From news.cuanschutz.edu
Diabetes specialist and leader Cecilia Low Wang, MD, explains how diabetes devices like continuous glucose monitors and automated insulin delivery systems continue to evolve to help improve health outcomes for patients with diabetes
For years, a painful prick of the finger multiple times a day was the go-to method for a patient with type 1 diabetes to monitor their glucose levels — a key component to managing their health. However, in recent decades, technological advancements have led to the development of wearable continuous glucose monitors that offer less pain and more data collection. Physicians and scientists have taken it a step further to innovate devices that aim to not only monitor glucose levels but also use the glucose data to deliver insulin automatically when needed.
Despite these important advances, not all health care providers are familiar with these devices — including what their benefits and limitations are. To raise more awareness, Cecilia Low Wang, MD, a nationally recognized leader in the field of diabetes, explained this technology during a University of Colorado Anschutz Department of Medicine Grand Rounds presentation. As director of the glucose management team at the University of Colorado Hospital, program director for the Diabetes Fellowship Training Program, and a professor of endocrinology, metabolism, and diabetes at CU Anschutz, she has witnessed first-hand the value — and need — for these devices.
“Diabetes technologies have been advancing rapidly,” she said. “At the same time, the prevalence of diabetes has risen dramatically over the past few decades.”
According to the American Diabetes Association, 38.4 million Americans had diabetes as of 2021. That number is predicted to increase in the upcoming years, she explained. It’s a pressing issue given that with diabetes treatment comes the risk of hypoglycaemia — a condition where the body shuts down due to low blood sugar (glucose) levels — and an increased risk of microvascular complications such as eye disease, nerve damage, and kidney disease, and cardiovascular conditions such as heart failure, heart attacks, strokes, and peripheral artery disease.
“When people develop microvascular complications, their quality of life can go downhill and their lifespan and health span are cut short,” Low Wang said. “We want to monitor glucose because it helps us reduce these risks for patients.”
A risk continuum
A person’s risk of hypoglycaemia and microvascular complications depends on the type of diabetes they have and how advanced it is, also known as a risk continuum, Low Wang explained. The people with the highest risk are those with type 1 diabetes and those with more advanced stages of type 2 diabetes. The lowest risk is among people with prediabetes — either pre-type 1 diabetes (also called “stage 2 type 1 diabetes”) or pre-type 2 diabetes — but even those with pre-type 2 diabetes are “already at double the risk for macrovascular complications,” she said. Macrovascular complications include strokes, coronary heart disease, and peripheral artery disease.
Nearly all individuals with type 1 diabetes will require insulin therapy, whereas about 25% of individuals with type 2 diabetes are on insulin therapy.
“Insulin has a very narrow therapeutic window. When we’re trying to get toward normal glucose levels, that increases the risk for hypoglycemia,” she said, explaining that administering more insulin than a person needs in any given moment can result in too much glucose being removed from the bloodstream. “This is why we need to monitor glucose levels.”
Finger pricks to wearable monitors
From 1983 to 1993, the Diabetes Control and Complications Trial — a pivotal national research program — was conducted. It demonstrated that individuals with type 1 diabetes who achieved intensive control of their glucose levels experienced a vast decrease in the risk of eye disease, kidney disease, and nerve damage, underscoring the value of monitoring glucose levels in order to improve health outcomes.
In 1999, the U.S. Food and Drug Administration (FDA) approved the first continuous glucose monitoring system, but the data was not visible to the person using it. A patient would still have to prick their finger several times over the course of three days before then taking the device to a clinic to have a physician tell them the data.
“One of the problems is that finger sticks are incredibly painful,” Low Wang said. “This was the impetus for scientists to try to think of other ways to monitor glucose.”
Over the years, there have been many improvements in continuous glucose monitoring, Low Wang explained. Today, there are wearable devices that people can place on their arm to measure their glucose levels 24 hours a day and deliver real-time information.
“In these wearable devices, the device will measure glucose every minute or every five minutes,” she said. “The glucose data are then sent either to a separate reader or to an application on a smartphone or smartwatch.”
Overall, these devices have proven valuable in several ways, such as by decreasing the need for finger sticks to measure blood glucose levels, showing the glucose trend, increasing patient satisfaction, helping patients and providers collect more data to understand a patient’s glucose trends over time, and alerting patients when they are in danger of hypoglycemia, Low Wang explained.
“Continuous glucose monitoring has revolutionized the self-management of type 1 diabetes,” she said. “Patients have less hypoglycaemia, better glucose control, and better patient-reported and clinical outcomes.”
Automating insulin delivery
Although continuous glucose monitoring systems have been useful in helping alert patients when they need insulin or to treat a low glucose level, adhering to a complex regimen — particularly remembering to take an injected medication every day, at the correct dose, multiple times a day — is incredibly difficult, Low Wang said. It’s common for patients to miss doses of insulin, which is concerning because a single missed insulin dose can have a negative effect on their glucose control.
In the past decade, a key technological advancement has been the development of automated insulin delivery systems that combine continuous glucose monitoring and insulin pumps using a “control algorithm.”
Low Wang noted that a benefit of automated insulin delivery systems (also called “hybrid closed-loop systems”) is that the devices are able to deliver different amounts of insulin according to glucose values, trends, and predicted glucose, allowing for more customized and personalized care.
“Automated insulin delivery has revolutionized the management of type 1 diabetes,” she said. “What our patients tell us is that they can sleep through the night and live their lives without constantly thinking about their diabetes. Parents of children with diabetes are able to breathe a little easier.”
However, there are several limitations to these devices. For instance, there is a time lag in sensor glucose values, delayed action of insulin since it is being delivered subcutaneously instead of through the portal system, and many potential technical issues such as sensor connectivity, missing sensor data, problems with tubing, and so on. Other barriers can include the cost of the device and being able to access it depending on insurance coverage. The overall accuracy of continuous glucose monitoring is also an issue, Low Wang noted.
“Despite the limitations, for the most part, automated insulin delivery systems increase the amount of time that patients are in an optimal glycemic range and decrease the burden of diabetes care,” she said.
Who these devices can help
Low Wang explained that automated insulin delivery systems should be considered as a potential tool for all patients with type 1 diabetes and those with insulin-deficient diabetes. Among patients with type 2 diabetes, automated insulin delivery is now FDA-approved. Low Wang recommends that physicians consider these devices for all type 2 diabetes patients who are on multiple daily injections of insulin — while continuous glucose monitoring should be considered in anyone who requires at least one injection of insulin a day — or those who are using the medications in the sulfonylurea or glinide class.
The FDA has approved over-the-counter continuous glucose monitors, making some devices available to people without the need for a prescription. Although these direct-to-consumer devices may be useful for some patients, Low Wang cautioned that there could be issues with getting accurate readings and interpreting the glucose data, so patients should consult their physician before purchasing one.
“The first minimally-invasive and non-invasive continuous glucose monitoring systems are on the horizon,” she said. “Recently, the FDA approved the first fully autonomous, needle-free glucose sensor. It’s not on the market yet, so stay tuned. We’ll see more exciting advances in the coming months and years.”
https://news.cuanschutz.edu/department-of-medicine/diabetes-devices-insulin-glucose
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