The ABCD Freestyle Libre audit confirms the transformative effect of flash glucose monitoring on the lives of people with type 1 diabetes, with significant reductions in diabetes distress, hypoglycaemia parameters, admissions due to glycaemic emergencies and HbA1c.
While these are cohort and not randomised controlled trial data, the size of the cohort – with data from almost 5,000 users – is impressive. The reduction in HbA1c alone would likely meet NICE cost-effectiveness standards, as Libre is so much cheaper than the real-time continuous glucose monitoring costs included in the cost-effectiveness analysis from NICE clinical guideline NG17. If the reduction in glycaemic emergencies is also factored in, there is a compelling cost-effectiveness case for much wider access to NHS-funded Freestyle Libre for people with type 1 diabetes.
While NHS England has mandated that clinical commissioning groups fund Libre on the basis of defined criteria, with an expectation that 20% of people with type 1 diabetes qualify, the main indication remains people needing to perform capillary blood glucose testing a minimum of eight times per day, on the grounds that the cost of Libre in this group will be offset by the reduced cost of blood glucose testing. Thus, funding in most cases remains based on a purely economic model rather than a clinical model.
These audit data indicate that we should be promoting clinically-based criteria for NHS funding with the aim of benefitting those unable to achieve target HbA1c (probably using the target of <58 mmol/mol (7.5%) to ensure cost-effectiveness) or suffering from problematic hypoglycaemia where alarmed continuous glucose monitoring is not definitely indicated from a safety perspective. Given that the National Diabetes Audit shows around 70% of people with type 1 diabetes have an HbA1c >58 mmol/mol, and that a significant proportion of those whose HbA1c is <58 mmol/mol may be struggling with problematic hypoglycaemia, there may be a strong health economic argument for making Freestyle Libre available to all people with type 1 diabetes if the gains reported from this audit are sustainable and translatable to larger cohorts.
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Attempts to achieve remission, or at least a substantial improvement in glycaemic control, should be the initial focus at type 2 diabetes diagnosis.
9 May 2024