Industry Leaders Talk About CGM, Insulin Delivery, and Time in Range
By Andrew Briskin
Continuous glucose monitors (CGM) and other advancements in diabetes technology over the past decade have given people with diabetes a greater ability to manage their glucose levels and insulin dosing. Read what experts had to say about these advancements at diaTribe’s latest Musings panel – Tools to Reach Your Target: CGM and Smart Insulin Delivery.
The last decade has brought unparalleled advancements in diabetes technology: continuous glucose monitors (CGM), smart pens, automated insulin delivery (AID), and more. This technology has enabled the use of Time in Range (TIR), (the percent of time spent each day within a healthy glucose range), as well as Time Below Range and Time Above Range (the time spent with a glucose level that is too low or too high) to help people better manage their diabetes on a daily basis. TIR metrics can also give actionable information about insulin dosing each day.
Experts in diabetes technology and clinical care discussed these topics in-depth at diaTribe’s recent Musings panel discussion, “Tools to Reach Your Target: CGM and Smart Insulin Delivery.” You can watch the full panel discussion here.
The panelists started the conversation by identifying the advantages of TIR over A1C, the current standard for evaluating glucose management. “[A1C] reflects mean glucose, and I say ‘reflects’ because in some individuals it’s a good reflection, and in others, glucose may run higher or lower than the average,” said Dr. David Price, vice president, medical affairs at Dexcom. “Because it’s an average [of your glucose levels], it does not tell you time spent high or low. And that’s what these CGM metrics can do, which can be really useful in managing [diabetes]. Time in Range metrics provide a lot more granularity and insights about the changes an individual needs to make in their diabetes management.”
More and more people are realizing the benefits of CGM and gaining access to this technology; clinical trial data has only further supported how the devices can help people with diabetes improve glucose management.
“A few weeks ago at [the Advanced Technologies and Treatments for Diabetes conference in Barcelona], we announced results of a meta-analysis of 75 observational studies showing improvements in A1C for those using CGM,” said Laura Brandner, director of real world evidence programs at Abbott Diabetes Care. “We have published other real-world evidence that confirms that the Freestyle Libre system is associated with reductions in A1C for adults and children sustained up to 24 months.” This type of evidence, which comes from real-world trials, looks at the use of devices or medications outside of a controlled clinical trial setting – allowing researchers to see how these innovations work in the real-world.
Price added that in an additional study on the impact of CGM in people with type 2 diabetes who are on long-acting insulin, TIR improvements were profound. Price noted that because of the continuous feedback that CGM data provides, people could modify their food choices, physical activity, and potentially be more adherent to their daily insulin regimen. The data from CGM enabled people to constantly adjust, leading to significant improvements in TIR.
The panelists agreed that one of the most important features of CGM and TIR has been the ability to use this data to help make adjustments to daily insulin dosing. This extends not only to those using an insulin pump or AID system, but also those using injections with syringes or pens.
“[Smart pen caps] communicate with [CGM] and the smartphone apps, providing a digital solution for people on multiple daily injections,” said Dr. Jim Malone, chief medical officer at Bigfoot Biomedical. “Those taking long-acting and rapid-acting insulin now have technology that can provide a recommended insulin dose based on the prescriber’s input, can adjust the dose based on size of the meal, and can supply information about a correction dose. I think CGM is a great tool to help people on insulin, especially those on injections.”
Additionally, being comfortable using CGM data can be a great first step for people looking to improve their TIR.
“I don’t think there’s one secret answer [to improve your TIR], but I think the first step is knowing your data, and knowing that it’s just a number,” said Dr. Ananta Addala, one of the panelists and an instructor in the division of pediatric endocrinology and diabetes at Stanford University.
“Having a lot of [CGM] data can be a great starting point, as long as there isn’t judgment associated with it,” Addala said. “Then you can start having that conversation with your care team about where you honestly are and where you want to go, starting with the little incremental changes, things to improve Time in Range one or two percent. Know your data, have some kindness, decide what you are willing to do, and ask for help in taking that first step and going forward.”
There has been no shortage of innovation in diabetes technology. But how do we make CGM easier to get, more affordable, and in the hands of more people who can benefit from it?
“Individuals in low socioeconomic groups, on public insurance, and racial and ethnic minorities all have limited access to technology,” said Addala. “Lowering the threshold for people to have the choice to start on diabetes technology will be a really important way to address the disparities we’re seeing, both in terms of technology use and glycemic outcomes.”
Price and Malone agreed, and Malone added that “it’s very frustrating for us in the diabetes community when our patients can’t get access to CGM, a real breakthrough tool. All the professional societies say the standard of care is if you’re on insulin, type 1 or type 2, you should have access to CGM, but insurance companies have been slow to reimburse this technology. CGM is literally life-saving, and we should continue to work hard to make it accessible to all.”
When asked about her concerns regarding the future of CGM, Brandner discussed limited access to CGM and hopes to see greater advocacy efforts directed toward health policy and insurance companies. “The best healthcare solution is the one that helps the most people. We know from analyzing the data from millions of CGM users that CGM is a game changer, and we’re excited to put out more evidence that giving people access to this information enables them to make better and smarter healthcare decisions.”
Finally, each of the panelists voiced their excitement about the future of CGM and insulin delivery. Two CGM devices, Abbott’s Freestyle Libre 3 and Dexcom G7, are currently undergoing review by the FDA.
Along with the release of the Freestyle Libre 3 in Europe, “Abbott is also partnering with different insulin delivery, digital coaching, and technology companies to bring integrated solutions to streamline diabetes care and develop AID systems compatible with Freestyle Libre 3,” Brandner said. One of these partnerships was recently announced with Ypsomed and CamDiab to develop an AID system for the European market that is compatible with the Freestyle Libre 3.
Regarding Dexcom G7, Price highlighted the device’s greater customization of features and thinner and smaller transmitter. “G6 has been amazing, G7 will be even better,” he said. Find out more details about the G7 in “An Inside Look at the Dexcom G7.”
Malone was particularly excited about the implications of these advancements for smart pen caps. “I’m excited about applying insulin dosing algorithms to patients taking injections,” he said. “Right now, our system takes doses recommended by the clinician, but doesn’t automatically modify those doses the way that AID does. Once we test and evaluate this, I think we can bring some of the advances of an AID system to people who are on daily injection therapy.”
Efforts to expand access to CGM, develop newer and easier ways to dose insulin, and enhance the use of TIR as a metric for glucose management, all provide optimism about the future, giving people with diabetes the tools they need to successfully manage their diabetes.
“CGM has empowered me to be the pilot of my diabetes management,” said Diane Scherer, diaTribe’s development director and panel moderator, who has had type 1 diabetes for 37 years. “The knowledge CGM provides can facilitate more accurate insulin dosing and can give us all greater peace of mind in what is, in all honesty, a dangerous drug we rely on for our survival.”