On The Cover

Terri D’Arrigo

Continuous glucose monitoring (CGM) has come a long way since the first system, the Medtronic MiniMed CGM, was approved by FDA in 1999. Cumbersome parts have given way to sensors that are worn like a patch and convey data to apps on smartphones, and nearly all CGM systems no longer require fingerstick blood glucose calibration.

Last March FDA approved the first CGM system that does not require a prescription, the Dexcom Stelo Glucose Biosensor System. The Stelo is intended for anyone 18 years and older who does not use insulin, such as patients who manage their diabetes with oral medications and individuals without diabetes who want to better understand how diet and exercise affect their glucose levels.

Then in June FDA approved two more systems that do not require a prescription, the Abbott Lingo and the Abbott Libre Rio. The Lingo is designed for people without diabetes who are looking to improve their overall health and wellness, and the Rio is designed for adults with T2D who do not use insulin and typically manage their diabetes through lifestyle modifications. As Pharmacy Today went to press, the Rio was not yet available, but the Stelo and the Lingo were available through their manufacturers’ websites.

“Just making these systems available without a prescription is going to increase their accessibility in a much-needed way,” said Lindsey Miller, PharmD, clinical assistant professor at the University of Mississippi School of Pharmacy. “So much of the conversation about CGMs when they first came out was about how we could get them to more people.”

A need for patient education

Patient education is vital to getting the most out of a CGM system. To that end, pharmacists need to be prepared to guide patients in making decisions about CGM devices and how to use the information they provide, especially if their patients do not have diabetes and are new to monitoring glucose.

“It’s important for pharmacists to know what options are out there and what might be the best to recommend for each specific patient,” said Diana Isaacs, PharmD, BCPS, BCACP, BC–ADM, director, Education and Training in Diabetes Technology and co-director, Endocrine Disorders in Pregnancy at Cleveland Clinic Endocrinology and Metabolism Institute. “Sometimes it’s a matter of options, like the alerts the system offers, how the apps work, or how long the sensors last. But sometimes it’s about cost. If insurance covers a prescription CGM, it might cost less than buying a nonprescription one.”

Miller said that pharmacists need to be familiar with the technology from the ground up.

“Patients will need to know how the CGM works, what are the customizable ranges, even if the phone will be compatible with their device—things you may not know to discuss with patients unless you get that education yourself,” Miller said. “I had some patients I was trying to start on a CGM, and when we went to the app store, the app just wasn’t available for everyone’s phones. It’s a good thing we figured that out before we put the [sensors] on.”

Pharmacists should know how to troubleshoot tech problems, said Panteha Kelly, RPh, BCACP, assistant clinical professor of pharmacy and UCSD Diabetes Self-Management Clinic coordinator at the University of California, San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences.

“If the CGM gives you an error, how can you fix it? What would you do if the CGM just doesn’t work? How can you reach the manufacturer for them to send you another one?” she said.

Kelly added that it is critical that patients understand the difference between measurements taken with CGM systems and measurements taken with blood glucose meters.

“They may notice that the readings don’t match and want to know why,” she said. “Pharmacists can explain that blood glucose meters measure sugar that is attached to the red blood cells in one moment in time, but CGMs use interstitial fluid and give you more of a trend of glucose over time.”

Many student pharmacists learn how to use CGM systems while in pharmacy school, but pharmacists long in practice may need to be proactive in getting training for newer systems.

“The manufacturers want their sensors to be sold, so if you reach out to a company or their representatives and say that you want the training, they might be open to [providing sample systems and training],” Kelly said. She added that the manufacturers often also provide handouts to give to patients.

The nonprescription CGM systems include patient education in their accompanying apps. For example, patients who notice that their glucose is spiking can read an article in the app about how carbohydrates or stress can cause glucose to rise.

“The benefit to this education is that it can drive behavior change,” said Isaacs. “Patients might also realize they need to go to their health care providers. I can see [these CGM systems] leading to more diagnoses and hopefully better management of diabetes and glucose.”

Benefits and challenges of pharmacist-led CGM

There is evidence to suggest that pharmacistled CGM can improve outcomes in patients, at least in ambulatory care. In a review published in the November/December 2023 issue of JAPhA, researchers sought out studies that evaluated clinical outcomes or opportunities/barriers to pharmacist-driven CGM.

They found 10 studies that were conducted in the ambulatory care setting, which together showed that pharmacist-driven CGM is associated with a mean reduction in A1C of 0.47% to 1.8%, greater achievement of glycemic goals, and more time in target glycemic range.

Pharmacist-driven CGM in ambulatory care was also shown to improve patients’ health behavior, diabetes self-efficacy, and ability to manage their nutrition with respect to their diabetes.

However, the researchers only found one study that evaluated pharmacist-driven CGM in a community pharmacy setting, even though community pharmacies are where most CGM devices are dispensed for most patients who have insurance.

These results suggested that pharmacist-led CGM services in the community setting may improve quality of life, increase CGM device use, and promote patient empowerment, but the study was limited because of low power and a large loss to follow up.

One potential reason for the lack of research on CGM services in community pharmacies is that there are simply fewer community pharmacies that provide the services.

“A lot of that comes back to billing capability,” said Miller, who was not involved in the research. “If you’re not paid for the services, it’s harder to implement a CGM program in a systematic way where you can get good data from it.”

“Workflow is another challenge, and one of the biggest barriers we see as clinical services grow in the community pharmacy setting,” Miller added. “Workflow needs to be designed in a way that engages the patient through products and dispensing, but also allows the pharmacist time to appropriately assess, implement, and document the services with the patient.”

Then there is the question of what to do with the data CGM provides, especially for community pharmacies that are not linked to a health system or medical center.

“Who looks at it? How is it incorporated into follow-up visits?” said Isaacs. “You might be looking at the data on the person’s phone, but how do you get the data into their chart?”

Despite the challenges pharmacists may face in providing CGM services, the effort is worth it, said Miller. She recalled a patient with T2D for whom CGM had a profound effect.

“His diabetes had not been controlled for a while, but once we got him on CGM, the feedback I got from him was how empowered he felt,” Miller said. “He was excited to show me on his phone that numbers were green instead of red. He would show his readings to his kids. When he ate something, he could see how that affected his sugar and make other choices next time. He felt like he was in control of his diabetes again. It all comes back to the impact on patients.”  ■

APhA launches community pharmacy CGM certificate training program

In March 2025, APhA will launch its CGM certificate training program Clinical Implementation of Continuous Glucose Monitoring in the Community Pharmacy, an educational experience designed to equip pharmacists with the knowledge, skills, and confidence needed to perform CGM services. The program has two components: 8 hours of online didactic training and a 4-hour live program that will first be offered at the 2025 APhA Annual Meeting & Exposition in Nashville and then will be available as special offerings in the future and through APhA’s licensed partner program. Pharmacists who participate in the program must take an assessment after their study to obtain the certificate.

“This is content driven by pharmacists, put together for pharmacists by pharmacists,” said Hailey Mook, PharmD, senior manager, Custom Education at APhA. “At 12 hours total, it’s a big commitment, but it’s very flexible in the way we designed it. The mixed modality and practice resources in the program are made to fit the schedule of busy community pharmacists.”

Mook added that the program will evolve with the technology and availability of CGM.

“We update all of our education on an annual basis, and I’m sure that there will be more to learn as more devices come to the community pharmacy,” Mook said. “That could include what complementary services would be beneficial to offer and how to use the [nonprescription] CGM devices, what the workflow in the pharmacy should look like for them, and how to set up a business model for them.”

“CGM services are part of the future for community pharmacists,” said Diana Isaacs, PharmD, BCPS, BCACP, BC–ADM, who served on the program’s advisory board. “One in six adults live with diabetes, and all pharmacists have patients with diabetes come into their pharmacies.”

The didactic program has nine modules:

• Introduction to CGM.
• CGM devices.
• Evolution of CGM: Integration with insulin delivery.
• CGM targets and reports.
• Troubleshooting CGM technology.
• Medication adjustment and patient education based on CGM data.
• Billing for CGM devices and services.
• CGM business planning.
• Optimizing CGM access and efficiency.

The live program will enable pharmacists to do the following:

• Discuss an effective approach for identifying patients who may benefit from CGM services.
• Operate a variety of CGM devices appropriately.
• Identify and troubleshoot potential issues with CGM device attachment.
• Analyze CGM reports and provide clinical recommendations based on CGM data.
• Practice educating patients based on CGM data using shared decision making and motivational interviewing principles.
• Summarize CGM-related recommendations effectively for interdisciplinary providers and patients.
• Outline an implementation plan for CGM services in their pharmacy.

“The program covers everything a pharmacist needs to know, from the differences between interstitial and blood glucose all the way up to billing so pharmacists can make CGM services sustainable for their practice,” said advisory board member Lindsey Miller, PharmD. “Providing these services is another way we can show our expertise as pharmacists and counsel patients on interventions that can make a big impact on their lives. But the business part of the program will appeal to community pharmacists because that part of CGM services is much needed in that setting.”

This education was made possible by an educational grant from The Leona M. and Harry B. Helmsley Charitable Trust. For more information on the training program, visit www.pharmacist.com/Education/Certificate-Training-Programs/Clinical-Implementation-of-CGM-in-the-Community-Pharmacy. ■