Chuck Green

Within the next five years, people with diabetes will wear sensors that will alert them to healthy food choices when they arrive at a restaurant, predicts David Klonoff, MD, medical director of the Diabetes Research Institute, Mills-Peninsula Medical Center in San Mateo, CA.

The GPS-based technology, says Klonoff, will be preprogrammed with dietary preference information based on a sound diet that is less likely to raise blood glucose levels and leads to slightly lower A1c levels and complications.

Klonoff also projects more widespread use of continuous glucose monitors (CGMs) that include alarms with personalized notifications. The alarms signal for very low or very high glucose levels before they become dangerous and, as a result, reduce the incidence of hospital admissions for hypoglycemia. Eventually, CGMs also will decrease the rates of admission for chronic complications of diabetes related to high glucose levels, such as heart attack and kidney failure, he says.

CGM technology will also become more portable, accurate, last longer, require less calibration, and yield more decision support, according to Klonoff. “The technology will gradually push self-monitoring of blood glucose out of the marketplace for about half of patients who currently use it.”

Michael LeMay, MD, an endocrinologist at Hartford Hospital in Hartford, CT, agrees that CGM devices will continue to evolve and improve. Already, the latest CGMs are more portable and powerful than first-generation models, he says. They’re also easier to use and the science behind them is exponentially more accurate

In addition to an alarm that alerts users to high or low glucose levels, he says CGMs may include features such as:

The ability to record (based on user input) meals, physical activity, and medicines;

The ability to download data to a computer or smart device so trends can be monitored more easily; and

The ability to immediately transmit information to the smartphone of a parent, partner, or caregiver.

One study of women with type 1 diabetes found that the use of a CGM during pregnancy results in healthier moms and babies. The study showed that using a CGM during and prior to pregnancy improves health outcomes because women who used a CGM spent 100 extra minutes per day with blood sugars in a healthy range. That results in their babies being less likely to have hypoglycemia postpartum.
	The study appeared in The Lancet in 2017.

According a survey of 339 patients and healthcare providers that appeared in Diabetes in Control in March, 39% of patients with type 1 diabetes are using CGMs and healthcare providers see a steady upward trend in their adoption, In fact, providers who took the survey estimate that 77% of their type 1 patients will be using CGM five years from now.

Practitioners believe CGM usage in patients with type 2 diabetes will soar in the next five years. Currently, they estimate 11% of these patients are using CGMs; in five years, they expect that will increase to 46%.

But according to Schafer Boeder, MD, Division of Endocrinology, at the University of California, San Diego, only about 15% to 20% of patients with type 1 diabetes-and a much smaller percentage of patients with type 2 diabetes-in the United States, are believed to be using a CGM.

“Cost is a major barrier, though lack of familiarity by both patients and providers is also an issue,” he says.

Although LeMay encourages patients to use CGMs, issues like insurance coverage prohibit some from doing so. “I’ll give a patient a sample sensor, which they get used to and love, but when they try to put in a prescription for it, they find it’s too expensive. Sometimes, insurance companies lag behind.”

Chuck Green has covered healthcare for more than 10 years.

Up Next: 'The Artifical Pancreas' by Karen Appold 

Medtronic released its MiniMed 670G automated insulin delivery pump in 2017, a major step toward a fully automated insulin delivery system (also known as an artificial pancreas), for type 1 diabetes patients. “This is the first commercially available device to use continuous glucose monitoring information to adjust insulin doses,” says Anders L. Carlson, MD, medical director, International Diabetes Center. “Using an algorithm inside the insulin pump, the system adjusts insulin doses up or down accordingly to target a healthy glucose level.”

Data show improved average diabetes control, more time spent in a more ideal blood glucose range, and fewer blood glucose readings in the low range. “This is important because both high and low glucoses are associated with significant complications and costs,” Carlson says. Hypoglycemia hospital admissions from the emergency department, for instance, cost an average of $1.2 billion per year, so any technology that prevents levels from going too low is a major advancement.

Carlson says the next step would be to create a fully “closed loop” device, rather than a “hybrid closed loop” device, which will be smart enough to give a quick burst of insulin when the patient eats without having to tell the device that they are going to eat something. Currently, patients must enter their blood glucose and amount of carbohydrates they estimate are in a meal. Then, based on programed settings, the pump delivers an appropriate burst of insulin. To close the loop, the device would need to be able to handle that rapid increase in blood glucose following a meal or snack. Several groups are working on this, and newer systems may involve other hormones in addition to insulin being placed in the insulin pump.

David Klonoff, MD, of the Diabetes Research Institute, Mills–Peninsula Medical Center, San Mateo, CA, expects hospitalized people with diabetes to be treated with a combination of hardware and software advances that are uncommon in hospitals today. Patients will be fitted with a rapidly equilibrating CGM device, and insulin doses will be ordered by software programmed with their outpatient daily insulin dose, insulin sensitivity factor, and carbohydrate-to-insulin ratio, he says. This process will culminate in tighter mean glycemic control with less hypoglycemia, and translate into lower costs, as well as a reduced length of hospitalization.
	Schafer Boeder, MD, Division of Endocrinology, at the University of California, San Diego says use of CGM in hospitals-even for those not on CGM as outpatients-is an area of active research. If CGMs can reduce inpatient hypoglycemia events, decrease complications, shorten hospital stays, and/or reduce readmissions, it may become a standard technology in the hospital.

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Author | Chuck Green

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