# Updates to NICE guidance for CGM



## nekromantik (Feb 12, 2022)

hello
in November the guidance to NICE for CGM funding on NHS was changed to make it easier to get one.
anyone in a CCG that has agreed to give them one?


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## Bruce Stephens (Feb 12, 2022)

nekromantik said:


> in November the guidance to NICE for CGM funding on NHS was changed to make it easier to get one.


The proposed updates were published for consultation but I don't think that's finished yet. (I seem to remember April being the expected time.)


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## nekromantik (Feb 12, 2022)

Bruce Stephens said:


> The proposed updates were published for consultation but I don't think that's finished yet. (I seem to remember April being the expected time.)


Ah did not know that.
So that means if its updated in April then CCGs wont apply it until June/July time maybe


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## Bruce Stephens (Feb 13, 2022)

nekromantik said:


> So that means if its updated in April then CCGs wont apply it until June/July time maybe


I don't know how long it'll take, but I'd guess June/July would be the earliest. I imagine the fastest part will be opening Libre 2 to those that don't currently have it (still around 40%, I think).


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## nekromantik (Feb 13, 2022)

Bruce Stephens said:


> I don't know how long it'll take, but I'd guess June/July would be the earliest. I imagine the fastest part will be opening Libre 2 to those that don't currently have it (still around 40%, I think).


i currently self fund Dexcom as I wanted real time CGM so wont be interested in Libre 2.
however in middle of house purchase as first time buyer so not sure how long I can keep self funding for haha
Libre 3 I would not mind going onto as its real time also.


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## helli (Feb 13, 2022)

nekromantik said:


> I currently self fund Dexcom as I wanted real time CGM so wont be interested in Libre 2.


As regularly mentioned, Libre 2 can be made to be a CGM with apps such as Diabox and xDrip. So don't discount it for it's lack of functionality compared to Dexcom if it is offered on prescription.


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## nekromantik (Feb 13, 2022)

helli said:


> As regularly mentioned, Libre 2 can be made to be a CGM with apps such as Diabox and xDrip. So don't discount it for it's lack of functionality compared to Dexcom if it is offered on prescription.


Would that be as accurate as Dexcom? Is the bubble mini purchased once or do you have to replace it every x days?


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## helli (Feb 13, 2022)

nekromantik said:


> Would that be as accurate as Dexcom? Is the bubble mini purchased once or do you have to replace it every x days?


We are all different. I had a trial of Dexcom and found it less accurate than Libre 2 with xDrip.
XDrip allows you to calibrate the ISR to BG algorithm making it (for me) more accurate than native LibreLink app.
And, with Libre 2, there is no need for a Bubble, Miaomiao or any other transmitter because Libre 2 sensors send the readings to the app via Bluetooth and the app determines whether the alarm threshold has been breached.
The "hacks" hijack the Bluetooth signal from the sensor.


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## Pumper_Sue (Feb 13, 2022)

nekromantik said:


> Ah did not know that.
> So that means if its updated in April then CCGs wont apply it until June/July time maybe


Wake up you are dreaming again  It's guidance only which I suspect the CCG's will point out on more than one occasion.
Seeing pigs fly would be a bigger probability than getting a CGM out of my CCG


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## everydayupsanddowns (Feb 13, 2022)

Pumper_Sue said:


> Wake up you are dreaming again  It's guidance only which I suspect the CCG's will point out on more than one occasion.
> Seeing pigs fly would be a bigger probability than getting a CGM out of my CCG



Well, perhaps a little strong  but it will certainly be interesting to see how CCGs in different parts of the country react to the new recommendations.

I can remember when libre went on the list of prescribable items initially - but almost none were prescribed until a lot of work was done and the whole allocations of budgets from NHS England was altered!

But yes, as Sue says, there will not be a statutory requirement for the bean counters to provide funding. I am cautiously optmistic that it will help though - at least the evidence of cost effectiveness / health economics has now been evaluated in CGM’s favour, which wasn’t the case with studies published up to 2015. That can only be a good thing IMO


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## nonethewiser (Feb 13, 2022)

everydayupsanddowns said:


> at least the evidence of cost effectiveness / health economics has now been evaluated in CGMs favour, whuch wasn’t the case with studies published up to 2015. That can only be a good thing IMO



Is that so, know own control has improved greatly since getting libre, more so libre 2 with alarms. 

Tech over last decade has been amazing & long time coming, just need non evasive bg testing to come available sometime soon.


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## trophywench (Feb 13, 2022)

I gave Sue's post a thumbs up, not because I like the message but because our CCG has always been backward coming forward to embrace ANY technology that's happened since I moved here in 1998.


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## Bruce Stephens (Feb 13, 2022)

nonethewiser said:


> Is that so, know own control has improved greatly since getting libre, more so libre 2 with alarms.


Not sure the cost effectiveness assessments have been published (I haven't seen them, anyway), but (as expected) the more widespread prescribing of Libre has produced positive data on incidents of DKA and hypos needing hospital attention, and HbA1c (all reduced, on average with use of Libre). I presume it's easy to price treatments of DKA and hypos, and maybe there's some model for the benefits of HbA1c reduction. Also I presume there's data on average reductions in cost for test strips.


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## rayray119 (Feb 14, 2022)

nekromantik said:


> i currently self fund Dexcom as I wanted real time CGM so wont be interested in Libre 2.
> however in middle of house purchase as first time buyer so not sure how long I can keep self funding for haha
> Libre 3 I would not mind going onto as its real time also.


Yeah. I kept having problems with the libre and using 3rd parts apps make me a llittle bit uneasy about breaking rules so ill be interested at least at sompoint trying it and may be abble to fix if it its goes wrong. Also be interested if they lasted as there were supposed. I know I might not be able to try it.


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## nonethewiser (Feb 14, 2022)

Bruce Stephens said:


> Not sure the cost effectiveness assessments have been published (I haven't seen them, anyway), but (as expected) the more widespread prescribing of Libre has produced positive data on incidents of DKA and hypos needing hospital attention, and HbA1c (all reduced, on average with use of Libre). I presume it's easy to price treatments of DKA and hypos, and maybe there's some model for the benefits of HbA1c reduction. Also I presume there's data on average reductions in cost for test strips.



Certainly 2 version will see reduction in hypo's & dka because of alarms, dont know cost of hospital stays but sure ambulance call out is around £500.


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## Bruce Stephens (Feb 14, 2022)

nonethewiser said:


> Certainly 2 version will see reduction in hypo's & dka because of alarms, dont know cost of hospital stays but sure ambulance call out is around £500.


Yes, so it's quite easy to believe Libre is a net saving: reduce test strip usage a bit and an ambulance/paramedic bike call out once in a while. And (especially for DKA) expensive hospital visits (though I presume they're much rarer).

(I presume that was all pretty clear beforehand, too. My guess is the various costs come out of different budgets making it hard just to do the sensible thing and offer Libre to all of us.)


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## travellor (Feb 14, 2022)

nonethewiser said:


> Is that so, know own control has improved greatly since getting libre, more so libre 2 with alarms.
> 
> Tech over last decade has been amazing & long time coming, just need non evasive bg testing to come available sometime soon.



Not entirely sure on "non invasive" testing.
But I can see a nano bot technology and an injected sensor and communication to an external reader.


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## Pattidevans (Feb 14, 2022)

everydayupsanddowns said:


> But yes, as Sue says, there will not be a statutory requirement for the bean counters to provide funding. I am cautiously optmistic that it will help though - at least the evidence of cost effectiveness / health economics has now been evaluated in CGM’s favour, which wasn’t the case with studies published up to 2015. That can only be a good thing IMO


That is interesting that they are taking into account health economics when doing the studies.  I think it goes further than DKA/ambulance call outs though... the long term has to be taken into account too... blindness, amputations etc.  If all those can be avoided in addition to the ambulances/hospital visits etc. then it has to be win-win.


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## Bruce Stephens (Feb 14, 2022)

Pattidevans said:


> the long term has to be taken into account too... blindness, amputations etc.


Those are surely trickier to cost, but yes, I'd have thought reductions (on average) in HbA1c ought to be worth something. Similarly, many of us who use them find them to make life easier (to the extent that we were willing to pay for them) which also ought to be valued (in terms of reducing diabetic stress).


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## rayray119 (Feb 14, 2022)

Bruce Stephens said:


> Yes, so it's quite easy to believe Libre is a net saving: reduce test strip usage a bit and an ambulance/paramedic bike call out once in a while. And (especially for DKA) expensive hospital visits (though I presume they're much rarer).
> 
> (I presume that was all pretty clear beforehand, too. My guess is the various costs come out of different budgets making it hard just to do the sensible thing and offer Libre to all of us.)


However I offen found I needed to double check with a finger pick when I had a libre thef hadnt failed yet but because it would be hit and miss sometimes really acurte other times far out that's while they weree working.  The things inserts me about dexcom is the dropping fast alerms


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## Bruce Stephens (Feb 14, 2022)

rayray119 said:


> However I offen found I needed to double check with a finger pick when I had a libre thef hadnt failed yet but because it would be hit and miss sometimes really acurte other times far out that's while they weree working. The things inserts me about dexcom is the dropping fast alerms


Yeah, it doesn't seem to work for everyone. And some people just don't like it (find the extra information itself stressful). I can understand both.


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## rayray119 (Feb 14, 2022)

Bruce Stephens said:


> Yeah, it doesn't seem to work for everyone. And some people just don't like it (find the extra information itself stressful). I can understand both.


Yeah I'll still be interested in trying something else if opportunity came along just to see if that worked. Sometimes extra informalion is stressful and sometimes useful to know what's happening(you just can't win)


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## everydayupsanddowns (Feb 14, 2022)

Pattidevans said:


> That is interesting that they are taking into account health economics when doing the studies.  I think it goes further than DKA/ambulance call outs though... the long term has to be taken into account too... blindness, amputations etc.  If all those can be avoided in addition to the ambulances/hospital visits etc. then it has to be win-win.



Yes for the 2015 update alongside the evidence review, they undertook a completely novel piece of computer modelling which took the potential A1c improvement (based on published studies) and the risk reduction vs cost of complications treatment based on an ‘average’ T1 (using data from the National Diabetes Audit among others).

The snag was that in the published studies that met the PICO criteria (right population, intervention, comparator and outcomes), the HbA1c improvement data just weren’t that impressive  At least, not for an intervention at that price point.

Interestingly NICE aren’t just interested in survival either, they measure the quality-of-life side of things with a measure called QALY (quality adjusted life years). And the price tag for ‘cost effectively’ giving someone a whole extra year in full health is pretty hefty.


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## Pattidevans (Feb 14, 2022)

Yes, I see what you are saying Mike.


everydayupsanddowns said:


> The snag was that in the published studies that met the PICO criteria (right population, intervention, comparator and outcomes), the HbA1c improvement data just weren’t that impressive  At least, not for an intervention at that price point.


My Hba1c has actually not improved at all, but time in range has improved so much... which should reduce complications.  It's hard to quantify really.


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## rayray119 (Feb 22, 2022)

strangelly enough if i was a child it looks like I would qualify now for dexcom or likewise.


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## SaltyMermaid (Feb 23, 2022)

nekromantik said:


> hello
> in November the guidance to NICE for CGM funding on NHS was changed to make it easier to get one.
> anyone in a CCG that has agreed to give them one?


I.m pretty new to CGM .. I.ve self funded over the past 2 months.. and have asked consultant to prescribe for me .. he said his hands are tied and unless I.m type 1 ..its a no. 
I.m insulin dependent type 2. .. 
I understand the difference.. 
I'd love to come off insulin .but no matter what changes I make or what I do.. I need more and more.. 
Help a newbie (to CGM out ,) 
I.m.also in N.ireland so we are 5 yrs behind in health ..


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## rayray119 (Feb 23, 2022)

SaltyMermaid said:


> I.m pretty new to CGM .. I.ve self funded over the past 2 months.. and have asked consultant to prescribe for me .. he said his hands are tied and unless I.m type 1 ..its a no.
> I.m insulin dependent type 2. ..
> I understand the difference..
> I'd love to come off insulin .but no matter what changes I make or what I do.. I need more and more..
> ...


Wasn’t it said that flash would be available for some type 2s?


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## Bruce Stephens (Feb 23, 2022)

rayray119 said:


> Wasn’t it said that flash would be available for some type 2s?


Yes, the draft guidelines are here: https://www.nice.org.uk/guidance/indevelopment/gid-ng10264/documents


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## rayray119 (Feb 23, 2022)

Bruce Stephens said:


> Yes, the draft guidelines are here: https://www.nice.org.uk/guidance/indevelopment/gid-ng10264/documents


do you recon is it type 1s can get a choice of cgm over flash like pervoislly  implied? its only a month now that the guidelines are due to published right.


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## rayray119 (Feb 23, 2022)

howver i have trobule with docotrs and dsn understanding nice guidelines as it is, with regards to testing. i forgot bring things up with the consudents yesterday I had planed to put the the nice guidelines in fount of them.


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## Bruce Stephens (Feb 23, 2022)

rayray119 said:


> do you recon is it type 1s can get a choice of cgm over flash like pervoislly implied? its only a month now that the guidelines are due to published right.


I only know what's been published. The corresponding page for T1 is this one https://www.nice.org.uk/guidance/indevelopment/gid-ng10265/documents

The (proposed) guidance does say to offer patients a choice. The evidence review for CGM also talks a lot about patient choice being significant (see pages 36, 37).

It seems clear the intent is to offer everyone some kind of CGM (isCGM or rtCGM), and inevitably the initial default is likely to be isCGM (in the form of Libre 2). When that just doesn't work for someone I presume there'll be an attempt to find something that does.

But how all this will translate to what happens once CCGs look at the costs and clinics consider the devices they can support isn't something I can judge. (I note there's an economic report there which I found interesting. The main findings are summarised in the overall evidence review. The evidence review notes the changing landscape of what's available, meaning that rtCGM is getting cheaper and isCGM is gaining some of the same features as rtCGM.)

I still find it surprising that there's not much difference in reported quality of life between CGM and SMBG. That seems very odd to me: while some people report not liking the devices (finding data from them overwhelming), most seem to, with Partha Kar and other consultants regularly reporting patients crying with happiness when they're able to get Libre on prescription. And, of course, many of us bought (and buy) CGM devices out of our own pockets.


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## rayray119 (Feb 23, 2022)

Bruce Stephens said:


> I only know what's been published. The corresponding page for T1 is this one https://www.nice.org.uk/guidance/indevelopment/gid-ng10265/documents
> 
> The (proposed) guidance does say to offer patients a choice. The evidence review for CGM also talks a lot about patient choice being significant (see pages 36, 37).
> 
> ...


i already know that the libre wasn't working for me.


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