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CGM "Debate" Finds Benefits, Barriers to Uptake for Type 2 Diabetes

Mary Caffrey
A light-hearted format for the discussion at the 77th Scientific Sessions of the American Diabetes Association still brought out the seriousness of the issue: too many with type 2 diabetes have poor glycemic control, and another medication may not be the answer.
Pettus sought to dispel several myths about CGM and basal insulin: (1) titration with self-monitoring isn’t perfect; (2) people will use the results, as seen in one study that showed patients using CGM ate fewer calories, lost weight, and exercised more; (3) hypoglycemia is a significant problem in T2D, and tests with CGM showed people had events that might have gone unnoticed, but the CGM allowed them to act.

In response, Polonsky said a 2014 study involving CGM in T2D patients on basal insulin produced great results—but also involved frequent contact with the patients. There were 10 visits over 6 months, more than would happen in the real world. “Was it the CGM, or the remarkable support these folks got?” he asked.

When Pettus and Polonsky switched sides to discuss CGM use for those on oral agents, Polonsky—who is an advocate of advancing CGM in the right populations—presented data to show the dismal data on T2D, despite the ever-increasing number of medication choices.

“Why is it that so many folks have a tough time taking medications?” he asked. “Nobody is unmotivated to want to live a long life—we are at best ambivalent.”

“We know there are active fears about medication,” Polonsky said. By contrast, CGM can offer a chance “to become engaged and stay engaged.” The use of feedback, he said, “is the most underutilized tool we have.”

For some patients, CGM doesn’t have to be all the time or forever. Polonsky envisions that some T2D patients could “rent” CGM for a month, then maybe a few weeks a year, to get in touch with the patterns of their behavior and the effect on glycemic control.

Polonsky knows there’s an argument that patients will never understand the data. That’s the wrong question, he said. “What if we provided help and support so they know what these numbers mean?”

“Can we help people have this ‘Aha!’ experience?” he asked.

He read a case study of a T2D patient who started using CGM and now couldn’t imagine going back to “being blind” managing his diabetes without it. “The government might not think I need this,” the person wrote, referencing Medicare’s old policy, “but you’ll have to pry it from my cold, dead hands.”

Pettus ended with a photo of a crowded waiting room, likely in a primary physician’s office. The practical reality, he said, is that time constraints and insurance barriers make it too easy to just write a prescription than to take time to teach patients how to use CGM.

Pettus and Polonsky agree that CGM should only be tried in patients who show some willingness—the question is how to identify who they are, and they agreed more evidence is needed. CGM costs would need to come down, and the technology would have to become even easier to use. Insurance coverage will remain a barrier until there’s more evidence that the technology is cost-effective.

But Polonsky said the idea that patients with T2D might not use CGM because doctors are too busy, “makes me very sad.” 

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