Endocrine News Podcast - ENP96: Automated Insulin Delivery Systems

Host: Aaron Lohr
Guest: Dr. Grazia Aleppo, Professor of Medicine at Northwestern University
Release Date: December 18, 2024

1. Introduction to Automated Insulin Delivery (AID) Systems

In the latest episode of the Endocrine News Podcast, host Aaron Lohr engages in a comprehensive discussion with Dr. Grazia Aleppo, a renowned expert in endocrinology, about the evolving landscape of Automated Insulin Delivery (AID) Systems. These systems have garnered significant attention for their potential to revolutionize diabetes management, particularly for individuals with Type 1 Diabetes (T1D). Dr. Aleppo brings her expertise from presenting at the Endocrine Society's Type 1 Diabetes Fellows Program to shed light on the intricacies of AID systems.

2. Understanding AID Systems and Their Components

Dr. Aleppo begins by elucidating the fundamental components of AID systems. An AID system typically comprises:

• Insulin Pump or Pod: Delivers insulin as required.
• Insulin Container: Stores the insulin necessary for delivery.
• Algorithm: Processes data to modulate insulin delivery.
• Continuous Glucose Monitor (CGM): Provides real-time glucose readings.

These components work in tandem to automate insulin delivery based on the input from the CGM. However, Dr. Aleppo emphasizes that current AID systems are hybrid closed loops, meaning users must still manually announce meals to adjust insulin doses.

“These are still hybrid closed loops. So the user has to still take a dose of insulin. We call the meal announcement. They’re not fully closed yet.”
— Dr. Grazia Aleppo [01:35]

3. Challenges in Initiating AID Systems

Transitioning to AID systems presents several challenges. Dr. Aleppo compares adopting a new AID system to learning to use a new smartphone, highlighting the necessity for personalized training tailored to each patient’s background and experience with diabetes management.

“The challenge is how do I start this patient? Making sure they get the best out of the system. Instead of doing that cookie cutter training, you need to adapt to the patient.”
— Dr. Grazia Aleppo [02:24]

Key challenges include:

• Diverse Patient Backgrounds: Patients transitioning from multiple daily injections, standard pumps, or other AID systems.
• Individual Needs: Variations in understanding, fear of hypoglycemia, and other personal factors necessitate customized training approaches.

4. Limitations of Current AID Systems

While AID systems offer significant advancements, they are not without limitations. Dr. Aleppo articulates several constraints that users must navigate:

1. Semi-Automation: Users must manually announce meals by inputting carbohydrate intake and administering pre-bolus insulin doses.

   “They are not fully closed yet... the person who uses needs to take insulin for their meals.”
   — Dr. Grazia Aleppo [03:35]

2. Sensor Lag Time: CGMs have inherent lag times, especially during hypoglycemic events, which can lead to delayed insulin suspension and subsequent rebound hyperglycemia.

   “The sensor still has some we call lag time... that can cause rebound high glucose.”
   — Dr. Grazia Aleppo [03:27]

3. Insulin Characteristics: Current rapid-acting insulins are not as physiologic as endogenous insulin, leading to delayed onset and the need for meticulous timing with meals.

4. Infusion Site Issues: Challenges such as cannula dislodgment or occlusions can impair insulin absorption, necessitating constant vigilance and potential site changes.

5. Exercise Management: Physical activity requires preset adjustments to AID settings, which are not entirely automated and demand user intervention before and after exercise sessions.

5. Suitability of AID Systems for All Type 1 Diabetes Patients

Dr. Aleppo posits that while AID systems are poised to become the standard of care for T1D, their effectiveness hinges on the patient's willingness and ability to utilize the technology consistently. Psychological factors play a crucial role, as some individuals may resist wearing devices continuously due to personal discomfort or lifestyle preferences.

“AID should become or are going to become the standard of care for people with type 1, but the person has to be willing to use it.”
— Dr. Grazia Aleppo [07:59]

Additional considerations include:

• Customization Needs: Different systems cater to varying preferences, such as high customizability for detail-oriented users versus more straightforward systems for those preferring minimal adjustments.
• Patient Autonomy: Emphasizing the importance of patient choice in selecting the most compatible AID system to align with their daily routines and personal comfort.

6. Training for Optimal Use of AID Systems

Effective utilization of AID systems necessitates comprehensive training. Dr. Aleppo outlines the essential aspects of training programs:

• System Setup: Ensuring correct configuration tailored to individual needs.
• Failure Recognition: Teaching patients to identify and respond to system failures, such as sensor inaccuracies or infusion site issues.
• Backup Plans: Establishing protocols for manual insulin administration in case of system malfunctions.
• Continuous Education: Providing ongoing support to accommodate system updates or transitions between different AID platforms.

“Training means understanding what to change, how to change, when to change particular settings...”
— Dr. Grazia Aleppo [10:23]

Dr. Aleppo underscores the critical nature of training, given the potential risks associated with insulin delivery errors, and advocates for continuous monitoring to maintain system efficacy and patient safety.

7. Strategies to Optimize AID System Outcomes

Optimizing the benefits of AID systems involves a symbiotic relationship between the patient and the technology. Dr. Aleppo suggests several strategies:

• Data Analysis: Regularly reviewing glucose reports to identify patterns and make informed adjustments to insulin delivery settings.
• Personalized Tweaks: Adjusting insulin timing, carbohydrate ratios, and activity modes based on individual glucose trends and lifestyle factors.
• Collaborative Approach: Engaging patients in understanding how the system interacts with their behavior to foster a cooperative management strategy.

“This is a symbiotic experience with the system because there is the intelligence of the patient and the machine they need to live together is co-pilot.”
— Dr. Grazia Aleppo [13:03]

By fostering an adaptive and responsive management approach, patients can maximize the potential of their AID systems to achieve better glycemic control.

8. Barriers to Accessing AID Systems

Despite their benefits, several barriers hinder widespread access to AID systems:

• Financial Constraints: High out-of-pocket costs due to insurance deductibles and varying coverage policies can make AID systems prohibitive for many patients.

  “If patients have these high deductible premiums and they have to spend $5,000 before the insurance takes over, they spend half of the year paying out of pocket for supplies that’s very expensive.”
  — Dr. Grazia Aleppo [14:51]

• Insurance Limitations: Complex approval processes, especially for Medicaid and Medicare patients, and limitations on the duration of equipment warranties restrict access to newer technologies.

• Technical Literacy: Varying levels of comfort and proficiency with technology can impede effective use, particularly among older adults or those with limited educational resources.

• Infrastructure Challenges: Ensuring consistent access to necessary supplies and support systems, especially for children who require assistance in school settings.

Dr. Aleppo advocates for efforts to minimize health disparities by ensuring that AID systems are accessible to all individuals who can benefit from them, regardless of socioeconomic status or insurance coverage.

“We have an obligation not only to try to overcome, but especially to also minimize health disparities. We need to offer this system to everyone.”
— Dr. Grazia Aleppo [14:51]

9. Conclusion and Future Directions

The episode concludes with an affirmation of the transformative potential of AID systems in diabetes care, tempered by an acknowledgment of the existing challenges that must be addressed to realize their full benefits. Dr. Aleppo emphasizes the importance of personalized care, continuous education, and systemic efforts to enhance accessibility, underscoring the collective responsibility of healthcare providers and stakeholders to support patients in their journey toward optimal diabetes management.

Host Aaron Lohr wraps up by directing listeners to additional resources available through the Endocrine Society’s learning platforms, encouraging continued education and engagement with emerging therapies in endocrinology.

For more information or to join the Endocrine Society, visit www.endocrine.org.