Clinical insights from continuous glucose monitor use in patients living with type 1 diabetes in rural Malawi

Background:
People living with type 1 diabetes (PLWT1D) in low-resource settings face numerous barriers to achieving glycaemic targets. Use of continuous glucose monitoring (CGM) is increasing but uptake remains low in sub-Saharan Africa. In 2022, a randomised controlled trial (RCT) evaluating feasibility of CGM was conducted in Neno, Malawi. This is a retrospective sub-study examining three-month blood glucose trends from participants randomised to the CGM arm.

Methods:
This is a sub-study of a 2:1 parallel arm open randomised controlled trial to assess the feasibility and impact of CGM. Ambulatory glucose profiles (AGP) from 29 participants in the CGM arm were reviewed by clinicians. Two patient reports with AGP patterns exemplifying observed trends were identified and described in detail, and interventions were highlighted.

Results:
Time below optimal blood glucose range was highest from 12 am to 6 am: 7.0%, 6.9%, and 5.1% for months one, two, and three respectively. From baseline to endline, the average absolute value (increase or decrease) of the percentage change in total daily dose (TDD) of insulin was 11.2%. Case studies of two patients who demonstrated a positive impact of CGM are reported.

Conclusions:
CGM provided compelling insights into blood glucose trends with significant clinical implications, specifically high prevalence of overnight hypoglycaemia. The ability to monitor blood glucose levels is critical because high variability and severe hypoglycaemia increase the risk of morbidity and mortality. CGM is a tool that can enhance patient education and the ability to guide treatment decisions for patients and clinicians in low-resource settings.