Wide Variation in CGM Settings for Kids With Diabetes Signals Education Gaps

CHICAGO -- Kids using continuous glucose monitors (CGMs) to manage their diabetes often do not have settings in place to alert them and their caregivers about out-of-range sugar levels, suggesting possible gaps in education and onboarding, real-world data showed.

In a study that included 150 children and teenagers using CGMs for their type 1 or type 2 diabetes, a high glucose alarm was never set on 27% of the devices while 13% never set up alerts for when the lower limit had been reached and 31% had no indication when a loss of signal occurred, according to Victoria Ochs, a third-year medical student at Indiana University School of Medicine in Indianapolis.

More importantly, some never changed the default setting that comes from the manufacturer, which may lead to alarms sounding that are inappropriate for the patient and result in them ignoring the signals entirely, she said at a press conference at ENDO 2023, the annual meeting of the Endocrine Society.

Ochs gave the example of a patient who sets their high alarm at 150 mg/dL when their blood sugars are constantly running at 200 mg/dL. "They are going to get alerts all the time," she told MedPage Today, and the patient will eventually tune them out. "It's called 'alarm fatigue.' That's why it's really important to optimize the information they're getting."

The study found it was more common for patients and parents to set fewer alarms than recommended, and even when users did set alerts, they were often significantly different cutoffs from those recommended.

"Overall, the wide variability of observed alarm settings indicates likely educational gaps in continuous glucose monitoring onboarding and use," Ochs said. "This study shows that there is both the opportunity for the diabetes healthcare team to mention alarm-use best-practices during onboarding and to continue to message and work with patients and families to optimize use on an ongoing basis."

CGMs automatically track glucose levels throughout the day and night, allowing patients to see their glucose levels at a glance at any time and review how glucose changes over a few hours or days to see trends. Observing glucose levels in real time can help with making more informed decisions throughout the day about how to balance food, physical activity, and medicines, including insulin, Ochs suggested.

However, few data exist on how real-time CGM alarms are used in the pediatric population, she said.

To evaluate this, the researchers scrutinized data on 150 children using the Dexcom G6 CGM. Patients had a median age of 14 years old, a median hemoglobin A1c of 7.8%, and mean time-in-range of 47%. The researchers reviewed 2 weeks' worth of CGM reports from each participant, which included alarm settings.

Low glucose alarms were set by 131 of the patients, high glucose alarms were set by 109, and loss of signal alarms were set by 103 of the patients.

Thresholds for alerts often differed from the recommended glucose limits (250 mg/dL for high and 70 mg/dL for lower limit), Ochs said. For the higher limits, patients set alarms ranging from 120 to 400 mg/dL, while users' settings ranged from 60 to 100 mg/dL for the low glucose level alerts. And variation was seen among repeat alerts for a high glucose level (where 2 hours is recommended), with participants having repeat alerts set anywhere from 15 minutes to 3 hours.

The researchers found that patients on insulin pumps were more likely to use certain alarms more than injection patients, and found that younger study participants, specifically children 12 and under, were more likely to use a majority of the available alarms than older participants.

In commenting on the study findings, Maria Stamou, MD, PhD, of Mass General Brigham/Harvard Medical School in Boston, told MedPage Today that "clinicians have been and should continue to spend time with their patients and caregivers to review their continuous glucose monitoring data and settings and determine what causes blood sugars to go up and down during the day and night."

"It is very important to address alarm fatigue with our patients and assess each patient's needs individually by focusing on diabetes and continuous glucose monitoring/pump education," added Stamou, who was not involved in the study.

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