Automated Insulin Delivery: Six Universal Observations and Understandings

This content originally appeared on diaTribe. Republished with permission.

By Laurel Messer

Six universal facts about automated insulin delivery systems, and the things you should keep in mind about this revolutionary technology

Automated insulin delivery (AID) systems are moving towards the forefront of diabetes management. AID systems combine continuous glucose monitors (CGM) with smart algorithms to automatically adjust insulin delivery.

The Tandem Control-IQ system was recently cleared by the FDA, and the Insulet Horizon and Medtronic Advanced Hybrid Closed Loop systems are beginning pivotal trials. These are encouraging developments. As more systems move through the pipeline and eventually into the commercial market, important patterns are emerging in user expectations and user experience. As a diabetes nurse, certified diabetes educator and research investigator, I, along with my team at the Barbara Davis Center, have worked with nearly every AID system in the pipeline, and other systems that will never make it to market. Here are six insights we have gleaned, which seem to be universal (thus far) to all AID systems:

1. You can always beat an AID system with compulsive diabetes management

Many people with diabetes compulsively attend to diabetes care in order to achieve ultra-tight glucose ranges – and are the first to ask about automated systems. What ends up happening is that these “super-users” are invariably frustrated that the system is not yielding the same results that they were able to achieve with their own calculations and management. An important point is that many automated systems are excellent at reducing mental burden for taking care of diabetes, excellent at reducing hypoglycemia, and adequate at improving glucose levels. Humans can beat automated systems if they attend to diabetes care near-constantly. The individuals who will likely be satisfied with AID are those who are comfortable with an A1C in the 7s or above, but they want to reduce the mental load of adjusting settings and micromanaging high glucose levels. The most important question to ask is, “Why do I want to start using an automated system?” If it is to achieve near-perfect glucose levels, the system will likely disappoint. If it is to reduce the burden of “thinking like a pancreas” all the time, it may be a good option. AID will excel at the marathon of diabetes care but may disappoint in the hour-to-hour sprint.

2. Systems work best when you let them work

Using both research and commercial systems, we have seen all the ways to “trick” AID systems—entering phantom carbohydrates, changing set points, performing manual corrections, overriding recommended doses. More often than not, these behaviors lead to glucose instability – reactionary highs and lows from the system destabilizing. All systems will perform best if they are used according to user instructions. This is difficult for the individual who would prefer to micro-adjust settings or desire control over all insulin delivery. Most systems work best when users learn to trust them.

3. Give the system a chance – 2-4 weeks before deciding long term potential

It may benefit us to think about AID like a new significant relationship – it can take some time to “settle.” I mean this both on an interaction level (learning how to respond to alerts, when to intervene, when to let it ride) and on an algorithm level (allowing the system to adjust internal algorithm parameters based on usage). In addition, programmable user settings may need some adjustment in the first few weeks of use, so working with diabetes educators can be helpful for initial set-up and early follow-up.

4. Bolusing is still king

If I could go back in time, I would caution device manufacturers against any whisper of not needing to bolus with AID systems. Bolusing is the singular most important action a person with diabetes can do to optimize insulin delivery on current and near-future automated systems. This will be true until insulin action time gets exponentially faster or artificial intelligence gets better at predicting human behavior, neither of which is on the immediate horizon. In order for people with diabetes to see the best performance on any system (automated or manual), they need to bolus before carbohydrates are consumed. Specific to AID, the timing of the bolus (prior to carb intake) is especially important, as the system will automatically increase insulin delivery after an initial rise of glucose levels, so a late bolus (e.g., after the meal) could lead to insulin stacking and hypoglycemia.

5. Rethinking low treatments

Low glucose levels (hypoglycemia) still happen when using automated systems. What is different with AID is that the system has been trying to prevent the low by reducing/suspending insulin, possibly hours before the low occurs. This means that an individual may need to consume significantly fewer carbs to bring glucose levels back into range – perhaps 5-10 grams of carb at first, reassessing 15-20 minutes later. This can be difficult when wanting to eat everything in sight; however, it can reduce the chance of rebounding into the 200s after over-treating.

6. Infusion sets are still infusion sets

While AID algorithms are revolutionary, the infusion set is not. It is the same plastic or steel cannula that occludes, kinks, or inflames. This hardware limits automated systems and can very quickly lead to hyperglycemia or diabetic ketoacidosis (DKA). It is important for people using AID to recognize signs of infusion set failure – persistent hyperglycemia, boluses that do not bring glucose levels down, ketones, vomiting, etc. Knowing how to treat ketones (via syringe injection of insulin and set change) can prevent a hospital admission or worse.

I love that the diabetes community learns from its members and experiences. Check out our Barbara Davis Center PANTHER (Practical Advanced THERapies for diabetes) website for our team’s latest insights on automated insulin delivery, and tools for people with diabetes, clinicians, and engineers.

Are you considering AID? Feel free to share this article with your healthcare team. For more information about AID systems that are currently available or in the pipeline, click here.

About Laurel

Laurel H. Messer is a nurse scientist and certified diabetes educator at the Barbara Davis Center for Diabetes, University of Colorado School of Medicine, Aurora, CO. She has spent the last 15 years studying how to best utilize new diabetes technologies, and remembers fondly teaching families to wrap up their corded CGM system in a plastic shower bag for bathing. Ok, not that fondly, but look how far we have come! Dr. Messer works with the Barbara Davis Center PANTHER team (Practical Advanced Therapies for diabetes), conducting clinical research trials on promising technologies to make life better for children, adolescents, and adults living with type 1 diabetes. Get in touch at Laurel.Messer@cuanschutz.edu

Source: diabetesdaily.com

Review: Genteel Lancing Device

Regularly checking blood glucose levels is an integral part of optimizing diabetes management, and in particular for patients who use insulin. However, frequent finger pricks can be uncomfortable and even painful for some, especially for children, which may be a deterrent to regular blood glucose testing. Genteel is the only currently-available lancing device on the market that is FDA-approved for both finger and alternative site testing and uses a unique technology to minimize the pain of finger pricks for blood sample collection.

Who They Are

Genteel was founded by Dr. Christoher Jacobs, a biomedical engineer. A friend of his was diagnosed with type 2 diabetes and expressed the challenges of the condition, including the pain he experienced from frequent testing. As a result, Dr. Jacobs set out to develop a device that would minimize the pain of obtaining a blood sample, and the Genteel device was born.

What It Is

The Genteel lancing products make use of several ways to minimize the pain of fingersticks. They allow users to select a variable “contact tip” size to minimize the penetration of the lancet under the skin. Also, the products make use of vacuum technology to help draw out a drop of blood for testing automatically, instead of having to squeeze the site.

Image by Genteel

There are two products available — the Genteel Lancing Device and the Genteel Plus Lancing Device. The basic lancing device is only compatible with the provided “butterfly touch” lancets, whereas the upgraded version is compatible with many other lancet types.

Check out the video below that explains exactly how the device works:

My Review

Personally, I found the device to be a bit elaborate and not very practical in terms of ease of use. When the product was first brought to the market, it was reviewed by Ginger Vieira, and I agree with much of her commentary regarding the product size, appearance, and lack of discreteness in use.

However, I can confirm that obtaining a blood sample was not painful for me, whether sampling from the fingertip or from the alternate site (my palm). While I still felt the contact of the lancet, it was definitely not painful and was certainly much more comfortable than many of the fingersticks I have experienced in almost 13 years of testing my blood sugar on a daily basis.

I can see that for some patients, for example, small children, this device may help to eliminate the fear and discomfort of checking blood sugar levels, and hopefully help the user achieve more frequent tests, and as a result, better glycemic control. The stickers included for decorating the lancing device are sure to be a hit with the kids, too.

The products aren’t cheap though! The base model costs $49.99 and the upgraded version $99.99.

Where to Buy

Both the basic and plus models can be purchased directly from the Genteel website. You can read more about each device before making the decision here:

Conclusions

While the Genteel lancing device may not be everyone’s favorite choice, it certainly helps with comfortably and painlessly obtaining a blood sample for testing, which might be a huge consideration for some patients, and in particular, for small children.

Have you tried Genteel products? Please share your thoughts and experiences in the comments.

Source: diabetesdaily.com

Time Flies! Don’t Wait to Use Your Year-End Insurance Benefits on a New Insulin Pump

Time for a new insulin pump? Regardless of the time of year, with the t:slim X2™ insulin pump, you won’t need to replace it when the next big features arrive. Stacey Simms shares how using your year-end insurance benefits can be your best option to pay less.
Source: diabetesdaily.com

Diabetes Medicines That Help Your Waistline and Your Heart

This content originally appeared on TCOYD: Taking Control of Your Diabetes. Republished with permission.By Daniel Einhorn Among the dirty little secrets of the older diabetes medicines was that they usually made you gain weight, they could cause low blood sugar suddenly and unexpectedly, and they had no particular benefit to the most important consequence of […]
Source: diabetesdaily.com

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