1
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Simonson GD, Criego AB, Battelino T, Carlson AL, Choudhary P, Franc S, Gershenoff D, Grunberger G, Hirsch IB, Isaacs D, Johnson ML, Kerr D, Kruger DF, Mathieu C, Martens TW, Nimri R, Oser SM, Peters AL, Weinstock RS, Wright EE, Wysham CH, Bergenstal RM. Expert Panel Recommendations for a Standardized Ambulatory Glucose Profile Report for Connected Insulin Pens. Diabetes Technol Ther 2024. [PMID: 38758213 DOI: 10.1089/dia.2024.0107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2024]
Abstract
Background: Connected insulin pens capture data on insulin dosing/timing and can integrate with continuous glucose monitoring (CGM) devices with essential insulin and glucose metrics combined into a single platform. Standardization of connected insulin pen reports is desirable to enhance clinical utility with a single report. Methods: An international expert panel was convened to develop a standardized connected insulin pen report incorporating insulin and glucose metrics into a single report containing clinically useful information. An extensive literature review and identification of examples of current connected insulin pen reports were performed serving as the basis for creation of a draft of a standardized connected insulin pen report. The expert panel participated in three virtual standardization meetings and online surveys. Results: The Ambulatory Glucose Profile (AGP) Report: Connected Insulin Pen brings all clinically relevant CGM-derived glucose and connected insulin pen metrics into a single simplified two-page report. The first page contains the time in ranges bar, summary of key insulin and glucose metrics, the AGP curve, and detailed basal (long-acting) insulin assessment. The second page contains the bolus (mealtime and correction) insulin assessment periods with information on meal timing, insulin-to-carbohydrate ratio, average bolus insulin dose, and number of days with bolus doses recorded. The report's second page contains daily glucose profiles with an overlay of the timing and amount of basal and bolus insulin administered. Conclusion: The AGP Report: Connected Insulin Pen is a standardized clinically useful report that should be considered by companies developing connected pen technology as part of their system reporting/output.
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Affiliation(s)
- Gregg D Simonson
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Amy B Criego
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Tadej Battelino
- University Medical Center Ljubljana, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Anders L Carlson
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Pratik Choudhary
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - Sylvia Franc
- Diabetes and Metabolic Diseases Department, Sud Francilien Hospital, Corbeil-Essonnes, France
| | | | - George Grunberger
- Grunberger Diabetes & Endocrinology, Bloomfield Hills, Michigan, USA
| | - Irl B Hirsch
- University of Washington School of Medicine, Seattle, Washington, USA
| | | | - Mary L Johnson
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - David Kerr
- Center for Health Systems Research, Sutter Health, Santa Barbara, California, USA
| | - Davida F Kruger
- Division of Endocrinology, Diabetes, Bone and Mineral Disease, Henry Ford Health System, Detroit, Michigan, USA
| | - Chantal Mathieu
- Department of Endocrinology, UZ Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Thomas W Martens
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
| | - Revital Nimri
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Faculty of Medical and Health Sciences, Tel-Aviv University, Tel-Aviv, Israel
| | - Sean M Oser
- University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Anne L Peters
- USC Keck School of Medicine, Los Angeles, California, USA
| | | | - Eugene E Wright
- South Piedmont Area Health Education Center, Charlotte, North Carolina, USA
| | | | - Richard M Bergenstal
- International Diabetes Center, HealthPartners Institute, Minneapolis, Minnesota, USA
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2
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Khalilnejad A, Sun RT, Kompala T, Painter S, James R, Wang Y. Proactive Identification of Patients with Diabetes at Risk of Uncontrolled Outcomes during a Diabetes Management Program: Conceptualization and Development Study Using Machine Learning. JMIR Form Res 2024; 8:e54373. [PMID: 38669074 PMCID: PMC11087850 DOI: 10.2196/54373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 01/12/2024] [Accepted: 01/20/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND The growth in the capabilities of telehealth have made it possible to identify individuals with a higher risk of uncontrolled diabetes and provide them with targeted support and resources to help them manage their condition. Thus, predictive modeling has emerged as a valuable tool for the advancement of diabetes management. OBJECTIVE This study aimed to conceptualize and develop a novel machine learning (ML) approach to proactively identify participants enrolled in a remote diabetes monitoring program (RDMP) who were at risk of uncontrolled diabetes at 12 months in the program. METHODS Registry data from the Livongo for Diabetes RDMP were used to design separate dynamic predictive ML models to predict participant outcomes at each monthly checkpoint of the participants' program journey (month-n models) from the first day of onboarding (month-0 model) up to the 11th month (month-11 model). A participant's program journey began upon onboarding into the RDMP and monitoring their own blood glucose (BG) levels through the RDMP-provided BG meter. Each participant passed through 12 predicative models through their first year enrolled in the RDMP. Four categories of participant attributes (ie, survey data, BG data, medication fills, and health signals) were used for feature construction. The models were trained using the light gradient boosting machine and underwent hyperparameter tuning. The performance of the models was evaluated using standard metrics, including precision, recall, specificity, the area under the curve, the F1-score, and accuracy. RESULTS The ML models exhibited strong performance, accurately identifying observable at-risk participants, with recall ranging from 70% to 94% and precision from 40% to 88% across the 12-month program journey. Unobservable at-risk participants also showed promising performance, with recall ranging from 61% to 82% and precision from 42% to 61%. Overall, model performance improved as participants progressed through their program journey, demonstrating the importance of engagement data in predicting long-term clinical outcomes. CONCLUSIONS This study explored the Livongo for Diabetes RDMP participants' temporal and static attributes, identification of diabetes management patterns and characteristics, and their relationship to predict diabetes management outcomes. Proactive targeting ML models accurately identified participants at risk of uncontrolled diabetes with a high level of precision that was generalizable through future years within the RDMP. The ability to identify participants who are at risk at various time points throughout the program journey allows for personalized interventions to improve outcomes. This approach offers significant advancements in the feasibility of large-scale implementation in remote monitoring programs and can help prevent uncontrolled glycemic levels and diabetes-related complications. Future research should include the impact of significant changes that can affect a participant's diabetes management.
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Akturk HK, McKee AM. Emerging Technologies and Therapeutics for Type 1 Diabetes. Endocrinol Metab Clin North Am 2024; 53:81-91. [PMID: 38272600 DOI: 10.1016/j.ecl.2023.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Abstract
Recent years witnessed advancements in diabetes technologies and therapeutics. People with type 1 diabetes have more options to control their blood glucose, prevent hypoglycemia, and spend more time with their loved ones. Newer diabetes technologies and therapeutics improve the quality of life and boost the confidence of people with type 1 diabetes. In parallel to changes in the diabetes technology field, stem cell research has been evolving. Gene editing and production of β cells from stem cells are ongoing. The current focus of cure studies is how to increase the survival of cells produced with stem cells. New adjunctive therapies are under development.
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Affiliation(s)
- Halis Kaan Akturk
- Barbara Davis Center for Diabetes, University of Colorado, 1775 Aurora Court, Room 1319, Aurora, CO 80045, USA.
| | - Alexis M McKee
- Division of Endocrinology, Metabolism & Lipid Research, Washington University in St. Louis School of Medicine, St Louis, MO, USA
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Kaplan A, Boivin M, Bouchard J, Kim J, Hayes S, Licskai C. The emerging role of digital health in the management of asthma. Ther Adv Chronic Dis 2023; 14:20406223231209329. [PMID: 38028951 PMCID: PMC10657529 DOI: 10.1177/20406223231209329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 09/25/2023] [Indexed: 12/01/2023] Open
Abstract
The most common reasons seen for lack of asthma control include misconceptions about disease control, low controller treatment adherence, poor inhaler technique, and the resulting underuse of controllers and overuse of short-acting beta2 agonists (SABAs). Narrowing these care gaps may be achieved through well-designed patient education that considers the patient's motivation, beliefs, and capabilities regarding their asthma and its management and empowers the patient to become an active participant in treatment decisions. Digital health technologies (DHTs) and digital therapeutic (DT) devices provide new opportunities to monitor treatment behaviors, improve communication between healthcare providers and patients, and generate data that inform educational interactions. DHT and DT have been proven effective in enhancing patient self-management in other chronic conditions, particularly diabetes. Accelerated integration of DHT and DT into the management of asthma patients is facilitated by the use of digital inhalers that employ sensor technology ("smart" inhalers). These devices efficiently provide real-time feedback on controller adherence, SABA use, and inhaler technique that have the strong potential to optimize asthma control.
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Affiliation(s)
- Alan Kaplan
- Department of Family and Community Medicine, University of Toronto, 14872 Yonge Street, Aurora, Toronto, ON L4G 1N2, Canada
- Family Physician Airways Group of Canada, Markham, ON, Canada
| | | | | | - James Kim
- Faculty of Medicine, University of Calgary, Calgary, AB, Canada
| | | | - Christopher Licskai
- Division of Respirology, Department of Medicine, Western University, London, ON, Canada
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Heinemann L, Jendle J. Language Matters: Connected Pens, Smart Pens, Connected Smart Pens, or Just Digital Pens? J Diabetes Sci Technol 2023; 17:875-877. [PMID: 36602039 PMCID: PMC10347989 DOI: 10.1177/19322968221148508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Affiliation(s)
| | - Johan Jendle
- School of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
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6
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Singh A, Afshan N, Singh A, Singh SK, Yadav S, Kumar M, Sarma DK, Verma V. Recent trends and advances in type 1 diabetes therapeutics: A comprehensive review. Eur J Cell Biol 2023; 102:151329. [PMID: 37295265 DOI: 10.1016/j.ejcb.2023.151329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/12/2023] [Accepted: 06/03/2023] [Indexed: 06/12/2023] Open
Abstract
Type 1 diabetes (T1D) is a chronic autoimmune disease characterized by the destruction of pancreatic β-cells, leading to insulin deficiency. Insulin replacement therapy is the current standard of care for T1D, but it has significant limitations. However, stem cell-based replacement therapy has the potential to restore β-cell function and achieve glycaemic control eradicating the necessity for drugs or injecting insulin externally. While significant progress has been made in preclinical studies, the clinical translation of stem cell therapy for T1D is still in its early stages. In continuation, further research is essentially required to determine the safety and efficacy of stem cell therapies and to develop strategies to prevent immune rejection of stem cell-derived β-cells. The current review highlights the current state of cellular therapies for T1D including, different types of stem cell therapies, gene therapy, immunotherapy, artificial pancreas, and cell encapsulation being investigated, and their potential for clinical translation.
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Affiliation(s)
- Akash Singh
- Stem Cell Research Centre, Department of Haematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Noor Afshan
- Stem Cell Research Centre, Department of Haematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Anshuman Singh
- Stem Cell Research Centre, Department of Haematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Suraj Kumar Singh
- Stem Cell Research Centre, Department of Haematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Sudhanshu Yadav
- Stem Cell Research Centre, Department of Haematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India
| | - Manoj Kumar
- ICMR-National Institute for Research in Environmental Health, Bhopal, India
| | | | - Vinod Verma
- Stem Cell Research Centre, Department of Haematology, Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
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7
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Moreno-Fernandez J, Díaz-Soto G, Girbes J, Arroyo FJ. Current Perspective on the Potential Benefits of Smart Insulin Pens on Glycemic Control in Patients With Diabetes: Spanish Delphi Consensus. J Diabetes Sci Technol 2023:19322968231178022. [PMID: 37264627 DOI: 10.1177/19322968231178022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
INTRODUCTION Diabetes mellitus (DM) is a chronic disease with high morbidity and mortality, and glycemic control is key to avoiding complications. Technological innovations have led to the development of new tools to help patients with DM manage their condition. OBJECTIVE This consensus assesses the current perspective of physicians on the potential benefits of using smart insulin pens in the glycemic control of patients with type 1 diabetes (DM1) in Spain. METHODS The Delphi technique was used by 110 physicians who were experts in managing patients with DM1. The questionnaire consisted of 94 questions. RESULTS The consensus obtained was 95.74%. The experts recommended using the ambulatory glucose profile report and the different time-in-range (TIR) metrics to assess poor glycemic control. Between 31% and 65% of patients had TIR values less than 70% and were diagnosed based on glycosylated hemoglobin values. They believed that less than 10% of patients needed to remember to administer the basal insulin dose and between 10% and 30% needed to remember the prandial insulin dose. CONCLUSIONS The perception of physicians in their usual practice leads them to recommend the use of ambulatory glucose profile and time in range for glycemic control. Forgetting to administer insulin is a very common problem and the actual occurrence rate does not correspond with clinicians' perceptions. Technological improvements and the use of smart insulin pens can increase treatment adherence, strengthen the doctor-patient relationship, and help improve patients' education and quality of life.
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Affiliation(s)
- Jesús Moreno-Fernandez
- Endocrinology and Nutrition Department, Ciudad Real General University Hospital, Ciudad Real School of Medicine, University of Castilla-La Mancha, Ciudad Real, Spain
| | - Gonzalo Díaz-Soto
- Endocrinology and Nutrition Service, University Clinical Hospital of Valladolid, School of Medicine, University of Valladolid, Valladolid, Spain
| | - Juan Girbes
- Endocrinology Service, Hospital Arnau de Vilanova, Valencia, Spain
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8
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Vargas E, Nandhakumar P, Ding S, Saha T, Wang J. Insulin detection in diabetes mellitus: challenges and new prospects. Nat Rev Endocrinol 2023:10.1038/s41574-023-00842-3. [PMID: 37217746 DOI: 10.1038/s41574-023-00842-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/19/2023] [Indexed: 05/24/2023]
Abstract
Tremendous progress has been made towards achieving tight glycaemic control in individuals with diabetes mellitus through the use of frequent or continuous glucose measurements. However, in patients who require insulin, accurate dosing must consider multiple factors that affect insulin sensitivity and modulate insulin bolus needs. Accordingly, an urgent need exists for frequent and real-time insulin measurements to closely track the dynamic blood concentration of insulin during insulin therapy and guide optimal insulin dosing. Nevertheless, traditional centralized insulin testing cannot offer timely measurements, which are essential to achieving this goal. This Perspective discusses the advances and challenges in moving insulin assays from traditional laboratory-based assays to frequent and continuous measurements in decentralized (point-of-care and home) settings. Technologies that hold promise for insulin testing using disposable test strips, mobile systems and wearable real-time insulin-sensing devices are discussed. We also consider future prospects for continuous insulin monitoring and for fully integrated multisensor-guided closed-loop artificial pancreas systems.
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Affiliation(s)
- Eva Vargas
- Department of Nanoengineering, University of California San Diego, La Jolla, CA, USA
| | - Ponnusamy Nandhakumar
- Department of Nanoengineering, University of California San Diego, La Jolla, CA, USA
| | - Shichao Ding
- Department of Nanoengineering, University of California San Diego, La Jolla, CA, USA
| | - Tamoghna Saha
- Department of Nanoengineering, University of California San Diego, La Jolla, CA, USA
| | - Joseph Wang
- Department of Nanoengineering, University of California San Diego, La Jolla, CA, USA.
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9
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Messer LH, Vigers T, Akturk HK, Forlenza GP, Huss KB, Karami AJ, Malecha E, Oser SM, Polsky S, Pyle L, Shah VN, Wadwa RP, Oser TK. Increasing Use of Diabetes Devices: What Do Health Care Professionals Need? Clin Diabetes 2023; 41:386-398. [PMID: 37456091 PMCID: PMC10338282 DOI: 10.2337/cd22-0092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Abstract
Despite evidence of improved diabetes outcomes with diabetes technology such as continuous glucose monitoring (CGM) systems, insulin pumps, and hybrid closed-loop (HCL) insulin delivery systems, these devices are underutilized in clinical practice for the management of insulin-requiring diabetes. This low uptake may be the result of health care providers' (HCPs') lack of confidence or time to prescribe and manage devices for people with diabetes. We administered a survey to HCPs in primary care, pediatric endocrinology, and adult endocrinology practices in the United States. Responding HCPs expressed a need for device-related insurance coverage tools and online data platforms with integration to electronic health record systems to improve diabetes technology uptake in these practice settings across the United States.
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Affiliation(s)
- Laurel H. Messer
- University of Colorado School of Medicine, Barbara Davis Center for Diabetes, Aurora, CO
| | - Tim Vigers
- University of Colorado School of Public Health, Department of Biostatistics and Informatics, Aurora, CO
- University of Colorado School of Medicine, Department of Pediatrics, Aurora, CO
| | - Halis K. Akturk
- University of Colorado School of Medicine, Barbara Davis Center for Diabetes, Aurora, CO
| | - Gregory P. Forlenza
- University of Colorado School of Medicine, Barbara Davis Center for Diabetes, Aurora, CO
| | - Kelsey B. Huss
- University of Colorado School of Medicine, Department of Family Medicine, Aurora, CO
| | - Angela J. Karami
- University of Colorado School of Medicine, Barbara Davis Center for Diabetes, Aurora, CO
| | - Emily Malecha
- University of Colorado School of Medicine, Barbara Davis Center for Diabetes, Aurora, CO
| | - Sean M. Oser
- University of Colorado School of Medicine, Department of Family Medicine, Aurora, CO
| | - Sarit Polsky
- University of Colorado School of Medicine, Barbara Davis Center for Diabetes, Aurora, CO
| | - Laura Pyle
- University of Colorado School of Public Health, Department of Biostatistics and Informatics, Aurora, CO
| | - Viral N. Shah
- University of Colorado School of Medicine, Barbara Davis Center for Diabetes, Aurora, CO
| | - R. Paul Wadwa
- University of Colorado School of Medicine, Barbara Davis Center for Diabetes, Aurora, CO
| | - Tamara K. Oser
- University of Colorado School of Medicine, Department of Family Medicine, Aurora, CO
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10
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Ruissen MM, Montori VM, Hargraves IG, Branda ME, León García M, de Koning EJ, Kunneman M. Problem-based shared decision-making in diabetes care: a secondary analysis of video-recorded encounters. BMJ Evid Based Med 2023; 28:157-163. [PMID: 36868578 DOI: 10.1136/bmjebm-2022-112067] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/12/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVES To describe the range of collaborative approaches to shared decision-making (SDM) observed in clinical encounters of patients with diabetes and their clinicians. DESIGN A secondary analysis of videorecordings obtained in a randomised trial comparing usual diabetes primary care with or without using a within-encounter conversation SDM tool. SETTING Using the purposeful SDM framework, we classified the forms of SDM observed in a random sample of 100 video-recorded clinical encounters of patients with type 2 diabetes in primary care. MAIN OUTCOME MEASURES We assessed the correlation between the extent to which each form of SDM was used and patient involvement (OPTION12-scale). RESULTS We observed at least one instance of SDM in 86 of 100 encounters. In 31 (36%) of these 86 encounters, we found only one form of SDM, in 25 (29%) two forms, and in 30 (35%), we found ≥3 forms of SDM. In these encounters, 196 instances of SDM were identified, with weighing alternatives (n=64 of 196, 33%), negotiating conflicting desires (n=59, 30%) and problemsolving (n=70, 36%) being similarly prevalent and developing existential insight accounting for only 1% (n=3) of instances. Only the form of SDM focused on weighing alternatives was correlated with a higher OPTION12-score. More forms of SDM were used when medications were changed (2.4 SDM forms (SD 1.48) vs 1.8 (SD 1.46); p=0.050). CONCLUSIONS After considering forms of SDM beyond weighing alternatives, SDM was present in most encounters. Clinicians and patients often used different forms of SDM within the same encounter. Recognising a range of SDM forms that clinicians and patients use to respond to problematic situations, as demonstrated in this study, opens new lines of research, education and practice that may advance patient-centred, evidence-based care.
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Affiliation(s)
- Merel M Ruissen
- Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Victor M Montori
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Ian G Hargraves
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
| | - Megan E Branda
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, Minnesota, USA
| | - Montserrat León García
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Biomedical Research Institute Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Eelco Jp de Koning
- Department of Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Marleen Kunneman
- Knowledge and Evaluation Research Unit, Mayo Clinic, Rochester, Minnesota, USA
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
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Sparre T, Hammershøy L, Steensgaard DB, Sturis J, Vikkelsøe P, Azzarello A. Factors Affecting Performance of Insulin Pen Injector Technology: A Narrative Review. J Diabetes Sci Technol 2023; 17:290-301. [PMID: 36540004 PMCID: PMC10012375 DOI: 10.1177/19322968221145201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Insulin treatment is an essential hormone replacement therapy for the survival of people with type 1 diabetes and is often used for treatment in type 2 diabetes, particularly as the disease progresses. Advances in insulin therapy have been made since its discovery, including production of human insulin and development of insulin analogs with improved efficacy and safety profiles. The different types of available insulin formulations allow health care professionals to personalize treatment to an individual's needs. Generally, insulin requires parenteral administration via subcutaneous injection owing to very low oral bioavailability. METHODS This article reviews the human, technological, economical, and regulatory factors affecting the performance of insulin pens and the relationship between them. Opportunities and challenges that insulin pen injections may encounter in the future are also considered. RESULTS Insulin delivery devices, together with other factors, influence dose accuracy, convenience, and quality of life, contributing to easier medication administration with high efficacy and safety. For patients, ease of use, fast and accurate drug delivery, and painless injection are the most valuable features of an insulin injection device. For manufacturers, technological feasibility and economic viability also need to be considered when developing injection devices. CONCLUSION Insulin pen injectors are generally preferred over vial and syringe, although access may be limited in some health care systems. Insulin pen injectors can adapt to different insulin regimens and formulations and have the potential to acquire dosing data in real time.
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Affiliation(s)
- Thomas Sparre
- Novo Nordisk A/S, Søborg, Denmark
- Thomas Sparre, MD, PhD, Novo Nordisk A/S,
Vandtårnsvej 112, Søborg 2860, Denmark.
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12
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Calegari LP, Tortorella GL, Fettermann DC. Getting Connected to M-Health Technologies through a Meta-Analysis. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4369. [PMID: 36901379 PMCID: PMC10001891 DOI: 10.3390/ijerph20054369] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2023] [Revised: 02/23/2023] [Accepted: 02/25/2023] [Indexed: 06/18/2023]
Abstract
The demand for mobile e-health technologies (m-health) continues with constant growth, stimulating the technological advancement of such devices. However, the customer needs to perceive the utility of these devices to incorporate them into their daily lives. Hence, this study aims to identify users' perceptions regarding the acceptance of m-health technologies based on a synthesis of meta-analysis studies on the subject in the literature. Using the relations and constructs proposed in the UTAUT2 (Unified Theory of Acceptance and Use of Technology 2) technology acceptance model, the methodological approach utilized a meta-analysis to raise the effect of the main factors on the Behavioral Intention to Use m-health technologies. Furthermore, the model proposed also estimated the moderation effect of gender, age, and timeline variables on the UTAUT2 relations. In total, the meta-analysis utilized 84 different articles, which presented 376 estimations based on a sample of 31,609 respondents. The results indicate an overall compilation of the relations, as well as the primary factors and moderating variables that determine users' acceptance of the studied m-health systems.
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Affiliation(s)
- Luiz Philipi Calegari
- Department of Industrial Engineering, Federal University of Santa Catarina, Florianópolis 8040-900, SC, Brazil
| | | | - Diego Castro Fettermann
- Department of Industrial Engineering, Federal University of Santa Catarina, Florianópolis 8040-900, SC, Brazil
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13
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Conget I, Artime E, Duque N, Díaz-Cerezo S, Rubio-de Santos M. Connected insulin systems in diabetes patients in Spain: Present and future perspectives. ENDOCRINOL DIAB NUTR 2023; 70:155-157. [PMID: 36925231 DOI: 10.1016/j.endien.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 10/29/2022] [Indexed: 03/15/2023]
Affiliation(s)
- Ignacio Conget
- Diabetes Unit, Department of Endocrinology and Nutrition, Hospital Clínic i Universitari, Barcelona, Spain; CIBERDEM, Centro de Investigación Biomédica en Red de Diabetes y Enfermedades Metabólicas [Biomedical Research Network Centre for Diabetes and Metabolic Diseases], Madrid, Spain; IDIBAPS, Institut d'Investigacions Biomèdiques August Pi i Sunyer [August Pi i Sunyer Biomedical Research Institute], Barcelona, Spain
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14
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Cvenkel B, Kolko M. Devices and Treatments to Address Low Adherence in Glaucoma Patients: A Narrative Review. J Clin Med 2022; 12:jcm12010151. [PMID: 36614952 PMCID: PMC9821329 DOI: 10.3390/jcm12010151] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 12/05/2022] [Accepted: 12/21/2022] [Indexed: 12/28/2022] Open
Abstract
Poor adherence to topical glaucoma medications has been linked to worse visual field outcomes in glaucoma patients. Therefore, identifying and overcoming the adherence barriers are expected to slow down the progression of disease. The most common barriers to adherence, in addition to the lack of knowledge, include forgetfulness, side effects of medications, difficulties with drop instillation and low self-efficacy. Symptoms and signs of ocular surface disease, which importantly reduce patients' quality of life, are decreased by using preservative-free topical medications. Sustained drug delivery systems using different vehicles seem promising for relieving the burden of drop administration. Currently, only the bimatoprost sustained-release intracameral implant is available for clinical use and single administration. In the era of digitalization, smart drug delivery-connected devices may aid adherence and, by sharing data with care providers, improve monitoring and adjusting treatment. Selective laser trabeculoplasty as first-line treatment delays the need for drops, whereas minimally invasive glaucoma procedures with and without devices combined with cataract surgery increase the likelihood of patients with early-to-moderate glaucoma to remain drop free or reduce the number of drops needed to control intraocular pressure. The aim of this narrative review is to present and discuss devices and treatments that may improve adherence by reducing the need for drops and side effects of medications and aiding in glaucoma monitoring. For the future, there is a need for studies focusing on clinically important outcomes, quality of life and the cost of intervention with longer post-interventional follow up.
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Affiliation(s)
- Barbara Cvenkel
- Department of Ophthalmology, University Medical Centre Ljubljana, 1000 Ljubljana, Slovenia
- Medical Faculty, University of Ljubljana, 1000 Ljubljana, Slovenia
- Correspondence:
| | - Miriam Kolko
- Department of Drug Design and Pharmacology, University of Copenhagen, 2100 Copenhagen, Denmark
- Department of Ophthalmology, Copenhagen University Hospital, Rigshospitalet, 2600 Glostrup, Denmark
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15
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Connected insulin systems in diabetes patients in Spain: Present and future perspectives. ENDOCRINOL DIAB NUTR 2022. [DOI: 10.1016/j.endinu.2022.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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16
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Kobayati A, Haidar A, Tsoukas MA. Glucagon-like peptide-1 receptor agonists as adjunctive treatment for type 1 diabetes: Renewed opportunities through tailored approaches? Diabetes Obes Metab 2022; 24:769-787. [PMID: 34989070 DOI: 10.1111/dom.14637] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/14/2021] [Accepted: 01/01/2022] [Indexed: 12/24/2022]
Abstract
Exogenous insulin has been the mainstay treatment for individuals living with type 1 diabetes (T1D). Although there has been tremendous growth in both pharmacological and technological advancements, insulin monotherapy has proven to be insufficient for maintaining optimal glycaemic targets for most adults with T1D. At present, there is still no breakthrough for the treatment of T1D. Adjunctive pharmacotherapies might therefore complement insulin management to achieve better glycaemic control, while possibly offering additional benefits. Recent interest in re-purposing glucagon-like peptide-1 receptor agonists (GLP-1RAs), a leading antihyperglycaemic medication class approved for type 2 diabetes, has prompted the field to seek extended potential for the T1D population. The adjunctive use of GLP-1RAs has been at the forefront of T1D research, albeit with some conflicting trial findings to date. However, the potential of GLP-1 agonism for T1D may have been underestimated, possibly from missed opportunities or categorized effects. Moreover, some GLP-1RAs have demonstrated extra-pancreatic potential with emerging multi-organ protection involving the heart, kidneys, liver and brain in varied cohorts, which may bode well for the growing T1D profile of comorbid complications. This narrative review aims to summarize and critically appraise the current evidence-based literature from large-scale randomized controlled trials and closed-loop system pilot studies that examined GLP-1RAs as adjunctive therapy for T1D. Furthermore, we outline uncharted opportunities with GLP-1 agonism using versatile approaches in selected T1D populations that may inspire and re-direct future research in this field.
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Affiliation(s)
- Alessandra Kobayati
- Division of Experimental Medicine, Department of Medicine, McGill University, Montreal, Quebec, Canada
| | - Ahmad Haidar
- Department of Biomedical Engineering, McGill University, Montreal, Quebec, Canada
| | - Michael A Tsoukas
- Division of Endocrinology, McGill University Health Centre, Montreal, Quebec, Canada
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17
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Ilkowitz J, Wissing V, Gallagher MP. Pediatric Smart Insulin Pen Use: The Next Best Thing. J Diabetes Sci Technol 2022; 16:635-640. [PMID: 34474591 PMCID: PMC9294571 DOI: 10.1177/19322968211041362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In the pediatric population, insulin pump therapy, or CSII, is often considered the gold standard for intensive diabetes management. Insulin pump technology offers families and caregivers many beneficial features including a calculator for insulin dosing and the ability to review diabetes management data to provide data-driven diabetes management. However, for those who find CSII challenging or choose to use multiple daily injections (MDI) there is an option that offers similar features called the Smart Insulin Pen (SIP). Even though SIP technology provides a safe and data-driven diabetes self-management tool for the pediatric population using MDI, there is limited pediatric specific literature. This article will describe current options, data-driven diabetes management, benefits, challenges and clinical use of SIP technology in the pediatric population.
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Affiliation(s)
- Jeniece Ilkowitz
- The NYU Pediatric Diabetes Center,
Hassenfeld Childrens’ Hospital at NYU Langone, New York, NY, USA
- Jeniece Ilkowitz, RN, MA, CDCES, The NYU
Pediatric Diabetes Center, Hassenfeld Childrens’ Hospital at NYU Langone, 135
East 31st street, Floor 2, New York, NY 10016, USA.
| | - Vanessa Wissing
- The NYU Pediatric Diabetes Center,
Hassenfeld Childrens’ Hospital at NYU Langone, New York, NY, USA
| | - Mary Pat Gallagher
- The NYU Pediatric Diabetes Center,
Hassenfeld Childrens’ Hospital at NYU Langone, New York, NY, USA
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18
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Sparre T, Hansen NAB, Wernersson AS, Guarraia M. Development of an Insulin Pen is a Patient-Centric Multidisciplinary Undertaking: A Commentary. J Diabetes Sci Technol 2022; 16:617-622. [PMID: 34852662 PMCID: PMC9158249 DOI: 10.1177/19322968211058707] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The goal of human-centered insulin pen design is to relieve the treatment burden of a chronic condition and help affected individuals to feel free of disease. The patient as well as their entire ecosystem should be considered. At Novo Nordisk A/S, we believe that embedding human-centered design at the heart of our development processes is best achieved with multidisciplinary experts in-house to work alongside product development teams and, importantly, the end user. Novo Nordisk introduced the first commercially available insulin pen in 1985 and has continued to develop reusable/durable and prefilled insulin pens to meet different patient needs, through to the latest NovoPen 6 and NovoPen Echo Plus with SMART technology. Human-centered design is essential for delivering meaningful and practical solutions for individuals with diabetes.
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Affiliation(s)
- Thomas Sparre
- Novo Nordisk A/S, Søborg, Denmark
- Thomas Sparre, MD, PhD, Novo Nordisk A/S,
Vandtårnsvej 112, DK-2860 Søborg, Denmark.
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19
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Marks BE, Williams KM, Sherwood JS, Putman MS. Practical aspects of diabetes technology use: Continuous glucose monitors, insulin pumps, and automated insulin delivery systems. J Clin Transl Endocrinol 2022; 27:100282. [PMID: 34917483 PMCID: PMC8666668 DOI: 10.1016/j.jcte.2021.100282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 11/01/2021] [Accepted: 11/27/2021] [Indexed: 02/06/2023] Open
Abstract
There have been tremendous advances in diabetes technology in the last decade. Continuous glucose monitors (CGM), insulin pumps, and automated insulin delivery (AID) systems aim to improve glycemic control while simultaneously decreasing the burden of diabetes management. Although diabetes technologies have been shown to decrease both hypoglycemia and hyperglycemia and to improve health-related quality of life in individuals with type 1 diabetes, the impact of these devices in individuals with cystic fibrosis-related diabetes (CFRD) is less clear. There are unique aspects of CFRD, including the different underlying pathophysiology and unique lived health care experience and comorbidities, that likely affect the use, efficacy, and uptake of diabetes technology in this population. Small studies suggest that CGM is accurate and may be helpful in guiding insulin therapy for individuals with CFRD. Insulin pump use has been linked to improvements in lean body mass and hemoglobin A1c among adults with CFRD. A recent pilot study highlighted the promise of AID systems in this population. This article provides an overview of practical aspects of diabetes technology use and device limitations that clinicians must be aware of in caring for individuals with CF and CFRD. Cost and limited insurance coverage remain significant barriers to wider implementation of diabetes technology use among patients with CFRD. Future studies exploring strategies to improve patient and CF provider education about these devices and studies showing the effectiveness of these technologies on health and patient-reported outcomes may lead to improved insurance coverage and increased rates of uptake and sustained use of these technologies in the CFRD community.
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Affiliation(s)
- Brynn E. Marks
- Division of Endocrinology and Diabetes, Children’s National Hospital, 111 Michigan Ave, NW, Washington, DC 20010, USA
| | - Kristen M. Williams
- Division of Pediatric Endocrinology, Diabetes, and Metabolism, Columbia University Irving Medical Center, 1150 St Nicholas Avenue, New York, NY 10032, United States
| | - Jordan S. Sherwood
- Diabetes Research Center, Division of Pediatric Endocrinology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
| | - Melissa S. Putman
- Division of Endocrinology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115, United States
- Diabetes Research Center, Division of Endocrinology, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114, United States
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20
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Newman C, Ero A, Dunne FP. Glycaemic control and novel technology management strategies in pregestational diabetes mellitus. Front Endocrinol (Lausanne) 2022; 13:1109825. [PMID: 36714590 PMCID: PMC9877346 DOI: 10.3389/fendo.2022.1109825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 12/21/2022] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Pregestational diabetes (PGDM) is an increasingly common and complex condition that infers risk to both mother and infant. To prevent serious morbidity, strict glycaemic control is essential. The aim of this review is to review the glucose sensing and insulin delivering technologies currently available for women with PGDM. METHODS We reviewed online databases for articles relating to technology use in pregnancy using a combination of keywords and MeSH headings. Relevant articles are included below. RESULTS A number of technological advancements have improved care and outcomes for women with PGDM. Real time continuous glucose monitoring (rtCGM) offers clear advantages in terms of infants size and neonatal intensive care unit admissions; and further benefits are seen when combined with continuous subcutaneous insulin delivery (insulin pump) and algorithms which continuously adjust insulin levels to glucose targets (hybrid closed loop). Other advancements including flash or intermittent scanning CGM (isCGM) and stand-alone insulin pumps do not confer as many advantages for women and their infants, however they are increasingly used outside of pregnancy and many women enter pregnancy already using these devices. DISCUSSION This article offers a discussion of the most commonly used technologies in pregnancy and evaluates their current and future roles.
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Affiliation(s)
- Christine Newman
- School of Medicine, College of Medicine, Nursing and Health Science, University of Galway, Galway, Ireland
- Department of Diabetes and Endocrinology, Galway University Hospital, Galway, Ireland
- Diabetes Collaborative Clinical Trials Network, University of Galway, Galway, Ireland
- *Correspondence: Christine Newman,
| | - Adesuwa Ero
- Department of Diabetes and Endocrinology, Galway University Hospital, Galway, Ireland
| | - Fidelma P. Dunne
- School of Medicine, College of Medicine, Nursing and Health Science, University of Galway, Galway, Ireland
- Department of Diabetes and Endocrinology, Galway University Hospital, Galway, Ireland
- Diabetes Collaborative Clinical Trials Network, University of Galway, Galway, Ireland
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21
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Masierek M, Nabrdalik K, Janota O, Kwiendacz H, Macherski M, Gumprecht J. The Review of Insulin Pens-Past, Present, and Look to the Future. Front Endocrinol (Lausanne) 2022; 13:827484. [PMID: 35355552 PMCID: PMC8959107 DOI: 10.3389/fendo.2022.827484] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 02/02/2022] [Indexed: 12/17/2022] Open
Abstract
Currently, there are about 150-200 million diabetic patients treated with insulin globally. The year 2021 is special because the 100th anniversary of the insulin discovery is being celebrated. It is a good occasion to sum up the insulin pen technology invention and improvement which are nowadays the leading mode of an insulin delivery. Even though so many years have passed, insulin is still administered subcutaneously, that is why devices to deliver it are of great importance. Insulin pens have evolved only through the last decades (the reusable, durable pens, and the disposable, prefilled pens) and modern smart insulin pens have been developed in the last few years, and both types of the devices compared to traditional syringes and vials are more convenient, discrete in use, have better dosing accuracy, and improve adherence. In this review, we will focus on the history of insulin pens and their improvement over the previous decades.
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Affiliation(s)
- Małgorzata Masierek
- Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Nabrdalik
- Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
- *Correspondence: Katarzyna Nabrdalik,
| | - Oliwia Janota
- Students’ Scientific Association by the Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Hanna Kwiendacz
- Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Maksymilian Macherski
- Students’ Scientific Association by the Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Janusz Gumprecht
- Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
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22
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Ospelt E, Noor N, Sanchez J, Nelson G, Rioles N, Malik FS, Basina M, Indyk J, Vendrame F, Schmitt J, Scott ML, Ebekozien O. Facilitators and Barriers to Smart Insulin Pen Use: A Mixed-Method Study of Multidisciplinary Stakeholders From Diabetes Teams in the United States. Clin Diabetes 2022; 41:56-67. [PMID: 36714258 PMCID: PMC9845084 DOI: 10.2337/cd22-0068] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
This study sought to identify barriers and facilitators to successful smart insulin pen (SIP) use and gauge prescribing practices and integration into clinical practice by assessing provider and care team perspectives at participating endocrinology clinics within the T1D Exchange Quality Improvement Collaborative. The identified provider-related, patient-related, and clinic- and operational-level barriers and facilitators varied based on clinic knowledge, capacity, and resources. High-impact barriers included insurance coverage and prescribing processes; high-impact facilitators included improved diabetes clinic visit quality and use of SIPs as an alternative to insulin pump therapy. Findings indicated the need for provider and care team education and training on proper SIP features, use, and prescribing.
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Affiliation(s)
- Emma Ospelt
- T1D Exchange, Boston, MA
- Corresponding author: Emma Ospelt,
| | | | - Janine Sanchez
- University of Miami Miller School of Medicine, Miami, FL
| | | | | | | | | | | | | | | | | | - Osagie Ebekozien
- T1D Exchange, Boston, MA
- University of Mississippi School of Population Health, Jackson, MS
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23
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Aungst TD. Reevaluating medication adherence in the era of digital health. Expert Rev Med Devices 2021; 18:25-35. [PMID: 34913793 DOI: 10.1080/17434440.2021.2019012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Medication adherence is a worldwide issue impacting more than half the population. The cost associated with nonadherence is tremendous and has spurred the growth of novel technologies to address this growing problem. AREAS COVERED This perspective covers the different digital health medication adherence tools that have come to market in the past decade and their clinical impact. These digital interventions and their applicability to medication adherence across different stakeholders are then evaluated. EXPERT OPINION Digital health will play a significant role in creating new pathways to care in the 2020s. However, the current design of medication adherence tools has not demonstrated a clinical impact that will be relevant for the digital health space without a change in redesign factoring in relevant stakeholders' incentives to address adherence issues. A focus on only adherence has not yielded the economic or clinical benefit as expected, which is likely due to a lack of focus on broader drug-related problems (DRPs) that are causative factors beyond adherence alone. As such, adherence tools will see disparate uptake, likely due to condition-specific interventions rather than adherence issues as a whole, and future endeavors will need to address the larger DRP considerations to actualize clinical outcomes.
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24
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Shah NA, Levy CJ. Emerging technologies for the management of type 2 diabetes mellitus. J Diabetes 2021; 13:713-724. [PMID: 33909352 DOI: 10.1111/1753-0407.13188] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/19/2021] [Accepted: 04/25/2021] [Indexed: 01/02/2023] Open
Abstract
Diabetes mellitus is a global health problem affecting 422 million people worldwide, of which 34.2 million live in the United States alone. Complications due to diabetes can lead to considerable morbidity and mortality related to both microvascular and macrovascular disease. While glycosylated hemoglobin testing is the standard test utilized to evaluate glycemic control, emerging targets like "time in range" and "glycemic variability" often provide more accurate assessments of glycemic fluctuations and have implications for diabetes complications and quality of life. Patients with diabetes face considerable burdens of self-care including frequent glucose monitoring, multiple insulin injections, dietary management, and the need to track daily activities, all of which lead to reduced adherence and psychological burnout. From the provider perspective, limited patient data and access to self-management tools lead to treatment inertia and a reduced ability to help patients achieve and maintain their glycemic goals. In the past few decades, there have been considerable advances in treatment-based technology and technological applications designed to help reduce patient burden and provide tools for better self-management. These advances make real-time clinical data available for clinicians to make necessary changes in treatment regimens. In this review, we discuss the latest emerging technologies available for the management of people with type 2 diabetes mellitus.
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Affiliation(s)
- Nirali A Shah
- Division of Endocrinology, Diabetes and Bone Metabolism, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Carol J Levy
- Division of Endocrinology, Diabetes and Bone Metabolism, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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25
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Grunberger G, Sherr J, Allende M, Blevins T, Bode B, Handelsman Y, Hellman R, Lajara R, Roberts VL, Rodbard D, Stec C, Unger J. American Association of Clinical Endocrinology Clinical Practice Guideline: The Use of Advanced Technology in the Management of Persons With Diabetes Mellitus. Endocr Pract 2021; 27:505-537. [PMID: 34116789 DOI: 10.1016/j.eprac.2021.04.008] [Citation(s) in RCA: 121] [Impact Index Per Article: 40.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations regarding the use of advanced technology in the management of persons with diabetes mellitus to clinicians, diabetes-care teams, health care professionals, and other stakeholders. METHODS The American Association of Clinical Endocrinology (AACE) conducted literature searches for relevant articles published from 2012 to 2021. A task force of medical experts developed evidence-based guideline recommendations based on a review of clinical evidence, expertise, and informal consensus, according to established AACE protocol for guideline development. MAIN OUTCOME MEASURES Primary outcomes of interest included hemoglobin A1C, rates and severity of hypoglycemia, time in range, time above range, and time below range. RESULTS This guideline includes 37 evidence-based clinical practice recommendations for advanced diabetes technology and contains 357 citations that inform the evidence base. RECOMMENDATIONS Evidence-based recommendations were developed regarding the efficacy and safety of devices for the management of persons with diabetes mellitus, metrics used to aide with the assessment of advanced diabetes technology, and standards for the implementation of this technology. CONCLUSIONS Advanced diabetes technology can assist persons with diabetes to safely and effectively achieve glycemic targets, improve quality of life, add greater convenience, potentially reduce burden of care, and offer a personalized approach to self-management. Furthermore, diabetes technology can improve the efficiency and effectiveness of clinical decision-making. Successful integration of these technologies into care requires knowledge about the functionality of devices in this rapidly changing field. This information will allow health care professionals to provide necessary education and training to persons accessing these treatments and have the required expertise to interpret data and make appropriate treatment adjustments.
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Affiliation(s)
| | - Jennifer Sherr
- Yale University School of Medicine, New Haven, Connecticut
| | - Myriam Allende
- University of Puerto Rico School of Medicine, San Juan, Puerto Rico
| | | | - Bruce Bode
- Atlanta Diabetes Associates, Atlanta, Georgia
| | | | - Richard Hellman
- University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | | | | | - David Rodbard
- Biomedical Informatics Consultants, LLC, Potomac, Maryland
| | - Carla Stec
- American Association of Clinical Endocrinology, Jacksonville, Florida
| | - Jeff Unger
- Unger Primary Care Concierge Medical Group, Rancho Cucamonga, California
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26
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Rodbard D, Garg SK. Standardizing Reporting of Glucose and Insulin Data for Patients on Multiple Daily Injections Using Connected Insulin Pens and Continuous Glucose Monitoring. Diabetes Technol Ther 2021; 23:221-226. [PMID: 33480828 DOI: 10.1089/dia.2021.0030] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background: Recent development and availability of several connected insulin pens with digital memory are likely to expand the availability of glucose and insulin metrics that previously had been available only for the much smaller number of people using insulin pumps. It would be highly desirable to standardize data presentations to avoid the chaotic emergence of multiple formats that might reduce the clinical utility of connected pens. Methods: We reviewed the literature and analyzed data displays from multiple blood glucose monitoring, continuous glucose monitoring (CGM), insulin pump, and automated insulin delivery systems, and methods for combination of glucose and insulin data. We examined multiple forms of presentation and now propose a prototype for a standardized method for data analysis and display, focusing on the content and format of a one-page dashboard summary for patients on multiple daily injection (MDI) insulin regimens. Results: We propose the following metrics to be included in the one-page report: (A) glucose metrics: simplified glucose distribution in the form of a stacked bar chart showing percentages of time below-, above-, or within-target ranges overall and (optionally) by date, by time of day, or day of the week; (B) insulin metrics: types and doses, and timing of basal and bolus insulin; (C) an enhanced ambulatory glucose profile or "AGP+" showing glucose data points and/or distributions (10th to 90th percentiles), dosages and timing of basal and bolus insulins and (optionally) graphical display of risk of hypoglycemia and hyperglycemia; and (D) user experience regarding technology usage, frequency of alerts for hypo- and hyperglycemia, and information regarding lifestyle, meals, exercise, and sleep, if available; and (E) clinical insights and interpretation. Conclusion: We propose a prototype for a dashboard summary report of glucose, insulin, meals, and activity data intended for providers and patients on MDI using connected pens and CGM. Our goal is to stimulate development of a standardized approach.
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Affiliation(s)
- David Rodbard
- Biomedical Informatics Consultants LLC, Clinical Biostatistics Department, Potomac, Maryland, USA
| | - Satish K Garg
- Barbara Davis Center for Diabetes, Departments of Medicine and Pediatrics, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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27
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El Fathi A, Fabris C, Breton MD. Titration of Long-Acting Insulin Using Continuous Glucose Monitoring and Smart Insulin Pens in Type 1 Diabetes: A Model-Based Carbohydrate-Free Approach. Front Endocrinol (Lausanne) 2021; 12:795895. [PMID: 35082757 PMCID: PMC8785345 DOI: 10.3389/fendo.2021.795895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Multiple daily injections (MDI) therapy is the most common treatment for type 1 diabetes (T1D), consisting of long-acting insulin to cover fasting conditions and rapid-acting insulin to cover meals. Titration of long-acting insulin is needed to achieve satisfactory glycemia but is challenging due to inter-and intra-individual metabolic variability. In this work, a novel titration algorithm for long-acting insulin leveraging continuous glucose monitoring (CGM) and smart insulin pens (SIP) data is proposed. METHODS The algorithm is based on a glucoregulatory model that describes insulin and meal effects on blood glucose fluctuations. The model is individualized on patient's data and used to extract the theoretical glucose curve in fasting conditions; the individualization step does not require any carbohydrate records. A cost function is employed to search for the optimal long-acting insulin dose to achieve the desired glycemic target in the fasting state. The algorithm was tested in two virtual studies performed within a validated T1D simulation platform, deploying different levels of metabolic variability (nominal and variance). The performance of the method was compared to that achieved with two published titration algorithms based on self-measured blood glucose (SMBG) records. The sensitivity of the algorithm to carbohydrate records was also analyzed. RESULTS The proposed method outperformed SMBG-based methods in terms of reduction of exposure to hypoglycemia, especially during the night period (0 am-6 am). In the variance scenario, during the night, an improvement in the time in the target glycemic range (70-180 mg/dL) from 69.0% to 86.4% and a decrease in the time in hypoglycemia (<70 mg/dL) from 10.7% to 2.6% was observed. Robustness analysis showed that the method performance is non-sensitive to carbohydrate records. CONCLUSION The use of CGM and SIP in people with T1D using MDI therapy has the potential to inform smart insulin titration algorithms that improve glycemic control. Clinical studies in real-world settings are warranted to further test the proposed titration algorithm. SIGNIFICANCE This algorithm is a step towards a decision support system that improves glycemic control and potentially the quality of life, in a population of individuals with T1D who cannot benefit from the artificial pancreas system.
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