In-depth

Revolutionising diabetes care

In In-depth

The latest technology for managing type 1 diabetes is now approved for use on the NHS as part of a pilot scheme, with potentially life-changing benefits

On 15 June 2021, the then NHS chief executive Simon Stevens announced that an ‘artificial pancreas’ – a hybrid closed-loop insulin delivery system – would be made available to adults and children with type 1 diabetes on the NHS as part of a pilot programme. His announcement came almost exactly 100 years after the discovery of insulin, and has the potential to “revolutionise the life of people with type 1 diabetes”, according to the NHS.

Using the latest technology, an artificial pancreas continually monitors blood glucose and automatically adjusts the amount of insulin given through a pump. This can eliminate finger prick tests and prevent life-threatening hypoglycaemic attacks.

“The challenges of managing diabetes are relentless and for some people, diabetes technology can be life-changing,” says Faye Riley, senior research communications officer at Diabetes UK, “Diabetes technologies aren’t available to everyone with type 1 diabetes, and we know that around 70 per cent of people with type 1 diabetes don’t have blood glucose levels within the target range. Hybrid closed-loops have the potential to change this and allow more people to have stable and safe blood glucose levels, while removing a huge amount of burden – making living with type 1 diabetes easier and improving quality of life.”

Growing need

In type 1 diabetes, blood glucose levels are too high because the body can’t make the hormone insulin. According to the Juvenile Diabetes Research Foundation (JDRF), around 400,000 people in the UK have type 1 diabetes, including around 29,000 children. The number of new diagnoses of type 1 diabetes is increasing by around four per cent each year.

Insulin pumps and continuous glucose monitors already exist, and increasing numbers of people with type 1 diabetes are using these technologies to manage their glucose levels. The NHS Long Term Plan, published in January 2019, committed to making non-invasive glucose monitoring technology available to 20 per cent of people with diabetes and all pregnant women with type 1 diabetes. The health service delivered on these ambitions, with maternity services across the country now able to offer non-invasive glucose monitors to pregnant women, and over 40 per cent of people living with type 1 diabetes benefitting from flash glucose monitoring.

Hybrid closed-loop insulin delivery systems take diabetes management one step further, by getting the insulin pumps and continuous glucose monitors to work together. The glucose monitor constantly measures blood glucose and sends the data to the looping programme, which tells the insulin pump how much insulin the patient needs. The pump then delivers the right amount of insulin directly into the bloodstream, offering much better glucose control.

“Currently, people with type 1 diabetes rely on a routine of finger-prick blood tests and insulin injections or infusions to stay alive,” says Conor McKeever, research communications manager at the JDRF. “Artificial pancreas – or closed-loop – technology removes much of this burden. These systems combine an insulin pump and a glucose monitor to automatically deliver insulin to people with type 1 diabetes via a complex algorithm.”

Pilot scheme benefits

Artificial pancreas technology isn’t new. Professor Roman Hovorka at the University of Cambridge published his initial clinical trial results on the first artificial pancreas prototype in 2014. But this new pilot programme means that up to 1,000 type 1 diabetes patients will now benefit from the technology through the NHS, with the hope that it will become more widely available on the NHS in the future. In the pilot programme, participating centres will submit data via the NHS’s National Diabetes Audit and the results will feed into the evidence assessment by the National Institute for Health and Care Excellence (NICE). “When fully realised, artificial pancreas technology will fundamentally change life with type 1 diabetes,” says Conor. “As things stand, we estimate that a child diagnosed with type 1 at the age of five faces up to 19,000 injections and 50,000 finger-prick blood

tests by the time they are 18. But by working with a range of insulin pumps and glucose monitors, artificial pancreas systems will lift the burden of managing a condition that is relentlessly unpredictable day and night.”

According to NHS England, the 1,000 patients will be selected from around 25 specialist diabetes centres in England, based on set clinical criteria. Once chosen, patients will be offered the hybrid closed-loop insulin delivery system for up to 12 months. The patients will be a representative mix of adults and children living with type 1 diabetes, including those from ethnic minority groups and more deprived communities.

Dr Partha Kar, consultant endocrinologist at Portsmouth Hospitals NHS Trust, and national specialty advisor on diabetes at NHS England, says that eligible patients will have type 1 diabetes, will already be using a pump or device such as the FreeStyle Libre and won’t be reaching their target blood glucose levels. “An artificial pancreas may be the next step for them,” he says. “Using this technology for automated self-management means less intervention from patients and consultants – they will just need monitoring from time to time. It will be the equivalent of having a heart or lung transplant.”

Management awareness

Type 1 diabetes can be a complex condition to keep under control. Community pharmacies can raise awareness of technologies that are already widely available on the NHS, such as flash glucose monitoring and insulin pumps. According to Diabetes UK, patients with diabetes can also use apps and smart technology to help monitor their weight, exercise levels and carbohydrate intake.

Dr Kar says that some people with type 1 diabetes still don’t know enough about the technology that already exists. “The FreeStyle Libre device has been very popular, for example, but more people could benefit from it,” he says. “It’s a community device, meaning it’s very easy to use and patients don’t need to see a specialist. The computer does the monitoring for them. If patients are already using these devices, ask if they are happy with their current level of blood glucose control and make sure they’re aware of what poor control can do – the effect on their eyes, kidneys, feet, for example. If their diabetes is still not being well controlled, direct them back to their GP or specialist centres, if necessary.”

Faye stresses that technology isn’t the right approach for everyone, so it’s important to get feedback from patients. “People with diabetes need the right education and support from healthcare professionals to make the best use of it and avoid technology burnout,” she says. “This is when people can feel overwhelmed by the amount of information they’re getting from technology, adding to the burden of managing diabetes.”

On the horizon

As research continues and technology develops, the options for treating diabetes grow.

According to Diabetes UK, researchers are working to develop and test artificial pancreas systems that use both insulin and another hormone called glucagon. Glucagon raises blood glucose levels and could be delivered to help people avoid hypoglycaemic attacks and give patients even tighter blood glucose control.

Faye says scientists are also looking to build a fully automated artificial pancreas. “This would eliminate the need for people with diabetes to manually count and enter carbohydrate intakes in order to get their insulin at mealtimes,” she says. “It would do the job of a healthy pancreas with very little input from the user. This would mean they no longer have to worry about short- or long-term blood sugar control or worry about their risk of complications.”

Research is also looking into ways to prevent type 1 diabetes developing in the first place. “At JDRF, we believe that by driving research and accelerating access to treatments, we will create a world without type 1 diabetes,” says Conor. “This means that, in the future, we will be able to turn off the autoimmune attack that destroys the insulin-producing beta cells and restore people’s ability to produce their own insulin. Our research into immunotherapies and beta cell regeneration is laying the foundation for this. In the meantime, JDRF research has led to new developments in diabetes technology and treatment that are improving the lives of people with type 1 diabetes by removing the burden of managing the condition.”

Type 1 and type 2: diabetes explained

Around eight per cent of people in the UK with diabetes have type 1 diabetes, while more than 90 per cent have type 2 diabetes. The two conditions are similar, but have some distinct differences.

In type 1 diabetes, the body doesn’t make any of the hormone insulin, which controls blood glucose levels. This means blood glucose levels get too high. Signs and symptoms include needing to urinate frequently, feeling very thirsty, losing weight without trying to, genital itching or thrush, and slow wound healing – these tend to occur quickly, in a few days or weeks, especially in children. Over time, this can damage the heart, eyes, feet and kidneys.

Type 1 diabetes can’t be cured. Patients need daily insulin injections or an insulin pump to keep their blood glucose levels under control, and they also need to monitor their blood glucose levels. They must watch what they’re eating – especially carbohydrates – and their exercise habits, and need annual diabetes checks to look for signs of complications. Type 1 diabetes isn’t caused by age, diet or lifestyle, and doctors still don’t know exactly why it occurs, but it can be linked to certain ‘high-risk’ genes. It is an autoimmune reaction, which causes the immune system to attack the beta cells in the pancreas that make insulin. This may be triggered by a viral infection, changes in the gut microbiome or environmental triggers, or a combination of these.

In type 2 diabetes, the body doesn’t make enough insulin or the insulin it does make fails to work properly. This is called insulin resistance. Family history, being overweight, aged over 40 and certain ethnic backgrounds, such as South Asian, increase the risk. Type 2 diabetes symptoms are similar to those of type 1 diabetes, but tend to appear slowly so they are often missed. Type 2 diabetes may be managed through exercise and diet, although some people also need medication such as tablets (e.g. metformin) or insulin. While type 2 diabetes can’t be cured, in some cases, it can be put into remission with diet and lifestyle changes.

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