The Authors Respond

DISCLOSURES
No outside funding supported this study. The authors have nothing to disclose.


■■ The Authors Respond
Thank you for the letter and interest regarding our article, "Effect of Pharmacist-Driven Professional Continuous Glucose Monitoring in Adults with Uncontrolled Diabetes," published in the May 2020 issue of JMCP. 1 We appreciate the feedback and the opportunity to respond.
We agree that unblinded personal continuous glucose monitoring (CGM) is appropriate for many patients, is the future of home monitoring of glucose levels, and requires more research to promote policy and practice change to bring these services to all patients who could benefit from them. We do maintain, however, that there are many scenarios when blinded professional CGM can also be used. The main reason often cited is related to cost, as mentioned in the previous letter, since this approach can save the patient money while also providing a lucrative reimbursement potential for the clinic. 2 Some clinicians may also use it as a first step to see if a CGM-naive patient may be interested in and willing to use CGM before making the jump to personal CGM. Additionally, professional CGM can be useful for patients with low health literacy or those simply not interested in the level of education and training needed to appropriately and safely use personal CGM. Ziegler et al. (2020) mention several other justifications for intermittent use of CGM that might be applied to professional CGM. 3 Finally, we would argue that professional CGM can also be used to educate and empower patients regarding the effects of medication adherence, diet, and physical activity, although anecdotal, and can do so in a clinician-guided manner to promote safe changes and avoid dangerous glucose excursions resulting from patient-initiated changes. We do not contend the value of unblinded personal CGM, but highlight that of professional CGM.
Regarding the comment about CGM report metrics, since this study focused on CGM implementation as an intervention, rather than studying device accuracy, comparing with plasma glucose values, or exploring current glucose trends within a whom flash CGM is not well studied but used frequently in clinical practice.
However, important considerations must be mentioned in interpreting the results and should be considered in the broad sense of the need for seeking policy and practice change to allow more patients with diabetes to take advantage of flash CGM. First, the authors used professional flash CGM, which is blinded to the patient. Although this was likely driven by payer considerations, unblinded CGM is more appropriate for the vast majority of patients. Unblinded flash CGM allows for glucose data to be viewable by the patient immediately and, when combined with diabetes education, can empower patients to recognize how diet, physical activity, and medications affect glucose levels. 3 Second, the benefits to CGM monitoring include ability to assess additional glycemic metrics beyond HbA1c, such as time in range, time below and above range, glycemic variability, and magnitude and frequency of glucose fluctuations. It appears that the authors made pharmacologic and nonpharmacologic interventions based on this CGM data but did not report these as outcomes. In order to enact changes to policy, which will increase coverage of flash CGM in a broader diabetes population by payers, these metrics must be reported as clinical research outcomes in studies evaluating flash CGM.
Finally, an important limitation in assessing the intervention is lack of comparison with a clinic without a pharmacist presence. Therefore, the results should be interpreted in light of the potential bias from how a pharmacist presence can influence clinical decision making among providers. It was also not mentioned if patients in the physician group had a pharmacist involved in their care during the study time frame.
While the value of a pharmacist-driven CGM service is not being questioned, careful consideration should be given to applying these findings in practice. Investigators are urged to follow best practices in CGM outcomes reporting, which have been previously reported. 4 Prospectively, randomized studies evaluating outcomes with unblinded flash CGM in a team-based care setting involving a pharmacist are needed to demonstrate that CGM metrics can be used in clinical decision making and correlate with meaningful diabetes-related outcomes.