In the country’s fight against the diabetes epidemic, the weapon that is aggressively promoted in patients is as small as a quarter and is worn on the abdomen or arm.
A continuous glucose monitor contains a small sensor that is placed just under the skin, which alleviates the need for patients to poke their fingers every day to check their blood sugar. The monitor keeps glucose levels up at all times, sends readings to patients’ cell phones and doctor and warns patients when the readings are too high or too low.
According to investment firm Baird, nearly 2 million people with diabetes carry the monitors today, twice as many as in 2019.
There is little evidence that continuous monitoring of glucose (CGM) leads to better results for most people with diabetes – the estimated 25 million American patients with type 2 disease who do not inject insulin to regulate their blood sugar, health experts say. Yet manufacturers, as well as some physicians and insurers, say the devices help patients control their diabetes by giving almost immediate feedback on diet and exercise changes compared to once-a-day finger stick tests. And they say it can reduce costly complications of the disease, such as heart attacks and strokes.
Continuous glucose monitors are not cost-effective for patients with type 2 diabetes who do not use insulin, said Dr. Silvio Inzucchi, director of the Yale Diabetes Center, said.
Of course, pushing a device on the arm once every two weeks is easier than doing multiple finger sticks, which cost less than $ 1 a day, he said. But ‘the price point for these devices is not justifiable for ordinary people with type 2 diabetes.’
Without insurance, the annual cost of a continuous glucose monitor ranges from nearly $ 1,000 to $ 3,000.
Lower prices help promote more use
People with type I diabetes – who make no insulin – need the regular data from the monitors to inject the right dose of a synthetic version of the hormone via a pump or syringe. Since insulin injections can cause life-threatening drops in their blood sugar, the devices also give a warning to patients when this happens, especially helpful during sleep.
People with type 2 diabetes, another disease, do make insulin to control the upswing after eating, but their bodies do not respond as powerfully as people without the disease. About 20 percent of type 2 patients still inject insulin because their bodies are not making enough and oral medications cannot control their diabetes.
Doctors often recommend that patients with diabetes test their glucose at home to see if they are achieving treatment goals and learn how medication, diet, exercise and stress affect blood sugar levels.
However, the most important blood test that doctors use to monitor diabetes in people with type 2 disease is called hemoglobin A1c, which measures the average blood glucose levels over long periods of time. No finger prick tests or glucose monitors look at A1c. It can not, as this test involves a larger amount of blood and must be done in a laboratory.
The continuous glucose monitors also do not assess blood glucose. Instead, they measure the interstitial glucose level, which is the sugar level found in the fluid between the cells.
It seems that companies are determined to sell the monitors to people with type 2 diabetes – those who inject insulin and those who do not – because it is a market of more than 30 million people. In contrast, approximately 1.6 million people have type 1 diabetes.
The price drop has contributed to increasing the demand for monitors. The Abbott FreeStyle Libre, one of the leading and cheapest brands, costs $ 70 for the device and about $ 75 a month for sensors, which need to be replaced every two weeks.
Another factor was the expansion of insurance coverage.
Almost all insurers cover continuous glucose monitors for people with type 1 diabetes, for whom it is a proven lifesaver. According to Baird, nearly half of people with type 1 diabetes use a monitor.
A small but growing number of insurers are starting to cover the device for some Type 2 patients who do not use insulin, including UnitedHealthcare and CareFirst BlueCross BlueShield, based in Maryland. These insurers say they have seen initial success among members who use the monitors along with health coaches to keep their diabetes under control.
The few studies – mostly small and paid for by device makers – that examine the impact of monitors on a patient’s health show conflicting results in lowering hemoglobin A1c.
Inzucchi said the monitors helped some of his patients who did not need insulin – and did not want to stick their fingers – to change their diet and lower their glucose levels. Doctors said they saw no evidence that the readings led patients to permanently change their diet and exercise routines. They said that many patients who do not use insulin may be better off taking a diabetes class, going to a gym, or visiting a nutritionist.
“I do not see the added value with CGM in this population with the current evidence we have,” said Dr. Katrina Donahue, director of research at the University of North Carolina, Department of Family Medicine, said. “I do not know if more technology is the right answer for most patients.”
Donahue co-authored a major 2017 study in JAMA Internal Medicine that showed no benefit in lowering hemoglobin A1c after one year of regularly checking glucose levels through finger-stick testing for people with type 2 diabetes.
It made a big difference in my health.
She assumes that the measurements did little to change patients’ eating and exercise habits in the long run – which probably also applies to continuous glucose monitors.
“We need to be judicious about how we use CGM,” said Veronica Brady, a certified diabetes educator at the University of Texas Health Science Center and spokeswoman for the Association of Diabetes Care and Education Specialists. The monitor makes sense when used for several weeks when people change medications that may affect their blood sugar levels, or for people who do not have the skill to do finger-stick tests.
Some patients, such as Trevis Hall, give recognition to the monitors to help them get their disease under control.
Last year, Hall’s health plan, UnitedHealthcare, gave him a free monitor as part of a program to control his diabetes. He said it does not hurt if he attaches the monitor to his abdomen twice a month.
The data showed Hall (53) of Fort Washington, Maryland, that his glucose reached dangerous levels several times a day. “It was worrying at first,” he said of the warnings the device would send to his phone.
The lectures helped him over months change his diet and exercise routine to prevent the nails and bring the disease under control. These days, it means a brisk walk after dinner or a vegetable along with dinner.
“It made a big difference in my health,” Hall said.
The manufacturers of the devices are increasingly promoting it as a way to motivate healthier eating and exercise.
The manufacturers are spending millions of dollars to encourage doctors to prescribe continuous glucose monitors, and they are advertising directly to patients on the Internet and in TV commercials, including a spot with singer Nick Jonas in this year’s Super Bowl.
Kevin Sayer, CEO of Dexcom, one of the leading manufacturers of monitors, told analysts last year that the type of non-insulin type 2 is the future. “Our team has often told me that when it’s going, it’s going to explode. “It’s not going to be small, and it’s not going to be slow,” he said.
“I believe patients will always use it at the right price with the right solution,” he added.