Should we utilize Diabetes Technology in Type 2 diabetes patients?

Yanery’s Agosto Vargas, MD Disclosures

None Use of technology should be individualized, based on a patient’s needs, desires, skill level, and availability with technology/devices. Purpose

Technology is not intended for everyone. What is diabetes technology

Term used to describe the hardware, devices, and software that diabetic patients use to help manage their condition Categories

• Insulin administration • Pen • Syringe • Pump • Blood glucose monitor • Meter • CGM • Hybrid devices Boris Kovatchev. A century od Diabetes Technology: Signals, Models and artificial Pancras Control. 2019

Glucose oxidase monitors

Uric acid

Galactose

Xylose Medication Acetaminophen Interactions L-dopa Ascorbic acid

Glucose dehydrogenase monitors

Icodextrin (used in peritoneal dialysis) Glucose monitor Glucose meter accuracy

• Oxygen • Glucose oxidase monitors are sensitive to oxygen: should be available in patient with normal oxygen saturation • Higher oxygen tension • Falsely low glucose reading • Low oxygen tension • Falsely high • Glucose dehydrogenase: not sensitive to oxygen Glucose meter accuracy

Counterfeit Temperature strips Klonoff DC, Parkes JL, Kovatchev BP, et al . Investigation of the accuracy of 18 marketed blood glucose monitors. Diabetes Care 2018; 41:1681–1688 • Adjust food intake, exercise, or pharmacologic therapy to achieve specific goals • Needs multiple dextro daily that could become overwhelming Self • 6-10 dextro daily monitoring • Once daily SMBG does not change A1c use at 1 year • Some improvement reported at 6 months aprox. 0.2 -0.3% • Insufficent evidence when to prescribed SMGB in patient only in basal insulin with or w/o oral therapy From: Glucose Self-monitoring in Non–Insulin-Treated Patients With Type 2 Diabetes in Primary Care Settings: A Randomized Trial

JAMA Intern Med. 2017;177(7):920-929. doi:10.1001/jamainternmed.2017.1233

Copyright 2017 American Medical Association. Date of download: 11/29/2020 All Rights Reserved. • They’re not always covered by insurance. • Diabetic ketoacidosis • Dislodgment • Occlusion • Lipohypertrophy • They’re more expensive than other Cons of insulin options pumps in type • More education programs • Risks of infection 2 patients • Mood disorders • Not suitable for moderate and severe cognitive impairment • Wearability • T2DM patients does not showed significant A1c reduction CGM devices disadvantage

Need the ability to do SMGM to calibrate the device

Frequent scanning minimum once every 8 hours

Impact quality of life

Overwhelming CGM devices disadvantage Frequent detachment

No alerts at night

Medical Insurance approval/Cost

Taking medications with acetaminophen, such as Tylenol™*, fever reducers, or cold medicine, while wearing the sensor may falsely Medtronic raise your sensor glucose readings. The level of inaccuracy depends on Guardian the amount of acetaminophen active in your body and may be different Sensor 3 for each person. Always check the label of any medications to confirm whether acetaminophen is an active ingredient Eversense

• Mannitol or sorbitol, when administered intravenously, or as a component of an irrigation solution or peritoneal dialysis solution, may increase blood mannitol or sorbitol concentrations and cause falsely elevated readings of your sensor glucose results. Sorbitol is used in some artificial sweeteners, and concentration levels from typical dietary intake do not impact sensor glucose results • Antibiotics of the tetracycline class may falsely lower sensor glucose readings. You should not rely on sensor glucose readings while taking tetracyclines. Ananda Basu, Sona Veettil, Roy Dyer, Thomas Peyser, and Rita Basu.Diabetes Technology & Therapeutics.Feb 2016.S2-43-S2-47. Dexcom CGM Substance Description Risk Safety Recommendation System(s) Taking medications with acetaminophen (such as Tylenol) while wearing the sensor falsely raise your sensor glucose Acetaminophen is contraindicated with G4 PLATINUM G4 PLATINUM readings. The level of inaccuracy depends on the amount of CGM system. Use alternative glucose monitoring acetaminophen active in your body and may be different for approaches. each person. Medication used to treat pain Acetaminophen/Paracetamol Acetaminophen is contraindicated with G5 Mobile CGM and fever Acetaminophen is contraindicated with G4 PLATINUM CGM G5 Mobile system. Do not rely on CGM data produced by G5 Mobile if system. Use alternative glucose monitoring approaches. you have recently taken acetaminophen. Taking higher than the maximum dose of acetaminophen (e.g. You can take a standard or maximum acetaminophen dose G6, G6 Glucose > 1 gram every 6 hours in adults) may affect sensor readings of 1 gram (1,000 mg) every 6 hours and still use sensor Program, G6 Pro and make them look higher than they really are. readings to make treatment decisions. If you are taking hydroxyurea, your sensor glucose readings will be higher than your actual glucose, which could result in Talk to your physician about alternative glucose G4 PLATINUM missed hypoglycemia alerts. The level of inaccuracy depends monitoring approaches. on the amount of hydroxyurea in your body. If you are taking hydroxyurea, your sensor glucose readings will be higher than your actual glucose, which could result in Do not use your Dexcom CGM System for diabetes missed hypoglycemia alerts or errors in diabetes management, treatment decisions if you are taking hydroxyurea. Talk to G5 Mobile, G6 such as giving yourself a higher dose of insulin due to falsely your physician about alternative glucose monitoring high sensor glucose values. The level of inaccuracy depends on approaches. the amount of hydroxyurea in your body.

Medication used in the If you are taking hydroxyurea, your sensor glucose readings Do not use your Dexcom CGM System for diabetes will be higher than your actual glucose, which could result in treatment decisions if you are taking hydroxyurea. Talk to Hydroxyurea treatment of diseases including G6 Glucose Program cancer and sickle cell anemia. errors in diabetes management. The level of inaccuracy your physician about alternative glucose monitoring depends on the amount of hydroxyurea in your body. approaches. The use of hydroxyurea will result in sensor glucose readings that are higher than actual glucose levels. The level of inaccuracy in sensor glucose readings is based on the amount of hydroxyurea in the body. Relying on sensor glucose results Do not use the Dexcom CGM System for making diabetes while taking hydroxyurea could result in missed hypoglycemia G6 Pro treatment decisions or assessing glucose control when alerts or errors in diabetes management, such as giving a taking hydroxyurea higher dose of insulin than necessary to correct falsely high sensor glucose values. It can also result in errors when reviewing, analyzing and interpreting historical patterns for assessing glucose control. Patient point of view

• Contact dermatitis • Skin infections • Cellulitis • Abscess • Overwhelming • Too much data • Unknown how to deal with it • Diabetes burnout • Technology will be attached to you all the time • Increase appetite, develops obesity Summary

• Cost • Fixed income • Multiple medical conditions • Medical Insurance Coverage • Medical complications • Infections • Compliance • Overconfidence Take home message…

✓Simply having a device or an application does not change outcomes unless the patient engages with it to create positive health benefits

✓Technology is a tool for diabetes management is not MAGIC!!! Reference

• ADA. iabetes Technology: Standards of Medical Care in Diabetes 2020. Diabetes Care Jan; 43(Supplement 1): S77-S88 • Ananda Basu, Sona Veettil, Roy Dyer, Thomas Peyser, and Rita Basu.Diabetes Technology & Therapeutics.Feb 2016.S2-43-S2- 47.http://doi.org/10.1089/dia.2015.0410 • Hanseen NMJ, Scheijen JLIM, Jossal A et al. Higher plasma methylglyoxal levels are associated with incident cardiovascular disease in individuals with type 1 diabetes: a 12-year follow-up study. Diabetes 2017;66:2278–2283pmid:28588100 • Boris Kovatchev, A Century of Diabetes Technology: Signals, Models, and Artificial Pancreas Control, Trends in Endocrinology & Metabolism, Volume 30, Issue 7, 2019,Pages 432-444,https://doi.org/10.1016/j.tem.2019.04.008. • Foster NC, Beck RW, Miller KM, Clements MA, Rickels MR, DiMeglio LA, Maahs DM, Tamborlane WV, Bergenstal R, Smith E, Olson BA, Garg SK. State of Type 1 Diabetes Management and Outcomes from the T1D Exchange in 2016-2018. Diabetes Technol Ther. 2019 Feb;21(2):66-72. doi: 10.1089/dia.2018.0384. Epub 2019 Jan 18. Erratum in: Diabetes Technol Ther. 2019 Apr;21(4):230. PMID: 30657336; PMCID: PMC7061293. • Landau, Z., Raz, I., Wainstein, J., Bar‐Dayan, Y., and Cahn, A. (2017) The role of insulin pump therapy in type 2 diabetes mellitus, Diabetes Metab Res Rev, 33: e2822. doi: 10.1002/dmrr.2822. • Street T, Crabtree T.SJ., Wilmot E. Diabetes Technology. Br J Diabetes 2019;19:136-140 • Klonoff DC, Parkes JL, Kovatchev BP, et al . Investigation of the accuracy of 18 marketed blood glucose monitors. Diabetes Care 2018; 41:1681–1688 • Hess, Amy. What is a CGM. 2020. Remedy Health Media • Yogish C Kudva, Andrew J Ahmann, Richard M Bergenstal, James R Gavin, III, Davida F Kruger, L Kurt Midyett, Eden Miller, Dennis R Harris, Approach to Using Trend Arrows in the FreeStyle Libre Flash Glucose Monitoring Systems in Adults, Journal of the Endocrine Society, Volume 2, Issue 12, December 2018, Pages 1320– 1337, https://doi.org/10.1210/js.2018-00294 • Young LA, Buse JB, Weaver MA, et al.; Monitor Trial Group. Glucose self-monitoring in non-insulin-treated patients with type 2 diabetes in primary care settings: a randomized trial. JAMA Intern Med 2017;177:920–929