The Effect of Discontinuing Continuous Glucose Monitoring in Adults With Type 2 Diabetes Treated With Basal Insulin

A Randomized Clinical Trial of a Culturally Tailored Diabetes Education Curriculum With and Without Real-Time Continuous Glucose Monitoring in a Latino Population With Type 2 Diabetes: The CUT-DM With Continuous Glucose Monitoring Study

BACKGROUND

Data on culturally tailored diabetes education with and without real-time continuous glucose monitoring (RT-CGM) in Latinos with type 2 diabetes, who are not on intensive insulin management, is lacking.

RESEARCH DESIGN AND METHODS

This is an open-label randomized control trial of Latinos with uncontrolled (HbA1c > 8.0%) type 2 diabetes conducted in a Federally Qualified Health Center (FQHC). All participants received 12 one-hour culturally tailored education sessions. Patients were randomized (1:1) to education sessions only (blinded CGM) or cyclic (50 days wear: 10 days on, 7 days off) RT-CGM. The primary outcome was a change in HbA1c from baseline to 12 weeks in those with or without CGM. Secondary outcomes included 24-week HbA1c, CGM, and metabolic parameters.

RESULTS

Participants (n = 120) were 46 years old on average, 44% female, 98% preferred Spanish language, 30% with income <$25,000, 68% uninsured and 26% using basal insulin only. Mean 1-hour session attendance and RT-CGM wear was 7.0 (±4.4) and 27.9 (±20.5) days, respectively. Mean baseline HbA1c was 10.5% (±1.8). HbA1c reduced by 1.9% (95% confidence interval [CI]: 1.5-2.3) overall (P < .001). Participants in the RT-CGM group reduced HbA1c at 12 weeks by 2.3% (95% CI: 1.5-3.2) compared to 1.5% (95% CI: 0.6-2.3) in the blinded CGM group (P =.04). At 24 weeks, overall HbA1c reduction was maintained but between-group differences attenuated.

CONCLUSIONS

In a Latino type 2 diabetes population that was primarily noninsulin-requiring, virtually delivered, culturally tailored education improved HbA1c, with RT-CGM conferring greater improvement. RT-CGM should be an adjunctive therapy to diabetes education, irrespective of insulin use but continued cyclic CGM use may be needed for sustained effect.

Addressing the Diabetes Tsunami Requires Expanded Access to Diabetes Technologies

The use of continuous glucose monitoring (CGM) and automated insulin delivery (AID) technologies can improve patient outcomes and overall quality of life while helping to reduce the long-term costs. However, current eligibility criteria imposed by many major commercial insurers limit access to these technologies among a large portion of the diabetes population. This narrative review and commentary highlights the evidence supporting the use of CGM and AID in the various diabetes populations, discuss the current eligibility criteria that make these technologies inaccessible to individuals who would benefit, and present recommendations for modifying these criteria.

Addition of continuous glucose monitoring to glucagon-like peptide 1 receptor agonist treatment for type 2 diabetes mellitus - An economic evaluation

BACKGROUND

Both glucagon-like peptide 1 receptor agonists (GLP-1 RAs) and continuous glucose monitoring (CGM) have been shown to improve glycated hemoglobin A1c (A1c) levels among patients with type 2 diabetes mellitus (T2DM). Recently, a US real-world study found statistically significant improvements in A1c levels among patients using GLP-1 RA and a CGM device, compared with a matched cohort receiving only GLP-1 RA.

OBJECTIVES

To assess the cost-effectiveness from a US payer perspective of initiating CGM (FreeStyle Libre Systems) in people living with T2DM using a GLP-1 RA therapy, compared with GLP-1 RA alone.

METHODS

A patient-level microsimulation model was run for 10,000 patients over a lifetime horizon with 3.0% discounting for costs and utilities. Patient characteristics were based on the overall population of the US real-world study and the subgroup of patients not using intensive insulin. The effect of CGM was modeled as a persistent reduction in A1c compared with GLP-1 RA alone (overall = 0.37%; patients not using intensive insulin = 0.34%). Costs ($2,023) and disutilities were applied to diabetes complications and acute diabetic events. Outcomes were assessed as quality-adjusted life years (QALYs).

RESULTS

The base-case incremental cost-effectiveness ratio (incremental costs/incremental QALYs) for GLP-1 RA plus CGM vs GLP-1 RA alone was $40,968/QALY in the overall cohort (cost = $484,180 vs $473,938; QALYs = 13.37 vs 13.12). Among patients not using intensive insulin, the incremental cost-effectiveness ratio was $43,095/QALY. Scenario analysis showed that the model results were robust to changing assumptions. Probabilistic sensitivity analysis showed that GLP-1 RA plus CGM had a 64% probability of being cost-effective at a willingness-to-pay threshold of $100,000 per QALY.

CONCLUSIONS

From a US payer perspective, CGM is cost-effective when added to GLP-1 RA therapies for the treatment of T2DM, including for patients not using intensive insulin.

"Now I can see it works!" Perspectives on Using a Nutrition-Focused Approach When Initiating Continuous Glucose Monitoring in People with Type 2 Diabetes: Qualitative Interview Study

BACKGROUND

Food choices play a significant role in achieving glycemic goals and optimizing overall health for people with type 2 diabetes (T2D). Continuous glucose monitoring (CGM) can provide a comprehensive look at the impact of foods and other behaviors on glucose in real time and over the course of time. The impact of using a nutrition-focused approach (NFA) when initiating CGM in people with T2D is unknown.

OBJECTIVE

This study aims to understand the perspectives and behaviors of people with T2D who participated in an NFA during CGM initiation.

METHODS

Semistructured qualitative interviews were conducted with UNITE (Using Nutrition to Improve Time in Range) study participants. UNITE was a 2-session intervention designed to introduce and initiate CGM using an NFA in people with T2D who do not use insulin. The intervention included CGM initiation materials that emphasized the continuous glucose monitor as a tool to guide evidence-based food choices. The materials were designed to support conversation between the CGM user and diabetes care provider conducting the sessions. A rapid matrix analysis approach was designed to answer two main questions: (1) How do people who participate in an NFA during CGM initiation describe this experience? and (2) How do people who participate in an NFA during CGM initiation use CGM data to make food-related decisions, and what food-related changes do they make?

RESULTS

Overall, 15 people completed interviews after completion of the UNITE study intervention: 87% (n=13) identified as White, 60% (n=9) identified as male, mean age of 64 (SD 7.4) years, mean T2D duration of 7.5 (SD 3.8) years, and mean hemoglobin A1c level of 7.5% (SD 0.4%). Participants fluently discussed glycemic metrics such as time in range (percent time with glucose 70-180 mg/dL) and reported regularly using real-time and retrospective CGM data. Participants liked the simplicity of the intervention materials (eg, images and messaging), which demonstrated how to use CGM data to learn the glycemic impact of food choices and suggested how to adjust food choices for improved glycemia. Participants reported that CGM data impacted how they thought about food, and most participants made changes because of seeing these data. Many of the reported changes aligned with evidence-based guidance for a healthy lifestyle, including prioritizing nonstarchy vegetables, reducing foods with added sugar, or walking more; however, some people reported behavior changes, such as skipping or delaying meals to stay in the target glucose range. A few participants reported that the CGM amplified negative feelings about food or eating.

CONCLUSIONS

Participants agreed that pairing nutrition information with CGM initiation instructions was helpful for their diabetes care. In general, the NFA during CGM initiation was well received and led to positive changes in food choices and behaviors during a 2-month intervention.

Improved Glycemic Control in Insulin-Treated Individuals With Poorly Controlled Type 2 Diabetes Through Combined Structured Education With Real-Time Continuous Glucose Monitoring

BACKGROUND

We evaluated the efficacy of structured individualized education combined with real-time continuous glucose monitoring (rt-CGM, Dexcom G6) in improving glycemic outcomes in insulin-treated adults with poorly controlled type 2 diabetes (T2D).

METHODS

This multicenter, 16-week, single-arm study included 66 adults with T2D (multiple daily insulin [MDI]: 33; basal insulin: 33) with a ≥7.8%. Each cohort comprised 15 participants aged ≥60 years. The participants attended four educational sessions. The primary outcome was a change in glycated hemoglobin (HbA1c) levels between baseline and week 16.

RESULTS

Sixty-four individuals were included in this study, with a mean age of 58.3 ± 12.4 years. The mean HbA1c levels decreased from 9.0% at baseline to 7.1% at 16 weeks in the MDI group (difference: -1.8%, 95% confidence interval [CI] = -2.3 to -1.3) and from 8.8% to 7.0% in the basal insulin group (difference: -1.8%, 95% CI = -2.1 to -1.4). In the total population, the mean time in range 70 to 180 mg/dL increased by 25.2% (6 hours 4 minutes, 95% CI = 20.6 to 29.8), whereas the time in tight range 70 to 140 mg/dL increased by 17.3% (4 hours 10 minutes, 95% CI = 14.0 to 20.7). Both groups maintained a target of <1% of the time below the range of <54 mg/dL. Improvements in HbA1c and CGM metrics were comparable between individuals aged ≥60 years and those aged <60 years (all P-values for interaction >.1).

CONCLUSIONS

In adults with poorly controlled insulin-treated T2D, rt-CGM use with structured education significantly improved the HbA1c and CGM metrics, primarily by reducing hyperglycemia, regardless of age.

American Diabetes Association Professional Practice Committee, ElSayed NA, McCoy RG, Aleppo G, Balapattabi K, Beverly EA, Briggs Early K, Bruemmer D, Echouffo-Tcheugui JB, Ekhlaspour L, Garg R, Khunti K, Lal R, Lingvay I, Matfin G, Pandya N, Pekas EJ, Pilla SJ, Polsky S, Segal AR, Seley JJ, Stanton RC, Bannuru RR. 7. Diabetes Technology: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Long-Term Improvements in Glycemic Control with Dexcom CGM Use in Adults with Noninsulin-Treated Type 2 Diabetes

Aims: The objective of this real-world, observational study was to evaluate change in continuing glucose monitoring (CGM) metrics for 1 year after CGM initiation in adults with noninsulin-treated type 2 diabetes (T2D). Methods: Data were analyzed from Dexcom G6 and G7 users who self-reported: T2D, ≥18 years, gender, no insulin use, and had a baseline percent time in range (TIR) 70-180 mg/dL of ≤70%. Outcomes were change in CGM metrics from baseline to 6 and 12 months overall and for younger (<65 years) and older (≥65 years) cohorts. Additional analyses explored the relationship between use of the high alert feature and change in TIR and time in tight range (TITR) 70-140 mg/dL. Results: CGM users (n = 3,840) were mean (SD) 52.5 (11.2) years, 47.9% female, mean TIR was 41.7% (21.4%), and 12.4% of participants were ≥65 years. Significant improvement in all CGM metrics not meeting target values at baseline was observed at 6 months, with continued improvement at 12 months. Mean baseline TIR increased by 17.3% (32.1%) from 41.7% (21.4%) to 59.0% (28.9%), and mean glucose management indicator decreased by 0.5% (1.2%) from 8.1% (0.9%) to 7.6% (1.1%) (both P < 0.001). Participants who maintained or customized the high alert default setting of 250 mg/dL had a greater increase in TIR and TITR compared with participants who disabled the alert. Days of CGM use over 12 months were high in 84.7% (15.9%). Conclusion: In this large, real-world study of adults with suboptimally controlled T2D not using insulin, Dexcom CGM use was associated with meaningful improvements in glycemic control over 12 months. Use of the high alert system feature was positively associated with glycemic outcomes. High use of CGM over 12 months suggests benefits related to consistent CGM use in this population.

Addressing Inequity in Continuous Glucose Monitoring Access: Leveraging the Hospital in the Continuum of Care

BACKGROUND

While continuous glucose monitoring (CGM) has transformed the care of people with diabetes (PWD) in the ambulatory setting, there continue to be significant barriers to access. With CGM on the horizon in the acute care setting, it is important to consider the potential for this shift to improve ambulatory CGM access to those at the highest risk of morbidity and mortality.

METHODS

In this commentary, we review the existing literature on the specific barriers to CGM access for individuals with diabetes in the United States including racial disparities, provider bias, cost and shortage of specialty diabetes care. Key areas explored include the importance of CGM in diabetes management, the consequences of disparities in access to CGM, and leveraging the inpatient setting to promote equitable care and better outcomes for PWD.

RESULTS

We present a vision for a new care model, which leverages the transition of care from the hospital to successfully incorporate CGM into the discharge plan.

CONCLUSIONS

Given that CGM utilization is associated with improved outcomes and reduced rates of hospitalization and emergency department visits, a care model that facilitates CGM access upon transition from inpatient to ambulatory care can enhance health equity and quality of life for people with diabetes.

Continuous glucose monitoring-based metrics and the duration of hypoglycaemia events with once-weekly insulin icodec versus once-daily insulin glargine U100 in insulin-naive type 2 diabetes: an exploratory analysis of ONWARDS 1

BACKGROUND

Continuous glucose monitoring (CGM) can provide a comprehensive assessment of glycaemic control. This exploratory analysis of the ONWARDS 1 trial assessed CGM-based metrics and CGM-derived hypoglycaemia duration in insulin-naive individuals with type 2 diabetes treated with subcutaneous once-weekly insulin icodec (icodec) versus once-daily insulin glargine U100 (glargine U100).

METHODS

ONWARDS 1 was a 78-week (52-week main treatment phase and a 26-week treatment extension phase plus a 5-week follow-up), randomised, open-label, treat-to-target, phase 3a trial done at 143 sites (outpatient clinics and hospital departments) across 12 countries. Adults (aged ≥18 years) with type 2 diabetes (HbA1c: 7·0-11·0%) who had not previously received insulin were randomly assigned (1:1) via an interactive web-response system to once-weekly icodec or once-daily glargine U100. Double-masked CGM data were collected during treatment initiation (weeks 0-4), midtrial (weeks 22-26), end of main phase (weeks 48-52), end of extension phase (weeks 74-78), and follow-up (weeks 78-83). Secondary and exploratory outcomes were CGM-based metrics, including the mean percentages of time in glycaemic range (TIR; sensor glucose 3·9-10·0 mmol/L [70-180 mg/dL]), time in tight range (TITR; 3·9-7·8 mmol/L [70-140 mg/dL]), time above range (TAR; >10·0 mmol/L [>180 mg/dL]), and time below range (TBR; <3·9 mmol/L [<70 mg/dL] and <3·0 mmol/L [<54 mg/dL]), and CGM-derived hypoglycaemic episode durations (episodes defined by sensor glucose <3·9 mmol/L [<70 mg/dL for ≥15 consecutive minutes]). Analyses were done in the full analysis set (all randomly assigned participants). The ONWARDS 1 trial is registered with ClinicalTrials.gov, NCT04460885, and is complete.

FINDINGS

Participants were enrolled and randomly assigned in ONWARDS 1 between Nov 25, 2020, and Dec 1, 2022 (n=492 in each treatment group). During treatment initiation, we observed no statistically significant differences in the mean percentages of TIR, TITR, TAR, and TBR with icodec versus glargine U100. During the midtrial, end of main phase, and end of extension phase periods, the mean percentages of TIR and TITR were statistically significantly greater and the mean percentages of TAR statistically significantly lower with icodec versus glargine U100. The mean percentages of TIR met the internationally recommended CGM target (>70%) with icodec but not with glargine U100 during the three periods. TBR (<3·9 mmol/L [<70 mg/dL] and <3·0 mmol/L [<54 mg/dL]) was low and below recommended targets (<4% and <1%, respectively) across all study periods in both treatment groups, with no statistically significant differences between treatment groups for the lower threshold (<3·0 mmol/L [<54 mg/dL]). During the follow-up period, mean percentages of TIR, TITR, TAR, and TBR did not statistically significantly differ with icodec versus glargine U100. The duration of overall hypoglycaemic episodes was similar between treatment groups throughout the trial (median duration ≤35 min).

INTERPRETATION

These CGM data support the long-term efficacy and safety of icodec versus glargine U100 during treatment and indicated no increase in the duration of individual hypoglycaemic episodes with icodec versus glargine U100 in insulin-naive individuals with type 2 diabetes.

FUNDING

Novo Nordisk.

Impact of continuous glucose monitoring on emergency department visits and all-cause hospitalization rates among Medicaid beneficiaries with type 2 diabetes treated with multiple daily insulin or basal insulin therapy

BACKGROUND

The increasing prevalence of diabetes in the United States continues to drive a steady rise in health care resource utilization, especially emergency department visits and all-cause hospitalizations, and the associated costs.

OBJECTIVE

To investigate the impact of continuous glucose monitoring (CGM) on emergency department visits and all-cause hospitalizations among Medicaid beneficiaries with type 2 diabetes (T2D) treated with multiple daily insulin injections (MDIs) or basal insulin therapy (BIT) in a real-world setting.

METHODS

In this retrospective, 12-month analysis, we used the Inovalon Insights claims dataset to evaluate the effects of CGM acquisition on emergency department visits and all-cause hospitalizations in the Managed Medicaid population. The analysis included 44,941 beneficiaries with T2D who were treated with MDIs (n = 35,367) or BIT (n = 9,574). Primary outcomes were changes in the number of emergency department visits and all-cause hospitalizations following 6 months after acquisition of CGM (post-index period) compared with 6 month prior to CGM acquisition (pre-index period). The first claim for CGM was the index date. Inclusion criteria were as follows: aged younger than 65 years, diagnosis of T2D, claims for short- or rapid-acting insulin (MDI group) or basal insulin (not rapid-acting) (BIT group), acquisition of a CGM device between January 1, 2017, and September 30, 2022, and continuous enrollment in their health plan throughout the pre-index and post-index periods.

RESULTS

In the MDI group, all-cause inpatient hospitalization rates decreased from 3.25 to 2.29 events/patient-year (hazard ratio = 0.12; 95% CI = 0.11-0.13; P < 0.001) and emergency department visit rates decreased from 2.15 to 1.86 events/patient-year (hazard ratio = 0.52; 95% CI = 0.50-0.53; P < 0.001). In the BIT group, all-cause inpatient hospitalization rates decreased from 1.63 to 1.39 events/patient-year (hazard ratio = 0.11; 95% CI = 0.09-0.12; P < 0.001) and emergency department visit rates decreased from 1.60 to 1.43 events/patient-year (hazard ratio = 0.47; 95% CI = 0.44-0.50; P < 0.001).

CONCLUSIONS

Acquisition of CGM is associated with significant reductions in emergency department visits and all-cause hospitalizations among people with T2D treated with MDIs or BIT.

Best practices and rationale for expanding Medicaid access to continuous glucose monitoring

Numerous studies have demonstrated that use of continuous glucose monitoring (CGM) significantly improves overall glycemic control and reduces the frequency and severity of hypoglycemic events in individuals treated with intensive insulin, nonintensive insulin, and noninsulin therapies, with reductions in both all-cause and diabetes-related health care resource utilization and lower costs. However, implementation of CGM including prescribing and assessment of the ambulatory glucose profile to make clinical decisions in primary care settings is low. A recent pilot program was initiated at MetroHealth System (Cleveland, Ohio) to implement a CGM integration program for primary care offices throughout the system. Based on the experience and successes from this health system as well as current literature, rationale will be discussed to support the expansion of CGM to individuals enrolled in all Medicaid programs.

Using continuous glucose monitoring to measure and improve quality metrics: Updates on the Healthcare Effectiveness Data and Information Set 2024 Glucose Management Indicator measure

Value-based diabetes care is a proactive approach to providing quality care to individuals with diabetes. This approach focuses on improving clinical outcomes rather than the volume of services provided. Implementation of value-based diabetes care requires an established set of standardized quality measures against which all stakeholders can assess and benchmark their performance. The National Committee for Quality Assurance recently added the Glucose Management Indicator to its Healthcare Effectiveness Data and Information Set. The Glucose Management Indicator can be used as a measure of glucose control. This article discusses the benefits of value-based care, the importance of diabetes quality measures, and how the rapidly increasing adoption of continuous glucose monitoring is impacting these measures while improving the lives of individuals with diabetes.

Advances in diabetes technology within the digital diabetes ecosystem

Ongoing innovations in glucose monitoring, insulin delivery, and telehealth technologies have created a digital diabetes ecosystem populated by connected tools and technologies that have been shown to improve clinical outcomes, lower costs, and reduce the burden of diabetes. Advances in connected continuous glucose monitoring devices, insulin pumps, and insulin pens have led to the development of automated insulin delivery systems that modulate insulin infusion based on sensor glucose data. Similar integrations of continuous glucose monitoring and connected blood glucose meter data into "smart" pens have lessened the guesswork of intensive insulin management for individuals who prefer traditional injection therapy. A growing number of health apps that can be accessed through smartphones and wearable devices provide information and advice that support individuals in adopting healthier lifestyles. The differences in features and functionality give users the ability to select the devices that best meet their unique requirements and preferences. This article reviews the most current digital diabetes technologies and discusses how the connectivity of these tools can create an overarching architecture of feedback mechanisms that monitor an individual's health status, motivate and enhance adherence to self-management, and provide advice and decision-support tools to clinicians as well as other members of the health care team to make living with diabetes more manageable.

Interruption of Continuous Glucose Monitoring: Frequency and Adverse Consequences

BACKGROUND

Removal of diabetes devices, including insulin pumps and continuous glucose monitoring (CGM), is a common practice due to hospital policies, interference with imaging studies, medications, and surgical interventions. Furthermore, these devices are inherently prone to malfunction, adhesive failure, and issues with insertion that can lead to a reduction in wear time. Prescription and dispensing practices provide an exact number of sensors per month without redundancy to account for the realities of daily CGM use.

METHODS

A RedCap survey was completed by adult patients with type 1 or type 2 diabetes (T1D or T2D) who utilize CGM followed in the Diabetes Center at Washington University in St Louis.

RESULTS

Of 384 surveys sent, 99 were completed. Participants had a mean age of 54 years, T1D 69%, female 70%, White 96%, non-Hispanic 96%, and a mean duration of diabetes mellitus (DM) 28 years. Of the cohort, 100% used CGM (80.2% Dexcom, 13.5% Freestyle Libre, 6.3% Medtronic), 61% insulin pump, and 41% Hybrid closed-loop (HCL) systems. CGM-related disruption events included device malfunction (in 85.4% of participants), insertion problems (63.5%), and falling off (61.4%). Medical care-related disruption occurred most frequently in the setting of imaging (41.7%), followed by surgery/procedures (11.7%) and hospitalization (4.4%). Adverse glycemic events attributed to CGM disruption, including hyperglycemia and hypoglycemia, occurred ≥4 times in 36.5% and 12.4% of the cohort, respectively.

CONCLUSIONS

Disruption in CGM use is common. Lack of redundancy of CGM supplies contributes to care disruption and adverse glycemic events.

Continuous glucose monitoring for the routine care of type 2 diabetes mellitus

Although continuous glucose monitoring (CGM) devices are now considered the standard of care for people with type 1 diabetes mellitus, the uptake among people with type 2 diabetes mellitus (T2DM) has been slower and is focused on those receiving intensive insulin therapy. However, increasing evidence now supports the inclusion of CGM in the routine care of people with T2DM who are on basal insulin-only regimens or are managed with other medications. Expanding CGM to these groups could minimize hypoglycaemia while allowing efficient adaptation and escalation of therapies. Increasing evidence from randomized controlled trials and observational studies indicates that CGM is of clinical value in people with T2DM on non-intensive treatment regimens. If further studies confirm this finding, CGM could soon become a part of routine care for T2DM. In this Perspective we explore the potential benefits of widening the application of CGM in T2DM, along with the challenges that must be overcome for the evidence-based benefits of this technology to be delivered for all people with T2DM.

The Glucose Management Indicator: Time to Change Course?

Laboratory measurement of hemoglobin A1c (HbA1c) has, for decades, been the standard approach to monitoring glucose control in people with diabetes. Continuous glucose monitoring (CGM) is a revolutionary technology that can also aid in the monitoring of glucose control. However, there is uncertainty in how best to use CGM technology and its resulting data to improve control of glucose and prevent complications of diabetes. The glucose management indicator, or GMI, is an equation used to estimate HbA1c based on CGM mean glucose. GMI was originally proposed to simplify and aid in the interpretation of CGM data and is now provided on all standard summary reports (i.e., average glucose profiles) produced by different CGM manufacturers. This Perspective demonstrates that GMI performs poorly as an estimate of HbA1c and suggests that GMI is a concept that has outlived its usefulness, and it argues that it is preferable to use CGM mean glucose rather than converting glucose to GMI or an estimate of HbA1c. Leaving mean glucose in its raw form is simple and reinforces that glucose and HbA1c are distinct. To reduce patient and provider confusion and optimize glycemic management, mean CGM glucose, not GMI, should be used as a complement to laboratory HbA1c testing in patients using CGM systems.

Reduction in Diabetes-Related Hospitalizations and Medical Costs After Dexcom G6 Continuous Glucose Monitor Initiation in People with Type 2 Diabetes Using Intensive Insulin Therapy

INTRODUCTION

Some people with type 2 diabetes (T2D) require intensive insulin therapy to manage their diabetes. This can increase the risk of diabetes-related hospitalizations. We hypothesize that initiation of real-time continuous glucose monitoring (RT-CGM), which continuously measures a user's glucose values and provides threshold- and trend-based alerts, will reduce diabetes-related emergency department (ED) and inpatient hospitalizations and concomitant costs.

METHODS

A retrospective analysis of US healthcare claims data using Optum's de-identified Clinformatics® Data Mart database was performed. The cohort consisted of commercially insured, CGM-naïve individuals with T2D who initiated Dexcom G6 RT-CGM system between August 1, 2018, and March 31, 2021. Twelve months of continuous health plan enrollment before and after RT-CGM initiation was required to capture baseline and follow-up rates of diabetes-related hospitalizations and associated healthcare resource utilization (HCRU) costs. Analyses were performed for claims with a diabetes-related diagnosis code in either (1) any position or (2) first or second position on the claim.

RESULTS

A total of 790 individuals met the inclusion criteria. The average age was 52.8 (10.5) [mean (SD)], 53.3% were male, and 76.3% were white. For claims with a diabetes-related diagnosis code in any position, the number of individuals with ≥ 1 ED visit decreased by 30.0% (p = 0.01) and with ≥ 1 inpatient visit decreased by 41.5% (p < 0.0001). The number of diabetes-related visits and average number of visits per person similarly decreased by at least 31.4%. Larger relative decreases were observed for claims with a diabetes-related diagnosis code in the first or second position on the claim. Total diabetes-related costs expressed as per-person-per-month (PPPM) decreased by $341 PPPM for any position and $330 PPPM for first or second position.

CONCLUSION

Initiation of Dexcom G6 among people with T2D using intensive insulin therapy was associated with a significant reduction in diabetes-related ED and inpatient visits and related HCRU costs. Expanded use of RT-CGM could augment these benefits and result in further cost reductions.

Insulin initiation in patients with type 2 diabetes is often delayed, but access to a diabetes nurse may help-insights from Norwegian general practice

Objective: We opted to study how support staff operational capacity and diabetes competences may impact the timeliness of basal insulin-initiation in general practice patients with type 2 diabetes (T2D).Design/Setting/Outcomes: This was an observational and retrospective study on Norwegian primary care patients with T2D included from the ROSA4-dataset. Exposures were (1) support staff size, (2) staff size relative to number of GPs, (3) clinic access to a diabetes nurse and (4) share of staff with diabetes course (1 and 2 both relate to staff operational capacity, whereas 3 and 4 are both indicatory of staff diabetes competences). Outcomes were 'timely basal insulin-initiation' (primary) and 'attainment of HbA1c<7%' after insulin start-up (secondary). Associations were analyzed using multiple linear regression, and directed acyclic graphs guided statistical adjustments.Subjects: Insulin naïve patients with 'timely' (N = 294), 'postponed' (N = 219) or 'no need of' (N = 3,781) basal insulin-initiation, respectively.Results: HbA1c [median (IQR)] increased to 8.8% (IQR, 8.0, 10.2) prior to basal insulin-initiation, which reduced HbA1c to 7.3 (6.8-8.1) % by which only 35% of the subjects reached HbA1c <7%. Adjusted risk of 'timely basal insulin-initiation' was more than twofold higher if access to a diabetes nurse (OR = 2.40, [95%CI, 1.68, 3.43]), but related only vaguely to staff size (OR = 1.01, [95%CI, 1.00, 1.03]). No other staff factors related significantly to neither the primary nor the secondary outcome.Conclusion: In Norwegian general practice, insulin initiation in people with T2D may be affected by therapeutic inertia but access to a diabetes nurse may help facilitating more timely insulin start-up.

Effects of continuous glucose monitoring on glycaemic control in type 2 diabetes: A systematic review and network meta-analysis of randomized controlled trials

AIMS

The aim of this study was to assess the efficacy of continuous glucose monitoring (CGM) versus self-monitoring of blood glucose (SMBG) in maintaining glycaemic control among people with type 2 diabetes mellitus (T2DM).

MATERIALS AND METHODS

The protocol was registered in PROSPERO (CRD42023387583). PubMed, Web of Science, EMBASE and OVID databases were searched from 1 January 2000 until 31 December 2022 for randomized controlled trials comparing CGM with SMBG in glycaemic control among the outpatients with T2DM. The primary endpoint was glycated haemoglobin, while the secondary endpoints included time in range, time below range and time above range. Both traditional and network meta-analyses were conducted to explore the efficacy of CGM on glycaemic control in T2DM.

RESULTS

Eleven high-quality studies, involving 1425 individuals with T2DM, were identified. Traditional meta-analysis revealed that CGM exhibited a significantly decreased [mean difference (MD): -0.31, 95% confidence interval (CI) (-0.45, -0.18)], time above range [MD: -9.06%, 95% CI (-16.00, -2.11)], time below range [MD: -0.30%, 95% CI (-0.49, -0.12)] and a significantly increased time in range [MD: 8.49%, 95% CI (3.96, 13.02)] compared with SMBG. The network meta-analysis showed that real-time CGM can improve the glycaemic control of patients with T2DM to the most extent.

CONCLUSIONS

CGM could provide T2DM with greater benefits in glycaemic management compared with SMBG, particularly in patients using real-time CGM. These findings provide an updated perspective on previous research and offer guidance for CGM use in T2DM.

American Diabetes Association Professional Practice Committee, ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 7. Diabetes Technology: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Patient Perspectives on the Benefits and Challenges of Diabetes and Digital Technology

Diabetes technology continues to evolve, advancing with our understanding of human biology and improving our ability to treat people with diabetes. Diabetes devices are broadly classified into the following categories: glucose sensors, insulin delivery devices, and digital health care technology (i.e., software and mobile applications). When supported by education and individually tailored, technology can play a key role in optimizing outcomes. Digital devices assist in diabetes management by tracking meals, exercise, sleep, and glycemic measurements in real time, all of which can guide physicians and other clinicians in their decision-making. Here, as people with diabetes and patient advocates, as well as diabetes specialists, primary care providers, and diabetes care and education specialists, we present our perspectives on the advances, benefits, and challenges of diabetes technology in primary care practices.

Comprehensive Telehealth Model to Support Diabetes Self-Management

Importance

As the number of patients with diabetes continues to increase in the United States, novel approaches to clinical care access should be considered to meet the care needs for this population, including support for diabetes-related technology.

Objective

To evaluate a virtual clinic to facilitate comprehensive diabetes care, support continuous glucose monitoring (CGM) integration into diabetes self-management, and provide behavioral health support for diabetes-related issues.

Design, Setting, and Participants

This cohort study was a prospective, single-arm, remote study involving adult participants with type 1 or type 2 diabetes who were referred through community resources. The study was conducted virtually from August 24, 2020, to May 26, 2022; analysis was conducted at the clinical coordinating center.

Intervention

Training and education led by a Certified Diabetes Care and Education Specialist for CGM use through a virtual endocrinology clinic structure, which included endocrinologists and behavioral health team members.

Main Outcomes and Measures

Main outcomes included CGM-measured mean glucose level, coefficient of variation, and time in range (TIR) of 70 to 180 mg/dL, time with values greater than 180 mg/dL or 250 mg/dL, and time with values less than 70 mg/dL or 54 mg/dL. Hemoglobin A1c was measured at baseline and at 12 and 24 weeks.

Results

Among the 234 participants, 160 had type 1 diabetes and 74 had type 2 diabetes. The mean (SD) age was 47 (14) years, 123 (53%) were female, and median diabetes duration was 20 years. Median (IQR) CGM use over 6 months was 96% (91%-98%) for participants with type 1 diabetes and 94% (85%-97%) for those with type 2 diabetes. Mean (SD) hemoglobin A1c (HbA1c) in those with type 1 diabetes decreased from 7.8% (1.6%) at baseline to 7.1% (1.0%) at 3 months and 7.1% (1.0%) at 6 months (mean change from baseline to 6 months, -0.6%, 95% CI, -0.8% to -0.5%; P < .001), with an 11% mean TIR increase over 6 months (95% CI, 9% to 14%; P < .001). Mean HbA1c in participants with type 2 diabetes decreased from 8.1% (1.7%) at baseline to 7.1% (1.0%) at 3 months and 7.1% (0.9%) at 6 months (mean change from baseline to 6 months, -1.0%; 95% CI, -1.4% to -0.7%; P < .001), with an 18% TIR increase over 6 months (95% CI, 13% to 24%; P < .001). In participants with type 1 diabetes, mean percentage of time with values less than 70 mg/dL and less than 54 mg/dL decreased over 6 months by 0.8% (95% CI, -1.2% to -0.4%; P = .001) and by 0.3% (95% CI, -0.5% to -0.2%, P < .001), respectively. In the type 2 diabetes group, hypoglycemia was rare (mean [SD] percentage of time <70 mg/dL, 0.5% [0.6%]; and <54 mg/dL, 0.07% [0.14%], over 6 months).

Conclusions and Relevance

Results from this cohort study demonstrated clinical benefits associated with implementation of a comprehensive care model that included diabetes education. This model of care has potential to reach a large portion of patients with diabetes, facilitate diabetes technology adoption, and improve glucose control.

Coverage for Continuous Glucose Monitoring for Individuals with Type 2 Diabetes Treated with Nonintensive Therapies: An Evidence-Based Approach to Policymaking

Numerous studies have demonstrated the clinical benefits of continuous glucose monitoring (CGM) in individuals with type 1 diabetes (T1D) and type 2 diabetes (T2D) who are treated with intensive insulin regimens. Based on this evidence, CGM is now a standard of care for individuals within these diabetes populations and widely covered by commercial and public insurers. Moreover, recent clinical guidelines from the American Diabetes Association and American Association of Clinical Endocrinology now endorse CGM use in individuals treated with nonintensive insulin regimens. However, despite increasing evidence supporting CGM use for individuals treated with less-intensive insulin therapy or noninsulin medications, insurance coverage is limited or nonexistent. This narrative review reports key findings from recent randomized, observational, and retrospective studies investigating use of CGM in T2D individuals treated with basal insulin only and/or noninsulin therapies and presents an evidence-based rationale for expanding access to CGM within this population.

Expanding the Role of Continuous Glucose Monitoring in Modern Diabetes Care Beyond Type 1 Disease

Application of continuous glucose monitoring (CGM) has moved diabetes care from a reactive to a proactive process, in which a person with diabetes can prevent episodes of hypoglycemia or hyperglycemia, rather than taking action only once low and high glucose are detected. Consequently, CGM devices are now seen as the standard of care for people with type 1 diabetes mellitus (T1DM). Evidence now supports the use of CGM in people with type 2 diabetes mellitus (T2DM) on any treatment regimen, not just for those on insulin therapy. Expanding the application of CGM to include all people with T1DM or T2DM can support effective intensification of therapies to reduce glucose exposure and lower the risk of complications and hospital admissions, which are associated with high healthcare costs. All of this can be achieved while minimizing the risk of hypoglycemia and improving quality of life for people with diabetes. Wider application of CGM can also bring considerable benefits for women with diabetes during pregnancy and their children, as well as providing support for acute care of hospital inpatients who experience the adverse effects of hyperglycemia following admission and surgical procedures, as a consequence of treatment-related insulin resistance or reduced insulin secretion. By tailoring the application of CGM for daily or intermittent use, depending on the patient profile and their needs, one can ensure the cost-effectiveness of CGM in each setting. In this article we discuss the evidence-based benefits of expanding the use of CGM technology to include all people with diabetes, along with a diverse population of people with non-diabetic glycemic dysregulation.

Relationship Between Time in Range and Dusk Phenomenon in Outpatients with Type 2 Diabetes Mellitus

Purpose

The dusk phenomenon refers to a spontaneous and transient pre-dinner hyperglycemia that affects glucose fluctuation and glycemic control, and the increasing use of continuous glucose monitoring (CGM) has facilitated its diagnosis. We investigated the frequency of the dusk phenomenon and its relationship with the time in range (TIR) in patients with type 2 diabetes mellitus (T2DM).

Patients and Methods

This study involved 102 patients with T2DM who underwent CGM for 14 days. CGM-derived metrics and clinical characteristics were evaluated. A consecutive dusk blood glucose difference (pre-dinner glucose minus 2-hour post-lunch glucose) of ≥ 0 or once-only dusk blood glucose difference of < 0 was diagnosed as the clinical dusk phenomenon (CLDP).

Results

We found that the percentage of CLDP was 11.76% (10.34% in men, 13.64% in women). Compared with the non-CLDP group, the CLDP group tended to be younger and have a lower percentage of TIR (%TIR^3.9-10) and higher percentage of time above range (%TAR^>10 and %TAR^>13.9) (P ≤ 0.05). Adjusted for confounding factors, the binary logistic regression analysis showed a negative association of CLDP with %TIR (odds ratio < 1, P < 0.05). We repeated the correlation analysis based on 70%TIR and found significant differences in hemoglobin A1c, fasting blood glucose, mean blood glucose, standard deviation of the sensor glucose values, glucose coefficient of variation, largest amplitude of glycemic excursions, mean amplitude of glycemic excursions, glucose management indicator, and percentage of CLDP between the two subgroups of TIR ≤ 70% and TIR > 70% (P < 0.05). The negative association between TIR and CLDP still remained after adjustment by the binary logistic regression analysis.

Conclusion

The CLDP was frequently present in patients with T2DM. The TIR was significantly correlated with the CLDP and could serve as an independent negative predictor.

Objective sleep characteristics and continuous glucose monitoring profiles of type 2 diabetes patients in real-life settings

AIM

To investigate the association between objective sleep parameters and glycaemic variability determined by continous glucose monitoring (CGM) among patients with type 2 diabetes, given the significant role of sleep in glycaemic control.

METHODS

In this study, CGM was carried out in 28 patients with T2D (aged 62.3 ± 4.8 years, 57% women). Sleep characteristics were assessed by actigraphy within the CGM period. CGM-derived outcomes included glucose level, and percentages of time in range (TIR) and time above range (TAR) during the monitoring period. Associations between intraindividual night-to-night variations in sleep characteristics and overall CGM outcomes were analysed using linear regression. Associations between sleep characteristics during each night and time-matched CGM outcomes were analysed using linear mixed models.

RESULTS

A total of 249 person-days of CGM, coupled with 221 nights of sleep characteristics, were documented. Greater standard deviation (SD) of objective sleep duration (minutes) between measurement nights was associated with higher glucose level (coefficient 0.018 mmol/L [95% confidence interval {CI} 0.004, 0.033], P = 0.017), smaller proportion of TIR (% in observation period; coefficient -0.20% [95% CI -0.36, -0.03], P = 0.023), and greater proportion of TAR (coefficient 0.22% [95% CI 0.06, 0.39], P = 0.011). Later sleep midpoint (minutes from midnight) was associated with greater SD of glucose during the same sleep period (coefficient 0.002 minutes [95% CI 0.0001, 0.003], P = 0.037), longer nocturnal sleep duration was associated with smaller coefficient of variation of glucose level in the upcoming day (-0.015% [95% CI -0.03, -0.001], P = 0.041).

CONCLUSION

Objectively determined sleep duration and sleep midpoint, as well as their daily variability, are associated with CGM-derived glucose profiles in T2D patients.

Status of continuous glucose monitoring use and management in tertiary hospitals of China: a cross-sectional study

OBJECTIVE

This study aims to reveal the use and management status of continuous glucose monitoring (CGM) in tertiary hospitals in China and to determine the potential factors affecting the application of CGM, based on which more effective solutions would be produced and implemented.

DESIGN

An online, cross-sectional study was conducted from October 2021 to December 2021.

SETTING

Eighty-three tertiary hospitals in China were involved.

PARTICIPANTS

Eighty-three head nurses and 281 clinical nurses were obtained.

OUTCOME

Current condition of CGM use and management, the factors that hinder the use and management of CGM, scores of current CGM use and management, as well as their influencing factors, were collected.

RESULTS

Among the 83 hospitals surveyed, 57 (68.7%) hospitals used CGM for no more than 10 patients per month. Seventy-three (88.0%) hospitals had developed CGM standard operating procedures, but only 29 (34.9%) hospitals devised emergency plans to deal with adverse effects related to CGM. Comparably, maternal and children's hospitals were more likely to have a dedicated person to assign install CGM than general hospitals (52.2% vs 26.7%). As for the potential causes that hinder the use and management of CGM, head nurses' and nurses' perceptions differed. Head nurses perceived patients' limited knowledge about CGM (60.2%), the high costs of CGM and inaccessibility to medical insurance (59.0%), and imperfect CGM management systems (44.6%) as the top three factors. Different from head nurses, CGM operation nurses considered the age of CGM operators, the type of hospital nurses worked in, the number of patients using CGM per month and the number of CGM training sessions as potential factors (p<0.05).

CONCLUSIONS

The study provides a broad view of the development status of CGM in China. Generally speaking, the use and management of CGM in China are not yet satisfactory, and more efforts are wanted for improvement.

The Association of Glucose Variability and Dementia Incidence in Latinx Adults with Type 2 Diabetes: A Retrospective Study

Latinx adults with both cognitive dysfunction and type 2 diabetes mellitus (T2DM) are significantly more likely than Latinx adults with diabetes alone to have complications such as cardiovascular disease. Glucose variability may be a risk for dementia, but the course of glucose variability in the time before a dementia diagnosis for Latinx adults with T2DM has not been examined. We used a 10-year retrospective cohort of medical records of Latinx patients with T2DM who had at least one use of a continuous glucose monitor. The objective was to examine how glucose variability was associated with future dementia diagnoses. A total of 116 charts were included. Mean of daily differences and mean amplitude of glycemic excursions were more strongly associated with dementia diagnoses than other variability indices (p < .01). Understanding the relationships between cognitive function, glucose variability, and barriers to health care can translate into improved interventions to enhance diabetes care.

7. Diabetes Technology: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Efficacy of intermittent short-term use of a real-time continuous glucose monitoring system in non-insulin-treated patients with type 2 diabetes: A randomized controlled trial

AIM

To evaluate the efficacy of intermittent short-term use of a real-time continuous glucose monitoring (RT-CGM) system in non-insulin-treated patients with type 2 diabetes (T2D) uncontrolled with oral antidiabetic drugs (OADs).

MATERIALS AND METHODS

In this multicentre, randomized prospective study, 61 participants were randomly assigned to treatment group 1 (one session of RT-CGM), treatment group 2 (two sessions of RT-CGM with a 3-month interval between sessions) and a control group. All participants used blinded continuous glucose monitoring for up to 6 days with education before randomization, and RT-CGM was additionally applied for 1 week in the intervention groups. The primary outcome was change in HbA1c at 6 months.

RESULTS

Among 61 participants, 48 subjects completed the study (baseline HbA1c 8.2% ± 0.5%). At 3 months, a significant HbA1c reduction was observed in treatment group 1 (adjusted difference = -0.60%, P = .044) and treatment group 2 (adjusted difference = -0.64%, P = .014) compared with the control group. However, at 6 months, only treatment group 2 achieved a significant HbA1c reduction (adjusted difference = -0.68%, P = .018). Especially in the treatment groups, patients performing self-monitoring of blood glucose (SMBG) at least 1.5 times/day showed a significant HbA1c improvement, at both 3 and 6 months, but those performing SMBG less than 1.5 times/day showed no significant improvement.

CONCLUSIONS

In non-insulin-treated patients with T2D uncontrolled with OADs, intermittent short-term use of RT-CGM was an effective method for glucose control, especially in those performing SMBG frequently.

Cost-Effectiveness of a Real-Time Continuous Glucose Monitoring System Versus Self-Monitoring of Blood Glucose in People with Type 2 Diabetes on Insulin Therapy in the UK

INTRODUCTION

Real-time continuous glucose monitoring (rt-CGM) involves the measurement and display of glucose concentrations, potentially improving glucose control among insulin-treated patients with type 2 diabetes (T2D). The present analysis aimed to conduct a cost-effectiveness analysis of rt-CGM versus self-monitoring of blood glucose (SMBG) based on a USA retrospective cohort study in insulin-treated people with T2D adapted to the UK.

METHODS

Long-term costs and clinical outcomes were estimated using the CORE Diabetes Model, with clinical input data sourced from a retrospective cohort study. Patients were assumed to have a baseline glycated hemoglobin (HbA1c) of 8.3%. Patients using rt-CGM were assumed to have a 0.56% reduction in HbA1c based on the mean difference between groups after 12 months of follow-up. Reduced fingerstick testing when using rt-CGM was associated with a quality of life (QoL) benefit. The analysis was performed over a lifetime time horizon from a National Health Service (NHS) perspective, including only direct costs from published data. Future costs and clinical outcomes were discounted at 3.5% per annum. Extensive sensitivity analyses were performed.

RESULTS

Projections showed that rt-CGM was associated with increased quality-adjusted life expectancy of 0.731 quality-adjusted life years (QALYs) and increased mean total lifetime costs of Great British pounds (GBP) 2694, and an incremental cost-effectiveness ratio of GBP 3684 per QALY compared with SMBG. Key drivers of outcomes included HbA1c reduction and reduced fingerstick testing QoL benefit.

CONCLUSIONS

Over patient lifetimes, rt-CGM was associated with improved clinical outcomes and is highly likely to be cost effective versus SMBG in people with T2D on insulin therapy in the UK.

Effects of Patient-Driven Lifestyle Modification Using Intermittently Scanned Continuous Glucose Monitoring in Patients With Type 2 Diabetes: Results From the Randomized Open-label PDF Study

OBJECTIVE

To investigate the effects of patient-driven lifestyle modification using intermittently scanned continuous glucose monitoring (isCGM) in patients with type 2 diabetes (T2D).

RESEARCH DESIGN AND METHODS

We conducted a 12-week, open-label, randomized controlled trial. A total of 126 participants were 1:1 randomized to either the intervention group (structured education + isCGM) or the control group (standard care with blood glucose monitoring). The Self-Evaluation Of Unhealthy foods by Looking at postprandial glucose (SEOUL) algorithm was developed and applied to aid structured education in guiding patients to follow healthy eating behavior depending on the postprandial glycemic response. The primary end point was the change in HbA1c level from baseline.

RESULTS

Implementation of the SEOUL algorithm with isCGM was associated with greater improvement in HbA1c than with standard care (risk-adjusted difference -0.50%, 95% CI -0.74 to -0.26, P < 0.001). Participants in the intervention group had a greater reduction in fasting blood glucose and body weight (-16.5 mg/dL, 95% CI -30.0 to -3.0, P = 0.017; -1.5 kg, 95% CI -2.7 to -0.3, P = 0.013, respectively). The score sum for the Korean version of the revised Summary of Diabetes Self-Care Activities Questionnaire increased in both groups but to a greater extent in the intervention group (mean difference 4.8, 95% CI 1.7-8.0, P = 0.003). No severe hyperglycemia or hypoglycemia was reported in either group of patients.

CONCLUSIONS

Patient-driven lifestyle modification primarily focused on eating behavior using isCGM effectively lowered HbA1c levels in patients with T2D.

Reduced Rate of Acute Diabetes Events with Flash Glucose Monitoring Is Sustained for 2 Years After Initiation: Extended Outcomes from the RELIEF Study

Background: The RELIEF study has previously shown a fall in the rate of acute diabetes events (ADEs) in people living with type 1 diabetes (PwDT1) or people living with type 2 diabetes (PwDT2) in the 12 months after initiation of flash glucose monitoring (FLASH) in France. The 2-year follow-up has provided new insights on the frequency of ADEs, including severe hypoglycemia and diabetic ketoacidosis (DKA), during use of FLASH. Methods: The RELIEF study included 31,446 PwDT1 and 41,027 PwDT2 with a first delivery of FreeStyle Libre (FSL) between August 1 and December 31, 2017. Hospitalizations for DKA, severe hypoglycemia, diabetes-related coma, and hyperglycemia were recorded for the 12 months before and 24 months after FSL initiation. Persistence of the FSL system use was estimated through a Kaplan-Meier survival curve. Change in usual blood glucose monitoring was estimated through acquisition of blood glucose test strips. Results: In the 2 years after FSL initiation, hospitalizations for ADEs were reduced by 49% and by 48% in PwDT1 or PwDT2, respectively, driven by reductions in DKA. After 2 years, 88% of patients persisted with the system and estimated mean consumption of blood glucose test strips had fallen after 2 years by -82% and by -84% in type 1 diabetes mellitus and type 2 diabetes mellitus, respectively. Conclusion: Use of FSL consistently reduces the rates of hospitalization for ADEs, mainly DKA, 2 years after initiation, confirming this is not a transitory effect. Use of FSL also results in a clear and progressive drop in use of blood glucose test strips over the 2-year period.