FreeStyle Libre system in T2D: Clinical evidence and case studies

At a virtual symposium fittingly held on World Diabetes Day, distinguished speakers Dr Eden Miller, Diabetologist, Diplomate of American Board of Obesity Medicine, Executive Director and Co-Founder, Diabetes Nation, Diabetes and Obesity Care, St. Charles Hospital Bend, Oregon, US, and Professor Alice Kong, Endocrinologist, Department of Medicine and Therapeutics, The Chinese University of Hong Kong, shared clinical evidence and case studies on the use of the FreeStyle Libre continuous glucose monitoring (CGM) system in patients with type 2 diabetes (T2D). Dr Lee Lea Im Chua, Family Physician & Director, Bedok Medical Centre, Singapore, chaired this Abbott-sponsored symposium, which was well attended by healthcare professionals from the Asia Pacific region.

A globally prevalent chronic condition, diabetes is a major cause of mortality and morbidity, leading to complications such as blindness, kidney failure, heart attacks, stroke, amputation, and premature death. T2D, the most common form of diabetes, can be prevented and managed through diet, physical activity, medication, regular screening, and treatment for complications.

“There has been a paradigm shift in the way we manage diabetes, notably, moving from physician-directed protocols to patient-centered care. We are excited to learn how technology can enable patients to participate more in their self-management,” said Chua in her opening remarks.

No more finger pricks
The FreeStyle Libre is an exciting new technology that engages, educates, and empowers patients to participate in their care. Much less intrusive than traditional blood glucose monitoring, the FreeStyle Libre eliminates the need for painful finger pricks, through the use of a small, discreet, water-resistant sensor placed on the upper arm, that automatically captures glucose readings day and night, for up to 14 days.

“The FreeStyle Libre CGM gives a complete picture, which is not captured using HbA_1c or traditional blood glucose monitoring,” Miller said. “HbA_1c is an average reading, giving a broad view of a patient’s glucose history over 2 to 3 months. It does not reflect intra- and inter-day glycaemic excursions. For example, three patients may have an A_1c of 7 percent, but the time within range may differ widely,” explained Miller. (Figure 1) The time within range – the percentage of time a diabetic patient’s blood sugar is within target values – provides more actionable information than A_1c alone and should complement A_1c. [Diabetes Care 2019;42:1593-1603]

“When assessing the ambulatory glucose profile, the aim is to increase the time in range, while decreasing the time below and above range, as well as reducing glycaemic variability,” asserted Kong.

Evidence for FreeStyle Libre in T2D
Clinical studies have shown improved outcomes associated with the use of the FreeStyle Libre system in T2D. In a retrospective, observational study, initiation of the FreeStyle Libre system reduced the mean HbA_1c by 0.8 percent at 6 months and 0.6 percent at 12 months in T2D patients on long-acting insulin and non-insulin therapy, a significant change from baseline (p<0.0001). (Figure 2) Interestingly, the non-insulin group showed a greater reduction in A_1c (0.9 percent at 6 months and 0.7 percent at 12 months) from baseline, compared with the long-acting insulin group (0.6 percent at 6 months and 0.5 percent at 12 months). [ADA* Virtual Meeting 2020, abstract 84-LB]

In another study, the use of the FreeStyle Libre system was associated with a 30 percent reduction in acute diabetes events (hyper- and hypoglycaemia) and a 13 percent reduction in all-cause hospitalizations in T2D patients without bolus insulin. (Figure 3) Acute diabetes event rates dropped from 0.071 to 0.052 events/patient year, while all-cause hospitalization rates decreased from 0.180 to 0.161 events/patient year. [ADA Virtual Meeting 2020, abstract 85-LB]

These findings proved that the FreeStyle Libre is a cost-effective and predictive, safety tool with demonstrated clinical benefits. “CGM provides an essential tool to improve patient engagement and illumination of glycaemia to healthcare providers. This enables practitioners and patients to make more informed decisions,” said Miller.

“It is a good device to educate patients with newly diagnosed T2D on what diet and lifestyle changes to adopt,” added Kong. “CGM allows the direct observation of glycaemic excursions and daily profiles, which can inform on immediate therapy decisions and lifestyle modifications.”

Considered a vital component of lifestyle modification, nutrition therapy aims to support healthy eating patterns to improve glycaemic, blood pressure, and cholesterol levels, as well as achieve body weight goals. “With a culture centered around carbohydrate-rich foods, dietary education is especially challenging for Asian diabetic patients,” commented Kong. “CGM provides data on how to adjust treatment regimen and is helpful for personalized diabetes management.”

Case sharing on FreeStyle Libre
Sharing her clinical experience with the use of FreeStyle Libre, Kong said: “One of my T2D patients in his 80s had suboptimal A_1c above 10. He assumed that the high levels were largely due to his consumption of dim sum. Surprisingly, CGM data revealed that his dinner of fish with tomatoes, which he believed to be healthy, caused even larger spikes in his glucose levels. He found that the dish contained a large amount of added sugar, and was able to adjust his diet accordingly.”

“Another patient, a 62-year-old Chinese man with T2D, dyslipidaemia, hypertension, fatty liver, and benign prostatic hypertrophy, had a long list of medications. CGM helped him to improve and control his glycaemic levels without adding more medication,” shared Kong. “For another patient, a 72-year-old Chinese man, CGM eased his fear of hypoglycaemia and gave him the confidence to use basal insulin.”

“We increasingly recognize that there is a large inter-individual variability in response to diet, exercise, and other lifestyle factors, and how these interplay with medication to impact glycaemic levels. We no longer just respond to a patient’s HbA_1c. We must actively alert our patients to stay ahead of their disease progression by incorporating their day-to-day habits,” concluded Chua.