DIABETICMedicine DOI: 10.1111/dme.12759
Editor’s Selection: This Month’s Highlighted Articles
Continuous glucose monitoring used with an insulin pump: should we recommend it to people with diabetes and can we afford it? Diabet. Med. 32, 571 (2015) One of the classic messages from the Diabetes Control and Complications Trial (DCCT; http://diabetes.niddk.nih.gov/ dm/pubs/control/) was that improvement in glycaemic control was possible by intensifying insulin regimes, which led to a dramatic reduction in microvascular disease but at the expense of hypoglycaemia. Using insulin pump therapy (continuous subcutaneous insulin infusion), many people with Type 1 diabetes are getting closer to achieving HbA1c targets than is possible using a basal-bolus regime; however, we are all familiar with a cohort of patients who have difficulty with recognition of hypoglycaemic symptoms and such people are at particular risk at night. Unrestrained hypoglycaemia can lead to coma and death. In this group of people with diabetes, the use of a real-time continuous glucose monitoring system, in addition to continuous subcutaneous insulin infusion, is an important facet of their everyday life. Currently, the continuous glucose monitoring system can be free-standing or part of a closed feedback loop whereby, once the glucose crosses a certain pre-set threshold, the insulin delivery will be suspended for a set time period; so-called glucose sensor-augmented insulin pump therapy. There is good evidence of the therapeutic benefit of continuous glucose monitoring, with a recent metaanalysis of randomized controlled trials using individual patient data confirming reductions in HbA1c with a reduction of hypoglycaemic episodes [1]. Unfortunately, in the UK and in many countries, whilst many providers accept the use of insulin pumps, this is not the case for continuous glucose monitoring, the availability of which in the UK has become a postcode lottery, depending who is funding the patient’s healthcare. In draft NICE guidelines (December 2014), out for consultation, (http://www.nice.org.uk/guidance/gid-cgwaver122/ resources/type-1-diabetes-update-draft-nice-guideline2), it is proposed to: Consider real-time continuous glucose monitoring for adults with type 1 diabetes who are willing to commit to using it at least 70% of the time and to calibrate it as needed, and who have any of the following that persist despite optimised use of insulin therapy and conventional blood glucose monitoring:
Cover image: ª Medtronic.
If these guidelines are adopted, this may give access to many more people with diabetes who require real-time continuous glucose monitoring. The two papers that I have chosen as this month’s highlighted articles, and that are free for download, are directly relevant to this issue. In the first paper, Roze et al. (page 618) made use of the CORE Diabetes Model, which simulates diabetes progression and the development of complications, to conduct a health-economic analysis of continuous glucose monitoring in Type 1 diabetes. They show improvements in glycaemic control, associated with a glucose-augmented pump, that led to a reduced incidence of diabetes-related complications and a longer life expectancy. They then went on to associate these findings with an incremental cost-effectiveness ratio of 367,571 SEK (£28,647) per quality-adjusted life-year gained, which represents good value in Sweden. The second paper by New et al. (page 609) supports previous observations that the use of continuous glucose monitoring reduces time spent outside glucose targets compared with conventional glucose monitoring; however, the novel aspect of this study is that glucose targets were achieved with or without the use of audible alarms. The importance of this observation is that, whilst many people using continuous glucose monitoring use the alarm function, many abandon its use because of the alarms, and there is now preliminary evidence that in some of these people one can advise turning off of the audible alarms for glucose targets. G. A. Hitman Editor-in-Chief Diabetic Medicine
more than one episode a year of severe hypoglycaemia
with no obviously preventable precipitating cause complete loss of awareness of hypoglycaemia frequent (more than two episodes a week) asymptomatic
hypoglycaemia that is causing problems with daily activities extreme fear of hypoglycaemia
ª 2015 The Author. Diabetic Medicine ª 2015 Diabetes UK
Reference 1 Pickup JC, Freeman SC, Sutton AJ. Glycaemic control in type 1 diabetes during real time continuous glucose monitoring compared with self monitoring of blood glucose: meta-analysis of randomised controlled trials using individual patient data. BMJ 2011; 343: d3805.
571
Copyright of Diabetic Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Editor’s Selection: This Month’s Highlighted Articles
Continuous glucose monitoring used with an insulin pump: should we recommend it to people with diabetes and can we afford it? Diabet. Med. 32, 571 (2015) One of the classic messages from the Diabetes Control and Complications Trial (DCCT; http://diabetes.niddk.nih.gov/ dm/pubs/control/) was that improvement in glycaemic control was possible by intensifying insulin regimes, which led to a dramatic reduction in microvascular disease but at the expense of hypoglycaemia. Using insulin pump therapy (continuous subcutaneous insulin infusion), many people with Type 1 diabetes are getting closer to achieving HbA1c targets than is possible using a basal-bolus regime; however, we are all familiar with a cohort of patients who have difficulty with recognition of hypoglycaemic symptoms and such people are at particular risk at night. Unrestrained hypoglycaemia can lead to coma and death. In this group of people with diabetes, the use of a real-time continuous glucose monitoring system, in addition to continuous subcutaneous insulin infusion, is an important facet of their everyday life. Currently, the continuous glucose monitoring system can be free-standing or part of a closed feedback loop whereby, once the glucose crosses a certain pre-set threshold, the insulin delivery will be suspended for a set time period; so-called glucose sensor-augmented insulin pump therapy. There is good evidence of the therapeutic benefit of continuous glucose monitoring, with a recent metaanalysis of randomized controlled trials using individual patient data confirming reductions in HbA1c with a reduction of hypoglycaemic episodes [1]. Unfortunately, in the UK and in many countries, whilst many providers accept the use of insulin pumps, this is not the case for continuous glucose monitoring, the availability of which in the UK has become a postcode lottery, depending who is funding the patient’s healthcare. In draft NICE guidelines (December 2014), out for consultation, (http://www.nice.org.uk/guidance/gid-cgwaver122/ resources/type-1-diabetes-update-draft-nice-guideline2), it is proposed to: Consider real-time continuous glucose monitoring for adults with type 1 diabetes who are willing to commit to using it at least 70% of the time and to calibrate it as needed, and who have any of the following that persist despite optimised use of insulin therapy and conventional blood glucose monitoring:
Cover image: ª Medtronic.
If these guidelines are adopted, this may give access to many more people with diabetes who require real-time continuous glucose monitoring. The two papers that I have chosen as this month’s highlighted articles, and that are free for download, are directly relevant to this issue. In the first paper, Roze et al. (page 618) made use of the CORE Diabetes Model, which simulates diabetes progression and the development of complications, to conduct a health-economic analysis of continuous glucose monitoring in Type 1 diabetes. They show improvements in glycaemic control, associated with a glucose-augmented pump, that led to a reduced incidence of diabetes-related complications and a longer life expectancy. They then went on to associate these findings with an incremental cost-effectiveness ratio of 367,571 SEK (£28,647) per quality-adjusted life-year gained, which represents good value in Sweden. The second paper by New et al. (page 609) supports previous observations that the use of continuous glucose monitoring reduces time spent outside glucose targets compared with conventional glucose monitoring; however, the novel aspect of this study is that glucose targets were achieved with or without the use of audible alarms. The importance of this observation is that, whilst many people using continuous glucose monitoring use the alarm function, many abandon its use because of the alarms, and there is now preliminary evidence that in some of these people one can advise turning off of the audible alarms for glucose targets. G. A. Hitman Editor-in-Chief Diabetic Medicine
more than one episode a year of severe hypoglycaemia
with no obviously preventable precipitating cause complete loss of awareness of hypoglycaemia frequent (more than two episodes a week) asymptomatic
hypoglycaemia that is causing problems with daily activities extreme fear of hypoglycaemia
ª 2015 The Author. Diabetic Medicine ª 2015 Diabetes UK
Reference 1 Pickup JC, Freeman SC, Sutton AJ. Glycaemic control in type 1 diabetes during real time continuous glucose monitoring compared with self monitoring of blood glucose: meta-analysis of randomised controlled trials using individual patient data. BMJ 2011; 343: d3805.
571
Copyright of Diabetic Medicine is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
