Pump - now and in 10 years time

[LittleGreyCat]

Last week I met a T1 in London who was over the moon because she had just had a pump fitted and it was making an amazing difference to her life.

We chatted about possible advances, the main one being adding continuous glucose monitoring so that the pump became a sort of external replacement pancreas.

I suggested that within the next 10 years, given the current pace of technological development, pumps should have reduced in price enough to be available to everyone, not just T1s (or insulin dependant T2s) with major BG control problems.

I then suggested that perhaps they could be made available to all T2s.

She didn't seem to be able to comprehend why T2s would want or need a pump.

This could just be T1 blindness to the needs of T2s (T2s often have much the same about T1s) but it seemed a logical progression.

As I see it the major problem which causes diabetic complications such as retinopathy and neuropathy is the inability (an/or unwillingness) to maintain good BG control.

Unless this is due to such a massive insulin resistance that no therapy can help, then insulin should assist in managing BG.

So logically if all diabetics were fitted with an artificial external pancreas their BG control should no longer be a problem and all the diabetic specific problems should no longer be problems, saving the NHS potentially an enormous amount of money.

It would, however, give a carte blanche for continuing the lifestyle which ******** your pancreas up.
But that just puts T2s back on the same playing field as all the bad lifestylers who aren't diabetic.
[Note that I know that only about 80% of diabetics are obese on diagnosis, and 20% (perhaps not the same 20%?) maintain thye NICE guielines for BG, cholesterol etc.]

So what does the team think?
Any reason not to give everyone a pump?
Mass production should force the price down a lot.

Cheers

LGC

 

[jopar]

The prices will never come down as it's a piece of medical kit!

But the main problem is that Insulin pumps will continue to improve and change, and older pumps will be discontinued, so prices won't change that much....

I'm surprised about her reaction though..

All a pump is; is a insulin delivery system the only criteria for a pump, is the need to use insulin to treat diabetes so it's just as viable for a T2 as it is for a T1 diabetic....

Actually there are a couple of T2's that do have pump funding in this county!

As to why NICE hasn't looked into viability of pumps for T2's I don't really know, may be is because the insulin regimes greater differently than what normally found within the T1's... As sometimes T2's only need background insulin support, or just some quick acting insulin support!

 

[LittleGreyCat]

In the past (possibly still) on this forum there has been some (US based?) support for the idea that all T2s should go on insulin immediately to rest the pancreas and perhaps revive it.

We currently have the driving licence restrictions in the UK to discourage us from going onto insulin except as a last resort, but with a well tested artificial pancreas I would think that the risk of a hypo would be much reduced and restrictions on insulin users might be reduced or lifted altogether.

I don't think the NICE guidelines look forward very far - I expect that the question of the broader use of pumps will not arise until there is much more history of supply and use and reliability.

Agreed that the suppliers do not have a major motive for reducing cost - but the NHS should really be doing regular financial projections to look at alternative strategies to reduce the long term cost of diabetic care.

Apart from taxing cheese and cream, that is. :roll:

Cheers

LGC

 

[phoenix]

I certainly think that there is quite a bit of evidence to show that the early use of insulin, sometimes only temporarily can be very effective for some people with T2.

A couple of years ago I remember seeing a video with Prof Kerr from BDEC suggesting that there was a great need for a simpler pump for people with T2. He suggested that the complexity of mutiple basal rates and types of bolus wasn't necessary for those who had some pancreatic function left.
This isn't a long way away, in fact such a pump has received a 510k clearance (pre marketing safety clearance) in the US.
http://www.valeritas.com/vgo.shtml
I think that the NHS is short sighted on their almost blanket denial of pumps to people diagnosed with T2. We've discussed the fact that T2 is a big catch all and there are many people who I think could benefit. The ironic thing is that it isn't new technology; portable insulin pumps were first used in 1978 at Guys Hospital


Implanted pumps are available they are still used 'experimentally' here in France. (not many, I think the number of users is in the hundreds). They have been used with T2s and according to a position statement

When compared to subcutaneous insulin therapy in randomized controlled studies, implantable pumps allow significantly reduced blood glucose fluctuations and improved quality of life in both type 1 and type 2 diabetic patients, and a significant weight decrease in type 2 diabetic patients. While

http://www.em-consulte.com/article/8060 ... ePM#N1015B
(I met a lady who had an implanted pump for a couple of years, she hated it but isn't necessarily representative as she didn't stick with a normal pump for long either)
The programmes that could allow a closed loop system are still under development. They were trialling them a couple of years ago but everything seems to have gone very quiet so perhaps they have hit big problems.

So logically if all diabetics were fitted with an artificial external pancreas their BG control should no longer be a problem and all the diabetic specific problems should no longer be problems, saving the NHS potentially an enormous amount of money.

It would, however, give a carte blanche for continuing the lifestyle which ******** your pancreas up.
But that just puts T2s back on the same playing field as all the bad lifestylers who aren't diabetic.

Not with todays technology, even with a CGM. There is a great misunderstanding sometimes on this forum as to just what it takes to get good control with a pump. It requires self discipline , calculation. and knowing how ones body works. Injected insulin can't work immediately,nor can it be withdrawn immediately. I don't know of anyone with good control who eats a lot of high glycemic, highly refined foods or who doesn't exercise (in its broadest sense)
Even if a closed loop system meant that enough insulin was 'injected' to lower high levels, there would still be spikes as the system has to be reactive. Moreover, if someone who ate more than they needed and did no exercise, they would just get fatter and become more insulin resistant . They would still have a high risk of heart disease whichis already the most prevalent complication of diabetes.

 

[LittleGreyCat]

<snip>

So logically if all diabetics were fitted with an artificial external pancreas their BG control should no longer be a problem and all the diabetic specific problems should no longer be problems, saving the NHS potentially an enormous amount of money.

It would, however, give a carte blanche for continuing the lifestyle which ******** your pancreas up.
But that just puts T2s back on the same playing field as all the bad lifestylers who aren't diabetic.

Not with todays technology, even with a CGM. There is a great misunderstanding sometimes on this forum as to just what it takes to get good control with a pump. It requires self discipline , calculation. and knowing how ones body works. Injected insulin can't work immediately,nor can it be withdrawn immediately. I don't know of anyone with good control who eats a lot of high glycemic, highly refined foods or who doesn't exercise (in its broadest sense)
Even if a closed loop system meant that enough insulin was 'injected' to lower high levels, there would still be spikes as the system has to be reactive. Moreover, if someone who ate more than they needed and did no exercise, they would just get fatter and become more insulin resistant . They would still have a high risk of heart disease whichis already the most prevalent complication of diabetes.

I am assuming at least one significant advance in the next ten years.
[Not guaranteeing - just assuming for the sake of argument.]

An artificial pancreas is unlikely ever to match a properly functioning one but I think it could probably evolve to be sensitive enough to moderate spikes and to keep average BG well under control.

I am not clued up on pumps, but I have learned from posts here that manually injected insulin is intended to go into the belly fat and people have had almost instant hypos when they have accidentally hit a small blood vessel and injected insulin straight into the blood stream.
The Valeritas device you linked to is also described as sub-cutaneous.
So presumably a device spliced into a blood vessel could be a lot quicker acting - both in starting the addition of insulin and in stopping it when the BG level drops.

Agreed that the main issues still remain of diet, heart disease, lifestyle etc. but those also exist for the 80% of obese people who are not diabetic.

So an advanced artificial pancreas could significantly reduce the risk factors associated specifically with poor BG control (which I think are the ones most hitting the NHS budget).

Reducing the over consumption of unsuitable foods is a whole seperate issue discussed in other topics

Cheers

LGC