Nocturnal Continuous Glucose Monitoring: Accuracy and Reliability of Hypoglycemia Detection in Patients with Type 1 Diabetes at High Risk of Severe Hypoglycemia

Background: A reliable method to detect biochemical nocturnal hypoglycemia is highly needed, especially in patients with recurrent severe hypoglycemia. We evaluated reliability of nocturnal continuous glucose monitoring (CGM) in patients with type 1 diabetes at high risk of severe hypoglycemia. Patients and Methods: Seventy-two type 1 diabetes patients with recurrent severe hypoglycemia (two or more events within the last year) participated for 4 nights in blinded CGM recordings (Guardian (R) REAL-Time CGMS and Sof-Sensor (R); Medtronic MiniMed, Northridge, CA). Blood was drawn hourly from 23:00 to 07:00 h for plasma glucose (PG) measurements (gold standard). Results: Valid data were obtained in 217 nights. The sensitivity of CGM was 65% (95% confidence interval, 53-77%) below 4 mmol/L, 40% (24- 56%) below 3 mmol/L, and 17% (0-47%) below 2.2 mmol/L. PG and CGM readings correlated in the total measurement range (Spearman's rho = 0.82; P < 0.001). In the normo- and hyperglycemic ranges CGM underestimated PG by 1.1 mmol/L (0.9-1.2 mmol/L) (P < 0.001); in contrast, in the hypoglycemic range (PG < 4 mmol/L) CGM overestimated PG levels by 1.0 mmol/L (P < 0.001). The mean absolute relative differences in the hypo- (<= 3.9 mmol/L), normo- (4-9.9 mmol/L), and hyperglycemic (>= 10 mmol/L) ranges were 45% (37-53%), 23% (22-25%), and 20% (19-21%), respectively. Continuous glucose error grid analysis indicated a clinical accuracy of 56%, 99%, and 93% in the hypo-, normo-, and hyperglycemic ranges, respectively. Conclusions: The accuracy in the hypoglycemic range of nocturnal CGM data using Sof-Sensor is suboptimal in type 1 diabetes patients at high risk of severe hypoglycemia. To ensure clinical useful sensitivity in detection of nocturnal hypoglycemic episodes, an alarm threshold should not be lower than 4 mmol/L.