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State-of-the-Art Pediatrics

May 2019

Modern Management of Type 1 Diabetes in the Digital Age

                                       
Author: Ryan McDonough, DO | Co-Medical Director, Children's Mercy Diabetes Center | Assistant Professor of Pediatrics, UMKC School of Medicine

Column editor: Amita R. Amonker, MD | Pediatric Hospitalist | Assistant Professor of Pediatrics, UMKC School of Medicine
 
Diabetes treatment would forever be changed when insulin was first administered to a 14-year-old boy at the University of Toronto in 1922. Prior to its discovery, starvation was the only available treatment and most children would ultimately succumb to diabetic ketoacidosis.1 We’ve come a long way since 1922, and the treatment modalities we have today are changing at an increasingly rapid pace. 

In today’s world, the use of technology to support diabetes has become the mainstay of therapy for the majority of children and adolescents diagnosed with type 1 diabetes (T1D).2 With an incidence of one in 600 children, T1D remains one of the most common chronic diseases of childhood.3 At Children’s Mercy, we take care of around 2,100 children and adolescents with T1D, and diagnose 250-300 new cases each year. 

Many children will ultimately rely on a number of diabetes technologies, including smart insulin pens, continuous glucose monitors (CGM), and insulin pumps for their routine management. In the sections below we’ll take a deeper dive into each of these devices, and review how they interact with one another to be the basis for the “artificial pancreas.” For the non-endocrinologist, mastery and ability to titrate these devices isn’t the goal, but rather a familiarity with what they are capable of doing that can serve as a conversation-starter about T1D, and how it impacts your patients’ lives.

We’re often asked why all kids with diabetes aren’t on these technologies. Despite knowing that they can reduce the burden of diabetes and potentially improve outcomes, not all families are ready, some kids would prefer “not be attached to anything” and unfortunately, state insurance is unlikely to cover their use. That said, approximately 70% of Children’s Mercy patients use an insulin pump and 30% are on a CGM.                    
 
Smart Insulin Pens     
 
Traditional insulin pen devices do not record doses, nor aid in dose calculation. The advent of smart insulin pens allows the user to connect their insulin administration device to an app on their phone. In addition to providing real-time data, they track insulin administrations, and help calculate the appropriate dose. This data can be shared with the patient’s health care team both during clinic visits, and between encounters.      
 
Continuous Glucose Monitors (CGM) 
 
Likely one of the biggest developments in T1D care in the past decade has been the explosion of CGM. These devices are inserted into the subcutaneous fat and are changed every 7-10 days by the patient/family. Interstitial glucose levels are measured, and algorithms then report values analogous to blood glucose every five minutes. The major draw to these devices is threefold: the increase in available data (6-10 BGs/day when doing finger stick versus 288 readings/day from the CGM), contextualization/trending/alerting (arrows and alarms can indicate and predict rapid rises and falls in the BG), and data sharing (data from CGM can be shared with caregivers in real time).    
  
Insulin Pumps 
 
Insulin pumps were first utilized in the late 1970s. What originally developed as backpack-sized devices, are now the size of a hospital-issued pager. An important difference between shots and the pump is that a pump ONLY uses rapid-acting insulin (i.e., aspart, lispro). Pumps deliver a continuous background (basal) infusion of rapid-acting insulin that mimics the normal pancreatic secretion and replaces the need for injectable basal insulins (glargine, determir, etc.). The infusion rates are set by providers and are manually adjusted based on glucose patterns. People who use pumps (often called “pumpers”) are still required to count carbohydrates, check their BG, and give insulin boluses. The pump allows them to do this without the need for extra injections, as each infusion site lasts two to three days. Insulin pumps can deliver fractions of units of insulin (as small as 0.025 units) that cannot be given by pens.   
 
“Artificial Pancreas” 

The use of quotes in this header is deliberate. Despite rapidly changing and improving technology, there still is no true “artificial pancreas” that allows a patient to “set it and forget it.” The integration of CGM data and insulin pumps has allowed us to achieve the next step to full automation. The Hybrid-Closed-Loop is a level of automation that allows the CGM data to calculate and determine the basal insulin doses provided by the pump. Each 5-minute CGM reading is processed through an algorithm that uses continual learning to decide exactly how much insulin to give (or not to give) in the following five minutes, repeating 288 times/24 hours. Data shows that this type of technology reduces time hypoglycemic, increases time BGs are in target, and reduces sustained hyperglycemia. However, even with the most dedicated and well-controlled patient, only about 85-90% of their day is in this automated mode. When they get “kicked out” of automation they are back to the standard program, where the CGM and pump work independently.   

These technologies are changing every day. The FDA approves new and upgraded versions of these systems more often than even the most tech-savvy parent/patient/endocrinologist can keep up with. The future for diabetes technology is exciting, and we expect that enhancements and new developments will make T1D easier to live with until a cure is found!  

References       

1. History of Diabetes. American Diabetes Association. www.diabetes.org. Accessed January 30, 2019. 

2. State of Type 1 Diabetes Management and Outcomes from the T1D Exchange in 2016-2018. Foster NC, Beck RW, Miller KM, et al. Diabetes Technology & Therapeutics. 2019 Jan; 21(2):1-7.        

3. Children and Adolescents: Standards of Medical Care in Diabetes – 2019. Diabetes Care. 2019 Jan; 42(Suppl. 1): S148-S164.