good afternoon everyone good afternoon everyone welcome to facebook live session from dr markets diabetes and obesity center i'm dr kirti so today we will be discussing about latest technologies in the management of diabetes technologies in diabetes management has come a long way from blood glucose meters to cgm insulin pen to insulin pumps and much more these newer devices are easier to use and less invasive optimization of glycemic control has shown to reduce complications and technologies are evolving to offer more precise treatment they are offering solution to overcome frequently encountered barriers and empower people living with diabetes but technologies can also prove to be a burden if not properly used so dear friends it's time to know what is the best for you welcome sir thank you we would like to start with the first question regarding choosing the right glucometer glucometer as the is the part of life of every patient suffering with diabetes we would like to know more about the new developments in the glucometers so again uh you know it is very important and relevant first thing is you know it's uh way back in 2005 that international diabetes federation came out with the clinical practice recommendations recommending the availability of glucose test meter for every person with diabetes so it is recommended that every person with diabetes whether it is type 1 or type 2 should have a glucometer now unfortunately india you know there are multiple reasons why we don't have that practice of advising glucometer to everyone or everyone using a glucometer that is largely missing and unfortunately very small number of people with diabetes use glucometer regularly to test their own glucose values and keep it under control so it is one of the reasons why people are largely not controlled in new york they are uncontrolled percentage is higher than the global percentage only about 30 percent of people with diabetes achieve good glucose control on an average now uh glucose meter is something like you know [Music] what's that say so can you drive blindly i will say can you drive with blindfold no not at all so this is uh you know treating blood glucose levels without using a glucose meter and without regularly testing where the glucose levels are going it is lined like driving on a road with your eyes closed you are taking medication you are taking precautions you may be very good with diet to exercise but you don't know what your glucose levels are and you don't know what is the impact of whatever you are doing on your glucose levels so it is like you know if you are not using a glucometer it is live like driving blindfold on a busy street and you are very much in for an accident so knowing your glucose values is as important as you know opening your eyes to see anything can you see anything with closed eyes no so you cannot know your glucose levels unless you test them people will come and high glucose values moderately high glucose values there are no symptoms and majority of people with type 2 diabetes do not get any symptoms because of iq so you there is no way of knowing you know what your glucose levels are unless you test glue now when you are taking a glucometer there are multiple challenges now there are i think more than 100 brands of glucose meters available in the market so there are very clear-cut regulatory you know [Music] regulations that tell you what glucometers you should buy so all the glucose meter that's that should be that are standardized should confirm to iso 2013 you know standards recommendation and you can check on glucose meter whether it is conforming to the iso 2013 standards or not second thing is uh you know you should people try to compromise on the cost of glucose meter but i think this is the thing which you should buy as best option and the cost difference between the cheaper or the you know best glucometers is not very significant but if you are not having a good glucose meter and you can't trust the readings given by the glucose meter you you cannot control your glucose fat so it is very important not only to have a glucose meter but to have a good glucose meter or rather the best possible glucose meter which gives you an accurate value of glucose so that you can make a decision whether you need to change treatment change diet pattern change exercise whatever it is very important tool that every diabetes person should have and should have a standardized first best possible glucose meter for self care so can you please throw light on the glucometers which are new into in the market which say it's no blood no prick yeah so other uh issue that comes with glucose meters is that people are you know uh they avoid pricking the finger so now what we use breaking devices so called the insular pens uh they they have a very sharp you know lancet inside them which is not visible so person cannot see the needle all person has to do is put the pen tip on a finger motif and just press the button and it will stab and create a blood draw and they are so thin and the requirement for blood with the new glucose meters is very small so something like 5 micro liter is the drop size that is required to test blood glucose which you which is almost 10 times or 10 of what used to be required or more so a very small amount of blood is required finer landsats are there pain is very less so you can and if you don't have to do it frequently you can use that but recently there are glucose meters which have become available that you don't need any pricking of the finger and you can test glucose and there is another option which has come become available is the continuous glucose sensors so you can apply a sensor on the back of arm and you have a you know you can say decoder or controller which by simply swiping or taking it closer to sensor you can read what is the glucose value at that point of time now uh drawback of these things is that they are quite expensive they are quite expensive second thing is not everybody needs to test 10 times or 20 times every day so you don't need these devices if you are well controlled maybe testing four to seven times a week will also be very good if you're not controlled yes you have to test frequently and you should test frequent as frequently as advised by your treating physician till you achieve a good glycemic control or good glucose so testing is important uh prick you the finger pricking or the needle stabbing you can avoid by using the newer devices which have become available but [Music] because the sensor is reading at intervals of 5 to 15 minutes so sensor is not continuously reading the glucose the time interval between two readings is anything between 5 to 15 minutes so it is phased but it is more or less continuous and you can get all anything between 96 to 28 values for 24 hours now somebody who has type 1 diabetes where you need to give three to four times of insulin injection every day and you know that there are large fluctuations happening in response to meals or exercise and especially type one usually happens in children and children you know they have you can't control their lifestyle very much so there you need to test frequently and usual recommended frequencies about seven times a day so these are people who actually do very well with the continuous glucose monitoring because they all you need to do is apply a sensor once in seven to 14 days time and you can keep checking their sugar even if you want to check 100 times a day you can do it but you don't need to make an extra stab on the finger to test glucose you know suppose the child has to go for a birthday party you can't tell him or her not to go to friend's birthday party now you want to make sure that child is having you know a decent glucose level before going whether child needs additional dose of insulin before going so all you need to do is just flash it swipe it over the sensor and the controller will give you the value and you can decide whether you need to give some extra insulin to the child or tell her tell him or her to take some precautions when you know at the party and so on so to add on these um these cesium devices are so easy to use that they can be applied by themselves also and they can be managed very well so patients or patients caregivers family members support people they can be trained to you know uh apply these sensors themselves it is not difficult it is not difficult at all okay for a gdm patient so gestational diabetes is a situation where we want very strict control see gestational diabetes for you know everybody's information means diabetes during pregnancy now this can be pre-existing diabetes or this can be a diabetes which is new onset during pregnancy a pregnancy is a critical phase where you want to maintain glucose levels in a narrow range to make sure that you have good outcomes for both mother as well as baby so gestational diabetes is a situation where two lives are affected right and providing a good like glucose control actually improves health calm outcomes for both mother as well as baby it is not just the delivery part of the baby a good glucose control during pregnancy it reduces the risk of having you know overweight obesity multiple problems in baby during the later parts of life if the glucose control is poorer or there is higher degree of insulin there is chances of getting you know premature births uh childhood obesity um a dollar cent obesity only onset of diabetes increased risk of blood pressure so many things can happen in baby oils so uh providing a good glucose control during the pregnancy period is very very important and certainly cgm can be very helpful in monitoring the glucose during the time because we want everyone to monitor at least four to seven times during daily during that period and second thing is it is a limited period you know the most of the ladies who will develop diabetes do it after 20 weeks of 24 weeks of pregnancy so almost half of it is already gone so you need to do the good control or good monitoring only for three to four months which is very much doable and it is cost effective also so this was about the monitoring of blood glucose levels so let's next point which is very important is the testing let's talk about the lab testing and the point of care testing which we are very particular about these days yeah so uh as we were talking that we need to monitor glucose so this can be done at home by the patient right or the somebody at home can monitor fermentation can do the finger stabbing and now another important thing is the new blood glucose monitors they have connected apps in the phones so once you do the blood test automatically your telephone also records that blood glucose value and it populates a table so later on whenever you are visiting your physician you can just take out the report for last two weeks four weeks whatever tests you have done at whatever time that it will show what is what was out of range what was in the range what was going above the range below the range so all these things are doable with connected apps and all these new uh glucometers from you know best companies they have connected apps now and they help you in deciding what when treatment is required to change and so many things so that is one plus point with the newer globometers now this was the self-money but diabetes management is beyond glucose testing all type 2 diabetes patients and all type 1 diabetes patients also are at risk of developing long-term complications so there are two major sets of complications microvascular and macro vascular and you have to see that if you are keeping the a1c level which is the glycosylated hemoglobin level less than seven percent the risk of complications is significantly reduced now what is a1c a1c is a glycosylated form of hemoglobin what is glycosylated form of hemoglobin so once the glucose is circulating in blood it it damages all the proteins when the glucose levels start going up so similarly it damages the hemoglobin in red blood cells which can be easily measured as a glycosylating hemoglobin so as long as the glucose levels are within the control range or target range of say about 100 to 140 uh in the individual the group a1c levels will remain less than 6.5 also if the a1c levels are up to seven percent the risk of complications is significantly low but after that it has increased and as the a1c goes up the signal there is a significant increase in the risk of now suppose somebody comes to the clinic for a visit and you want to see a1c now what option you have you send the person to lab get the report next day and call the person next day or talk to them on phone you can't decide whether you need to change treatment or not and here unfortunately in india people don't come to visit on a predefined time right because everybody has to pay out of pocket so the irregularity of with this is poor so so many times patient will come who is not even testing his glucose we don't know the average glucose level now what i have to do is i have to either tell the patient to go home test again get the test done come again a lot of this money wasted for uh you know try repeat travel repeat with it's a lot of time wasted and so on because i can't take a decision now same facility if i'm using it as a point of care testing all i need to do is do a fingerprint break test for a1c five minutes i know that a1c is normal so largely this patient is doing fine i know how to manage him if the a1c is high i know what next step should be but then this can give me immediate answer and i can help me in making a decision avoid a repeat visit if it is avoidable or the plan the next line of action as far as the treatment decision is concerned similarly now there are meters available for testing lipid profile so you want to check lipid profile now there is no need to check empty stomach or fasting lipid profiles most you know large number of labs still stick to that practice of getting a fasting sample now you don't realize that to get a fasting sample first patient has to go home second if he's a working person it is unlikely that he will be able to reach a lab in the fasting state before he has to go to work so it is generally you know lingering on and it is delayed third thing is uh you know you have to go to lab first give the sample collect the report come for a repeated this all can be avoided you don't need to do a fasting sample do a non-fasting lipid profile you can do it with a finger prick you can know all the lipid reports right at point of care and you can take a decision what is to be changed right so and you should know only thing is you should know whether you are doing a lip fasting lipid or non-fasting for non-fasting lipid the cutoff for triglyceride level is slightly higher that is all similarly if there is a doubt on kidney function you can do it with the fingerprint in your clinic practice you can check urine micro albumin in clinical practice so there are so many things that you can do at point of care which help in deciding that treatment needs to change or know second thing is to test for complications again there are devices available which tell you instantly whether this person has a damage to nerve or the circulation is getting compromised or simple fundus camera can tell you give you an image inside the eye and you can take a call whether there is significant damage to the eyes or no and accordingly you can plan the treatment strategy so nowadays you don't need to actually uh and you know every patient who's coming to you for a clinic visit most of the people have to come on working day so they have to their buck lose their work right they are losing their work they have to take a holiday or and if you put them for another day for lab or for their workup they have to lose another but if you have adequate good point of care testing machines and you have you know facility for evaluating the microvascular complications everything can be done in one go you can make a decision that okay this patient has you know this is a glucose value this is a1c this is lipid profile kicking function you can test for the nerves blood circulation fundus and you can decide now this is the final line of treatments and depression but this is very much doable with the availability of newer technologies now it is not difficult at all and in fact the glucose meters now connect with the centralized software which is loaded in the doctor's you know chamber or laptop so even the once the person is testing the glucose values can they automatically can integrate with the you're treating physicians uh software also similarly there are blood blood pressure monitors which communicate with the phone app there are weighing scales now which can communicate with the app in the phone so whatever you are monitoring can get transferred to a app which gives a comprehensive value of say 7 days 14 days and whenever you are visiting the doctor all the readings are with me so there are so many things which have evolved with technology that can be used to improve care and simplify care that is more important so basic aim is to improve the patient care and provide comprehensive care without complicating the you know lifestyle or the treatment strategies and through these technologies sir to some extent we can empower the patient also what i feel absolutely patient gets fully empowered with this patient knows facing and tap you know check sugar at home patient can monitor glucose all the time at home patient can easily check blood pressure at home rain is fine so if the person is maintaining decent glucose values decent pulse rates most of the time when you check blood pressure pulse rate is also reflected on the meter so you know what is going on and most of the time you know that you are doing fine or you are not doing so we have discussed about the monitoring of blood sugars we have discussed about the testing devices and what tests we should be doing for the patients now coming next to the treatment part so till date what we are seeing is people are using syringes for their insulin injections but we have smart devices available so we would like you to discuss about those things yeah so conventionally we have been using you know insulin syringes but now i think it is more than 15 years that we have been using pens or injectors or maybe two decades and using insulin pens actually changes the whole scenario for a syringe to be used you know you need to first withdraw the insulin into the syringe make sure that air bubble is removed you have to make sure that you are using accurate amount that is required to be drawn and then inject okay and the needle size is longer usually with the syringe it is 8 mm while the needle size in the pen needle is about 4 to 5 mm so you can do with smaller needles in the pan second thing is every time you need to you know withdraw ideally the syringes that we get are disposable so you that adds to the cost of treatment third thing is accuracy there are a lot of people with diabetes who have compromised with the vision so measuring the insulin accurately and injecting accurately becomes little cumbersome right injecting with the pen device is much more easier than injecting with the syringe so you may not be able to inject properly with syringe but injecting with pen it has its own ill bit mechanisms making sure that you are injecting the right amount and it will get locked once the insulin is delivered and so on third thing is the needle that is used is thin and short so the pain with the pen syringe pen neutrals is much less as compared to the syringe fourth thing is the pen every pen has its you know compatible cartridge which is the actually the something like a vial which contains insulin but it is shaped which is fitted with the which can fit only into that pen or the pen has a disposable insulin cartridge which is once you finish insulin you have to throw the pen it's a disposable pen so there is no mismatch in uh you know use of the strength of insulin and the device but unfortunately that is not the state with the syringe in the vials the insulin vials there are two different strengths of insulin available have 40 units per ml and 100 units per ml and the color coding for two different you know syringes is also different 40 iu syringes red colored and 100 io syringes orange color now most of the time people the physicians don't have time to explain all this and this leads to errors for injection somebody using a 140 iu insulin 40 units per ml insulin injects with 100 iu per ml will get only 40 percent of the dose because the insulin contains 40 units per ml but the syringe is drawing 1 ml according to 100 units per ml right now if you change make the situation other way you use the 100 iu insulin and you use 40 io 7 you will inject 2.5 times the insulin and patient can get into severe hypoglycemia so this this you know matching the syringe and oil and insulin all these things become very very important but when you are using pen it is a standard thing and if your disposable pen there is no problem you can easily inject even with visual compromise there is a clicking sound with every unit you know that is injected so once you have to dial a dose even if you can't see the number on the pen how many units you are dialing you can count the clicks so you want to inject 10 units you would rotate the dialer and count 10 clicks you will be at 10 units then there are pens which have you know lengths over the number read where the number is displayed so the number gets enlarged and you can read it despite visual compromise so these things give you you know multiple advantages sec third thing is there is accuracy you are not looking at the cartridge when you are filling insulin insulin is already there in the cartilage and you have decided you you will take 10 units you dial 10. now is programmed to dial only 10 units there is no dosing error so all these things are big advantage with insulin plans and now we have injecting devices or injectors are there uh though they are not very popular because of cost and other issues and of course then there are insulin pumps so people especially the children who need four times or six times insulin every day they can be given advice the insulin pump and what insulin pump is like a small pager which is can be you know one on a sling or belt and there is small tubing which connects to the cannula which is inject placed under the skin and it is continuously injecting insulin now there are two types of pumps one is that you program the pump through give x amount of insulin per minute or per hour it is a programmed device and continuously person is getting insulin and then with every meal you can tell the patient to you know take by press a button take so much insulin extra so there is a continuous insulin being given which is the total requirement which is you know programmed according to the body needs and additional needs for food again person can inject extra similarly the this is the pump which is manually done but now we have pumps with which is called closed loop system so you have a continuous glucose monitoring sensor placed on a on the abdominal wall or over the skin at particular point and there is a glucose pump which is connected and this sensor is sending all the messages to the pump so pump is getting the glucose values on continuous basis and you can program the pump and pump will also display what is the glucose value which you are seeing right and you can program the pump to keep say a glucose value in the range of 90 to 140 so there is something called suspend function as the glucose value stop tends to go towards 90 the insulin infusion will stop so it will suspend insulin delivery and once the insulin the glucose levels come back in that range you can again activate the pump and start insulin injection similarly when it is going high it give you a beep once it is going above the ring and you can increase the insulin dose to keep it down the the closed loop system now we have with artificial intelligence so pump gets programmed to understand that if the glucose level is going so much then there is so much insulin is required so for x amount of glucose y amount of insulin is required so if x plus 5 is happening y plus 0.5
will happen at the insulin delivery level this is based on the ai algorithm so pump is reading in glucose levels changing the insulin dosing and infusing at a differential rate depending on the glucose so a lot of artificial intelligence has been you know now uh utilized to program these pumps or delivery devices so all these things are now available only thing is uh cost is there with the newer technologies but in due course the cost will also come down and i'm sure you know we'll see more and more news for this in fact now we have disposable insulin pumps also which are available so that's how the technology is changing you know from uh monitoring to point of care testing to insulin delivery to devices and so many things and the it is not just the devices the insulins we used you know that currently is the 100 years of insulin also we have completed 100 years of insulin the discovery so the initial insulin that we use used to have only 10 units in per per ml and it the batch used to be calibrated every time and the impurity level was 50 000 parts per million currently we are able to get insulin as 100 units per ml so the amount to be injected is 10 percent less and impurity level is less than five parts per minute compared to fifty thousand parts per million then earlier we used to have only one variety of system now we have insulins which are customized which are designed to give a desirable effect so they are called designer insulin which we are using now the analogies the insulin antibodies or insulin allergies which used to be there have become virtually non-existent within uh so technology is playing role at multiple levels actually if we talk about living with any chronic condition it's a little tough and through this technology usage we can reduce the barriers basically definitely with use of newer technologies uh if one can afford you know if you cost because india but you know unfortunately insurance doesn't cover the outdoor care for diabetes outside india in european countries in u.s there is coverage for diabetes care so people get pumped as part of insurance people get disposable there's part of insurance all type 1 diabetes are being advised pumps given by national um you know health system in uk and europe so all these things are becoming are you know frequently used there india also we will see more usage for these things but with use of technologies we can certainly empower patients help them achieve better glucose controls help them prevent complications and have a better quality of life we have few questions can i take yes why not so is there any simple device to measure hb agency for patients at home no we don't no say people can have you know that same device used at home but it is not worthwhile because it is the the device is quite expensive it is simple you need to do with the finger test finger stick test you can do it another very important question which is very confusing for the patients is can a lancet be repeatedly used so before i go to that second thing you know whenever we are using a point of care device or home care device we have to also comprehend why we are using so glucose meter at you home usage is very important because you need to check your glucose every day or every second but for a1c testing you need to you don't need to test it every day you need to test once in three months and if you are well controlled you need to test only once in six months you don't need a device for home care here right glucose meter is important blood pressure monitor is important weighing scale is important but a1c testing on at home is not required so it can be done at the point of care at the clinic that you are visiting second thing is repeated use of landsat actually is not advisable all these uh you know things whether it is syringes or needles or lancets they are one use disposable uh you know what should i say these are not devices actually these are components of devices and they are one use they are disposable but you know this this is the recommendation this is ideal but what is happening lot of people keep using lancets repeatedly they keep using the syringe needles or the pen needles repeatedly yes we understand cost is a constraint in indian setting if the needle gets damaged need all these needles have you know coating which keeps them free of infection also and which makes them smooth for injection so uh with repeated injections these tips get you know damaged so they become more painful and they will cause more damage to skin which is not visible because you know very small thin tips still they are damaged so the pain will become more and the chances of infection will also increase with repeated usage but yes people use it but we don't recommend more than three usage for the pen needle and for lancets again you know don't use it more than two to three times especially if it causes pain then immediately change second thing is syringe needle or landsat or for that matter glucometer also or the insulin pen also if there are two persons in at home with diabetes both should have different pens different lancets different glucometers different set of gadgets same gadget should not be used for you know two percent another very important question by a viewer is which finger should be used for pricking see best is to use a finger which you don't don't commonly use for work so it's best to do it on left hand and you can do it on middle finger or ring finger which is not used for holding anything most of the time when you are holding something you will use first thumb first finger and middle finger ring finger and little finger they are not part of grip right so same and if you're doing with left hand from the left hand you are using these fingers less if you are a left-handed person use breaking one right hand in any case when you are doing cell if you are a right-hand person you will use the lancet flicker a pen with right hand so you have to do it on left hand second thing is when you are pricking normally what the tendency is to prick on the fingertip in front of the fingertip right so here usually the skin is also thicker and this is the part which will be used when you are picking up something or you know touching something if you test on the side you get blood easily because the skin's hair is slightly thinner and second thing you are not when you are touching here it is a prick has happened on site so it doesn't pain much so it's better to do it on the you know non-dominant hand on the fingers that are less commonly involved in routine functioning on the side of the not on the front of the fingertips is there any other point you would like to add more to the session today um i think we have discussed most of the things and most of the important points we have highlighted and in case there are any questions people are free to post on our first facebook page we keep you know discussing them repeatedly in fact we keep getting ideas what people want to know more and we try to cover them but i think we have touched upon most of the important things that people need to know and of course we will come with more and more ideas and more information on in future sessions since we have few requests yes session hindi we will try to do it in you know uh hybrid mode hybrid mode is the most popular now so we will do english in the combined that is not a problem you know we we started doing some sessions we did in hindi but then we had viewers from uh different uh parts of country or others outside country also wanted english so we came back to english but we can do it in a hybrid mode and what we can also do is that we can keep repeating the sessions in different language like we know only two languages i think that will be good search that can be done so another thing holy is approaching so we have requests to make this holy uh festival special for us for diabetes people definitely so holy and diabetes will keep a session and they want to specially sir what we are planning for the next session is to make this a holy special session for persons suffering with diabetes and will be bringing recipes for the patients uh which will be diabetes friendly recipes good i think that can be a good thing and people can enjoy as we have earlier also mentioned people all people with diabetes should enjoy all festivals and they can do it definitely only thing is they just need to keep some precautions in mind that's it but there will be a twist this time we will be having a chef great very nice perfect so that brings to the end of this session thank you everyone for joining thank you thank you everyone and uh let's hope to see you all uh just before holi thank you
2022-03-16