b'Servicemembers With Uncontrolled Diabetes Allowed to Remain In Militaryhypoglycemic unawareness; history ofFigure 2 HbA1c before and after deployment. Data represent mean recurrent,unexplained,severehypo- HbA1c +/ SD. . glycemicevents(i.e.,bloodglucose less than 50 mg/dl), history of recurrent episodesofketoacidosis,hospitaliza-tionsforuncontrolledglucoselevels and frequent nocturnal hypoglycemia.Withproperdocumentation,the devices can be used in pregnant women withpoorlycontrolleddiabetesor gestationaldiabetes,accordingtothe health system.The previous TRICARE criteria for CGMswasmuchmorerestrictive,Source: Mil Med, Volume 185, Issue 3-4, March-April 2020, Pages 486492, https://doi.org/10.1093/milmed/usz311generally limiting their use to Type 1 diabetics who demonstrate significant A history of recurrent, unexplained,time patients were in hypoglycemia by difficultyregulatingtheirglucosesevere hypoglycemic events or50% over 12 months, even as backup levels and demonstrate severe conse- hypoglycemic unawareness (i.e.,self-monitoredbloodglucosetesting quencesforout-of-rangebloodglu- blood glucose less than 50 mg/dl); declined from nearly four times a day cose levels. First established in 2008, A history of recurrent episodes ofto 0.2 times per day. 3when the devices were bulky and notketoacidosis; Thegreateraccuracyofthelatest particularlyreliable,thepolicyhadgenerationofCGMshasreducedorHospitalizations for uncontrolled1 no significant updates for more thanMil Med, Volume 185, Issue 3-4, March-April 2020, Pages 486492, https://doi.org/10.1093/milmed/usz31 forverification eliminatedtheneedglucose levels; ora decade. The content of this slide may be subject to copyright: please see the slide notes for details. of results with glucometer readings or According to the policy, only Type 1 Frequent nocturnal hypoglycemia. frequent calibration by patients. As a diabetics were allowed to use a CGMA real-world study presented at theresult, the FDA has approved several for up to 72 hours on an intermittentAmericanDiabetesAssociation78 th devices that eliminate the need for fin-basis, not more than six times per year,ScientificSessionsin2018summerger sticks entirely.if their physician documented: foundthatindividualswithType11Folaron I, True MW, Kazanis WH, WardianGlycosylated hemoglobin leveldiabeteswhousedCGMshadbet- JL, et. Al. Diabetes by Air, Land, and Sea: (HBA1c) is greater than 9.0% orterglycemiccontrol,spentlongerEffect of Deployments on HbA1c and BMI. less than 4.0%; time in range and had lower risk forMilitary Medicine, Volume 185, Issue 3-4, History of unexplained largehypoglycemia than those who used aMarch-April 2020, Pages 486-92, https://doi.fluctuations in daily glucose valuestraditional glucometer. Patients usingorg/10.1093/milmed/usz311.before meals (greater than 150 mg/dl); a CGM had a mean HbA1c of 7.5%2 Munshi M, Toschi E, Slyne C, et al. Use comparedto8.5%fortheglucom- of real time continuous glucose monitoringHistory of early morningeter users. Two-thirds of those using(CGM) in real life clinical practice compared fasting hyperglycemia (dawnthe traditional finger stick method ofwith finger-stick glucose monitoring. Poster phenomenon); presentation at: ADA 2018 78th Scientific Ses- History of severe glycemicmonitoringexperiencedoneormoresions; June 22-26, 2018; Orlando, FL. Poster excursions; or clinically significant episode of hypo- 959.glycemia, nearly twice the rate seen in3Haak T, Hanaire H, Ajjan R, Hermanns N,Hypoglycemic unawareness. those using a CGM. 2 Riveline JP, Rayman G. Use of flash glucose-Use of a CGM for more than 72 hoursPatients with Type 2 diabetes achievedsensing technology for 12 months as a oronacontinuousorperiodicbasissimilar benefits. A study in 139 patientsreplacement for blood glucose monitoring in may be covered for patients who meetwith Type 2 diabetes on intensive insu- insulin-treated Type 2 diabetes. Diabetes Ther. the above criteria and have documenta- lin therapy determined that use of fac- 2017;8:573-586.tion showing: tory-calibrated, flash CGM reduced the 2020 COMPENDIUM OF FEDERAL MEDICINE 71'