The
long-awaited FreeStyle Libre 2 has arrived in the UK, and is now available on
NHS prescription as a straightforward replacement for Libre 1.
It
has to be said that compared to all that is going on in the world of healthcare
at the dawn of 2021, this is of relatively minor importance, but it is
nevertheless good for those of us living with diabetes to have a small piece of
good news to greet the new year, and a welcome reminder that the NHS continues
to move forward and evolve policy even in the midst of the Covid-19 Pandemic, its biggest ever
challenge.
I
hope that this post can answer a few questions, give everyone living with Type
One Diabetes something realistic to look forward to in terms of improving their
well-being, and as I have always done since becoming involved in a small way
with the diabetes community, can do something to widen access to the benefits of
a small but life-changing device.
A couple
of formalities before I move on:
Firstly,
a disclaimer: I am able to review Libre 2 at this early stage having been
provided with two sensors and a reader by the manufacturers Abbott. I am one of
a number of UK users to whom this opportunity has been offered, with no strings
attached other than a requirement to disclose that fact. I have been part of
this group since early 2015, having been one of the first in the UK to use
Libre after its launch in late 2014. I was able to afford to self-fund it at
the time, and as soon as I started using it, found it to be the single
innovation which could most improve my life with diabetes. I wrote good things
about it on social media and in a blog, and was subsequently contacted by Abbott to ask if I
could feature in some promotional material, and was invited to gatherings of
people with diabetes to share knowledge and opinions across different countries.
We have never been asked to endorse or advertise Abbott's products. I have
always been acutely aware of my good fortune, and have tried to use it to help
spread the benefits of Libre as widely as possible, and that remains the case
with this latest new version.
Secondly,
a caution: the roll-out of Libre 2 is under way, but at a time when the NHS is
under extreme pressure, and it is perfectly reasonable if HCPs are unable to
prioritise requests to switch to it, or to deal with queries and concerns. If
you read on, you will see that I am very positive about it, but I am at present
unsure whether I will be able to get Libre 2 sensors on prescription straight
away. I shall ask, but with a clear expectation that I may have to be a patient
patient. Please show patience and understanding if you can't get it; it's
great, but you can live without it for a few more weeks while greater needs are
attended to.
So
what is there to say about FreeStyle Libre 2?
Well
relatively little to be honest - and that's a good thing! It's the Libre that millions
around the world have grown to know and love, but with what many saw as its
main weakness now addressed: it can warn you when you're going low or high. In that
sense, it is much closer to a “true” CGM than Libre 1 and therefore a big step
forward. And it's still free to those who meet the criteria.
The
sensors look the same, come in the same familiar yellow box with a different
name on, and are applied with the same applicator. Out of the box, it is impossible to distinguish a Libre 2 sensor from a Libre 1 one. Crucially, they cost the
same, so no CCG or doctor should have any reason to delay or refuse a switch on
cost grounds.
You
don't even need a new reader if you've been using the LibreLink phone app, but
if you want to use a reader, you do need to change it, and Abbott will swap it
free of charge. I did ask for a reader, and will explain why later in this
post...
You
don't have to set the alarms, but if you don't set at least one of low or high,
there seems little point in getting it at all! I set mine for low (it defaults
to the widely accepted 3.9) but not high, and it worked faultlessly. On my
first day using it, I started the sensor after breakfast and deliberately took
my usual dose of insulin but with a bit less to eat (be careful if you do that; I
was home all morning with others in the house!) Sure enough, my level fell and even
though I knew it was falling both by how I felt and by a few swipes, I waited
with excitement for the alarm. (I am easily amused). When it came, it was strident
and persistent:
It
would be hard to ignore or to sleep through it. A quick swipe in response to that prompt, and you immediately see what the problem is:-
So with some small satisfaction, on my first
night wearing it, I turned off the 1:30 am alarm which had been on my phone for
almost 20 years, safe in the knowledge that I would be awoken if my BG was
falling, a problem from which I have on occasions suffered, and which twice in
my early days with diabetes led to alarming (for my wife!!!) seizures. I am
pleased to say it didn't go off, and I had a good night's sleep.
PS - on the second night the alarm did go off, at 1:05, waking me and startling Mrs L. I had sort-of hoped it would, and accidentally-on purpose didn't have a bed-time snack as I normally do, despite a relatively low reading at that time. So another slightly risky induced low and it really has proved its worth.
So
yes, in that sense, a big improvement in my diabetes management: one less
hassle (that 1:30 am alarm was a minor irritant) and one less worry. FreeStyle
Libre 2 will indeed Wake me up, before I go-go too low. There you go - a
song title for this post, as always. Who needs an excuse to watch George Michael and Wham! at their 1984 best?
Any
disadvantages?
Well
basically that you still have to swipe and read to find out what the level actually
is, although self-evidently if it triggers at 3.9 or whatever, that's what your
level must be if you swipe immediately. The trend arrow (still in my view the
most important feature of Libre) tells you whether it's falling sharply or
gently, but if a low alarm sounds it would be unwise to ignore and do nothing. If you want warning before it gets that low, set it at a higher trigger level;
I am always fine at 3.9 and nowhere near needing assistance at that level, but
YDMV so others might wish to be warned before it gets that low.
Personally
I would find high alarms annoying. Highs are not immediately threatening in the
way that lows are, and I don't need a device to tell me when I'm thirsty,
blurry-eyed and generally feeling like I've got a hangover without the
pleasurable memory of a good night out. I may yet set up a high alarm, maybe at a level higher than I normally venture, for me maybe towards 20.
You
can only have alarms on one device, the one you scan first at start-up. I use
the phone app most of the time, but as I said earlier, I opted, with this first
sensor, to use a reader as the alarms device. So why did I ask for a new reader?
Two
things:
Firstly,
I find it easier and more instant than the phone app. On my phone, getting a
reading is sometimes a bit hit and miss as you try to hit the sweet spot of NFC,
whereas the reader is always very quick to pick up a reading once it's near the
sensor. I think the Libre 2 one is even better at this than its predecessor, but
mine was getting on a bit (6 years old). In the night, I want quick and instant
access, and keeping a reader by my bed makes it easy to check having barely woken
up. Moreover, I resist using a phone at night. If you're not careful, whilst
checking BG you see a message or breaking news notification that tempts you to
open it, and before you know it, you're wide awake and fretting about something
or someone. I choose to shut down my link to the outside world at bedtime and I
prefer to keep it that way if possible.
Secondly,
driving. I covered this aspect in a blog post once before (it's here) and it
launched some debate and dissent. However, when I do resume driving further
than the two miles to my local supermarket or pharmacy, I believe that Libre 2
will add another level of safety. I shall keep the reader on my dashboard where
it will warn me if I have failed to recognise a falling BG level. (I might even
set it at the proverbial “5 to drive”) and the same reasons why I avoid the
phone at night apply even more when driving. Indeed, as I said in that previous
post, to hold a phone for any reason whilst driving is illegal, whereas to hold
a Libre reader isn't (it’s not an internet-connected communication device). If
the alarm has gone off, a driver could check it with minimal disruption to
concentration whilst driving, for example on a quiet, straight road, by pulling
in if safe to do so, or dare I say on a straight and quiet motorway. No more
dangerous than eating a sweet, sipping water, glancing at the SatNav, changing
radio station or changing the heating temperature I believe.
Oh,
and one more reason? It's a tasteful shade of blue, as opposed to the black of Libre 1:
So
there you have it. Libre 2 is undoubtedly a no-brainer improvement on Libre 1,
and I would assume any current user would wish to change as soon as possible. Those
who fret about alleged inaccuracy and constantly compare Libre readings to finger
prick tests will probably still find reason to criticise it, because it's still
flash not CGM, so the same cautions about time lag between interstitial fluid
and blood glucose apply. But remember BG levels move fast at times for anyone
with T1D, so there will always be discrepancies - try pricking two different
fingers a few seconds apart and you might get a shock at how even that can
vary.
I
remain a tech-sceptic diabetic: I have never really seen reason to seek pump therapy,
let alone a looping add-on, as I find that the multiple daily injections that I
administer (often well in excess of the basic 5) are of minimal interference
with my life - barely more hassle than going to the loo. All the tech stuff
seems more trouble than it's worth and often appears for some to become more of
an absorption than the condition it purports to render easier to manage. I am famously not really very interested in diabetes, so ironically this makes me prefer MDI for now.
FreeStyle
Libre does, however, liberate us from the biggest burden and frustrating paradox of diabetes, that
inescapable reality of which I often speak: that the drug which keeps us alive
is also, in day-to-day terms, a constant threat to our wellbeing. All we need
to mitigate that threat is a still small voice to remind us when we are in danger.
I
hope that most of those who are lucky enough to have FreeStyle Libre on
prescription will experience a smooth switch to Libre 2 sooner rather than
later, and in broader terms, I hope that non-invasive monitoring will rapidly supersede
what already seems to me to be the archaic and messy practice of drawing blood
from our fingers. Basic guidance from Abbott is here:
https://www.freestylelibre.co.uk/libre/fsl2Replacement.html
In
conclusion, there are, as always, thanks and acknowledgements to be delivered:
Firstly, to the team at Abbott, who have brought to the
market a device which is both valued by patients and affordable to publicly funded
healthcare systems across the world. The company has been criticised when any
issues occur, notably with sensor supplies, and the fact of their having a monopoly
on a prescription device has been questioned, but in my experience, they have
continued to listen to feedback, and to innovate and evolve the product in
response to feedback. Libre 3, a refinement of 2, has been approved and is already
on its way in due course.
Secondly, to HCPs who have recognised the potential value
of having non-invasive monitoring available at an affordable cost to a mass
market; they were led by Professor Partha Kar, OBE, who
despite his constant claims to be “just doing his job” took on the task of
getting Libre approved by the NHS and rattled enough cages to make it happen,
driven by the interests of those whom he serves, not those for whom he works.
And finally to those patient voices who have in various ways made clear that Libre was a genuine leap forward in diabetes self-management. Libre was launched and expanded in the full glare of social media, and particularly in the early days, people only became aware of its existence through online communities. Early adopters like Laura Cleverly taught others about it through You Tube videos, and I for one first saw a Libre on the arms of friends like Abby Brown, Philippa Robilliard and Lindsay Wilson at the first GBDoc get-together in 2015. More recently, Nick Cahm did much to ensure that the NHS availability became much less of a lottery by his relentless number-crunching, and he has continued to be an authoritative voice on all matters Libre on social media.
The success of FreeStyle Libre has taught us much about the value of partnership and teamwork in healthcare. A good news story amidst very dark times.
Note:
please speak to your diabetes care team in order to initiate a change to Libre
2. If you have any questions that I haven't answered, do feel free to get in
touch via comments, or on social media.
