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Director, USC Clinical Diabetes Program
Professor of Clinical Medicine
Keck School of Medicine of USC
Los Angeles, California
Anne Peters, MD, has disclosed that she has received consulting fees from Abbott Diabetes Care, AstraZeneca, Lilly, Medscape, Novo Nordisk, Vertex, and Zealand; has received funds for research support from Abbott Diabetes Care, Dexcom, and Insulet; and has ownership interest in Omada Health and Teladoc.
The American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD) recently published joint consensus guidelines on the management of type 1 diabetes in adults. I was pleased to cochair these important guidelines, which outline for the first time evidence-based standards for the diagnosis and glycemic management of people living with type 1 diabetes. These guidelines aim to mirror the joint ADA/EASD guidance on type 2 diabetes that has been so impactful. The new guidance was designed to aid any healthcare professional who manages patients with type 1 diabetes, including primary care practitioners, endocrinologists, and diabetes educators. Moreover, published guidelines support individuals who need access to devices and tools to help manage their disease because patients and practitioners can point to the guideline recommendations when working with their insurance companies.
What Do the New Guidelines Say About Diabetes Technology?
Data have consistently shown that the best tool for monitoring patients with type 1 diabetes is continuous glucose monitoring (CGM). In particular, randomized clinical trials of real‑time CGM devices, which offer alarms and alerts, have demonstrated improved A1C levels and/or a reduction in episodes of hypoglycemia in patients using insulin pumps and multiple daily injections. Intermittently scanned CGM also has shown benefit, primarily in observational studies, and is preferred by most patients compared with traditional blood glucose monitoring. Although some people are resistant to CGM technology because they do not like to be constantly reminded of their blood sugar or wear something on their skin, the choice of device can be individualized, and CGM has become the pillar of management. The new guidelines recommend offering CGM to patients regardless of whether their glycemic targets are being met.
Regarding insulin pumps, data show that automated insulin delivery systems are one of the best tools we have, and we believe those systems should be available to all patients with type 1 diabetes. However, these systems are more complex than other insulin pumps, so patients should be allowed to decide whether automated insulin delivery is feasible for them. In addition, healthcare professionals should gauge whether the individual is a good candidate for operating a system with that level of complexity. Some patients may choose a standard pump that is not automated because it fits their lifestyle. The guidelines recommend querying all individuals on whether they would like to change insulin therapy. For those desiring a change, the guidelines recommend switching to pump or hybrid closed-loop technology if the patient is an appropriate candidate.
Regarding patient preferences, the new guidelines allow flexibility for patients with type 1 diabetes to choose the strategies that will work best for them. This is an important consideration because, in my opinion, type 1 diabetes is one of the hardest chronic diseases with which to live. Patients face many daily decisions when managing their diabetes—including when, whether, and what to eat; when to give insulin; and whether their blood sugar is high enough to exercise—and it can be taxing. Our aim with the guidance was to identify the available tools that can help people manage these daily decisions while allowing them to choose what is easiest for their individual circumstance. We know that all these tools work, and we want the person who must operate these systems to do so in the way they are most comfortable. Moreover, the guidelines recognize that patients with type 1 diabetes can change the tools they rely on; there is no mandate of how to do this, except that one must give insulin.
It also is critically important to recognize the psychological aspect of this disease, and allowing room for patients to choose can help with the mental load of living with type 1 diabetes. Indeed, the guidelines describe the need for psychosocial support, because depression, anxiety, eating disorders, and other coexisting issues can arise from living with a disease that demands consistent attention.
Barriers to Diabetes Technology
As a practitioner, I would be remiss not to mention the barriers one may face to the use of diabetes technologies. One of the greatest barriers is helping patients obtain coverage for these devices, and individual practices will need to determine how to best facilitate this. Usually, each patient will need to ask their own insurance company whether a particular device is available from a pharmacy or distributor. If it is available from a pharmacy, it can be directly and easily prescribed. If it must be obtained from a distributor, covered distributors are chosen by the insurance company, and the patient can start the process of ordering device supplies with the appropriate distributor. Requirements for documentation vary, and healthcare professionals should work to fulfill these needs.
Once a new device is obtained, it is critical that patients receive adequate education about how to use it. To this end, the new guidelines recommend coupling diabetes education, training, and follow-up with the use of these devices. Patients need to be taught how to interactively use the data from the CGM to improve their outcomes, how to adjust insulin doses for trend arrows, and how to look at weekly metrics to see if they are within their target range.
Establishing patients on these devices is only one half of the equation for device use. Utilizing the data from CGM for retrospective analysis by healthcare professionals is the other, and this can be a barrier for many practices. Indeed, downloading the data from devices can be a logistical challenge for even the most organized practices, and interpreting the data requires education and training. Many healthcare professionals may not be accustomed to reviewing the data, but the new guidelines urge regular access and review of CGM data as part of clinical management. I often advise practitioners to work with representatives from the medical device companies to determine the best system for obtaining and reviewing CGM data, because they have a self-interest in helping you understand how to best use these devices. Establish a lead person in your practice—possibly a diabetes educator—to set up a data management system, and then get into the habit of downloading and reviewing the data.
How will the new joint ADA/EASD guidelines for managing type 1 diabetes influence your practice? Answer the polling question and join the conversation by posting a comment.