Wednesday, October 14, 2020

Part Three of a Three Part Series on Continuous Glucose Monitoring

by David Kliff – The Diabetic Investor

When it comes to innovate new therapies or medical devices there is a lag time between introduction, adoption and full-blown usage. This pattern is playing out right this very moment with continuous glucose monitoring. It should surprise no one that early adopters of this revolutionary technology are endocrinologists and their intensively managed patients. CGM is successfully penetrating this segment of the diabetes patient population.

Yet as we look to the future CGM offers the potential to forever change how all patients with diabetes manage their condition. Intensively managed patients may be the early adopters of this technology, but they are just the tip of the iceberg. So let’s take out the crystal ball and look to see how CGM will be used in the future.

In the near-term future thanks to CGM technology we will soon see what was once thought to be a dream, a true closed loop insulin delivery system or what some call an artificial pancreas. The systems available today driven by insulin pumps combined with CGM and insulin dosing algorithms will look like rotary telephone technology in just a few short years. It won’t be long before these systems morph into a system that a patient slaps on, turns on and forgets about.

As whiz bang and way cool as these systems will be, they will not for a variety reasons impact a substantial percentage of the insulin using patient population. While insulin pump therapy has been around for more than 30 years, is well established and readily accessible only 35% of the Type 1 population and less than 5% of the Type 2 population use an insulin pump, numbers that have not change much over the last 10 years even with all the advancements in insulin pump therapy.

Therefore we will see systems that combine a connected insulin pen, CGM, insulin dosing algorithm   and app. While these systems will require a higher level of patient participation, we anticipate wide spread adoption. Insulin dosing has always been a tricky subject for physicians and their patients as there are multiple variables that go into the calculation. Thanks to CGM and insulin dosing algorithms much of the heavy lifting once performed by the patient will be done by the system.

One of the misunderstood aspects of these systems is they are not static but dynamic. Or put another way the system learns and adjusts. Perhaps the best way to think about this is insulin dosing algorithms are effectually a form of artificial intelligence. Like other forms of AI the more data they gather the more they are used they more they learn. We anticipate that the early studies now underway for these systems will show excellent results which will pave the way for wide spread adoption.

Adding fuel to the fire here will be another advantage as these systems will be cost effective, will require little in the way of patient training while providing excellent outcomes. The only obstacle these systems cannot overcome is the human element, to be effective the patient has to follow the instructions given by the system. The system can gather the data and learn but the patient must do their part to fully benefit.

However we see the real potential with patients who do not use insulin, by far the largest group of patients. As we all know the biggest obstacle standing between this patient population and better outcomes is therapy compliance or adherence. Put simply we’d see much better outcomes if patients took their meds as they are prescribed. That they did not skip doses or manipulate doses.

Thanks to CGM physicians will have a clearer picture as to what is and what is not going on. The key of course is a CGM that is patient friendly. Thankfully that day is almost here as soon we will have CGM systems that are slap it on turn it on and that’s it. No fingerstick calibrations, no extra devices to collect the data and best of all they will be very affordable.

Even better for the physicians the analytics will be done for them, they will know before seeing the patient what is and what is not happening. We hate to state the obvious but there are only so many reasons why a patient is not achieving good control. Nine times out of ten it usually comes down to what we said before therapy adherence. Armed with CGM data and the analytics the physician can show the patient what’s going on, no more guess work.

We anticipate the healthcare system and economics to drive adoption of these systems. Diabetes is not just growing at epidemic rates it is becoming a huge financial crisis for payors and employers. Numerous studies have shown that patients under good control not only live healthier lives but also avoid many of the very costly complications due to poorly controlled diabetes.

Even with all the advancements we have seen in diabetes therapies and devices one indisputable facts remains, a fact that has not changed in the last 20 years, almost two-thirds of all patients are not under good control. Hence the reason diabetes has morphed from a healthcare crisis into an economic crisis. Thanks to CGM, insulin dosing algorithms and advanced analytics i.e. AI  we now have the tools to do what has never been done before, forever change how diabetes is managed.

Yet diabetes is not the only condition where CGM can have this impact. In the future CGM will become an equally powerful tool to combat another, excuse the expression, huge problem. Research indicates that CGM can also be used to combat obesity. The same sophisticated algorithms and analytics which will help patients better manage their diabetes will be adjusted to help a patient lose weight. Although in the very early stages this transformation is underway with early studies looking very promising.

Some early research also suggest CGM can be used to monitor cardiovascular conditions. Again this work is very early stage but now that smartwatches can monitor heart rates this early research indicates that when this data is combined with CGM data preventive measures can be taken.

Today everyone looks at CGM as strictly a tool for patients with diabetes. More specifically they see it as tool for insulin using patients. But as we noted earlier this is just the tip of the iceberg and not just for diabetes. These systems we have today have already achieved the necessary level of accuracy. Costs are coming down which will drive even greater adoption. The last domino to fall will be the results from the studies which are now underway. Studies that go beyond uses in diabetes but obesity and cardiovascular too.

There is no question that CGM has a very bright and very promising future. We know of few other tools which have the transformative potential of CGM. It won’t happen overnight and there surly will be some hiccups along the way. But one thing is clear CGM is here and here to stay.