The Evolution of Diabetes Technology: How Are We Doing?
Recently, while walking through a busy airport, two people in my group activated the metal detectors and were stopped and subjected to a routine search. Both individuals wore insulin pumps and showed their pumps to the airport security guards. But the officials seemed neither interested in nor concerned about these devices. As it turned out, the metal detectors were set off by a combination of handheld computers, blood glucose meters, and expensive Waterman pens. Still, I was curious about the lack of response regarding the insulin pumps, so I asked one guard if he had ever seen one.
"I see these everyday," he said. He added that thanks to some quick instructions from a recent passenger, he could even find someone's average blood glucose, assuming the same meter was available. Imagine that . . . the airport security guard was trying to be my diabetes educator!
This brings to mind the tremendous recent advances in our technologies to improve diabetes care. It does not stop with home blood glucose monitoring and insulin pumps. The technologies available now and those to come in the future can only bring excitement to patients and their physicians.
For example, I find the new computer programs that help analyze home blood glucose data particularly helpful,1 although they are not yet widely used. Insulin pens are finally becoming popular in the United States, and our patients are learning about this convenient method of insulin administration. We now have powerful new agents for treating insulin resistance. Continuous subcutaneous glucose sensors are now a realitynot something only George Jetson would use. New fingerstick devices have been long awaited, although this challenge still needs some work. And large-scale trials of human islet cell transplants are now being discussed.
The greatest surprise for me has been the increasing popularity of continuous subcutaneous insulin infusion (CSII), a trend that may have been furthered by the fact that former Miss America Nicole Johnson was a "pumper." But perhaps I should not be surprised. Delivering continuous insulin to better mimic a functioning -cell has always seemed a more physiological manner to provide insulin, particularly in type 1 diabetes.2 By incorporating the rapid-acting insulin lispro (Humalog), CSII therapy has become even more compelling.3
Others now seem to agree. It is estimated that in early 2000, there are more than 80,000 people in the United States wearing insulin pumps (Linda Fredrickson, MA, RN, CDE, personal communication). No wonder the airport security guards are familiar with this new technology.
I wish I could say that this increase in pump use has been linked to better patient outcomes. We are awaiting prospective and retrospective trials for both type 1 and type 2 diabetes with insulin lispro and with the newest short-acting insulin analog, insulin aspart (Novolog). The use of CSII is quite different with these new insulins compared to regular insulin, and older data regarding pump therapy (including HbA1c and hypoglycemia) need to be reassessed. My prediction is that newer data will show significantly better outcomes.
However, the broad use of CSII by many physicians has generated new concerns. In the past year, I have seen numerous new patients who were wearing an insulin pump but did not know how to best use their pump or, for that matter, how to treat their diabetes. We see patients who only occasionally measure their blood glucose, do not understand how to match carbohydrates with insulin, do not understand how different types of food affect glycemia, and do not supplement with additional insulin for premeal hyperglycemia. These are not good candidates for CSII.
Clearly, none of our new technologies will be appropriate for all patients. For that matter, not all of them will be suitable for all clinicians.
The major reason for this problem can be summarized in one word: time. We simply don't have enough of it to do everything necessary to manage our patients most effectively.
There are certainly other reasons. For example, I do not believe that we make adequate use of the expertise of clinical nurse specialists and dietitians. Very few of us can practice in an environment similar to that in the landmark Diabetes Control and Complications Trial,4 in which nonphysician health care professionals manage the majority of the diabetes care. This issue is related less to time constraints and more to reimbursement problems.
I predict that CSII will become quite common for people with type 2 diabetes, who are generally managed by primary care physicians. This assumes that there will be a paradigm change for how most of us manage patients with diabetes. Other technologies, particularly those involved with noninvasive or minimally invasive blood glucose monitoring, will also be widely used.
As exciting as this is, let us pause for a reality check. One recent survey found that only 50% of patients received a yearly dilated eye exam, 27% were screened for diabetic nephropathy, and 35% maintained blood pressures <140/90 mmHg (The American Diabetes Association target is 130/85 mmHg.5) Other surveys have shown similar results over the past 10 years. If this is our accepted standard, how realistic is it to push forward with all of these new technologies? What about old technologies? How well do we use home blood glucose testing? One recent survey noted that it is underutilized.6 And insulin pumps? My experience with some patients, as noted above, is quite disappointing.
We need to develop a better way to regulate patient selection and education for all of our new technologies. Until now, the insurance companies have been the only "diabetes police" for this task. It seems to me that there should be better solutions, but I am not sure what they are. Ideally, new technologies that improve our patients' outcomes should be both easy to implement and cost-effective. I am hopeful that, at least most of the time, this will be the case.
1Hirsch IB: How to use home blood glucose monitoring data most effectively. Clinical Diabetes 16:194-95, 1998.
2Unger J: A primary care approach to continuous subcutaneous insulin infusion. Clinical Diabetes 17:113-20, 1999.
3Zinman B, Tildesley H, Chiasson J-L, Tsui E, Strack T: Insulin lispro in CSII: results of a double-blind crossover study. Diabetes 46:440-43, 1997.
4The DCCT Research Group: The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 329:977-86, 1993.
5Sugarman JR, Norman J, Kessler LD, Presley RJ, Baumgardner GS, Yue JS, Beyer CS: Pilot test of the DQIP and FACCT diabetes measures, Washington State, 1997 [Abstract]. Diabetes 48 (Suppl 1):A422, 1999.
6Harris MI, Eastman RC, Cowie CC, Flegal KM, Eberhardt MS: Racial and ethnic differences in glycemic control in adults with type 2 diabetes. Diabetes Care 22:403-408, 1999.
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