Hot topics in diabetes management
Our guest author is Annie Astle, an award winning diabetes blogger who is more commonly found writing The Understudy Pancreas. We asked Annie to provide her take on just two of the headlining areas currently impacting upon diabetes management. All opinions within this article are that of the author.
There are a plethora of technological advancements and new products coming to market at a rapid pace, all making bold claims about changing the landscape of diabetes management. However, engagement by people living with diabetes remains a key concern and each manufacturer and HCP should put the PWD voice at the forefront of their new product developments and education.
Off Label Challenges
It’s no secret that people are choosing to hack their insulin pumps and run their own rigs however this presents it’s own set of challenges to HCPs. With no certification or warranty, there are obvious issues for them to be seen to be promoting these advancements. However, many HCPs may prefer not to ignore the advancements and the obvious benefits their patients are gaining from using these homemade solutions. Surely the end goal for all concerned in the management of diabetes, when a PWD chooses to utilise these loop devices, is that there is the same level of engagement between HCP and PWD as somebody who chooses not to use these tools to manage their diabetes, or are just unaware that these options even exist? This topic has lately been brought to the attention of key decision makers at conferences such as this year’s ATTD in Vienna or even more recently, the ADA in Orlando, which saw an entire stream dedicated to #WeAreNotWaiting AP solutions, airing these debates, bringing this topic out of the shadows and casting light and igniting mature discussion about how best to support these off label technological advancements.
There are no easy answers or solutions to this situation, yet the scenario can no longer be ignored. Clinical skepticism is understandable, but there needs to be engagement and understanding in order to move forward. Those using this technology are doing so not for the thrill or jeopardy involved in using products off label. They are using it as current technological solutions are not fit for their purposes and they have been able to source something that does fit with their lives and meet their needs. It is wonderful to see a more mature attitude being deployed around “Looping” and it would be good to see this continue throughout future conferences, without fear of retribution for any party involved.
Time in range
This marks a stark shift change from the slavish regard that has hitherto been awarded to a person’s HbA1c. Moving away from using HbA1c as the marker upon which one’s diabetes management is judged is long overdue. The measurement is flawed and will often belie what is actually happening for the person living with diabetes. No two HbA1c results are equivalent. Even if they purport to be so. Two people may post identical results, and the assumption may be that they are both effectively managing their diabetes. However, one of those people may spend 80% of their time in range whilst the other may only spend 30% of time in range. Their matching results don’t highlight that one person may have wildly fluctuating bg levels and spend the majority of their time oscillating between high blood sugars and low blood sugars. The effect that will have on an individual, and the stress it will impose physically upon their body is not highlighted in the HbA1c measurement.
Turning instead to time in range measurements is a welcome step change. However, the easiest way in which to measure this is through access to continuous glucose monitoring or flash glucose sensing. To receive a similar picture with Self Monitoring Blood Glucose (SMBG) checks, one would need to finger stick blood check every five minutes. That would be 12 separate holes in one’s fingers every single hour. Plus, one would need to forgo all sleep in order to monitor what was happening overnight. Not an entirely practical solution. A full, true picture can only be obtained by using continuous glucose checking technologies that are available within the market place. This technology is rapidly advancing. In earlier incarnations, there were accuracy discrepancies which led to some HCPs distrust of the tech. Not to mention the people actually living with diabetes. But people living with diabetes are a resourceful bunch and always found ways to make the advancements work for them. Ensuring calibrations were adhered to, only calibrating when blood sugars were not fluctuating too much, and a hundred other little hacks that the wearer just discovers over time using the product.
Nowadays, the developments in this field have been rapid and effective. We now stand poised on a horizon where CGM (which actually measures interstitial fluid glucose not blood glucose which historically meant there was a lag between the displayed number and actual bg reading) may be more accurate than some SMBG monitoring. Potentially some people are actually calibrating their CGM out by using SMBG monitors that don’t adhere to the latest ISO standards. This is a huge issue as Care Commission Groups (CCG) strive to save more money and promote the use of less effective (or cheaper) SMBG monitoring. With budgetary constraints as their patients are often left with a less effective tool to try and keep their blood sugars within their desired range. If time in range is to become the new gold standard in diabetes care, there needs to be greater understanding from the payers about the importance of access to effective tools to manage this. Commissioning groups are unaware of the benefits that some people living with diabetes may see from using CGM and FGS. There needs to be a greater emphasis on engagement with all interested parties – payers / clinicians / and most critically people living with or caring for someone with diabetes.
The last time diabetes saw such a monumental shift in the way the condition was managed was in the early 1980s when blood glucose checks became the gold standard for managing blood sugar levels, switching from urine dip checks. The impact this had on management was enormous. However, there was much resistance to the change and it took a long time for the switch to be universal, accepted and funded. If we are expecting people living with diabetes to extend their time in range and this is to be the new norm upon which their management is measured, then funding equitable access and education to real time monitoring must take precedence. Along with the understanding that this will not be a universal panacea. There will be many people living with diabetes for whom this technology and information will be overwhelming and unhelpful. The key message is always “Right device. Right person. Right time.”.