Banting Memorial Lecture 2014 Technology and diabetes care: appropriate and personalized

Abstract

Continuous subcutaneous insulin infusion was initially developed as a research procedure in the 1970s but quickly became a routine treatment for selected people with Type 1 diabetes. Continuous subcutaneous insulin infusion and other diabetes technologies, such as continuous glucose monitoring, are now an established and evidence-based part of diabetes care, but there has been some confusion about effectiveness and best use, particularly because of conflicting results from meta-analyses. This is because literature summary meta-analyses (including all trials) are inappropriate for therapeutic and economic decision-making; such meta-analyses should only include trials representative of groups likely to benefit. For example, for continuous subcutaneous insulin infusion, this would be those with continued disabling hypoglycaemia or elevated HbA1c levels. Alternatively, individual patient data meta-analysis allows modelling of covariates that determine effect size, e.g. in the case of continuous glucose monitoring, baseline HbA1c and frequency of sensor usage. Diabetes technology is therefore an example of personalized medicine, where evaluation and use should be both appropriate and targeted. This will also apply to future technologies such as new 'patch' pumps for Type 2 diabetes, closed-loop insulin delivery systems and nanomedicine applications in diabetes that we are currently researching. These include fluorescence lifetime-based non-invasive glucose monitoring and nanoencapsulation of islets for improved post-transplant survival.

Is insulin pump therapy effective in Type 1 diabetes?

“…Uptake and support for CSII vary between countries [34] and there is some evidence that there is an association between pump use and HbA 1c in different regions. Data from > 50 000 children and adolescents with Type 1 diabetes were analysed from three large registries in Germany/Austria, the Type 1 diabetes (T1D) Exchange in the USA, and the England and Wales National Paediatric Diabetes Audit [35].…”

Smooth muscle‐generated methylglyoxal impairs endothelial cell‐mediated vasodilatation of cerebral microvessels in type 1 diabetic rats

“…Type 1 diabetes mellitus (T1D) is the syndrome that arises in children and adolescents when insulin‐producing beta cells of the pancreas are destroyed by their immune system (American Diabetes Association, ). Although a wide variety of forms of exogenous insulin is available to assist in the regulation of blood glucose in T1D to near physiological levels before and after meals (Pickup, ), tight glycaemic control for some is usually not achieved on a daily basis due to fears of hypoglycaemia. One of the consequences of this inadequate control is functional deterioration of the vasculature in end organs (Petitti et al , ).…”

Insulin Pumps

“…3 In a letter commenting on the Little et al article, Edelman 8 makes the point that the intensive strategies used in the trial, including monthly visits and weekly telephone calls, are not deliverable in routine care. Moreover, the low adherence rate for CGM in the study (57%, with only 17% using CGM > 80% of the time) is below the usage rate at which greater CGM effectiveness vs. SMBG is known to occur-at least for HbA1c 9 and INSULIN PUMPS S-27 probably also for hypoglycemia reduction. It is important also that the cohort of patients in the study of Little et al…”

“…Little SA 1 , Leelarathna L 2 , Walkinshaw E 3 , Tan HK 4 , Chapple O 5 , Lubina-Solomon A 3 , Chadwick TJ 6 , Barendse S 7 , Stocken DD 6 , Brennand C 6 , Marshall SM 1 , Wood R 6 , Speight J [7][8][9] , Kerr D 10 , Flanagan D 4 , Heller SR 3 This manuscript is discussed also in the article on Diabetes Technology and the Human Factor, p. S-109.…”

“…It does not mean that there is no role for diabetes technologies like CSII and CGM in everyday diabetes management. As we have argued before, 9 the pathway of best care in type 1 diabetes is most sensibly and cost-effectively based on a sequential pathway, starting with MDI, then for those that fail to achieve target control on MDI, a trial of CSII, and finally for those who have not achieved target control on CSII, a trial of sensor-augmented pump therapy.…”