Episode 39: Abbott FreeStyle Libre - Accuracy, Simplicity and What's Next

Michael Skarlatos from Abbott UK Medical Affairs joins John Pemberton for the second manufacturer episode of the CGM Series. A former diabetes specialist dietitian at University Hospitals of Leicester, Michael brings real clinical experience to an honest breakdown of the FreeStyle Libre 2 Plus and 3 Plus.

This episode covers:
- Why Abbott accuracy data qualifies these sensors for insulin dosing: ICGM approved, 20/20 performance ~95-96%, outside-40/40 error rate 0.2%
- What 70% smaller means in practice: form factor, stigma, and the all-in-one applicator on Libre 3 Plus
- Pump integrations now and the roadmap: CamAPS FX, Omnipod 5, and what is coming
- Libreview: why Abbott moved off Glooko and what population health management enables
- Libreview Pro in SystmOne and EMIS with SNOMED-coded CGM metrics
- A critical data nuance: glucose measured every minute on the patient app but recorded every 5 minutes in clinical downloads
- Continuous ketone monitoring: what Abbott has in development and who benefits most

CHAPTERS
00:00 Introduction and CGM Series overview
00:57 Michaels background and Leicester NHS Trust
02:25 Moving from NHS to Abbott Medical Affairs
03:27 Accuracy credentials: ICGM approval and 20/20 performance
05:44 FreeStyle Libre 3 Plus: size and form factor
09:25 Pump integrations: CamAPS FX, Omnipod 5, and the roadmap
10:19 ICGM interoperability: US vs CE marking in Europe
12:05 Fifteen-day wear period
12:28 Abbott market history: free samples and patient-led adoption
14:04 Simplicity of onboarding and multi-language support
16:58 Starter clinics: taking onboarding off the HCP
19:33 Libreview and population health management
23:21 EHR integration, SNOMED codes, and QOF implications
25:46 Practical tips: Bluetooth connectivity and the app cache
29:23 Minute-by-minute data vs five-minute trend recording
30:58 Low glucose event thresholds and hypo underreporting
31:42 Continuous ketone monitoring: what is coming from Abbott
37:52 CGM beyond type 1 and patient advocacy
40:17 Closing thoughts

LINKS
Show notes: https://theglucoseneverlies.com/episode-38-freestyle-libre-abbott/
YouTube: https://youtu.be/IW1sa5APHU8
CGM Series: https://theglucoseneverlies.com/10-13-cgm-series/
GNL Explorers: https://theglucoseneverli

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Transcript

SPEAKER_02 0:11

Welcome to the Glucose Never Lies podcast. And this is the CGM series. And this is the second manufacturer we've had come on where we've discussed in the first two episodes about the need for transparency of data, about having make sure that the CGMs are assessed in an effective way so we can trust that they've been assessed effectively and are robust enough for insulin dosing. So we obviously had DEXOM on the first session, which discussed about their product range that's available for people. And today is the second big hitter. Well, the main player, certainly within the UK and worldwide, up there with DEXCOM, is obviously the Abbott with their product range. And I'm very fortunate to be joined today from Mike from their UK medical affairs team. So Mike, do you want to introduce yourself to the audience and tell them a little bit about your background in history? Because I know you're a dietitian by trade, is that right?

SPEAKER_01 0:56

I am, yeah. Yeah. So first of all, thank you for having me on, John. This is great to be here. Um, my background is working as a diabetes specialist dietitian. I started my journey as a dietitian back in 2013 when I graduated. My first role was working out in the community in Warwick and then moved to Leicester and specialised in diabetes in 2015. And since that point, I've always enjoyed working within the area of diabetes, um, worked in providing structured education, supporting structured education, um, supported technology on boarding within the service, um, supported a team called the Eden team as well to provide healthcare professional education and supported with some of the clinical research as well within Leicester.

SPEAKER_02 1:39

Yeah, so it's a pretty robust background in terms of your working with the NHS, and I obviously know of you, but not necessarily a direct relationship when you're working at Leicester. I know the Leicester team pretty well, and obviously the Eden project is particularly well known. So obviously, you were doing good things there because Abbott have come and poached you from the the NHS and taken you into a clinical role, which is great because for me, I've been on the other side, I've worked for industry and come back for various different reasons. But from a personal perspective, to go from a almost sheltered environment in the NHS sometimes to that sort of corporate bottom line is actually a good thing for you as a person because it makes you deliver results, but it's also a different experience. So, what's it been like as a transition from you from that sort of clinical position to now working in a corporate environment?

SPEAKER_01 2:25

Yeah, well, you know, it's definitely a change that goes without saying, you know, it's a different way of working. But the nice thing I'd say about working on the other side, if you like, or working with Abbott, is it's still a way to make a difference, but from a different angle. So a lot of what I do in my role is supporting healthcare professionals, um, particularly healthcare professionals who might be new to using this technology. Uh, we support them with education, with some mentorship. And it's really nice actually to be able to use some of my clinical experience to support others who might be newer to using this sort of technology.

unknown 2:57

Cool.

SPEAKER_02 2:57

Well, I know your boss, Elmer, he's a good man. So I know he I know only pickers good people. So that's that's that's good. Um, so obviously Yeah, exactly. Um so obviously that's a bit of insluit to you because I think it's important when people come on here. Um it's important for me that when we're talking about things, people have been in the game in terms of and actually you know delivered this education to people with diabetes, they really understand the difference between um what a product is in features and what it means to people in real life. And I think you're well positioned to help us walk through and understand the the the what the Abbott you know offering has from the CGM space. But just to kind of lay the groundwork, because I know we've been through on the first couple of things with uh Othma and the DSN forum, the accuracy, I think it is worth a special note that obviously the Abbott portfolio, particularly the Freestyle Libre 2 Plus and 3 Plus, in terms of accuracy data, is right up there at the top. It has a large number of participants, it has ICGM approval from their states, which there isn't a gold standard across the world, but if there was, that's as close as there is to it. And certainly when we've discussed before about the 2020 performance, which is basically the percentage of regions you can really trust for a completely great decision. You're up at like 95-96%. And then in terms of the outside of 40-40, the ones that are going to make an error, uh, if you follow them, that's like a down at 0.2%. So in terms of an accuracy profile, it's like right up there with the best, if not the best. So I'll kind of box that off for you because we don't really want to talk about accuracy today, because the reason why you're here, the only systems that have got good enough data for insulin dosing, in my opinion, are going to make it onto the show. So we'll we'll box that off. But it is important to make that note because when a company or has gone to great lengths to ensure that their product has been tested robustly, it's important to note that for people who are listening because there are different levels of available data, and certainly from the Abbott perspective, from the Freestyle Libre to M3 Plus, it's up there with the very best. So I'll I'll do that promotion for you because I'm a big accuracy advocate. And for me, along with DEXCOM, realistically with the I mean they're they're the two absolute pinnacles in terms of the available data we've got for really understanding the risk. Real understanding the risk is extremely low, and therefore, you know, instant dosing becomes so much easier on those kind of systems. So now that that's boxed off, tell us a little bit about the profile. So we're going to talk, presumably, Freestyle Libra 2 Plus, 3 Plus is the sort of the main component. So where do you want to take it? So a bit what the situation is, people have turned up and they've gone, right? These are the accurate sensors. We're happy with that. Great. What do these individual offerings have for me as a person beyond that? Maybe it's to do with like size or length of wear or simplicity or integrations of the things. What kind of things like strike you as the most important things to discuss about either of those two? We'll we'll pick one first and then we'll go down the other one after on. So which one do you want to pick?

SPEAKER_01 5:44

Yeah, well, I guess um, okay, well, let's start with the Libra three plus, maybe for example. So Libra three plus, um, if we're pointing out the obvious visual difference, you know, it is smaller, um, about the size of a pound coin compared to a two plus, which is about the size of a uh two pound coin. Um, so it's 70% smaller, and even the size difference can make a big impact for a lot of patients. Um, you know, I'm just reflecting on.

SPEAKER_02 6:08

I was just gonna say as well, because kind of like one thing that I'd noticed, I've worn it quite a few times, is it's not just that the size and the width of it, it seems to be down on the profile, the height. And for me, that's important because the thing that annoys me the most about sensors all the time is knocking them off on door frames because I have mine on the side of my arm, but that thing never got knocked off because it was tiny. It was like it did the profile, how much it stuck up was really tiny. So that that was something I loved about it because I was never knocking it off.

SPEAKER_01 6:34

Do you know what? This reminds me actually in clinic, what I used to hear about the most with the Libra Free sensor is that when people put t-shirts on, they're much less likely to catch it because exactly like you said, it's it's uh you know, it's thinner, it's uh less bumpy. So it's um you know, it's a little bit easier for some people to wear. The other thing that stands out for me as well in regards to visibility is um, you know, I used to work in a young adult clinic, so teenagers, young people between the ages of 16 to 21, living with type 1 and sometimes type 2 diabetes, diabetes stigma plays a big part there. Um people don't always like their diabetes to be visible. So even the option of having a smaller sensor, again, made a huge difference to those individuals too. So that's obviously really, really important.

SPEAKER_02 7:14

And I guess I guess into well, just interject there, because in terms of competitors, it's always important. I I I'll do this part, you don't need to do this part because you know it's like intercelling. But you know, people listening will be like, okay, that's the smallest one, but how much smaller is it than the competitors? Well, it's definitely more than half smaller than a DEXCON G7 for a start. As you said, it's 70% smaller than the Freestyle Libre 2 offering. And in terms of the other offerings that will be on here, which will be the Rush Smart Guide, potentially in the future, the care centre and the ICANN, it's at least 50% smaller than all those. So it's basically at least half the size, if not smaller, and also profile-wise in height, at least half, you know, 50% lower. So that's quite a lot. That I mean, when I looked at it when the next iteration came, I was quite surprised at how much smaller it was. Because usually, like an improvement will come like 30%. You'd be like, oh yeah, all right, that's a bit, but it ain't much. But this was actually a form factor, it's a massive shift. There must have been some serious technology advancements to allow that to happen. Is there anything that you can share with us? Was something different with the technology that allows it to be so small?

SPEAKER_01 8:15

Yeah, I mean, so I mean it'd be great if there was an engineer here to really go into the detail, I think, for you, but um, I guess it does just come down to sort of shrinking the hardware and you know the part that uses the software as well within the sensor to make it work.

SPEAKER_02 8:29

It's like the microchips have probably got more powerful, the ability to a Bluetooth has been stronger for a smaller output, which is what you would expect as you know, however many years on. But as I've seen other products come out, I haven't seen such a big size different change. So it would be interesting. Be interesting to uh I'll try and do some investigating to find out what was it that kind of made the the huge engineering shift that allowed such a difference. And I don't know, maybe the guys don't want to give it away and give it away to the competitors, but um, yeah, we'll see that. So we've got size covered, it's definitely at least 50% smaller than the rest, a lot of low profile, very helpful for not knocking it off on door frames, and also particularly helpful for people who don't want to be as visible with their diabetes, if they got, you know, like you say, stigma, or they just don't want it to kind of be bad bambooing on the shirt and stuff. So, and you know, as we're talking with males all the time, size is a big deal, but in this case, the smaller the better. So we'll we'll take that. Absolutely. What a tag what a tagline. You can yeah, the markets department can borrow that one if you want. Um so yeah, so we've got size covered. What what yeah what else is different then with the freestyle Libre 3 in terms of the advancements and the integrations and what what it has to offer?

SPEAKER_01 9:35

Yeah, I think even with integrations, you know, there is a difference between you know the 3 Plus and the 2 Plus. So the 3 Plus, if we're thinking about pumps, for example, the 3 Plus would connect with the Ipside Med Pump and works with the Cam APS hybrid closed loop pump system. The 2 Plus works with Omnipod 5. And, you know, if over the two pumps that we are currently connected with and and work with, what I would say is from a company point of view, ABBA are working really, really hard to become, you know, hopefully the most connected sensor out there. And the reason why we want to do that, more importantly, is to provide patients with more choice. Um so we do hope that in the future, and what we're likely to see, hopefully, in the future, is more connectivity with other pump systems.

SPEAKER_02 10:18

And I know it's different in different places in the world because I'm pretty sure that Freestyle Libre 2 in the States is connected with the tandem. I believe so. And but and obviously you're there there's all sorts of whispers. I know you can't confirm these things. So I'll I'll just kind of put it out there from the ATT DMC speculation from me. But obviously, you know, you would expect the major systems like the Omnipod 5 system, the obviously the tandem, T Sling when the control IQ Plus comes and things like that. Eventually, not straight away, but eventually there will be the offering. And it's it's interesting because I have a bit of an understanding of the regulatory perspective. It's interesting, obviously, when you get a new integration in Europe, sometimes it's more difficult now because in the US you have the interoperability of ICGM, and you also then have the interoperability of the ACE pumps, which means that you don't have to kind of do as much work because we're happy with the accuracy there, we're happy with the pump, therefore they can connect together straight away, which is probably why the tandem, which is uh an ace pump, with uh the Freestyle Libre 2, which is a ICGM sensor, was very easy for them to connect over there. Whereas obviously in CE marking, there isn't that interoperability standard for them to just go, yeah, these two we're happy with, let's just connect them together. You don't need a fresh set of data, you don't need anything else because we know that these are robust. And it's just interesting that normally the states is behind on those things, but actually with that integration and that interoperability, that foresight of the regulations actually quite important because it means that when the improvements in the sensor technology come, as we're describing, they can be available to the user straight away. It's not like you've got to do another trial, another safety and efficacy when you know already it's a you know a really good system. It's it's just hopefully that will change as we go forward. But yeah, so integrations, looking to push forward obviously on those. Um so we've got the size, we've got the integrations. What other things in terms of sort of like length of use are we are we at at the moment?

SPEAKER_01 12:05

Yeah, yeah. So in terms of length of use, so the three plus and the two plus sensors have a wear period of 15 days. So, you know, users who use either or both sensors will see will be able to use uh use the gluc the sensors and see the glucose data coming through for 15 days at a time. So that means two sensors a month, which is yeah, fairly easy, I think, for most prescribers to who had to repeat prescriptions.

SPEAKER_02 12:28

Yeah, and I mean I think it's fair to say, and I this might have been before you joined Abbott, but it was very interesting at the time from a healthcare professional because remember when the Freestyle Libra One came out, and um I was I'd just gone back into clinical practice at that point. And the thing that I really liked from the beginning days, back in the good old days, was when center technology came out, it had to prove its worth by being an adjunctive system first, show that it's kind of built on the accuracy and eventually get non-adjunctive. And now obviously part of my whole thing is it's just too easy to jump through to non-adjunctive. But that by the by, but I remember when the Freestyle Libra first came out, it was kind of like, how do you approach the market? Do you go through the standard way of secondary care, or do you just go for it and like make it available, you know, kind of for patients to try for free? And if they really like it, then you know, then the pressure comes from the patients. And that's basically what happened. You know, loads of free samples were given out, the patients absolutely loved it because they scanned it, they could see the results there, and they were just like, I'm not doing these finger pricks all the time. I'm just gonna push like hell for it. And it it was a risky move in some ways from ABBA, and you won't be able to speak to that, but it was also a very important move for the people with diabetes because it gave them a an opportunity to get hold of something if they really believed in it, then push it forward, but it could also collapse at the same time. So, no risk, no reward. But I I'm I'm I'm all for that. It's just an interesting journey, and then obviously, yeah, that's led to when Freestyle Libra 2 came out on prescription, it's basically taken the market completely within FP10 or GP land, you know, over 90% of the sensors. There's obviously something with that that makes it easy for people to use. What would so what if, you know, because when I when I speak to people, it's like, why is why is the Freestyle Libra 2 such a high prescription level? And all people said it's because it's so easy to apply and use. So tell us a little bit about what the setup's like, tell us a little bit about how you know the simplicity, because presumably that's a huge part of what's made it such a success.

SPEAKER_01 14:21

Yeah, I and I I think it's kind of multifactorial, isn't it? There's so many things that that sort of fall into the answer to that question. Um but but in terms of simplicity of use, I would say um, you know, even within the packaging, there's really easy to follow pictorial information on how to apply the first sensor, and it's purposely built to make it as easy as possible, whether it's the two plus or even the three plus to make it easy to apply. Now, actually, one of the benefits of a three plus system, I suppose, is that it's all in one. Um so rather than having, you know, the sensor, which is separate, and then have yeah, having to apply the applicator, it's just all in one, which makes it so much easier and reduces plastic use as well, which is brilliant.

SPEAKER_02 14:58

It's interesting you say that because that people think, oh, it's such a small thing. But actually, for the first time, for a user, if you do something used to get the freestyle too, they even go, What do I do with this? I've got to pull and peel this off, and you kind of it's an extra layer of confusion that they don't need before they can just go, do you know what? I just turn this thing and bang it on. Like it it you can't actually get it wrong. It's almost impossible to get it wrong. But that's again, you know, as products develop, they're they're seemingly small for some people, but actually for if you're putting, I don't know, 20, 30, 40, 60,000 people on one of these devices, those time put those time points and those things actually add up as you go along. So yeah, just just interesting for me because that's you know, I've put plenty of people on a freestyle Libra too, and from parents and kids with very poor literacy and understanding, those things really count.

SPEAKER_01 15:43

And you know what, it's for that reason as well, that we've purposely tried to create different ways to help support people to what to what we call on board, so to start using this technology, you know, whether it's uh following the instructions within the packaging, whether it's following the instructions on the app, whether it's uh you know using video resources to support, to walk people through on how to set up the app, put on the first sensor, connect it and follow the those instructions and learn a little bit how to use it. But we've also tried to purposely create resources in different languages as well, because we don't just want you know people who can only speak English to access this technology, want everybody to be able to access this technology. And I guess the other thing as well, which is hopefully quite helpful to healthcare professionals, is we are trying to support healthcare professionals out there by, you know, support them with what we call starter clinics, which effectively are just clinics aimed at supporting new patients who are new to this technology, to support them in applying the first sensor, providing some education on how the sensor works and going through some basic education there and then handing back to the healthcare professional. So we'll what we're aiming to do is reduce the burden for healthcare professionals because you know we know most healthcare professionals don't have enough time as it is, you know. And like you said, even though applying a sensor should be fairly straightforward and easy, it still takes time and a consultation.

SPEAKER_02 16:58

Yeah, I mean that is that's actually a really interesting point because it's I think it's slightly different in pediatrics because pediatrics have more staff. They have like a dedicated funding stream with the the best practice tariff, that's the one. And should probably know that considering I work in pediatrics. But yeah, the best practice tariff. So that's not so much an issue. So we sometimes don't see that. But then when I speak to my adult colleagues, they're like, yeah, what we want to spend our time doing is walking through with the patients what their data is, the behavioural stuff to help them with, what their patterns are showing, etc. etc. That's where that's our skill level. That's kind of what we're doing, not really kind of there to just jockey people putting on, you know, pieces of equipment. Whereas if the company provides a support network that enables that part to be done robustly, effectively, you know, I I mean I'll be one for cutting corners all the time. I forgot to give them like the the number for the helpline and what to do for this. But if you've got someone and it's their job to do that, they'll cover that effectively, which means that when the review comes in, you can prioritize your time for there. So I think again, from a an all-round offering, that is very important. And it sounds like they'll start a clinic. So are they being taken up well, like nationally?

SPEAKER_01 18:03

Yeah, pretty well, especially in primary care. So, as we know, you know, there are more and more people who are managed by GPEs practice nurses and are starting to use this technology. And particularly in in you know, primary care. We I guess we had less time in secondary care working in a hospital, but but actually they have a very small amount of time for their consultations. So it is really supportive for them, particularly because technology is new to them in primary care. And the nice thing about it as well is it's not just, I mean, we do offer face-to-face starter clinics, but also remote as well. So you patients don't have to worry about traveling to another appointment. They can do it from the comfortability of home if that is easier for them.

SPEAKER_02 18:43

Yeah, I mean, that's that's massive because I know we where I work, we've done a couple of programmes where we did the CGM Academy face-to-face, which was great. But we require people to come in four times, four or five times, a lot of travelling, a lot of time off work. As soon as we took it virtual, the families are just like, this is so much better because we can do it after school, we can do some of the learning in our own time. Therefore, having that opportunity just to kind of you know, don't have to take days off work, don't take afternoons off work, and all of a sudden it becomes more accessible because they're not having to take time off there. So to have that offer and on both is is useful. And what's the kind of situation? Because I know that obviously the the freestyle Libre, again, a bold move, but probably in the long term a good business decision was to take uh the Libre readings out of Gluco and bring it onto their own platform for LibreView. And again, you know, kind of from a initially from a perspective of the healthcare professionals, that's frustrating because all of a sudden you had everything on one platform and now you've got to have two or three open. But it does allow you to take control of your platform and it's very notable that you can sort people by time and range on the you know in the platform, which means that if you as a clinic, you want to look at your population as a whole, you have got the ability to stratify based on what their time and range is and various different other metrics, which means if you've got a proactive service, you've got a platform that allows you to be a little bit more nimble. And also it means that if I today come to you and go, do you know what what I'd really like to see is X, Y, and Z, can you make it happen? You can make it happen if you really want to make it happen, but you can't make Gluco make it happen for you. It's it's interesting because I think from a level of boldness and a level of you know pushing things forward in the way that you believe it should be done, I think Abbott have certainly pushed the charge with that, and which frustrates some people, but I think for other people who have also got that proactive mindset, it may be a bit of annoyance at the beginning, but there are opportunities that develop themselves because of that, such as you know, like this population population health. So, what's what's it like in primary care? Because obviously secondary care, you know, diabetes, you know what timing range is, you know, all this stuff. All of a sudden they're gonna have these dashboards and they're like, here's all our patients with these numbers. Are they okay with them? Do they find it easy? What's the what's the deal?

SPEAKER_01 20:55

Yeah, great question. Um, it probably feels like right now how it felt for us back in 2017. You know, when this technology was new, when we were new to using it, um learning how to interpret the data, what that means clinically, what advice to give based on that information. So it is new. I think that it's being taken up really, really well. And, you know, it's being championed by a lot of people out there in primary care who are using it really well with their patients. And I guess I've seen really, really good results. I think one thing to say actually, and this is a big part of my role, but of course, part of my job and part of my colleagues' jobs as well, are to be out there providing support and education to primary care healthcare professionals or any healthcare professional, but particularly in primary care at the moment, where this technology is really, really new. And we offer that in different ways. So, again, it could be face to face education, it could be remote based education. We provide mentorship as well to support them when they have patients on LibreView, and are just wondering how to interpret that and you know, how to make clinical decisions based on that uh data. We can provide the education on how to interpret the data. Um, but yeah, I mean. It is starting to grow. You know, we are starting to thankfully see a lot of people who are managed out in primary care have access to this technology too, which is great. Um, and the other thing, I guess, to mention as well, which is um I guess kind of hot off the press and happening right now, but that we are integrating LibreView into electronic um record systems. So systems like System One, systems like EMIS, there is a way now for what we call LibreView Pro, which is the integrated version, to be installed within their setup of System One or EMIS. And there are a few steps to that, but the benefit really is it just again, it reduces the burden on the healthcare professional. So rather than having you know two windows open, it's just the you know, the electronic record system that's open. And they're still able to see all the same data, all the same reports that we would normally see on LibreView, um, but just seen internally within the electronic record system. And the the other added benefit, I suppose, which um I again um will start to be recognized more and more in the future, is is that the metrics, so we CGM metrics like average glucose level, um, yeah, GMI or time and range, all of those metrics are coded. So we have a snow med, what we what would they call SNOMED code. So exactly, so it's gonna be make it so much easier in the future when it comes to things like auditing, for example. Quoth points. Quaff points means money.

SPEAKER_02 23:23

Quaff points means money. Right I know this because I've got type one myself, and I get my phone call every year like you need to come in for your blood pressure, your cholesterol, your HPA1C, blah, blah, blah, blah. And I know they're obviously looking out for me, but they're also thinking, I need these ticks in this code. So when it comes to quoth point time and handing out the dollar, then you know, kind of we've got our things covered. But on a serious level, if you've already got that integration built in, and if all of a sudden metrics such as you're describing, whether it's GMI, timing range, average glucose, etc. etc., becomes recognised as counting towards quaff points, that then becomes a massive advantage to the surgeries to have more people on a certain device because ultimately it means that they'll be getting reimbursed effectively for looking after the people who they support. So I mean, I think that's like that as anything. It's your record keeping is the bane of everyone's life. If all of a sudden you've got that thing in front of you and you're able to do some sort of copy-paste function into the emiss notes or system one, whatever it is, and it's just there for you, and it saves you a few minutes here and there, that adds up a lot over a long period of time.

SPEAKER_01 24:28

Yeah, absolutely. And and the aim here is that it just speeds up the functionality for the healthcare professional too. Um, and also, I suppose importantly, when it's integrated, we want it to make a seamless process for the patient too. We want it to make it easier for them to share their data with the healthcare professional, and that information is more easily accessed.

SPEAKER_02 24:47

So we've covered size, obviously, the difference there, and obviously the freestyle Libre 2 has the same 15 days, the same level of accuracy. So, you know, from that perspective, it's great. We've got integrations of varying kinds, the Libra Freestyle Libre 2, obviously, with the Omnipod 5 system at the moment, and obviously we're thinking about the Freestyle Libre 3 with the Cam APS and some few other integrations to come as we move forward. We've talked about obviously integration with electronic um healthcare records, we've talked about simplicity of onboarding, onboarding offerings. Um, so we've covered a lot of the sort of the structural and what kind of makes it, you know, sort of unique. What are the sort of from you've picked up from either your educators, yourself, your teams internally about what how to get the best out of it? So whether it's to do with insertion tips or whether it's to do with wear tips or whether it's to do with things that you hear commonly that you kind of, you know, messages that are really working well for people that you obviously there's supposed to so much feedback coming in. There's patterns that come up of like what makes effective use. Is there anything that you can share with us from there that has been kind of passed down?

SPEAKER_01 25:53

Oh gosh, yeah, there's quite there's probably quite a lot, really. I suppose in terms of uh, you know, in terms of functionality, I guess um one top tip I guess I can possibly share that is maybe really helpful for healthcare professionals in particular to hear is that if uh you know sometimes if if patients do find up, their sensor disconnects from the app or you know, when when it's you know when they're using it. Sometimes that can be due to you know the app being closed in the background. Now, if you were to look at this, if you were to look at my phone, my phone's terrible, I never close down any apps and it drives my wife crazy. So I've got about a million apps running in the background, which would probably mean I'll be pretty good if I was using the sensor because the app will just always be running. But it's not uncommon to and I'm doing this because it's literally swiping up, isn't it? So when people swipe up to close down an app, that can sometimes um you know disconnect the Bluetooth connection between the phone and and the sensor. And I don't think um, you know, patients, people using the sensors necessarily realize that. It's not their fault, they just don't realize that causes a disconnection. But just reminding patients to keep the app open in the background is um, you know, really, really helpful. It just I guess provides a little bit more confidence as well that that connection is still working. It's just that the app needs to be running.

SPEAKER_02 27:04

Yeah, and I think a few times that we've had patients, especially if they've got a busy phone, and when I say a busy phone, they have got like so many things going on there, is that every device has a cachet, which is basically a locally stored set of data, which means that the system doesn't have to keep working so hard by keep going fetching things so it keeps it locally. But the problem is if that gets really built up, the way that I think about it is like in your immediate memory, like your short-term memory, you've got space for five or six things. And if that's completely rammed up with kind of loads of stuff going on, you're completely fried and you can't communicate very well. Whereas if that's clear, all of a sudden you kind of your thinking is clear. So you can actually clear the cachet of your phone, but it depends on the operator that you've got. You would need to contact the operator or get on Chat GPT or something. But if you go and clear that cachet in the background, you can really find that the communication between not just your your sensor, but other things that you would really like to prioritize from your phone makes a huge difference. But that's the way that I envisage it in my mind. It's like you've got a million things going on, you just can't concentrate, etc., which is basically my life. Um, so to be able to get rid of the cachet every now and then is really helpful, and it's just a top tip for any any any pump in any you know any sort of device situation. But if you're having connection problems, really think about getting the the local cachet cleared and you can find that a lot of those situations disappear. So obviously maintaining that connection and keeping that that app open. And I guess also another key thing is making sure that that app is on your front screen or on your bottom bar, so it's always there and visual and easy to see because ultimately you know you want to be checking in with that and make sure it's there. It's if it's hard to find, sometimes you can't then all of a sudden just flick it on back pretty quickly. So that's probably something as an educator or a person with diabetes when you do install it, get it on your front screen or get it on your ribbon down at the bottom. That way, then you can you know access it at the time of need fairly simply.

SPEAKER_01 28:53

Yeah, it's a really good tip, actually. Keep it on the home screen, really good idea.

SPEAKER_02 28:57

So is anything from kind of like um aware perspective? Because I know there's sort of some differences between um most of the CGMs will have an updated reading, say, every five minutes, which will then become available real time and it updates along with the um the the trend arrow, for example. What is it I know there's some slight differences of the freestyle Libra 2 and 3 in terms of availability and changing readings? What's what's the differences?

SPEAKER_01 29:23

Yeah, so uh with both sensors, you know, it monitors and measures glucose levels minute by minute. So glucose levels are measured in the interstitial fluid minute by minute, and then that glucose data is you know uploaded to and sent across to the phone or to the reader, whichever's being used, and then that that information is then available for the person to see. Now, I guess if you were to look in like the historic data, if you were to look at the daily logs, for example, for graphs that show you the data across the period of a day, that data gets recorded every five minutes. Um, and that's what creates the trend.

SPEAKER_02 29:58

So this is actually a good point, and it's an interesting one that we've had a few times. So it's pros and cons for this. The pros is as a person with diabetes, you've got a minute, nine-minute play, and you can sort of see what's going on. But what you can find, we found a few times, is the patient will come back and say, Oh, I had a 3.8 there, and it's not showing up because actually the the improved data every five minutes doesn't show that. So it's just really as a healthcare professional, because I've fallen into this. If someone comes back and tells you that they've had two or three lows, they're like, No, you haven't, it's not in your download, you can't see it. You haven't had a low, and then they've taken pictures of it on the screen and like, okay, yeah, yeah, you did. But again, the advantage is the patient gets an update every minute, but obviously the the challenge with that is sometimes from the healthcare professional there can be a disconnect. So I think it's just awareness. If your healthcare professional has awareness of that, then they'd be like, just basically trust the people with diabetes. If they said they've had a low, I think they've had one, but that will be the reason why. So it's just kind of a note for people to understand with every benefit that comes a sort of a not a challenge, but you know, just something to understand.

SPEAKER_01 30:56

I think the just to add a little bit there as well, John, I think the other consideration is low glucose events, because low glucose events, of course, are recorded when glucose levels drop below 3.9, but remain below 3.9 for 15 minutes or more. Patients will, people living with diabetes will say that they've had hypos, they've been troubled with hypose, but if they're really good at identifying it and treating it really quickly, it might not necessarily be recorded as a low glucose event. And sometimes that can get missed by healthcare professionals. And it is just simply that they might not be aware that low glucose events are being recorded under those circumstances. So, I mean, it goes back to your point. Obviously, you know, trust the patient, trust what the patients are saying and you know, looking out for where those hypodes might be happening in the daily grass might be sometimes a really good way of identifying that if it's not obvious from the low glucose events or even from the time below range.

SPEAKER_02 31:42

I don't really want to be able to speak about it too much, but I guess this is probably just to whet the appetite for people for the future. Because obviously we've discussed um the benefits of the freestyle Libra 2 and 3, obviously the range of things there, everything from form factor to integrations to making things easier, and then some top tips around sort of communication. So hopefully people have got an understanding that if they're interested in CGM, they want something small, they want something accurate, they want something simple. You know, that's why a lot of people will choose the the freestyle Libra, you know, portfolio. There's kind of like the the main situations, but obviously integrations coming in are helpful. But people are always looking into the future and kind of what's coming. And if you're at the ATTV, you wouldn't have been able to walk around without missing continuous ketone uh monitoring. Now you might not be able to speak about it too much, but what you might be able to do is kind of give us a wet of the appetite of what's kind of the environment around it, what's the what's the situation where we are with product development if you're allowed to kind of give us just an overview of of what it is and what the future might hold.

SPEAKER_01 32:42

Yeah, so um, it's really difficult. So because the product isn't released, we can't talk too much about it.

SPEAKER_02 32:48

I'll do it for you because you don't need to do this, okay. So I've got a bit of an insight because I obviously was at the ATTD, but what happens is with a company such as where Mike is in the UK, he's unable to talk about products that haven't been released yet. But I don't have that because I don't work for the company, so I can tell you. So it's great. Um so ABBA got a continuous ketone meter coming and be available at some point soon. There is some consensus sort of guidelines and some ideas around how this is going to be used. So, very similarly to your continuous glucose monitor, it's going to measure ketones continuously in the same space where it measures the glucose level. So obviously, we're going to have two signals potentially going through into a device. And I guess that'll be the interesting thing for the future is are you going to see the trace or are you just going to get an alarm at a level where you want to be taking some action, which is probably going to be the case because you wouldn't want to see just a line running in at 0.1, 0.2. It's just like a waste of time. You just want a little ping when you want to take some action. So I think there's probably enough for now. But basically, the product is like ready. Um, the validation work is ongoing. The potential benefit is individuals will be notified when their ketone level hits a certain level for a certain amount of time. Those things are probably still yet to be deciphered because probably still finding out what normally happens to people's ketone levels with type 1 diabetes over a week, over a month, over a year, and see how many times that they would have really wanted to take action and how many times they've had a false alarm. And I think that's the interesting thing for me is when that information becomes available, is who are the groups are going to benefit the most? You would think, well, the people who have DKA frequently would obviously be number one. But now we also have a lot of people going on to automated insulin delivery systems. You would think that that is going to be helpful because if the glucose level is rising and the ketones are kicking in, then you want to be taking a hit sooner, you know, a look at it sooner, especially pump therapy. Maybe not so much the injections potentially because you've got that coverage along actin insulin. And then you've got pregnancy, you've got, you know, kind of various different conditions where uh actually having ketones is really not good very acutely. Those are the kind of populations you would think that would get a real uptick in the benefit of having it. So I think that's you know, it's interesting what to come. We're moving from one measurement to two measurements, and that for some people will be great, and for other people it'll be like too much information, unless the the alarms, it's like the boy who cried wolf. If the alarms go off too many times and it's not action on, then it's like crying wolf. But if they go off when they're needed, it can be a really useful tool. So I'm looking forward to seeing where that sweet spot is moving forward. But it's it's nice for people with diabetes to know like we're kind of there with continuous glucose monitoring, and we're there with the integrations with insulin delivery and insulin only. We're kind of we've got the most out of that now with AID. What's the next thing? Is it a dual hormone? Is it kick you know, ketones for a separate analyte? What's the next frontier for people with diabetes to make their life either easier or less risky? Uh, and obviously Abbott are playing a huge part of that in terms of pushing this continuous ketone monitoring forward. Um, and I guess this space will develop over the next year, and you might be able to come back and tell us a bit more when you're not able to. You probably know load, you just sat on your hands because you're not allowed to, otherwise you'll get sacked. So that's that's all that's all good. We'll we'll get you back on when the release date is, and you can kind of give us a little bit more information on your what are the what are the levels it goes that are, what's the data saying about who's you know going to be useful for, etc. So we'll we'll pencil that one in for the future once um once Elmo lets you get out, once she lets you get out on the ketone train, we'll we'll get you back on at that point. Um is there anything that you we've we've missed? Where would people go? So if they've listened to this and thought, do you know what? I am either on CGM and I'm on a two, I want to think about a three. If I'm on another sensor, I quite like the sound of that. If I'm thinking about going onto an AID system, I want to have a look at what how this sensor works with the other ones. Where should they go to find out further information?

SPEAKER_01 36:50

Yeah, great question. So the easiest place really is the Abbott website, isn't it? So on the Abbot website, there's lots and lots of different information about both sensors, how they work, uh, even details and information on things like top-level accuracy. But also there are, you know, there's more information on other topics as well, such as, you know, if you wanted to know more around um, you know, diet and lifestyle, for example, and some tips on, you know, maybe cooking methods or different recipes. There's even a section within the website that covers that. Um, there's also the Libra Academy. So the Libra Academy is part of the, you know, you can access it through the Libra website, but there are some learning modules on there as well, which can be really, really helpful for people who are maybe newer to his technology or just want maybe some top-up information on the technology. But of course, they can also contact us. So they you'll find the customer care line number on the ABAT website. It wouldn't be too difficult also to um, you know, contact a local representative from Abbott too. He can always support and provide more information.

SPEAKER_02 37:51

Cool. Well, I mean, actually, it just crossed my mind there. I mean, obviously, my my podcast is pretty much type 1 centric, but as the guidelines have opened up for people with type 2 diabetes, CGM is now becoming a lot more available for people who are on injections of insulin. So I'm sure there's probably people who are in that space or they know someone who's in that space, that the actual the guidance is now CGM should be available, and most of the places in the UK have it. Sadly say Birmingham don't. And so if you're in Birmingham and you're not happy about that, you should definitely like kick off about that. That's that's how it happened to get the people with type 1 diabetes access to CGM. It was people with um the condition, particularly in this case type 2, and they're on injections and the national guidance is for them to have access to CGM. And you know, the the local funder, which is your ICB or integrated care board, has a certain amount of money to spend on their population, and often it's those who shout loudest to get it first. If you're not happy about that, it's no point in moaning about it, you just need to stand up and make some noise. So that's what the people with type 1 diabetes did. So if that's you with type 2, that's what you do, you make some noise. But yeah, so it's just important there, you know, it's really expanding. And, you know, there's gonna be obviously other things out into people, you know, in their pre-diabetes or healthy living space, um, the worried well, which I would classify under quite quite easily. Um, you know, kind of people who uh are interested in biohacking and biometrics and stuff. So, you know, these technologies are gonna become part of daily life, like step counters, heart rates, etc. But it's important that the technologies that do do that are of the highest quality. I think it's you know it's fair to say what we cut off at the beginning, Abbott belongs in that category. So um, yeah, I just want to take this opportunity to say first of all, thank you for taking some time out for updating us really with kind of what the differences are between the two and the three and what the sort of the key benefits are, and really expand the knowledge on that the integrations not only with the pumps, but with the sort of uh electronic systems, with the Libra Academies, with the startup clinics, the kind of the different things that people might not be aware of, especially if you're working in the healthcare professional space, they could contact their local representative if they're under the pump and struggling to onboard people. Well, that could be taken off them and they could just deal with the bits that makes them, you know, that they enjoy doing the most and makes it, you know, the the most out of their time for their particular trust as well. So is there anything you want to leave the listeners with, or are you kind of just happy to sign off?

SPEAKER_01 40:17

Um, I guess all I would say is the future is bright. Sounds like a bit of a cliche, doesn't it? But there's a lot um a lot of innovation happening. And, you know, I I think particularly within ABBA, um, you know, the beauty of working with BABA is we get a bit of a glimpse into uh what's to come and what's what's being worked on. And there is a lot of innovation happening to hopefully make lives easier for people that live with diabetes. So um, yeah, thank you for having me, John. I'd love to come back and talk more about that in the future. But um for now, thank you very much.

SPEAKER_02 40:46

Well, on that note, I'll close us off and then I'll ask you the real questions once we're off air and I'll find out what's going on. So but no, I really do appreciate your time, and I'm sure that the listeners who have um checked this out will be clear on what the offerings is, know where to go, and understand that you know the the offering that the Freestyle Libre 2 and 3 Plus have, accurate, simple, small, you know, does what it says on the tin and is a really good option to helping people support management with their you know their daily life. So that's the step and one done. It'll be on to the uh the next one next time. But yeah, again, really appreciate your time and thanks for listening, and we'll uh we'll catch up soon. So much. Thank you, everyone.