Technological Advances in Diabetes Care: Where Are We Going?
Irl B. Hirsch, MD, Guest Editor

There are several books in my library that I consider so important I will not even lend them to colleagues. (I’ve learned the hard way that once gone, they may never return.) Intensive Insulin Therapy, by Schade, Santiago, Skyler, and Rizza, published in 1983, is one of these books.

This publication, more than any other, assembled all of the information available at that time about how to use new tools to meticulously control blood glucose levels. These tools included home blood glucose monitoring, glycated hemoglobin assessment, and continuous subcutaneous insulin infusion (CSII) pumps. One of the themes of the book was that, although the hypothesis existed that glucose control was associated with the microvascular complications of diabetes, definitive proof was still lacking, and there was concern that the benefits of glucose control could be outweighed by the risk of hypoglycemia.

The improved technology to manage diabetes, particularly type I diabetes, in the early 1980s, resulted in funding for the Diabetes Control and Complications Trial (DCCT), which was published in 1993.¹ Finally, there was dramatic proof that the large investments in new tools to better manage diabetes could improve the lives of patients. Still, there certainly has been controversy about how the DCCT applies to those with type II diabetes.^2,3

One of the reasons I enjoy browsing through Intensive Insulin Therapy is that it helps put into perspective how quickly our technology has changed and thus has improved our ability to manage diabetes. The first sentence of the preface of that book states, “During the last five years, approaches to the treatment of insulin-dependent diabetes mellitus diabetes have changed radically.” Few could have predicted how the explosion of new tools would affect diabetes care.

Studies examining the effectiveness of these new tools, their psychosocial implications, and how to use older technologies to manage diabetes invaded the diabetes literature. A Medline search (Figure 1) crudely exemplifies these changes. In searching for the combination of “diabetes” and “treatment,” there is a linear fourfold increase in papers in the literature from the 5-year intervals spanning from 1975–1979 to 1990–1994.

Due to the improved understanding of some of the basic mechanisms of both type I and type II diabetes, numerous new technologies and medications are now being tested. Thus, it would not be surprising if the linear increase in number of published papers shown in Figure 1 becomes an exponential increase over the next 10 years.

Unfortunately, not all of the predictions from Intensive Insulin Therapy were accurate. For example, it was predicted that implantable insulin pumps and glucose sensors would soon be commercially available. Although there is still great hope for these developments, implantable pumps are not commercially available in the United States and are still in the developmental phase. On the other hand, we have learned much about how to best use CSII, the mechanisms of hypoglycemia unawareness, and the treatment implications of this.

Figure 1 also helps to explain why it is so difficult for us to keep up with the new technologies and drug therapies being developed. Although we rightly can be concerned about how we can stay current as advances in diabetes care continue at such a pace, I am even more concerned about how general health-care providers will learn the new information. Perhaps we will be more dependent on the World Wide Web or some other type of electronic Continuing Medical Education in the near future.

In this issue’s From Research To Practice section, we offer reviews and commentaries by several experts about some of the key advances in diabetes care. First, John R. White, Jr., PharmD, summarizes the status of our pharmacological therapies for type II diabetes. After reviewing the available drugs, Dr. White develops a provocative algorithm for how the drugs can be best used.

Next, we examine the topic of insulin pumps. CSII was first described 18 years ago, yet, until recently, it was rarely used. For the younger-onset cohort with diabetes in southern Wisconsin from 1990 to 1992, only 1.3% of the population used CSII.⁴ However, it is now estimated that, nationally, this number has already doubled (personal communication, Linda Fredrickson, MA, RN, CDE).

The reason for the increase in CSII use is likely multifactorial. The positive results of the DCCT in 1993 (and the fact that, by the end of the study, 42% of subjects received their insulin by CSII⁵), increased patient and health-care provider comfort, and improved pumps and accessories have probably all contributed.

There is also some evidence that CSII may help reduce the risk of hypoglycemia.⁶ Neil H. White, MD, CDE, reviews a recent study examining this hypothesis in further detail. Ruth Farkas-Hirsch, MS, RN, CDE, then reviews a description of how one hospital ensures that its obstetrics unit nurses maintain competency with CSII.

The introduction of insulin lispro this year is another major development. This is the first of what will hopefully be numerous insulin analogs, all with different pharmacokinetic advantages. David S. Schade, MD, and Patrick J. Boyle, MD, review the efficacy and safety data for insulin lispro.

The previous few years have also brought much discussion of im-plantable insulin pumps. Yet, to date, they are only commercially available in Europe. Christopher Saudek, MD, reviews the status of this technology, and Debra Haire-Joshu, PhD, RN, CDE, examines data reporting on the impact of implantable pumps on self-care behaviors.

Finally, and in some respects more importantly, how will we afford these new tools? Perhaps the new technologies will actually make diabetes therapy less expensive, particularly if they are more effective in managing hyperglycemia. For now, though, we must rely on economic models assessing diabetes treatment strategies with our current capabilities. Frank Vinicor, MD, comments here on a provocative report from Israel assessing the costs of preventing the complications of type I diabetes.

We have come a long way since the publication of Intensive Insulin Therapy in 1983. In many respects, the future appears even brighter now. I hope you find this From Research To Practice section helpful and stimulating.

References

¹The 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.

²Nathan DM: Inferences and implications. Do results from the Diabetes Control and Complications Trial apply in NIDDM? Diabetes Care 18:251-57, 1995.

³Tattersall R: Targets of treatment for NIDDM. Diabetes Res Clin Pract 28 (Suppl):S49-55, 1995.

⁴Klein R, Klein BEK, Moss SE, Cruickshanks KJ: The medical management of hyperglycemia over a 10-year period in people with diabetes. Diabetes Care 19:744-50, 1996.

⁵The DCCT Research Group: Implementation of treatment protocols in the Diabetes Control and Complications Trial. Diabetes Care 18:361-76, 1995.

⁶Hirsch IB, Farkas-Hirsch R, Cryer PE: The use of continuous subcutaneous insulin infusion for the treatment of hypoglycemia unawareness. Diabetes Nutr Metab 4:41-43, 1991.