Wednesday, June 10, 2020

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

That’s a question, friends, not news of a new Medicare policy on insurance coverage. The fact still is: Medicare will only cover a Continuous Glucose Monitor (CGM) for type 1s and type 2s who inject meal-time (not just basal) insulin.
Current government policy is designed to help mealtime insulin users 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 and co-morbidities from higher levels of glucose in the blood. And, IMHO, as the cost of treating 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 that are macrovascular include some cancers, stroke, and heart disease; the ADA "compliant" patients (with an A1c of 7.0%), have TWICE the risk of CVD as non-diabetics. See Type 2 Nutrition #345R - How Diabetic Do You Want to Be (Part 2).docx.
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 to achieve, given 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%) in carbohydrates. All carbs 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 is 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) over the course of the day. The best way to do that is to monitor your blood sugar continuously, 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 a “hypo” (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. Metformin 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. But, 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, introduced 3/18, is about $5,000 US a year. That’s 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 old Freestyle Libre included sensors good for 10 days, but the new FDA approved 14-day sensor is now 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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