Evidence Based Practice Continuous Glucose Monitoring Accuracy
Clinicians strive to practice evidence-based medicine, but good evidence is not always available to address key clinical questions. There have been significant technological advances in managing diabetes in recent years, but the evidence has not developed as quickly as the technology. However, two recent, notable randomized controlled trials have shed light on the appropriate use of continuous glucose monitoring.
Continuous glucose monitors allow a patient and clinician to more closely monitor glucose control by evaluating time in target range, time in hypoglycemia, and time in hyperglycemia. A continuous glucose monitor has a subcutaneous sensor that measures the interstitial fluid glucose at a minimum of every five minutes, and the sensor's transmitter continuously sends data to its receiver.
Although there has been strong evidence for the use of continuous glucose monitoring in patients with type 1 diabetes, similar evidence has not existed for patients with type 2 diabetes. The DIAMOND trial, a real-world randomized controlled trial published in 2017, was a real-world randomized controlled trial that evaluated continuous glucose monitoring in 158 type 2 diabetes mellitus patients who required multiple daily insulin injections. The trial reported that the use of continuous glucose monitoring facilitated better glycemic control than was achieved by usual care (i.e., care relying solely on self-monitored blood glucose); however, insufficient hypoglycemic events occurred in the two arms to draw conclusions about the impact of continuous glucose monitoring on hypoglycemia.1
Management of diabetes during pregnancy is of critical importance, as the consequences of suboptimal care are potentially devastating. A national study found that stillbirths are 5 times more frequent in diabetes mellitus patients than in nondiabetic patients, occur more often in pregnancies with suboptimal glycemic control, and accounted for the majority of perinatal mortality in infants of diabetic mothers.2 Epidemiologic studies also report increases in major congenital malformations in infants born to women with type 1 and type 2 diabetes mellitus, most of which develop before the seventh week of gestation. Studies estimate a 30% increase in malformation risk for every 1% increase in HbA1c, making the first trimester a critical period for receiving high-quality care.3, 4 Currently, a therapeutic goal for these patients is to have normal HbA1c at conception.5 Intrauterine growth retardation, preeclampsia, and fetal hypoxia may also complicate pregnancies in women with pre-existing diabetes. These risks continue in the second and third trimesters. Given the potential for these complications, high-quality preconception care is critical.2
Despite the importance of euglycemia in pregnancy, the evidence for continuous glucose monitoring in pregnant diabetes mellitus patients has been limited. In 2017, an open-label, multicenter, randomized controlled trial of 215 pregnant patients with type 1 diabetes mellitus found that, as compared with self-monitoring of blood glucose, continuous glucose monitoring was associated with a small, yet significant, reduction in HbA1c and in time spent in hyperglycemia, plus an increased time spent in the glucose target range. Hypoglycemic events were similarly low between arms. There were fewer large-for-gestational age babies and days in the NICU in the continuous glucose monitoring arm.5
These new trials add significant data to the evidence base for managing diabetes mellitus, but additional research needs to be done to establish the best use of technology in managing this chronic disease. As new studies are published, it will be critical for stakeholders involved in both healthcare policy and direct patient care to incorporate the best available evidence into treatment to improve the outcomes that matter to patients.
– Barbara J. Moore, MD (April 10, 2018)
The information contained in this article concerns the MCG care guidelines in the specified edition and as of the date of publication, and may not reflect revisions made to the guidelines or any other developments in the subject matter after the publication date of the article.
Image courtesy Shutterstock/Nata photo
References
- Beck RW, et al. Continuous glucose monitoring versus usual care in patients with type 2 diabetes receiving multiple daily insulin injections: a randomized trial. Annals of Internal Medicine 2017;167(6):365-74.
- Mathiesen ER, et al. Stillbirths in diabetic pregnancies. Best Practice & Research: Clinical Obstetrics and Gynaecology 2011;25(1):105-11.
- Landon MB, Catalano PM, Gabbe SG. Diabetes mellitus complicating pregnancy. In: Gabbe SG, Niebyl JR, Simpson JL, Landon MB, Galan HL, Jauniaux ER, Driscoll DA, Berghella V, Grobman WA, editors. Obstetrics: Normal and Problem Pregnancies, 7th ed. Philadelphia, PA: Elsevier; 2017:862-98.
- McCance DR; Diabetes in pregnancy. Best Practice & Research: Clinical Obstetrics and Gynaecology 2015;29(5):685-99.
- Feig DS, et al. Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial. Lancet 2017;390(10110):2347-59.
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Source: https://www.mcg.com/blog/2018/04/10/continuous-glucose-monitoring-evidence-technology/
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