobelli Dia Care 2016;39:502-510
A1c has many limitations: Glycemic Variability
16

17
… and SMBG is not as accurate as people often think
2016 FDA Guidance on Home BG Meter Accuracy
 95% of BG meter values must be within 15% of true lab value
 Therefore, if lab-measured glucose is 100 mg/dl:
- BG meter has to be within 15 mg/dl (85-115 mg/dl) 95% of time

18
2016 FDA Guidance on Home BG Meter Accuracy
 Therefore, if lab-measured glucose is 100 mg/dl:
https://www.diabetestechnology.org/surveillance.shtml

19
CGM is not the same as it was in 1999
 Bulky
 Painful insertion
 Expensive
 Poor accuracy
 Multiple calibrations
 <3 day wear
 Data trapped
 Slimmer
 Easier to insert
 Improving reimbursement
 Improved accuracy
 No calibrations
 10+ day wear
 Data liquidity
1999 2021

20
… and major trends will drive increased interest in use
1. Accuracy, size, cost, & availability
2. Cloud data upload
3. Analytic software & digital coaching tools
4. Telehealth
5. Shift toward value-based care (sort of)
… and don’t forget: People really don’t like doing fingersticks!

21 CGM Use Beyond Type 1 Diabetes | Mar 11 2021 | @aaronneinstein
Rapid Rise in Telehealth Rates During COVID19
UCSF – Endocrinology Visits

22 CGM Use Beyond Type 1 Diabetes | Mar 11 2021 | @aaronneinstein
Rapid Rise in Telehealth Rates During COVID19
UCSF – Endocrinology Visits

Endocrinology remains one of the top users of telehealth in the US

24
Summary: Context for CGM Use Beyond T1D
 Diabetes rates continue to grow globally
 Direct US healthcare spend on diabetes is $237B
 Lifestyle & behavior change are cornerstones of diabetes prevention & treatment
 Neither SMBG nor A1c are effective tools to enable lifestyle & behavior change
 CGM has gotten cheaper, easier, more accessible
 Telehealth is here to stay

26
DIAMOND Study Group (2017) – 158 adults with T2D using multiple daily insulin injections
Results at 24
weeks
CGM Group Control
(Blinded CGM)
Group
P values
Mean A1c 7.5% 7.9% 0.005
Fingersticks 2.9/day 3.8/day <0.001
Time per day <70
mg/dL
4 minutes 12 minutes
QoL metrics No difference
Beck, R. W. et al. Continuous Glucose Monitoring Versus Usual Care in Patients With Type 2 Diabetes Receiving
Multiple Daily Insulin Injections: A Randomized Trial. Ann Intern Med 167, 365–374 (2017).

27
Park C and Le Q. The effectiveness of continuous glucose monitoring in patients with type 2 diabetes: a systematic review of literature and meta-analysis. DTT. 2018.
Meta-Analysis of CGM in People with Type 2 Diabetes (1 of 2)
 1384 patients
 65.5% insulin users
 4902 patients
 69.1% insulin users

28
Meta-Analysis of CGM in People with Type 2 Diabetes (2 of 2)
Ida et al. Utility of Real-Time and Retrospective Continuous Glucose Monitoring in Patients with Type 2 Diabetes Mellitus: A Meta-Analysis of Randomized Controlled Trials.
J Diabetes Res 2019, 1–10 (2019).

29
Miller et al; 84-LB; Diabetes 2020 Jun; 69 (Supplement 1)
Reduction in A1c after CGM initiation – retrospective, observational

30
CGM in T2D on rapid-acting insulin - retrospective, observational
Bergenstal et al; 69-OR; Diabetes 2020 Jun; 69 (Supplement 1)

31
Miller et al; 85-LB; Diabetes 2020 Jun; 69 (Supplement 1)
CGM in T2D on no rapid-acting insulin - retrospective, observational

32
Feb 2018 to Dec
2018
• Mean Follow-Up:
4.2 months
• 191 participants
had telemedicine
visit with Endo

33
CGM + Shared
Medical Appointments
Simonyan, A. R. et al. Continuous Glucose Monitoring
Shared Medical Appointments Improve Diabetes
Self‐Efficacy and Hemoglobin A1C. J Am Coll Clin Pharm
(2021) doi:10.1002/jac5.1409.
• 171 participants – 69% T2D
• Baseline A1c average 8.64%
• Baseline Meds: 76% basal insulin, 63%
bolus; 2% on no medications

34
CGM + Shared Medical Appointments
 Significant improvements in
diabetes self-efficacy scores
 0.83% A1c reduction
(p <0.001) in people with T2D
Simonyan, A. R. et al. Continuous Glucose Monitoring Shared Medical Appointments Improve Diabetes Self‐Efficacy and
Hemoglobin A1C. J Am Coll Clin Pharm (2021) doi:10.1002/jac5.1409.

35
Case: 70 yo man with T2D on Metformin
 No microvascular complications, diabetes diagnosis approx.
2-3 years ago
 Coronary artery disease, multiple stents
 A1c 7.3% on 500mg Metformin BID
 A1c 6.5% on 1000mg Metformin BID and decreased dessert
 Never does fingersticks

36
A1c 6.5% - 7.3%

37
A1c 6.5% - 7.3%

38

39

40
Pre and Post Meal BGs Miss Spike
81
99
114
131
129
112
100

42
Cost Effectiveness Estimates: T2D not on prandial insulin
Fonda et al (2016)
 0.10 yr life expectancy gain
 0.07 quality-adjusted life expectancy gain
 Estimated cost of $9,319 per life year gained
 Estimated cost of $13,030 per QALY gained

43
What about people
without diabetes?

44
Glucotypes – Hall et al
57 healthy participants without diabetes
Hall H et al. Glucotypes reveal new patterns of glucose dysregulation. PLoS Biol. 2018 Jul

45
Glucotypes – Hall et al
Clinical metabolic phenotypes created based on CGM data
Hall H et al. Glucotypes reveal new patterns of glucose dysregulation. PLoS Biol. 2018 Jul
 All 3 glucotype patterns observed within traditional categories
 Severe glucose variability present in 25% of “normoglycemic”
 Is it possible that increased glucose variability might represent an
earlier (or different) method of determining risk?
 What is the predictive value of a CGM “severe glucotype”?

46
Many Questions Remain
 Which population segments? Basal insulin. Non-insulin medications.
No medications. Pre-diabetes. No known pathology. Athletic
performance.
 Cost effectiveness in each population?
 What’s the right “dose”? Duration? Frequency?
 What care model is needed? CGM alone? CGM accompanied by
coaching? What intensity of coaching?

Continuous Glucose Monitoring and Its Use Beyond Type 1 Diabetes

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Continuous Glucose Monitoring and Its Use Beyond Type 1 Diabetes

Similar to Continuous Glucose Monitoring and Its Use Beyond Type 1 Diabetes (20)

Recently uploaded

Recently uploaded (20)

Continuous Glucose Monitoring and Its Use Beyond Type 1 Diabetes

Editor's Notes