Next step in diabetes care: Use CGM data to inform treatment decisions
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Key takeaways:
- CGM has changed the way providers assess glycemic control for people with diabetes.
- Providers and patients will both have a role in using CGM to manage diabetes and make treatment decisions in the future.
BOSTON — Continuous glucose monitoring has transformed the field of diabetes over the past 25 years. The technology can be used by both providers and people with diabetes to improve disease management, according to a speaker at ENDO 2024.
Richard M. Bergenstal, MD, executive director of the International Diabetes Center, HealthPartners Institute in Minneapolis, detailed the history of CGM in the conference’s 2024 Clark T. Sawin Memorial History of Endocrinology Lecture. Bergenstal cited CGM and other diabetes devices as playing a pivotal role in the improvement in diabetes management during the 21st century. However, he said providers must continue to improve their implementation of CGM and effectively use the data from the devices in their management of diabetes.
“We have decades of comfort with the HbA1c. That’s good, that’s an incredible marker of your risk,” Bergenstal said during the Clark T. Sawin Memorial History of Endocrinology Lecture. “But I want to get across this bridge ... to get clinicians comfortable with using time in range and time below range to adjust therapy and change management as opposed to just assessing.”
History of CGM
This year marks the 25th anniversary of the FDA approval of the first CGM device. In 1999, the Medtronic MiniMed was approved by the FDA for people with diabetes. This was followed by the approval of the GlucoWatch Biographer in 2001. Bergenstal cited these approvals as the first step on his roadmap of the effective use of CGM, which was published in Diabetes Spectrum in 2023.
From 2006 to 2014, CGM progressed in several ways, according to Bergenstal. The devices became more accurate and no longer required calibration. They became nonadjunctive and more interoperative. A major step forward occurred in 2012, when the International Diabetes Center and Helmsley Charitable Trust partnered to convene a panel of diabetes experts to standardize CGM metrics. The panel’s findings led to the creation of CGM targets, including time in range encompassing a glycemic level of 70 mg/dL to 180 mg/dL. The panel also determined people with diabetes should try to achieve a time in range of more than 70%.
The number of CGM trials conducted expanded immensely in the late 2000s and through the 2010s. A systematic review and meta-analysis of 15 trials, published in Diabetes Care in 2020, found CGM improved time in range and decreased time above range, time below range and glucose variability for people with type 1 or type 2 diabetes. Additionally, results from the REPLACE trial, published in Diabetes Therapy in 2017, found that use of flash CGM lowered hypoglycemia by 43% more than self-monitoring blood glucose.
The integration of CGM with insulin pumps and insulin pens was another milestone in diabetes management. Bergenstal credited Aaron J. Kowalski, PhD, for publishing a roadmap for the use of automated insulin delivery that paved the way for CGM to be integrated with multiple types of devices.
“We’re in the era now of starting to mix and match,” Bergenstal said. “Some companies will [integrate] with them all, some will pick just one piece of this.”
Using CGM
With more data and more device approvals, providers have begun looking at CGM metrics to inform treatment decisions. Bergenstal noted that the American Diabetes Association changed its assessment of glycemic control recommendation in the 2021 Standards of Care to allow other glycemic measurements outside of HbA1c. The recommendations were further updated to specify the use of time in range or glucose management indicator for glycemic assessment.
“Now is the time to really put [CGM] into action,” Bergenstal said.
Bergenstal said providers can take a two-pronged approach to diabetes management. With real-time data and integrated devices, people with diabetes can review their glycemic status and make treatment adjustments. Additionally, providers can review data retrospectively through the cloud or electronic health records and make further adjustments.
In a study published in Diabetologia in 2024, researchers randomly assigned adults with type 2 diabetes, 1:1:1, to a CGM intervention group that was taught to use data to make insulin dose and timing adjustments, a conventional group using integrated CGM without additional education, or a control group not using CGM. Researchers found the intervention group had a greater HbA1c reduction than the other groups.
More CGM innovations are still to come, according to Bergenstal. Expanded indications for CGM use during pregnancy, in the hospital, by people with type 2 diabetes who do not use insulin and by those with prediabetes are on the horizon. Future diabetes devices may include CGM with continuous ketone monitors, noninvasive CGMs and smartwatches that can act as a CGM. Additionally, AI will have an even greater role.
“There’s data in the [ambulatory glucose profile] that can guide decisions for the best drugs to use, lifestyle choices and other risk factors,” Bergenstal said. “We’re looking forward to AI helping us look at patterns.”
References:
Bergenstal RM. Diabetes Spectr. 2023;doi:10.2337/dsi23-0005.
Haak T, et al. Diabetes Ther. 2017;doi:10.1007/s13300-016-0223-6.
Kim JY, et al. Diabetologia. 2024;doi:10.1007/s00125-024-06152-1.
Kowalski AJ. Diabetes Technol Ther. 2009;doi:10.1089/dia.2009.0031.
Maiorino MI, et al. Diabetes Care. 2020;doi:10.2337/dc19-1459.
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Bergenstal RM. L01. Presented at: ENDO annual meeting; June 1-4, 2024; Boston.
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