Continuous Glucose Monitoring: An Opportunity to Understand and Individualize Diabetes Management

What is Continuous Glucose Monitoring (CGM) System?

CGM is a device capable of constantly evaluating interstitial glucose levels, acquiring and compiling the data for real-time and future use. The transmitter itself is normally only a few inches in size and has a small filament that is inserted into the skin.

It is placed on the upper arm or stomach and is left in place for several weeks at a time. In addition to the transmitter, a monitor is also part of the system and should be carried near the patient to record the data for long-term storage. Once placed, a patient’s glucose levels are taken every few minutes without any necessary action on the part of the patient.

Diabetes Management With a CGM

For patients with diabetes, a CGM offers the opportunity for close monitoring of glucose levels and far less traditional finger sticks with a lancing device and glucometer. Although a patient may still need to perform finger sticks to determine their blood glucose level if they feel an imminent reading is required (the interstitial glucose monitored via CGM lags slightly behind that of blood glucose from a finger stick), this is far less invasive to many patients who were previously doing multiple finger sticks throughout each day.

Diabetes management is complex and can be overwhelming for a patient. If blood glucose levels are not in range, it means 1 of 2 scenarios are occurring—the patient is either hypoglycemic or hyperglycemic. With a CGM, a patient is notified any time their levels fall into 1 of those 2 undesirable states and helps them to know when to bring those levels back into range. Hypoglycemia is an acute problem that can be deadly.

CGM alarms for low glucose can prevent situations from becoming critical for a patient. Hyperglycemia mainly contributes to the chronic micro and macrovascular problems caused by diabetes, so although less time-sensitive, it is important for a patient to know when it is occurring so they can learn to prevent the imbalance in the future.

CGM Benefits for Patients

Although some may already be imagining the influx of possible benefits a CGM provides for a patient, the major positive outcome is increased understanding, individualization of care, and improved adherence to disease state management. It is a frequently used phrase that “diabetes is a smart person’s disease” and receiving that initial diagnosis can be intimidating.

Therefore, a benefit for a patient using a CGM is an expansion of their knowledge and awareness regarding a diabetes diagnosis. A healthy diet is a huge factor in diabetes management, but many patients do not know what that means or have a grasp on what certain foods do to their body when consumed.

CGM systems provide colorful graphs, charts, and analyses of a patient’s fluctuating glucose levels. These can be used as critical tools in depicting the effects of food and lifestyle for a patient.

By highlighting spikes or dips in the data and then asking the patient what occurred on that day, it allows the patient to gain insight into their own habits. Seeing their glucose levels skyrocket on a day they ate only fast food can be an eye-opening experience.

On the flip side, giving the patient praise for a day in-range and asking what was done differently on that day can reinforce positive behaviors and show the patient that lifestyle changes can lead to quantifiable benefits. Moreover, CGM systems provide security for a patient worried about hypoglycemic events.

Patients at risk for experiencing hypoglycemia are those who are administering insulin to manage their diabetes. If the insulin dose is too high or the patient’s meals did not balance with the dose, hypoglycemia can occur.

Patients are aware that hypoglycemia is dangerous, so they often express fear when insulin therapy is suggested. Informing a patient that using a CGM in conjunction with their insulin will alert them to falling glucose levels can ease patient concern and keep them adherent.

Additionally, this sense of security extends into the night. CGM systems monitor levels 24/7 and produce alarms that awaken a patient if their glucose levels fall even while they are asleep.

Challenges of CGM Systems

Despite a CGM system’s numerous benefits for patients, they also have several challenges. The first obstacle that must be overcome is the hesitation a patient may have to the idea of having a device on their body and the fear of it being painful.

A common misunderstanding that patients have is that a CGM involves a needle being placed into their body. Once they realize the only part that enters through the skin is a small flexible filament, some of that initial fear can be removed. Along those same lines, some patients present with hesitation due to the technological aspect of the device. They can even be defensive that they do not want technology involved or do not have the skills needed to maintain any form of technology.

There is a level of responsibility necessary with a CGM that presents as a challenge. For data to be consolidated, a patient must come in-range of the CGM monitor—whether they are using their phone and an app for this or if the system requires its own additional monitoring device—at certain intervals of time depending on the specific system in use. If this does not occur, the data gathered will have gaps and provide only limited insight. Moreover, some patients may not be able to initially interpret the data gathered; hence, if they do not have an accessible health care professional to assist them, this could exist as another downfall to the system.

Lastly, CGM systems can be costly for a patient. Affording the initial monitor can be pricey, let alone the transmitters that must be changed every few weeks. Depending on the patient’s insurance, CGMs may be out of their budget without additional means of financial assistance.

A Pharmacist’s Role

CGMs are an opportunity for the patient to gain a better understanding and individualized control of their diabetes and for pharmacists to use their skills to improve a patient’s quality of life and health management. Looking at the challenges associated with a CGM, most occur in the beginning of use. A pharmacist can be at the forefront of initiating a patient on a CGM by identifying patients and helping them to eliminate those initial barriers.

To begin, a pharmacist may suggest that a patient starting on, or those who are administering, ongoing insulin therapy talk to their physician if they are still struggling to keep their glucose levels in range or are experiencing hypoglycemic events. Patients and physicians alike may not always have great lengths of insight on CGM systems and making a patient aware of the opportunity may open new discussions with their health care professionals.

Next, a pharmacist can help patients overcome the various sources of hesitation related to starting a CGM by counseling at the first pick-up on what the device looks like (highlighting the filament and overall non-invasive design of the device), how placement is done, upkeep of the device (including daily activities such as if it is water-resistant or what to do if it falls off early), and an overview on the technology-side of the system (how to view and use the monitor and how to ensure data are uploaded and saved).

After a patient is initiated on the CGM, a pharmacist can help them read and interpret the data to help to guide future decisions and make maintainable goals.

Conclusion

Overall, as health technology continues to expand, it is important that pharmacists are advocates for bringing the opportunities to our patients. CGM systems are one of the ways in which we can help to make a diabetes diagnosis and management less intimidating and less foreign to a patient. Increasing awareness in the possibility and use of a CGM can change how patients maintain their health and ensure their disease management is being individualized.

About the Authors

Katie Cook is a PharmD candidate at Duquesne University School of Pharmacy in Pittsburgh, Pennsylvania, who anticipates graduating in spring 2022.

Jonathan Ogurchak, PharmD, CSP, is the CEO and cofounder of STACK, a pharmacy information management platform, and serves as preceptor for a virtual Advanced Pharmacy Practice Experiential Rotation for specialty pharmacy, during which this article was composed.