Sunday, April 7, 2019

Type 2 Nutrition #480: CGMs for Non-Insulin Dependent Type 2s?


That’s a question, folks, not news of a new Medicare policy on insurance coverage. The fact is: Medicare will still only cover a Continuous Glucose Monitor (CGM) for type 1s and type 2s who inject meal-time insulin.
Current government policy is designed to avoid hypos and is cost-driven. Hypos from accidental overtreatment with insulin by the patient are acute and can be life threatening if not addressed quickly. They frequently result in emergency room visits and hospitalizations. Regrettably, for non-insulin dependent type 2s, Medicare does not foster a long-term approach to blood glucose self-management (BGSM). They do not consider the costly complications from higher levels of glucose in the blood. And as the cost of treating the complications and co-morbidities of T2D soars, Medicare should cover CGMs for non-insulin dependent T2s.
Diabetic complications take many years to develop. Microvascular complications include 1) nerve damage (peripheral neuropathy), the leading cause of amputations; 2) loss of sight (retinopathy), and 3) end-stage kidney disease (nephropathy), requiring dialysis. The co-morbidities of T2D are macrovascular: some cancers, stroke, and heart disease; the ADA "compliant" patients (with an A1c of 7.0%), have TWICE the risk of CVD.
Why does the government set such a low standard for doctors and patients? Because achieving the ADA’s modest ≤7.0% A1c control goal is still difficult with the government’s one-size-fits-all Dietary Guidelines. Type 2 diabetes is a DIETARY disease, but the Dietary Guidelines for all Americans are still based on an eating pattern that is very high (55-60%) carbohydrate. All carbs sooner or later become “sugar” (glucose) in the blood. Eating so many carbs while trying to manage your blood glucose requires increasingly more meds. But the USDA/HHS, abetted by Big Agriculture and Big Pharma, are stuck in the status quo.
So, if the patient understands this and wants to lower their blood sugars on a day-to-day basis, they need to know what foods (and other factors such as hormones) affect their blood sugar (glucose). The best way to do that is to monitor your blood sugar frequently, and “eat to the meter,” i. e., change what you eat.
As I am not an insulin-dependent type 2 who injects meal-time insulin, my options for obtaining a CGM are limited to cash-only, i.e., out-of-pocket. I recently looked into this and learned the following:
For context, I treat my type 2 diabetes primarily with a Very Low Carb “Eating Pattern.” My only diabetes med is Metformin, and I am assured by my physician, “You can’t get hypoglycemia from just Metformin.” My own experience since 2002 confirms this. I am in no danger whatsoever of hypos, even with extended fasting.  Metformin works on the liver (and gut) and improves insulin sensitivity. It has no effect on the pancreas.
So, if you are not able to use insurance to cover the cost of purchasing a CGM system (sensors and readers, or transmitters and receivers), you have 2 choices: Dexcom and Freestyle Libre. If you don’t have or aren’t eligible to use insurance, cost is the main factor. That eliminates one choice for me.
The new Dexcom G6 (3/18), at about $5,000 US a year, is expensive. It is more accurate in hypos, includes alarms and has an integrated mobile app. It automatically downloads results to a Bluetooth-enabled device. The 10-day sensor is a little bulky, but if you’re insurance eligible, and get hypos, it’s definitely the way to go.
The new Freestyle Libre 14-day (8/18) is much less expensive, but still costly at $1,620 a year ($135/mo). The previous Freestyle Libre included sensors good for 10 days, but the new FDA approved 14-day sensor should now be in pharmacies. It may be slightly less accurate than a Dexcom, but it has a shorter “warmup” period (1 hr. vs. 2 hr.) for new sensors. However, it has no alarms for hypos. It has a 90-day memory and an excellent suite of reports (daily reports and 14-day summaries). It does not have its own integrated mobile app and must be “read” every 8 hours. However, a startup, Ambrosia, has a workaround called BluCon. Given my needs, and the cost disparity, it’s a no-brainer. If I decide to do it, I’ll opt for the Freestyle Libre 14-day.

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