AGDT Working Group for Diabetes & Technology
AGP Ambulatory Glucose Profile
AGPD Working Group for Paediatric Diabetology
AID Automated Insulin Delivery
CGM Continuous Glucose Monitoring
G-BA Federal Joint Committee
GOD Glucose oxidase
GDH glucose hydrogenase
FDA Federal Drug Administration
iscCGM Intermittent-scanning CGM
ISF Interstitial fluid
KV Association of Statutory Health Insurance Physicians (KV)
MARD Mean Absolute Relative Difference rtCGM Real-time CGM
SMBG Self-measurement of capillary blood glucose concentration
Overview
Diabetes mellitus is characterized by pronounced glucose fluctuations resulting from
missing or insufficient physiological control systems. The aim of diabetes therapy
is to limit these fluctuations by administering insulin, antidiabetics or by making
lifestyle changes. Regular glucose measurements are indispensable for monitoring the
progress of diabetes therapy and are used either to make immediate decisions on the
appropriate dosage of antidiabetic medication or on the intake of carbohydrates. The
retrospective analysis of the metabolic situation using the HbA1c measurement serves
mainly to assess the long-term risk for microvascular and macrovascular
complications. The HbA1c value does not, however, provide information about glucose
fluctuations that lead to acute complications such as hypoglycaemia and
ketoacidosis.
In recent decades, metabolic self-monitoring has been carried out by measuring
capillary blood glucose with appropriate monitoring systems (blood glucose meters;
SMBG systems). Over the last 30–40 years, these have undergone significant
further development in terms of size, manageability and analytical capabilities.
Over time, some systems are able to achieve a measurement accuracy that comes close
to that of laboratory systems. However, SMBG has the decisive disadvantage of only
displaying a single glucose value and cannot make concurrent statements about the
change rate and speed (increase, decrease) of glucose. This can result in
inappropriate therapy decisions, e. g. by administering corrective insulin
when the glucose value is rapidly decreasing. In addition, the amount of SMBG data
depends on the patient's ability and decision to perform the measurements.
As a result, nightly or asymptomatic hypoglycaemia, for example, often go
undetected.
Systems for continuous glucose monitoring (CGM) in interstitial tissue fluid (ISF)
have been available for about 15 years: While measurements with SMBG systems under
everyday conditions are performed on average 4–7 times daily in adults with
type 1 diabetes, CGM systems provide a complete 24-hour overview and deliver
measured values at 5 min intervals. The registered CGM profiles visualize
the glucose trend, i. e. they display fluctuations in glucose concentrations
which are the result of metabolic processes which are both relatively unpredictable
and only partly influenceable, such as meals, physical activities, stress, illness,
etc. In order to improve glucose control, timely knowledge of the current glucose
value and its dynamics is important information in order to both optimize it and
avoid acute complications. Although satisfactory glucose control is possible in many
patients who perform sufficiently frequent SMBG measurements, CGM can promote
participation in life and reduce psychological stress. This applies in particular to
children with type 1 diabetes who are not yet able to identify physical symptoms,
e. g. hypoglycaemia. The number of blood glucose measurements required daily
is often more than 20 – which often places a high burden on both children
and parents. This is especially the case for regular night-time measurements.
Furthermore, CGM systems are a technical innovation that enable systems with
Automated Insulin Delivery (AID).
In the past, it was difficult for people with diabetes to practice professions in
which they could have endangered themselves and other people in the event of a
hypoglycaemia, e. g. pilot, bus driver or policeman. Thanks to CGM systems,
these people can participate in working life and are able to learn their living
(provided for by law in § 49 SGB (German Social
Code/Sozialgesetzbuch) IX and necessary and sensible for society as a
whole).
In practice, systems called the real-time CGM systems (rtCGM) are used which directly
display the measurement results. Current glucose values are displayed numerically
and graphically, as are glucose trends which indicate the direction and change rate
of the glucose value. Programmable alarms that warn of hypoglycaemia and
hyperglycaemia provide additional safety. However, long-term metabolic optimisation
requires continuous use of the rtCGM systems and how patients use CGM systems in
real life has not yet been examined in depth.
The current generations of rtCGM systems have considerably improved measurement
accuracy compared to systems of earlier generations. Irrespective of this, there may
be deviations between the measured concentrations in the two compartments of blood
and tissue glucose due to a physiological time lag, especially in the case of rapid
increases and decreases in the glucose trend. The rtCGM systems are usually based on
what are called needle sensors, which enable the measured glucose values to be
displayed directly on special receiving and display devices (handhelds), insulin
pumps or via an app on a smartphone. As an alternative to the needle sensors which
must be replaced every seven to ten days, an implantable long-term sensor for an
rtCGM system (service life up to 6 months) is currently available.
Another frequently used variant of CGM systems is a needle sensor system called
intermittent scanning CGM (iscCGM) in which the reader must be held close to the
sensor to scan the measured values. After scanning, the current glucose value and
the retrospective continuous glucose data (determined every 15 min) of the last
8 h are displayed. This system cannot be calibrated. This CGM system is also
used by patients with type 2 diabetes and is an alternative to SMBG. Another
advantage of this system is the lower costs. IscCGM can also be an important
training tool where it is only used for a short period of time, depending on the
situation. Being able to evaluate all the factors which influence the glucose course
is very informative. One disadvantage of the first-generation systems was the lack
of alarms. Nonetheless, thanks to the relatively simple and fast scanning, it was
already possible to reduce the number of hypoglycaemia and hyperglycaemia with that
first generation of devices. The second generation of devices now offers alarm
functions (see below).
Current evaluations from the USA of a large number of patients with type 1 diabetes
who use CGM systems point to a lack of improvement in glucose control among many
users. In our view, this is evidence that simply providing technical options is not
sufficient per se, but that patients and diabetes teams must be fully trained in the
proper use of this diagnostic option. In addition, regular retrospective data
analysis is necessary to adapt the therapy to achieve sustained metabolic
improvement. Many patients only make therapy adjustments using the real-time display
of their display device or smartphone to react to the displayed current glucose
value and the trend arrow (“navigation aid”). They do not download
the CGM data to a computer or smartphone at regular intervals in order to assess the
overall progress over time. For this reason, this should always be done during
doctor-patient consultations, even if this exchange can be time-consuming. The
manufacturers support users with ever better software solutions for evaluating CGM
data. Such analyses can also provide concrete indications for the modification of
diabetes therapy. All in all, the patient should have an active view of the glucose
levels and work with them. The physician and the diabetic test team should also
regularly support the patient with a constructive data analysis.
In the following, the various options for glucose measurement using a uniform
structure are explained. The decision tree in ([Fig. 1])
provides a quick overview of which glucose measurement system is best suited for
which individual patient. The starting point is the patient coming to the practice
or clinic. The diabetes team then needs to recognize the patient’s medical
needs and discuss the various options for glucose measurement. The patient,
diabetologist and diabetes consultant should all jointly make the decision as to
which option is best for the patient. The CGM system used should be changed if it
does not properly meet the medical needs of the patient. A product change might,
however, require a certain amount of lead time due to the validity duration of a
prescription.
Fig. 1 Decision tree for the various glucose measurement options.
SMBG=self-measurement of capillary blood glucose concentration;
CGM=continuous glucose monitoring; rtCGM=real-time CGM,
iscCGM=intermittent-scanning CGM.
The decision as to which system fits the patient best should be guided primarily by
medical and social indications (e. g. hypoglycaemia, pregnancy, professional
life and private life), not by economic aspects. SMBG is the first level that every
patient should master and use. Only then should a conversion to rtCGM/iscCGM take
place. The decision as to which of the two CGM options currently offered is suitable
depends on the individual conditions of the patient. Intensive training in the
selected form of diabetes therapy is a prerequisite and is essential when choosing
CGM. If the possibilities of rtCGM are not being used fully, switching to iscCGM is
an option. Conversely, if the therapy goals are not being achieved or if glucose
control is unstable under iscCGM, it may be useful to switch to rtCGM. Not adhering
to rtCGM or iscCGM should lead to ending the use of these systems.
The procedure may differ for children. Nowadays they often first receive an insulin
pump and a CGM system quickly follows. In many cases, children under 2 years of age
receive both directly because up to 20 SMBG measurements per day are too stressful
for both child and parents. This patient group benefits greatly from the new
technical options.
Statements on the therapeutic use of the glucose monitoring values obtained by
various patient groups are made in the respective DDG (German Diabetes
Society/Deutsche Diabetes Gesellschaft) practical recommendations.
These practical recommendations do not mention product names for blood glucose
monitoring systems, although there is a clear need for a positive list. Similarly,
no information is provided on the technical details of specific products, as their
further development is too rapid (see the manufacturers' homepages).
This practical recommendation is not an evidence based S3 guideline and, accordingly,
statements are not supported by literature quotations. The recommendations are based
on the clinical and practical experience of the authors and the evidence derived
from studies for the purpose of the achieving the best possible usability in
everyday life. As well, no statements are made on the diabetes diagnosis and the use
of glucose measurement systems to do so (see the corresponding practical
recommendation).
The authors of this practical recommendation are members of Working Group for
Diabetes and Technology/AG Diabetes & Technologie e. V. (AGDT) and/or the
Working Group for Paediatric Diabetology/Arbeitsgemeinschaft für
Pädiatrische Diabetologie e. V., (AGPD), which are working groups under the
umbrella of the DDG. The AGDT has issued a number of statements and publications on
aspects which are dealt with in this practical recommendation; these can be found on
the DDG and AGDT homepages. This practical recommendation was created together with
the Commission for Laboratory Diagnostics in Diabetology/ Kommission für
Labordiagnostik in der Diabetologie (KLD). Statements also come from the current S3
guideline on type 1 diabetes, published in March 2018, and the S3 guideline for
children and adolescents [Neu A, Bürger- Büsing J, Danne T, Dost A,
Holder M, Holl RW, Holterhus PM, Kapellen T, Karges G, Kordonouri O, Lange K,
Müller S, Raile K, Schweizer R, von Sengbusch S, Stachow R, Wagner V,
Wiegand S, Ziegler R. Diagnosis, Therapy and Follow-Up of Diabetes Mellitus in
Children and Adolescents/ Diagnostik, Therapie und Verlaufskontrolle des Diabetes
mellitus im Kindes- und Jugendalter. S3 guideline of the DDG and AGPD 2015, AWMF
registration number 057–016 © Deutsche Diabetes Gesellschaft (DDG)
2015. p. 1–18], which was published under the leadership of the AGPD in
2015.
Self-Measurement of Capillary Blood Glucose Concentration (SMBG)
Self-Measurement of Capillary Blood Glucose Concentration (SMBG)
Goals/Indications
In order to achieve the therapy goals (e. g. an HbA1c value set with the
treating physician, reduction of hypoglycaemia, improvement of the preprandial
or postprandial BG values), properly trained patients with diabetes mellitus
regularly measure the glucose concentration in capillary blood samples to
monitor the glucose trend (information on the correctly performing the
measurement is found in ([Table 1]). Blood glucose
measurements are also used to detect acute metabolic disorders (hypoglycaemia or
hyperglycaemia).
Table 1 Practical procedure in capillary blood glucose
measurement.
Preparation
|
-
Wash and dry hands before measuring, as food
residues, skin cream or disinfectants can falsify
the measurement. If this is not possible, wipe off
the first drop of blood and use the second drop for
the measurement.
|
|
Lancing
|
Lance the side of the fingertip:
|
|
|
|
|
Measurement
|
Know the special features of the respective SMBG system,
e.g:
|
|
|
|
|
(Important when outdoor temperatures are low or high.) Test
strips are sensitive.
|
|
|
|
Measurement results
|
Measurement results must be documented, values must be
recorded in a diary or electronic documentation options must
be used.
|
|
Do not trust measured values blindly.
|
-
Despite correct execution of the measurement
procedure, the measurement result may be incorrect!
Patient symptoms are more important than a
measurement value, in case of discrepancies repeat
measurement.
|
SMBG systems
|
|
|
With different therapy approaches (oral therapy, bedtime insulin administration,
conventional insulin therapy (CT), intensified insulin therapy (ICT), insulin
pump therapy (CSII)) and different diabetes types (type 1, type 2 with and
without insulin therapy, pancreatic diabetes mellitus, gestational diabetes and
others), different times and frequencies for measuring blood glucose
concentrations are common and objectively indicated ([Table
2]). The glucose measurement results are used to adjust the insulin
dose or other antidiabetic drugs, modify exercise to the current glucose
situation or carbohydrate intake for an (imminent) hypoglycaemia.
Table 2 Recommendations for the use of SMBG in the various
types of diabetes and forms of therapy.
Diabetes
|
Therapy
|
Measurement frequency
|
Measurement situation Preprandial: before the meal
Postprandial: 1.5 h after meal
|
Measurement interval
|
Test strip requirement
|
Type 1
|
ICT
|
At least 5×daily
|
Preprandial and possibly postprandial, before going to
bed
|
On a daily basis
|
> 5 strips dailyAt least 600 strips per
quarter
|
At night (2:00 a.m. to 4:00 a.m.)
|
Every 2–3 weeks
|
In special situations (suspected hypoglycaemia, sport,
illness, before driving ...)
|
When required
|
Type 1 children and adolescents
|
ICT
|
At least 10×daily
|
Preprandial, postprandial, before going to bed, at night
|
On a daily basis
|
> 10 strips daily At least 1000 strips per
quarter
|
In special situations (before/at/after
sports,
|
When required
|
During feverish infectious diseases ...)
|
Every 2–3 h
|
Type 1
|
Insulin pump
|
At least 5×daily
|
Preprandial and possibly postprandial,
|
On a daily basis
|
> 5 strips dailyAt least 600 strips per
quarter
|
Before going to bed at night (2:00 a.m. to 4:00 a.m.)
|
Every 2–3 weeks
|
In special situations (suspected hypoglycaemia, sport,
illness, before driving, technical mistake ...)
|
When required
|
Type 1 children and adolescents
|
Insulin pump
|
At least 12×daily
|
Preprandial, postprandial, before going to bed, at night
|
On a daily basis
|
> 12 strips dailyAt least 1200 strips per
quarter
|
In special situations (before, during or after sports),
|
When required
|
During infectious diseases, technical mistake ...)
|
Every 2–3 h
|
Type 1 with hypoglycaemia perception disorder
|
ICT/insulin pump
|
At least 8×daily
|
Preprandial and postprandial, before going to bed
|
On a daily basis
|
> 8 strips dailyAt least 800 strips per
quarter
|
At night (2:00 a.m. to 4:00 a.m.)
|
Every 2 weeks
|
In special situations (suspected hypoglycaemia, sport,
illness, before driving, technical mistake ...)
|
When required
|
Type 2
|
ICT
|
At least 4×daily
|
Preprandial and possibly postprandial, before going to
bed
|
On a daily basis
|
> 4 strips dailyAt least 500 strips per
quarter
|
At night (2:00 a.m. to 4:00 a.m.)
|
Every 2–3 weeks
|
In special situations (suspected hypoglycaemia, sport,
illness, before driving ...)
|
When required
|
Type 2
|
CT
|
At least 2×daily
|
Preprandial (before injection)
|
Daily
|
> 2 strips dailyAt least 250 strips per
quarter
|
At night (2:00 a.m. to 4:00 a.m.)
|
Every 2–3 weeks
|
In special situations (suspected hypoglycaemia, sport,
illness, before driving ...)
|
When required
|
Type 2
|
Bedtime insulin
|
At least 2×daily
|
Preprandial fasting, before going to bed
|
On a daily basis
|
> 2 strips dailyAt least 200 strips per
quarter
|
At night (2:00 a.m. to 4:00 a.m.)
|
Every 2–3 weeks
|
In special situations (suspected hypoglycaemia, sport,
illness, before driving ...)
|
When required
|
Type 2 with hypoglycaemia risk
|
Sulfonylurea therapy
|
At least 2×per week
|
Preprandial fasting, before going to bed
|
1×per week
|
> 1/2 strip dailyAt least 50 strips
per quarter
|
At night (2:00 a.m. to 4:00 a.m.)
|
Every 2–3 weeks
|
In special situations (suspected hypoglycaemia, sport,
illness, before driving ...)
|
When required
|
Type 2 without hypoglycaemic risk
|
Oral therapy
|
|
In special situations (manifestation, for training purposes,
failure to achieve the therapy goals ...)
|
When required
|
At least 50 strips per quarter
|
Type 1/Type 2 Pregnancy
|
ICT/insulin pump
|
At least 7×daily
|
Preprandial and postprandial, before going to bed
|
On a daily basis
|
> 7 strips dailyAt least 700 strips per
quarter
|
At night (2:00 a.m. to 4:00 a.m.)
|
On a weekly basis
|
In special situations (suspected hypoglycaemia, sport,
illness, before driving, technical mistake ...)
|
When required
|
Gestational diabetes
|
Nutrition
|
At least 15×per week
|
Fasting,
|
On a daily basis
|
At least 350 strips per quarter
|
Preprandial and postprandial, before going to bed
|
3×per week
|
Gestational diabetes
|
Insulin
|
At least 7×daily
|
Preprandial and postprandial, before going to bed
|
On a daily basis
|
> 7 strips dailyAt least 650 strips per
quarter
|
At night (2:00 a.m. to 4:00 a.m.)
|
Every 2 weeks
|
In special situations (suspected hypoglycaemia, sport,
illness, before driving, technical mistake ...)
|
When required
|
There is a clear indication for SMBG in patients with type 1 or insulin-dependent
type 2 diabetes.
Measuring glucose not only involves proper patient training on how to precisely
and correctly perform the glucose measurements, but it also necessary to have an
understanding of how the measurement results are converted into therapeutic
steps.
Frequency of measurements
Patients with type 1 diabetes and ICT with multiple insulin injections daily or
an insulin pump should measure blood glucose concentration at least 4 times
daily (preprandial and before bedtime) and every 2–3 weeks during the
night. In addition, measurements may be taken in special situations,
e. g. to check the effects of meals, in suspected hypoglycaemia, sport,
illness, holidays, when driving a car, etc. This results in an average need for
at least 5 glucose test strips per day ([Table 2]).
Patients with type 1 diabetes and hypoglycaemia perception disorder form a
special group. In addition to the measurement times already described,
measurements are carried out before each car journey, during physical activity,
during sport and during everyday work. This results in a quarterly requirement
of at least 800 test strips. The need for test strips in children, especially
toddlers, increases even further as children cannot reliably express themselves
regarding the symptoms of hypoglycaemia or hyperglycaemia and are also more
prone to much faster and more intense glucose fluctuations than adults with type
1 diabetes.
Patients with insulin-dependent type 2 diabetes with ICT should also determine
preprandial and occasionally postprandial glucose levels and measure them before
bedtime. The daily requirement is at least 4–5 test strips, which
corresponds to at least 500 test strips per quarter. Patients with
insulin-dependent type 2 diabetes and CT or bedtime therapy require at least
1–2 measurements per day; the quarterly requirement is therefore at
least 150–250 test strips.
Patients with non-insulin-dependent type 2 diabetes undergoing sulfonylurea
therapy require test strips for detecting hypoglycaemia.
Practical experience shows a requirement of at least 50 test strips per
quarter.
It makes medical sense to provide all patients with type 2 diabetes and oral
antidiabetic therapy with at least 50 test strips per quarter in case of
manifestation or for training purposes or if the therapy goals are not
achieved.
Pregnant women with a pre-existing type 1 or type 2 diabetes perform preprandial
and postprandial glucose measurements, resulting in a requirement of at least 7
test strips per day, i. e. at least 700 test strips per quarter. Women
with gestational diabetes should always measure fasting blood glucose and
postprandial glucose 2–3 times per week. In cases of insulin dependence,
regular preprandial and postprandial glucose measurements are necessary which
leads to a requirement of at least 7 test strips per day.
Measurement method
In the SMBG systems commonly used by patients, the enzyme used is either glucose
oxidase (GOD) or glucose hydrogenase (GDH). The glucose oxidase method is
susceptible to substance and drug interferences (e. g. ascorbic acid,
paracetamol, blood oxygen content). As well, relevant interferences must be
taken into account, especially in patients with multimorbidities (interferences
caused by medications, uric acid, etc.). For patients with high or low
haematocrit values, the monitoring systems (manual/test strip package
insert) should be checked for compatibility to the patient.
Available systems
There are many different SMBG systems currently available from various suppliers.
Overviews of the properties of these systems are primarily based on the
information provided by the manufacturers. Many modern SMBG systems have
additional functions, such as data storage and readout, marking of values as
preprandial or postprandial, colour coding of displayed values for immediate
assessment, a light at the test strip slot, bolus calculators, calculation of an
estimated HbA1c value or the possibility of transmitting data to an
app/cloud (connectivity).
Specifications for measurement quality/standards
Like all medical devices, blood glucose monitoring systems have CE marking. CE
marking is not a mark of quality and after the introduction of the systems to
the market, there is no systematic evaluation of their measurement quality. Over
time, many independent evaluations have shown that some systems on the market
exhibit inadequate measurement quality.
The SMBG systems currently available on the market must meet the requirements of
ISO Standard 15 197:2015.
Costs/refund of expenses
Health insurance covers the costs for blood glucose monitoring systems (device
and test strips) for patients with type 1 diabetes and patients with
insulin-dependent type 2 diabetes.
Patients with type 2 diabetes who do not undergo drug therapy or who take oral
antidiabetics without a hypoglycaemic risk are only covered by statutory health
insurance in special situations (unstable metabolic conditions, readjustment or
change with an increased risk of hypoglycaemia).
The prescribing physician shall determine the number of test strips deemed
appropriate for the given insulin-dependent patient. An exact indication is
important. For example, a manifestation or pregnancy with type 1 or type 2
diabetes has a significantly higher test strip consumption ranking than in CT
does. In reality, the prescribability of blood glucose test strips is regulated
by a Federal Joint Committee/Gemeinsamer Bundesausschuss (G-BA) decision
and is laid down in the Pharmaceutical Directives/Arzneimittel
Richtlinien Annex III (Overview of prescription restrictions and
exclusions/ Übersicht über
Verordnungseinschränkungen und -ausschlüsse). The Association of
Statutory Health Insurance Physicians/ Kassenärztliche
Vereinigungen (KV) regulates the prescription of blood glucose meters and test
strips. The health insurance companies and the KV signed a common guiding
framework, agreements and contracts leading to joint recommendations as to which
costs are covered for which type of diabetes and of therapy. These
recommendations are, however, not binding.
Quality control (internal and external/interlaboratory
comparisons)
Quality control for personal glucose measurement systems can be performed with a
system-specific control solution. Ideally, quality control should be carried out
at home every time a new test strip package is opened and for the situations
specified in the operating instructions.
According to the German Medical Association guidelines (Rili-BÄK), SMBG
systems used for glucose measurement in laboratories, clinics and practices must
meet the requirements for internal quality control (control solution
measurements) but not those for external quality control (interlaboratory
comparisons). The internal quality control for SMBG systems in use must be
carried out regularly in every practice. The implementation of external quality
control by participating in interlaboratory comparisons can provide additional
information on measurement quality.
Safety issues/side effects
An incorrect SMBG measurement results in the administration of an incorrect
insulin dose, which can have immediate and significant consequences such as
severe hypoglycaemia. Therefore, when training patients, it is imperative to
focus on the prerequisites for correct glucose measurement using SMBG systems
([Fig. 2]).
Fig. 2 Factors which influence the SMBG measurement result.
For the patient, lancing a fingertip to obtaining a blood drop can be a painful
procedure. Despite the modern lancing devices available today, lancing is still
felt and repeatedly lancing the same sites can lead to considerable scarring of
the fingertips and reduced sensitivity in the future.
Younger children, who do not yet understand the necessity of these measures, may
experience considerable psychological stress and disturbance of the parent-child
relationship. Nonetheless, even for adult patients, the pain that is
self-inflicted several times a day can be a psychological burden.
Practical implementation of the measurement
During the measurement, it is important to consider the factors that are
important for a correct measurement ([Fig. 2]) (see
Guidelines for Blood Glucose Self-Monitoring/Leitfaden zur
Blutzuckerselbstkontrolle:
https://www.vdbd.de/Downloads/Blutzucker-Selbstkontrolle-Stand1142
014.pdf.
Use with different patient groups
The market is usually only divided into patients with type 1 or type 2 diabetes
and women with gestational diabetes. In reality, however, there are a number of
subgroups, especially when it comes to SMBG. There are hardly any monitoring
systems on the market that are suitable for patients with impaired vision or for
the blind (devices with speech output or acoustic instructions for use). The
same applies to elderly patients with limited manual dexterity. They need
devices with simple operation and a clearly legible display.
Training/psychological aspects
The preparatory steps for SMBG, in particular obtaining a capillary blood drop,
as well as correctly performing the actual measurement require theoretical and
practical training. Ideally, this should be done using the system that the
patient will later use. A one-off introduction is often not enough,
i. e. the various steps to be taken should be repeatedly trained,
discussed and closely supervised.
Since performing SMBG in public (school, workplace, restaurant, etc.) makes it
visible that the person is suffering from diabetes, those affected often do not
perform a measurement in such situations. This can entail significant risks as
acute glucose derailments are then not detected. The patients’
understandable desire for discretion makes other glucose monitoring options (see
below) attractive. However, not all patients want to permanently wear a
technical device on their body or be disturbed by alarms.
Comment
The performance of SMBG monitoring systems has improved in recent decades to such
an extent that considerable further improvements are no longer to be expected in
the foreseeable future. SMBG systems still have the largest market share of
glucose monitoring systems in the field of diabetes technology – in
part, due to the lower costs compared to rtCGM/iscCGM systems.
Continuous measurement systems such as rtCGM and iscCGM, however, are gaining in
acceptance and importance.
One important option for further development of SMBG systems is their
interoperability, i. e. improved automatic availability of measurement
results for evaluating data in programs or apps. In the future, the merging of
data including those from the insulin dose (by using smart pens), carbohydrates
(by an automated analysis of the carbohydrate content of meals) or exercise (by
using data from fitness wristbands) will enable the calculation of the optimal
insulin dose thanks to the possibility of analysing data from many sources.
Future bolus calculators will be able to process such data and thus relieve
patients of error-prone calculations.
Real-time CGM (rtCGM)
Goals/indications
When using rtCGM systems, therapy goals can be better achieved by increasing the
quality and quantity of information (continuous display of the current glucose
value, trend display and alarms when pre-set limit values are reached) ([Tables 3]
[4]). The
continuous use of rtCGM systems can enable motivated users to achieve their
therapy goals of reducing: the HbA1c value, glucose variability, hypoglycaemic
frequency and duration and the occurrence of severe hypoglycaemia. The
indication of the current glucose value, the current trend as well as the
glucose trend over the last 3/6/12/24 h helps
both in assessing the current glucose control and in assessing the effect of
therapeutic interventions on food intake, physical activity or other influencing
factors. Patients must make proper use of the quantity and quality of
information offered and translate it into therapeutic interventions. To master
such a complex task, patients must be trained in theory and practice and become
technically proficient at using their rtCGM system.
Table 3 Factors that have an influence on the CGM measurement
result.
Application error:
|
|
|
|
|
|
Environmental conditions:
|
-
Sensor insertion site (upper arm, abdomen, thigh,
buttocks) with individually variable blood
circulation
|
-
Pressure on the sensor position by belt, waistband,
sleeping position (false low values, poor reception
at the end device)
|
|
|
|
Table 4 Parameters for characterizing CGM data (retrospective
analysis).
Consensus ATTD: all parameters should be available to assess
CGM data
|
Time-in-Range/Time-in-target-Range
(TIR):>70
|
70–180 mg/dl
3.8–10 mmol/l
|
Hypoglycaemia<4%
|
Level 1
|
70 mg/l 3.9 mmol/l
|
Level 2
|
54 mg/dl 3.9 mmol/l
|
Severe hypoglycaemia
|
External help required
|
Hyperglycaemia
|
Level 1
|
>180 mg/dl
> 10 mmol/l
|
Level 2
|
>250 mg/dl
> 13.8 mmol/l
|
Ketoacidosis
|
Clinical diagnosis
|
Glycaemic variability
|
|
Coefficient of variation/standard deviation
|
Mean glucose value
|
|
–
|
Estimated HbA1c
|
|
–
|
CGM visualization
|
|
Ambulatory glucose profile (AGP)
|
Episodes of hyper-, hypoglycaemia
|
|
At least 15 min duration
|
Night and day times
|
|
00:00 a.m. to 6:00 a.m.; 6:00 a.m. until 11:59 PM
|
Recommendation on the amount of data that should be available
for evaluation
|
|
At least 2 weeks with 70%-80% CGM data
|
Indications for using rtCGM apply for the following patient groups ([Fig. 1]):
In consultation between patient and physician, an individual decision must be
made as to whether rtCGM use is medically necessary and sensible ([Figs. 1]
[3]). The
significant benefit of rtCGM for many patients is indisputable, although it
might not be indicated for every patient. A test phase can be helpful for the
patient and the diabetes team to weigh the individual benefit.
Fig. 3 Practical procedure for starting rtCGM (blue:
doctor/patient; yellow: training/introduction to technology; brown:
costs approved or to be carried by the patient).
rtCGM systems can be used either as stand-alone devices, e. g. for
patients with ICT, or in combination with an insulin pump.
In sensor-augmented pump therapy (SaP), the rtCGM system is directly coupled to
the pump. Whereas in the first generations the pump display was only used to
display the rtCGM data, in current generations, the interaction has been further
developed so that the insulin pumps stop the basal insulin infusion
automatically if hypoglycaemia is imminent. In the future, rtCGM will enable the
establishment of a closed loop (technical healing of diabetes). This means that
the current glucose information is used to automatically adapt the infusion rate
of an insulin pump to the glucose trend (Automated Insulin Dosing (AID)). For
example, the two AID systems currently on the market outside Germany (and since
September 2019 one in Germany as well) automatically adjust the basal rate but
there is no fully automatic adjustment of insulin delivery for meals.
Almost all rtCGM systems also allow the measured values to be transferred to a
cloud. From there, the data can be forwarded to family members or the diabetes
team if the patient so desires (connectivity).
In addition, a long-term rtCGM system is available in which the sensor is
inserted under the skin with minimal surgical intervention. The glucose
concentration in the interstitial fluid is continuously calculated and
transmitted to a smartphone/smartwatch by means of a transmitter which can be
removed at any time from the skin above the transmitter. This is the only rtCGM
system where vibration alarms of the transmitter are available directly on the
body in addition to the usual alarms triggered by the smartphone/receiver. The
sensor is removed by a certified physician after its functional period of up to
180 days.
In our opinion, the majority of patients who request a more intensive diabetes
therapy should first use an rtCGM/iscCGM system together with an insulin pump.
Studies demonstrate the benefit of rtCGM in patients who perform ICT with
multiple daily injections in terms of HbA1c value improvement and reduction of
hypoglycaemia risk. A rtCGM/iscCGM system is not a prerequisite for the optimal
use of a CSII, but it is much simpler, more differentiated and safer to
implement. One exception are children with type 1 diabetes, who should begin
with an insulin pump and an rtCGM at the time of manifestation, especially at an
age below 6–8 years.
Measurement method
In the transcutaneous needle sensors of the rtCGM systems currently available on
the German market, glucose is measured using an enzymatic method (GOD, see SMBG)
in the ISF in subcutaneous fatty tissue ([Table 5]).
The transcutaneous rtCGM systems have a life cycle of up to 10 days after which
the glucose sensor should then be replaced according to the
manufacturer's instructions. The sensors normally transmit an average
value obtained every 5 min to the corresponding receiving device. As
with blood glucose monitoring systems, medication can result in interferences
(e. g. paracetamol, see device operating instructions) and all factors
that have an influence on the measurement result must be taken into account
([Table 6]).
Table 5 Information on current rtCGM and iscCGM system(s); the
systems are in constant development.
CGM model (dated 6.2019)
|
Associated sensor
|
Approval age group
|
Life cycle per sensor
|
Connectivity smartphone/ wearable
|
Connectivity insulin pump
|
Calibration
|
Initialisation phase
|
Recommended place of insertion
|
Glucose display
|
Glucose range**
|
Replacement for blood glucose measurements
|
Abbott Freestyle Libre (without alarm)
|
Sensor FreeStyle Libre
|
From 4 years
|
up to 14 days
|
Yes, Android and iOS App, Follower App
|
No
|
Factory calibrated
|
1 h
|
Upper arm
|
After scan, every minute
|
40–500 mg/dl*
2.2–27.7 mmol/l
|
Yes, with adherence to company specifications
|
Abbott Freestyle Libre 2 (with high/low alarm)
|
Sensor FreeStyle Libre 2
|
From 4 years
|
up to 14 days
|
Yes, Android and iOS App, Follower App
|
No
|
Factory calibrated
|
1 h
|
Upper arm
|
After scan, every minute
|
40–500 mg/dl*
2.2–27.7 mmol/l
|
Yes, with adherence to company specifications
|
Dexcom G5 Mobile CGM Sys- tem1
|
Dexcom G5 Sensor
|
From 2 years
|
up to 7 days
|
Yes, Android, iOS, App, Follower App Smartwatch/Apple
Watch
|
No
|
Yes
|
2 h
|
Abdomen, upper buttocks (children and adolescents
2–17 years)
|
Every 5 min
|
40–400 mg/dl
2.2–22.2 mmol/l
|
Yes, with adherence to company specifications
|
Dexcom G6 CGM System
|
Dexcom G6 Sensor
|
From 2 years
|
up to 10 days
|
Yes, Android, iOS, App, Smartwatch/ Apple Watch
Smart/Apple Watch
|
No
|
Factory calibrated optional
|
2 h
|
Abdomen, upper buttocks (children and adolescents
2–17 years)
|
Every 5 min
|
40–400 mg/dl
2.2–22.2 mmol/l
|
Yes, with adherence to company specifications
|
Medtronic Guardian Connect1
|
Medtronic Guardian Sensor 3
|
Without age limit
|
up to 7 days
|
Yes, iOS, App; Follower App
|
No
|
2 h after insertion, 6 h after first calibration, then every
12 h
|
2 h
|
Abdomen; upper buttocks; (upper arm)
|
Every 5 min
|
40–400 mg/dl
2.2–22.2 mmol/l
|
No
|
Medtronic 640G Insulin Pump1,2
|
Medtronic Guardian Sensor 3
|
Without age limit
|
up to 7 days
|
No
|
Yes, Smart-Guard (switch off before low)
|
|
|
|
|
|
No
|
Medtrum A6 touch care
|
Medtrum A6 touch care CGM
|
From 2 years
|
up to 7 days
|
Yes, Android, IOS, Apple Watch.
|
Yes (switch off before low)
|
Every 12 h
|
2 h
|
Upper arm, abdomen, buttocks
|
Every 2 min
|
40–450 mg/dl
|
No
|
Sensesonics Eversense CGM System Cooperation of Roche
Diabetes Care
|
Eversense Sensor
|
From 18 years
|
up to 180 days
|
Yes, Android, iOS, App Apple Watch
|
No
|
4×every 2 h after insertion, then every 12 h
|
24 h
|
Upper arm (implanted)
|
Every 5 min
|
40–400 mg/dl
2.2–22.2 mmol/l
|
No
|
Company portals: www.dexcom.com; www.freestylelibre.de;
www.medtronic-community.de; www.medtronic-diabretes.de; www.medtrum.com;
www.eversense.de. 1 Paracetamol can lead to incorrectly high
CGM values with some sensors - depending on the level of the dose acting
in the body. The information provided by the manufacturers must
therefore be carefully checked. The companies that have listed this
interaction in their technical information are marked here.
2The Ascensia Contour Next Link 2.4 blood glucose meter,
which can be connected to the MiniMed Medtronic 640G and used for
calibration, bolus and correction insulin calculation, has a measuring
range of 20–600 mg/dl. CGM glucose levels of the
Guardian 3 sensor can be displayed on the insulin pump between 40 and
400 mg/dl (2.2–22.2 mmol).
Table 6 Tips for interpreting the indications on the display of
the CGM device. In the interpretation, the last 2–3 h of the
trend curve must be taken into account. The meaning of the trend
arrows varies from manufacturer to manufacturer.
|
Abbott Libre 1/2
|
Dexcom G5/6
|
Medtronic Link 3
|
Medtrum A6
|
Roche/Sensonics Eversense
|
→
|
<1 mg/dl/min
< 0.06 mmol/min
|
< 1 mg/dl/min
< 0.06 mmol/min
|
|
present
|
< 1 mg/dl/min< 0.06 mmol/min
|
↘
|
1–2 mg/dl/min
0.06–0.11 mmol/min
|
1–2 mg/dl/min
0.06–0.11 mmol/min
|
|
present
|
1–2 mg/dl/min0.06–0.11 mmol/min
|
↑ ↓
|
> 2 mg/dl/min
> 0.11 mmol/min
|
> 2 mg/dl/min
> 0.11 mmol/min
|
1–2 mg/dl/min
0.06–0.11 mmol/min
|
present
|
> 2 mg/dl/min> 0.11 mmol/min
|
↑↑ ↓↓
|
|
> 3 mg/dl/min
> 0.2 mmol/min
|
> 2 mg/dl/min
> 0.11 mmol/min
|
present
|
|
↑↑↑ ↓↓↓
|
|
|
> 3 mg/dl/min
> 0.2 mmol/min
|
|
|
With the implantable long-term rCGM systems, the glucose measurement is
fluorescence-based which can lead to short-term measurement interruptions,
especially at the beginning during bright sunlight.
Available systems
The rtCGM systems available to date were not directly intended to be used for a
therapy decision (insulin dose adjustment); an adjustment of the insulin dose
should therefore be based on the measurement result of an SMBG measurement and
not on the CGM data (adjunctive usage). In practice, however, many patients rely
on the accuracy of the rtCGM data and use them to make treatment decisions.
There are now two rtCGM systems by one manufacturer where the therapy
decision/insulin dose adjustment is permitted on the basis of the CGM
measurement result (non-adjunctive usage), and other systems will follow. With
the latest generation of one rtCGM system, there is no need for calibration (as
with both iscCGM systems (see below)). However, calibration is possible,
i. e. the measurement supplied by this rtCGM system can be related to
the blood glucose value. In some patients, the accuracy of the measurement seems
to be improved by one calibration per day, especially if this is done in the
first days after the sensor is inserted. It should be noted that various factors
influence the quality of rtCGM measurements (as well as for iscCGM systems).
Such patient factors include the patient's BMI, the specific body site
where the glucose sensor is inserted, the ambient temperature and the external
pressure on the sensor (e. g. during sleep).
The performance of rtCGM systems is usually evaluated in clinical trials funded
by the manufacturers. Head-to-head studies, in which patients wear more than one
rtCGM system at the same time (up to 3 different systems, each with 2 devices
from the same company), provide important information on the analytical
performance of the rtCGM systems in direct comparison.
Specifications for measurement quality/standards
For the approval of rtCGM systems, there are no established standards for
evaluating measurement accuracy as there are for SMBG monitoring systems. If and
when this could take place cannot be foreseen. Recently, the U.S. Food and Drug
Administration (FDA) published guidelines on how it believes the measurement
quality of rtCGM systems should be characterized (iCGM). So far, only one system
meets these requirements.
By defining the “Mean Absolute Relative Difference” (MARD), an
attempt is made to describe the measurement quality of an rtCGM system. To
determine the MARD value, the difference between individual measured blood
glucose values and simultaneously-determined rtCGM values is calculated. This
value determined in clinical studies is significantly influenced by the study
protocol used and the selection of the patients examined. The MARD value should
therefore only be used as a guide.
Another parameter which deals with the measurement quality of an rtCGM system is
the “Precision Absolute Relative Deviation” (PARD), calculated
simultaneously for the same patient from the direct comparison (see above) of an
rtCGM system with a second sensor from the same system.
Costs/refund of expenses
Based on a positive assessment of benefit by IQWiG, the G-BA published a decision
in 2016 providing for cost coverage of rtCGM if the patient submitting the
application fulfils defined criteria (as is the case for therapeutic devices).
The prescription for an rtCGM system can only be made by a specialist doctor
such as: doctor of internal medicine, endocrinology and diabetology or a doctor
of internal medicine specialised in general
medicine/paediatrics/juvenile medicine with the recognition
“Diabetologe DDG” (German Diabetes Society Diabetologist) or
with comparable qualifications recognised by the respective regional medical
association or doctors specialised in paediatrics and juvenile medicine with the
paediatric endocrinology and diabetology recognition. In reality, the
implementation of the G-BA decision varies greatly in the various KVs, despite
the now available standardized guideline of the Health Insurance Medical
Service/Medizinische Dienst der Krankenversicherung (MDK).
The written application should be based on the MDK guideline and it might be
helpful to use the rtCGM application proposal of the DDG/ AGDT
(available online on the DDG and AGDT homepages). In addition to this
application form, the MDK requests glucose protocols and accepts both digital
and handwritten formats. The content of the protocols also varies between the
different MDKs. It makes sense for patients to draw up a letter describing their
individual prerequisites, daily requirements and motivation for using an rtCGM
system.
In practice, the problem is that when a new CGM system comes onto the market,
some manufacturers offer a type of ‘exchange programme’, while
others do not. This can involve a justified change, e. g. to a new
generation of sensor-supported pumps or to CGM systems with new functions. If
company X comes onto the market with a new pump linked to a CGM system and the
patient still has a similar CGM system and performs ICT, experience shows that
the change is difficult because the MDK initially wants the patient to try out
pump X alone with the “old” CGM system. If the HbA1c value then
decreases, the claim to a CGM system for the pump is voided; consequently, the
patients actively prevent this–otherwise it would become necessary to
write another letter of assessment explaining this paradox.
The time required by the diabetes team for the application, the medical
instruction on the rtCGM systems and the training is not reflected by the cost
carriers (health insurance companies). The EBM number in use since April 2017 is
to be understood as a medical instruction number. Individual or group training
courses are regulated differently throughout Germany depending on the federal
state, KV district and cost carrier. Some health insurance companies do offer
additional support. The AOK Baden-Württemberg, for example, rewards the
training for rtCGM (SPECTRUM) and for iscCGM (flash) under certain
conditions.
Quality control (internal and external/interlaboratory tests)
There are no quality controls for rtCGM systems. The SMBG measurements performed
regularly for calibrating the rtCGM systems and further SMBG measurements are
the only possibility for drawing conclusions about measurement quality.
Carefully performing blood glucose measurements for calibration at times of low
glucose fluctuations and correctly entering these values are prerequisites for
obtaining reliable glucose measurements from rtCGM systems.
Safety issues/side effects
There are a number of safety aspects to be considered when using this diagnostic
option:
-
What happens when the rtCGM measurement results are used to make therapy
decisions?
-
What is the quality used to detect low glucose levels, i. e. how
well is hypoglycaemia detected in everyday life?
-
What are the clinical consequences of miscalculations due to incorrectly
performing SMBG?
-
What incorrect measurements (=low glucose values) occur,
e. g. when the patient lies on the sensor at night?
-
Does the patient hear the alarms? Do they take place in time to be able
to react adequately?
-
As described in the rtCGM system operating instructions, SMBG
measurements must be carried out when implausible results are
obtained!
Only two rtCGM systems by one manufacturer are approved in Germany to date if
patients want to adapt their insulin therapy based on the measurement results
obtained by an rtCGM system; however, due to the predominantly good sensor
measurement quality, this is also practiced by many patients using other
systems. The measurement quality of rtCGM systems in the hypoglycaemic range is
not satisfactory, therefore SMBG should be performed for symptoms indicative of
hypoglycaemia (with conflicting rtCGM glucose values). SMBG measurement is also
recommended if the rtCGM system indicates hypoglycaemia without symptoms of
hypoglycaemia. In the case of rapid tissue glucose changes (induced
e. g. by food intake or sport), there may be physiological and technical
differences between the glucose concentrations in blood and ISF. These
differences are not measurement errors, they stem from the fact that glucose is
measured in two different compartments. The clinical experience of some
diabetologists indicates that with such extreme differences, the alignment of
therapy adjustments to rtCGM readings is safer than the alignment to SMBG
readings alone.
rtCGM systems displays the glucose trend from the near past into the close future
using trend arrows ([Table 6]). It should be noted
that the direction of the trend arrows can change rapidly, especially
postprandially. For many people with diabetes, the trend arrows are an important
basis for metabolic corrections, which is why their correct interpretation is a
prerequisite for making correct therapy decisions.
So far, there have been no structured recommendations for widespread use. In a
new publication by German experts on the interpretation of trend arrows, a first
structured handling instruction was given. Although the proposals should be as
generally-valid, manufacturer-independent, easily-understandable, concrete and
practicable as possible, they nevertheless need to be individually-adaptable in
order to make therapy changes by using the interpretation of the trend arrow to
adjust doses.
The use of trend arrows has quickly become better and more uniform thanks to
tabular score cards in the form of rotating disks for adjusting the preprandial
and/or postprandial insulin dose, the individual insulin sensitivity and
the current starting glucose level. The score cards are available for different
diabetes types and age groups. The aim is both to reduce short-term fluctuations
in glucose levels and to favourably influence metabolism in the long-term. There
is still a major need for properly-trained diabetes facilities to provide
patients with differentiated, appropriate training so that they can make better
use of the potential that trend arrows offer ([Table
5]). In addition, care must also be taken to ensure that, in case of
hypoglycaemia, the intervals between the intake of fast-acting carbohydrates are
not too short ([Table 6]), so that the intake of
these substances does not result in hyperglycaemia.
Wearing glucose sensors on the skin with a plaster for several days and repeated
use of the same skin site can lead to skin reactions in these areas. The
reactions range from mild skin irritations to the development of contact
allergies against components (especially acrylates) in the adhesives
and/or the housing of the transmitters, which represent a considerable
impairment and can make further use of a CGM system impossible. For these
patients the implanted long-term rtCGM with daily changeable silicone plaster is
a therapy option.
Conditions to be observed in practice
In all rtCGM systems, algorithms are integrated which convert the measured
current flow or the fluorescence signals of the sensor into glucose values based
on blood glucose calibration values, reduce the noise of the electronic
measurement signal and eliminate implausible values. The algorithms of the
companies are different (e. g. different time delays to blood glucose,
different calibration methods, differences depending on the blood glucose meter
used for calibration); little is known about how they work. This point should be
considered by the patient when changing the rtCGM system. The handling and
concept of the systems can also differ considerably. For this reason, the
patient should receive proper instruction after a system change in order to
understand the changes in the calibration process, the data evaluation with the
new software and to react correctly.
Use with different patient groups
The G-BA decision sets out clear guidelines on the patient groups eligible for
cost reimbursement of rtCGM systems, namely for insulin-dependent diabetes with
ICT or CSII. In view of the number of people with type 2 diabetes (the scope of
the costs) and the heterogeneity of this patient group, the decision on whether
it makes sense for individual patients to use rtCGM can be quite varied.
The use of rtCGM makes sense in the following cases:
-
In patients who perform ICT with multiple injections daily or with an
insulin pump
-
For patients with specific, individual problems (type 1 or type 2)
-
Temporarily for therapy review in patients taking oral antidiabetics that
may induce hypoglycaemia
-
During pregnancy
-
In patients with pronounced secondary diseases, e. g. a painful
peripheral polyneuropathy
-
For training purposes
-
To compensate for a handicap caused by diabetes at work
The only implanted long-term rtCGM system to date offers additional vibration
alarms on the body and a plaster which is well-tolerated in patient and
occupational groups with specific indications as compared to the transcutaneous
rtCGM systems.
Training/psychological aspects
rtCGM is a very potent, but also cost-intensive diagnostic and therapeutic tool.
A prerequisite for optimal use, especially with regard to the modification of
therapy, is that patients and medical staff are comprehensively trained. It is
not considered sufficient for patients to be solely instructed by the
manufacturers in device-specific aspects. The AGDT and AGPD have developed the
manufacturer-independent rtCGM training program SPECTRUM. The time required to
train patients in the diabetes practices is considerable and the patients
themselves must receive qualified training. The training units can be taught
individually or together, depending on the patient's needs; they can be
taught to groups or individuals in both outpatient and inpatient settings. In
the case of children, the MDK in individual KVs rejects the 3-day inpatient
training courses (SPECTRUM modules 1–4), although this is the only
option for many clinics (=no day clinic, outpatient generally not
billable). Furthermore, some families need more time (migration background,
language problems, social hardships, calculation problems) when dealing with
readjustment of the system and simultaneous training and also need individual
instruction throughout the day. The G-BA decision on the necessity of a training
course on rtCGM does not specify how and in which setting it is to take
place.
An evaluation study for SPECTRUM (=CGM TRAIN) has been started; this is
the prerequisite for this training to be billable. Only when this is possible
can diabetologists widely offer such time-consuming and personnel-intensive
training courses.
Patients with a CGM system should not only receive initial training but should
also be trained over time in order to make optimum use of the possibilities of
rtCGM-supported therapy and because of the new generations of devices that are
constantly being developed.
For patients, the permanent availability of information on the glucose trend in
their own bodies can be both a blessing and a curse. On the positive side, rtCGM
warns of acute events and helps optimise glucose control. Patients who make
intensive use of the information and advice provided by the rtCGM systems report
a significant increase in safety, freedom and quality of life; this applies in
particular to children and their families. Many parents can sleep through the
night for the first time in years without having to get up several times at
night to carry out an SMBG. Furthermore, the reduction in lancing for SMBG
measurements, especially in children, is a significant psychological relief.
On the other hand, the rtCGM system constantly reminds the patient of diabetes.
Frequent alarms (e. g. when alarm limits have not been sensibly
programmed) can disturb and unsettle patients and their relatives immensely,
especially if they are false positives. Some patients feel bothered by
constantly wearing a technical system in everyday life and their body awareness
is impaired. As a result, these patients do not wear the rtCGM system
continuously, but only situatively. Other patients are not in agreement with
their readings being passed on to family members or members of the diabetes
team. They see it as an invasion of their privacy with negative feedback and
consequences.
Proper training and experience with rtCGM systems is important not only for
patients, but also for diabetes teams. The requirement should be that physicians
who care for patients with CGM systems have sufficient experience with the
different systems and data analyses. In addition, the required software should
also be available in the doctor’s office and used during consultation
with the patient.
Even if the insertion and removal of the implantable long-term rtCGM system can
be performed by diabetologists who are usually not surgically active, and it can
be integrated into the standard procedure, sufficient experience and ongoing
routine are still necessary. The physician carrying out the procedure must be
certified accordingly by the manufacturer. It is also advisable that only
practices or clinics that continuously perform these procedures in sufficient
numbers function as centres.
Comment
Continuous glucose monitoring is rapidly gaining importance in the context of
modern diabetes therapy due to the advantages of the permanent availability of
glucose data and the reduction (to prevention) of hypoglycaemia and glucose
fluctuations.
One requirement of the G-BA decision is that data security must be safeguarded
when using an rtCGM system, i. e. the measured data (even if uploaded to
a cloud) should not be accessible and traceable for third parties. It is
therefore important to inform patients of the legal situation in this
respect.
Each manufacturer offers its own software for evaluating rtCGM data. The software
programs can be complex in parts and require an introduction. In order for CGM
data to be read and analysed more frequently (whether by the users or the
diabetes team), it would be extremely helpful to standardise the evaluation and
presentation of the data. There are concrete proposals for the presentation of
the measured values in a recent consensus paper on CGM. The Ambulatory Glucose
Profile (AGP) is only of the options recommended for the analysis of the data
([Fig. 4]). For data analysis with AGP there are
practical recommendations. A workbook with case studies is used for the
consecutive therapeutic conclusions.
Fig. 4 Examples of interquartile and interdecile glucose
variability and possible causes of these glucose fluctuations.
*The assessment of the AGP is restricted by an irregular daily
routine. IQR: interquartile range (interquartile range,
25th–75th percentiles), IDR:
interdecile range (interdecile range,
10th–90th percentiles).
Manufacturers periodically bring new generations of their rtCGM systems onto the
market - with improvements in measurement quality, more simplified handling,
improvements in interoperability and connectivity. If such models (or a
combination of insulin pump and rtCGM) offer the patient a relevant therapeutic
advantage, it should be possible to apply for a change before the expiry of the
one-year flat-rate care charge (rtCGM) or four-year flat-rate care charge
(insulin pump). There are a number of innovative measurement principles in
preclinical and clinical development that will address some of the drawbacks of
the rtCGM systems available to date, as well as offer new options and be more
cost-effective to manufacture.
The constant availability of glucose values in rtCGM systems makes it possible to
supply bolus computers with significantly more data than was previously possible
with SMBG values; however, there are still no corresponding systems.
Alternatively, the rtCGM values can be transferred to apps on smartphones in the
future and their algorithms can make suggestions for the insulin dose.
Intermittent scanning CGM (iscCGM)
Intermittent scanning CGM (iscCGM)
Targets/indications
The use of iscCGM uses trend displays of the currently scanned glucose value and
the presentation of retrospective CGM data to help achieve therapy goals by
avoiding acute complications. The measurement technology of the iscCGM systems
(see below) is based on a technology similar to that of rtCGM systems. The costs
of this option are lower than those of rtCGM systems. However, the first version
of the iscCGM system did not have an alarm function ([Table
5]). Similar to SMBG, the success of the follow-up depended on the
patient being active. Nonetheless, iscCGM already brought a reduction in the
frequency of lancing the finger and a scanning process requiring minimal effort.
With the second generation of devices, it has become possible to turn on
threshold limit alarms (hypoglycaemia alarm, hyperglycaemia alarm). However,
this method does not directly reflect the currently-measured value, the value
this is only available after an active scan. The AGDT has prepared an updated
statement on replacing blood glucose measurements by measurements using rtCGM or
iscCGM systems (https://www.
deutsche-diabetes-gesellschaft.de/fileadmin/Redakteur/Stellung-
nahmen/2019/Stellungnahme_der_AGDT_2019_5_28_clean. pdf).
Currently, the National Association of Statutory Health Insurance Funds
(Spitzenverband der Gesetzlichen Krankenversicherung GKV) has decided that these
second-generation devices are an rtCGM system as per the G-BA decision, and that
they will be included in the catalogue of therapeutic devices and aids, and can
therefore be prescribed. In terms of cost allocation, there is then no longer
any differentiation between rtCGM and iscCGM. With the introduction of the
Medical Devices and Therapeutic Devices Reform Act 2017/Hilfsmittel- und
Heilmittelreformgesetzes 2017, it was stipulated the GKV must examine medical
devices for which a listing is submitted within 3 to 6 months. The GKV examines
whether there is a significant change to a method that has already been
evaluated. If the GKV comes to the conclusion that this is not the case, the
application is approved, and the aid is included in standard care.
However, there are differences between rtCGM systems and iscCGM systems because
regular automatic transmission and display of the values to a receiver does not
take place with iscCGM. An iscCGM cannot be calibrated either. Furthermore, it
is possible to switch off the alarm functions and the selection of different
alarm functions is limited to threshold alarms. In order to be able to provide
the individual patient with the best option for a CGM system, we still consider
a medical differentiation between rtCGM and iscCGM systems to be useful.
Measurement method
From a measurement point of view, iscCGM is a transcutaneous CGM method based on
electrochemical needle sensor technology with low drift of the measurement
signal. The manufacture of these sensors can be standardised in such a way that
calibration of the glucose measurement during manufacture is possible and no
further calibration by the patient is required. Therefore, patients can largely
do without SMBG, unless, e. g., hypoglycaemia symptoms do not match the
values and the glucose trend displayed, or very high glucose values or strong
glucose fluctuations are present. Due to the factory calibration, calibration
errors by the patient are not possible with iscCGM. However, the iscCGM
measurement cannot be related to the current blood glucose value if there are
discrepancies. As with all CGM systems, the prerequisite for measurement quality
is consistently high sensor quality during production. This is a particular
challenge for all sensor manufacturers as production increases.
Available systems
Two iscCGM systems by the same manufacturer are currently available on the market
([Table 5]). The life cycle of the iscCGM sensor
is 14 days. To transfer the data, the reader or a smartphone with the
corresponding app must be actively brought by the user to the inserted glucose
sensor. The continuously monitored glucose values (every 15 min) of the last
8 h and the current value are transmitted and displayed on the device
the current glucose value, a trend arrow and a glucose profile. If the device
has measured low or high glucose values since the last scan, the first
generation of devices provides this information when transferring the values to
the reader. A direct alarm function appeared in the next model which emits an
alarm message if the glucose value exceeds or falls below a set threshold.
However, an active scan must first be performed to display the current glucose
value and the type of alarm. Irrespective of the new alarm function, data must
still be retrieved every 8 h by scan so that no data gaps occur. There
is no automatic transmission and recording of all measured values
to/from the receiver.
Many patients now use an app on their smartphone to read or scan the data. It is
important to consider which glucose sensors can be read with which device
generation of the readout device.
Specifications for measurement quality/standards
Just as for rtCGM systems, there are no established standards for assessing the
measurement quality of iscCGM systems. Studies have provided information on the
MARD value of this system.
Costs/refund of expenses
The second generation iscCGM system has a general alarm function that is
differentiated by scanning into hypoglycaemia/hyper-glycaemia alarm or
contact loss. At present, IQWiG has not performed an assessment of benefit for
iscCGM (in the older version without alarm and the new version with alarm).
Despite this initial legal situation, the iscCGM system has now been included in
the index of health insurance aid numbers, based on the considerable interest in
this iscCGM system by a large number of people with diabetes and as a more
cost-effective alternative to rtCGM systems. Some health insurance companies no
longer reimburse the cost of test strips for SMBG if an iscCGM has been
approved; others try to replace the iscCGM system with approved rtCGM
systems.
Quality control by the user (internal and external/interlaboratory
tests)
There are no quality controls for the iscCGM systems. The SMBG measurements for
calibration, which need to be carried out regularly, are no longer necessary, so
that no conclusions can be drawn about the measurement quality of these systems
in everyday life. However, the manufacturer expressly describes the necessity of
additional SMBG measurements in certain situations in the respective operating
instructions.
Safety issues/side effects
As with rtCGM, there are security aspects to be considered when using iscCGM (see
above). Since there are no regular calibration measurements, it is not possible
to monitor whether the iscCGM system exhibits sufficient measurement quality in
specific individual cases and situations. In this system too, patients should
perform SMBG measurements according to the specifications in the operating
instructions (e. g. in the case of hypoglycaemia symptoms, especially in
low but also in very high glucose ranges), regardless of what the iscCGM system
indicates.
Wearing glucose sensors on the skin for 14 days and repeated use of the same skin
site can lead to skin reactions in these areas. The reactions range from mild
skin irritations to the development of contact allergies in some patients. The
allergic reaction is not only a considerable impairment, it can make the further
use of this system impossible and can lead to accompanying reactions to the
plasters when using other technical systems (e. g. an insulin pump).
Conditions to be observed in practice
The iscCGM system data can be read and analysed with a company-specific software.
In everyday life it should be noted that sensor artefacts (these are long
hypoglycaemic episodes displayed which have not actually occurred) can occur as
a result of lying on the sensor while sleeping; this also applies to rtCGM
systems with needle sensors.
Use with different patient groups
iscCGM can be used in patients who perform ICT or CSII without pronounced
hypoglycaemia perception disorder. The use of iscCGM should also be considered
in cases of less complex therapy schemes ([Fig. 1]).
Thus, the use of iscCGM can also be intermittent, i. e. adapted to
requirements, in oral therapy with hypoglycaemia risk, during therapy changes or
while participating in a training course. The results of a clinical study are
available for patients with type 1 and type 2 diabetes who are undergoing
intensified insulin therapy.
Training/psychological aspects
There is a training program (flash) for iscCGM, which was evaluated in a clinical
study. The development was financed by the manufacturer of the system and is
tailored to this product. Some differences, especially the lack of alarms in the
first generation iscCGM system, result in the training course covering different
topics than the rtCGM training program. Some patients find it beneficial not to
be constantly disturbed by alarms, especially during the night. The
self-determined, occasional retrieval of glucose values and the omission of
calibration measurements are also deemed pleasant.
The second generation of devices allows the activation of a high and a low alarm
and, after an alarm message by a scan, displays the current measured value. The
high and low alarms are distinguished by acoustically different alarm tones.
These newly available options require additional training similar to rtCGM
systems.
Comment
There is no general reimbursement or EBM number for training and consultation on
iscCGM systems. For the diabetes team, this means that the care effort in most
KV areas is not rewarded.
HbA1c
Goals/Indications
The long-term quality of glucose control has a direct influence on the risk of
the occurrence of diabetes-associated secondary diseases. The HbA1c value
measurement allows an evaluation of the glucose control over time. The HbA1c
value is mainly determined by the blood glucose values of the last 2–3
months and has been used in diabetology for many years as a quality indicator
for glucose control. However, the HbA1c value does not permit an adequate
statement on glucose variability. The attending physician should set an HbA1c
therapy goal based on the individual situation of the patient. In particular, if
a patient does not perform SMBG, an HbA1c measurement at quarterly intervals is
necessary to obtain an overview of the quality of glucose control. If the
patient performs type of self-testing, the HbA1c value must always be evaluated
in combination with the results of the self-testing. As considerable intra- and
interindividual deviations between the measured HbA1c value and the
simultaneously-determined SMBG values can occur in individual patients,
e. g. due to diseases or other factors, the HbA1c value should never be
considered on its own ([Table 7]).
Table 7 Causes for incorrect HbA1c values.
Physiological causes
|
|
Falsely low
|
Falsely high
|
Opportunities
|
Erythrocyte formation
|
Increased
|
Slows down due to lack of available iron
|
|
Very high
|
Iron deficiency anaemia
|
Pregnancy
|
Infectious anaemia
|
Bleeding, blood loss
|
Tumour-induced anaemia
|
Blood transfusion
|
|
Erythropoietin administration
|
|
Iron supplementation
|
|
Erythrocyte breakdown:
|
Too soon
|
Too late
|
Haemolytic anaemia
|
Splenectomy
|
Chronic renal insufficiency
|
Aplastic anaemia
|
Cirrhosis of the liver
|
|
Folic acid deficiency?
|
|
Hemoglobinopathies:
|
Hemoglobinopathies:
|
Spherocytosis
|
Laboratory technical causes
|
|
|
|
False high - ONLY for HPLC- HbA1c measurements through
carbamylation
|
False high - ONLY for immunological HbA1c measurements
|
Possibilities for objectification:
|
Terminal renal insufficiency, uraemia,
crea>5 mg/dl
|
Betalactam antibiotics
|
-
Newer HPLC columns are no longer influenced by
carbamylation, ask laboratory.
-
Laboratory method other than HPLC required:
-
Immunological technique
-
Enzymatic technique
(written note on the laboratory request form)
|
Alcoholism (acetaldehyde)
|
Contraceptive pill
|
|
Aspirin (from 500 mg/d over weeks)
|
HAES
|
|
Other causes
|
|
Falsely low
|
Falsely high
|
|
|
Nutritional (alcohol, fat)
|
Pharmaceuticals:
-
Immunosuppressants
-
Protease inhibitors
|
|
|
|
Genetically-induced hyperglycation in certain ethnic
groups
|
|
|
|
Age
|
|
|
|
Organ transplantation
|
|
|
|
Hypertriglyceridemia
|
|
|
Hereditary causes
|
Hereditary causes
|
|
In practice, the measurement of other glycated proteins (e. g.
fructosamine) is of secondary importance.
Measurement method
There are a number of different methodological approaches to measuring HbA1c; in
practice, a few have become established and are frequently used.
Available systems
There are various systems on the market; they can be differentiated according to
measuring principles and laboratory systems, POCT (Point of Care) systems and
small desktop devices that can also be used by patients.
Specifications for measurement quality/standards
In recent decades, the measurement quality of the HbA1c value measurement has
been significantly improved by a number of measures, in particular by the
creation of suitable reference material. However, there are still considerable
differences in measurement results between laboratories using identical blood
samples; even intra-laboratory differences can be substantial.
Costs/refund of expenses
The costs for the HbA1c value measurements are borne by the cost carriers for all
patients with diabetes.
Quality control (internal and external/interlaboratory tests)
According to the specifications of the Rili BÄK for HbA1c, the operators
of corresponding devices must participate in an internal and external quality
control. Unit-use POCT systems are excluded from external quality control; if
HbA1c is used for diabetes diagnosis, interlaboratory comparisons are required.
Up until now, the guideline for the pass limit for external quality control
(=interlaboratory comparisons) was±18%. In future, this
figure will be reduced to 8% (with a transition period of several
years). The requirements for internal quality control will be simultaneously
reduced from 10–3%. Furthermore, commutable (exchangeable)
control material (whole blood) is now used in the interlaboratory comparisons,
which improves quality control considerably. Overall, this measure contributes
to a significant improvement in the measurement quality of this parameter, which
is important for diabetology.
Safety issues/side effects
When using different HbA1c measuring methods, differences are observed that are
relevant for therapy: Various systems can display HbA1c measured values
differing by 0.5% for the same blood sample. If a patient has a
relatively low therapeutic target, such differences may increase the risk of
hypoglycaemia. The erythrocyte life span has a considerable influence on HbA1c.
Diseases that change the erythrocyte life span, correspondingly influence the
HbA1c value ([Table 7]). For example, due to the
significantly shortened erythrocyte life span, pronounced haemolytic anaemia can
lead to low HbA1c values which are independent of the mean glucose values.
Practical implementation of the measurement
Information on the practical implementation and interpretation of the measurement
results is provided in the Diabetes Diagnosis practical recommendation. An HbA1c
value (eHbA1c) can be calculated from fasting glucose values measured over a
certain period of time and individual 7-point blood glucose profiles. Using
rtCGM data, a glucose management index (GMI) can be calculated in addition to
HbA1c that reflects the predominant quality of glucose control from such data
over a period of time. At the request of the American health authorities,
another term is used to avoid suggesting that this parameter corresponds to the
HbA1c value.
Conditions to be observed in practice
The use of POCT devices for HbA1c value measurement allows the currently measured
HbA1c value to be discussed directly with the patient. There is also no need to
send a blood collection tube to a laboratory. However, the measurement quality
of all POCT systems is not sufficient.
Use with different patient groups
The HbA1c value measurement provides the desired information on long-term glucose
control in almost all diabetes types. In older patients it should be noted that
the HbA1c value increases physiologically (see Diabetes Diagnosis practical
recommendation).
Training/psychological aspects
In diabetes training, the concept of the HbA1c value should be explained to the
participants so that they understand the importance of target values and work
towards achieving their target values. However, thanks to the availability of
CGM data, the focus can be placed on the reduction of glucose fluctuations as a
medium-term therapeutic goal. If individual patients are deeply afraid of severe
hypoglycaemia, they will tend to aim for rather high HbA1c values. The opposite
is true for patients whose goal it is to avoid diabetes-associated sequelae
(“low-flying patients”) because of extreme fear.
Comment
In principle, the use of rtCGM/iscCGM systems also provides an overview
of the quality of glucose control over time. Thus, an average glucose value over
time can be calculated that correlates with the HbA1c value. The importance of
the HbA1c value remains high despite the availability of CGM data. The HbA1c
value is currently the only relevant surrogate endpoint associated with
subsequent complications. New endpoints that are obtained by properly evaluating
the data provided by CGM systems, such as “Time-in-Range” (TiR)
and “Time-below-Range” (TbR), facilitate the assessment of
glucose control quality ([Table 4]). The TiR and TbR,
for example, better reflect fluctuations in glucose concentrations than the
HbA1c value, but the parameters in the software programmes of the various
manufacturers are also system-dependent. In our view, parameters derived from
CGM, such as TiR/TbR, complement but do not replace the HbA1c value.
(https://www.deutsche-diabetes-gesellschaft.de/file-
admin/Redakteur/Stellungnahmen/2019/20190509_KLD_Stel-
lungnahme_Time_in_Range_2019_final.pdf)
The measurement quality of the CGM system used has an influence on the TiR.
Summary and outlook
The glucose measurement and control options presented have revolutionized diabetes
therapy over the past 40 years, providing patients with an unprecedented degree of
flexibility and safety in dealing with their disease.
This development has accelerated significantly over the last two decades, and the
market launch of AID systems will represent another quantum leap in diabetes
therapy.
All methods for glucose monitoring are subject to rapid change and further
development. Therefore, the statements formulated here should be continuously
updated through current literature reviews and observance of the
manufacturers' homepages. There is a need for an independent institute to
evaluate the performance of the measurement systems on the market, especially after
their market launch. This is also due to the weaknesses of the previous CE marking
system. It will take years before the improvements that come with the currently
revised CE system take effect.
Unfortunately, there is no European authority which is primarily concerned with
medical devices (as is the case with medicine); this is covered by the EU
Commission. The German authorities (BfArM) also have relatively few practical
options, since medical devices are a country issue. A dialogue between all parties
involved, i. e. manufacturers, cost carriers, health policymakers,
practitioners and patients - under the leadership of the German Diabetes
Society/AGDT - in the format of a round table would help to identify and
remedy deficiencies in order to significantly improve the situation.