A year ago, Alicia Hunt was having trouble with her diabetes.
She had been diagnosed with Type 1 diabetes at the age of 10, and after more than two decades with the disease, the Saint John, N.B., mother had seen more than her share of problems.
“I’ve had retinopathy, I’ve had to have surgery in both of my eyes to save my vision,” she said. She had severely reduced kidney function, and a “very, very low” quality of life.
“I was essentially housebound because my blood sugars were not stable and they would have these very, very wide swings. It was actually very dangerous for me to be out on my own.”
In January, the 33-year-old received a new tool that she says simplified her care: a “hybrid closed loop system” that continually monitors her blood sugar and automatically adjusts her insulin dosage.
“The last eight months have been fabulous, actually. I have energy, I am able to get up in the run of the day with normal blood sugars and take my daughter to the park.”
Technology like this is a “rapidly emerging area of care,” according to Seema Nagpal, vice-president of science and policy for Diabetes Canada.
In a paper published Wednesday in the New England Journal of Medicine, researchers examined the effectiveness of an even more automatic system, adding to the body of evidence that these technologies are helpful for many — and moving medical technology closer to developing a true artificial pancreas.
Closing the loop
The estimated 300,000 Canadians with Type 1 diabetes, like Hunt, don’t produce enough insulin to keep their blood sugar within a stable range, according to Sarah Linklater, chief scientific officer for the Juvenile Diabetes Research Foundation Canada.
They have to frequently measure their glucose and then dose insulin accordingly, she said. “That’s a constant job of refining and tweaking how much insulin you take according to how much glucose is in your blood.”
You might also have to adjust your dosage if you exercise, or before you eat a meal, she said.
“It’s a really complex treatment regimen. And even the most vigilant, careful patient, it’s extremely hard to get it right.”
There are consequences to getting it wrong: spending too much time outside the target blood sugar range elevates your risk of long-term health problems like cardiovascular disease, nerve issues that can lead to amputation, retinal damage that can lead to blindness, as well as the chances of having a dangerous hypoglycemic episode where your blood sugar drops so low you pass out.
“The real fear is a hypoglycemic episode that has you either lose consciousness or have a car accident,” she said.
Until recently, people were required to inject insulin in order to bring down their blood glucose, Nagpal said.
Some newer technologies, like glucose monitors and insulin pumps, help to automate the testing and dosing functions — partly replacing the old finger-prick tests, and injections of insulin from needles or pens.
What makes the newer technologies different is they connect the two, she said, reading a patient’s glucose level and automatically delivering an insulin dosage to keep that level within an optimum range.
Hunt’s device is the Medtronic MiniMed 670G, which is the only hybrid closed loop system approved in Canada. While Medtronic didn’t want to provide the number of devices sold since it was approved in Canada roughly one year ago, the company said that it was used by over 200,000 people worldwide.
It’s two pieces, she said, one being an insulin pump “about as big as a credit card but about as wide as a wallet” that she typically keeps in her front pants pocket. It’s connected to her body with a small clear tube to deliver insulin. She also has a monitor, about the size of a toonie, taped to her body to monitor her glucose. The two pieces use a computer algorithm to talk to each other.
With it, she said, she has been much more stable and healthy, even recovering much of her kidney function. “The pump doesn’t do everything for you, but it takes care of all these little things in the background that you’re constantly trying to do on the run every day,” she said.
It’s not fully automatic — with the current technology, patients still have to manually adjust their insulin dosage before a meal, or to deal with big spikes in their blood sugar. Someday things might become more automatic and more fully close the loop, Linklater said, and the technology is getting smaller and more responsive all the time.
“You can see where it’s headed is that these systems are going to be almost unnoticeable.”
There’s good evidence that these kinds of devices work to keep people within their safe blood glucose range, she said, and recent meta-analyses have suggested the same. “With all of these devices, the newer devices coming out, we see that people spend more time in that range,” she said, which lowers their risk of complications.
Her group advocates for patient choice, she said, and some people might not want to constantly wear a machine or use these computerized devices.
Handing over the responsibility for something as important as your blood glucose to a computer is a big ask for many people with diabetes, Hunt said.
“When you live with Type 1 diabetes, you have to be a little bit of a control freak,” she said. While she trusts her medical team at the Horizon Health Network, “giving up that control to a person is one thing. Giving it up to a machine with algorithms is a totally different experience.”
She gave it a try partly because she didn’t think there was “a whole lot further for me to drop.”
Both Diabetes Canada and JDRF Canada say they would like to see better access to technology like this for patients for whom there are proven medical benefits. Access and coverage vary widely from province to province, Linklater said, and her organization is trying to make it more affordable.
If someone is considering a hybrid closed-loop system and has nothing to lose, Hunt recommends they try it, as it’s made a big difference for her.
“I can’t tell you the quality of life that I have personally gained from this technology.”