The American Diabetes Association (ADA) Standards of Medical Care represent the latest evidence-based recommendations for guiding clinical practice. According to the most recent edition of these guidelines, Level A evidence from the MOBILE study supports the use of real time continuous glucose monitoring (rtCGM) in patients with insulin-treated type 2 diabetes (T2D) regardless of regimen. The findings from the MOBILE study likewise demonstrate the value of rtCGM across typically underserved demographics of patients impacted by social determinants of health (SDOH). Taking the ADA recommendations into consideration, payers are formulating coverage policies that facilitate appropriate access to rtCGM, improved outcomes in T2D, and proven per-member-per-month (PMPM) cost savings.
American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons With Diabetes Mellitus
The American Association of Clinical Endocrinology (AACE) with a task force of medical experts developed evidence-based guideline recommendations regarding the use of advanced diabetes technology in clinical settings. The guidelines reveal that ensuring universal access to advanced diabetes technologies is anticipated to result in improved glycemia and allowing more persons with diabetes to achieve glycemic targets, improve quality of life, and potentially reduce burden of care. Furthermore, diabetes technology can improve the efficiency and effectiveness of clinical decision-making.
|Who would benefit from routine use of CGM?|
|When is one method of CGM (real-time CGM vs. intermittently scanned monitoring) preferred over the other?|
|Real-time CGM should be recommended over intermittently scanned CGM for:||isCGM should be considered for:|
1Grade A; High Strength of Evidence; BEL 1; 2Grade A; Intermediate-High Strength of Evidence; BEL 1; 3Grade A; Intermediate Strength of Evidence; BEL 1; 4Grade B; Intermediate Strength of Evidence, BEL 1; 5Grade B; Low-Intermediate Strength of evidence; BEL; 6Grade D; Low Strength of Evidence/Expert Opinion of Task Force; BEL 4
Source: National Institute for Health and Care Excellence (NICE) Guideline – Diabetes in Pregnancy: Management from Preconception to the Postnatal Period (2020)
Key Takeaway: In December 2020, NICE reviewed the evidence and changed the recommendations on intermittently scanned CGM (isCGM, also commonly referred to as flash) and continuous glucose monitoring during pregnancy for women with type 1 diabetes.
Recommendations for Managing Diabetes During Pregnancy-
Offer continuous glucose monitoring (CGM) to all pregnant women with type 1 diabetes to help them meet their pregnancy blood glucose targets and improve neonatal outcomes.
Offer intermittently scanned CGM (isCGM, commonly referred to as flash) to pregnant women with type 1 diabetes who are unable to use continuous glucose monitoring or express a clear preference for it.
Consider continuous glucose monitoring for pregnant women who are on insulin therapy but do not have type 1 diabetes, if:
For pregnant women who are using isCGM or continuous glucose monitoring, a member of the joint diabetes and antenatal care team with expertise in these systems should provide education and support (including advising women about sources of out-of-hours support).
For a short explanation of why the committee made the 2020 recommendations and how they might affect practice, see the rationale and impact section on flash and continuous glucose monitoring on pages 35-36 in the Guideline. Full details of the evidence and the committee’s discussion are in evidence review A: continuous glucose monitoring.
Key Takeaway: The intended place in therapy is as an alternative to routine blood glucose monitoring in people (over 2 years old), including pregnant women, with type 1 or type 2 diabetes, who use multiple daily insulin injections or use insulin pumps and are self-managing their diabetes. Dexcom G6 could reduce costs and would benefit the healthcare system by improving long-term outcomes, reducing the need for intensive treatment and, in the short term, reducing severe hypoglycaemic events leading to hospital admissions. Remote care may reduce the need for hospital visits.
Source: Diabetes Care
Key Takeaway: The ADA Standards of Medical Care in Diabetes provides the most authoritative and current guidelines for diabetes care. The recommendations are intended to provide clinicians, patients, researchers and payers with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. Following are ADA recommendations regarding CGM:
rtCGM should be used continuously for maximal benefit.
isCGM should be scanned frequently throughout the day (minimum of once every 8 hours)
7.9: When used properly, real-time CGM’s in conjunction with multiple daily injections and continuous subcutaneous insulin infusion (A) and other forms of insulin therapy (C) are a useful tool to lower and/or maintain A1c levels and/or reduce hypoglycemia in adults and youth with diabetes.
7.10: When used properly, intermittently scanned CGM’s in conjunction with multiple daily injections and continuous subcutaneous insulin infusion (B) and other forms of insulin therapy (C) can be useful and may lower A1c levels and/or reduce hypoglycemia in adults and youth with diabetes to replace self-monitoring of blood glucose.
Level of Clinical Evidence: A = Clear evidence from well-conducted, generalizable randomized controlled trials that are adequately powered; B = Supportive evidence from well-conducted cohort studies; C = Supportive evidence from poorly controlled or uncontrolled studies
Source: American Association of Clinical Endocrinologists
Conclusion: CGM improves glycemic control, reduces hypoglycemia, and may reduce overall costs of diabetes management. Expanding CGM coverage and utilization is likely to improve the health outcomes of people with diabetes.