Endocrinol Metab.  2023 Oct;38(5):472-481. 10.3803/EnM.2023.1805.

The Benefits Of Continuous Glucose Monitoring In Pregnancy

• Yoo JH
• Kim JH

• KMID: 2546978
• DOI: http://doi.org/10.3803/EnM.2023.1805

Abstract

Previous studies have consistently demonstrated the positive effects of continuous glucose monitoring (CGM) on glycemic outcomes and complications of diabetes in people with type 1 diabetes. Guidelines now consider CGM to be an essential and cost-effective device for managing type 1 diabetes. As a result, insurance coverage for it is available. Evidence supporting CGM continues to grow and expand to broader populations, such as pregnant people with type 1 diabetes, people with type 2 diabetes treated only with basal insulin therapy, and even type 2 diabetes that does not require insulin treatment. However, despite the significant risk of hyperglycemia in pregnancy, which leads to complications in more than half of affected newborns, CGM indications and insurance coverage for those patients are unresolved. In this review article, we discuss the latest evidence for using CGM to offer glycemic control and reduce perinatal complications, along with its cost-effectiveness in pregestational type 1 and type 2 diabetes and gestational diabetes mellitus. In addition, we discuss future prospects for CGM coverage and indications based on this evidence.

Keyword

Blood glucose; Diabetes mellitus, type 1; Diabetes mellitus, type 2; Diabetes, gestational; Pregnancy in diabetics; Pregnancy outcome

Reference

1. Mackin ST, Nelson SM, Kerssens JJ, Wood R, Wild S, Colhoun HM, et al. Diabetes and pregnancy: national trends over a 15 year period. Diabetologia. 2018; 61:1081–8.

2. Feig DS, Hwee J, Shah BR, Booth GL, Bierman AS, Lipscombe LL. Trends in incidence of diabetes in pregnancy and serious perinatal outcomes: a large, population-based study in Ontario, Canada, 1996-2010. Diabetes Care. 2014; 37:1590–6.

3. Son KH, Lim NK, Lee JW, Cho MC, Park HY. comparison of maternal morbidity and medical costs during pregnancy and delivery between patients with gestational diabetes and patients with pre-existing diabetes. Diabet Med. 2015; 32:477–86.

4. Murphy HR, Howgate C, O’Keefe J, Myers J, Morgan M, Coleman MA, et al. Characteristics and outcomes of pregnant women with type 1 or type 2 diabetes: a 5-year national population-based cohort study. Lancet Diabetes Endocrinol. 2021; 9:153–64.

5. Ahmed RJ, Gafni A, Hutton EK, Hu ZJ, Sanchez JJ, Murphy HR, et al. The cost implications of continuous glucose monitoring in pregnant women with type 1 diabetes in 3 Canadian provinces: a posthoc cost analysis of the CONCEPTT trial. CMAJ Open. 2021; 9:E627–34.

6. Roze S, Isitt J, Smith-Palmer J, Javanbakht M, Lynch P. Long-term cost-effectiveness of Dexcom G6 real-time continuous glucose monitoring versus self-monitoring of blood glucose in patients with type 1 diabetes in the U.K. Diabetes Care. 2020; 43:2411–7.

7. Murphy HR, Bell R, Cartwright C, Curnow P, Maresh M, Morgan M, et al. Improved pregnancy outcomes in women with type 1 and type 2 diabetes but substantial clinic-to-clinic variations: a prospective nationwide study. Diabetologia. 2017; 60:1668–77.

8. Kristensen K, Ogge LE, Sengpiel V, Kjolhede K, Dotevall A, Elfvin A, et al. Continuous glucose monitoring in pregnant women with type 1 diabetes: an observational cohort study of 186 pregnancies. Diabetologia. 2019; 62:1143–53.

9. Nielsen LR, Ekbom P, Damm P, Glumer C, Frandsen MM, Jensen DM, et al. HbA1c levels are significantly lower in early and late pregnancy. Diabetes Care. 2004; 27:1200–1.

10. Beck RW, Riddlesworth T, Ruedy K, Ahmann A, Bergenstal R, Haller S, et al. Effect of continuous glucose monitoring on glycemic control in adults with type 1 diabetes using insulin injections: the DIAMOND Randomized Clinical Trial. JAMA. 2017; 317:371–8.

11. Martens T, Beck RW, Bailey R, Ruedy KJ, Calhoun P, Peters AL, et al. Effect of continuous glucose monitoring on glycemic control in patients with type 2 diabetes treated with basal insulin: a randomized clinical trial. JAMA. 2021; 325:2262–72.

12. Leelarathna L, Evans ML, Neupane S, Rayman G, Lumley S, Cranston I, et al. Intermittently scanned continuous glucose monitoring for type 1 diabetes. N Engl J Med. 2022; 387:1477–87.

13. Aleppo G, Beck RW, Bailey R, Ruedy KJ, Calhoun P, Peters AL, et al. The effect of discontinuing continuous glucose monitoring in adults with type 2 diabetes treated with basal insulin. Diabetes Care. 2021; 44:2729–37.

14. Aronson R, Brown RE, Chu L, Bajaj HS, Khandwala H, Abitbol A, et al. Impact of flash glucose monitoring in people with type 2 diabetes inadequately controlled with non-insulin antihyperglycaemic therapy (IMMEDIATE): a randomized controlled trial. Diabetes Obes Metab. 2023; 25:1024–31.

15. Feig DS, Donovan LE, Corcoy R, Murphy KE, Amiel SA, Hunt KF, et al. Continuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): a multicentre international randomised controlled trial. Lancet. 2017; 390:2347–59.

16. Murphy HR, Rayman G, Lewis K, Kelly S, Johal B, Duffield K, et al. Effectiveness of continuous glucose monitoring in pregnant women with diabetes: randomised clinical trial. BMJ. 2008; 337:a1680.

17. Majewska A, Stanirowski PJ, Tatur J, Wojda B, Radosz I, Wielgos M, et al. Flash glucose monitoring in gestational diabetes mellitus (FLAMINGO): a randomised controlled trial. Acta Diabetol. 2023; 60:1171–7.

18. Zaharieva DP, Teng JH, Ong ML, Lee MH, Paldus B, Jackson L, et al. Continuous glucose monitoring versus self-monitoring of blood glucose to assess glycemia in gestational diabetes. Diabetes Technol Ther. 2020; 22:822–7.

19. ElSayed NA, Aleppo G, Aroda VR, Bannuru RR, Brown FM, Bruemmer D, et al. 15. Management of diabetes in pregnancy: standards of care in diabetes-2023. Diabetes Care. 2023; 46(Suppl 1):S254–66.

20. Scott EM, Bilous RW, Kautzky-Willer A. Accuracy, user acceptability, and safety evaluation for the freestyle libre flash glucose monitoring system when used by pregnant women with diabetes. Diabetes Technol Ther. 2018; 20:180–8.

21. Castorino K, Polsky S, O’Malley G, Levister C, Nelson K, Farfan C, et al. Performance of the Dexcom G6 continuous glucose monitoring system in pregnant women with diabetes. Diabetes Technol Ther. 2020; 22:943–7.

22. Norgaard SK, Mathiesen ER, Norgaard K, Ringholm L. Comparison of glycemic metrics measured simultaneously by intermittently scanned continuous glucose monitoring and real-time continuous glucose monitoring in pregnant women with type 1 diabetes. Diabetes Technol Ther. 2021; 23:665–72.

23. Jensen DM, Korsholm L, Ovesen P, Beck-Nielsen H, Moelsted-Pedersen L, Westergaard JG, et al. Peri-conceptional A1C and risk of serious adverse pregnancy outcome in 933 women with type 1 diabetes. Diabetes Care. 2009; 32:1046–8.

24. Maresh MJ, Holmes VA, Patterson CC, Young IS, Pearson DW, Walker JD, et al. Glycemic targets in the second and third trimester of pregnancy for women with type 1 diabetes. Diabetes Care. 2015; 38:34–42.

25. Yamamoto JM, Murphy HR. Benefits of real-time continuous glucose monitoring in pregnancy. Diabetes Technol Ther. 2021; 23(S1):S8–14.

26. Garcia-Patterson A, Gich I, Amini SB, Catalano PM, de Leiva A, Corcoy R. Insulin requirements throughout pregnancy in women with type 1 diabetes mellitus: three changes of direction. Diabetologia. 2010; 53:446–51.

27. Murphy HR. Continuous glucose monitoring targets in type 1 diabetes pregnancy: every 5% time in range matters. Diabetologia. 2019; 62:1123–8.

28. Tundidor D, Meek CL, Yamamoto J, Martinez-Bru C, Gich I, Feig DS, et al. Continuous glucose monitoring time-in-range and HbA1c targets in pregnant women with type 1 diabetes. Diabetes Technol Ther. 2021; 23:710–4.

29. Scott EM, Feig DS, Murphy HR, Law GR; CONCEPTT Collaborative Group. Continuous glucose monitoring in pregnancy: importance of analyzing temporal profiles to understand clinical outcomes. Diabetes Care. 2020; 43:1178–84.

30. Levy CJ, Kudva YC, Ozaslan B, Castorino K, O’Malley G, Kaur RJ, et al. At-home use of a pregnancy-specific zoneMPC closed-loop system for pregnancies complicated by type 1 diabetes: a single-arm, observational multicenter study. Diabetes Care. 2023; 46:1425–31.

31. Dodesini AR, Borella ND, Lepore G, Bonfadini S, Corsi A, Scaranna C, et al. Real-world insulin treatment in pregnant women with type 1 diabetes using an advanced hybrid closedloop system. Diabetes Technol Ther. 2023; 25:516–8.

32. Lee TT, Collett C, Man MS, Hammond M, Shepstone L, Hartnell S, et al. AiDAPT: automated insulin delivery amongst pregnant women with type 1 diabetes: a multicentre randomized controlled trial: study protocol. BMC Pregnancy Childbirth. 2022; 22:282.

33. Voormolen DN, DeVries JH, Sanson RM, Heringa MP, de Valk HW, Kok M, et al. Continuous glucose monitoring during diabetic pregnancy (GlucoMOMS): a multicentre randomized controlled trial. Diabetes Obes Metab. 2018; 20:1894–902.

34. Kim KS, Hong S, Han K, Park CY. The clinical characteristics of gestational diabetes mellitus in Korea: a National Health Information Database Study. Endocrinol Metab (Seoul). 2021; 36:628–36.

35. Garcia-Moreno RM, Benitez-Valderrama P, Barquiel B, Gonzalez Perez-de-Villar N, Hillman N, Lora Pablos D, et al. Efficacy of continuous glucose monitoring on maternal and neonatal outcomes in gestational diabetes mellitus: a systematic review and meta-analysis of randomized clinical trials. Diabet Med. 2022; 39:e14703.

36. Majewska A, Stanirowski PJ, Wielgos M, Bomba-Opon D. Efficacy of continuous glucose monitoring on glycaemic control in pregnant women with gestational diabetes mellitus: a systematic review. J Clin Med. 2022; 11:2932.

37. Paramasivam SS, Chinna K, Singh AK, Ratnasingam J, Ibrahim L, Lim LL, et al. Continuous glucose monitoring results in lower HbA1c in Malaysian women with insulin-treated gestational diabetes: a randomized controlled trial. Diabet Med. 2018; 35:1118–29.

38. Alfadhli E, Osman E, Basri T. Use of a real time continuous glucose monitoring system as an educational tool for patients with gestational diabetes. Diabetol Metab Syndr. 2016; 8:48.

39. Yu F, Lv L, Liang Z, Wang Y, Wen J, Lin X, et al. Continuous glucose monitoring effects on maternal glycemic control and pregnancy outcomes in patients with gestational diabetes mellitus: a prospective cohort study. J Clin Endocrinol Metab. 2014; 99:4674–82.

40. Huhn EA, Linder T, Eppel D, WeiBhaupt K, Klapp C, Schellong K, et al. Effectiveness of real-time continuous glucose monitoring to improve glycaemic control and pregnancy outcome in patients with gestational diabetes mellitus: a study protocol for a randomised controlled trial. BMJ Open. 2020; 10:e040498.

41. National Institute for Health and Care Excellence. Diabetes in pregnancy: management from preconception to the postnatal period. London: NICE;2020.

42. Korean Diabetes Association. Clinical practice guidelines for diabetes. Seoul: KDA;2023.

43. Murphy HR, Feig DS, Sanchez JJ, de Portu S, Sale A; CONCEPTT Collaborative Group. Modelling potential cost savings from use of real-time continuous glucose monitoring in pregnant women with type 1 diabetes. Diabet Med. 2019; 36:1652–8.

44. Yoo JH, Kim JH. Advances in continuous glucose monitoring and integrated devices for management of diabetes with insulin-based therapy: improvement in glycemic control. Diabetes Metab J. 2023; 47:27–41.

45. Choudhary P, de Portu S, Delbaere A, Lyon J, Pickup JC. A modelling study of the budget impact of improved glycaemic control in adults with type 1 diabetes in the UK. Diabet Med. 2019; 36:988–94.

46. Fonda SJ, Graham C, Munakata J, Powers JM, Price D, Vigersky RA. The cost-effectiveness of real-time continuous glucose monitoring (RT-CGM) in type 2 diabetes. J Diabetes Sci Technol. 2016; 10:898–904.

47. Isitt JJ, Roze S, Sharland H, Cogswell G, Alshannaq H, Norman GJ, et al. Cost-effectiveness of a real-time continuous glucose monitoring system versus self-monitoring of blood glucose in people with type 2 diabetes on insulin therapy in the UK. Diabetes Ther. 2022; 13:1875–90.

48. Yoo JH, Kim G, Lee HJ, Sim KH, Jin SM, Kim JH. Effect of structured individualized education on continuous glucose monitoring use in poorly controlled patients with type 1 diabetes: a randomized controlled trial. Diabetes Res Clin Pract. 2022; 184:109209.

49. Heinemann L, Freckmann G, Ehrmann D, Faber-Heinemann G, Guerra S, Waldenmaier D, et al. Real-time continuous glucose monitoring in adults with type 1 diabetes and impaired hypoglycaemia awareness or severe hypoglycaemia treated with multiple daily insulin injections (HypoDE): a multicentre, randomised controlled trial. Lancet. 2018; 391:1367–77.

50. Lind M, Polonsky W, Hirsch IB, Heise T, Bolinder J, Dahlqvist S, et al. Continuous glucose monitoring vs conventional therapy for glycemic control in adults with type 1 diabetes treated with multiple daily insulin injections: the GOLD Randomized Clinical Trial. JAMA. 2017; 317:379–87.

51. Beck RW, Riddlesworth TD, Ruedy K, Ahmann A, Haller S, Kruger D, et al. Continuous glucose monitoring versus usual care in patients with type 2 diabetes receiving multiple daily insulin injections: a randomized trial. Ann Intern Med. 2017; 167:365–74.