Expanding the Role of Continuous Glucose Monitoring in Modern Diabetes Care Beyond Type 1 Disease

Evaluation of glycemia risk index and continuous glucose monitoring-derived metrics in type 1 diabetes: a real-world observational study

Objectives

The Glycemia Risk Index (GRI) quantifies the risk of glycemic events by considering both hypoglycemic and hyperglycemic episodes, offering a comprehensive evaluation of glycemia. While associations between GRI and various glycometric indicators have been established in clinical trials using continuous glucose monitoring (CGM), real-world assessments, particularly with intermittent scanning CGM (isCGM), are underexplored. This study examines these associations and their clinical implications in individuals with Type 1 Diabetes (T1D).

Methods

We conducted a retrospective study involving individuals with T1D undergoing intensive insulin therapy. All participants had used isCGM for at least three months. We collected clinical, metabolic, and glycemic data and calculated the GRI, with its components for hypoglycemia (CHypo) and hyperglycemia (CHyper). We then assessed the correlation between the GRI and traditional glycemic metrics in relation to the coefficient of variation (CV).

Results

The study included 194 patients (105 males, 89 females) with a median age of 21.5 years for adults and 16 years for adolescents. Of these, 62.4% were on multiple daily injections, and 37.6% used insulin pumps. GRI showed a significant negative correlation with Time in Range (%TIR70 - 180) (p  < 0.001) and a positive association with various glycemic measures such as glycemic variability (r = 0.33, p < 0.001). Individuals with lower glycemic variability (CV< 36%) had significantly higher %TIR70 - 180 (63% vs. 39%, p < 0.01) and lower GRI (40 vs. 45.8, p < 0.01), CHyper (20 vs. 24, p = 0.01), and CHypo (2.6 vs. 3.4, p < 0.01).

Conclusions

GRI correlates with key glycemic metrics, indicating its potential utility in comprehensive glycemia assessment. These findings highlight the importance of individualized treatment approaches and suggest GRI's clinical relevance in optimizing glycemic management strategies for individuals with T1D.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-025-01569-w.

Use of Glucose Monitoring Devices Among Adults with Diabetes in Germany: Results from Nationwide Surveys Conducted in 2017 and 2021/2022

Background: Devices for continuous glucose monitoring (CGM) have been developed to optimize blood glucose control and liberate people with diabetes from finger-prick glucose measurements. Since 2016, the devices have been reimbursed in Germany for people with diabetes receiving insulin therapy, resulting in their increased use among people with type 1 diabetes (T1D) and type 2 diabetes (T2D). We investigated the prevalence of CGM use and its associated factors among German adults with diabetes in 2017 and 2021/2022. Methods: Participants aged 18 years or older with diagnosed diabetes were identified from two nationwide population-based telephone surveys in 2017 (n = 1396) and 2021/2022 (n = 1456). Prevalence and dynamics of CGM use were examined overall and stratified by sociodemographic and diabetes-related characteristics. Factors associated with CGM use were obtained from logistic regression models. Results: The overall prevalence of CGM use was 8.2% in 2017 and 16.6% in 2021/2022. An increase in CGM use was observed across all the subgroups except for those without antidiabetic medications. CGM use increased from 31.1% to 75.4% in adults with T1D, from 6.3% to 13.6% in adults with T2D, and from 14.6% to 36.7% in all insulin users. In both surveys, younger age, insulin use, T1D, and reporting hypoglycemia were associated with CGM use. In addition, in 2017, higher education level and absence of obesity were associated with CGM use, whereas in 2021/2022, participation in the diabetes self-management education program and higher self-assessed quality of diabetes care were associated with CGM use. Conclusion: Among adults with diabetes in Germany, CGM use increased about twofold within 5 years, irrespective of sociodemographic factors. Educational inequality in CGM use diminished over time. The higher self-rated quality of diabetes care associated with the recent use of CGM provides further evidence to support its use among all adults with diabetes in Germany.

Addition of continuous glucose monitoring to glucagon-like peptide 1 receptor agonist treatment for type 2 diabetes mellitus - An economic evaluation

BACKGROUND

Both glucagon-like peptide 1 receptor agonists (GLP-1 RAs) and continuous glucose monitoring (CGM) have been shown to improve glycated hemoglobin A1c (A1c) levels among patients with type 2 diabetes mellitus (T2DM). Recently, a US real-world study found statistically significant improvements in A1c levels among patients using GLP-1 RA and a CGM device, compared with a matched cohort receiving only GLP-1 RA.

OBJECTIVES

To assess the cost-effectiveness from a US payer perspective of initiating CGM (FreeStyle Libre Systems) in people living with T2DM using a GLP-1 RA therapy, compared with GLP-1 RA alone.

METHODS

A patient-level microsimulation model was run for 10,000 patients over a lifetime horizon with 3.0% discounting for costs and utilities. Patient characteristics were based on the overall population of the US real-world study and the subgroup of patients not using intensive insulin. The effect of CGM was modeled as a persistent reduction in A1c compared with GLP-1 RA alone (overall = 0.37%; patients not using intensive insulin = 0.34%). Costs ($2,023) and disutilities were applied to diabetes complications and acute diabetic events. Outcomes were assessed as quality-adjusted life years (QALYs).

RESULTS

The base-case incremental cost-effectiveness ratio (incremental costs/incremental QALYs) for GLP-1 RA plus CGM vs GLP-1 RA alone was $40,968/QALY in the overall cohort (cost = $484,180 vs $473,938; QALYs = 13.37 vs 13.12). Among patients not using intensive insulin, the incremental cost-effectiveness ratio was $43,095/QALY. Scenario analysis showed that the model results were robust to changing assumptions. Probabilistic sensitivity analysis showed that GLP-1 RA plus CGM had a 64% probability of being cost-effective at a willingness-to-pay threshold of $100,000 per QALY.

CONCLUSIONS

From a US payer perspective, CGM is cost-effective when added to GLP-1 RA therapies for the treatment of T2DM, including for patients not using intensive insulin.

Beyond the Pain Management Clinic: The Role of AI-Integrated Remote Patient Monitoring in Chronic Disease Management - A Narrative Review

Remote Patient Monitoring (RPM) stands as a pivotal advancement in patient-centered care, offering substantial improvements in the diagnosis, management, and outcomes of chronic conditions. Through the utilization of advanced digital technologies, RPM facilitates the real-time collection and transmission of critical health data, enabling clinicians to make prompt, informed decisions that enhance patient safety and care, particularly within home environments. This narrative review synthesizes evidence from peer-reviewed studies to evaluate the transformative role of RPM, particularly its integration with Artificial Intelligence (AI), in managing chronic conditions such as heart failure, diabetes, and chronic pain. By highlighting advancements in disease-specific RPM applications, the review underscores RPM's versatility and its ability to empower patients through education, shared decision-making, and adherence to therapeutic regimens. The COVID-19 pandemic further emphasized the importance of RPM in ensuring healthcare continuity during systemic disruptions. The integration of AI with RPM has refined these capabilities, enabling personalized, real-time data collection and analysis. While chronic pain management serves as a focal area, the review also examines AI-enhanced RPM applications in cardiology and diabetes. AI-driven systems, such as the NXTSTIM EcoAI™, are highlighted for their potential to revolutionize treatment approaches through continuous monitoring, timely interventions, and improved patient outcomes. This progression from basic wearable devices to sophisticated, AI-driven systems underscores RPM's ability to redefine healthcare delivery, reduce system burdens, and enhance quality of life across multiple chronic conditions. Looking forward, AI-integrated RPM is expected to further refine disease management strategies by offering more personalized and effective treatments. The broader implications, including its applicability to cardiology, diabetes, and pain management, showcase RPM's capacity to deliver automated, data-driven care, thereby reducing healthcare burdens while enhancing patient outcomes and quality of life.

Criteria for Personalised Choice of a Continuous Glucose Monitoring System: An Expert Opinion

Despite the growing evidence supporting the outpatient use of continuous glucose monitoring (CGM) for improving glycaemic control and reducing hypoglycaemia, there is a need for a detailed understanding of the specific features of CGM devices that best meet individual patient needs. This expert opinion, based on a comprehensive literature review and the personal perspectives of clinicians, aims to provide the healthcare professionals (HCPs) with a comprehensive framework for selecting CGM devices. It evaluates the current state of CGM technology, categorizing features into essential features, major drivers of choice, and additional/useful features. Moreover, the practical model presented outlines a patient's journey with CGM, emphasising the importance of aligning device features with patient needs. This includes understanding the patient's lifestyle, clinical conditions, and personal preferences to optimize CGM use and improve diabetes management outcomes.

Beyond the insulin pump: Unraveling diabetes tech dependency

The use of technology for Type 1 diabetes (T1D) has significantly developed in the last 20 years leading to several benefits in life-style management but also to potentially overreliance and addiction to such life changing devices. Insulin pumps (CSII) being small, discreet and sophisticated, offer features such as customizable basal rates, bolus calculators and integration with Continuous Glucose Monitoring (CGM) systems becoming a must have for diabetic patients. Indeed CGM, firstly introduced in the late 1990s and now being highly sophisticated provide trends and patterns hence allowing a better management of T1D. In this review we inquire the multifactorial aspects of dependency on diabetes technology, focusing not only on the benefits and the advancements these automations offer, but also the challenges, limits and possible risks associated with overreliance on them. Specifically, the impact that early introduction to technology had on patients, the dependency on CSII and CGM, the importance of learning and self-management skills and strategies for addressing unexpected events.

Time-in-range derived from self-measured blood glucose in people with type 2 diabetes advancing to iGlarLixi: A participant-level pooled analysis of three phase 3 LixiLan randomized controlled trials

AIM

To evaluate the efficacy of a fixed-ratio combination of insulin glargine 100 U/mL plus lixisenatide (iGlarLixi) in people with type 2 diabetes (T2D) using derived time-in-range (dTIR).

METHODS

Participant-level data from LixiLan-L, LixiLan-O and LixiLan-G were pooled and dTIR (70-180 mg/dL), derived time-above-range (> 180 mg/dL) and derived time-below-range (dTBR; < 70 mg/dL) were calculated from participant seven-point self-monitored blood glucose profiles.

RESULTS

This pooled analysis included data from 2420 participants receiving iGlarLixi (n = 1093), iGlar (n = 836), Lixi (n = 234) or a glucagon-like peptide-1 receptor agonist (GLP-1 RA) (n = 257). Numerically greater improvements in least square (LS) means dTIR were seen from baseline to end of treatment (EOT) with iGlarLixi (25.7%) versus iGlar (15.8%), Lixi (11.7%) or GLP-1 RA (16.2%). At EOT, the mean (standard deviation) dTBR was 0.71% ± 3.4%, 0.61% ± 3.2%, 0.08% ± 1.0% and 0.0% ± 0.0% for iGlarLixi, iGlar, Lixi and GLP-1 RA, respectively. In a subgroup analysis, participants aged younger than 65 years (n = 1690) and 65 years or older (n = 713) showed numerically greater improvements in LS means dTIR from baseline to EOT with iGlarLixi versus iGlar, Lixi or GLP-1 RA.

CONCLUSIONS

iGlarLixi achieved improvements in dTIR, with low dTBR values, providing further evidence to inform clinical outcomes with the use of iGlarLixi.

Adherence to Self-Monitoring of Blood Glucose and Its Related Factors Among Type 2 Diabetic Patients Attending Al-Ahsa Primary Health Care Centers in Saudi Arabia

BACKGROUND

Self-monitoring of blood glucose (SMBG) is a crucial component of diabetes management, but adherence remains suboptimal. This study aimed to evaluate adherence to SMBG among type 2 diabetic patients in Al-Ahsa, Saudi Arabia.

METHODS

A cross-sectional study was conducted among 398 type 2 diabetic patients attending primary healthcare centers. Data were collected through face-to-face or virtual interviews and electronic health records. Adherence levels were categorized as low, moderate, and high.

RESULTS

The majority of participants exhibited moderate adherence to SMBG (58.5%), while 27.1% had low adherence, and 14.3% were highly adherent. The use of oral hypoglycemic medications and insulin injections was associated with higher adherence (p<0.001). Comorbidities, physical exercise, diet, frequency of medical visits, and attendance at diabetes education sessions did not significantly influence adherence.

CONCLUSIONS

Suboptimal adherence to SMBG was observed among type 2 diabetic patients in Al-Ahsa. Targeted interventions addressing individual barriers and integrating technology may improve SMBG adherence and diabetes management.

Continuous glucose monitoring for the routine care of type 2 diabetes mellitus

Although continuous glucose monitoring (CGM) devices are now considered the standard of care for people with type 1 diabetes mellitus, the uptake among people with type 2 diabetes mellitus (T2DM) has been slower and is focused on those receiving intensive insulin therapy. However, increasing evidence now supports the inclusion of CGM in the routine care of people with T2DM who are on basal insulin-only regimens or are managed with other medications. Expanding CGM to these groups could minimize hypoglycaemia while allowing efficient adaptation and escalation of therapies. Increasing evidence from randomized controlled trials and observational studies indicates that CGM is of clinical value in people with T2DM on non-intensive treatment regimens. If further studies confirm this finding, CGM could soon become a part of routine care for T2DM. In this Perspective we explore the potential benefits of widening the application of CGM in T2DM, along with the challenges that must be overcome for the evidence-based benefits of this technology to be delivered for all people with T2DM.

Appropriateness and acceptability of continuous glucose monitoring in people with type 1 diabetes at rural first-level hospitals in Malawi: a qualitative study

OBJECTIVES

The purpose of this qualitative study is to describe the acceptability and appropriateness of continuous glucose monitoring (CGM) in people living with type 1 diabetes (PLWT1D) at first-level (district) hospitals in Malawi.

DESIGN

We conducted semistructured qualitative interviews among PLWT1D and healthcare providers participating in the study. Standardised interview guides elicited perspectives on the appropriateness and acceptability of CGM use for PLWT1D and their providers, and provider perspectives on the effectiveness of CGM use in Malawi. Data were coded using Dedoose software and analysed using a thematic approach.

SETTING

First-level hospitals in Neno district, Malawi.

PARTICIPANTS

Participants were part of a randomised controlled trial focused on CGM at first-level hospitals in Neno district, Malawi. Pretrial and post-trial interviews were conducted for participants in the CGM and usual care arms, and one set of interviews was conducted with providers.

RESULTS

Eleven PLWT1D recruited for the CGM randomised controlled trial and five healthcare providers who provided care to participants with T1D were included. Nine PLWT1D were interviewed twice, two were interviewed once. Of the 11 participants with T1D, six were from the CGM arm and five were in usual care arm. Key themes emerged regarding the appropriateness and effectiveness of CGM use in lower resource setting. The four main themes were (a) patient provider relationship, (b) stigma and psychosocial support, (c) device usage and (d) clinical management.

CONCLUSIONS

Participants and healthcare providers reported that CGM use was appropriate and acceptable in the study setting, although the need to support it with health education sessions was highlighted. This research supports the use of CGM as a component of personalised diabetes treatment for PLWT1D in resource constraint settings.

TRIAL REGISTRATION NUMBER

PACTR202102832069874; Post-results.

Leveraging continuous glucose monitoring for personalized modeling of insulin-regulated glucose metabolism

Continuous glucose monitoring (CGM) is a promising, minimally invasive alternative to plasma glucose measurements for calibrating physiology-based mathematical models of insulin-regulated glucose metabolism, reducing the reliance on in-clinic measurements. However, the use of CGM glucose, particularly in combination with insulin measurements, to develop personalized models of glucose regulation remains unexplored. Here, we simultaneously measured interstitial glucose concentrations using CGM as well as plasma glucose and insulin concentrations during an oral glucose tolerance test (OGTT) in individuals with overweight or obesity to calibrate personalized models of glucose-insulin dynamics. We compared the use of interstitial glucose with plasma glucose in model calibration, and evaluated the effects on model fit, identifiability, and model parameters' association with clinically relevant metabolic indicators. Models calibrated on both plasma and interstitial glucose resulted in good model fit, and the parameter estimates associated with metabolic indicators such as insulin sensitivity measures in both cases. Moreover, practical identifiability of model parameters was improved in models estimated on CGM glucose compared to plasma glucose. Together these results suggest that CGM glucose may be considered as a minimally invasive alternative to plasma glucose measurements in model calibration to quantify the dynamics of glucose regulation.

Continuous Glucose Monitoring: A Possible Aid for Detecting Hypoglycemic Events during Insulin Tolerance Tests

The combined pituitary function test evaluates the anterior pituitary gland, while the insulin tolerance test evaluates growth hormone deficiencies. However, successful stimulation requires achieving an appropriate level of hypoglycemia. Close medical supervision for glucose monitoring is required during hypoglycemia induction and the test is often very tedious. In addition, a capillary blood sugar test (BST) and serum glucose levels may differ greatly. An alternative approach may be utilizing a continuous glucose-monitoring (CGM) system. We provide three cases in which CGM was successfully used alongside a standard BST and serum glucose levels during the combined pituitary function test to better detect and induce hypoglycemia. Three participants who were diagnosed with multiple pituitary hormone deficiencies during childhood were re-evaluated in adulthood; a Dexcom G6 CGM was used. The CGM sensor glucose and BST levels were simultaneously assessed for glycemic changes and when adequate hypoglycemia was reached during the combined pituitary function test. The CGM sensor glucose, BST, and serum glucose levels showed similar glucose trends in all three patients. A Bland-Altman analysis revealed that the CGM underestimated the BST values by approximately 9.68 mg/dL, and a Wilcoxon signed-rank test showed that the CGM and BST measurements significantly differed during the stimulation test (p = 0.003). Nevertheless, in all three cases, the CGM sensor mimicked the glycemic variability changes in the BST reading and assisted in monitoring appropriate hypoglycemia nadir. Thus, CGM can be used as a safe aid for clinicians to use during insulin tolerance tests where critical hypoglycemia is induced.