Debate: Can Technology Eliminate Hypoglycemia? (ADA 2020)

Advances in diabetes technology have brought forth a lot of new and valuable tools to people living with diabetes. From continuous glucose monitors (CGMs), to insulin pumps, to integrated systems that can automatically adjust insulin delivery based on CGM reading to safeguard against hypoglycemia, diabetes tech is rapidly evolving. For all insulin users, low blood glucose is of particular concern; too much insulin on board can quickly result in an emergency situation, if not promptly addressed.

At the American Diabetes Association (ADA) 80th Scientific Sessions, experts debated the following important question:

Can technology alone solve the problem of hypoglycemia in diabetes?

Dr. Richard M Bergenstal, MD from the International Diabetes Center at Park Nicollet argued “for”, while Dr. Emma G. Wilmot, MD from the University Hospitals of Derby and Burton present her case “against” this notion. Here is the synopsis from this exciting debate. Notably, both presenters disclosed numerous relationships with technology companies and pharmaceutical companies.

Yes, Technology Alone Can Solve the Issue of Hypoglycemia

Dr. Bergenstal began by defining four specific “problems” of hypoglycemia:

  1. “Dangerous levels and ripple effects of hypoglycemia”—low blood glucose levels can cause mental turmoil and may prevent patients from striving for optimal glycemia
  2. Defining hypoglycemia
  3. Detecting hypoglycemia
  4. Preventing hypoglycemia

We have been pretty unsuccessful at preventing hypoglycemia; that is, until technology was introduced,” he stated.

Strikingly, the presenter mentioned that after over 20 years of improvements to the average a1C levels, they are now increasing across the board. Dr. Bergenstal attributed this largely to people’s fear of hypoglycemia. He also mentioned a recent paper that indicates that, sadly, we are also experiencing a “resurgence in diabetes-related complications.”

Next, the presenter addressed the importance of consistently defining hypoglycemia. He explained that the official definitions of hypoglycemia (as defined for clinical trials reporting) have been evolving in recent years, now often defined by levels.

Then, the speaker moved forward to discuss that CGM technology was critical to the most thorough detection of hypoglycemia, noting that self-monitoring of blood glucose (SMBG, or finger-sticks) did not present the whole picture of blood glucose trends, making it more likely that low blood glucose could go unnoticed. Moreover, he argued that the accuracy of today’s CGM devices are on par with many blood glucose meters.

As far as the capability of technology in preventing hypoglycemia, Dr. Bergestal presented data from a very large international study showing that CGM use resulted in a tremendous decrease in both hyperglycemia and hypoglycemia, across a large patient population, across the board. He also presented data from several other studies that demonstrated the benefits of CGM technology as related to the incidence of hypoglycemia.

Next, he also addressed the role of “smart insulin pumps” that communicate with CGMs in helping to further reduce hypoglycemia. Strikingly, the results from one study using an “automated basal/hybrid closed loop system (closed loop at all times with meal-time manual assist bolusing)” resulted in a 100% reduction in hypoglycemia. The presenter also showed some case reports that suggested more technology (CGM + Pump vs. CGM + MDI) may yield better glycemic management. Furthermore, he touched upon several other advancements, ranging from faster-acting insulin formulations on the market and in development to smart insulin pens, and their relevance in improving outcomes (see below).

Dr. Bergenstal had this to say in conclusion:

“Technology can address [all four problems of hypoglycemia]… We’re going now from just good clinical care, to really ethics and just morality, I think. This journal of HealthCare Ethics Committee Forum, they looked at and postulated that continuous glucose monitoring is really a matter of justice. I know that sounds a little extreme, but if it can do what I’m showing you it can do, and people are struggling every day, maybe they really do have a right to use this technology… I think we better rely on technology to prevent the highs and the lows of diabetes.”  

No, Technology Alone Cannot Solve the Issue of Hypoglycemia

Dr. Emma Wilmot began by sharing that she loves diabetes technology, and that it plays an important role in reducing hypoglycemia. “However, technology ALONE can solve the problem of hypoglycemia? If only it were that simple,” she stated.

The speaker went on to present data showing that despite CGM use, as many as 25% of users are still experiencing severe hypoglycemia. She argued that “structured education” in diabetes management plays a more central role in reducing hypoglycemia, pointing to numerous research studies showing significantly improved outcomes following a formal diabetes education program.

Moreover, Dr. Wilmot commented on the role of hypoglycemia unawareness, and how reducing the incidence of low blood glucose levels via educational programs, also helped to mitigate hypoglycemia unawareness, in turn likely reducing severe hypoglycemia even more.   In contrast, she stated that there is no research to show that technology use can help to mitigate hypoglycemia unawareness. Furthermore, the presenter discussed several studies that showed “no additional benefit” of technology use (CGM and/or insulin pumps).

Technology is not for all,” Dr. Wilmot noted, citing issues like various technical problems, alarm fatigue, and site skin reactions. Strikingly, according to data from T1 Exchange, “41% had stopped using CGM in the past year.” Similarly, she noted, “30% of youth discontinued the hybrid closed-loop system”. Access and affordability is another paramount issue, she noted.

Rebuttals

While Dr. Bergenstal remarked that he understood and appreciated the role of patient education programs, he noted in his rebuttal, that the glycemic outcomes are not optimal in these patient populations, stating he believes technology can give us better control, reducing both hypo- and hyperglycemia.

Dr. Wilmot concurred that the levels of glycemia currently being achieve are “nowhere near good enough” and also agreed that several established educational programs are now incorporating technology education as well. However, she maintained that technology alone was not the sole solution.

Dr. Bergestal concurred with this, but also stated that technology is “outpacing everything else we’ve thrown at hypoglycemia so far.”

Conclusions

While most will agree that technology use can help to reduce hypoglycemia, whether it can be altogether (or even mostly) overcome with technology use alone remains a point of debate. Undoubtedly, the role of education in diabetes management plays a pivotal role. There is no “set-it-and-forget-it” in diabetes management today, not quite yet, anyway, and certainly not across the board for patients. Perhaps, as smart technology evolves further and becomes more mainstream, it may eventually overtake patient education in importance when it comes to preventing adverse events.

What are your thoughts on this subject?

Source: diabetesdaily.com

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