Continuous Glucose Monitor Use Prevents Glycemic Deterioration in Insulin-Treated Patients with Type 2 Diabetes.

Karter AJ ，Parker MM ，Moffet HH ，Gilliam LK ，Dlott R ... -  《-》

Association of Real-time Continuous Glucose Monitoring With Glycemic Control and Acute Metabolic Events Among Patients With Insulin-Treated Diabetes.

Karter AJ ，Parker MM ，Moffet HH ，Gilliam LK ，Dlott R ... -  《-》

Initiation of Continuous Glucose Monitoring Is Linked to Improved Glycemic Control and Fewer Clinical Events in Type 1 and Type 2 Diabetes in the Veterans Health Administration.

To determine the benefit of starting continuous glucose monitoring (CGM) in adult-onset type 1 diabetes (T1D) and type 2 diabetes (T2D) with regard to longer-term glucose control and serious clinical events. A retrospective observational cohort study within the Veterans Affairs Health Care System was used to compare glucose control and hypoglycemia- or hyperglycemia-related admission to an emergency room or hospital and all-cause hospitalization between propensity score overlap weighted initiators of CGM and nonusers over 12 months. CGM users receiving insulin (n = 5,015 with T1D and n = 15,706 with T2D) and similar numbers of nonusers were identified from 1 January 2015 to 31 December 2020. Declines in HbA1c were significantly greater in CGM users with T1D (-0.26%; 95% CI -0.33, -0.19%) and T2D (-0.35%; 95% CI -0.40, -0.31%) than in nonusers at 12 months. Percentages of patients achieving HbA1c <8 and <9% after 12 months were greater in CGM users. In T1D, CGM initiation was associated with significantly reduced risk of hypoglycemia (hazard ratio [HR] 0.69; 95% CI 0.48, 0.98) and all-cause hospitalization (HR 0.75; 95% CI 0.63, 0.90). In patients with T2D, there was a reduction in risk of hyperglycemia in CGM users (HR 0.87; 95% CI 0.77, 0.99) and all-cause hospitalization (HR 0.89; 95% CI 0.83, 0.97). Several subgroups (based on baseline age, HbA1c, hypoglycemic risk, or follow-up CGM use) had even greater responses. In a large national cohort, initiation of CGM was associated with sustained improvement in HbA1c in patients with later-onset T1D and patients with T2D using insulin. This was accompanied by a clear pattern of reduced risk of admission to an emergency room or hospital for hypoglycemia or hyperglycemia and of all-cause hospitalization.

Reaven PD ，Newell M ，Rivas S ，Zhou X ，Norman GJ ，Zhou JJ ... -  《-》

Real-time continuous glucose monitoring improves glycemic control and reduces hypoglycemia: Real-world data.

To study the effect of real time continuous glucose monitor (RT-CGM) use on glycemic parameters in patients with diabetes mellitus (DM) in real world practice. We retrospectively studied 91 adult subjects with DM who had been using Dexcom™ RT-CGM. Two consecutive hemoglobin A1c (HbA1c), both prior to and after at least 3 months of RT-CGM initiation, were collected. A total of 31 subjects completed a 5-14 day user blinded CGM using a Freestyle Libre™ prior to RT-CGM initiation. The first two week period following at least 3 months use of RT-CGM was analyzed for CGM metrics. A total of 51.6 % of subjects had T1DM, 34.1 % used continuous subcutaneous insulin infusion (CSII), and 62.6 % had DM for > 10 years. Both HbA1c obtained following RT-CGM initiation decreased significantly compared to baseline (8.11 + 1.47% vs 7.69 + 1.25 %; P = 0.002 & 8.16 + 1.51 % vs 7.62 + 1.06 %; P = 0.001). Subjects with baseline HbA1c > 7.0 % showed even more robust reduction in both HbA1c after RT-CGM initiation (8.74 + 1.24 % vs 7.99 + 1.22 %; P = 0.000 & 8.74 + 1.32 % vs 7.85 + 1.07 %; P = 0.001). On comparison of CGM metrics, there was a significant reduction in time spent in hypoglycemia (sugars < 70 mg/dl) including severe hypoglycemia (sugars < 54 mg/dl) after initiation of the RT-CGM (9.16 + 8.68 % vs 1.29 + 2.21 %; P = <0.001 & 4.58 + 5.43 % vs 0.28 + 0.58 %; P = <0.001). CoV of glucose was also decreased significantly (39.61 + 9.36 % vs 31.06 + 6.74 %; P = <0.001) with RT- CGM use. RT-CGM use for at least 3 months in patients with DM results in meaningful HbA1c reductions with stable glycemic control without increasing the risk of hypoglycemia.

Kant R ，Antony MA ，Geurkink D ，Gilreath N ，Chandra L ，Zipprer E ，Munir KM ，Chandra R ，Parker VG ，Verma V ... -  《-》

Beyond HbA1c.

It can scarcely be denied that the supreme goal of all theory is to make the irreducible basic elements as simple and as few as possible without having to surrender the adequate representation of a single datum of experience. The diaTribe Foundation convened a meeting on the topic of glycemic outcomes beyond HbA1c on 21 July 2017, in Bethesda (MD, USA), focusing on potential uses of continuous glucose monitoring (CGM). Understanding patterns of glycemia in people with diabetes has long been a focus of approaches to improving treatment, and over the past few years this has become an available modality for clinical practice. Glucose levels are not the only biologic parameters affecting HbA1c levels; HbA1c changes with anemia or, more subtly, with changes in rates of erythrocyte turnover not reflected in hemoglobin levels outside the normal range. Renal disease often is associated with lower HbA1c than would be predicted based on an individual's glycemic levels. Furthermore, HbA1c levels tend to increase with age and are higher in some ethnic groups; for example, people of African ethnicity have higher HbA1c levels than people of Northern European descent. Indeed, we have argued that even as a measure of mean glycemia HbA1c is inherently imprecise. Overall, for some 20% of people with diabetes, HbA1c levels are substantially higher, or substantially lower, than those that would be predicted from mean blood glucose levels. If one recognizes that HbA1c is, at best, a partial measure of mean glycemic exposure, one must surely accept that HbA1c does not reflect variability within a day, from day to day, and from period to period. Many glucose-lowering medicines, particularly the sulfonylureas and insulin, cause hypoglycemia, with consequent negative effects on quality of life and patient-reported outcomes, as well as association with weight gain and adverse macrovascular outcome; hypoglycemia will, of course, not be captured by HbA1c measurement. Based on these considerations, HbA1c may be more limited than generally recognized as a surrogate marker of optimal diabetes treatment, leading the European Medicines Agency to consider relying less on this measure, with the implication that novel approaches will be required for clinical practice and for clinical trials in developing future medicines. In surveys performed by a market research company (dQ&A Market Research, San Francisco, CA, USA) and reported at the Bethesda meeting, among >3000 people with type 1 (T1D) or type 2 (T2D) diabetes both receiving and not receiving insulin, the majority reported a sense that their diabetes care is not very successful and that too much of their time was spent outside the 70-180 mg/dL (3.9-10.0 mEq/L) range. Although self-monitoring of capillary blood glucose (SMBG) is an important tool for patients to use in understanding glycemic excursions, CGM offers a far superior technology in this regard and can avoid the erroneous conclusions often accompanying the use of the inherently indirect measurement of HbA1c. Duration and severity of hypoglycemia may come to be considered important medication efficacy measures, rather than just being considered safety outcomes. Glucose cut-off levels suggested at the meeting may be: <54 mg/dL (3.0 mEq/L) for severe hypoglycemia, <70 mg/dL (3.9 mEq/L) for low blood glucose levels, >180 mg/dL (10.0 mEq/L) for high blood glucose levels, and >240 mg/dL (13.3 mEq/L) for serious high blood glucose levels. An important part of both SMBG and CGM technologies will be the development of data transmission and storage modalities to better provide feedback to people with diabetes and health care providers in adjusting a variety of treatments, as well as their growing use in insulin dose adjustment algorithms; important in such approaches will be the integration of SMBG with CGM to recognize potential measurement errors and to improve the accuracy and assurance of patients and providers that the CGM results are accurate, a particular concern for readings in the hypoglycemia range, but remaining an issue throughout the clinical glycemia range. However, one must recognize that many commercially available SMBG instruments also fail to exhibit required accuracy, and that the indirect relationship between HbA1c and blood glucose suggests that HbA1c is at best limited in its portrayal of glycemic exposure. All these modalities play a role, but the use of CGM appears crucial to the development of better approaches to clinical treatment with multiple views allowing understanding of patterns of glycemic exposure. We look forward to further improvements in this methodology.

Bloomgarden Z 《-》