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[IP] Editorial from Clinical Diabetes

 VOL. 18 NO. 2 Spring 2000


        The Evolution of Diabetes
 Technology: How Are We Doing?

                  Irl B. Hirsch, MD, Editor=20

 Recently, while walking through a busy airport, two people in my
 group activated the metal detectors and were stopped and subjected
 to a routine search. Both individuals wore insulin pumps and
 showed their pumps to the airport security guards. But the officials
 seemed neither interested in nor concerned about these devices. As it
 turned out, the metal detectors were set off by a combination of
 handheld computers, blood glucose meters, and expensive Waterman
 pens Still, I was curious about the lack of response regarding the
 insulin pumps, so I asked one guard if he had ever seen one.=20

 "I see these everyday," he said. He added that thanks to some quick
 instructions from a recent passenger, he could even find someone's
 average blood glucose, assuming the same meter was available.
 Imagine that . . . the airport security guard was trying to be my
 diabetes educator!=20

 This brings to mind the tremendous recent advances in our
 technologies to improve diabetes care. It does not stop with home
 blood glucose monitoring and insulin pumps. The technologies
 available now and those to come in the future can only bring
 excitement to patients and their physicians.=20

 For example, I find the new computer programs that help analyze
 home blood glucose data particularly helpful,1 although they are not
 yet widely used. Insulin pens are finally becoming popular in the
 United States, and our patients are learning about this convenient
 method of insulin administration. We now have powerful new agents
 for treating insulin resistance. Continuous subcutaneous glucose
 sensors are now a reality=97not something only George Jetson would
 use. New fingerstick devices have been long awaited, although this
 challenge still needs some work. And large-scale trials of human
 islet cell transplants are now being discussed.=20

 The greatest surprise for me has been the increasing popularity of
 continuous subcutaneous insulin infusion (CSII), a trend that may
 have been furthered by the fact that former Miss America Nicole
 Johnson was a "pumper." But perhaps I should not be surprised.
 Delivering continuous insulin to better mimic a functioning -cell
 has always seemed a more physiological manner to provide insulin,
 particularly in type 1 diabetes.2 By incorporating the rapid-acting
 insulin lispro (Humalog), CSII therapy has become even more

 Others now seem to agree. It is estimated that in early 2000, there
 are more than 80,000 people in the United States wearing insulin
 pumps (Linda Fredrickson, MA, RN, CDE, personal
 communication). No wonder the airport security guards are familiar
 with this new technology.=20

 I wish I could say that this increase in pump use has been linked to
 better patient outcomes. We are awaiting prospective and
 retrospective trials for both type 1 and type 2 diabetes with insulin
 lispro and with the newest short-acting insulin analog, insulin aspart
 (Novolog). The use of CSII is quite different with these new insulins
 compared to regular insulin, and older data regarding pump therapy
 (including HbA1c and hypoglycemia) need to be reassessed. My
 prediction is that newer data will show significantly better

 However, the broad use of CSII by many physicians has generated
 new concerns. In the past year, I have seen numerous new patients
 who were wearing an insulin pump but did not know how to best use
 their pump or, for that matter, how to treat their diabetes. We see
 patients who only occasionally measure their blood glucose, do not
 understand how to match carbohydrates with insulin, do not
 understand how different types of food affect glycemia, and do not
 supplement with additional insulin for premeal hyperglycemia.
 These are not good candidates for CSII.=20

 Clearly, none of our new technologies will be appropriate for all
 patients. For that matter, not all of them will be suitable for all

 The major reason for this problem can be summarized in one word:
 time. We simply don't have enough of it to do everything necessary
 to manage our patients most effectively.=20

 There are certainly other reasons. For example, I do not believe that
 we make adequate use of the expertise of clinical nurse specialists
 and dietitians. Very few of us can practice in an environment similar
 to that in the landmark Diabetes Control and Complications Trial,4
 in which nonphysician health care professionals manage the majority
 of the diabetes care. This issue is related less to time constraints and
 more to reimbursement problems.=20

 I predict that CSII will become quite common for people with type 2
 diabetes, who are generally managed by primary care physicians.
 This assumes that there will be a paradigm change for how most of
 us manage patients with diabetes. Other technologies, particularly
 those involved with noninvasive or minimally invasive blood
 glucose monitoring, will also be widely used.=20

 As exciting as this is, let us pause for a reality check. One recent
 survey found that only 50% of patients received a yearly dilated eye
 exam, 27% were screened for diabetic nephropathy, and 35%
 maintained blood pressures <140/90 mmHg (The American Diabetes
 Association target is 130/85 mmHg.5) Other surveys have shown
 similar results over the past 10 years. If this is our accepted
 standard, how realistic is it to push forward with all of these new
 technologies? What about old technologies? How well do we use
 home blood glucose testing? One recent survey noted that it is
 underutilized.6 And insulin pumps? My experience with some
 patients, as noted above, is quite disappointing.=20

 We need to develop a better way to regulate patient selection and
 education for all of our new technologies. Until now, the insurance
 companies have been the only "diabetes police" for this task. It
 seems to me that there should be better solutions, but I am not sure
 what they are. Ideally, new technologies that improve our patients'
 outcomes should be both easy to implement and cost-effective. I am
 hopeful that, at least most of the time, this will be the case.=20


 1Hirsch IB: How to use home blood glucose monitoring data most
 effectively. Clinical Diabetes 16:194-95, 1998.=20

 2Unger J: A primary care approach to continuous subcutaneous
 insulin infusion. Clinical Diabetes 17:113-20, 1999.=20

 3Zinman B, Tildesley H, Chiasson J-L, Tsui E, Strack T: Insulin
 lispro in CSII: results of a double-blind crossover study. Diabetes
 46:440-43, 1997.=20

 4The 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.=20

 5Sugarman JR, Norman J, Kessler LD, Presley RJ, Baumgardner GS,
 Yue JS, Beyer CS: Pilot test of the DQIP and FACCT diabetes
 measures, Washington State, 1997 [Abstract]. Diabetes 48 (Suppl
 1):A422, 1999.=20

 6Harris MI, Eastman RC, Cowie CC, Flegal KM, Eberhardt MS:
 Racial and ethnic differences in glycemic control in adults with type
 2 diabetes. Diabetes Care 22:403-408, 1999.
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