Waiting for a Cure
Why you should get your hopes down about the Artificial Pancreas
By Wil Dubois
It's four in the frickin' morning when the Red Phone rings. It's a CrapCom 1 Alert. My Continuous Glucose Monitor is warning me that my death is imminent. It says my blood sugar is 44 mg/dL and dropping like a stone. The monitor shows two arrows down.
Instead of panicking, I groan.
Instead of springing into action, I yawn, scratch my chin, and mumble obscenities under my breath.
Instead of waking my wife to tell her to get the glucagon kit out just-for-in-case, I briefly consider rolling over and just trying to get back to sleep.
But what if this time the wolf really is at the door?
Pissed off in advance, I use my insulin pump's backlight to find my blood glucose meter on the dark nightstand. Squinting without my glasses, I fumble for a test strip, stick it in the bottom of the meter, lance my finger and give it a gentle squeeze. A small drop of the fluid that keeps me alive while giving me so much trouble appears, looking dark, almost black under the bluish pump light.
I touch the tip of the strip to the blood drop and magically the blood is gone, wicked up inside the strip for chemical analysis. In seconds I have my answer.
I'm not hypo.
Not by a long shot.
In point of fact, I'm really running too high. I'm 152 mg/dL.
And this is the technology that's going to drive the Artificial Pancreas? The fully automated technological wonder that everyone's so excited about? This is to be the heart of a system that's to automatically monitor our blood sugar day and night, feast and famine, at rest or at play—and increase or reduce our insulin as needed to maintain perfect control the way nature does for people without diabetes?
Don't get your hopes up.
In fact, get your hopes down.
Speaking as one of the oldest users of CGM in the country—as in continuously using continuous monitoring, not as in chronological age, although both may be true—I can definitively say that CGM is not ready for Prime Time when it comes to total control of an insulin pump.
Don't get me wrong. I love CGM. Shameless plug: I've even written an entire book about how great I think CGMs are, if you use them right.
But they are moody.
And recently, my CGM, like clockwork, has been having hissy-fits at 4 am. From bedtime until 4 am it hums along just fine, accurately reporting on the weather of my blood stream. Then at around 4 am it drops like a stone. Crazy. One night recently I was running high all night long from a macaroni n' cheese eating contest. I never got an alarm, but could see the "trace line" in the morning when I reviewed the overnight report. Nice and steady at 200 or so; then an EKG-like drop to 100 in a ten-minute period. "Low" for about 15 minutes; then the signal recovered, and bounced back up into the 200s.
These types of things happen to CGMs.
Sometimes your body drops and the CGM remains blissfully unaware. Two weeks ago, my Type 3 Glucose Monitor didn't like the color of my face. Apparently I was pale. My CGM showed me around 130. Flat and level. But wives know, and she insisted I do a finger stick. I was at 32 mg/dL. It took three bottles of glucose fluid and a bowl of cereal to get me back above 100. The CGM never strayed from its we're-doing-just-fine flat and level course during this whole adventure.
I worry that by writing about these little events the foes of CGM technology will seize on my anecdotes as arguments for why nobody should be using the technology in the first place. That would be grossly unfair to CGM. I confess to being the original CGM cheerleader, but it's true that CGM absolutely has a place in diabetes care.
The bottom line is that even with hiccups, personality issues, and the occasional nervous breakdown, a CGM can give you powerful insights into what your diabetes is up to and how well your therapy is designed to deal with it. Watching changes in the flow of numbers in near real time will also let you stave off trouble before it happens. If you're dropping like a rock a CGM will warn you about that the vast majority of the time. Will it's numbers be spot on? Hell no. Does it matter? Hell no. A drop is a drop, and something needs to be done about it so you don't drop dead.
Smart use of CGM keeps people out of the hospital in the short term, and out of the dialysis center in the long term.
But that doesn't mean it's ready to take the helm. Not yet.
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Well maybe not so much a furor as a controversy. The question, bluntly put, is whether or not a single HbA1c reading should be sufficient and adequate to diagnose diabetes — and whether the conditions under which the test was conducted should have any bearing on the diagnostic or non-diagnostic value of the test. The lede from