What a long strange trip ….

This morning while doing our normal web surfing we came across this piece of news;

“Since earning FDA clearance for its automated glucose monitoring system in 2017, OptiScan has introduced the device to select hospitals in the U.S. and Europe. Now, the company has raised $20 million in series E financing for a broader rollout of the system and to expand its platform to measure analytes other than glucose.”

Now we must admit this news caught us slightly off guard as we didn’t know that OptiScan was still in business. It also brought back memories of the very early days of CGM for way back in the day CGM was initially pitched as tool for the ICU. Those of us with more than a few gray hairs remember talking about the Portland Protocol and how keeping an ICU patient in a tighter range got them out of the ICU sooner therefore saving payors lots of money.

Fast forward to today and CGM is now on the verge of becoming the standard for glucose measurement and has the potential to forever change how diabetes is managed. Yet back in the day companies like Dexcom didn’t have many believers. Back then only a handful of people understood CGM and its tremendous potential. Yet being a business Dexcom did what they had to do to stay alive and made CGM usage in an ICU a central theme of every presentation.

Since everything we have written is in the archives section of our web site go ahead and go back say 15 years and read about Dexcom. We weren’t talking about CGM and patients we were talking about CGM in the ICU.

Today CGM is mainly seen as a tool for insulin using patients. Everyone sees sensor augmented insulin pumps and the coming of Tyler and thinks CGM and insulin using patients go together like peanut butter and jelly. They see sophisticated insulin dosing algorithms, smartphone connectivity and apps making insulin therapy easier than ever. All of which is true however what most don’t see is how CGM will also transcend insulin using patients and move to the masses.

They look at the two most popular systems the Dexcom G6 and Abbott’s FreeStyle Libre and cannot get beyond the present. What do we hear all the time; that as great as these systems are, they still cost too much and therefore will never go beyond insulin using patients. That no non-insulin using patient, nor their healthcare team will know what to do with all this damn data. That these less intensively managed patients won’t wear a CGM no matter how easy it is to use.

This lack of vision is somewhat understandable as 20 years ago no one could see what CGM has become for insulin using patients. Yet these people better get their vision checked as for as sure as the sun rises in the east and sets in the west CGM will not just become the standard for glucose measurement it will be a valuable tool for ALL patients not just those using insulin.
Let’s look at the standard arguments one at a time;

1. The Cost is too high. To us this argument is already mute as cost is already on the way down, it just hasn’t yet reached where it needs to be so CGM is used by the masses. But that won’t be the case for much longer and it’s not a question of if costs will get low enough but when. Our best estimate is that when Dexcom launches the G7 in 2020 costs will decrease to the point where CGM is affordable for ALL patients.

2. What to do with all the damn data is also a moot point as already we have apps that do all the heavy lifting for the patient and their healthcare team. Analyzing the data isn’t the problem it’s getting the patient to act on this data that’s the problem and this too will change. To us it’s only a matter of time before patients and their healthcare provider are incentivized for better outcomes. That finally patients will have skin in the game making them more amendable to following the recommendations made by the app that analyzes the data.

3. Less intensively managed patients won’t wear a CGM. Another moot point proved by the Libre patient base which is almost 50% Type 2’s. Yet what everyone can’t grasp just yet is that non-intensively managed don’t need to wear a sensor 24x7x365, that these patients will use maybe one sensor per month. That in the non-intensive space CGM will used as a discovery and maintenance tool.

There are other factors which will also drive greater CGM adoption for ALL patients. In the not so distant future Time in Range (TIR) will become a metric that joins HbA1c as what defines good control. TIR is already making its way into the insulin using world and will eventually makes it way to all patients.

The reality is that the CGM usage we are seeing today is just the tip of the iceberg, that in the future this usage will expand beyond what we see above the water line to the much larger base unseen below the water line. Usage by insulin using patients is merely laying the foundation for what will be a massive skyscraper.

The CGM journey has been a long one that isn’t over by a long shot. What a long strange trip it’s been and will continue to be.