Senzory – CGM, FGM

Jelikož se to tu opakuje stále dokola, sepsal jsem článek ohledně senzorů. Pro velkou část z Vás zde není nic nového, tak to číst ani nemusíte – ale pokud chcete, budu rád – aspoň mě opravíte, pokud tam budu mít nějakou chybu 🙂

Budu mluvit především o senzorech dostupných/hrazených v ČR, ale zmíním i zahraniční, zde oficiální cestou nedostupné.

 

Senzory jsou zařízení pro monitoring glykémie. Hodnoty měří z mezibuněčné tekutiny (v podkoží – ne ve svalu) a tak mají zpoždění oproti hodnotám z glukometru o cca 5-15 minut.

Na senzory přispívají zdravotní pojišťovny – bez ohledu na to, jestli jste na pumpě nebo perech. Metodika schvalování je napsána v tomto odkazu – začátek je o pumpách, o systémech pro kontinuální monitoraci se dočtete na spodní části první stránky a stránce druhé. Odkaz je zde: http://www.dm1.cz/wp-content/uploads/2016/11/Metodika-ostatn%C3%AD-poji%C5%A1%C5%A5ovny-1.10.16-1.pdf

nebo též metodika VZP – odkaz zde, začátek na spodní části strany 51: https://prod-publicweb-media.azureedge.net/media/Default/dokumenty/ciselniky/metodika_1000.pdf

Lékaři se někdy vymlouvají, že na senzory nemáte nárok. Často to není pravda. Jsou jasně daná kritéria a často to je mnohem spíše o vstřícnosti vašeho diabetologa.

Počet hrazených senzorů, vysílačů, přijímačů a jejich cena se různí. Je nutné neohlížet se jen na cenu – senzory od různých výrobců mají různou životnost a parametry. Aktualizované ceny lze nalézt na stránkách DiaHelpu na tomto odkazu: http://www.diahelp.cz/?page_id=5150

Dělení senzorů

Senzory se dělí na CGM = continual glucose monitoring = kontinuální monitorace glykémie (Medtronic – Enlite, Dexcom G4/G5) a FGM = flash glucose monitoring = (FreeStyle Libre). Rozdíl mezi nimi je, že u CGM vidíte data neustále aktualizovaná (perioda aktualizace automaticky po 5 minutách), zatímco u FGM vidíte data jen když provede úkon vyčtení (pokud neužijete pomocného zařízení, které tuto nevýhodu obchází).

FGM senzory:

FreeStyle Libre

V Čechách oficiálně nedostupné, přesto se poslední dobou častěji objevující. V budoucnu by se zde měly objevit oficiálně. Sliby o jejich vstupu do Čech slyšíme dlouho, leč zatím stále marně. Proto si je lidé shánějí nejčastěji v Anglii, nebo Rakousku (pozor – jsou i v Polsku, ale mají glykémii v jednotkách mg/dl)

Senzor je součástí vysílače – jakési kolečko. Zavádí se pomocí „nastřelováku“ do podkoží. Data jsou přijímána jejich přijímačem nebo mobilním telefonem s aplikací (v telefonu nutné NFC) po přiložení. Data jsou vyčtena i zpětně (archív 8 hodin), vidíte tedy nejen aktuální glykémii, ale pohyb glykémie v minulosti.

Největší nevýhodou je ona nutnost přikládání zařízení ke zjištění glykémie. Existuje řešení ve formě zařízení se jménem Bluecon. To se přidělá k vysílači a po té již automaticky odesílá data pomocí technologie bluetooth do mobilního telefonu. Velkou výhodou je absence nutnosti kalibrace. Senzor by měl být v přesnosti srovnatelný (možná i lepší) s Dexcom G5. Prvních 12 – 24 hodin je přesnost o něco nižší – než se senzor „usadí“.

Cena senzoru vychází v přepočtu na částku zhruba 1500 Kč a jeho životnost je přesně 14 dní.

Jelikož jsem toto zařízení nikdy reálně nepoužil, přikládám odkaz na web Petra Čvančara, kde najdete vyčerpávající info o tomto senzoru: https://blog.gandalf.cz/t1d-cs/senzor-freestyle-libre

CGM senzory:

Medtronic Enlite

Zde již jde o klasické kontinuální měření. Příjem probíhá buď přímo na pumpě (Minimed 640G – Enlite I), nebo může být přijímán mobilním zařízením od Apple (Enlite II) – už delší dobu je slibován přenos i do Android zařízení, ale aplikace zatím stále není dostupná. Systém nazývají Guardian Connect. Aplikace není složitá, lze nastavit úrovně alarmů.

Senzor je nastřelován pomocí „nastřelováku“ – po nastřelení probíhá „warm-up“, po kterém je uživatel vyzván ke kalibraci – další kalibrace je vyžadována vždy po 12 hodinách. K němu se připojuje vysílač. Tvarem připomíná mušličku. Vysílač je nabíjitelný pomocí jejich nabíječky. Výhoda vysílače je nízká výška, takže tolika nehrozí, že by o něj člověk zachytil. Přesto se doporučuje vysílač i senzor celý přelepit. Pro příjem na pumpě a na Apple zařízení jsou vysílače odlišné! Vysílač dostane pacient k inzulínové pumpě zdarma, ke Guardian Connect si musí pacient vysílač zakoupit (pojišťovna část přispívá, viz odkaz výše – v tabulce je i po jaké době pojišťovna přispívá).

Životnost senzoru je dle výrobce 6 dní. Životnost lze prodloužit „restartem“ – při zahlášení konce životnosti senzor odpojíte a opět připojíte k vysílači. To už ale sebou nese vyšší riziko ohledně nepřenosti měření. Nelze přesně říci, jak dlouho to lze takto provozovat, je to individuální a životnost ovlivňují i vlivy jako časté střídání glykémie a její vysoké výkyvy (vedou ke snížení životnosti). Před vypuknutím „krize“ a dočasným nedostatkem těchto senzorů na trhu (podzim 2017) byla obvyklá životnost až 14 dní, v současné době ale bývá obvykle do 10 dnů. Poslední dobou nemají Enlite dobrou reputaci – řada pacientů si stěžuje, že životnost někdy není ani garantovaných 6 dní a je nutné je reklamovat. Reklamace někdy proběhne úspěšně, někdy ne. Ve srovnání s Dexcom G5, nebo Libre jsou (podle pacientů) méně přesné.

 

Dexcom G4/G5

Přímým konkurentem Enlite jsou senzory Dexcom. Starší verze G4 lze přijímat na jejich přijímači, nebo na pumpě Animas (případně přenášet do mobilního telefonu neoficiálním (diabetickou komunitou vytvořeném) zařízením xbridge, které pomocí bluetooth přenáší data do mobilního telefonu). Novější verze G5 přenáší data přímo do oficiální aplikace od firmy Dexcom. Pracuje na zařízeních Apple i Android, ale oficiálně jen na vybraných zařízeních – viz odkaz: https://www.dexcom.com/ous-compatibility-page S originální aplikací nemám zkušenosti, takže prosím někoho, jestli by nesepsal zkušenosti do diskuze.

Senzor se do podkoží „napichuje“ pomocí – jak to popsat? – injekčního zařízení. Vypadá to děsivěji než aplikace Enlite, ale bolestivost je obdobná. Po napíchnutí senzoru se nacvakne vysílač. Po té probíhá dvouhodinový „warm-up“, kdy senzor neměří. Po jeho uplynutí je nutná dvojitá kalibrace – dvě změření glukometrem a po té vždy po 12 hodinách. První den senzor měří s o něco nižší přesností. Vysílač G4 má od výrobce garantovanou životnost půl roku. Vysílač G5 má garantovanou životnost 3 měsíce. Po uplynutí tohoto času by pacient měl vysílač vyhodit a zakoupit si nový. Lze to ale řešit neoficiální cestou – repasí. U G4 tedy po půl roce provedete výměnu baterií (případně najdete na internetu někoho šikovného, kdo to za Vás provede). U G5 lze po uplynutí třech měsíců přejít na neoficiální aplikaci pro příjem dat. Jmenuje se xDrip a s ní vysílač dokáže pracovat většinou skoro ještě další 3 měsíce (tento čas se často liší). Po té je nutné stejně jako u G4 vysílač buď vyměnit, nebo opět řešit repasi (v případě zájmu je možné mi napsat a já předám kontakt na zručného a zkušeného technika, který tuto repasi provede). Vysílače nejsou nejlevnější, pojišťovna na ně přispívá, ale i přesto jde o nemalou částku. Proto se komunita naučila provádět tyto repase a jsou zde i pokusy o úpravu ve formě opakovatelně nabíjecí verze, kterou by nebylo nutné odesílat na repasi, ale jen doma nabít.

Senzory oficiálně vydrží 7 dní, neoficiálně je životnost vyšší. Provádí se „restart“ jako u Enlite. I zde došlo v současné době ke zhoršení. Dříve nebyly vyjímečné případy, kdy senzory vydržely i 30 dní, dnes vydrží senzory většinou méně než 20 dní. Výhodou oproti Enlite (dle pacientů) je vyšší přesnost a spolehlivost. Nevýhodou je relativně vyšší finanční nákladnost a výška zařízení.

 

Závěr:

A zároveň upozornění na konec:

-pozor na paracetamol – ovlivňuje naměřené hodnoty…

-podezřelé hodnoty ověřovat vždy glukometrem – slepě nevěřit…

 

To by asi tak byl rychlý náhled do problematiky senzorů, která se tady neustále dokola objevuje. V případě zájmu třeba někdy sepíšu článek ohledně aplikace xDrip (alternativní aplikace pro příjem dat ze senzorů Dexcom), AndroidAPS (komunitou vytvořená „uzavřená smyčka“ – úprava bazálního inzulínu řízená aplikací, vzdálená správa inzulínové pumpy), NightScout (cloudové úložiště pro online sledování a správu – velmi oblíbené u rodičů – ale nejen u nich).

 

V případě nalezení chyb, nebo žádostí na úpravu dejte vědět – upravím 😉

Velmi děkuji autorovi Jimmy.Fox za možnost zveřejnění.

Autor: Jimmy Fox

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