One of the things that people like about Apple computers or the Windows interface is that it’s mostly dummy proof. Click on a few icons and you can connect to the internet or begin a new spreadsheet in Excel. You don’t need the foggiest idea of how the interfaces work.
What if automated insulin titration (a method of determining the appropriate concentration) systems could help bring the same type of transparency to the management of diabetes? If we could transfer the thinking aspects of diabetes management to a machine, legions of people with diabetes would find diabetes management a whole lot easier. There still would be people who would want to understand every step of the process and be able to replicate it manually, but I would bet dollars to donuts that they would be in the minority.
Which is why the recent study completed by the International Diabetes Center at Park Nicollet in Minneapolis is so interesting. The study was published online in Diabetes Technology and Therapeutics on May 12. It used an automated diabetes insulin delivery system under development to regulate patients’ insulin doses on a weekly basis.
Now there is credible evidence that shows that frequent adjustments of insulin doses based on changing patient circumstances can improve overall glycemic control. We see this directly in the Joslin’s Do It program. Each day of the four-day program, patients meet with the doctor and diabetes team and their medication regimen is titrated according to their previous day’s blood glucose numbers.
If everyone could be in contact with their health care team every day or even every week that would be great, but not very practical. Now at the Joslin we make every effort to teach our patients the understanding they need to make these types of changes on their own, but the reality is not every one has that capability and, more importantly, many people don’t want to be their own endocrinologist.
The study was what they call a feasibility trial. They were looking to see if the system would work and be safe. It was a small study involving 38 patients with type 1 and type 2 diabetes who were not at their A1C target. All patients were using insulin. The study had three arms: carbohydrate-counting type 1 patients using a basal bolus approach, type 2 patients using basal bolus without counting carbohydrates and type 2 patients on a twice daily insulin regimen without carbohydrate counting.
The trials lasted 16 weeks, consisting of a 4 week run-in phase to establish patient patterns and a 12 week titration phase. During the 12 week intervention period the software recommended 1,734 insulin changes. That’s an average of 45 changes per person. The researchers reviewed all the changes made by the software and only needed to override it on two occasions.
The results were impressive. Average blood glucose declined to 163.3 +- 35.1mg/dl which reached statistical significance and A1C dropped from 8.4+- 8% to 7.9+-9%. Despite this, episodes of hypoglycemia were reduced by over 25 percent.
Much as the majority of practical research currently going on, we are years from everyday use. But it is good to see progress in areas that can make life easier for people instead of only focusing on improving information transfer capabilities.