Updates on CGM -
improved accuracy, benefits of using it continuously, the patient experience,
new technologies
What makes ATTD different from other diabetes congresses is
its focus on new technologies.
This year there was a lot of talk about CGM, mainly about
its continued improvement in accuracy over the last few years, and evidence of
its efficacy in reducing severe episodes of hypoglycaemia, especially in
conjunction with the use of LGS (low glucose suspend) pumps.
John Pickup from London reported on a survey his team is
doing with patients using a CGM. They have been recording their stories and it
was fascinating to hear the benefits they are reporting from the continuous use
of the sensors. Parents and carers are sleeping better in the knowledge that
they don’t have to lie awake worrying about their child or partner; and
substantial benefits were reported in improving glycemic control and quality of
life.
The major downside of CGMs reported from John’s study, and
from other speakers, was the limited amount of training received by both
patients and HCPs in how to interpret the data. Doctors and patients need good
training and regular contact, together with motivation on both sides to improve
self management by patients
There is a huge amount of data generated by the sensors and
it’s important for doctors to drill down, look at individual days, to find the
story behind why particular highs and lows are happening, and then the patient
has to know what bolus to give in response to the data.
Another downside, of course, is the current lack of
reimbursement, and the fact that although the devices are improving in accuracy
they are small improvements each time and what is really needed is a step
change.
The key challenge to manufacturers it seems is not the
chemistry, it’s making the device small enough to be unobtrusive. Reasons for
limited use of CGMs are poor accuracy, poor user friendliness, too many false
alarms, and cost.
Key Takeaway: The takeaway for
manufacturers here is to make CGM data simpler to understand and use, and the
sensor unobtrusive.
The patient
experience - make things simpler, improve training, empowering patients to help
them self manage
It was good to hear about the value of evidence that is the
Voice of the PWD (and their carers). Several speakers gave the view that
clinical evidence is all very well and good but that what is important is the
way patients actually use devices in their daily lives and whether they do help
improve the quality of life or hinder it, eg by making patients feel
“different”, self conscious, “controlled” by diabetes, unable to make sense of
so much data.
Ralph Ziegler, a German pediatric Doctor gave a fascinating
talk about how CGM technology can help improve diabetes management in
pediatrics. His message was that the “Holy Grail” - the closed loop system – is
so called because it takes the decision making away from the patients so they
can get on with their lives.
He told us that what PWD hate is:
- · Pricking for SMBG
- · Fear of hypo’s
- · Looking different
- · Having to make the mechanical decisions of dosing
Professor Davis from Leicester is passionate about educating
patients to help them self manage. In her words, monitoring BG is only the
starting point. The challenge for manufacturers is how to display the
information in a way that helps patients make positive changes in the
management of their diabetes. She would like more work to be done to understand
what patients want from SMBG devices, and what HCPs want.
She had a message for HCPs too – only a minority of patients
get formal instruction on diabetes and how to use devices intelligently; it’s
important to review patients’ data with them and use it as a teaching tool to
enable them to understand what is going on in their own bodies. We need much
better education of patients.
Jan de Vries , from Amsterdam, also spoke about empowering
patients with technology, and we heard that in the Netherlands doctors receive
reimbursement for e-consultations.
Key Takeaway: Diabetes is not
just about numbers; technology also needs to address quality of life and ease
of effective self management to empower patients
CGM in hospital
The use of CGM in hospital, and particularly within ICUs was
another hot topic. We heard that 18-20% of inpatients in a London hospital have
diabetes, 30-40% of patients in hospital (in the US) have hypoglycaemic events,
and patients’ blood sugars rise with surgery.
Additionally, severe
hypoglycaemia is a risk factor for mortality in the critically ill. This all
impacts on nurse time, longer hospital stays, and higher mortality rates.
The important thing in ICU is to minimise glucose
variability and avoid hypo events. We heard that the thing that drives nurses
mad with CGMs is the alarms that go off, most of which are false
positives/negatives.
Key Takeaway: What is required
in an ideal CGM system, according to Dr Holzinger from Vienna is one that is
rapid, accurate, inert, robust, non invasive, cost effective.
Several different technologies were reported on, with
varying levels of accuracy. Currently available CGM systems are IV and subQ, ie
invasive, which brings risks of infection and thrombosis.
Echo Therapeutics
presented their non invasive (needle free), wireless, transdermal CGM that is
being developed for use in hospital critical care units. Because it is non
invasive there are no risks or discomfort associated with current needle-based
CGM systems. The system is undergoing trials and is expected to be CE marked
later this year.
New products that
caught our eye
We were interested to see the latest developments in the Debiotech Jewel pump. It’s not yet on
the market but appears to have been well engineered, with some exciting
features which address many of the still unmet needs of PWD. Having no tubes
there is no kinking, occlusions or air bubbles. It’s really small, thin and
lightweight and yet holds up to 500 units of insulin, meaning the patient can
use the pump for 7 days without having to refill it. In addition the programmer
is also a secure mobile phone and BG meter, making it discreet in the presence
of other people. The device is in late stage development and hasn’t yet
received CE marking or FDA clearance but the company intends to launch in the
EU first, followed by the US.
The Cequr PAQ
device is a very simple insulin patch
pump designed to meet the specific needs of people with type 2 diabetes who
could benefit from intensive insulin therapy. People with type 2 diabetes often report
skipping insulin injections. The device offers a simple basal delivery and push
button bolus, needs no programming and takes just one hour to learn. It
delivers 3 days of continuous basal insulin, with 7 different basal rates
available, and a bolus with the push of a button. The device has CE marking and
the company is looking to launch in Europe in 2013/14.
The Senseonics
implantable CGM is designed to be the first fully implantable CGM system that is highly accurate and
stable throughout its long sensor life. It stays under the skin for 6 months;
it measures BG levels every few minutes and sends alerts for impending
hyperglycemia and hypoglycemia. The mobile medical app uses a smartphone to
receive and display the sensor glucose data from the Senseonics transmitter.
Dexcom presented
their next generation sensor, the G4 platinum, said to be “the most accurate
and easy to use CGM”, that will share data on the cloud with caregivers. We
heard that it is expected to be included on the Animas and Tandem pumps in 12 months’
time.
The Sanofi iBGStar
is a tiny blood glucose meter that connects seamlessly with an iPhone, which
means you can view all your data in real time and share it with your HCP.
