Over the past few posts, you've seen me comment about diabetes technology -- mostly hardware and supplies -- in the context of a particular issue (hot weather or availability), but nothing really in terms of what I would like to see healthcare providers do in terms of better using existing technology, as well as what I should like to see pharmaceutical companies, software companies, and device manufacturers develop going forward. Because of the length of my wish list, I'm going to break this up into two posts.

For the purpose of these posts, "technology" includes biochemical agents (such as insulin, oral, and injectable medications) and laboratory tests as well as electromechanical and electrochemical devices (glucometers, pumps, etc.) and application software, I'm looking at both diagnostic and therapeutic uses, and I'm considering immediate and near-future timelines as well as things that might take a bit longer to develop.

Now

The first thing I'd like to see is more specific use of existing diagnostic tests: oral glucose tolerance tests, serum insulin tests, c-peptide tests, and GAD antibody tests. While fasting glucose and HbA1c tests are good first-level tests, there are enough variations under the general "type 1", and especially "type 2" umbrellas, an oral glucose tolerance test would give healthcare providers a first-level idea of whether, and to what degree, to advise a newly-diagnosed diabetic to restrict carbohydrates (beyond overall calorie restriction, if the patient is overweight or obese). While c-peptide and GADA tests may not indicate diabetes early in the progression of someone with either type 2 diabetes or LADA, a high serum-insulin level at the point of diagnosis would indicate insulin resistance. The possible combinations of high fasting glucose, glucose tolerance, and insulin resistance -- each addressed by a different class of oral diabetes medication -- would allow for a more specific initial therapy, with a better chance of bringing glucose levels and HbA1c back to normal (or therapeutic) levels as efficiently as possible, limiting or arresting potential complications. On the other hand, an "abnormal" c-peptide test or GADA test will indicate that a different type of diabetes management may be required.

I might want to see each of those tests run when someone (usually an adult) who does not have the typical symptoms (hunger, thirst, frequent urination, unexplained weight loss, etc.) is initially diagnosed, and again if and when an initially-successful therapy starts to fail. (This is particularly important for diagnosing LADA before years of frustration and potential complications enter the picture.)

The second thing I'd like to see is the diagnostic use of CGMs for both type 1 and type 2 therapy planning and analysis. While CGM technology is still in its "version 1.x"-ness, its trending information, in conjunction with a log, could help determine the best times for an individual patient to take a diabetes medication, or the best food strategies for getting the nutrition he needs with the best possible pre- and postprandial blood glucose profiles. This sort of "one time" or "as needed" diagnostic therapy, where full-time CGM use is not obviously necessary or is cost-prohibitive for the patient, could be accomplished with loaners from the doctor's office, lab, or manufacturer. Increasing the pervasiveness of CGM use should, through dint of increased volume, lower both access cost and consumables costs for those people for whom a full-time CGM is medically advisable or necessary.

The third thing I'd like to see is glucometer manufacturers either using a standard USB cable or including their proprietary data cables and software with every glucometer that is sold. This will make it easy for patients to see and manage our blood glucose logs, save them and send them to our healthcare providers, and/or upload them to our personal health records. Again, this is something that can be done today, without any additional research or FDA approval required.

Finally, I'd like to see gene and/or antibody analysis for celiac done at the point of type 1 diagnosis. The sooner we can get people with the dual diagnoses of autoimmune diabetes and celiac on appropriate diets, the less damage that will be done to their systems and the better they will feel. The question I have about that is how specific those tests will be in the absence of physical symptoms of celiac.

Short-Term Future

While the FDA is still soliciting comments for advice concerning mobile health applications and devices, one thing I'm missing in most of the logging programs I've examined is the ability to see an analysis of multiple data streams stacked so that one can easily analyze the effects of food on blood glucose and blood pressure, the effects of hyper- and hypoglycemia on blood pressure, and the effects of anything and everything else one would care to measure on, well, everything one is measuring and logging.

I'd also like to see data standardization, allowing any person, patient, or healthcare provider to download the readings from any measurement device into the same standard raw data record, from which it can be imported into a personal health record or electronic health record that will provide context and analysis to those readings. And while I'm at it, I'd like to see platform-independent management software, so those of us who need or prefer Macintosh computers or alternative operating systems (such as Linux, Chrome, or smartphone operating systems) can take advantage of the connectivity.

Tomorrow, I'll post my wish list for the longer-term future and summarize the two posts.