Partha Kar predicts closed loops will become standard care in the next 5 years

[Inka]

I was offered the Tslim, but unfortunately their cannulas are not suitable for anyone with dexterity problems. I use the Dex G6 and I would never ever trust them to bolus for a meal or a correction.

Like you I have to work very hard to achieve my results and yes very wearing but as already stated I can not and do not trust the sensors. I'm having a MRI scan tomorrow so will try a G7 to see how reliable it is after the scan.

I have the G7 and find it very accurate @Pumper_Sue I hope you find the same. I bolus off mine but almost always check before correcting as I’m very sensitive to insulin. With the Libre 2, I was constantly checking it against fingerpricks. The G7 is also beautifully small.

 

[Rob Oldfield]

They are struggling now big time with the roll out of sensors for all. My DSN comment was words to the effect that Partha was great in ambitions but hasn't worked out how the teams were supposed to sort everything and the NHS fund it.

Looking at the stats for closed loop it seems to be a boast that users can achieve 80% in range! I manage that without closed loop so I can't see any advantage and in all honesty the biggest issue with closed loop is the sensors are not accurate enough to be worth while looping with.

I'm in the same boat. Had a chat with consultant about closed loop systems at my last review and her view was that it would be a step back for me. She did question whether I was OK with the amount of time and effort I spend on keeping levels level but, given that I am, she - correctly I think - said that I'd hate closed loop. (....at least at the current stage of development.)

 

[Bruce Stephens]

For wider access there need to be positive high quality trial data, and, ideally, a reduction in the cost of whatever the treatment is.

My understanding is that cost reduction is required (and assumed).

 

[Bruce Stephens]

Not saying that some Type 1s would not benefit from closed loop but I thik it should be in exceptional circumstances rather than the norm and I feel that there is currently a big injustice in diabetes investment that needs addressing first.

The plan (based on the draft TA) was that around 25% would qualify for a closed loop in this first round. (The draft chose an HbA1c of 64 as the cutoff because it's apparently the average that pump users achieve.)

I'm sure they're looking at improving things for people with T2 as well. I think some with T2 need treatment that's basically the same as T1 and ought to be treated the same and I'd hope there'd be some convergence of guidelines.

While the evidence on self testing is generally a bit weak, I agree that's mostly that the evidence is weak rather than that it couldn't improve care. I think there's a case (as someone suggested) that people who want to test ought to be offered support, if only for a few months (and some later if desired). I also think there's lots of people with T2 who wouldn't want to self test and wouldn't do so (just as there were (and presumably are) many with T1 who don't monitor as much as recommended (though with T1 it's so much easier now)). That's an argument in favour of offering CGM to many more people with T2, but (as with T1) that'll take evidence of cost effectiveness and I suspect that'll be hard to produce.

 

[nonethewiser]

Thank you 🙂 the scan is a waste of NHS money as all they are doing is checking the cyst on my pancreas to see if it's turned cancerous. Have been told they wouldn't operate due to the other medical conditions I have! So not to sure why they are bothering.

Best of luck anyway.

 

[Eddy Edson]

I think there's a case (as someone suggested) that people who want to test ought to be offered support, if only for a few months (and some later if desired).

I guess there might be an interesting comparative outcomes study for UK vs Oz, which has this kind of regime for T2D self-testing. Probably not easy to do: differences in data availability and classifications, controlling for other differences etc.

 

[AndBreathe]

The plan (based on the draft TA) was that around 25% would qualify for a closed loop in this first round. (The draft chose an HbA1c of 64 as the cutoff because it's apparently the average that pump users achieve.)

I'm sure they're looking at improving things for people with T2 as well. I think some with T2 need treatment that's basically the same as T1 and ought to be treated the same and I'd hope there'd be some convergence of guidelines.

While the evidence on self testing is generally a bit weak, I agree that's mostly that the evidence is weak rather than that it couldn't improve care. I think there's a case (as someone suggested) that people who want to test ought to be offered support, if only for a few months (and some later if desired). I also think there's lots of people with T2 who wouldn't want to self test and wouldn't do so (just as there were (and presumably are) many with T1 who don't monitor as much as recommended (though with T1 it's so much easier now)). That's an argument in favour of offering CGM to many more people with T2, but (as with T1) that'll take evidence of cost effectiveness and I suspect that'll be hard to produce.

Well, for T2s, not supported on testing, cost improvements - if they are purely on consumables as opposed to more traditional pharmaceuticals, then cost saving will be tricky. The levels of testing recommended for some T2s is woefully inadequate.

Hey ho. We must live in hope.

 

[Bruce Stephens]

Well, for T2s, not supported on testing, cost improvements - if they are purely on consumables as opposed to more traditional pharmaceuticals, then cost saving will be tricky. The levels of testing recommended for some T2s is woefully inadequate.

I think it's plausible that self testing hasn't worked out very well because the trials looked at daft things (I think one recommended that patients not do anything based on the test results), and self testing is annoying to do so it seems important to make sure that the benefits are large enough to justify that.

I think the Cochrane review has added a note that some studies suggest a benefit for testing in the first year after diagnosis (presumably because people can get an idea about how different foods work, see what exercise does, etc.). I think the NHS ought to be offering that. And it feels plausible that offering a couple of Libre sensors might be even more helpful for that (and offer a view of what happens overnight too).

 

[AndBreathe]

I think it's plausible that self testing hasn't worked out very well because the trials looked at daft things (I think one recommended that patients not do anything based on the test results), and self testing is annoying to do so it seems important to make sure that the benefits are large enough to justify that.

I think the Cochrane review has added a note that some studies suggest a benefit for testing in the first year after diagnosis (presumably because people can get an idea about how different foods work, see what exercise does, etc.). I think the NHS ought to be offering that. And it feels plausible that offering a couple of Libre sensors might be even more helpful for that (and offer a view of what happens overnight too).

I think the Libre would have pros and cons. Only one "prick", applying the sensor, as opposed to each test, but it does deliver a LOT of information that could be mind blowing, if not explained, and then if a sensor is really off the person may be (inadvertently) misled.

Something. Just something would help for sure.

 

[BadaBing]

I'm sure Professor Kar is right and hybrid closed loops will (probably) become standard care by 2028. He keeps suggesting that he may step down as NHS England diabetes co-lead soon(ish). I hope he stays in post for many years yet, but if/when he does step back he/NHS England will need to find a successor who will keep up the momentum so there is no backsliding and then widen access eventually.

At the moment, it sounds like the manufacturers of the various cgms, pumps and connected proprietary software apps of which these HCLs will be comprised need to lower significantly their per unit profit expectations if they want NHS England to guarantee them HCL business at scale.

 

[helli]

I keep hearing about the need for more accurate CGMs and pumps that can react fast enough.
But what about insulin that works faster. Injected insulin is no where near as fast as that which a healthy pancreas can produce which is why we have to carb count - no pump/CGM combo can work fast enough to manage a large rise in BG (or a drop due to exercise) due to the speed on the insulin as well as the tech.

 

[trophywench]

The annoying thing for me personally is that when the time came for me to replace my pump a couple of years ago I could have Omnipod (no thanks, far too big in all directions esp outwards as I frequently collide with anything I happen to be walking past, so 'sticky outy' don't seem a good plan) The tandem rep told me a Tslim is a waste of time without Dexcom CGM, a Medtronic 640 (even though by then the 780 had replaced it) or another Roche Combo. What I really wanted was another Roche Insight as I've always hated filling cannulas from the minute I had my first pump, a Roche Combo which I gladly swapped for an Insight. Not without its challenges, first one just killed it's batteries pdq and eventually they replaced it and the new one didn't. Had to charge the handset/meter battery every single night when I went to bed but so what, don't test during the night. Plus I was instructed to turn the handset off after each time I used it for anything,, hence never had any problem when I needed the meter/handset to work any time from getting up in a morning to going to bed. However my lot didn't offer any replacements because of 'all the problems people have had with the meter/h batteries never lasting.' So - can I get a Dexcom CGM then, since the Rep says the Tslim is useless without it? No. We don't offer them unless we make a special case for someone. You aren't a special case. You could self fund Decom, but we don't know anything about how to do that. (and clearly, you are not interested enough to bother finding out, are you, thought I, or even that bothered whether I might be able to afford to?)

So I had another ruddy Combo, although I had to learn again how to work it myself since the DSN's there now don't have a clue. The one who set it up with me, told me to do something I queried there and then - having had my very first pump fail and have to be replaced, specifically caused by what she was telling me to do with the new one. After my failure for this reason they issued a warning that went out to all users and D clinics. I read the handbook that night - I'm right - she was wrong. Of course I told her. (Oh look - she isn't there now.)

I know very well closed loop isn't 'plug and play' - no D tech ever is, they're all hard work to begin with at least. BUT I'd really so love to be allowed to do that work setting one up to suit ME - and then for whatever short periods thereafter just be able to give my flippin brain a slight rest. Why the hell can't a D Clinic recognise that when a woman has spent over 50 years juggling her own D care, she might need a bit of a rest! (I don't believe you actually need any specific training to recognise this - ain't it a fact that when folk get older and also doing the same old same old (with a number of bells and whistles along the way, yeah, but at basic level just more of the same) every damn day of their life, it's bloody boring frankly and the only thing keeping me doing it is simply ME caring about whether I live or die, cos I'm no longer as convinced the NHS want to, that much. My previous Consultant did seem to care - but I'm no longer on his List and I've never felt as if I could unburden myself to him, just not that 'warm and friendly'. What used to be called a 'good bedside manner' - don't think so mate.

 

[BadaBing]

I keep hearing about the need for more accurate CGMs and pumps that can react fast enough.
But what about insulin that works faster. Injected insulin is no where near as fast as that which a healthy pancreas can produce which is why we have to carb count - no pump/CGM combo can work fast enough to manage a large rise in BG (or a drop due to exercise) due to the speed on the insulin as well as the tech.

I'm sure the insulin manufacturers R&D departments try to improve their insulin therapies continually.

The chemistry and pharmacology involved in developing a new, safe, "instantaneous-acting" insulin that will obtain a licence from the US FDA, UK MHRA (or other regulator) is far from straightforward. Gathering sufficient data from animal, then human, trials that a new insulin works precisely as intended - and won't cause unwanted hypos or a. n. other short/medium/long term issues (e.g. cardio-vascular) to put in front of a regulator to get an authorisation is not a quick process. And rightly so.

Perhaps something artificial intelligence might in future be able to speed up?

Does anyone use Novo Nordisks fiasp insulin? I understand it is supposed to start working very quickly, but I've never been prescribed it. I hear many integrated care systems won't prescribe it (cost reasons???)

 

[BadaBing]

The annoying thing for me personally is that when the time came for me to replace my pump a couple of years ago I could have Omnipod (no thanks, far too big in all directions esp outwards as I frequently collide with anything I happen to be walking past, so 'sticky outy' don't seem a good plan) The tandem rep told me a Tslim is a waste of time without Dexcom CGM, a Medtronic 640 (even though by then the 780 had replaced it) or another Roche Combo. What I really wanted was another Roche Insight as I've always hated filling cannulas from the minute I had my first pump, a Roche Combo which I gladly swapped for an Insight. Not without its challenges, first one just killed it's batteries pdq and eventually they replaced it and the new one didn't. Had to charge the handset/meter battery every single night when I went to bed but so what, don't test during the night. Plus I was instructed to turn the handset off after each time I used it for anything,, hence never had any problem when I needed the meter/handset to work any time from getting up in a morning to going to bed. However my lot didn't offer any replacements because of 'all the problems people have had with the meter/h batteries never lasting.' So - can I get a Dexcom CGM then, since the Rep says the Tslim is useless without it? No. We don't offer them unless we make a special case for someone. You aren't a special case. You could self fund Decom, but we don't know anything about how to do that. (and clearly, you are not interested enough to bother finding out, are you, thought I, or even that bothered whether I might be able to afford to?)

So I had another ruddy Combo, although I had to learn again how to work it myself since the DSN's there now don't have a clue. The one who set it up with me, told me to do something I queried there and then - having had my very first pump fail and have to be replaced, specifically caused by what she was telling me to do with the new one. After my failure for this reason they issued a warning that went out to all users and D clinics. I read the handbook that night - I'm right - she was wrong. Of course I told her. (Oh look - she isn't there now.)

I know very well closed loop isn't 'plug and play' - no D tech ever is, they're all hard work to begin with at least. BUT I'd really so love to be allowed to do that work setting one up to suit ME - and then for whatever short periods thereafter just be able to give my flippin brain a slight rest. Why the hell can't a D Clinic recognise that when a woman has spent over 50 years juggling her own D care, she might need a bit of a rest! (I don't believe you actually need any specific training to recognise this - ain't it a fact that when folk get older and also doing the same old same old (with a number of bells and whistles along the way, yeah, but at basic level just more of the same) every damn day of their life, it's bloody boring frankly and the only thing keeping me doing it is simply ME caring about whether I live or die, cos I'm no longer as convinced the NHS want to, that much. My previous Consultant did seem to care - but I'm no longer on his List and I've never felt as if I could unburden myself to him, just not that 'warm and friendly'. What used to be called a 'good bedside manner' - don't think so mate.

I don't mind having an Omnipod 5 with a Libre 3 or Libre 2. I prefer a tubeless pump. I think I can position the Omnipod 5 well enough around my lumps and bumps for it not to get knocked off too often.

My Consultant and DSN are completely empathetic/sympathetic to my wishlist. The only stumbling blocks? Waiting to see what the final NICE HCL technology statement says, then the inevitable wait while my local ICS tries for as long it possibly can to delay and stymie implementing the NICE HCL technology statement.

 

[Bruce Stephens]

Does anyone use Novo Nordisks fiasp insulin? I understand it is supposed to start working very quickly, but I've never been prescribed it. I hear many integrated care systems won't prescribe it (cost reasons???)

A few people have tried it (and continued with it). I think it's the same price. I'd expect some teams to prefer particular insulins (those they're most familiar with) so I wonder if it's more that than ICSs choosing not to offer it?

As I understand it it starts acting a bit earlier than NovoRapid but not that much sooner (and stops working a little earlier). That's what I got from looking at the published tables, anyway. (I can believe that for particular people it makes a big enough difference that it's a worthwhile improvement.)

 

[Satan’s little helper]

I'm sure the insulin manufacturers R&D departments try to improve their insulin therapies continually.

The chemistry and pharmacology involved in developing a new, safe, "instantaneous-acting" insulin that will obtain a licence from the US FDA, UK MHRA (or other regulator) is far from straightforward. Gathering sufficient data from animal, then human, trials that a new insulin works precisely as intended - and won't cause unwanted hypos or a. n. other short/medium/long term issues (e.g. cardio-vascular) to put in front of a regulator to get an authorisation is not a quick process. And rightly so.

Perhaps something artificial intelligence might in future be able to speed up?

Does anyone use Novo Nordisks fiasp insulin? I understand it is supposed to start working very quickly, but I've never been prescribed it. I hear many integrated care systems won't prescribe it (cost reasons???)

I read somewhere years ago. For any insulin to mimic the natural process properly. The theory was, it needed to be administered in the bile duct near the upper intestine?
It kinda made sense. But the practically of it would be harder to implement.

 

[Bruce Stephens]

I read somewhere years ago. For any insulin to mimic the natural process properly. The theory was, it needed to be administered in the bile duct near the upper intestine?
It kinda made sense. But the practically of it would be harder to implement.

I think that's right: subcutaneous injection is probably not ideal. We're also missing amylin which would likely make just using a faster insulin not as good as real beta cells. I presume it wouldn't work just to mix in some amylin with the insulin, or maybe it's harder to manufacture (or doesn't last as long as insulin, or something).

 

[Satan’s little helper]

I think that's right: subcutaneous injection is probably not ideal. We're also missing amylin which would likely make just using a faster insulin not as good as real beta cells. I presume it wouldn't work just to mix in some amylin with the insulin, or maybe it's harder to manufacture (or doesn't last as long as insulin, or something).

At the end of the day. It’s still basically Banting’s concept we ram under the skin. (Whatever we use.)
If we had a “Time Machine” and went back to meet him? I wonder what his response would be regarding the tech we carry in our pockets or about our person. “Hello, we’re from 2023.”
He’d probably look at us the same “way” a pump user does when they realise I’m on MDI. I had this from a chance encounter with another Libre user on a night out, a couple of months back. (Other pump users suggest I contact Mr Kar?)
Having said that. I also met a proud Libre using 50 year medalist pumper and her husband on a walk about 2 weeks back in an arboretum. Which was an utter joy. No mention of the bloke.

 

[helli]

Does anyone use Novo Nordisks fiasp insulin?

I have been using it for a few years.
It took a bit to get used to but it still works much much faster than NovoSluggish unless my levels are high.
If my levels are in the 4s it acts pretty much instantly so I have to take it after I eat.
If my levels are over 10, it is like injecting water until suddenly, about a hour later, it works.

 

[nonethewiser]

Does anyone use Novo Nordisks fiasp insulin? I understand it is supposed to start working very quickly, but I've never been prescribed it. I hear many integrated care systems won't prescribe it (cost reasons???)

Used it in pump for last few years having used novorapid before, took to it straight away & find it does work slightly faster than novo but tails off by 3 hour mark.

Like @helli it can be bit like water in double figures but found this to be same with all insulin's I've used.