COMMENTARY

Integrated Care and New Technologies in Type 1 Diabetes

Chantal Mathieu, MD, PhD; Mark Harmel, MPH, CDCES

Disclosures

August 25, 2022

This transcript has been edited for clarity.

Type 1 diabetes is one of the diseases that is most challenging to treat if you are an endocrinologist. It is because type 1 diabetes has such a profound impact on the life of the people living with it. In recent years, we've had many new tools like insulin analogs, insulin pumps, glucose sensors, and also the hybrid closed loop systems. Still, the basis for the therapy of people with type 1 diabetes is the team approach.

In Europe, and particularly in my little country, in Belgium, this integrated approach where the whole team with not only the specialist — endocrinologist or diabetologist ­— but also the diabetes educator, the dietitian, the psychologist, and of course, the person living with the disease is a part of this team, which is so important. In my eyes, it is key to have integrated care when you are talking about treatment of people with type 1 diabetes.

In Europe, we have the advantage of having integrated care in most countries with access that is reimbursed — again, in most countries — through our universal access to healthcare. This is organized in different, country-specific ways, but there's one commonality, which is this principle of solidarity, where every citizen of a country will contribute, to a bigger or lesser extent, to healthcare in the country. When you have this universal healthcare, it means that you do not have to focus so much on administration but rather on how to best treat the person with type 1 diabetes sitting in front of you.

We do have access to insulin analogs, which are now the standard of care in the treatment of people with type 1 diabetes, and to technologies like pumps, sensors, and the hybrid closed loop systems. In Europe, we do have, for instance, one of the advanced hybrid closed loop systems, the 780G of Medtronic, which we are using often. It's very advanced and we do see that, across the countries in Europe, we are achieving time in ranges — time spent between 70 and 180 mg/dL of more than 70% — which is really important when we're talking about reducing the burden of type 1 diabetes for those living with it.

If I'm asked about the biggest advantage of different hybrid closed loop systems, it is really reducing the weight of this rucksack of type 1 diabetes on the back of people living with this disease by these assisted systems. Having a good night's rest, having stable glycemia during the night, and also having a reliable fasting glycemia you wake up with… One of my patients once told me, "This makes half of my day if I can start with a good glycemia and do not have to think how to correct what is happening."

We're looking particularly forward to having not only hybrid closed loop systems with tubed CSII, so pumps with catheters, but also having intelligent patch pumps. We're looking forward to having different systems coming to us with patch pumps, sensors connected to them, and then algorithms working with these pumps, adapting the flow of the insulin to the glycemia, and also, giving boluses when people are eating.

Again, in Europe, we do have access to multiple systems and multiple algorithms. For instance, the Diabeloop algorithm, an algorithm that came from French endocrinologists, is one of these algorithms that is open to be used with different pumps and with different sensors. This is really where I think we're going, namely this promiscuous behavior where you will select the pump that suits best, the person having to carry the pump, the sensor that suits best, the person carrying the sensor, and then the algorithm that you know best or that you think is best for the patient sitting in front of you.

Another advantage of living in Europe is that we have access to adjunct therapies for people with type 1 diabetes. We do have a label for use of low-dose sodium-glucose cotransporter 2 (SGLT2) inhibitors like dapagliflozin and the mixed SGLT1/2 inhibitor sotagliflozin at low doses in individuals with a body mass index (BMI) > 27. Recently, the company of dapagliflozin did pull the label, but we have had some experience with these agents in people with type 1 diabetes.

What became clear is that when you use SGLT2 inhibitors in people living with type 1 diabetes, they are efficacious in lowering A1c, in lowering weight, and in lowering total insulin dose. The price you pay is an increased risk, where about 20%-25% of people suffer from genital infections, mainly women, when we use the SGLT2 inhibitors, but also diabetic ketoacidosis is happening.

As we published recently in Diabetes Care in 2022 by Palanca and colleagues, we showed that, in real-world experience, we do see around 3.5% of people who, when they use SGLT2 inhibitors on top of their intensive insulin therapy, do develop diabetic ketoacidosis. Despite being used in specialized centers with well-trained medical teams and also by well-informed patients, we saw that the label of European Medicines Agency (EMA), namely using low doses of SGLT2 inhibitors and only using it in individuals with a BMI > 27, was indeed the safest way to use these adjunct therapies in people with type 1 diabetes. When using the low dose and using it only in those with a BMI > 27, we saw the least risk of diabetic ketoacidosis.

I hope that in the future, we will see outcome trials also in individuals with type 1 diabetes, looking at hard endpoints, such as heart failure and kidney protection, for instance, because there's no reason to expect that the cardiorenal protection that is seen in people with type 2 diabetes or people without diabetes with SGLT2 inhibitors wouldn't happen in people with type 1 diabetes. Also, we had some glimpses about this renal protection in our real-world observation study.

It is exciting times in Europe where we are able to work in an environment of universal access to health care, where we have access to integrated care, and where we have access to novel technologies, including hybrid closed loop systems, and adjunct therapies for people with type 1 diabetes.

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