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• W3200345800 abstract "The Diabetes Canada Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada (CPG) were last published in 2018 (1Diabetes Canada Clinical Practice Guidelines Expert CommitteeDiabetes Canada 2018 clinical practice guidelines for the prevention and management of diabetes in Canada.Can J Diabetes. 2018; 42: S1-S325PubMed Scopus (22) Google Scholar). Rapid uptake of new monitoring technologies by persons living with diabetes and uncertainty among health-care professionals prompted a review of evidence emerging since our previous recommendations for “Monitoring Glycemic Control” (2Berard L.D. Siemens R. Woo V. Diabetes Canada 2018 clinical practice guidelines for the prevention and management of diabetes in Canada: Monitoring glycemic control.Can J Diabetes. 2018; 42: S47-S53Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar). We have updated the title for this topic to align with Diabetes Canada’s position statement on “Language Matters” (3Banasiak K. Cleary D. Bajurny V. et al.Language Matters - A Diabetes Canada Consensus Statement.Can J Diabetes. 2020; 44: 370-373Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar). A consolidated search strategy (for adults, children and pregnant women) was developed by modifying and updating PICO (population, intervention, comparison and outcome) questions used for the 2018 CPG (chapters 9, 34, 35, 36). A systematic search of the literature for relevant articles published from November 1, 2017 to October 28, 2020 was performed by the health science librarians at the McMaster Evidence Review and Synthesis Team (MERST). The MERST team reviewed all relevant citations at title, abstract and full-text levels. Relevant citations were abstracted and critically reviewed by a methodologist from MERST. All MERST staff (librarians and methodologists) were without financial or intellectual conflict. The full-text citations and critical appraisal reports were provided to the expert working group. Members of the expert working group were selected by the CPG Steering Committee with the goal of ensuring representation of diverse perspectives (across disciplines, and academic and community settings), appropriate content and methodologic expertise, while limiting the potential of financial conflict, as much as possible. Diabetes Canada has a formal policy to manage conflict of interest for the CPG Steering Committee. The expert working group reviewed the citations, graded the evidence, drafted the revised recommendations and created the initial draft of the preamble document to accompany the revised recommendations. For this update, the CPG Steering Committee reviewed the cited evidence independently and suggested revisions to the draft recommendations and the text. The grading of recommendations was reviewed independently by the Independent Methods Review Co-Chair (D.R.). The finalized recommendations were unanimously approved by the CPG Steering Committee. Glucose monitoring remains a cornerstone of diabetes management. It allows people living with diabetes and their health-care providers to assess glycemic status and adverse effects, and to determine the effectiveness of glucose lowering therapies. Testing of glycated hemoglobin (A1C) continues to be the primary modality to ensure that glycemic goals are being met and the recommended frequency of testing remains unchanged. However, A1C is a measure of chronic glycemic levels over months and does not provide information that can inform immediate/short-term decisions. To measure glucose levels in real time, different modalities exist currently and new technologies are being studied. To address this expanding field, the terminology used to describe the different modalities needs to adapt to allow for future growth and has been updated in Table 1.Table 1Terminology for different glucose monitoring modalitiesNew termPrevious termDefinitionCapillary blood glucose (CBG)Self-monitored blood glucose (SMBG)Determination of glucose in the capillary blood using finger sticksIntermittently scanned continuous glucose monitoring (isCGM)Flash glucose monitoring (FGM)Measurement of interstitial fluid glucose via intermittent scanning of sensing deviceReal-time continuous glucose monitoring (rtCGM)Continuous glucose monitoringMeasurement of interstitial fluid glucose via a sensing device that is continuously transmitting the data to a device with real-time display for viewing at any timeMasked continuous glucose monitoring (mCGM)∗mCGM is a diagnostic tool for use by diabetes care providers, not for diabetes self-management.Professional continuous glucose monitoringMeasurement of interstitial fluid glucose via a sensing device that stores the data to be retrieved at a later time∗ mCGM is a diagnostic tool for use by diabetes care providers, not for diabetes self-management. Open table in a new tab To maintain consistency with other chapters in the 2018 CPG, the language within the recommendations has been modified, such that interventions supported by Grade A, Level 1 evidence, and confirmed as appropriate through clinical experience, are now written as “should be used” in place of the previous language of “may be offered.” The population, intervention and expected outcome benefit is clearly indicated in each recommendation and the action language should reflect the confidence in the evidence provided. For people living with type 1 diabetes who use basal-bolus injection therapy or continuous subcutaneous insulin infusion (CSII), rtCGM has been shown to reduce A1C (4Deiss D. Bolinder J. Riveline J.-P. et al.Improved glycemic control in poorly controlled patients with type 1 diabetes using real-time continuous glucose monitoring.Diabetes Care. 2006; 29: 2730-2732Crossref PubMed Scopus (443) Google Scholar, 5Beck R.W. Riddlesworth T. Ruedy K. 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: 371-378Crossref PubMed Scopus (550) Google Scholar, 6Lind M. Polonsky W. Hirsch I.B. 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: 379-387Crossref PubMed Scopus (350) Google Scholar, 7Battelino T. Phillip M. Bratina N. et al.Effect of continuous glucose monitoring on hypoglycemia in type 1 diabetes.Diabetes Care. 2011; 34: 795-800Crossref PubMed Scopus (376) Google Scholar, 8Garg S.K. Voelmle M.K. Beatson C.R. et al.Use of continuous glucose monitoring in subjects with type 1 diabetes on multiple daily injections versus continuous subcutaneous insulin infusion therapy: A prospective 6-month study.Diabetes Care. 2011; 34: 574-579Crossref PubMed Scopus (65) Google Scholar, 9Battelino T. Conget I. Olsen B. Schütz-Fuhrmann I. Hommel E. Hoogma R. et al.The use and efficacy of continuous glucose monitoring in type 1 diabetes treated with insulin pump therapy: a randomised controlled trial.Diabetologia. 2012; 55: 3155-3162https://doi.org/10.1007/s00125-012-2708-9Crossref PubMed Scopus (357) Google Scholar) and increase glucose time in range (TIR) (5Beck R.W. Riddlesworth T. Ruedy K. 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: 371-378Crossref PubMed Scopus (550) Google Scholar,7Battelino T. Phillip M. Bratina N. et al.Effect of continuous glucose monitoring on hypoglycemia in type 1 diabetes.Diabetes Care. 2011; 34: 795-800Crossref PubMed Scopus (376) Google Scholar,8Garg S.K. Voelmle M.K. Beatson C.R. et al.Use of continuous glucose monitoring in subjects with type 1 diabetes on multiple daily injections versus continuous subcutaneous insulin infusion therapy: A prospective 6-month study.Diabetes Care. 2011; 34: 574-579Crossref PubMed Scopus (65) Google Scholar,10Haskova A. Radovnicka L. Petruzelkova L. et al.Real-time CGM is superior to flash glucose monitoring for glucose control in type 1 diabetes: The CORRIDA randomized control trial.Diabetes Care. 2020 Nov; 43: 2744-2750Crossref PubMed Scopus (0) Google Scholar), while simultaneously reducing duration and incidence of hypoglycemia (5Beck R.W. Riddlesworth T. Ruedy K. 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: 371-378Crossref PubMed Scopus (550) Google Scholar,7Battelino T. Phillip M. Bratina N. et al.Effect of continuous glucose monitoring on hypoglycemia in type 1 diabetes.Diabetes Care. 2011; 34: 795-800Crossref PubMed Scopus (376) Google Scholar, 8Garg S.K. Voelmle M.K. Beatson C.R. et al.Use of continuous glucose monitoring in subjects with type 1 diabetes on multiple daily injections versus continuous subcutaneous insulin infusion therapy: A prospective 6-month study.Diabetes Care. 2011; 34: 574-579Crossref PubMed Scopus (65) Google Scholar, 9Battelino T. Conget I. Olsen B. Schütz-Fuhrmann I. Hommel E. Hoogma R. et al.The use and efficacy of continuous glucose monitoring in type 1 diabetes treated with insulin pump therapy: a randomised controlled trial.Diabetologia. 2012; 55: 3155-3162https://doi.org/10.1007/s00125-012-2708-9Crossref PubMed Scopus (357) Google Scholar, 10Haskova A. Radovnicka L. Petruzelkova L. et al.Real-time CGM is superior to flash glucose monitoring for glucose control in type 1 diabetes: The CORRIDA randomized control trial.Diabetes Care. 2020 Nov; 43: 2744-2750Crossref PubMed Scopus (0) Google Scholar, 11Heinemann L. Freckmann G. Ehrmann 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: 1367-1377Abstract Full Text Full Text PDF PubMed Scopus (224) Google Scholar) in adults and children. These glycemic benefits of rtCGM have been demonstrated in trials recruiting adults and children with A1C at target (<7.5%) (6Lind M. Polonsky W. Hirsch I.B. 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: 379-387Crossref PubMed Scopus (350) Google Scholar) or above target (4Deiss D. Bolinder J. Riveline J.-P. et al.Improved glycemic control in poorly controlled patients with type 1 diabetes using real-time continuous glucose monitoring.Diabetes Care. 2006; 29: 2730-2732Crossref PubMed Scopus (443) Google Scholar, 5Beck R.W. Riddlesworth T. Ruedy K. 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: 371-378Crossref PubMed Scopus (550) Google Scholar, 6Lind M. Polonsky W. Hirsch I.B. 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: 379-387Crossref PubMed Scopus (350) Google Scholar,9Battelino T. Conget I. Olsen B. Schütz-Fuhrmann I. Hommel E. Hoogma R. et al.The use and efficacy of continuous glucose monitoring in type 1 diabetes treated with insulin pump therapy: a randomised controlled trial.Diabetologia. 2012; 55: 3155-3162https://doi.org/10.1007/s00125-012-2708-9Crossref PubMed Scopus (357) Google Scholar); and in trials which included adults at or above target (8Garg S.K. Voelmle M.K. Beatson C.R. et al.Use of continuous glucose monitoring in subjects with type 1 diabetes on multiple daily injections versus continuous subcutaneous insulin infusion therapy: A prospective 6-month study.Diabetes Care. 2011; 34: 574-579Crossref PubMed Scopus (65) Google Scholar). As well as reducing biochemical (i.e. not necessarily symptomatic) hypoglycemia, rtCGM has been shown to reduce episodes of severe hypoglycemia in adults with a history of severe hypoglycemia or impaired awareness of hypoglycemia using multiple daily injections (MDI) (11Heinemann L. Freckmann G. Ehrmann 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: 1367-1377Abstract Full Text Full Text PDF PubMed Scopus (224) Google Scholar). rtCGM has also been shown to improve quality of life and hypoglycemia distress in adults with type 1 diabetes (11Heinemann L. Freckmann G. Ehrmann 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: 1367-1377Abstract Full Text Full Text PDF PubMed Scopus (224) Google Scholar, 12Polonsky W.H. Hessler D. Ruedy K.J. Beck R.W. Diamond Study GroupThe impact of continuous glucose monitoring on markers of quality of life in adults with type 1 diabetes: Further findings from the DIAMOND randomized clinical trial.Diabetes Care. 2017; 40: 736-741Crossref PubMed Scopus (132) Google Scholar, 13Lawrence J.M. Laffel L. Wysocki T. Xing D. Beck R.W. Huang E.S. et al.Quality of Life Measures in Children and Adults with Type 1 Diabetes: The Juvenile Diabetes Research Foundation Continuous Glucose Monitoring Randomized Trial.Diabetes Care. 2010; 33: 2175-2177https://doi.org/10.2337/dc10-0331Crossref PubMed Scopus (80) Google Scholar). For people living with type 2 diabetes using basal-bolus injection therapy, a randomized controlled trial of 158 subjects demonstrated that the use of rtCGM reduced A1C to a greater extent than usual care, with more time spent in the target range and less time spent above range at 24 weeks (14Beck R.W. Riddlesworth T.D. Ruedy K. 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: 365-374Crossref PubMed Scopus (221) Google Scholar). Therefore, it is now recommended that rtCGM may be used to improve glycemic levels in those with type 2 diabetes on basal-bolus injection therapy, with a reminder that successful use of rtCGM is dependent on the duration of time it is used, along with the importance of providing it in association with structured education and therapeutic programs (see section Importance of Diabetes Self-Management Education). The use of isCGM has been shown to be beneficial for people living with type 1 or type 2 diabetes using insulin therapy to decrease time spent in hypoglycemia (15Bolinder J. Antuna R. Geelhoed-Duijvestijn P. et al.Novel glucose-sensing technology and hypoglycaemia in type 1 diabetes: A multicentre, non-masked, randomised controlled trial.Lancet. 2016; 388: 2254-2263Abstract Full Text Full Text PDF PubMed Scopus (496) Google Scholar, 16Haak T. Hanaire H. Ajjan R. et al.Flash glucose-sensing technology as a replacement for blood glucose monitoring for the management of insulin-treated type 2 diabetes: A multicenter, open-label randomized controlled trial.Diabetes Ther. 2017; 8: 55-73Crossref PubMed Scopus (279) Google Scholar, 17Oskarsson P. Antuna R. Geelhoed-Duijvestijn P. et al.Impact of flash glucose monitoring on hypoglycaemia in adults with type 1 diabetes managed with multiple daily injection therapy: A pre-specified subgroup analysis of the IMPACT randomised controlled trial.Diabetologia. 2018; 61: 539-550Crossref PubMed Scopus (85) Google Scholar). Randomized controlled trials of isCGM compared to capillary blood glucose (CBG) testing in type 1 and type 2 diabetes have not consistently demonstrated differences in A1C (18Castellana M. Parisi C. Di Molfetta S. et al.Efficacy and safety of flash glucose monitoring in patients with type 1 and type 2 diabetes: A systematic review and meta-analysis.BMJ Open Diabetes Research & Care. 2020; 8Crossref Scopus (14) Google Scholar). However, in a recent health technology assessment, other glucose parameters have been shown to improve. Compared with CBG testing, people using isCGM spent, on average, 1 hour more in target glucose range (95% confidence interval [CI] 0.41–1.59) and 22 minutes less in a high glucose range (95% CI −0.69 to −0.05) per day and less glucose variability among those with type 1 diabetes (19Health OntarioFlash glucose monitoring system for people with type 1 or type 2 diabetes: A health technology assessment.Ontario health technology assessment series. 2019; 19: 1-108Google Scholar). A meta-regression, which included clinical trials and observational studies (which are subject to a number of biases) in type 1 and type 2 diabetes, suggested isCGM could reduce A1C by 0.55%, with the magnitude of A1C reduction being proportional to baseline A1C (20Evans M. Welsh Z. Ells S. Seibold A. The Impact of Flash Glucose Monitoring on Glycaemic Control as Measured by HbA1c: A Meta-analysis of Clinical Trials and Real-World Observational Studies.Diabetes Therapy : Research, Treatment and Education of Diabetes and Related Disorders. 2020; 11: 83-95https://doi.org/10.1007/s13300-019-00720-0Crossref PubMed Scopus (57) Google Scholar). However, as is true with any form of glucose monitoring, the act of monitoring may not of itself improve glucose levels, but, rather, provide data that permits users and providers to take actions to impact glucose levels underlying the importance of diabetes self-management education (see below). Two studies have directly compared rtCGM with isCGM in adults with type 1 diabetes. rtCGM users spent more TIR and less time below range (TBR) than isCGM users in a 5-week randomized study in adults with normal awareness of hypoglycemia using MDI or CSII (21Hásková A. Radovnická L. Petruželková L. Parkin C.G. Grunberger G. Horová E. et al.Real-time CGM Is Superior to Flash Glucose Monitoring for Glucose Control in Type 1 Diabetes: The CORRIDA Randomized Control Trial.Diabetes Care. 2020; 43: 2744-2750https://doi.org/10.2337/dc20-0112Crossref PubMed Scopus (15) Google Scholar). In an 8-week study of individuals with impaired awareness of, or recent severe hypoglycemia using MDI, rtCGM reduced time in hypoglycemia and fear of hypoglycemia, which was not seen with isCGM (22Reddy M. Jugnee N. Laboudi El A. Spanudakis E. Anantharaja S. Oliver N. A randomized controlled pilot study of continuous glucose monitoring and flash glucose monitoring in people with Type 1 diabetes and impaired awareness of hypoglycaemia.Diabetic Medicine: A Journal of the British Diabetic Association. 2018; 35: 483-490https://doi.org/10.1111/dme.13561Crossref PubMed Scopus (130) Google Scholar). Superiority of rtCGM to protect from hypoglycemia in this high-risk population was supported in the extension phase of this study, where switching to rtCGM was associated with significant reduction in TBR in subjects originally randomized to isCGM (23Reddy M. Jugnee N. Anantharaja S. Oliver N. Switching from Flash Glucose Monitoring to Continuous Glucose Monitoring on Hypoglycemia in Adults with Type 1 Diabetes at High Hypoglycemia Risk: The Extension Phase of the I HART CGM Study.Diabetes Technology & Therapeutics. 2018; 20: 751-757https://doi.org/10.1089/dia.2018.0252Crossref PubMed Scopus (45) Google Scholar). A pragmatic, open-label 12-month study of the use of masked CGM every 3 months, for 5 to 14 days before their clinical visit, compared to usual clinical care among those with type 2 diabetes in general practice, showed no difference in the primary endpoint of A1C at 12 months (24Furler J. O'Neal D. Speight J. et al.Use of professional-mode flash glucose monitoring, at 3-month intervals, in adults with type 2 diabetes in general practice (GP-OSMOTIC): A pragmatic, open-label, 12-month, randomised controlled trial.The Lancet Diabetes and Endocrinology. 2020; 8: 17-26Abstract Full Text Full Text PDF PubMed Scopus (18) Google Scholar), but there was an increase in TIR at 12 months and lower A1C at 6 months. Similarly, a randomized study of 148 people living with type 2 diabetes treated with insulin compared the effects of masked CGM and usual care with CBG testing in primary and secondary care settings and did not show a difference in the primary endpoint of TIR but did show a greater reduction in A1C with no increase in hypoglycemia (25Ajjan R.A. Jackson N. Thomson S.A. Reduction in HbA1c using professional flash glucose monitoring in insulin-treated type 2 diabetes patients managed in primary and secondary care settings: A pilot,multicentre, randomised controlled trial.Diabetes & Vascular Disease Research. 2019; 16: 385-395Crossref PubMed Scopus (27) Google Scholar). Given the conflicting data regarding the effects of the use of masked CGM, no recommendation can be made at this time. In a study of the performance of rtCGM (Dexcom G6) in 32 pregnant women with diabetes (type 1, type 2 and gestational diabetes) across sensor wear sites, accuracy of rtCGM was acceptable (overall mean absolute relative difference [MARD] was 10.3%) when compared to venous glucose measures, which were taken during a period of 6 hours when participants were allowed to eat freely. rtCGM was also found to be acceptably accurate in the hypoglycemic range (<3.8 mmol/L), with a mean absolute difference of 0.5 mmol/L between 3-3.8 mmol/L and 0.35 mmol/L at glucose levels of 2.2-3.0 mmol/L. Comparing different sites, the posterior upper arm was found to be most accurate, with a MARD of 8.7%, followed by the buttock (11.2%) and the abdomen (11.5%) (26Castorino K. Polsky S. O’Malley G. et al.Performance of the Dexcom G6 continuous glucose monitoring system in pregnant women with diabetes.Diabetes Tech & Ther. 2020; 22: 943-947Crossref PubMed Scopus (15) Google Scholar). The use of isCGM in pregnant women with diabetes has also been studied for accuracy and safety. In a study of 74 pregnant women with type 1, type 2 or gestational diabetes, isCGM was found to have good agreement with CBG (overall MARD 11.8%), with high levels of user satisfaction (27Scott E.M. Bilous R.W. 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 Technology & Ther. 2018; 20: 180-188Crossref PubMed Scopus (61) Google Scholar). The Continuous Glucose Monitoring in Women with Type 1 Diabetes in Pregnancy (CONCEPTT) trial randomized 325 women (215 pregnant and 110 planning pregnancy) with type 1 diabetes, to rtCGM, in addition to CBG testing or CBG testing alone (28Feig D.S. Donovan L.E. Corcoy R. et al.Conceptt Collaborative GroupContinuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): A multicentre international randomised controlled trial.Lancet. 2017; 390: 2347-2359Abstract Full Text Full Text PDF PubMed Scopus (269) Google Scholar). Pregnant rtCGM users spent more time in the target range of 3.5 to 7.8 mmol/L (68% vs 61%, p=0.0034) and less time above the range (>7.8 mmol/L) (27% vs 32%, p=0.0279) than did pregnant participants using CBG testing alone, with comparable severe hypoglycemic episodes and time spent with hypoglycemia. Neonatal health outcomes were significantly improved, with a lower incidence of large for gestational age (LGA) infants (OR 0.51, 95% CI 0.28–0.90, p=0.021), fewer neonatal intensive care unit (NICU) admissions lasting more than 24 hours (OR 0.48, 95% CI 0.26–0.86, p=0.0157), and a lower risk of neonatal hypoglycemia (OR 0.45; 95% CI 0.22–0.89, p=0.025). No benefit was observed for women planning a pregnancy (28Feig D.S. Donovan L.E. Corcoy R. et al.Conceptt Collaborative GroupContinuous glucose monitoring in pregnant women with type 1 diabetes (CONCEPTT): A multicentre international randomised controlled trial.Lancet. 2017; 390: 2347-2359Abstract Full Text Full Text PDF PubMed Scopus (269) Google Scholar). A budget impact model, where the National Health Service in England was used, estimated the total cost of pregnancy and delivery in women with type 1 diabetes using CBG testing with or without rtCGM. The potential annual cost savings of using rtCGM was estimated to be approximately £9.5 million, with the principal driver being reduced need for NICU and reduced duration of stay in NICU (29Murphy H.R. Feig D.S. Sanchez J.J. et al.Modelling potential cost savings from use of real-time continuous glucose monitoring in pregnant women with type 1 diabetes.Diabet Med. 2019; 36: 1652-1658Crossref PubMed Scopus (10) Google Scholar). Taken together, these data support updating the recommendation that rtCGM should be used in women with type 1 diabetes during pregnancy to improve blood glucose levels, and to reduce the risk for LGA infants, neonatal hypoglycemia and NICU admissions >24 hours. To date, there have been no randomized trials using isCGM in pregnant women with type 1 or type 2 diabetes. In an observational cohort study of 186 women with type 1 diabetes attending pregnancy care at 2 tertiary care antenatal clinics in Sweden (92 women used rtCGM and 94 women used isCGM), TIR (3.5 to 7.8 mmol/L) was similar in the 2 groups, although time spent in hypoglycemia was higher in the isCGM group. Pregnancy outcomes were associated with CGM metrics and the incidence of LGA was similar in the 2 groups (52% rtCGM vs 53% isCGM) (30Kristensen K. Ogge L.E. Sengpiel V. et al.Continuous glucose monitoring in pregnant women with type 1 diabetes: An observational cohort study of 186 pregnancies.Diabetologia. 2019 Jul; 62: 1143-1153Crossref PubMed Scopus (53) Google Scholar). The TIR achieved in this observational study (reaching 60% in the third trimester) was similar to the control arm, but lower than the intervention arm of CONCEPTT. While isCGM has not yet been shown to reduce neonatal morbidity in women with type 1 diabetes, these data are reassuring, but these observational data are not sufficient to conclude non-inferiority. Achieving optimal glycemic targets is more important than the technology employed. The effectiveness of rtCGM or isCGM for glycemic or fetal outcomes has not yet been studied in pregnant women with type 2 diabetes. Frequent CBG testing is essential to guide management of gestational diabetes (31Hawkins J.S. Casey B.M. Lo J.Y. et al.Weekly compared with daily blood glucose monitoring in women with diet-treated gestational diabetes.Obstet Gynecol. 2009; 113: 1307-1312Crossref PubMed Scopus (34) Google Scholar). Both fasting and postprandial testing are recommended to guide therapy in order to improve fetal outcomes (32de Veciana M. Major C.A. Morgan M.A. et al.Postprandial versus preprandial blood glucose monitoring in women with gestational diabetes mellitus requiring insulin therapy.N Engl J Med. 1995; 333: 1237-1241Crossref PubMed Scopus (520) Google Scholar). In a randomized trial of 293 women with newly diagnosed gestational diabetes, after 1 week of daily CBG testing (4 times per day: fasting and 2 hours postprandial), women who did not require pharmacotherapy were randomized to testing (4 times per day), either daily or every other day (33Mendez-Figueroa H. Schuster M. Maggio L. et al.Gestational diabetes mellitus and frequency of blood glucose monitoring.Obstetrics and Gynecology. 2017; 130: 163-170Crossref PubMed Scopus (14) Google Scholar). The alternate day approach was non-inferior for birthweight and there were no differences in the need for medical therapy, gestational age of delivery, rate of LGA or preeclampsia. Consistent use of CBG testing was found to be higher in the every-other-day group (89% compared with 92%, p=0.01). It is, therefore, reasonable to reduce testing to every other day after 1 week of testing daily, if glucose levels do not indicate the need for pharmacotherapy. There have been no new randomized trials or cohort studies using rtCGM or isCGM in women with gestational diabetes since 2018. More studies are needed to assess the benefits of rtCGM or isCGM in women with gestational diabetes. Among children and adolescents with type 1 diabetes, frequent CBG testing (4 or more tests per day) was associated with lower A1C (34Formosa N. Blood glucose monitoring in children and adolescents with type 1 diabetes mellitus.Malta Medical Journal. 2013; 25: 31-35Google Scholar,35Miller K.M. et al.Evidence of a strong association between frequency of self-monitoring of blood glucose and hemoglobin A1C levels in T1D exchange clinic registry participants.Diabetes Care. 2013 Jul; 36: 2009-2014Crossref PubMed Scopus (343) Google Scholar). In youth with type 2 diabetes on noninsulin antihyperglycemic therapy or insulin, low frequency of CBG testing was associated with higher A1C (36Weinstock R.S. Braffett B.H. McGuigan P. et al.Group, Today StudySelf-monitoring of blood glucose in youth-onset type 2 diabetes: Results from the TODAY study.Diabetes Care. 2019; 42: 903-909Crossref PubMed Scopus (5) Google Scholar). Two of 3 randomized controlled trials which included children as young as 6 years, comparing rtCGM to CBG testing, showed lower A1C and less TBR in both adults and children (7Battelino T. Phillip M. Bratina N. et al.Effect of continuous glucose monitoring on hypoglycemia in type 1 diabetes.Diabetes Care. 2011; 34: 795-800Crossref PubMed Scopus (376) Google Scholar,9Battelino T. Conget I. Olsen B. Schütz-Fuhrmann I. Hommel E. Hoogma R. et al.The use and efficacy of continuous glucose monitoring in type 1 diabetes treated with insulin pump therapy: a randomised controlled trial.Diabetologia. 2012; 55: 3155-3162https://doi.org/10.1007/s00125-012-2708-9Crossref PubMed" @default.
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• W3200345800 title "Blood Glucose Monitoring in Adults and Children with Diabetes: Update 2021" @default.
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