As a diabetes community, we stand on the precipice of major change within the gamut of glucose monitoring.
Studies continue to reveal the benefits of continuous glucose monitoring (CGM) in people with type 1 and type 2 diabetes, and these benefits are vast, particularly regarding improved diabetes management and blood glucose levels. Yet this technology could also help the NHS avoid preventable costs, and logic suggests that it is surely just a matter of time before CGMs are widely available.
Alas, that time has not come yet. For the moment, the majority of patients have to self-fund CGM use if they are not eligible on the NHS. This situation is the same for users of the FreeStyle Libre, a flash glucose monitoring device.
Dr Anna Breckenridge, a Consultant in Diabetes at Guy’s and St. Thomas’ hospital, spoke about the FreeStyle Libre at the Diabetes Professional Care conference this month, and believes much like how blood glucose meters eventually became widespread in diabetes monitoring, it won’t be long before the Libre is available to all people who would benefit, not just those who can afford it.
One of the aforementioned preventable NHS costs is hospital admissions for severe hypoglycemia. In 2015, the mean cost per hospital admission for severe hypos in England was shown to be £1,034[1], and it is estimated that severe hypos currently cost the NHS £13m a year. CGMs could help lower these figures significantly.
Earlier this year, CGM use was found to improve HbA1c in people with type 1 diabetes taking multiple daily injections, and also improve detection of hypoglycemia. Last year, an Endocrine Society task force in the US called CGMs the gold standard for adults with type 1 diabetes, and CGMs were reported in October to help nullify rising healthcare costs for people with type 2 diabetes.
But for the time being, NHS access to CGMs is limited, despite petitions to make CGMs available free to all adults and children with type 1 diabetes.
The National Institute for Health and Care Excellence (NICE) guidelines recommended use of just two CGM systems (MiniMed Paradigm Veo and Vibe and G4 PLATINUM CGM) for those who experience frequent severe hypos and possess hypo unawareness[2], while others may be eligible depending on circumstances. If you are not eligible, you have to pay for this technology yourself, and it’s not cheap.
The initial cost of a CGM varies between £1,000-£2,500, but the main cost, a running cost, is the sensors. These cost around £40-60 and have to be replaced after around a week (although they can last for longer). The FreeStyle Libre can cost up to £1,250 a year (£910 on the NHS).
Significantly more people with diabetes in England have been hospitalised with hypoglycemia in the last decade, and while there could be many reasons for this, including increased diabetes prevalence and the postcode lottery regarding access to diabetes education, it is a revelation that yields consideration of significant change, namely new treatment therapies.
Previously, NICE has stated it didn’t believe there was sufficient evidence for CGMs to be cost-effective enough to recommend widely, but this summer it published a report asking for leading healthcare professionals’ opinions on the FreeStyle Libre. The report revealed that “All four experts felt that this technology could offer benefits to patients.”
The next NICE review on CGMs is scheduled for 2019, and there is room for optimism. At the beginning of November the Libre was made available on the NHS, and will be offered to those with a greater clinical need for the device. Of course, given the device’s capabilities – it is more affordable than CGMs, reduces the need for so many blood sugar tests and provides graphs of your blood sugar trends – it is arguable that most people with type 1 diabetes would benefit from the Libre.
As worthwhile as the Libre could becomen, CGMs have shown to be even more effective at identifying hypoglycemia. One can only imagine the potential impact this could have if CGMs were not just cheaper and more widely available, but free.
We of course live in a country with the most magnificent health service, and the NHS’ free prescriptions of diabetes treatments for people with type 1 diabetes is of stark contrast to countries where patients have to pay for insulin, such as in the US. But the NHS has a need to cost-cut, particularly as diabetes makes up 10% of its annual budget, and experts have warned the cost of treating diabetes in the UK could hit £17 billion by 2035. It is imperative the NHS pushes ahead with investigating CGMs and education regarding these devices as a means of not just lessening the strain upon itself, but improving the health of people with diabetes nationwide.
CGM trials worldwide are ongoing. And should more studies yield positive data, it will become harder and harder for the NHS not to embrace CGMs as the future of glucose monitoring.
[1] https://drc.bmj.com/content/3/1/e000057
[2] https://www.nice.org.uk/guidance/dg21
