Daytime & Mealtime with Artie
The DiA's In-Control artificial pancreas system has to face many challenges to account for all the variability's of daily life like diet and exercise. With these challenges the DiA's acts less aggressive during daytime than overnight. With a target of 160 mg/dl, it seeks to avoid hypoglycemia (below 70 mg/dl). The DiA's does not treat hyperglycemia until I raise above 180 mg/dl. If DiA's predicts I am heading out of range (70-180 mg/dl) it will give a correction or reduce/suspend insulin. Since it is less aggressive, my numbers did run higher than I would normally prefer. With Artie the artificial pancreas I tended to stay in the 150-180 mg/dl range for much of the day. This does lead to more stable numbers and less of a roller coaster throughout the day which is the ultimate goal. Having the large swings and variability in blood sugar can become exhausting or can eventually do a lot of harm to your body. So the DiA's artificial pancreas is designed to give you much better control and ultimately reduce long term complications.
During meal time it is still required to enter carbs and blood glucose into a bolus calculator just like a regular insulin pump. When starting on the DiA's artificial pancreas I was surprised to learn I still had to manually count carbohydrates. I had always envisioned that the artificial pancreas would do all this work for me. The first artificial pancreas system when it comes to market will be "hybrid" closed-loop instead of fully automated closed-loop. It will still require some input from the user. I was told the reason for this is is because none of the current fast-acting insulin's on the market (Novolog, Humalog, Apidra) work fast enough. On traditional pump therapy I normally have to bolus up to twenty minutes before I eat to keep my numbers below 180 mg/dl. If I had not used a bolus calculator to tell Artie that we are eating and how much we ate than we would get a tremendous spike before the artificial pancreas could predict a high, make a treatment, and then the insulin could start working properly. So it's not necessarily the fault of the system itself but a limitation of our current rapid acting insulin's. Once we have a faster acting insulin it will be game changer with the artificial pancreas system.
I have found that just like life with no Artie, Artie also has trouble controlling blood sugars when eating diabetes unfriendly food. The more carbs and fatty food I eat the worst my blood sugars are going to be. What I have found though is that my highs are less high and tend to also come down much faster. I also have a much softer landing. My blood glucose under Artie rarely ever went above 250 mg/dl and not below 60 mg/dl. The only time it did go above 250 mg/dl was because of a site issue. I have greatly reduced my amount of hypoglycemia during the day. I have reduced my lows from greater than 6% of my Dexcom readings to about 2%.
Exercising with Artie
Biggest Takeaways:
1. Night time control is amazing. I wish the artificial pancreas could work as well the 16 hours I am awake as during the the 8 hours I sleep at night. I would choose Artie over my traditional insulin pump and cgm if nothing else but for the improved night time control. I almost never went low while asleep and almost always woke up between 90-120 mg/dl. I definitely felt much more rested and felt like I had more energy while on the artificial pancreas. See my last blog post No Rest for Artie, How the Artificial Pancreas Keeps Safe While We Sleep.2. The Artificial Pancreas reduces lows and decreases glucose variability. The first generation DiA's artificial pancreas won't eliminate your low blood glucose but definitely will reduce lows by predicting lows and reducing or turning off basal insulin. Since DiA's doesn't use glucagon it is almost impossible for it to completely eliminate lows but the system does a good job of keeping your blood glucose in a safe range. For example, if you are driving your car and come upon stopped traffic your instinct is to hit your brakes and stop your car. If you are going fast you might not be able to completely stop your car and still might have an accident. Without the brakes though your accident would have more than likely been a lot worse. The DiA's system controls the breaks of your artificial pancreas. It may not be able to stop you from going low if your glucose is dropping too rapidly but it will definitely give you a much softer and safer landing. During my 12 week study I went from almost 6% low blood glucose reading to about 2%. This was also another reason I felt better and had more energy.
3. The DiA's In-Control system is more conservative than I. The DiA's system seems to prefer keeping my blood glucose between 150-180 mg/dl during the day time. I am much more aggressive with my diabetes care than DiA's. If my blood glucose is above 140 mg/dl and I am giving myself a correction. DiA's will not provide a correction until I am predicted to go above 180 mg/dl. For this reason alone my average blood glucose and A1C actually increased during the study. My A1c increased from 6.8 to 7.2 and my average blood glucose went from 132 to 142 mg/dl. This was my biggest complaint about the system. I would like to see it a little more aggressive in correcting my blood glucose.
4. Bluetooth connectivity can be a challenge. The DiA's system relies on bluetooth connectivity for the communication from the Dexcom CGM to the Smartphone and from the Smartphone to the insulin pump. The bluetooth was unreliable and required a lot of trouble shooting, repairing, and rebooting. Many times these devices would come unpaired and I would have to stop what I was doing and reconnect the devices. If they became disconnected and I did not immediately tend to the devices I would receive a very loud and disturbing alarm much like a fire alarm which would keep alerting until I tended to the issue. Also, these alarms could not be deactivated or turned to vibrate or silent. This was sometimes a challenge if I was at work, in a meeting, or busy somewhere where I couldn't respond to the alarm right away. It became very obnoxious. I especially experienced a lot of communication issues at places with large groups of people like at airports and at stadiums. Sometimes I would have to change back to "open-loop" mode until I get to a place without the communication interference.
5. Further integration is a must. Having type 1 diabetes is not convenient in any way, shape, or form. We have lots of stuff we have to carry around and keep up with to manage our diabetes. The last thing we need is a system that is not user friendly or integrated and requires us to carry around several devices. In this study I had to carry the Dexcom receiver, an Android phone (not my smartphone), a blood glucose meter, and my insulin pump. There were too many moving parts to keep up with. It became a hassle trying to keep up with all the parts to the DiA's system and always having to have them on me. I could not leave the Smartphone or the cgm EVER. If I did walk away from the system more than a few feet I would lose my bluetooth connection. I had to keep the cgm receiver, pump, and Smartphone on me 24 hours a day 7 days a week. Definitely not convenient or user friendly.
Final Thoughts
As much as I found plenty of aspects to critique the DiA's artificial pancreas system I would trade my Omnipod and Dexcom G5 back in to wear it again today. As much as the system is imperfect it is still better than anything out on the market today. The first artificial pancreas systems will be very good but I guarantee they will just keep getting better and better. Look at today's insulin pumps compared to what we had 10-15 years ago. The first generation insulin pumps that came to market were massive and had little functionality. Also, we have to realize that the DiA's system I used was a trial version and not the final commercialized product. I am confident the commercialized product will be much more user friendly and much of the connectivity issues will be corrected. The purpose of the study is to test the safety of the system, not to test the user ability and convenience. Overall it was an amazing experience and I feel very blessed to have been part of this trial. I am currently waiting on word to hopefully start a new artificial pancreas trial with the University of Virginia in the coming months. I very much look forward to reconnecting with Artie and testing the newest version of the DiA's system.
