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‘Digiceuticals,’ new CGM devices, HbA1c alternatives transform diabetes management
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CHICAGO — The growing abundance of technology options for better diabetes management and the trend away from HbA1c as the only evaluation metric for the condition are important parallel phenomena, according to a speaker at the Cardiometabolic Health Congress.
Anne Peters, MD, director of USC clinical diabetes programs and professor of clinical medicine at the Keck School of Medicine at the University of Southern California, said during a presentation that health care providers must not only acknowledge but seek to understand these trends in order to help improve diabetes care.
The idea that HbA1c may not be infallible as an evaluation tool for diabetes management is nothing new, as HbA1c does not account for variability or instances of extreme lows and extreme highs and thus does not provide an entire picture, according to Peters, who noted this doesn’t mean Hba1c is not important, but that there are other data available.
“No one’s ever going to take away the HbA1c,” Peters said during her presentation. “But it’s an average. Does it tell you how to manage a patient? No.”
Some of the newer metrics that have grown in popularity include the ambulatory glucose profile, time-in-range and the glucose management indicator, which can be combined to provide a more precise idea of how a patient’s glucose is actually fluctuating over time, Peters said, noting that “a lot of this can lead to patient discussions.” Beginning this communication is key because it takes more than just more accurate metrics to improve diabetes management.
“Everybody thinks because we can measure a sugar, we can fix the outcome,” Peters said. “But we know that just measuring sugar doesn’t help.”
The dawn of ‘digiceuticals’
According to Peters, for the available data to become actionable, there has to be behavioral change and that’s where digital diabetes applications come into play. In fact, according to Peters, “there are more apps for diabetes than any other disease.”
The issue, however, is that having so many choices isn’t necessarily a good thing.
“If my patient is going to one of these apps, I want to know what the app is telling them,” Peters said. “You can find any app you want ... I really want to help patients find the right app for them because I know there are apps that can help.”
In many ways, choosing the right app is the same thing as choosing the right diabetes educator or medication for a patient, according to Peters, as there must be a familiarity and level of trust present for a health care provider to recommend these avenues of therapy.
Luckily for health care providers, reviewing and testing every single available app isn’t necessary. With the advent of what Peters called “digiceuticals,” health care providers can get a head start. Peters describes these apps, which are “clinically validated,” as “taking the clinic and putting it in your iPhone.” She noted they are regulated like drugs or devices.
For diabetes, there is the BlueStar and BlueStar Rx apps and like other apps, these can provide a more rewarding experience and even a “gamification” of the diabetes management process, according to Peters.
A range of device options
For these apps to work and for the data on other glucose measures other than HbA1c to inform treatment strategies, tools to gather these data are imperative. Just as there are numerous diabetes apps available, there are a variety of devices available to monitor insulin adherence and glucose levels, although Peters noted that socioeconomic barriers to accessing these devices exist.
For insulin, the InPen System (Companion Medical) is an effective tool for determining insulin dose adjustments and tracking adherence, Peters said.
On the CGM side, new systems have entered the market with increased accuracy at a steady rate over the last 2 decades, according to Peters, and that is only going to continue.
Current options on the market, she said, include the Dexcom G6 CGM System (Dexcom), the Freestyle Libre (Abbott), the Eversense (Senseonics Holdings) and the Guardian Connect (Medtronic).
While there are benefits and drawbacks for each of these systems, they all help to provide more accurate and timely data on glucose levels and with newer systems such as the recently FDA-approved Dexcom G6 Pro CGM system and the forthcoming Dexcom G7, the available technology will only expand and improve in the years to come, Peters said.
In addition, she said, more options involving integrated CGM and alternate controller-enabled infusion pumps are giving more choice in terms of which devices and systems to use.
Even with all this progress, there are still some who would like even more personalized devices. As part of what Peters called the “we’re not waiting movement,” do-it-yourself artificial pancreas systems have shown considerable promise. While Peters didn’t recommend that health care providers prescribe these options since they are not yet FDA-approved, she noted some of her own patients use these types of systems. Therefore, it may behoove health care providers to understand how these systems work and how best to help their patients utilize the data they provide, she said.
“It works better ... because its infinitely adjustable,” Peters said of these DIY devices, while noting that patient buy-in and intensive follow-up are required to ensure the benefits achievable.
Whether it’s with apps, FDA-approved devices or DIY systems, Peters emphasized that the health care provider plays a key role in ensuring patients are set up to receive the most benefit, regardless of which option they use.
“Technology is advancing rapidly and it’s changing the world,” Peters said. “I think we as providers need to be familiar with as many options as possible so we can allow our patients to choose and allow our individual patients to succeed.” – by Phil Neuffer
Reference:
Peters A. Moving Beyond A1C: Diabetes Devices and Their Clinical Use. Presented at: Cardiometabolic Health Congress; Oct. 10-13, 2019; Chicago.
Disclosure: Peters reports she has served on the advisory board at Abbott Diabetes Care, Bigfoot Biomedical, Lilly, Livongo, Mannkind, Medscape, Novo Nordisk and Sanofi; has received research funding from Dexcom and vTv Therapeutics and has stock options with Livongo, Mellitus Health, Pendulum Therapeutics, Omada Health and Stability Health.