Diabetes and Technology: Another Win!
On a typical outpatient day, my patients and families are always asking me about the best way to improve diabetes management. As I have stated multiple times, administration of insulin in combination with diet, exercise, and frequent blood glucose monitoring is the ticket! There is a plethora of insulin regimens, nutritional guidelines, and exercise strategies that come into play as well to help with the successful management of diabetes. Children’sNationalMedicalCenterand particularly our diabetes program, practices family-centered care, so we match the insulin regimen with the needs of our patients and families.
Many patients elect basal/bolus therapy either by continuous subcutaneous insulin infusion (CSII or insulin pump therapy) or multiple daily injections with a long acting basal insulin and rapid acting bolus analogue insulin. The constant query is:
Which of these types of basal/bolus therapies is the best?
Answer: They both work well.
More specific information is now available as we combine insulin pump therapy and continuous glucose monitoring. Along with the senior author, Sherita Hill Golden, Yeh, Brown, Maruthur published “Comparative Effectiveness and Safety of Methods of Insulin Delivery and Glucose Monitoring for Diabetes Mellitus: A Systematic Review and Meta-analysis” in the Annals of Internal Medicine, 10, July, 2012. The purpose of the paper was to meticulously review information about the latest technological advances in the delivery of insulin in association with glucose monitoring and therefore provide evidence-based guidelines for our patients and families.
The authors reviewed “how intensive insulin therapy-multiple daily injections (MDI) vs. rapid acting analogue-based continuous subcutaneous insulin infusion (CSII) or method of monitoring (self-monitoring of blood glucose-SMGB) versus real-time continuous glucose monitoring (rt-CGM) affects outcomes in type 1 and 2 diabetes mellitus.”
The authors used multiple databases to abstract their data and performed a meta-analysis by evaluating 33 randomized, controlled trials in both children and adults that compared CSII with MDI (19 studies), rt CGM with SMBG (10 studies), or sensor-augmented insulin pump therapy with both MDI and SMBG (4 studies).
What were the results?
- MDI and SCII demonstrated similar effects on hb A1c and severe hypoglycemia in children and adults with type 1 diabetes and adults with type 2 diabetes.
- In adults with type 1 diabetes adults, hb A1c levels decreased more with CSII than with MDI, but one study heavily influenced the final results.
- rt-CGM achieved a lower hb A1c level as compared with SMBG without any difference in hypoglycemia.
- Sensor-augmented insulin pump therapy decreased hbA1c levels greater than MDI and SBGM in children and adults with type 1 diabetes.
According to the authors, the biggest limitation was that many of the studies were small, of short duration, and limited only to Caucasians with type 1 diabetes.
What is the common denominator in this meta-analysis?
It appears that the real-time continuous glucose sensor may play a significant role in lowering hb A1c and in combination with the insulin pump may result in the best control (despite the above limitations). As we know, the rt-CGM in association with the CSII is the prototype for the “artificial pancreas.” My biggest concern is that the available technology will need to be available for everyone with diabetes. Will our healthcare system ensure that this technology become a reality for all individuals with diabetes? Will insurance companies cover the “artificial pancreas?” I believe we are moving in that direction.
However, despite the availability of this advanced technology, one must actually apply it appropriately to lower hb A1C. People with diabetes must be willing to wear the rt-CGM and act accordingly by checking blood sugar frequently by SBGM! As we know, adherence in teens is not always ideal!
Once again, it is our behavior that will ultimately determine the success of advancement in technology. Thus, in addition to advancements in technology, our behavioral scientists must continue to try to discover increasingly successful methods in an effort to improve adherence to these complex regimens that are still required to manage diabetes effectively.