Want to Optimize Your Insulin Doses? Exciting New Tools in Development!
By Adam Brown
The DreaMed Pump Advisor, Glooko app, Nutshell, and MyStar DoseCoach.
At the ATTD Conference in Milan, there was a big focus on new tools to help people with diabetes optimize their insulin doses – the DreaMed Pump Advisor with partner Glooko (for those on pumps), the Sanofi MyStar Dose Coach glucose meter (for type 2s), the Glooko mobile insulin dosing system (for type 2s), and Tidepool’s Nutshell app (for pump and CGM users). The basic idea of all the tools is similarly exciting – use past diabetes data to improve current dosing decisions – but the products vary in how they will do it. We summarize what they are and when they are coming below!
1. DreaMed Diabetes’ MD Logic Pump Advisor is a web-based algorithm that will recommend specific insulin pump settings changes (basal rate, correction factor, and active insulin time) based on patients’ past pump, exercise, CGM, fingerstick, and food data. For example, “Change basal rate from 0.95 u/hr -> 0.8 u/hr from 12-8am due to pattern of nighttime hypoglycemia.” This is very exciting for both patients and providers, as those numbers are very difficult to get right and hard to update based on intuition alone. This system will be tested in a preliminary study starting later this year. We’re not sure when the Advisor will come to market, but assume sometime in 2017 is the very earliest. Notably, DreaMed received $3.4 million from the Helmsley Charitable Trust’s Diabetes Data Innovation Initiative to develop the Pump Advisor – that was a big vote of confidence, as it was the only awardee among 70 applicants.
How does it work? DreaMed’s partner Glooko will collect diabetes device data through its mobile and web-based data management system (supporting 40+ glucose meters, Dexcom CGM, Freestyle Libre, Insulet’s OmniPod, and soon Medtronic pumps and sensors). This data is de-identified for privacy protection and then run through the DreaMed MD Logic Pump Advisor, which generates recommendations that are sent to a healthcare provider. The provider then views and approves the pump settings changes (or edits them), and with a click, sends the information to a patient’s Glooko app. The system will also give patients guidance on how to change their pump’s insulin settings – excellent!
2. Sanofi’s MyStar Dose Coach glucose meter has a built-in algorithm that gives people with type 2 diabetes guidance on changing basal insulin doses – e.g., “+2 units in the morning.” The meter was approved in Europe last December and we assume it could launch soon; we’re not sure about the US timing. ATTD was the first time we had ever seen MyStar Dose Coach on display. Two things are exciting about this product: (i) the dose adjustment algorithm is built right in to the meter, more convenient than uploading data or logging onto an app; (ii) after the provider sets up the meter, the dosing advice is given directly to patients on the meter (i.e., no need for provider approval). MyStar Dose Coach only works with Sanofi’s new basal insulin, Toujeo, and it will be available only for patients with type 2 at launch – we hope future versions will work with Lantus and help those with type 1.
How does it work? MyStar DoseCoach comes with three possible treatment plans based on well-accepted insulin adjustment algorithms – the plans differ based on aggressiveness and target range. Each plan is built into a key card that is inserted and activated by a healthcare professional. The algorithm (“Dose Helper”) is then individualized with a patient’s weight, starting dose, and usual dose time. The patient then uses the device like a normal blood glucose meter to measure morning blood glucose levels (fasting) and to record insulin doses. After the patient runs the Dose Helper algorithm, the device suggests an updated basal insulin dose based on the selected treatment plan.
3. Glooko’s Mobile Insulin Dosing System (MIDS) will suggest changes in long-acting insulin doses in people with type 2 diabetes. For example, “Increase basal insulin dose by two units based on averages of high fasting blood glucose in the mornings.” The system is still in the pilot testing phase, so we’re not sure when it could be launched in the US. It has a few advantages over the MyStar Dose Coach meter (see above): (i) it will work with over 40 glucose meters including numerous Bluetooth meters that sync automatically, since data is collected and analyzed in Glooko’s universal web-based platform or mobile app; (ii) it will work with a wide variety of long-acting insulins and treatment plan configurations; and (iii) healthcare providers can monitor remotely, and everything will be integrated into electronic health records. Of course, using the cloud for this system does bring a drawback relative to Dose Coach: patients have to upload their glucose meter data to the Glooko app or web portal, and then log in to the Glooko app to see the updated dosing instructions. Glooko will make this easy, but it is worth noting.
How does it work? A healthcare provider will configure insulin dose adjustment instructions within the Glooko web portal, including a patient’s basic information, type of insulin, glucose ranges, and insulin time periods. Templates can be saved for future reference. A patient will then receive the personalized dosing instructions on the Glooko mobile app, with reminders to check glucose and to take insulin doses. Periodically, the system will review glucose values and suggest an updated insulin dose: “It’s checkup time! Let’s see if your insulin dose needs to be adjusted.” The app will also send helpful safety alerts: “We’ve detected you have a reading under 70 mg/dl. Contact your physician….”
4. Tidepool hopes to release its Nutshell app within the next few months, improving mealtime insulin dosing by answering a simple question: “What happened the last time I ate this?”
Nutshell will not provide dosing advice like the apps above, though it will help patients easily search for previous meals (e.g., “tacos” or food at “The Little Chihuahua”) and see what insulin dose they took and what happened to their glucose. This will be most seamless for those using a pump and CGM, though we believe patients on a glucose meter and/or injections can still use Nutshell. We really like the app’s premise, since all of us tend to eat the same meals, and it makes perfect sense to look at what happened last time and make more informed decisions this time. Nutshell is currently in beta testing and will be available for free once it launches; it will be compatible with pumps from Animas, Insulet, Tandem, and Medtronic (via CareLink upload), CGMs from Dexcom and Medtronic (via CareLink upload), and glucose meters from Abbott (FreeStyle, and Libre following its US launch), Bayer, and LifeScan (OneTouch).
How does it work? In the Nutshell app, patients will write what they ate (e.g., “turkey sandwich”), and may also include a photo or location. On the back-end, Tidepool’s data management platform will integrate mealtime diabetes data into the entry: bolus insulin, carb count, pre- and post-meal blood glucose values. Later, patients can open the app and to see what happened the last time they ate this. Some of device data will flow automatically into Nutshell – for example, patients on the Dexcom G5 CGM and other BG meters connected to Apple’s Health app should see their data populated automatically. Those on most other devices will need to upload their data using the Tidepool Uploader, available now on the Google Chrome app store, which will make the data immediately available in Nutshell. As more devices connect to phones, this should get much easier. We were fans of Meal Memory when it launched, though it had some shortcomings we hope Nutshell will overcome: inability to search, no location-based notes, and more listed here.
We’d note that the currently available mySugr Logbook app can do some of the things Nutshell will do, though access to the search feature requires a small monthly subscription ($2.99), and it requires more real-time entry of glucose and insulin data (you cannot upload devices after the fact, except for two meters in Germany).
Insulin dosing adjustment remains one of the biggest challenges in diabetes, and we’re elated to see companies prioritizing tools to make it easier for both patients and healthcare providers. Of course, these systems will only work if patients upload their data, if providers use the tools, and if patients ultimately use the recommendations in their daily diabetes management. If the tools are useful, we’re optimistic all those will happen!