How Diabetes-Technology is Changing Diabetes Treatment and the - - PowerPoint PPT Presentation

How Diabetes-Technology is Changing Diabetes Treatment and the Doctor-Patient Relationship

Diabetes & Technology Management Webinar 03/2020 Thomas Züger, MD

UDEM, Inselspital thomas.zueger@insel.ch

Glucose Regulation in Healthy Individuals

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

Insulin Pancreas Glucose Sources

exogenous endogenous

Blood Glucose

Glucose Disposal

Feedback- Loop

«Glucose-Sensing»

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Glucose Regulation in individuals with diabetes

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

Insulin Pancreas Glucose Sources

exogenous endogenous

Blood Glucose

Glucose Disposal

Feedback- Loop

«Glucose-Sensing»

3

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

https://scopeblog.stanford.edu/2014/05/08/new-research-keeps-diabetics-safer-during-sleep/

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Glucose Regulation in Individuals with Diabetes

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

Insulin Pancreas Glucose Sources

exogenous endogenous

Blood Glucose

Glucose Disposal

Feedback- Loop

«Glucose-Sensing»

Algorithm controlled Closed-Loop

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Closing the Loop – Artificial Pancreas

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

Züger T et al. Ther Umsch. 2017;74(8):529-536. doi: 10.1024/0040-5930/a000953

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Low glucose suspend & smart guard

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 7

Minimed 670G – first Hybrid Closed-Loop system

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

Algorithm Mealtime Insulin- Bolus by Patient Algorithm Target 6.7 mM

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Open Source

• Open Source «do it yourself»

project

• Realtime access to CGM- (and

insulinpump-) data

• Allows for intergration of

different devices and algorithms to control glucose

http://www.nightscout.info/

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital 9

#OpenAPS - components

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

Nightscout

Remote Monitoring software

Last CGM-measurement Current glucose (CGM) Insulin on board (IOB) CHO stop Insulin stop Basal rate Last activity OpenAPS Glucose change expected glucose course

Components

Insulin-pump CGM sensor/transmitter

• APP

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#OpenAPS – data repository

• 80 OpenAPS data donors, 53 years of CGM data

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

3.9 – 10 mmol/l 77.5% >10 mmol/l 18.2% < 3.9mmol/l; 4.3%

Time in/out of range (%, mmol/L)

Melmer & Züger et al. Diabetes Obes Metab.2019 Züger T et al., ATTD Madrid 2020

2014 – 2018 UDEM Time in range (3.9-10.0 mmol/l) Time above range (>10.0 mmol/l) Time below range (≤ 3.9 mmol/l) Type 1 DM (n=188) 60.9 ±17.5 % 34.6 ± 18.6 % 4.6 ± 4.9 %

No (Hybrid) Closed Loop

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Technology in other areas of diabetes control

1 2 3 4 5

https://apps.garmin.com/en-US/apps/2be02a1d-1d52-4db6-8bd5-6f66fe5ca992

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

Glucose Sensor Night Scout

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Sport & Diab-Tech

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

map elevation CGM-Data

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Use of Technology in Type 1 Diabetes – CH/Germany/Austria

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

Van den Boom et al.; Diabetes Care. 2019 Nov;42(11):2050-2056. doi: 10.2337/dc19-0345

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The Tech-Paradoxon - Technology alone might not be the solution….

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

CGM use DM1 CGM use DM1

2010 - 2012 2016 - 2018 2010 - 2012 2016 - 2018

Foster NC et al., Diabetes Technol Ther. 2019 Feb;21(2):66-72.

US-Registry

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so much data/information, so little time!

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

YEAR 2000 2-3 min writing summary 11 min checking of blood glucose values (SMBG) 2 No continuous glucose monitoring (CGM) No wearables Rare in between visits contact YEAR 2020 16 min electronic medical record (EMR) per visit 1 20 min insulin pump data + 15 min pump settings (bolus calculator etc.) 2 30 – 40 % pat. with CGM (10 – 20 pages of CGM data) 3, 4 Integration of fitness data, meal data etc. Mail, phone-calls, data-sharing (cloud-solutions)

1 Overhage JM et al., Ann Intern Med, 2020 2 Comellas MJ et al., Diabetes Technol Ther, 2017 3 Foster NC et al., Diabetes Technol Ther, 2019 4 Hood KK et al., Diabetes Care, 2020

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growing numbers – decreasing resources

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

350 Mio 420 Mio 500 Mio

https://www.diabetesatlas.org/en/sections/demographic-and-geographic-outline.html

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The burden of diabetes for patients with diabetes (PWD)

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

Burden of time

• 2005: Average 58 min a day on self-care 1
• 2018 2:
• adult with T2DM 66 min a day
• child with T1DM 78 min a day

1 Safford MM et al., American Board Fa Pract, 2005 2 Shubrook JH et al., Diabetes Spectr, 2018

Daily activities Glucose Measurement & Recording Insulin / Drug Management Visit with health care providers

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Who takes care of the diabetes management?

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

“It is clear that diabetes remains unique among chronic conditions in the extent to which therapy is controlled by the patient and factors that shape behaviour”

David G. Marrero; American Diabetes Association President

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Self-adjustement of therapy between clinical visits

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

• Survey in 47 patients with DM1 on insulin-pump (average 6 years Diabetes duration = experienced)

never sometimes frequent all the time Nimiri R, Phillip M, ATTD Madrid, 2020

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Obstacles for technology utilization and self-adjustment

• Need to download data & contact HCP
• 50-70% of patients never download data of various

devices between visits 1

• Lack of knowledge / ability / confidence
• Patients report low confidence and competence to

undertake retrospective review of CGM data 2

• Lack of ability to interpret data (amount of data /

information overload) 3

• Decision making fatigue & alarm fatigue 2

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

1 Foster NC et al., Diabetes Technol Ther, 2019 2 Lawton J et al., BMC Endcrine Disorders, 2018 3 Welsh JB et al, Diabetes Thera, 2019

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New solutions are required

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

“digital” support in treatment optimization

(for patients and health care providers)

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Acceptance of automated decision support by PWD

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

Willing to try Would you be willing to use an algorithm that adjusts your insulin pump settings after downloading your devices at home? 71.7% Would you be willing to use an algorithm that suggests insulin dosing on real- time? 68.1% Would you be willing to get text messages each time you need insulin adjustment? 50% Would you trust dosing recommendations given by automatic algorithm? 82.6% Do you think that automated algorithm for insulin dosing will release some of the burden of managing diabetes? 76%

Nimri R., Carpel S, Gavan M, Phillip M, ATTD 2020, Madrid

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Optimization of Diabetes-/Insulintreatment

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

Physical activity glucose insulin wearables food Local hub: Reporting/Transfer/ Display

Real-time advice

Basal insulin Correction factor CHO Ratio Reminder/info

HCP Appointment, Telemedicine

• ffice

advice

security Diabetes data science:

• Metabolic models
• Pattern recognition
• Algorithms for

decision support & automatic control Data integration/ storage (virtual patient image) EMR / Personalized treatment

Adapted from Boris Kovatchev & Bruce Bode

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Decision support – how it may look like for PWD

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

The last 3 times after exercise you had night-time hypoglycemia! Ok – what do you recommend Reduce your basal insulin by 20% for 8h and eat 10g of Carbs after exercise

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2020 to 2030 – the decade of the Digital Diabetes Clinic?!

Diabetes Technology 03/2020 - Thomas Züger, UDEM Inselspital

Social Platform Reminder Messages EMR Integration Visit planning (care priority- zation) Outcome follow-up Data Transfer Diabetes apps Tele- medicine Research Decision support Education

Consensus on Digital/Virtual Diabetes Clinic, ATTD Madrid 2020

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Adapted from Phillip M, ATTD 2020, Madrid

Consensus on Digital/Virtual diabetes clinic

Madrid February 18th 2020 – Highlights

• Digital – Virtual diabetes clinic should be developed for all

patients with diabetes (PWD)

• Digital clinic aim to empower PWD to self treat their diabetes
• Data ownership should be regulated worldwide – it’s for the

patients to decide whom to share it with

• Digital clinic may replace some of the F2F appointments and

increase interactions between visits

• Easy, passive transmission of data from all different devices

to integrate, interpret and create a meaningful advice for both HCPs and PWD