The first decade of continuous glucose monitoring (CGM) was relatively slow due to challenges with accuracy, burden, and cost. However, as we are now about half-way through our second decade of CGM with much higher usage, it is fair to ask the question and speculate who will be using SMBG five years from now?
In the United States, in late 2017 Medicare, the payer for the elderly and disabled, started CGM coverage for individuals receiving multiple injections of insulin. The Medicare approval occurred shortly after the Freestyle Libre and Dexcom G5 launch, and thus this improved technology could be widely by those who previously couldn’t afford it. By late 2019 our type 1 population in our academic clinic was well over 70% CGM use. Our type 2 population, with over 80% using insulin, is over 25% CGM use (and no SMBG use)
However, our clinic is not the rule either in the US or elsewhere. We still have many payers in the US who will not pay for CGM and in fact are stingy with SMBG coverage. Worldwide the increase of diabetes is outpacing what we can afford. In the recent “IDF Atlas” it is predicted that in Africa there will be a 143% increase in diabetes prevalence. Currently in low-income countries there are approximately 60 million adults with diabetes where even obtaining insulin is a struggle. In these countries, it is not realistic to think CGM will become standard when currently SMBG is often difficult to obtain.
SMBG is not going away in the next 5 years, or for that matter the next 10 years. For most people in the world, expense is the primary reason CGM can’t be a reality and SMBG, even occasional, will be the only way to monitor diabetes.