AACE 26th Annual Scientific & Clinical Congress:

Evolving with Technology to Deliver More Personal Care

For endocrinologists and others caring for patients with diabetes, embracing innovations in medical device and software technology, understanding it, and helping patients do the same, is crucial to providing the best possible clinical care, based on a 2-day symposium, High Tech Innovations for Diabetes Mellitus,1 at the American Association of Clinical Endocrinologists 26th Annual Scientific and Clinical Congress, held May 3-7, 2017 in Austin, Texas.

The moderator of the medical technology session and 2 speakers shared highlights of their presentations with Endocrine Web.

Advancing Clinical and Personal Care Possible with the Data Explosion

"You can't really make adjustments in diabetes treatment if you can't see the data,'' said Irl B. Hirsh, MD, professor of medicine and Diabetes Treatment and Teaching Chair, at the University of Washington, Seattle.

Becoming familiar with data collection and sharing systems has become ''even more critical in the last year or 2," he told EndocrineWeb. Physicians must interpret much more data, he said, particularly because more and more evidence suggests that hemoglobin (Hb) A1c ''is a cruder test of glucose than we thought. Everyone's HbA1c is just specific to them."

This subtlety in blood results will increase the need for clinicians to pay closer attention to patients and their blood glucose levels, Dr. Hirsh said, including ''what is happening with insulin as it pertains to glucose at different times of the day. We have become a very HbA1c-centric medical society.1 Now that we have learned how crude it is, we need to become more glucose-centric. You can't manage insulin just by HbA1c alone."

Endocrinologists who evolve with technological innovations will assure optimal care for patients with diabetes.

Among his recommendations for colleagues who are not yet comfortable with the new technology,1 Dr. Hirsh suggested:

  • Start with the easy part—glucose meter data. "The gold standard is CareLink by Medtronics," he said, "and I have no [financial] conflict with Medtronics." Certainly, going forward, we can expect the choices will expand.  
  • No need to hire a consultant to help you become familiar with the device and software program. CareLink is free, and the company rep will help physicians gain comfort using it.
  • Involve patients in the process of learning how the device works. "Physicians need to instruct their patients to bring all their technology [to office visits]. You can't do an office visit in 2017 without having the device there to download the data."
  • Stay abreast of new developments.

What is Ahead for Continuous Glucose Monitors?

Session moderator, George Grunberger, MD, chair of the Grunberger Diabetes Institute in Bloomfield Hills, Michigan, provided a framework for continuous glucose monitors (CGM).1,2 He recommended keeping an eye on several companies and devices, including:

  • Dexcom, which launched its Dexcom G5 CGM—currently the only CGM system on the market that lets users treat without having to prick the finger (although fingersticks are required for calibration)—is preparing to launch a newer version, the G6 sensor in 2018. It promises longer wear, nearly doubling its use to 10-14 days instead of 7, and requiring just one calibration rather than 2.
  • Reporting on a 49-person trial of the new sensor worn for 10 days, an average error compared with lab measurements of 8.1% with one fingerstick for calibration a day was needed as compared to an estimated 8.8% error with none.3 And, 96% of the G6 readings were within 20% or 20 mg/dl of true glucose values.  Looking ahead, the company reports that a 1st generation Verily sensor will be launched in late 2018, with a 2nd generation upgrade already in the works for a 2020 release.
  • Medtronic introduced the Minimed 670G system as the only hybrid closed-loop system.4 The pump will provide access to glucose and insulin formulas from the home screen, working with a Guardian sensor 3 to control insulin dosing.
  • FreeStyle Libre Pro (Abbott),5 currently has only a professional version in the US, but FDA-approval of a patient version is expected soon. However, ''the personal version has more than 3,000 users in Europe. A single reader device is used to scan and activate all pro sensors. According to the company, it is small, easy to wear and needs no fingerstick calibration.4 "It will incredibly enlarge the market for people to constantly monitor glucose without the finger stick, for the vast majority of people with diabetes on insulin but not using insulin pumps."
  • Senseonics' Eversense CGM, under FDA review, has a long-term, pill-sized, implantable sensor that will be good for 90 days, and will send glucose readings to the app every 5 minutes.6,7

Praising the advances as invaluable resources to assist clinicians in helping to avert disasters, Dr. Grunberger said. However, with these advances come practical problems—from designating and training office staff to do the implantations and educating patient to finding out ''how to set up a high-tech office without going broke," he cautioned.

Looking Back to Move Ahead

William Tamborlane, MD, professor of pediatrics and chief of pediatric endocrinology at Yale School of Medicine, took a historic look at managing type 1 diabetes (T1D). "We did the first study to show that pump infusion would be effective for type 1," he said; that study was published in the New England Journal of Medicine in 1979.8

He cited 4 technological innovations worth noting during the past 20 years:

  • Insulin analogs
  • Smart insulin pumps
  • Improved blood glucose meters
  • Continuous glucose monitoring systems

Despite these advances, Dr. Tamborlane told EndocrineWeb that too many children and teen in the U.S. with T1D fail to achieve target Hb A1c goals, and the rates of severe hypoglycemia and diabetic ketoacidosis remain too high. Complicating the picture, Dr. Tamborlane said, is the fact that too few pediatric patients take full advantage of the high-tech advances that might otherwise help improve diabetic outcomes.

He cited data released in 2015 from the T1D Exchange Clinic Network and Clinic Registry, with information from more than 26,000 adults and pediatric patients enrolled.9 Only 17 to 21% of children reached the HbA1c goals of less than 7.5%, and teens ages 13 to 18 least likely to achieve target A1C levels. As a group, adults 26 to 50 were best able to get below 7%, but only 32% of adults achieved the desired HbA1c level, while 29% of those ages 50 and older did, and just 13% of those 18 to 26 achieved their target HbA1c.8

What will help turn this around? Technology, Dr. Tamborlane said, including CGM, sensors, the artificial pancreas, islet transplantation, and stem cells. Use of CGM among those under age 26 is uncommon, he said, ranging from only 5 to 7%.9 Among adults, use of CGM ranges from 13% (those 65 and over) with the highest users among 20 or 22% of younger adults.

However, no treatment of T1D will eliminate the risk of hypoglycemia unless there is a feedback control of insulin delivery, especially overnight, he said.

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