Real world Australian data show high CGM discontinuation rates in youth with T1D

By Sunalie Silva

12 May 2021

Almost 60% of adolescents and young adults with type 1 diabetes who initiated use of CGM discontinued it  – with almost all doing so within the first week of commencement, according to real-world experience reported from a Sydney hospital.

Endocrinologists and diabetes educators from Westmead Hospital Young Adult Diabetes Clinic, who reported the findings in Internal Medicine Journal , said poor glycaemic control seemed to predict those who were less likely to use CGM.

The findings come from a cohort of 151 patients aged 15-21 who had been eligible for the Federal government CGM subsidy under the National Diabetes Services Scheme, which came into effect in 2017.

Following a one hour CGM education program some 44 people opted to take up the device (25 Medtronic, 19 Dexcom).

But just two weeks later, at first follow up, just 18 (38% or 15.6% of all eligible youth) had continued using CGM, with many reporting discomfort and inconvenience as the most common reasons for dropout.

Other reasons given for discontinuation included interference with other activities such as sport and manual work, the sensor being easily dislodged, and disruptive alarms.

CGM can be confronting

Speaking to the limbic, Diabetes Educator and Westmead’s Young Adult Clinic program coordinator Ms Kaye Farrell said there was a significant difference in baseline HbA1c between those who continued and discontinued CGM (8.0% and 9.1% respectively).

The higher baseline HbA1c of those who discontinued CGM was an important finding, she added, given they are the people who could potentially gain the most from CGM.

“From a clinical point of view the technology helps us determine treatments and treatment adjustments but it does add a burden to young people’s management of diabetes,” she said, adding that the alarms and constant data were confronting for many participants – particularly those at risk of depression or diabetes burnout.

“For some people CGM can be confronting – particularly when they start seeing readings they really don’t want to see. If you’re not checking sugars frequently it’s very easy to push it to the background but when you start using a device that shows you exactly what’s happening, that can add to the burden of diabetes; and the easiest way to avoid that is to discontinue CGM.”

She said ensuring young people have realistic expectations of CGM prior to commencement, involving the young person in the decision making process and screening for depressive symptoms and signs of diabetes burden may improve continuation rates.

The recent approval of the flash glucose monitoring device without alarms may also improve uptake in the young adult age group, which Ms Farrell said appeared to be ‘more acceptable’ among younger adults.

Meanwhile those who continued with CGM were more likely to be using CSII, perhaps due to existing familiarity with devices, and, for some the additional benefit of augmenting pump function.

“People on insulin pumps perceived more benefit and weren’t as bothered by the alarms because of course through the pump they were able to use a function that would suspend the pump if their blood glucose was getting too low so they had the benefit of preventing hypoglycaemia which was one of the greatest fears people reported by the group and why many reported running their sugars high.”

Clinic visits

According to Ms Farrell, CGM users at baseline also had a higher number of clinic visits over 12 months prior to commencement – perhaps indicating that those who commence CGM may be more engaged in their diabetes care.

But the study also showed there was little overall impact on glycaemic control in those that stuck with the device compared to those who discontinued.

Of those that continued CGM, there was no significant difference in any glycaemic parameters at three months and six months compared to baseline although there was a trend to increased time in range.

At six months compared to baseline there was no change in HbA1c (8.2% vs 8.0%, P=0.8), CV of glucose (38% vs 39%, P=0.5), or % time in range (52% vs 58%, P=0.3).

Yet despite minimal change, Ms Farrell said hypoglycaemia worry scores, one of the selection criteria for accessing subsidised CGM in Australia for youth, were significantly decreased amongst those who continued CGM from baseline at 6 months (33 vs 18, P<0.01).

Meanwhile for CGM non-users six-month follow up HbA1c had deteriorated significantly compared to users.

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