Continuous Glucose Monitors in Canada
Continuous Glucose Monitors (CGMs) are tremendously valuable for people living with type 1 or type 2 diabetes. We’re here to break down the products available in Canada and help you navigate which device may be right for you.
What is a CGM
CGM stands for Continuous Glucose Monitor. It is a system made up of a sensor and a receiver designed to give people with diabetes easy access to real-time information about their blood glucose levels and patterns.
There are a few different CGMs available in Canada, but they all work pretty much the same way. A CGM sensor is a small plastic device about the size of a few large coins stacked on top of each other that attaches to your body with built-in adhesive. A small flexible filament on the sensor gets inserted a few millimeters under the surface of your skin that measures glucose levels and sends readings to a receiver or phone app every 5 minutes via Bluetooth.
The CGM reader or app displays a current reading of your blood glucose, a trend arrow to show the direction your blood glucose is moving and a historical graph – all extremely valuable information for an insulin-dependent person.
Why do CGMs matter
Before CGMs, people with diabetes had to check their blood glucose by pricking their finger and depositing a drop of blood on a plastic test strip placed in a glucometer. These tests are painful, messy, and importantly only give the user a snapshot of data in that exact moment.
Understanding not just blood glucose levels but also the direction and speed blood glucose is moving helps people living with diabetes manage their nutrition, insulin dosing and exercise with vastly improved precision.
Real-time blood glucose information also helps many users discover unexpected reasons for changes in their blood glucose levels. For instance, new discoveries about how blood glucose can be impacted by drinking a cup of coffee or going for a walk after a meal become more obvious for people using CGMs. For folks living with diabetes, this knowledge is power!
The most interesting and emerging use case for using a CGM is the ability to pair it with an automated insulin pump to create an ‘artificial pancreas’ – a system of connected devices that measure blood glucose and administer insulin automatically with little or no input from the user. These systems have proven to positively impact time-in-range for many people and hold great promise for the future of people living with diabetes as this technology gets easier to use, more powerful and more accessible.
Continuous glucose monitors like Dexcom’s G6 and G7, Freestyle’s Libre 2 and Medtronic’s Guardian sensors help to reduce the burden of diabetes management by providing ‘real-time’ information about how things like foods, exercise and stress affect blood sugars without having to poke your fingers all day to get a reading.
The sensors have a flexible filament that sits just below the surface of the skin and measures blood sugars every 1 to 5 minutes. CGMs use a transmitter that sends blood sugar readings to a smartphone or insulin pump using Bluetooth transmission that does not require internet (or wi-fi).
How do CGMs work
While CGMs are famously used to measure blood glucose, they technically don’t measure the amount of glucose present in your bloodstream.
CGMs measure the glucose level in your interstitial fluid – the fluid that fills the space around your body’s cells. The glucose level in interstitial fluid is almost identical to the glucose level of your blood, so CGMs are able to produce accurate, real-time blood glucose information without the need to draw blood.
CGMs have a small, flexible teflon filament that gets inserted just below your skin. CGMs come on a spring-loaded applicator that painlessly inserts the filament and attaches the device to your skin with adhesive all in one motion. Compared to the finger-prick method of testing blood glucose, CGMs are painless, clean and convenient.
CGMs are disposable and last between 7 and 14 days (depending on the CGM system chosen) before they have to be replaced. Some sensors require a separate reusable transmitter to be attached to the sensor that streams data to the reader device or mobile app (Dexcom G6, Medtronic Guardian 4), where other devices have a disposable sensor and transmitter all in one device (Dexcom G7, Freestyle Libre 2).
Sensors work best when they are attached to the soft, fatty tissue on the back of the arm, the abdomen, outer thigh, lower back or upper buttocks. Each user decides where to place the sensor on their own body based on comfort, preference and accuracy/effectiveness. The back of the arm typically provides the highest level of accuracy.
Are CGMs Accurate
Being able to access blood glucose information in real time is incredibly useful; however CGMs are only as useful as they are accurate, and they certainly aren’t perfect.
However, CGMs have become much more accurate as the technology has advanced and matured over the last decade. Today’s CGMs are reported to be accurate within 7 to 15% of the true value of blood glucose at any given time; however, CGM users need to be aware of a number of factors that may interfere with the accuracy of their device:
- CGMs may become less accurate when blood glucose is low (below 3.8 mmol/L)
- CGM accuracy may be affected by pressure or sleeping position
- Accuracy may be different if the sensor is placed on different areas of the body (e.g., arm vs abdomen)
- CGM data usually lags true blood glucose levels by up to 10-20 minutes, so your CGM could be showing a low number even when your blood glucose is rising
- Some generations of CGM systems may be affected by large doses of vitamin C and/or Tylenol (acetaminophen)
It is also important to note that individual sensors can be faulty and give off highly inaccurate readings. CGM manufacturers frequently caution users to check their blood glucose with a finger-prick device if how they feel does not match what their sensor is reading before administering insulin.
In Canada, blood glucose is measured in millimoles per liter (mmol/L), which is a common measurement used for chemicals. In the US, it is measured in milligrams per deciliter. CGMs have the ability to toggle the unit of measurement from mmol/L to mg/dl. For Canadians who ever want to convert a blood glucose number from the US measurement, the conversion math is approximately X mg/dl divided by 18.
How and where to get a CGM
CGMs are available for purchase without a prescription in Canada, but they are most commonly purchased with a prescription which enables the customer to submit the cost for reimbursement from their insurance company.
Some CGMs are available behind the counter at many local pharmacies:
- Freestyle Libre
- Freestyle Libre 2
- Dexcom G7
Other sensors are mostly only available purchased directly from the manufacturer or from specialty suppliers:
- Dexcom G6
- Medtronic Guardian 3 and 4
All devices available in the Canadian market are available for purchase via the Endor Health app, either through the shop or through prescription.
In the USA, CGMs are only available to be purchased with a prescription. Dexcom (Stelo) and Abbott have both recently announced the launch of CGMs aimed at the type 2 or pre-diabetes populations that will be available for purchase without a prescription.
Insurance Coverage
For people with type 1 diabetes, CGMs are covered under most provincial and private health benefit plans (e.g., employee benefits). Depending on your coverage, the cost of the device may be subject to coinsurance (e.g., co-pay), a deductible or annual maximum. Check with your provider to confirm your plan details. There is government funding available for rtCGM through the Assistive Devices Program (ADP), but the criteria is restrictive. Check with your healthcare provider to see if you qualify.
For people with type 2 diabetes, insurance coverage is much less common. Most provinces do not cover CGMs unless the individual is on intensive insulin therapy (long and fast acting insulins) and meets specific criteria. Federal coverage for CGMs is available through NIHB (Non-insured health benefits for First Nations and Inuit) for any individual taking insulin.
Why do payers treat the diabetic types so differently?
People with type 1 diabetes are insulin dependent and are at risk of both hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose). Both represent significant health risks, but hypoglycemia is unpredictable and presents a much more immediate, sometimes life-threatening risk on a minute-to-minute basis. A person with type 1 who is unaware of low blood glucose could become confused, disoriented or lose consciousness which generally would not happen to the type 2 population.
There is a movement toward making diabetes management technologies like pumps and CGMs available to people with type 2 who are on multiple daily injections, but are not qualified for current funding programs
Here is a summary of public health coverage for CGMs for major population areas:
Ontario
- Type 1 Diabetes: Covered under the Ontario Drug Benefit Program, and for those who meet certain criteria under the Assistive Devices Program (ADP).
- Type 2 Diabetes: Generally not covered unless on intensive insulin therapy and meeting specific criteria (using both long and fast acting insulins).
British Columbia
- Type 1 Diabetes: Covered under the BC PharmaCare program.
- Type 2 Diabetes: Not typically covered unless under exceptional circumstances.
Alberta
- Type 1 Diabetes: Covered under the Alberta Insulin Pump Therapy Program.
- Type 2 Diabetes: Not typically covered, may be considered case-by-case.
Quebec
- Type 1 Diabetes: Covered under the Régie de l’assurance maladie du Québec (RAMQ).
- Type 2 Diabetes: Limited coverage, generally not included.
Other Provinces and Territories
- Type 1 Diabetes: Varies by province, generally more likely to have some coverage.
- Type 2 Diabetes: Coverage is rare and typically not included.
Use by non-diabetic population
Until recently, CGMs were worn exclusively by people with diabetes. In the last few years, there has been a growing trend of CGM use amongst people who are metabolically healthy but also highly health-conscious people.
While approximately 10% of the North American population lives with diabetes, up to 33% of the population would qualify as prediabetic; meaning their HbA1c is somewhere between 5.7% and 6.4%.
Elevated glucose levels – even at the prediabetes level – have been associated with increased risk of health complications like cardiovascular disease and stroke. With growing interest in longevity as well as increased awareness of pre-diabetes, many individuals have taken to using CGMs to understand the impact of food on their blood glucose even though they don’t live with diabetes.
In the US where CGMs are difficult to access without a prescription, standalone companies like Levels and Superhuman have launched to help non-diabetic individuals access this technology and interpret the results.
Many people from the diabetes community are supportive of CGM adoption by the non-diabetic population because it encourages better metabolic health, it normalizes use of the device and helps to reduce the stigma of being seen with one. Others have been more critical and believe that CGM use outside diabetes makes it harder for people with diabetes to access the product, or that it trivializes use of a device that many people with diabetes wish they didn’t depend on for survival.
Device Guide
All CGMs in Canada come from one of three brands: Freestyle Libre (by Abbott), Dexcom, and Medtronic. Each sells a few different generations of device, similar to how you can buy an iPhone 13, 14 or 15 from your telecom provider.
We’ve divided the devices into categories to help you understand how the different generations stack up and the pros and cons of each. In the ‘state of the art’ generation, only the Dexcom G7 is available at the time of writing but we expect the others (like the Freestyle Libre 3) to become available in Canada in late 2024 or early 2025.
The State of the Art
Dexcom G7
Available in Canada: Yes
Sensor Cost: $89.99 per sensor from Endor Health
Monthly Cost: $269.97 (get 20% covered by Dexcom’s Patient Support Program via Endor Health)
Sensor Lasts: 10 days
Dexcom is considered to be the leading brand in the CGM market, with their G5 and G6 sensors pushing the technology forward in terms of accuracy and connectivity. Dexcom’s G7 sensor was launched in late 2023 in Canada and offers a number of improvements over prior generations.
With the G7, Dexcom has removed a lot of friction or barriers to wide adoption. It is now more widely available through pharmacies instead of direct from the company, it is cheaper to buy and more simple to apply and use.
What we love
- Less expensive than the Dexcom G6
- Smallest sensor available in Canada (until Libre 3 arrives)
- No separate transmitter required
- Much improved mobile app
- One-step application with intuitive device synchronization
- Fastest warmup time in the market at just 26 minutes
- Most accurate CGM in the market (until Libre 3 arrives)
- Apple watch integration for displaying blood glucose on your wrist
- Dexcom currently offers a patient support program that covers up to 20% of the cost of a sensor for people with prescription
Potential Downsides
- Sensors last 10 days compared to 14 days for the Freestyle Libre 2
- Does not yet integrate with any pumps in Health Canada approved method, though this expected to change this fall when the integration with Tandem t:slim is made broadly available
- Blood glucose data sent to reader every 5 minutes instead of every 1 minute for Freestyle Libre 2
Verdict
The Dexcom G7 has few weaknesses and represents the best combination of features, usability and value in the Canadian market at this time of writing. Pump users are eagerly awaiting pump integrations with this device.
Freestyle Libre 3
Available in Canada: No date yet, but it was approved July 2023 by Health Canada
Sensor Cost: Not available yet
Monthly Cost: Not available yet
Sensor Lasts: 14 days
The Freestyle Libre 3 was approved by Health Canada in 2023 but has not launched in the Canadian market. When it arrives, we expect it to maintain the popularity of the Libre 2 device and become a top choice for many segments of the population – specifically those who administer insulin manually or manage diabetes with diet. Most automated pump companies will be looking to quickly build integration into their insulin pump algorithms to be compatible with the Libre 3.
What we love
- Very small and discrete – the Libre 3 is the size of two pennies stacked together
- Continues with real-time streaming to your device which was a crucial update to the Libre 2 via software patch
- Market-leading accuracy
- Sensors last 14 days, so users have to change devices less frequently
- Sends data every 1 minute to your reader, which is the fastest in the market and gives the user the most up-to-date information about their blood glucose
- Maintains 14 days of blood glucose data on the sensor itself, a huge improvement over 8 hours for the Libre 2
- We expect it to remain relatively cost competitive and simple to use
Potential Downsides
- Not available in Canada yet, and no word on when it will be
- Not an option for pump users or loopers. Libre 2 did not offer connectivity to any insulin pumps available in Canada, and as of writing the Libre 3 does not connect with pumps either
- The mobile app lacks some customization and data compared to Dexcom
Verdict
The Freestyle Libre 3 is very small, very accurate and is a fantastic choice for people who manage diabetes without a pump. It works mostly the same as the Freestyle Libre 2 but with improved attributes, and we expect it to be a popular choice.
Medtronic Guardian 4
Available in Canada: Summer 2024
Transmitter Cost: included
Sensor Cost: $390
Monthly Cost: $390
Sensor Lasts: 7 days
Medtronic is a leading brand in the diabetes technology market. Their 780G insulin pump is a leader in automated insulin delivery, and the Guardian series of CGMs offers connectivity to these pumps that can vastly improve time-in-range and quality of life for insulin-dependent people.
The Guardian sensors have historically been mostly popular with people using Medtronic pumps and less so with the broader population. The Guardian 4 offers some improvement over the Guardian 3, namely eliminating the need for multiple finger-prick calibrations per day.
What we love
- Connectivity with Medtronic pumps enables automated insulin delivery
- No more finger-prick calibration
- Can unlock savings through a subscription when ordering direct from Medtronic
Potential Downsides
- Performs worse than Dexcom and Freestyle CGMs across most measurable dimensions
- Bulkier device to wear and requires overpatch tape to adhere
- Still requires separate rechargeable transmitter to attach to sensor
- Has to change devices more frequently than other sensors on the market
Verdict
The Medtronic Guardian 4 lags other CGMs in usability and features, but its ability to connect to Medtronic pumps makes it the obvious choice for a certain segment looking for automated insulin delivery. The elimination of finger-prick calibration is a big advancement for Guardian 3 users.
Detailed Feature Comparison
The State of the Art
The Prior Generation
Continuous Glucose Monitor FAQs
Can I buy a CGM in Canada? Do I need a prescription?
Yes, in Canada you can buy a CGM either with or without a prescription.
If you’re buying a CGM with a prescription, it may be eligible to be billed direct to your insurance plan or submitted for reimbursement if you have coverage.
Where can I buy a CGM?
Some CGM devices are available for purchase behind the counter at pharmacies, while others you have to order direct from the device company or a specialty medial device supplier.
- Available at a Pharmacy: Freestyle Libre, Freestyle Libre 2 and Dexcom G7. Some pharmacies may carry Dexcom G6
- Available from Specialty providers like Endor Health: Dexcom G6, Medtronic Guardian 3 and 4
How much does a CGM cost?
In Canada, a CGM can cost anywhere from $200 to $380 per month depending on the device. There are a few factors that can determine cost:
- What device: some CGMs are more affordable than others. For isntance, the Freestyle Libre sensors are typically more affordable where the Medtronic Guardian sensors are more expensive.
- How long does the sensor last: To get a full month of use, you’d need 2 Freestyle LIbre sensors, 3 Dexcom G7 sensors or 5 Medtronic Guardian sensors. So you have to look at the cost for a full month rather than the cost per sensor
- Insurance Coverage: Depending on your diabetes type and your insurance plan formulary, some deviecs may be covered where others are not. Call your insurance company to confirm.
Can I buy a CGM without diabetes?
Yes, anyone without diabetes can buy a CGM by:
- Buying one online from Endor Health or other online pharmacies
- Asking for one behind the counter at your local pharmacy
Most insurance companies will require a prescription and a diabetes diagnosis in order for CGM purchases to be eligible for reimbursement.
What is the cheapest way to get a CGM?
The cheapest way to get a CGM is to:
- Get a prescription from your doctor for a CGM to help with diabetes management
- Have CGM coverage through your benefits plan or provincial drug paln, and use direct billing to minimize out-of-pocket spend
- Purchase a device that fits within your coverage amount to minimize your co-pay
Some diabetes clinics may offer CGM samples for new customers from time to time, which are free!
Can Apple Watch monitor blood sugar?
No Apple Watch currently available can monitor blood sugar. There have been rumours and speculation for years that Apple is working on adding blood glucose monitoring to the Apple Watch via optical sensor, but as of writing it is unclear both if and when this will actually come to the market.
Dexcom recently announced connectivity with the Apple Watch, so Dexcom G7 users can now see blood glucose levels and alerts on their Apple Watch.