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Vol 24, No. 01, January 2020For e-subscribers (PDF)
FEATURES
Supporting Patients in Management of Diabetes
Diabetes is a disease that does not rest, patients with the chronic disease will have to be diligent in managing it daily. With majority of the time diabetes care requires self-management, the development of a reliable and effective personalized management system can benefit patient for positive clinical outcomes.

Diabetes is a chronic disease that is increasingly becoming a serious global health threat. Worldwide, 463 million people are living with diabetes and if the current trend persists the number is expected to have a 51 percent increase to 700 million by 2045. Within Southeast Asia, 88 million people between ages of 20 to 79 years are living with diabetes, translating to an 8.8 percent regional prevalence. This number is projected to increase to 153 million by 2045. Mortality rate due to diabetes in 2019 for the Southeast Asian region was more than 1.1 million. Total diabetes-related health expenditure for 2019 was USD 8.1 billion in Southeast Asia.1

Type 2 Diabetes (T2D) makes up 90 percent of all diabetic cases and is the most common type of diabetes. It is characterized by insulin resistance in which the cells of the body is less responsive to insulin resulting in reduced uptake of blood glucose. The resulting rise in blood glucose level is then associated with hyperinsulinemia this can cause the beta-cells in the pancreas to wear off. The decreased insulin secretion will then escalate the hyperglycaemic condition of the patient.

Self-Management of Diabetes

Besides the need to make regular trips to the doctor, the onus is on diabetic patients to manage their condition at home. Management of this lifestyle disease requires constant monitoring and balance of glucose levels in the blood. This would mean that the patient needs to keep track of their food intake and remember to take their insulin dosage when required. “It is sometimes like walking on a tightrope between hypoglycaemia and hyperglycaemia.” Said Dr. Julia Mader, Associate Professor of Medicine Division of Endocrinology and Diabetology Medical University of Graz, Austria.

For individuals with diabetes majority of care happens at home, self-managing the disease. With a bulk of the time spent on self-managing diabetes, individuals will only spend less than one percent of their time on their disease with a healthcare professional.

The demands of self-management can take a toll on the individual suffering from diabetes as well as their caregivers and family members around them. The need to be consistent with managing blood glucose levels can cause significant amount of emotional stress and lead to diabetes burnout. These patients will tend to neglect managing their condition which will escalate into other complications from diabetes such as retinopathy, poor oral health, cardiovascular disease, kidney disease, and neuropathy leading to lower limb complications. It was estimated that approximately 4.2 million deaths worldwide resulted from diabetes and its complications.1 Poor management of diabetes can thus cause increase mortality rates, burden of disease on healthcare systems, and healthcare expenditure. Recent study on the implications of diabetes complications on the economy and health system in China demonstrated significant burden on healthcare resources due to diabetes and its complications. In addition, the lack of understanding and knowledge on the severity of poorly managed diabetes will contribute to this burden.2

Lightening the Load

No doubt innovative technology will be utilised in assisting individuals to manage diabetes. Availability of mobile applications, communication systems to healthcare professionals will allow improved and motivated self-management of diabetes for better patient outcomes.

“Patients currently have the ability to measure their glucose at home and communicate this value via mobile communication systems to the diabetes specialist or diabetes nurse who might be in outpatient practice or a hospital. The values can then be input to the hospital’s management system.” Shared Dr Mader on what are the modern options used in self-management for diabetes patients.

Mobile applications such as the “mySugr” app play a vital role in diabetes management through the collection of relevant and essential data so as to assist the individual with diabetes in daily management of the disease. Some of its features include the ability to provide detailed analysis and generation of reports that can be used by doctors to assess how the patient is performing in between check-ups. The bolus calculator module helps patients to ensure accuracy in insulin dosages to prevent any unnecessary overdose. On top of collecting data and aiding insulin administration, the app contains user activated tasks and challenges that will help users to be motivated to focus on their treatment goals. Taken together these functions in the app will thus assist in addressing the clinical and psychological burden of diabetes, enhancing the self-management process for the patient. In a study on the impact of mySugr app usage on glycaemic control, showed that consistent use of logging therapy data for a period of six months among the study population of 440 randomly selected high-risk users with Type 1 Diabetes achieved statistically significant reduction in blood glucose levels.3

Improvements to other diabetes management products such as the insulin pump, blood glucose monitor (BGM), and continuous glucose monitoring system (CGM) also contribute to lightening the load of self-managing the disease. Some improvements include more compact blood glucose monitors and modularity of insulin pumps for patient convenience and maintenance.

With all the components needed for diabetes management available in the market when it comes to self-management of diseases, “one size does not fit all”. Individual patients would require different needs to manage their conditions, and thus proves the importance for an integrated personalized diabetes management system. An interoperable system where patients can have the choice of a combination of products is also essential for an effective diabetes management system. The system will then support diabetes patients in a structural manner in educating and monitoring their condition. The system will involve a network of platforms comprising of the insulin pump, care platform for healthcare professionals, mobile applications and blood glucose monitors. All these are accessible by both the patient and healthcare professional to monitor, guide, and motivate the diabetic individual to management their condition in an effective manner.

One novel device, an implantable glucose monitoring system provides an alternative to the traditional finger-prick method of checking blood glucose levels. A sensor is implanted into the skin of the patient by a medical professional, it is able to provide continuous use of up to 180 days before being replaced. The sensor is then able to connect wirelessly to a smart transmitter which via Bluetooth will send readings of continuous blood glucose levels to a mobile application. This new system will provide interoperability as the data from the sensor has the potential to be fed into insulin pumps as blood glucose levels are monitored continuously.

In a prospective, controlled, cluster-randomized study conducted to evaluate the potential of an integrated personalized diabetes management (iPDM) system to improve clinical outcomes of insulin-treated Type 2 Diabetes patients. 907 patients we randomly allocated to either the iPDM or the control group. Results showed a higher percentage of patients in the iPDM group with reduction of HbA1c greater than 0.5 percent.4 This proves the benefits of designing an integrated, structured, and personalised system in supporting effective diabetes management for better clinical outcomes.

Ensuring Quality

“It is of course necessary to provide patients with all different kinds of devices, but it is also important that these devices are of high quality.” Said Dr Rolf Hinzmann, Head of Global Medical and Scientific Affairs, Glucose Monitoring and Science at Roche Diabetes Care.

The quality of medical devices can be determined by its accuracy in measurements. When it comes to clinical outcomes of patients, ensuring accuracy of readings are paramount. Specifically, for diabetic patients, blood glucose monitoring has to be as accurate as possible in order to make the right treatment decisions. This is especially critical during self-management of diabetes, for example if the patient gets an inaccurate reading indicating hyperglycaemia, over administration of insulin may occur which could result in hypoglycaemic shock.

“We need to acknowledge that every measurement has measurement error.” Added Dr. Rolf Hinzmann.

The International Organization for Standardization (ISO) has in place definitive requirements for the accuracy of blood glucose meters. ISO 15197:2013 is the current version of ISO standards that outlines the accuracy of blood glucose meters. The standards allow a maximum of 15 percent variability in the blood glucose reading.

Other than the accuracy of the blood glucose meter, other components in the blood may also affect the overall reading of blood glucose. Interference by other substances in the blood can result in a false positive or false negative measurement. Some components that can interfere with blood glucose measurements are uric acid, ascorbic acid, oxygen pressure, haematocrit and certain drugs like acetaminophen.

Dr Rolf Hinzmann encourages healthcare professionals and patients to therefore choose blood glucose meters that show good accuracy based on repeated independent performance evaluations. Also, be mindful to check for package inserts for clear information about clinically relevant interference to blood glucose measurements.

References

  1. IDF diabetes atlas (2019) 9th Edition, International Diabetes Federation
  2. Mao, W., Yip, C.W. & Chen, W. Complications of diabetes in China: health system and economic implications. BMC Public Health 19, 269 (2019) doi:10.1186/s12889-019-6569-8
  3. Hompesch M., Kalcher K., Debong F., Morrow L. Significant Improvement of Blood Glucose Control in a High-Risk Population of Type 1 Diabetes Using a Mobile Health App – A Retrospective Observational Study. [Abstract, Poster]. ProSciento, Inc.(2017)
  4. Kulzer, B., Daenschel, W., Daenschel, I., Schramm, W., Messinger, D., Weissmann, J., … Heinemann, L. (2018). Integrated personalized diabetes management improves glycemic control in patients with insulin-treated type 2 diabetes: Results of the PDM-ProValue study program. Diabetes Research and Clinical Practice, 144, 200–212. doi: 10.1016/j.diabres.2018.09.002

This article was derived from the Roche Diabetes Care Innovation Programme at the International Diabetes Foundation Congress held in Busan, South Korea on 3rd December 2019

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