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In the nation’s fight against the diabetes epidemic, the go-to weapon aggressively promoted to patients is as small as a quarter and carried on the stomach or arm.
A continuous glucose monitor contains a tiny sensor inserted just under the skin, so patients don’t have to prick their fingers every day to check their blood sugar. The monitor continuously tracks glucose levels, sends readings to patients’ cell phones and physicians, and alerts patients when readings are too high or too low.
Nearly 2 million people with diabetes wear the monitors today, twice as many as in 2019, according to investment firm Baird.
There is little evidence that continuous glucose monitoring (CGM) leads to better outcomes for most people with diabetes – the 25 million American patients with type 2 disease who do not inject blood sugar. insulin to regulate their blood sugar, according to health experts. Still, manufacturers, as well as some doctors and insurers, say the devices help patients control their diabetes by providing almost instant feedback for diet and exercise changes compared to once-daily finger tests. And they say it can reduce costly complications of the disease, such as heart attacks and strokes.
Continuous blood glucose monitors are not cost effective for type 2 diabetes patients who do not use insulin, said Dr. Silvio Inzucchi, director of the Yale Diabetes Center.
Of course, it’s easier to place a device on the arm once every two weeks than it is to do it multiple fingers, which cost less than a dollar a day, he said. But “the price of these devices is not justifiable for routine use for the average person with type 2 diabetes.”
Without insurance, the annual cost of using a continuous glucose monitor ranges from nearly $ 1,000 to $ 3,000.
Lower prices help propel greater use
People with type I diabetes – who do not produce insulin – need frequent data from monitors in order to inject the appropriate dose of a synthetic version of the hormone, via a pump or syringe. Since insulin injections can cause potentially life-threatening drops in their blood sugar, the devices also provide a warning to patients when this happens, especially useful during sleep.
People with type 2 diabetes, a different disease, make insulin to control the comebacks after eating, but their bodies don’t respond as vigorously as people without the disease. About 20% of type 2 patients still inject insulin because their body does not make enough of it and oral medications cannot control their diabetes.
Doctors often recommend that diabetic patients test their blood sugar at home to see if they are meeting treatment goals and to find out how medications, diet, exercise, and stress affect blood sugar.
However, the crucial blood test that doctors use to monitor diabetes in people with type 2 disease is called hemoglobin A1c, which measures average blood sugar over long periods of time. Neither finger prick tests nor blood glucose monitors look at A1c. They cannot because this test involves a larger amount of blood and must be done in a laboratory.
Continuous blood glucose monitors also do not test blood sugar. Instead, they measure the level of interstitial glucose, which is the level of sugar found in the fluid between cells.
The companies seem determined to sell the monitors to people with type 2 diabetes – those who inject insulin and those who don’t – because it is a market of over 30 million people. In contrast, around 1.6 million people have type 1 diabetes.
Lower prices have helped fuel demand for monitors. The Abbott FreeStyle Libre, one of the biggest and cheapest brands, costs $ 70 for the device and around $ 75 per month for the sensors, which need to be replaced every two weeks.
Another factor has been the expansion of insurance coverage.
Almost all insurers cover continuous glucose monitors for people with type 1 diabetes, for whom it is a proven lifeline. Today, nearly half of people with type 1 diabetes use a monitor, according to Baird.
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 using the monitors with health coaches to help keep their diabetes under control.
The few studies – mostly small and funded by device makers – examining the impact of monitors on patient health show conflicting results in lowering hemoglobin A1c.
Still, said Inzucchi, the monitors have helped some of his patients who don’t need insulin – and don’t like to prick their fingers – change their diet and lower their glucose levels. Doctors said they saw no evidence that the readings cause patients to make lasting changes to their diet and exercise. They said many patients who don’t use insulin might be better off taking a diabetes education class, joining a gym, or seeing a nutritionist.
“I don’t see the added value of CGM in this population with the current evidence we have,” said Dr. Katrina Donahue, director of research in the Department of Family Medicine at the University of North Carolina. “I’m not sure if more technology is the right answer for most patients.”
Donahue was co-author of a landmark 2017 study in JAMA Internal Medicine that showed no benefit in lowering hemoglobin A1c after a year of regularly checking glucose levels through finger tests for people. with type 2 diabetes.
It made a big difference in my health.
She assumes that the measurements did little to change the eating and physical habits of patients over the long term – which is probably also true for continuous glucose monitors.
“We have to be wise in the way we use CGM,” said Veronica Brady, certified diabetes educator at the University of Texas Health Sciences Center and spokesperson for the Association of Diabetes Care & Education. Specialists. The monitors make sense if used for a few weeks when people are changing medications that can affect their blood sugar levels, she said, or for people who don’t have the dexterity to do finger tests.
Yet some patients like Trevis Hall give the monitors credit for helping them bring their disease under control.
Last year, Hall’s health plan, UnitedHealthcare, gave her a monitor at no cost as part of a program to help control her diabetes. He said it didn’t hurt when he tied the monitor to his stomach twice a month.
Data showed Hall, 53, of Fort Washington, Maryland, that his glucose reached dangerous levels several times a day. “It was alarming at first,” he said of alerts the device would send to his phone.
Over the months, the readings helped him modify his diet and exercise routine to avoid these spikes and bring the disease under control. Nowadays that means going for a brisk walk after a meal or having a veggie with dinner.
“It made a big difference in my health,” Hall said.
Manufacturers of the devices are promoting them more and more as a way to motivate healthier eating and physical activity.
Manufacturers spend millions of dollars pushing doctors to prescribe continuous blood glucose monitors, and they advertise directly to patients on the Internet and in TV commercials, including a spot featuring singer Nick Jonas at the Super Bowl this year.
Kevin Sayer, CEO of Dexcom, a leading manufacturer of monitors, told analysts last year that the type 2 non-insulin market is the future. “Our team often tells me that when this market disappears, it will explode. It won’t be small and it won’t be slow, ”he said.
“Personally, I believe that at the right price with the right solution, patients will use it all the time,” he added.
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