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You can’t manage what you can’t measure, CGM or SMBG?

Oct 01, 2019

“You can’t manage (and improve) what you can’t measure” - the golden rule of management is particularly true when it comes to managing diabetes.

Over the past few years, there has been an increasing use of continuous glucose monitoring (CGM), which includes both real-time CGM (rtCGM) and intermittently scanned CGM (isCGM).

Numerous studies have demonstrated significant clinical benefits of CGM use in people with diabetes regardless of insulin delivery method. It is estimated that 87% of people with type 1 diabetes, and 27% of people with type 2 diabetes on insulin treatment in the United States will use CGM by 2023, and it is expected that CGM would soon become a standard of care for glucose monitoring in developed countries.
HbA1c is currently recognized as the key surrogate marker for the development of long-term diabetes complications in people with diabetes, and has been used as the primary end point for many studies; however, its numerous limitations (lack of information on acute complications of hypo- and hyperglycemia, and glucose variability; confounded by certain conditions such as anemia, hemoglobinopathies, iron deficiency, and pregnancy), resulted in a need for novel metrics of glucose control (glucometrics), such as Mean Glucose; Time in Range (TIR); Time Above Range (TAR); Time Below Range (TBR); Glucose Management Indicator (GMI); Glycemic Variability (GV); Ambulatory Glucose Profile (AGP).
Despite the increasing use of CGM, Self-Monitoring of Blood Glucose (SMBG), although in use for almost four decades, remains the cornerstone of home and hospital glucose monitoring for the majority of people with diabetes worldwide. As demonstrated in large clinical trials that included SMBG as part of the multi-factorial intervention, glycaemic control in diabetes remains essential to prevent micro-vascular complications and reduce long-term risk of macro-vascular disease.
For people with diabetes on insulin treatment, frequent SMBG is key for achieving recommended glycaemic targets, and prevention of hypoglycemia and hyperglycemia. Increased daily frequency of SMBG in people with type 1 diabetes was significantly associated with lower HbA1c, and with fewer acute complications.
On the other hand, randomized controlled and observational trials in people with non-insulin treated type 2 diabetes on the use of SMBG for improvement of glycaemic control and/or reduction of risk for hypoglycemia provided mixed results.
Nevertheless, SMBG remains an essential tool for a proactive diabetes care approach in these people, as it provides immediate feedback on glycaemic control, rather than waiting months for the next HbA1c (retroactive approach). SMBG is necessary for education and understanding the behaviors of people with non-insulin treated type 2 diabetes, and should be individualized in terms of frequency, timing and communication with healthcare providers, as part of the structured diabetes management.
Unfortunately, SMBG is underutilized even in developed countries, and there are developing countries where SMBG is not available, or is available for the minority of patients, who mostly perform it once a month, or at no regular interval.


In this discussion, members are asked:

  1. What is the situation with availability of CGM and/or SMBG in your country, and are they reimbursed?
  2. How well are the healthcare providers and patients familiar with the glucometrics beyond A1c, such as Time in Range (TIR); Time Above Range (TAR); Time Below Range (TBR); Glucose Management Indicator (GMI); Glycemic Variability (GV); Ambulatory Glucose Profile (AGP), and the respective targets?
  3. What are the prospects of the more widely use of CGM, or increased availability of SMBG, in your country in the next 5 years?

Further recommended readings

Battelino T, Danne T, Bergenstal R, Amiel S, Beck R et al. Clinical Targets for Continuous Glucose Monitoring Data Interpretation: Recommendations From the International Consensus on Time in Range. Diabetes Care 2019; 42:1593–1603.


Information about the discussion leader

Ass Prof (Doc.) Ivica Smokovski, MD, PhD is a certified sub-specialist in Endocrinology and Specialist in Internal Medicine at University Clinic of Endocrinology, Diabetes and Metabolic Disorders Skopje, and Ass Professor (Doc.) at Faculty of Medical Sciences, University Goce Delcev Stip. He had a crucial role in creation of Diabetes Care module of the National e-Health System, covering total population of the country across all three healthcare levels, that is still in use. He is the author of numerous publications, including the State-of-the-Art article on Diabetes Care in Republic of Macedonia: Challenges and Opportunities, first comprehensive overview of the situation with diabetes in the country, estimated to have the second highest diabetes prevalence in Europe, as well as publications on First Stratified Diabetes Prevalence Data for Republic of Macedonia derived from the National e-Health System, and First Metabolic Control Results in Insulin-Treated Diabetes Patients for Republic of Macedonia derived from the National e-Health System.
Ivica has been honored with the Donnell D. Etzwiler International Scholar Award 2020.
This is the eighth in a series of discussions introducing some of the programme sessions that will be featured at the IDF Congress 2019 in Busan, Korea, 2-6 December 2019.