Continuous Glucose Monitors

[Freezeout]

Is anyone currently prescribing these/using these in practice? I've had a few patients ask about them but don't have much experience with them.

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[smq123]

Is anyone currently prescribing these/using these in practice? I've had a few patients ask about them but don't have much experience with them.

I am fortunate to have an endocrinologist in our multi-specialty clinic, so I don't. I have prescribed them in the past, but they're kind of a pain to get (especially if they have crappy or no insurance). I feel like if your glucose is that labile that you would benefit from one, you should also be seeing an endocrinologist.

 

[VA Hopeful Dr]

I've written a few, rarely will insurance cover it.

My local endocrine people suck so I tend to do more with the diabetics than most.

 

[FrustratedFamDoc]

Have several patients that have it through their endo. Questionable if it really makes much of a difference that I've personally seen in management. The ones that I've seen with it are typically poorly compliant anyway and a continuous monitoring device that reminds them of such is unlikely to change that, but hopefully I'm wrong on that one. Now the cath lab or in pt. rehab... those are definite lifestyle modifiers.

 

[Freezeout]

Interesting. The ones that have asked about it want it because you wouldn’t have to prick your finger and can just scan it or something along those lines.

 

[smq123]

Interesting. The ones that have asked about it want it because you wouldn’t have to prick your finger and can just scan it or something along those lines.

Oh, right, the FreeStyle Libre. I had one patient ask for it. He lost interest when I told him that it was mostly for people on insulin, and you have to implant something into your arm. I think he thought that you wore the device on top of your skin.

 

[Keona]

We have a diabetic nurse in our office. She is a dietician as well and sees patients and does the insurance stuff to see if they will qualify. I sign the papers she gives me to request them. We do them short term on people where we are having a really difficult time getting control. Sometimes it shows they probably aren’t actually taking any insulin. Other times the insulin dose is causing hypoglycemia and they are overcorrecting. I got my first successful long term cgm on a type 1 extremely brittle diabetic. It took the nurse months to get it but it showed us an odd middle of the night glucose spike and made the patient feel safe to sleep and not be worried she was going to die of hypoglycemia in her sleep. I’d stick them on tons of people if they weren’t so expensive and so much work to get!!

 

[deleted87716]

I've written for FreeStyle Libre a couple of times. I don't have that many patients who are interested in it. Most of my patients who use CGM are on insulin pumps, and are followed by endo.

 

[Bacchus]

I’ll prescribe the Libre. So much easier when the patient will pay OOP.

 

[BigSib]

Haven't ordered any yet and probably never will. I refer out nearly all of the type 1's unless they're well controlled, which from what I understand is most helpful for. I feel like the only people I would consider doing it for are those who are not adherent to checking their own sugars at the appropriate intervals and we need to gather better data to make an insulin or med change, and if that's the case then there's a deeper conversation to be had with the patient (e.g., motivation, diet, etc.).

 

[deleted87716]

CGMs are a tool of immense value for people with diabetes. CGMs are the most accurate way of assessing the status of blood sugar regulation, "in-real-time". Really all T1D should be wearing a CGM, along with T2D for at least 2-4 weeks while they dial in Afrezza. For the T1s there's no carb counting or complex meal titration, no stacking risk because of the kinetics, and so less risk of hypos. For the T2s, they get to restore post-prandial glucose homeostasis with potential for saving beta cells, possibly regenerating more over time.


But CGMs do not replace finger sticks entirely because the meter readings will still need to be performed to verify accuracy.

Standard glucose meters and the test strips have numerous drawbacks and limitations, and this method simply cannot and will not assess time in range, glucose variability, glucose flucuations, post-prandial glucose excursions, nor log time, duration and number of occurances for each hyper and hypo event. There's really no logical reason to not want a person with diabetes to use a CGM. Hyperglycemia is the primary cause of all the diabetes-related health conditions we see today, and without a CGM you aren't going to be able to assess blood glucose status in-real-time, and you're SOL for having an alarm alert you of a potentially fatal low while you're sleeping.

The poster with a patient that has extremely brittle type 1 diabetes—curious if you've checked the insulin injection and/or infusion sites for localized insulin-derived amyloidosis?

Let me guess...you're an Afrezza rep? They must've included a slide on LIDA in your sales training.

 

[Keona]

Whoever asked about the brittle diabetic I see nope I’ve not checked for anyloidosis. I have checked to make sure no injection site reactions or hypertrophy. I finally got to recheck her a1c and it improved tremendously since she wasn’t terrified of hypoglycemia with her insulin. Next step is a pump.

 

[deleted87716]

Whoever asked about the brittle diabetic I see nope I’ve not checked for anyloidosis.

That's because it's rare as hell. Only a handful of cases have been reported in the English literature.

 

[septoplasty]

That's because it's rare as hell. Only a handful of cases have been reported in the English literature.

Unless your on House.. than everyone has it.

 

[birchswing]

Oh, right, the FreeStyle Libre. I had one patient ask for it. He lost interest when I told him that it was mostly for people on insulin, and you have to implant something into your arm. I think he thought that you wore the device on top of your skin.

It barely goes into the skin, tiny little filament. It's less painful than a finger prick and you apply it once every 14 days. For me I don't even feel it going in. I wouldn't call it implanted. I've had no insurance coverage issues. Because it's a flash monitor my insurance covers it the same way they do glucose strips. I'm not on insulin, not on metformin, nothing—and I have 100% coverage. I have T2D with an A1C of 5.3% through diet and constant monitoring (before this I would test my sugar 10 plus times a day—the doctor's advice of going to a dietician who told me to test once in the morning and gave me low-fat recipes for potato salad did not work). I would have out-of-control diabetes if I hadn't learned how foods affect me. Knowing my numbers makes it so much easier to know how to eat. The out of pocket cost without insurance isn't that bad either.

Non-diabetics will use these more and more. Freestyle Libre has been OTC in the UK for a long time. Tim Cook espoused his weight loss using a CGM for non-diabetic purposes. And I know T1Ds who say that CGMs were more of a godsend than pumps ever were. I don't know in what manner these will go mainstream, but given that even non-health-anxiety people are suddenly interested in monitoring their daily steps, water intake, pulse, EKGs, etc on consumer electronics, I think it will find its way to a larger, non-prescribed market somehow.

 

[septoplasty]

Because it's a flash monitor my insurance covers it the same way they do glucose strips. I'm not on insulin, not on metformin, nothing—and I have 100% coverage.

But there is no evidence of this actually making a difference, if you monitor using the GI for references, you could probably determine how certain foods will affect you as well w/o this. I'm not saying you're wrong or anything, but like with all new tech/methods, there's gotta be some sort of vetting, because if Abbott starts marketing this to healthy individuals as one of those 'oh, just see what your sugars are like', than we're going to be over treating a lot of people..

I'm totally surprised your insurance covered this with IFG. I have trouble getting test strips for people who are on actual anti-glycemics (insurance dependent, i know, but still).

 

[deleted87716]

It barely goes into the skin, tiny little filament. It's less painful than a finger prick and you apply it once every 14 days. For me I don't even feel it going in. I wouldn't call it implanted. I've had no insurance coverage issues. Because it's a flash monitor my insurance covers it the same way they do glucose strips. I'm not on insulin, not on metformin, nothing—and I have 100% coverage. I have T2D with an A1C of 5.3% through diet and constant monitoring (before this I would test my sugar 10 plus times a day—the doctor's advice of going to a dietician who told me to test once in the morning and gave me low-fat recipes for potato salad did not work). I would have out-of-control diabetes if I hadn't learned how foods affect me. Knowing my numbers makes it so much easier to know how to eat. The out of pocket cost without insurance isn't that bad either.

Non-diabetics will use these more and more. Freestyle Libre has been OTC in the UK for a long time. Tim Cook espoused his weight loss using a CGM for non-diabetic purposes. And I know T1Ds who say that CGMs were more of a godsend than pumps ever were. I don't know in what manner these will go mainstream, but given that even non-health-anxiety people are suddenly interested in monitoring their daily steps, water intake, pulse, EKGs, etc on consumer electronics, I think it will find its way to a larger, non-prescribed market somehow.

Sorry, but if you aren't on insulin (much less a non-diabetic), there's no reason you need to be testing your blood sugar, much less using CGM. It provides little in the way of useful information, and just wastes money. Find something else to do for entertainment.

 

[birchswing]

Sorry, but if you aren't on insulin (much less a non-diabetic), there's no reason you need to be testing your blood sugar, much less using CGM. It provides little in the way of useful information, and just wastes money. Find something else to do for entertainment.

There are several counterarguments to this. One is that not everything in the field of medicine has a medical purpose. So even if you don't accept my claim that this helps me, you would have to also reject the entire field of unnecessary medical interventions including cosmetic procedures. The second is that this has helped me. I have a system where I eat by the numbers. My evidence is specific to me, but it is also meaningful to me. I will give you an example. My grandmother sends very "healthy" cookies from Oregon that are whole wheat and have some sort of berry filling. They taste like fig newtons but very earthy. A couple of those sends my glucose to 220. Take a milk chocolate bar from Trader Joe's, equivalent amount of sugar. My sugar goes to 130, 140 tops. I wouldn't know that without measuring. I have cyclical rises in cortisol as well (still of unknown origin because cortisol tests keep coming back with normal then abnormal results over 24 hours but seeing an endo to rule things out systematically). When I get a spell of raised cortisol, the sugars are much higher overall, and I pull back on carbohydrates even harder. I also wouldn't have realized that my spells I get also resulted in higher blood sugar. I suppose there isn't a study regarding type 2 diabetics and an intervention of constantly knowing their glucose levels as a form of treatment. But for me it has worked and been useful. I am curious as to whether the difference you see is in regard to insurance reimbursement. That is an area where I could find agreement. But if we separate that out and talk about health monitoring more generally, is it really necessary for everyone who has an Apple Watch to be monitored for an irregular heart rhythm constantly? I would not be surprised if glucose monitoring enters a mainstream market more broadly.

 

[deleted87716]

 

[birchswing]

You make a strong argument.

 

[deleted87716]

You make a strong argument.

As strong as is deserved.

 

[rokshana]

Oh, right, the FreeStyle Libre. I had one patient ask for it. He lost interest when I told him that it was mostly for people on insulin, and you have to implant something into your arm. I think he thought that you wore the device on top of your skin.

he is right, the free style libre has a 14 day sensor that sticks to the arm...the Eversense is an implantable CGM, but i don't think its commercially available yet.

CGMs make more sense for those on insulin or have hypoglycemic unawareness...those on medications that don't cause hypoglycemia don't really need to check their sugars that frequently...if at all.

 

[birchswing]

he is right, the free style libre has a 14 day sensor that sticks to the arm...the Eversense is an implantable CGM, but i don't think its commercially available yet.

CGMs make more sense for those on insulin or have hypoglycemic unawareness...those on medications that don't cause hypoglycemia don't really need to check their sugars that frequently...if at all.

FreeStyle Libre is not for someone with hypoglycemic unawareness. It's a flash monitor, not a "true" CGM. It has no alarms. It does not pro-actively push information. You have to scan it. My insurance treats it like strips. My insurance was paying almost $400 a month for my Accu-Chek Smartview strips. They pay only about $125 for my FreeStyle sensors.

You can jury-rig the FreeStyle Libre into a "true" CGM with an alarm by purchasing an after-market bluetooth device that sits on top of the freestyle sensor and connect it to certain apps on phones that can alert you when you're going low, but out of the box that is not a feature and it's not approved for that.

And yes, you're right about the sensor. The filament barely goes under the skin and the sensor sits on top. I literally don't feel it going in, whereas I do feel finger pricks for measuring glucose.

Freestyle is best thought of as a replacement for strips, except you get a lot more data points and it tells you whether your sugar is going up or down. "True" CGMs have alarms and can even work with pumps to automatically dispense insulin.

Edit: I should say it does not have alarms unless you scan it, so it would not be helpful during sleep for example. If you scan it and and are low there is an "alarm" but I'm not sure if that really counts because at that point it's only alerting you to something you can already see.

 

[rokshana]

FreeStyle Libre is not for someone with hypoglycemic unawareness. It's a flash monitor, not a "true" CGM. It has no alarms. It does not pro-actively push information. You have to scan it. My insurance treats it like strips. My insurance was paying almost $400 a month for my Accu-Chek Smartview strips. They pay only about $125 for my FreeStyle sensors.

You can jury-rig the FreeStyle Libre into a "true" CGM with an alarm by purchasing an after-market bluetooth device that sits on top of the freestyle sensor and connect it to certain apps on phones that can alert you when you're going low, but out of the box that is not a feature and it's not approved for that.

And yes, you're right about the sensor. The filament barely goes under the skin and the sensor sits on top. I literally don't feel it going in, whereas I do feel finger pricks for measuring glucose.

Freestyle is best thought of as a replacement for strips, except you get a lot more data points and it tells you whether your sugar is going up or down. "True" CGMs have alarms and can even work with pumps to automatically dispense insulin.

Edit: I should say it does not have alarms unless you scan it, so it would not be helpful during sleep for example. If you scan it and and are low there is an "alarm" but I'm not sure if that really counts because at that point it's only alerting you to something you can already see.

thank you, as a practicing endocrinologist, i appreciate being told by a...psychiatrist? how to utilize instruments for diabetes...if you would re read my post i said CGMs are for hypoglycemic unawareness, not the Free Style Libre...want to tell me about your adrenal fatigue too?

 

[birchswing]

thank you, as a practicing endocrinologist, i appreciate being told by a...psychiatrist? how to utilize instruments for diabetes...want to tell me about your adrenal fatigue too?

Oh no, please forgive me. I'm not a psychiatrist; I'm a psychiatric patient! It's a common mix-up, so you should not feel bad.

BTW, the consumer product we are discussing was developed by a private company and not any medical school or residency you attended and is available over the counter in most markets and not under the purview solely of endocrinologists, and you are in the family medicine forum just in case you weren't oriented to time, place, and person.

 

[rokshana]

Oh no, please forgive me. I'm not a psychiatrist; I'm a psychiatric patient! It's a common mix-up, so you should not feel bad.

BTW, the consumer product we are discussing was developed by a private company and not any medical school or residency you attended and is available over the counter in most markets and not under the purview solely of endocrinologists, and you are in the family medicine forum just in case you weren't oriented to time, place, and person.

it is not available in the US as OTC...so since this is an FM forum...in which i was responding to a FM physician's misconception about the Free Style Libre, why are you, a non medical person even here? I wasn't even really having a discussion with you..my post was for smq...

 

[rokshana]

But there is no evidence of this actually making a difference, if you monitor using the GI for references, you could probably determine how certain foods will affect you as well w/o this. I'm not saying you're wrong or anything, but like with all new tech/methods, there's gotta be some sort of vetting, because if Abbott starts marketing this to healthy individuals as one of those 'oh, just see what your sugars are like', than we're going to be over treating a lot of people..

I'm totally surprised your insurance covered this with IFG. I have trouble getting test strips for people who are on actual anti-glycemics (insurance dependent, i know, but still).

our health care dollars at work! here a guy who doesn't need this intense type of monitoring has it covered by his insurance and i have pts that can't afford their insulin pens and end up using syringes and needles to inject the NPH that they can afford from the Walmart (though that God for the Walmart! and all those grocery stores that give diabetes medications for free!).

 

[birchswing]

it is not available in the US as OTC...so since this is an FM forum...in which i was responding to a FM physician's misconception about the Free Style Libre, why are you, a non medical person even here? I wasn't even really having a discussion with you..my post was for smq...

Actually I had already responded to it before you and already explained that it was not an implantable device.

You'll have to explain what a "non-medical" person is. Is that like someone who says they are not political? I don't think it's possible to be non-medical nor do I believe it's possible to be non-political.

Medical literacy does not begin the day one enters medical school, and there are a number of fields and perspectives that contribute to medical knowledge, including the perspective of patients—especially one who has used and pays for the device in question and has found a use for it in treating diabetes. You contend that blood sugar monitoring is useless in someone not taking a hypoglycemia-causing drug. That is your perspective as a doctor. As someone diagnosed with type 2 diabetes, I have found measuring my blood sugar frequently to be very useful as a treatment method. Look at Tim Cook, a non-diabetic, who touts the use of CGM in weight loss. You might not like what you are hearing, but I believe the trend of people self-monitoring for health (or maybe in your opinion perceived health benefits) is already here, and I think glucose monitoring will be part of that in the near future.

 

[birchswing]

our health care dollars at work! here a guy who doesn't need this intense type of monitoring has it covered by his insurance and i have pts that can't afford their insulin pens and end up using syringes and needles to inject the NPH that they can afford from the Walmart (though that God for the Walmart! and all those grocery stores that give diabetes medications for free!).

FreeStyle Libre is less expensive for me and my insurance than glucose strips; it's also less expensive than insulin in most cases. My insurance is paying less now than they were before when I was being prescribed glucose strips.

There is some good news that came out on the insulin front two days ago:

Statement from FDA Commissioner Scott Gottlieb, M.D., on new actions advancing the agency’s biosimilars policy framework

 

[smq123]

As a reminder, SDN's mission is to serve as a discussion site for health professional students and health professionals (primarily physicians and student doctors).

While discussion and input from non-health professionals is not necessarily unwelcome, it is not the aim of this site to make such discussion a priority. As such, since this thread has been derailed, it will be closed. Further attempts to derail other threads will, unfortunately, result in thread closure and possibly warnings.

Thanks.