New diabetes technology improves care, but not cure-all

BOSTON – New technologic advances have changed the landscape of diabetes management, but effective treatment still comes down to how the patient uses any device, according to a presenter at the Cardiometabolic Health Congress.

Anne Peters, MD, professor at the Keck School of Medicine and director of Clinical Diabetes Programs at the University of Southern California, said new meters, insulin pumps and continuous glucose monitors improve glycemic control and give patients with diabetes more options, but the latest “smart” technology does not take the place of human interaction in diabetes care.

Anne Peters

“It’s a wonderful time to be in diabetes in part because of all of these devices that we have … but technology isn’t the answer,” Peters said during a presentation on new diabetes technology. “It’s always the human/technology interface that matters the most.”

Blood glucose meters

Self-monitoring of blood glucose is a mainstay of treatment, both for those with type 1 and type 2 diabetes, but meters have a major drawback, at least in the U.S., Peters said.

“They now come in different colors … you can put skins on the meters to make them look cute,” Peters said. “But, one of the problems is you still have to prick the finger. [In the future], we’re going to have ways to monitor blood sugar that don’t involve pricking the finger.”

The Abbott Freestyle Libre — not yet available in the United States — functions like a continuous glucose monitor without finger pricking, according to Peters.

“This one disk will last for 2 weeks and talks to a transmitter. Every time a patient wants to check blood sugar, they just swipe it,” Peters said.

The device is extremely popular in Europe despite the lack of government reimbursement for it, Peters said.

The device should be available in Canada in the next 2 years, Peters said.

Insulin pumps

Newer insulin pumps in development, such as the Medtronic 640G pump, are designed to resemble a cell phone, and not a pager, as older models were, Peters said. The Medtronic pump incudes full-color features and informative icons, making it easier to see, read and use than older generation models.

“You don’t have to scroll through screens to see what the active insulin is,” Peters said. “This should be available [in the United States] in the next year or so.”

The t:slim pump, which also includes a calculation of the body’s active insulin from past bolus doses (“insulin on board”), is another new option. However, this device does not wirelessly accept blood sugar levels, so the key to using the pump is that patients enter their blood sugar values, Peters said.

Many patients with type 1 diabetes prefer pod pumps, like the OmniPod, because of the lack of tubing required, according to Peters.

For patients with type 2 diabetes, patch pumps are an option. These offer a fixed basal rate and no electronic interface, so fine tuning of doses is not possible, Peters said. Patch pumps are filled with insulin daily and are worn on the body, with the patient squeezing the pump to give insulin doses in 2-unit increments between meals.

“This works for patients who don’t want to carry around a lot of pieces,” Peters said. “I’ve had a few patients on [patch pumps] …. and if your patient will do better on this and use it more effectively, I think it’s worth trying.”

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Continuous glucose monitoring

“I would put every person I have in my clinic on continuous glucose monitoring because I personally love the data,” Peters said. “It just fills in all the gaps. Those four finger sticks … does that really reflect the ups and downs of what [a patient’s] blood sugar levels might be?”

CGM devices continue to improve, with interfaces that wirelessly transmit data to smartphones or a cloud-based system. As an example, the Dexcom G5 mobile CGM, Peters said, helps caregivers to monitor their family members with diabetes, and also allows physicians to monitor several of their patients at once.

“[The technology] does wear out the battery a bit faster, but it goes right to their iPhone so [the patient] can look at it,” Peters said.

Closed-loop systems

Closed-loop artificial pancreas systems, in which an external pump communicates with a control algorithm that is “listening” to a sensor, has helped to improve glycemic control in studied patients, but there is room for improvement, according to Peters.

“We have learned a great deal from the testing of these devices,” Peters said. “I think the problem with these is that they’re still devices. They’re still external, they’re still subject to all the issues that infusion sets can cause, [including] skin reactions.”

The next step, Peters said, is the predictive stopping of basal insulin as a patient’s blood glucose begins to fall. Until that becomes a reality, Peters said, she will often counsel patients with pumps like the Medtronic Minimed 530G to preemptively reduce their basal rate by 50% when blood glucose levels start to fall. This step can be done for about an hour by setting temporary basal rates with the threshold suspend system.

“I teach my patients a bit about how to be their own artificial pancreas, and working with the temporary reduction or even increases [in basal insulin], I can get a lot of people to have much smoother glucose profiles,” Peters said.

Infusion site issues

Advertising for pumps often features a model with a “perfect, tape-less, lump-less abdomen,” often with a well-toned, flat stomach, Peters said.

In reality, “[patients] have sticky tape and lumps, and it just is not so aesthetic,” Peters said. Tape scarring, “pump lumps” and site infections can sometimes lead younger patients with diabetes to avoid the technology, and infusion site reactions remain an understudied issue that needs to be addressed.

“Patients on pumps for a long time often have so much scar tissue that it’s hard to get an infusion site that works really well,” Peters said. “So, this is not a seamless technology.” – by Regina Schaffer

Reference:

Peters AL. Advances in diabetes technology. Presented at: Cardiometabolic Health Congress; Oct. 21-24; Boston.

Disclosure: Peters reports receiving consulting or speaking fees from Amgen, Abbott Diabetes Care, Becton Dickinson, Biodel, Bristol-Myers Squibb/Astra Zeneca, Janssen, Lexicon, Lilly, Medtronic Minimed, Novo Nordisk, OptumRx, Sanofi, Takeda and Thermalin.