10/10/2018 Smart Technologies to Disclosures Enhance Diabetes Management and Communication None Robert J. Rushakoff, MD Professor of Medicine University of California, San Francisco robert.Rushakoff@ucsf.edu Telemedicine Medication/ Wearable Central Automation Monitoring Apps insulin Devices Platforms inpatient/outpatient Personal/central Delivery "Each blind man perceived the elephant as something different: a rope, a wall, tree trunks, a fan, a snake, a spear..." 1
10/10/2018 Diabetes And Technology Journals JOURNAL OF DIABETES SCIENCE AND TECHNOLOGY DIABETES TECHNOLOGY & THERAPEUTICS National/International DM technology meetings International Inpatient DM meetings Diva: Romeo and Juliet Romeo a six-ounce, hand-held device that resembles a pocket calculator. Glucose Monitor Programmed to beep at set times as reminder when to test blood sugar, take insulin, eat meals and exercise 3 month storage Robert Ratner, MD: It's not perfect for everybody. It's a lot of work, a lot of effort, and a lot of Records blood sugar patients are unwilling to do that. And, frankly, for a lot of patients, it's not With push of button, records insulin necessary. doses, amount of food eaten, intensity of exercise done and the times at which all Patient’s MD: Those who benefit most those whose diabetes is out of control and those who those activities took place are newly diagnosed and need to become aware of how different things affect them. Juliet Most people can use the system, for several months and then "graduate" to using just a diary and a simple blood sugar monitor. device produces printouts Those who want to, can buy their own system - hospitals lend or rent them to patients - but the Can send data to provider using a system is expensive and not always reimbursable by insurance. Romeo costs about $495; Juliet, telephone modem. $275. 2
10/10/2018 The treatment with DIANET vs conventional showed a better • metabolic control lower before breakfast: 87 +/- 6 vs 104 +/- 4 mg • Lower before lunch: 85 +/- 5 vs 104 +/- 4 mg • • Lower after dinner: 102 +/- 5 vs 124 +/- 6 mg) These results were associated with higher insulin doses in • the DIANET vs conventional treatment, and a significant reduction of hypoglycemic reaction in both group Diva: Romeo and Juliet Diva: Romeo and Juliet Chemstrip bG Chemstrip bG When strip gone - - device worthless Technology limited to single device (expensive and was not covered by When strip gone - insurance) - device worthless Time consuming ? Who really needed it Who will pay 3
10/10/2018 Diva: Romeo and Juliet Now 2019 Has anything changed since 1988? 4
10/10/2018 Requirements for Successful “technology” Use General Concerns with Data Make stuff easier to do Numbers, numbers and more For the patient; For the MD/Nurse/Pharmacist numbers: Integration Potential to overwhelm patients, Supports normal Workflow clinicians or other care givers Scalable ? How to actually interpret all the data and actually make real time use Sustainable of the information Cost effective Stupid stuff Key Issues While new technology is cool - - Have to show some improved outcomes Not short term studies Wrong time on meters (THINK FITBIT!!) Wrong time on pumps 5
10/10/2018 Continuous Glucose Monitoring Glucose Meters CGM devices continue to improve, with interfaces that Generally - - still have to prick finger wirelessly transmit data to smartphones You get glucose value or a cloud-based ? Remains on value for patients not on system. As an example, the Dexcom insulin G5 mobile CGM helps Patients on insulin - - more is better caregivers to monitor their family members with diabetes and also allows physicians to monitor several of their patients at once Glucose Meters: Abbot Freestyle Flash Glucose Meters: Abbot Freestyle Libre/Flash Measures glucose every minute in • interstitial fluid through a small (5mm long, 0.4mm wide) filament that is inserted just under the skin and held in place with a small adhesive pad. No finger prick calibration • • Disposable, water-resistant sensor can be worn on the back of the upper arm for up to 14 days A reader is scanned over the • sensor to get a glucose result painlessly in less than one second. • Scanning can take place while the sensor is under clothing 6
10/10/2018 Case 1: 54 yr old man with hx kidney transplant 7
10/10/2018 So, should everyone get a Libre? Getting A Freestyle Libre The good… The not-so-good… Medicare coverage Very convenient No alerts or alarms - Requires 4x fingerstick per day & 4x insulin injections per day No fingersticks - (alert next year) - Available via Medicare DME suppliers (eg Edgepark Medical Supplies, Byram Healthcare, Solara Medical Supplies, Edwards 12 hour warmup per sensor Provides more information Health Care Services, Better Living Now, and Mini Pharmacy) - (as of yesterday - - 1 hour) Gives BG direction/trends Private insurance – Available at retail pharmacies Accuracy not as good (but Cheaper than other CGMs consistent) Cash prices at retail pharmacies (Walgreens, CVS, etc) Slimmer size profile Need to carry a reader device - Reader - $70-100 (one time purchase) (for now - - phone in Europe) - 10 day sensor - $30-45 each / $90-150/month Insulin Pumps Next Gen CGMs Newer pumps more user friendly Dexcom G6 – NOW Available Some integration with CGM - 10-14 day wear Touch screen, small - no calibrations BUT - - still just pumps and requires a user who really - Data to phones knows how to interpret data, make changes, input correct - Alarms to phones and friends information. - Prelim data shows MARD* 8.1% with 1 calibration per day, 8.8% with no calibrations INTERACT WITH SOME PUMPS Dexcom / Verily CGM Data in real time on cloud based platform *mean absolute relative deviation 8
10/10/2018 Medtronic 670G Smart Continuous Glucose Monitoring Approved for people with T1D ≥ 14 years old on >8 units of insulin/day 670G Mode Options SmartGuard™ Full Manual - Pump settings programmed by Medtronic Pumps/CGM • low glucose suspend feature user two different • Low Glucose Suspend – Pump settings suspension of insulin delivery • programed by user. Insulin suspended if CGM when the glucose levels are value falls below threshold. predicted to hit the low limit in Low Glucose Prediction – Pump settings the next 30 minutes programmed by user. Insulin suspended if CGM • Suspension set to when the value predicted to fall below threshold. glucose levels hit the low limit. Closed Loop – After 2 day open loop period, Sensor MARD Avg • can automatically suspend insulin system automatically adjusts basal insulin Tslim/ (Dexcom)CGM infusion for a maximum of 2 based on CGM values to target of 120 mg/dL (or Guardian 3 - 10.55% 150 mg/dL during exercise). User must still hours when sensor glucose (SG) manually deliver insulin during meals and Enlite - 14% levels are predicted to approach ”announce” exercise. No automated correction a pre-determined threshold and, Dexcom G5 - 9% boluses based on CGM. Suggests correction without intervention, will resume amounts based on fingerstick result (similar to basal insulin delivery to its pre- current bolus wizard). set rate. Adolescents Other Closed Loop Systems in Development Tandem (t:slim x2) – Dexcom G6 (launched 2018 with Adults autosuspend) – (automode expected 2019) Bigfoot Biomedical – meal announcement will not require carb estimation Beta Bionics (dual hormone – glucagon and insulin) Median and Interquartile Insulet – Dexcom G6 (expected launch 2020) range of sensor glucose International Diabetes Closed Loop Consortium values midnight to midnight Diabeloop Gray and dotted line = Run In Pink and solid line = Study 9
10/10/2018 What have we found with the 670G? 670G: Who does what? Greater peace of mind Improved sleep quality Clinician-Set Patient Reduced fear of hypoglycemia - Carb ratio - Fingerstick calibrations More time in range - Active insulin time - Input carbohydrates Waking up more mornings with on-target BG - Manual mode settings - Announce exercise Less time at extreme high and low - Input fingersticks for correctional boluses Algorithm-Determined Less diabetes hassle - Auto basal Decreased sense of regimen burden - Insulin sensitivity factor Increased freedom to participate in activities - Auto mode targets 37 Diabetes Technology: 2017 Update Yes, the 670G works, but… Bottom Line on 670G The algorithm doesn’t really “learn” you. It adapts to past 6 days. 1. The system is relatively conservative. 2. It still takes a lot of work and patient input, You lose a lot of flexibility. 3. but, most of the time you have to “let go” - No manual boluses - No extended boluses - No temp basals It chooses sensitivity factors / correction automatically. You only 4. change carb ratios. Sensors can be somewhat unreliable. 5. Some patients may lose a sense of being in control. 6. 10
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