As a general internist, I appreciate the work of the ADA (American Diabetes Association) that identifies advances in diabetes care and adds these new developments to their comprehensive guidance called “Standards of Care''.  The SOC is published in Diabetes Care as a supplement every January.  The 2023 full version, abridged version, primary care, and other versions are all available online for free.  For providers, a free app is now available (ADA SOC) which allows real time access on your smartphone for quick guidance on specific patient care issues.  

On March 2, 2023, CMS announced expanded coverage of CGMs (Continuous Glucose Monitors) to include all insulin-dependent people and those with a history of problematic hypoglycemia.  These devices have progressively improved over the last decade and have now become the standard metric for diabetes care in people with type 1 diabetes.  The most recent registry data notes ~ 50% of children < 18 y/o have adopted this technology.  Even before the expanded coverage noted above, CGM use in older adults has become much more common.  This technology permits measurement of interstitial glucose every 5 minutes which may be reported real time to a smartphone or scanned at a minimum of every 8 hrs so trained patients may adjust their diabetes care.  

In both Type 1 and Type 2 diabetes, CGMs reduce the risk of serious hypoglycemia and improve time in range (>70%), time below range, & time above range.  A CGM consists of a wired sensor which is changed every 10-14 days, depending on the device.  Attached to this sensor is a transmitter which depending on the device may transmit to a smartphone (Dexcom G 5,6,7 series), or a scanner device (Freestyle Libre 1,2,3 series).  Both types allow patients to know their glucose value, their trend, and when to intervene to reduce excessive glucose variability.  Some devices are approved for use in the 80-250 range without correlation with fingerstick glucose measurements.  Some devices have alarms for hypoglycemia which can be quite helpful while sleeping.  The real time devices allow transmission of data to other smartphones, which could be a facility smartphone that a charge nurse carries to alert them when serious hypoglycemia alerts or trends are occurring.  

Use in children has been so well standardized that child care centers can care for children with type 1 diabetes using CGMs.  I’ve attached the well written ADA “Safe at School” guidance which reviews the commonly used CGMs and introduces the importance of a supported self-management plan called DMMP (Diabetes Medical Management Plan).  

Medtronic CGMs or some Dexcom CGMs may be paired with closed loop devices that are connected to insulin pumps that automatically adjust the insulin infusion (hold if hypoglycemic) on the basis of the interstitial glucose readings.  

As CGM use becomes more prevalent, you will be seeing post-acute patients who will insist on using their device to monitor their glycemic control, rather than our traditional glucometer approach.  As with insulin pumps, this should be safe and effective as long as the patient has a DMMP which they are able to communicate and follow.   

For developing facility policies, partnering with a local diabetes care specialist or hospital may be a good first step.  This is what I did with my facilities when we started caring for patients using insulin pumps.  In addition, I’ve attached some resources from the ADA for your use.  For staff training, YouTube has a number of helpful presentations.  

If you haven’t done so, now is the time to prepare your facility to support this established technology that permits safer and more effective glycemic control.

Resources:

1. ADA Choosing a CGM: https://diabetes.org/tools-support/devices-technology/choosing-cgm
2. ADA Advocacy for CGM:  https://diabetes.org/get-involved/advocacy/continuous-glucose-monitors
3. ADA CGM at School:  https://diabetes.org/sites/default/files/2020-06/CGMGuidelines.pdf
4. ADA Releases 2023 SOC:  https://diabetes.org/newsroom/press-releases/2022/american-diabetes-association-2023-standards-care-diabetes-guide-for-prevention-diagnosis-treatment-people-living-with-diabetes
5. Prescriber's Letter May 2023, a commercial product, has excellent detailed information on all available devices including drug interactions.  The annual fee is $143 for monthly issues, which are loaded with actionable valuable prescribing information.  You can register at:  Prescriber's Letter | TRC Healthcare