Content warning, of sorts. I’m going to talk about my experience with the continuous glucose monitor I’m trying out. This will include some PG-rated body part descriptions, so if that makes you awkward to read, consider skipping this post.
It has now been a week since I started testing out the Dexcom G6 CGM. And I have a number of opinions, some of which echo what I heard from another friend using the Dexcom before, and some that confirmed the suggestion of another friend a few years back. So let me share some of it.
The first thing we should talk about is the sensor, positioning and stickiness. As I said in the previous post, their provided options for the sensor positioning are not particularly friendly. I ended up inserting it on my left side, just below the belly button, away from where I usually would inject insulin. It did not hurt at all, and it’s not particularly in the way.
Unfortunately, I’m fairly hairy and that means that the sensor has trouble sticking by itself. And because of that, it becomes a problem when taking showers, as the top side of the adhesive strip tends to detach, and I had to stick it with bandage tape. This is not a particular problem with the Libre, because my upper back arm is much less hairy and even though it can hurt a bit to take it off, it does not hurt that much.
As of today, the sensor is still in, seventh day out of ten, although it feels very precarious right now. During one of the many videos provided during the original setup, they suggest that, to makes it more stable to stick, I should be using skin adhesive. I had no idea what that was, and it was only illustrated as a drawing of a bottle. I asked my local pharmacy, and they were just as confused. Looking up on their supplier’s catalogue, they found something they could special order, and which I picked up today. It turns out to be a German skin adhesive for £15, which is designed for urinary sheaths. Be careful if you want to open the page, it has some very graphical imagery. As far as I can tell, it should be safe to use for this use case, but you would expect that Dexcom would at least provide some better adhesive themselves, or at least a sample in their introductory kit.
I will also have to point out that the bulge caused by the sensor is significantly more noticeable than the Libre, particularly if you have tight-fitting shirts, like I often do in the summer. Glad I listened to the colleague who thought it would look strange on me, back a few years ago.
Let’s now talk about the app, which I already said before was a mess to find on the store. The app itself looks bare bones — not just for the choice of few, light colours (compare to the vivid colours of LibreLink), but also due to the lack of content altogether: you get a dial that is meant to show you the current reading, as well as the direction of the reading between “up fast” and “down fast”, then a yellow-grey-red graph of the last three hours. You can rotate the phone (or expect the app to read it as a rotation despite you keeping your phone upright) to see the last 24 hours. I have not found any way to show you anything but that.
The app does have support for “sharing/following”, and it does ask you if you want to consent to data sharing. Supposedly there’s an online diabetes management site — but I have not found any link of where that is from the app. I’ll probably look that up for another post.
You’ll probably be wondering why I’m not including screenshots like I did when I reviewed the Counter Next One. The answer is that the app prevents screenshots, which means you either share your data via their own apps, or you don’t at all. Or you end up with taking a picture of one phone with another one, which I could have, but I seriously couldn’t be bothered.
The Settings menu is the only interaction you can actually spend time on, with the app. It’s an extremely rudimentary page with a list of items name-value pairs effectively. Nothing tells you which rows are clickable and which ones aren’t. There’s a second page for Alerts, and then a few more Alerts have their own settings page.
Before I move onto talking (ranting?) about alerts, let me take a moment to talk about the sensors’ lifetime display. The LibreLink app has one of the easiest-to-the-eyes implementation of the lifetime countdown. It shows as a progress bar of days once you start the sensor, and once you reach the last day, it switches to show you the progress bar for the hours. This is very well implemented and deals well with both timezone changes (I still travel quite a bit) and daylight savings time. The Dexcom G6 app shows you the time the sensor will end with no indication of which timezone is taken in.
The main feature of a CGM like this, that pushes data, rather than being polled like the Libre, is the ability to warn you of conditions that would be dangerous, like highs and lows. This is very useful particularly if you have a history of lows and you got desensitised to them. That’s not usually my problem, but I have had a few times where I got surprised by a low because I was too focused on a task, so I was actually hoping it would help me. But it might not quite be there.
First of all, you only get three thresholds: Urgent Low, Low and High. The first one cannot be changed at all:
The Urgent Low Alarm notification level and repeat setting cannot be changed or turned off. Only the sound setting can be changed.
The settings are locked at 3.1mmol/L and 30 minutes repeat, which would be fairly acceptable. Except it’s more like 10 minutes instead of 30, which is extremely annoying when you actually do get an urgent low, and you’re trying to deal with it. Particularly in the middle of the night. My best guess of why the repeat is not working is that any reading that goes up or stays stable resets the counter of warning, so a
(3.1, 3.2, 3.1) timeseries would cause two alerts 10 minutes apart.
The Low/High thresholds are used both for the graph and for the alert. If you can’t see anything wrong with this, you never had a doctor tell you to stay a little higher rather than a little lower on your blood glucose. I know, though, I’m not alone with this. In my “usual” configuration, I would consider anything below 5 as “out of range”, because I shouldn’t linger at that value too long. But I don’t want a “low” alert at that value, I would rather have an alert if I stayed at that value for over 20 minutes.
I ended up disabling the High alert, because it was too noisy even with my usual value of 12 — particularly for the same reason noted above about the timeseries problem: even when I take some fast insulin to bring the value down, there will be another alert in ten minutes because the value is volatile enough. It might sounds perfectly reasonable to anyone who has not been working with monitoring and alerting for years, but to me, that sounds like a pretty bad monitoring system.
You can tweak the alerts a little bit for overnight alerts, but you can’t turn them off entirely. Urgent Low will stay on, and that has woken me up a few nights already. Turns out I have had multiple cases of overnight mild lows (around 3.2 mmol/L), that recover themselves without me waking up. Is this good? Bad? I’m not entirely sure. I remember they used to be more pronounced years ago, and that’s why my doctor suggested me to run a little higher. The problem with those lows, is that if you try too hard to recover from them quickly, you end up with scary highs (20mmol/L and more!) in the morning. And since there’s no “I know, I just got food”, or “I know, I just got insulin” to shut up the alerts for an hour or half, you end up very frustrated at the end of the day.
There is a setting that turns on the feature called “Quick Glance”, which is a persistent notification showing you the current glucose level, and one (or two) arrows determining the trend. It also comes with a Dexcom icon, maybe out of necessity (Android apps are not my speciality), which is fairly confusing because the Dexcom logo is the same as the dial that shows the trend in the app, even though in this notification it does not move. And, most importantly, it stays green as the logo even when the reading is out of range. This is extremely annoying, as the “quick glance” to the colour, while you’re half asleep, would give you the totally wrong impression. On the bright side, the notification also has an expanded view that shows you the same 3 hours graph as the app itself would, so you rarely if ever see the app.
Finally, speaking of the app, let me bring up the fact that it appears to use an outrageous amount of memory. Since I started using the Dexcom, I end restarting Pokémon Go every time I switch between it and WhatsApp and Viber, on a Samsung S8 phone that should have enough RAM to run all of this in the background. This is fairly annoying, although not a deal breaker for me. But I wouldn’t be surprised if someone using a lower-end phone would have a problem trying to use this, and would have to pay the extra £290 (excluding VAT) for the receiver (by comparison, the Libre reader, which doubles as a standard glucometer – including support for β-ketone sticks – costs £58 including VAT).
Since I just had to look up the price of the reader, I also have paid a little more attention to the brochure they sent me when I signed up to be contacted. One of the thing it says is:
Customize alerts to the way you live your life (day vs night, week vs weekend).
The “customization” is a single schedule option, which I set up for night, as otherwise I would rarely be able to sleep without it waking me up every other night. That means you definitely cannot customize them the way you live your life. For instance, there’s nothing to help you use this meter while going to the movies: there’s no way to silence the alerts for any amount of time (some alerts are explicitly written so that Android’s Do Not Disturb do not block them!), there’s no silent-warning option, which would have been awesome together with the watch support (feel the buzz, check the watch, see a low—drink the soda, see a high—get the insulin/tablet).
A final word I will spend on the calibration. I was aware of the Dexcom at its previous generation (G5) required calibration during setup. As noted last week, this version (G6) does not require that. On the other hand, you can type in a calibration value, which I ended up doing for this particular sensor, as I was worried about the >20mmol/L readings it was showing me. Turns out they were not completely outlandish, but they were over 20% off. A fingerstick later, and a bit of calibration, seem to be enough for it to report a more in-line value.
Will I stick to the Dexcom G6 over the Libre? I seriously doubt so by now. It does not appear to match my usage patterns, it seems to be built for a different target audience, and it lacks any of the useful information and graphs that the LibreLink app provides. It also is more expensive and less nice to wear. Expect at least one more rant if I can figure out how to access my own readings on their webapp.
I suppose the FDA hasn’t let them set the volume of the “urgent low” alert to anything other than shock-inducing-would-get-a-trigger-warning-if-in-a-movie loud? Especially annoying because most times when it (hyperbole here, but only slightly) scares the %$@% out of me, I’ve already noticed that I’m low (usually while BG was still at 75, already taken glucose, and entered that glucose into the app. I’m going to jailbreak my phone and install an “app-specific volume” tweak because of this.. Also nice would be to be able to set the alarm volume to something other than system volume – but that’s Apple’s problem (hence the jailbreak tweak).