By Emma Shepherd
Ananda Basu, MD, is director of the Diabetes Technology Program, a professor in the Department of Endocrinology, Diabetes and Metabolism, and a senior scientist in the Comprehensive Diabetes Center at UAB.Diabetes is costly to both the American health care system and the estimated 1 in 10 Americans who have the disease. According to the American Diabetes Association, costs in Alabama alone amount to about $5.9 billion annually.
As the number of people with type 1 and type 2 diabetes continues to rise, doctors and scientists are working together to find practical, patient-centered solutions that can also reduce the enormous costs of managing this chronic disease.
Ananda Basu, MD, is director of the Diabetes Technology Program and professor in the Department of Endocrinology, Diabetes and Metabolism at UAB. He says proper diabetes care can reduce outpatient visits and emergency room visits, which are some of the most expensive interactions with the health care system.
“One of the main goals of diabetes care is to help patients manage their blood glucose well so that they never have to visit the emergency room for diabetic ketoacidosis, a fatal complication of diabetes,” said Basu, who is also a senior scientist at Harvard University. . UAB Comprehensive Diabetes Center. “We want our patients with diabetes to live good lives without the stress of diabetes management – that's where diabetes technology comes into play.”
Continuous glucose monitors and insulin pumps
Basu is particularly interested in two diabetes management technologies: the continuous glucose monitor and the insulin pump.
Using a sensor on the arm or abdomen, a continuous glucose monitor, or CGM, provides readings to diabetics at continuous intervals throughout the day. These readings can be real-time or on-demand, whether the user chooses to get updates every five minutes or every few hours. The CGM sensor is usually changed every week or two.
An insulin pump is attached to the body, usually on the arm, abdomen, or near the hip, and can deliver insulin in a steady flow throughout the day, along with additional doses at mealtimes. Helps relieve the need for multiple insulin injections daily. Every two to three days, the user replaces the tube, refills the insulin cartridge, and moves the insulin pump to a different location.
Most insulin pumps deliver a small, continuous amount of insulin to the body throughout the day. This number is often determined with the help of an endocrinologist, but some insulin pump algorithms are able to predict the baseline dose a patient will need.
Continuous glucose monitoring sensorThere are two types of CGM insulin pump kits. The open loop system is patient dependent. They may notice that their blood sugar is high via a CGM and then instruct their insulin pump to deliver a certain amount of insulin. When an insulin pump is able to respond directly to a CGM reading without human intervention, this is a closed-loop system.
Closed-loop systems work by predicting where someone's blood sugar level might be in half an hour and sending signals via Bluetooth to the insulin pump to deliver insulin doses accordingly. What's more, these systems are constantly being upgraded to incorporate artificial intelligence, as well as adapt to changing conditions (including signals from the CGM device) in real-time — just like a chess player adapting to his opponent's changing moves, Basu says.
Many scientists, engineers and diabetes specialists are working together, seeking to make devices able to predict insulin needs even further, and to make algorithms better at keeping up with the nuances of human behavior.
“The closed-loop system makes our patients feel as if they have an artificial pancreas,” Basu said. “The CGM and insulin pump work together to control blood glucose without the patient having to worry about it.”
Artificial pancreas closure
For diabetics, the current version of the artificial pancreas is a continuous glucose monitor (CGM) and insulin pump combined into one device that monitors and delivers insulin. Several recent trials supported by the National Institutes of Health It has shown benefits in patients with type 1 diabetes from age 1 to age 65.
“As the director of the diabetes technology program, my patients often ask me when we will get an artificial pancreas,” Basu said. “The answer is that we already have several – three versions approved in the US alone. But more research is ongoing to improve the algorithms inside the artificial pancreas to make it fully automated and tailored to an individual patient with type 1 diabetes.”
Insulin dosing using an insulin pump and remote sensorsIn the future, Basu hopes that these devices will more accurately mimic the human pancreas by incorporating all the other hormones secreted by the pancreas, not just insulin. “This would be like giving the devices a full set of tools to control blood glucose,” Basu said.
Diabetes specialists and engineers face many challenges when creating a single device for multiple hormones. Currently, an artificial pancreas containing both insulin (lowers blood glucose) and glucagon (raises blood glucose) has been tested in clinical trials. These devices have four points of contact with the body — two sensors and two needles to deliver hormones — so they can be bulky, Basu says.
Even when a true artificial pancreas reaches the market, adoption may be slow, Basu adds. He points out that many diabetics today have not yet adopted CGM and insulin pump technology.
Why do patients hesitate?
The Centers for Disease Control and Prevention reports that 37.3 million Americans — about one in 10 — have diabetes. However, Basu says that only an estimated 350,000 people in the United States use insulin pumps, and 2.4 million use continuous glucose monitors.
Diabetes specialists largely agree that continuous diabetes monitors and insulin pumps work very well to manage diabetes and mitigate complications. So why do so many people with diabetes still choose not to use a CGM and/or insulin pump?
“I was ready to make a change and start managing my diabetes again and not let diabetes control me. Switching to a CGM and insulin pump was the best decision I ever made.” —Sarah Silverstein McIntosh
“Many of my patients are hesitant,” Basu said. “But when I set it up on a trial basis, I didn't have any patients who wanted to return the pump and CGM. Everyone wanted to keep the devices. It's really a game-changer for people with diabetes.”
Basu points out that for many patients who deal with diabetes daily, having an artificial pancreas can feel as if they are losing a degree of control over their diabetes. Ultimately, the research showed that those who use an insulin pump and continuous glucose monitors are able to spend a “greater percentage of time in range,” an observation that doctors and scientists use to measure how often a person with diabetes is within the ideal blood glucose range.
“Diabetics interested in using a CGM or insulin pump should always consult an endocrinologist and diabetes educator to learn more,” Basu said. “It's also important to understand what your health insurance provider covers when it comes to these devices.”
Sarah Silverstein McIntosh, a Birmingham native and mother of two, was diagnosed with type 1 diabetes when she was a young child. For her, switching to a CGM and insulin pump after decades of managing diabetes on her own was difficult, she says.
“After having my second child, I realized that managing diabetes was much more difficult with all the additional responsibilities of being a mother,” McIntosh said. “I was late on my medication and forgot to check my blood sugar. I was ready to make a change and start managing my diabetes again and not let my diabetes control me. Switching to a CGM and insulin pump was the best decision I ever made.
Ultimately, for McIntosh, it seemed like the right decision for her and her family.
“Life with a CGM and insulin pump is great,” she said. “They pair up and work hand-in-hand, allowing my blood sugar to stay under control. My A1C is exactly where I want it to be. Technology has made living with diabetes much easier to manage.”
