Continuous Benefits from Continuous Monitoring

Two years after Medicare began covering the use of continuous glucose monitors by seniors, the advantages are becoming clear. However, patient education on the proper use of these systems is vital to their success.

Some two years after Medicare began covering the use of continuous glucose monitors (CGM), seniors are increasingly reporting benefits, and a clinical trial has provided evidence that the monitors improve glucose control and reduce hypoglycemic events.

“Medicare access has made a huge difference,” says Anne Peters, MD, director of the University of Southern California Clinical Diabetes Program. “The thing that surprised me is how willing most seniors have been to adopt the new technology.”

“The majority of my patients are using it and seeing benefits,” says Grazia Aleppo, MD, professor of medicine and director of the Diabetes Education Program at Northwestern University. “They really feel much more confident and comfortable, and [appreciate that] they do not have to check their blood glucose [with fingersticks].”

Hard Evidence of Benefits

Results from the Wireless Innovation for Seniors with Diabetes Mellitus (WISDM) trial were previewed at an American Diabetes Association meeting last year by Richard Pratley, MD, the Crockett Chair in Diabetes Research at AdventHealth in Orlando, Fla. The study randomized patients over age 60 with type 1 diabetes to two groups and followed them for six months. One group used the Dexcom G5 CGM and the other used standard blood glucose meters. The CGM group spent less time in hypoglycemia (below 70 mg/dL) and two more hours per day in their target glucose range. The CGM group experienced significantly fewer severe hypoglycemia events. CGM use also significantly reduced hemoglobin A1c levels in an already well controlled cohort, Pratley said.

“As an endocrinologist and public health advocate, my interest is in making CGM more widely available. We’ve shown that it works from babies through seniors, across the ages, but it still needs to be coupled with education, support, and training on how to use it.” –  Anne Peters, MD, director, University of Southern California Clinical Diabetes Program, Los Angeles, California

“The data is compelling that using CGM in older adults tremendously reduces hypoglycemia compared to people using a glucose meter,” Aleppo says.

Monitors Wrapped in Red Tape

Aleppo and Peters agree that the first step in introducing a patient to the technology — meeting the requirements to qualify for Medicare coverage — can be burdensome.

The requirements include that the patient keep a 60-day log of four-times-a-day blood glucose measurements. Patients also need to be taking at least three insulin injections a day.

“There is the hassle of people getting used to the paperwork. There is a bureaucracy to it and a learning curve for patients and providers, but we have gotten a lot of the kinks worked out,” Peters says.

Choosing a System

A next step is choosing a system, and that choice tends to turn on the question of whether or not a system with alerts and alarms is appropriate for the patient. For the vast majority of users, the choice still comes down to the Dexcom G6 and the Abbott Freestyle Libre.

The Dexcom G6 communicates readings directly and automatically with a smart phone or other device, and features alarms and alerts that can highlight fast-changing glucose levels and approaching hypoglycemia. Medicare has changed a former controversial policy and now allows the Dexcom results to be shared among family members or caregivers via a smart phone. “Although it is not very common, those who do share like it a lot, and so do their families,” Aleppo says.

The Freestyle Libre is an intermittent scanning monitor that the patient must scan with a sensor to record readings. It does not provide any alarms or alerts, which many patients find simpler and less intrusive to use.

Both devices are factory-calibrated, and therefore do not require fingersticks for calibration. Newer Freestyle models go 14 days without calibration; the Dexcom G6 goes 10 days. The freedom from fingersticks alone is a major benefit for patients who have been sticking themselves for years, Aleppo says.

“I discuss with patients what the most appropriate device is for them,” Aleppo says. It is the patient’s choice, but she recommends the Dexcom with its alarm features for type 1 patients, especially those who have hypoglycemic unawareness, and type 2 diabetes patients with comorbidities who are at increased danger of hypoglycemia.

“Training for older people is paramount, because once they actually understand it, they use CGM very successfully. But if we underestimate the training, patients don’t do well. Some patients who are older are very capable and self-sufficient and can use this with minimal training.” – Grazia Aleppo, MD, professor of medicine; director, Diabetes Education Program, Northwestern University, Chicago, Illinois

“I have patients who sleep with the receiver under their pillow because they like getting an alarm if they go too low,” Peters says. Because patients are older, it may be necessary to turn up the volume on the alarms.

Importance of Training

“One thing that we have learned is that training is very important for these patients,” Aleppo says. “Training for older people is paramount, because once they actually understand it, they use CGM very successfully. But if we underestimate the training, patients don’t do well. Some patients who are older are very capable and self-sufficient and can use this with minimal training. Others require more. Even though they might have a smart phone, they might not know how to use it.” Some patients get “flustered” by seeing the little up and down arrows displays and need to learn the combinations of signals from their sensors.

And some patients on the Freestyle Libre must be trained on the importance of scanning it regularly. “But once they use it properly, they really are benefiting from these tools,” Aleppo says. She cites examples of patients who used to have severe hypoglycemic events that required ambulance rides to the emergency room — something that has not happened for years since they started on CGM.

Aleppo says that a noteworthy drawback of the Medicare rules “is that Medicare does not cover sensors when patients are in a hospital or in a nursing home or rehabilitation facility, so that has caused interruptions of CGM service to some patients.” The nurses and other staff at these facilities are often unfamiliar with the devices, so patients and their families need to have a plan of action to deal with this contingency. “We need to train the nursing staff and ancillary staff [in these facilities] because patients don’t want to be without these devices, especially when they are in the hospital or rehab facility,” Aleppo says.

“As an endocrinologist and public health advocate, my interest is in making CGM more widely available,” Peters says. “We’ve shown that it works from babies through seniors, across the ages, but it still needs to be coupled with education, support, and training on how to use it. I also want to increase its use in primary care. So getting it approved and proven that it works for seniors has been really important.”

— Seaborg is a freelance writer based in Charlottesville, Va. He wrote the March cover story about big data and its impact on endocrinology.

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