Insulin lowers blood glucose, which of course is a vital tool. However, there appears to now be shelf-stable glucagon [1], a hormone which can be injected similarly to insulin and raises blood glucose levels.
AFAIK there is only one company, Beta Bionics [2], that is working on commercialization of such technology with dual pumps. In this case, you could be more aggressive in either direction of pushing BG, because you have a safety net.
Because this feels like a holy grail / functional cure, I'm surprised the incredible DIY teams out there haven't trained their guns on doing this. Having both "turn it up" and "turn it down" knobs seems so much more valuable than squeezing the last 5% of efficacy of AID systems. I feel like glucagon is obviously "the answer", but I don't see much talk about it.
Is the problem that there is no hardware for dual hormone pumps? I would have thought by now they'd have hacked 2 patch-pump AIDs to work simultaneously.
For some background - I'm a T1D working on a search engine and conversational interface for integrating a bunch of new data sources and models into metabolic decision making: https://replica.health. I've also been a user of and worked on various open source artificial pancreas systems through the years, and am currently on Loop.
>I would have thought by now they'd have hacked 2 patch-pump AIDs to work simultaneously.
As you pointed out, the problem is not really hardware. It could technically be done in a straightforward way using two independently controlled insulin pumps, but the complexity and risk of the whole operation goes way up if you are taking way more insulin. Taking a bunch of insulin and glucagon at the same time is not necessarily a great idea either - they don't just annihilate each other without consequence and you could end up with secondary effects like gaining a bunch of weight.
>Because this feels like a holy grail / functional cure
Unfortunately it is not; even dual hormone systems have problems keeping up w/ the kinetics of glucose absorption and to address this there is also research into tri-hormonal systems, w/ amylin as the third hormone. In any case you will still need some a-priori info about meals and planned activities, though less so than with a single hormone system. Integration of exogenous data sources to provide this info to the APS is what we are working on at Replica.
Also, hate to be the bearer of bad news but beta bionics has shelved their dual hormone ambitions for now; their prototype device soon to be released is insulin-only. On the bright side there is a small Dutch company whose tech predates beta-bionics. They sell a dual hormone device and will give it to you for a ton of $ (and probably have you sign a bunch of waivers): https://www.inredadiabetic.nl/en/discover-the-ap/
Oh my gosh, this is the startup I considered starting last year when this issue became personal to me and I wrapped my brain around the complexity of insulin dosing.
There are a lot of challenges here but we absolutely need an external "brain" to correlate many data points, some trends, and reasonably estimate current insulin sensitivity.
Good luck with Replica! I built something sort of similar for my family (my 8 yo has T1D and a lot of life-threatening food allergies): https://saltie.app. Happy to chat as well, I can create an account for anyone interested, and I can share what I’ve learned in making this.
I formerly used to work in the diabetes management space, and I too would be interested in chatting seeing as I have acquired some modeling expertise in the meantime.
So I do not have a medical background. I have however worked a number of Industrial Control Systems (ICS) projects, and what you describe kind of sounds like a PID control loop, which also is not a simple push up/down approach.
From Wikipedia:"A proportional–integral–derivative controller (PID controller or three-term controller) is a control loop mechanism employing feedback that is widely used in industrial control systems and a variety of other applications requiring continuously modulated control. A PID controller continuously calculates an error value e(t) as the difference between a desired setpoint (SP) and a measured process variable (PV) and applies a correction based on proportional, integral, and derivative terms (denoted P, I, and D respectively), hence the name."
Getting PID control loops to work has a lot of research behind it, but it's still hard to get right with new hardware. I would imagine a PID control loop involving organics (wetware) would be much order, and harder still a PID control loop in organics with life-threatening failures possible.
PID works well for most industrial controls, but it's a blunt instrument. Its mainly valuable because it's simple and doesn't really require much knowledge of the plant to implement. No 'model' is really required, other than the vaguest knowledge of first order dynamics. Instead of model knowledge you just iteratively tune it until it works.
If you need a really optimal control trajectory minimizing or maximizing for some parameter, you are willing to do the system identification necessary for it to work, and you don't much care whether an electrician can understand how it works model-based controls are much better. as /u/Communitivity mentioned so called 'model based control' (which is an umbrella of techniques) is a much more powerful tool.
At this point all the major solutions are using an algorithm that would probably fall under the umbrella of "Model Predictive Control" rather than a vanilla PID controller. An absurd spate of patent trolling occurred back in the early 2000s related to Controller definitions like these though. Researchers patented the use of a "PID controller in artificial pancreas systems" [1][2] which slowed down the development of APSs by many years.
My father was an MD (psychiatrist) and had this saying:
- 1 drug, it works ok, still very patient specific.
- 2 drugs at the same time, only if you validated correctly at least one alone before.
- 3 at the same time: clusterfuck/total mess.
Base rule: do everything possible to use only one active ingredient/drug at a time.
I'm a type 1 diabetic on multiple daily injections -- a pump just introduces a lot of inconvenience for me, price aside. You have to track batteries and change tubing and make sure the tubing doesn't snag on things, and unplug the machine before taking a shower or bath, and ... blah blah blah...
All I need for MDI is to carry my syringes and vial around in a cold pack (I live in the tropics, lol) and I don't need to worry about hardware beyond that.
I'm in the same boat re. MDI over pumping. I can still keep very tight control without a bunch of cumbersome attachments (I do wear a flash sensor though).
Why vials and syringe rather than a pen though? I usually just carry the pen in my pocket and phone for monitoring. Even in hot weather I've not had problems with insulin losing potency noticeably before finishing a cartridge.
> In any case you will still need some a-priori info about meals and planned activities
Not necessarily, at least not via patient input. In the albeit small Inreda studies manual announcement of exercise and meals wasn't required (or an option). Medtronic also has a meal prediction algorithm on their newest offering that's a step towards a fully automated process and currently more or less obviates carb counting but isn't at the point where you don't have to announce a meal (yet).
Rather than integrating external data sources the algorithms are predicting based on historical glucose levels and/or insulin administration and it seems to be working.
Agree that patient input shouldn't be necessary, but to replace it we will need to include other inputs besides CGM in a systematic way to get the optimal results. My company is working on how to use contextual info automatically collected by your devices to help (detected activity, measured calorie burn, geofencing, data from meal-ordering apis, etc.). This is especially true given that the CGM data themselves are lagged due to averaging and/or kalman filtering going on under the hood. This is a fundamental problem; Inreda uses two identical CGMs for noise reduction purposes just so they can get clean data with less of a lag.
None of the systems claiming you don't have to do anything in terms of meal announcement are _working_ in the sense of achieving euglycemic parity, which should be the goal. I can say with certainty that the cgm logs from people who don't announce meals on the Inreda device do not look like they are from non-diabetics: there are still often large post-prandial spikes. Inreda likely does better than any single hormone system, but the problem is not solved in any sense.
> Agree that patient input shouldn't be necessary, but to replace it we will need to include other inputs besides CGM in a systematic way to get the optimal results.
I'm not going as far as to claim Medtronic's approach (I believe the only one commercially available with so-called meal prediction based on historical CGM and offers full correction boluses) is the optimal one, just that it is an approach that is at least very good (~80% time in target) and while it still requires meal announcements it's just the first step of what they're trying to do. Clearly we can expect further iterations of these algorithms as the technology matures.
> Inreda uses two identical CGMs for noise reduction purposes just so they can get clean data with less of a lag.
Just giving an example that this is possible without external input or data, your statement was that you will need a-priori information which is not necessarily the case. Whether such a system is optimal is a different question.
I haven't seen the raw data and highly doubt enough of it even exists for anyone to make a claim whether or not such a system can be optimized to the point necessary.
> None of the systems claiming you don't have to do anything in terms of meal announcement are _working_ in the sense of achieving euglycemic parity, which should be the goal.
For clarity to any less knowledgeable readers while time spent in euglycemia is a very important outcome measure it cannot come at the expense of severe hypoglycemia or severe hyperglycemia/diabetic ketoacidosis (i.e. an algorithm that improves euglycemia to 95% but has a 2% severe hypo time is less acceptable than 80% euglycemia and 0.5% severe hypo.)
To my knowledge no system on the market/generally available right now is claiming to be completely input free. The closest to my knowledge is again the MiniMed 780G discussed in my first point which will assuredly be iterated on.
Also to be clear I'm not being dismissive of what your company is working on, it's a very interesting and novel approach. It may even be necessary to achieve the optimal product. I look forward to reading about your results when you publish them. I'm just presenting alternatives and a brief overview of what other approaches are for HN readers who are likely unfamiliar with the topic being discussed.
Really appreciate the pointed commentary on this! Happy to make further prognostications about the success of CGM-input-only APSs via email.
For the record, when I say "Euglycemic Parity" what I really mean is a sort of Turing test (not time in range), where a data-driven Endocrinologist is asked to tell the difference between CGM records from a non-diabetic, and CGM records from a diabetic equipped with some control system. Passing this test should be our long term goal IMO and we will probably have to bring many techniques to bear to eventually achieve it.
I think the "no meal announcement" features are really valuable for traditionally underserved demographics who, for whatever reason, can't "get good" at managing their disease.
The difference between how quickly food and insulin hit your bloodstream make it seem like there is no way to "algorithm your way out of" meal announcements. Food hits almost immediately, and with variable strength depending on macronutrients in it, and insulin takes ~15 minutes to start working, and peaks at 1 hour, with no concern about BG levels. Can you square these 2 for me and make it make sense?
I think what you're missing for this to make sense is what is the desired outcome. For type 1 diabetics there are three important ones:
1. Time in severe hypoglycemia - ideally 0%
2. Time in severe hyperglycemia/diabetic ketoacidosis - ideally 0%
3. Time in euglycemia (also called time in target) - clinical target is >70% and for reference the median healthy non-diabetic is in target ~90-95% of the time.
Closed loop systems are very good at #1 and #2 as it takes a while for levels to get to the severe state and insulin can be administered (or withheld) based on CGM.
When we talk about algorithming out of meal announcements it's whether historical patient-specific blood glucose levels and insulin administrations (i.e. a prediction of what you eat and when) combined with CGM can keep #3 acceptable, not necessarily optimal. Medtronic is using this approach and their newest model more or less eliminates the need for accurate carb-counting but they still require meal announcements. The hope/idea is that this can potentially be eliminated in further iterations.
Another important thing to keep in mind which is sometimes lost in these discussions is that we don't treat numbers we treat patients (i.e. what are the clinical outcomes). Generally speaking, we assume the closer to normal the better but we don't have actual data about how much an extra X% outside of target ranges matters in terms of clinical outcomes and complication rates. We only really started getting this data with CGM and complications in these mild states would require very large cohorts and long (10-20 year) follow-ups to detect differences as they're likely to also be mild.
So while you're absolutely correct regarding the limitations and that an algorithm cannot outperform accurate carb-counting and meal announcements the missing piece is that it may be sufficient. Particularly if said algorithms result in improved time-in-target for patients who aren't good at managing their diabetes and find meal announcements cumbersome.
First of all, clearly you have a ton of knowledge in this space, and I'm feeling very lucky I get to learn from your experience here. I have one more last question/challenge:
I totally get that we "treat the patient" -- that's sort of what I'm hinting at with the demographics. But, in my opinion this thing you said:
> we don't have actual data about how much an extra X% outside of target ranges matters in terms of clinical outcomes and complication rates. We only really started getting this data with CGM and complications in these mild states would require very large cohorts and long (10-20 year) follow-ups to detect differences as they're likely to also be mild.
... is not the same as saying "we know that 70% TIR is safe to live with no complications". I don't think any of the guidelines are that confident, because there's not enough evidence yet. Consider this study (discussed at [1]):
> Overall, increasing time spent with glucose levels in the target range of 70–180 mg/dL (3.9–9.9 mmol/L) was associated with decreasing risk for microvascular complications. For instance, 50.0% of the 10 individuals in the lowest category for TIR (<40%) had at least one microvascular complication, compared with just 27.3% of the 99 people in the highest category for TIR (≥70%).
> Moreover, El Malahi said that the 180 people with microvascular complications had significantly lower average TIR than the 324 individuals without, at 60.4% versus 63.9%.
This suggests to me that a difference of 4% of TIR can seriously affect long-term outcomes. And, by the way, even those with the highest TIR still had microvascular complications higher than the normal population. On top of that, we know that genetic and environmental factors may be at play.
Therefore, my monkey math is that 75%+ as a TIR goal may mean that even if the patient is an order of magnitude more vulnerable to complications, microvascular or otherwise, they have a much better shot.
And, unfortunately, the typical western diet with 3 meals a day and snacks, you have to be "good at managing diabetes" to get to 75%+ TIR. Thanks for reading my ramble.
Sorry I know this is off topic, but I'm a recently diagnosed T1D and I would like to get more information about Loop and other loop-like open-source systems.
My son is T1D since age 7. He is now on the OmniPod pump and the Dexcom G6 sensor. It’s been a very effective combination that’s covered by insurance. The challenge with the open source projects is limited equipment that can be hacked.
Most people on loop have omnipod and dexcom g6 also so I don’t think it’s that limited. It’s true that it takes a few months for new devices to get integrated but open source APS are the only systems lets you choose what devices you want to use with them.
One thing I wish I'd been told more about when first diagnosed was the possibility of prolonging the honeymoon period. It was decades ago, and back then the advice was to eat a fairly normal diet and just dose as much insulin as needed.
If I was back in that position I'd go low carb high exercise from the start, and do everything I could to reduce my insulin requirements as much as possible. There are cases of new T1s coming of insulin completely, or just a low basal dose for multiple years.
Bummer to hear about beta bionics! My understanding was that the hardware they are releasing does have a place for glucagon, just not the software and additional reservoir required. I'm considering a switch to their pump since it seems like they've made it as automated as possible with insulin-only.
Would love to see/hear more about what you're working on!
This is very interesting, and I (T1D) would like to learn more. However, the e-mail signup doesn't work for me. ("Oops! Something went wrong while submitting the form.")
This is awesome. The obvious next step here would be integration with the pump to send the correct dose after the user confirms the app is correct in the food they are eating
My worry with this approach has been that infusion sites (both for insulin and glucagon) can become occluded, pulled out, etc. to suddenly render them completely ineffective, and that automated detection of these scenarios is not great.
You need to move forward, and therefore must occasionally have a foot on the gas (insulin). The gas pedal failing, causing you to stop moving forward, is not urgently dangerous (hyperglycemia). However, if your brakes (glucagon) can sometimes fail completely, that could cause you to die almost immediately if you're moving too fast toward danger (extreme hypoglycemia). Given this situation where brakes are unreliable, do you want your automated control system to rely on them and push you to dangerous speeds?
The detectability of failure is an excellent point. Anybody who uses the hardware can confirm it's not 100%. I think your point helps me re-frame the glucagon as more of an insurance backstop for when we accidentally hit the gas a little hard, rather than a permission slip to constantly be going too fast and constantly be slamming on the brakes.
Even in this framing, it still feels like an extraordinarily valuable addition, and relatively low risk. It's also, of course, more to add to the patient's maintenance, but might help them or their caregivers sleep at night.
> It's also, of course, more to add to the patient's maintenance
I agree with all that you've said, and this point in particular is extremely important. It's also the reason I moved from a DIY system like the one mentioned here, to a commercial system, once the latter was available. There is simply less hardware and software to juggle with the commercial system. There are fewer knobs, bells, and whistles, meaning I might not be able to tweak things to be in as tight control as might be possible with a DIY system (though with risks!), but overall it's been "good enough" for me, and greatly reduces the cognitive burden of having T1D. My experience clearly doesn't match everyone's, but considering I'm typically someone who loves to tinker, and has plenty of T1D experience (engineer, 34 years with T1D), I'm sure I'm far from the only one that feels this way. My glycemic control isn't significantly better than it was when I did it via constant monitoring and mental math, but the cognitive and emotional burden is much lower.
> However, if your brakes (glucagon) can sometimes fail completely, that could cause you to die almost immediately
Failure detection is via alarms to trigger patient action based on the continuous glucose monitor (which has a different set of reliability issues) as well as patient symptoms.
Hypoglycemia becomes symptomatic long before blood sugar is low enough to result in death or serious debilitation and T1D patients know their symptoms well. The risks are not nearly as dramatic as you're suggesting as one isn't/shouldn't be relying on glucagon to prevent severe hypoglycemia, I don't think any system is designed or being conceived to operate in such conditions.
Hypoglycemia isn't really much of a problem anymore with current CGMs and pumps.
> Hypoglycemia becomes symptomatic long before blood sugar is low enough to result in death or serious debilitation and T1D patients know their symptoms well.
There is a what seems to be a significant number of people who don't "feel their lows."
> Hypoglycemia isn't really much of a problem anymore with current CGMs and pumps.
Current CGM's can still require hours of "warm up", and many current pumps still must be removed for things like swimming so they don't get penetrated with water.
> There is a what seems to be a significant number of people who don't "feel their lows."
Severe hypoglycemia to the point of what was described (death) is not reported in any of the recent device studies.
Level 2 or moderate hypoglycemia, very different from death, is reported at < 0.5% in recent closed loop system studies.
> Current CGM's can still require hours of "warm up", and many current pumps still must be removed for things like swimming so they don't get penetrated with water.
Current CGMs are water resistant but conveniently one is also not administering insulin while swimming either. The bionic pancreas is also dependent on CGMs and has the same limitations.
I'm really not sure what point you're getting at. Hypoglycemia is not what's being improved upon with current advancements, it's time in target.
OK thanks, I get your points. What I was getting at is a disagreement with "Hypoglycemia isn't really much of a problem anymore with current CGMs and pumps." Because lots of people on current CGMs and pumps still deal with hypoglycemia, despite these pumps and CGMs making the situation so much better than otherwise.
You seem to be misunderstanding how these devices work.
Bihormonal pumps do not mean continuous infusions of both insulin and glucagon. The pumps pulse insulin when you're high and glucagon when you're low. They're not both administered at the same time or continuously infused in a "balanced state".
The context in this thread:
> However, if your brakes (glucagon) can sometimes fail completely
A bihormonal system would not result in more insulin being administered than an insulin-only system for a given blood sugar, if the glucagon pump fails we would have an insulin-only system where we have plenty of safety data. There is no mechanism by which a bihormonal system has higher risk of hypoglycemia than existing closed loop insulin system.
> Hypoglycemia becomes symptomatic long before blood sugar is low enough to result in death or serious debilitation and T1D patients know their symptoms well.
Often times in an acute setting, yes. However patients who have had diabetes (T1 or T2) for a long time often lose a lot of their hypoglycemia sensitivity and symptoms. It's not nearly that simple.
Hypoglycaemia during sleep is the big one. My hypo sensitivity isn't great, but if I'm awake I'll always notice before it gets really dangerous. Sleeping is a different story though. The days when even a slight low would jolt me wide awake in a sweat are gone though, and now I'm much more reliant on sensor alarms to not just sink silently deeper.
Yea you would need really good failure detection if you were going to "hit the gas" with a bunch of insulin. Part of the solution is going to be controlling risk via the dosing algorithm itself, so you never get in those situations where you are at risk of severe hypo in the event of a (glucagon) site failure.
I'm a type 1 insulin dependent. The three low tech "hacks" I've been happy with are the following. First I take a sublingual Melatonin most nights, Melatonin upregulates the insulin receptors and lowers my insulin requirements about 40% by my guess. The second one is dietary I add olive oil to my lunch and dinner, I feel this provides my body a reserve of non glucose energy. Finally I use a very small dose of cannabis most days, I like to get a puff or two and night, THC protects nerve cells from Hypoxia so I feel this keeps my brain cells going when my blood sugar gets low. I feel these three things, give me a leg up on my long term blood sugar control. I am thankful there are hackers and diy opensource initiatives. The CGM readers here in America Dexcom, and Libre both have crazy bad user interfaces. Libre will only let you pair to a single device, I had their device fail leaving a functional sensor in my arm, a quick idea I searched for opensource libre reader app and found two. One worked and started reading the sensor. Dexcom has the issue of being a 10 day use cycle so you run out on varying days of the week. Both take the FDA mandate to have low blood sugar alarms as a blank check to overide any controls about sound or do not disturb to bother about countdown to a new sensor. I liked that external libre2 reader as it was the only device or official app that can be silenced, but their rigid only pair with one device still angers me, what if my loved one want's to be able to scan my sensor? Low blood sugars are challenging as they affect my brain and I can answer an amazing amount of questions about my blood sugar wrong if I get too low, my brain trying to preserve energy can be dangerous at times. This was an issue more before CGM. Dexcom decides that it is OK to have a completely automatic warning at any hour of the night "your sensor will expire in six hours!!!", that warning has little to do with my care as it is too late to influence refill compliance and seems to have been ordered by the executives to some how improve their pRofItiBiLiTY. I am so much happier on a third party app with the silent reader as an extra. Sorry if this was long winded, being insulin dependent has bee a challenge over 40 years. The first 10 years they hadn't figured out that insulin reactions are much more subtle on human insulin than the older pig and cow derived ones were.
So my wife is a type 1er. The way glucagon fits into her life is that we have an emergency glucagon shot that she carries in her purse to use in the case of an emergency. The glucagon is more of an immediate emergency recovery. On the flip side glucagon doesn't lower the blood sugar which is dangerous when she is going high.
I may be misunderstanding something here.
I'm assuming the emergency you're referring to is low glucose. Why would you use a shot of glucagon rather than a dextrose tablet for that sort of emergency?
A glucose tablet and a glucagon shot can both be used in emergencies, but they are best used to treat different levels of emergencies. You can take a glucose tablet if you're coherent and conscious, but when you're incoherent or passed out from a severe hypoglycemia, someone else administering a glucagon shot is a lot easier and safer.
My wife has diabetes and her endocrinologist told me 5 years ago that the absence of shel-stable glucagon was the reason her insulin pump and glucose sensor weren't connected yet. Now she is actually using AndroidAPS, after I compiled it for her.
Really happy to see that there are people now working on both gradients!
There's a lot more going on in the body than this. Muscle protein influences insulin resistance. Diabetes is strongly associated with inflammation which may imply that infection or pH balance (or both) plays a role. For functional hypoglycemia, metabolic syndrome and T2D, dietary changes can have substantial positive impact.
I'm thrilled to see this is happening, but the chemical inputs and various metabolic factors are far more complex than "sugar in, one hormone to lower blood glucose levels and another to correctively raise it."
Glucagon should probably be a safety net, not something you use regularly. Taking too much insulin and compensating with glucagon leads to long term weight gain among other things.
Dual pumps are being worked on, but it's not yet clear that the improved glucose control justifies potential long term consequences.
My assumption is that the DIY Pancreas community is well-informed, technically capable, and highly motivated.
My guess is it hasn't done what you suggest for practical reasons related to supply chain, intended user base, and practical engineering considerations appropriate for high reliability mechanical design for medical use.
For example, the insulin delivery system has many points of failure. Any fault or failure is likely to have severe health impacts on the user. To a first approximation, doubling the number of pumps doubles the points of failure.
The only way to "cure" diabetes is to replace the pancreas or get the cells to go back to behaving the way they were before insulin resistance. The 1st is incredibly risky and wouldn't be pursued for that reason. The 2nd is most likely to lead to a cure, using a morphoceutical approach that reprograms or replaces the misbehaving cells.
No, there isn't a hardware problem and such systems exist. Several trials[1-3] dating back several years have looked at "bionic pancreas" or a closed loop bihormonal system.
Inreda (a Dutch company) has a CE-marked device[4] that can be clinically used but one limitation has been glucagon stability (has to be replenished daily). Tandem in the US was working on this as well but I haven't heard anything about them in a while, not sure how far along they are.
The Inreda product is still in the early stages of testing but fully functional. Small crossover trials seem promising (defined by more time in euglycemic state).
There is a competing approach with "intelligent insulin" or a self-regulating glucose sensitive insulin formulation that has different bioavailability depending on circulating glucose levels rather than relying on a monitor, this is farther out from clinical use.
One of the reasons bihormonal pumps haven't entered mainstream use yet is that it's more expensive/complicated and the current techniques of algorithmic predictions of hypoglycemic episodes and insulin delivery suspension are already very good that hypo isn't much of a problem with modern devices like Tandem's offering.
Medtronic has added a meal detection algorithm[5] that's really good too (the best on the market I'm told by my endo colleagues) and they say we're getting close to not needing meal announcement anymore, this practically eliminates carb counting. It's the first such algorithm to be in clinical use so we're not there yet but the expectation is that this approach will get us there.
The question (for glucagon) then becomes how clinically useful more time in euglycemia is as the hypo episode problem is essentially solved, we'll need more data to draw any conclusions and it will take a while for this particular question as many of the outcome measures are long-term (i.e. what are the long-term sequela of mild intermittent hyperglycemia, it's somewhere between nothing and uncontrolled diabetes but how far along on that line is the billion dollar question).
It's not clear from their site whether the Inreda product also has CGM built into it, or if it must be paired with one?
Glucose-responsive insulin also seems like science fiction as this point, but would be extremely powerful tool.
I'm very familiar with one of the most popular, closed-loop system combinations in the USA and I definitely don't feel the hypoglycemia problem is anywhere near "solved". There is too much volatility dictating a person's insulin sensitivity that even today's smartest systems will regularly give too much insulin, requiring treatment, or too little, resulting in prolonged hyperglycemia.
I agree that time-in-range is incredible today with the technology, comparatively, but there's still lots and lots of room for improvement.
Inreda integrates the CGM, [1] has more details on the setup.
> I'm very familiar with one of the most popular, closed-loop system combinations in the USA and I definitely don't feel the hypoglycemia problem is anywhere near "solved".
I should have been clearer, the moderate to severe hypoglycemia (level 2 and 3) problem is essentially solved with the newest generation of closed loop systems. Hypoglycemia in general is trending towards being solved particularly with the newest Medtronic devices, both from studies and what endocrinologists are seeing.
In some of the recent studies (which again are still small as these devices are new) I've come across there are no severe hypo episodes reported and % time in moderate hypoglycemia was (picking one study) ~0.3%[2].
The belief is that further iterations of these algorithms will continue to improve this hence why I said "solved" as in there is no strong need for a large treatment paradigm shift on the basis of moderate-severe hypoglycemia.
> There is too much volatility dictating a person's insulin sensitivity that even today's smartest systems will regularly give too much insulin, requiring treatment, or too little, resulting in prolonged hyperglycemia.
Hyperglycemia is a different discussion altogether that is not addressed by insulin delivery suspension or glucagon. The MiniMed 780G is probably the most advanced system out there with minimal patient input and time in target range is being reported as ~80% which is certainly getting there.
The thing is - the ideal solution injects 100% the right amount of insulin and no glucagon because insulin is a growth hormone and too much of it makes you gain weight. Body builders have been known to use insulin to gain muscle.
Yes, but the "patch pumps" like the Omnipod are small enough you think patients might tolerate 2 of them? Maybe they've already asked, and people wouldn't tolerate it.
Possibly. But it's more than that. You have site issues, even with one pump, that you need to navigate. There are only so many viable places on a body to attach a cannula for good absorptoin and, while small, these things aren't _tiny_ (especially the Omnipods where the site holds the cannula, pump and reservoir).
It'll be a while before we see highly reliable and well-tested dual-reservoir systems is my bet.
The complexities of balancing insulin and glucagon in a two-pump system are also high. And the feedback loop from sensors that detect BGL aren't super fast. My kid's Dexcom works on a 5 minute sample loop now. So you can't make decisions fast and when you do, you can't course correct a bad decision quickly.
I love that people are working on this stuff. The folks at https://wearenotwaiting.net/ are amazing and we even use NightScout here, but the fragility of the systems are stark and it'll be a ways to go before it's not just the brave pioneers pushing these frontiers for T1Ds.
You know what cyberpunk future I am looking forward to ; Bionic Arms/Limbs whi are chosen to be replaced, but in the place of the bicep is a blood filtering, monitoring mechanism that keeps your blood hyper oxygenated and tracked...
Although, to go along with the cyberpunk theme ; If you want to kill a Cyborg, you just rip off his arm...
It's fun to imagine a future where we can design human body parts better than our body but can't figure out how to unplug them without a mess. Damn Magsafe patent still holding up in 2077...
Note that as with every insulin-pump system, it still has two major pain points:
- subcutaneous insulin doesn't act immediately, as it would if it was injected in the blood directly. it peaks in an hour and then wanes off at 3-4 hours.
- it cannot know external factors like how much carbohydrates you are eating, or if you are planning to work out, etc. Like conventional pumps you have to enter it manually.
Buying a sandwich and not having to think about carb grams and predosing at all sounds like a dream to me.
My youngest daughter has been on a pump for six years now and she's completely burned out and apathetic about it all. It just all blurs together and her diabetes is not well managed at the moment. My oldest and I had a sort of impromptu intervention with her and she just broke down crying. It's a lot.
The pump she has, a t:slim X2 is better than her Medtronic, but the closed loop aspect (control iq) is impotent and rarely has a noticeable impact. Hopefully this tech will advance on a good pace and products will hit the market with more assertive control algorithms. Obviously there are dangers but we've already accepted that by hooking her up to a pump with enough insulin in it to kill her.
Due to NDAs I can't write too much about this but there is a lot of work being done on this front right now and I expect a new generation of these devices to be out for trial in the relatively near future. Pumps are getting smaller, which is one factor that helps and analysis is getting more accurate. Reliability and sensors are improving. But the timing aspect is critical especially without knowledge about environmental factors and the relatively long hysteresis of the feedback is a major obstacle to the big leap forward. Key here is that the body has more data about the situation than an outside device will ever have and that regulation in the body is a fairly global affair [1] so it can act faster and with more precision than you can ever do from a single site. These are all super tricky problems. But compared to the situation only a decade ago it is already much better and I fully expect at least one more round of breakthrough devices. Best of luck there, it's harsh to be a kid with such a demon on your shoulders.
I went through the same struggle with my own Type 1.
Feeling overwhelmed with responsibility, denying I am any different than anyone else, denying that I have to permanently manage a condition to be normal, denying that my own body would fail me, feeling helpless that even the "best" I could do would still involve invasive and frustrating treatments.
For me, it was a phase. Happened at about the same age (through my teens, basically) and took about that amount of time to just get through it. At some point I learned that with a bit of management, I can thrive and do just as well as anyone, especially with the new tools that we have now. It just took that psychological struggle to get there.
I am really sorry that you have to see your daughter struggling like that. I know exactly how helpless it feels.
Hang in there, lots of folks having similar experience!
We have been pretty impressed with the closed-ish loop of the Dexcom and Omnipod, it handles daily fluctuations due to more/less exercise etc. fairly well.
Still two separate handheld devices though, and quality always falls off when the sensor (every 10ish days) and pump (every 3 days) approach expiration.
I have family with diabetes and I feel some empathy with your situation. I've felt that second hand anxiety when my cousin started partying recklessly in uni and not managing it super well.
You're helping her manage it and that makes a massive difference. Those of us without diabetes usually aren't taking care of ourselves at 100% either. We're lucky to have access to amazing medical technology, so some scary seeming situations are pretty recoverable.
Hopefully a platitude or two helps a small amount :(
My 11/yo has the same pump. Control IQ is great...but it takes a cautious approach to adjustments of insulin delivery given that it can only lower blood glucose levels and not raise them. Hopefully dual-hormone pumps will come out in the next few years and the algorithms can be more aggressive.
In the end, our 11 year old ignores his pump much of the time. We have a bunch of SugarPixels around the house, so if his sugar is way off we know and can address it ASAP.
Have you tried putting your daughter on a different diet (low glycemic-index diet with more natural and keto-friendly foods)? This will make managing her diabetes a lot simpler and it'll make her feel better too.
I'm a type one diabetic and have been one for over 15 years now. Getting diagnosed is one of the best things that's ever happened to me. It got me to notice the huge impact diet and exercise have on the mind and body. I initially had issues like your daughter too but changing my eating habits and altering my life-style definitely had a profound effect and made it much easier to manage. If you need tips / help let me know and I'll do what I can. My number one tip is to stick to a more keto-based diet. It will make her blood sugar much easier to manage and has a lot of health benefits.
Thanks for the suggestion! She's 20 and living at school so I have limited influence over her diet. She's pretty much raising a middle finger at her diagnosis right now out of spite and frustration so it's a tricky situation. I've asked her to try to find a community that caters to diabetics at school (i know one exists but i tell her to join it it will not work) to feel less alone about the whole thing.
Ohhh I see and my apology for the misunderstanding!! Either way - she's still young and she has plenty of time to figure it out. If not - one other recommendation I have is getting lab tests done every 3 to 6 months and going for regular check-ups with a doctor. If you find a good doctor - they can make a big difference in getting patients to notice bad HB1C measures and can talk with her about keeping them in check and why it's so important to keep blood sugar levels within normal range. Either way - I wish her a lot of luck and my offer still stands if she (or you yourself) need any help or advice :)
Second this. Just adding fats and protien to a meal effect the meal’s glycemic index (even though it does nothing to glycemic load). I did a lot of research both times my wife was gestational diebetic, and while I already knew that fats helped to smooth bloodsugar levels, it was still wierd to see a dataset with toast having one of the highest glycemic while buttered toast was significantly lower on the scale.
This is trying to solve the wrong problem. Juvenile diabetes is almost always a human problem - not one of optimizing for treatment.
If you have a kid in their teens or 20's who is not entirely ignoring it out of spite, you're way ahead of the game. This problem is much harder to solve than tracking carbs and insulin doses, or changing diet/etc.
The person has to be ready to attack it. And for many young folks (and I assume older as well) this is where the problem lies. It takes a lot to really accept this is going to be your entire life, especially at an age where everyone (seemingly) around you are living these amazing care-free young adult lives, while you have this constant monkey on your back being a buzzkill. Very few individuals have the desire to "do their research" and start hacking on their health the way the HN community would tend to approach things.
Short of commenting on how heartbreaking it is as a parent to watch your kid go through this, I really have no good answers. I guess the topic of this discussion is it - a magic device you can slap on once a week and never think about again. Short of a device like that, I can't see this problem turning to technical vs. human any time soon.
If you think of our brains as a complex electrochemical reaction, the concept of activation energy is in play. And I just think that for some people in some situations their mind doesn’t have the wiring to generate sufficient potential gradient to achieve the activation energy required to motivate action. They can’t just will a thing, they need to rewire their brain first.
My daughter is on https://camdiab.com/ it really works a charm, we do have alarms for low glucose (like it can dip down to 3.1 if she does exercise) and rarely for high glucose, but these are things you would probably not even see without the constant monitoring. The data shows that she is extremely well managed since she started with the closed loop system.
Camaps demands that you have a particular model of phone (about a dozen androids and iphones) which makes it a bit more expensive I guess. Luckily we are on the NHS in the uk so my only expense as a parent is that I have to buy the posh phone, but then I guess that goes with having a teenager around anyway...
G6-cgm and Dana Diabecare-rs. We started with the Dana-i but it was glitchy and so we got the rs instead, which works a charm so far. We also use a setter device that talks to the Dana pump when you are filling it up and tells it how much insulin you are loading (this can be done manually also I think).
She has a samsung s-20 phone, previously we had a pixel 3 which bricked itself on Christmas Eve. I had a LG G7 which we tried to use, but although this is claimed to be compatible it turned out not to work. So we had injections over Christmas which was not great, but when the new phone turned up on 27th all was well again. Google replaced the Pixel, so I now have the replacement handset and it is ready to go as a fail over.
I'm on the Medtronic 780g hybrid loop and it's actually working. If I eat nothing and have no intense physical activity the CGM curve is a stable straight line.
It has indeed been improved substantially in the last couple of years. If you haven't upgraded the pump in that time I would definitely recommend you do so.
One thing about these pumps that doesn't seem to be advertised widely enough: they don't handle full sun well, so always keep at least one layer of clothing over the pump.
I am aware that I know next to nothing about the topic and that I am ignorant of countless complications. With that said, your pancreas also does not know that you plan to work out, at least I would assume so. So what is the crucial difference between a pancreas and insulin injections? That the response is delayed because the injection is not into the blood stream or does the pancreas also have better sensors to figure out how much insulin to release, or maybe even release things other than insulin? If it is the former, what obstacle is there for injecting into the blood stream? The infection risk of having a permanently open port into the circulatory system? If so, is there a similarly effective way to deliver insulin that is not into the blood stream and with less risks? Or could you have some kind of membrane in the port that only allows insulin to pass through but that is impermeable for pathogens? Or would that get clogged immediately?
The difference is the pancreas reacts immediately to changes and has no practical delay for its effects, same concept as PID controllers in engineering.
So the limiting factor is the subcutane delivery, i.e. if the insulin could be delivered into the blood stream, then continuous glucose monitoring and controlled precise insulin doses could work as well as the pancreas?
The subcutaneous part is not really solvable, but even if it were, "real" insulin is much faster than even the fastest insulins (lispros) that we currently have. So there is a delay between delivery and action. There is also a delay on the sensing side; the pancreas always knows what's up, but even cutting edge CGM technology has significant delays, mostly related to that subcutaneous issue from my understanding.
There are faster acting insulins creatively named "faster aspart" and "ultra rapid lispro" with the latter beginning to appear in the bloodstream at 2 minutes and reaching 50% effect around 20 minutes.
With that said the difference between CGM/pumps and the human body's mechanisms of blood glucose regulation is not purely due to pharmacokinetics, regulation of blood sugar is very complex and we still don't fully understand them but there are multiple hormones and factors affecting blood glucose regulation.
As one example some incretins are released in response to ingested food content and stimulate insulin secretion before blood glucose levels rise. We can't replicate that just by measuring blood glucose (not that we necessarily have to).
The homeostatic mechanisms of the human body are fascinatingly complex.
It's a huge oversimplification, but essentially yes.
The current external artificial pancreas solutions operate subcutaneously, and your pancreas gets to work more directly with your blood. Subcutaneous blood sugar readings lag about 20 minutes compared to actual blood (finger pricks), and subcutaneous insulin delivery lags behind a healthy pancreas by even longer.
There isn't much of a difference between injecting insulin (being diabetic) or getting your body to produce it. The main difference lies in having no automated mechanism for regulating blood sugar levels. Due to this - you have to calculate the correct amount of insulin you need for your meals and measure your blood sugar regularly to make sure it stays within balance. If your blood sugar levels tend to be higher than normal (i.e. you aren't injecting enough insulin), that isn't good. It is OK in the near term - but can be devastating in the long term due to health complications (i.e. blindness / nerve damage / etc..). If your blood sugars are fall too low - you can have severe consequences in the near term (i.e. die or have a seizure within 1 hour of injecting insulin). In other words - you need to always keep your blood sugar in check in order to survive and to be in good health. Some people find this extremely hard to do - some people like me embrace it.
Your pancreas actually does know things like that you've ingested a lot of carbohydrates before they enter the bloodstream, etc. Certainly there is also a response to exercise that occurs before you coiod easily detect it with a CGM. There are very complex brain-gut-pancreas interactions mediated by a variety of molecules/hormones.
So my wife is a type 1ner. She recently got a pump that also reads her transmitter and it will change the amount of insulin being delivered based on what the transmitter is saying. It isn't perfect she can overwhelm it if she eats a ton of carbs, but honestly it's gone from her pump/phone yelling at her 7-8 times a day about being high or low to maybe once a day or once every other day.
The biggest thing it has also done is regulate her blood sugar at night so we don't wake up anymore with the pump screaming at her that she needs to start shoving fruit snacks down her maw.
I have a family member on a similar system. You might/probably already know this, but I'll put it out there anyway in case I'm wrong.
The thing to watch out for is that if the CGM was previously alerting about frequent nighttime lows, there should probably be some basal dose adjustment made in the pump. The pump can cover incorrect basal dosages for a good range with its automatic adjustments, but it's better to periodically look at the numbers and see if it's regularly backing off the basal dose because it's too high.
You can build automation with *aps to do a bit better on these metrics than commercial systems—- e.g. responding to heart rate, or as someone else pointed out, noticing an SSID from a gym.
> - it cannot know external factors like how much carbohydrates you are eating, or if you are planning to work out, etc. Like conventional pumps you have to enter it manually.
Sign up for the waitlist of https://replica.health! It is designed to make capturing those external factors as painless as possible. Depending on what setup you have, it will be available in the next month.
I had a close friend with T1D who asked me to help him set up, and dial in a closed loop APS about two years ago. I took a deep dive into it and found it to be much, much more complicated than the PID type regulation I was expecting it to be. Plus, if I made a mistake, he might die. So I declined out of fear.
Unfortunately he did die just last March, alone in his apartment after slipping into a coma. His pump kept right on pumping him straight to his grave because the feedback loop of the system required human intervention, even if the human is incapacitated.
I wish I would have taken the risk, and I do hope this complicated, but solvable problem will be, and the solution made available to those who need it.
I am really sorry for your loss. I know you want to blame yourself but you could have just as easily killed them setting up the loop as well. Plus with no one to maintain the system they would have likely run into many issues. It isn't a system to be set up or maintained by those who aren't willing to dedicate a lot of time and understanding at this point and who are not technically inclined.
For most T1D the best prevention if you can afford it is still a CGM(which you need for the loop too) and making sure your low alert system works and you have another person connected to your data in case you are incapacitated with their low alert system set up. I'd also love to see this hooked up to EMS eventually too.
Unfortunately for many people the cost of a CGM or getting insurance to cover it is the prohibitive factor though. I really hope this part of the equation changes someday soon.
I absolutely love this development. Who better to take charge here than the people directly affected? They are as motivated as any to get it right, not because of a financial incentive but because their life is in the most literal sense at risk of getting it wrong. Of course the big players will all push the fear button, but that should be contrasted with the simple fact that they all have had (sometimes multiple) recalls.
Do not underestimate how hard it is to do this right, the people that built these DIY solutions have spent a ton of effort on them, probably more than the equivalent commercial players. But long term my prediction would be that the DIY movement will lose out. The competition has massive lobbying power, a lot of funding and looks like the safe option to outsiders, especially when there is feature parity. The main driver for this development was a simple one: all the parts were out there, but nobody was willing to take the plunge and build a closed loop system and have it certified. But that impetus is now gone and future improvements will be much higher hanging fruit.
But I'd love for them to stay around to keep the industry on its toes. Especially because commercial interests are always going to maximize profits, which for a disease that is so widespread and that affects so many lives should not be a factor. Incidentally: a modern insulin pump is a work of art, if you don't know how they work and you fancy technology I would encourage you to have a look at this.
I think it's awesome that DIY options are becoming more readily available. I'm t2d, but have a relatively hard time with glucose control overall. If I stick to eggs, meat and green veg, then I don't need much beyond the weekly Trulicity and daily Basaglar.
If I have anything else, beyond the various food intolerance issues I have, I'm also experiencing Gastroparesis, which means what I eat may hit sooner, later or much later... as much as 20+ hours later, so I usually have to take a lighter tough to insulin and be more diligent about followup checks. It's a literal roller coaster. At least having a Continuous Glucose Monitor (cgm) makes it easier to track.
Yes, the roller coaster is a great way to put it. One of my business partners had it so bad that whenever he was out of sight for longer than an hour or so people would start to worry if he was ok. We had a major crisis when he dropped off the radar for a full day, everybody pitched in until we found him (and not in a coma). Scary stuff, and with large variations between individuals in terms of severity and speed of onset of symptoms.
The worst, is the couple times I've experienced ketoacidosis... always feels like a cold/flu at first, and only when I'm coughing up water do I stop to take notice. I keep a keto mojo in addition to my cgm and glocometer... if my glucose is elevated at all, and my ketones are as well, time to start hourly injections until in normal range... I have my cgm alarm at 70 & 240, only because it will fire off many times after eating if I don't and takes a while to settle (few hours).
Definitely sucks having a broken metabolism. Wish I could go back to my 15-20yo self and totally stop consuming most processed food, seed oils and sugars. It's sad that a glucose tolerance and resting insulin tests aren't normalized since a1c won't start slipping until years later.
It's a huge problem. On the plus side though: there is an absolute mountain of information about this disease and there is substantial funding poured into getting it further under control. The holy grail (and artificial pancreas like a pace maker) is still a long way off. But substantial improvements have been made in the last decade and a half and I expect that trend to continue for a while.
What I love about this story is that the DIY community managed to break the log-jam of the manufacturers and the regulatory authorities by simply providing them with proof that it can work and can work reliably enough to be allowed on the market. That shortcut probably shaved at least a decade (possibly more) off the progress charts. Manufacturers were (to some degree rightly so) antsy about closed loop systems because it would require them to assume much more liability than they are normally used to, the symptom->diagnosis->action loop that you can engage in by close monitoring and patching together available systems cuts the human out of the loop: the system will function autonomously and a software error or hardware glitch has the potential to kill someone.
So the manufacturers were effectively all waiting on each other to show that this can be done safely and that holding pattern had already lasted for multiple years. In the meantime, the larger manufacturers had some time to gain the upper hand over reliability and teething problems of the newer generation of pumps and those came together just in time with continuous monitoring to enable a big step forward in a very hacked (but fully functional) way. No single manufacturer would have taken that risk at this point in time without that push. But now that it is done they can't be left behind either or they'll lose market share rapidly.
It's a pity that there are not more diseases (at least, not that I'm aware of) that would benefit from this approach, diabetes is unique in that respect.
Best of luck there. By the way: if you want to stay current with the developments in this field the best spot to look for is the announcement of trials, and sometimes the calls for volunteers for such trials.
For me, those features were always very gimmicky. When you arrive at the gym, you should've set the basal rate lower at least an hour ago. So it's not going to help unless you stay for multiple hours.
The meal detection mentioned is similarly lagging behind. For people who don't manage to tell their APS when they eat carbs, yeah it helps, but the outcome is not comparable to dosing before you eat.
I also found the calibration features to be too fiddly. Between sensor noise, sensor offset, and calibration, when they try to adapt the situation already changed.
I guess these features work better with a very regular lifestyle, which I lack :-) And while I don't like having to micro-manage some aspects, like carbs, I appreciate that AndroidAPS reduces my mental load quite a bit and enables living days that are never the same regarding exercise or meals.
I'll say, one thing I really appreciate about the fad aspects of Keto as a diet, is that there are a lot more low carb options out there. Of course, ymmv with various fiber varieties and low/no calorie sweeteners in practice. Makes it a little easier to keep carb load minimal. I still do far better sticking to eggs, meat and greens, but it's hard to do.
You just need to make sure it fails safe. If the OS or any software hangs or crashes just make sure the thing turns off and doesn't dump all the insulin or anything.
I would want a beep or something to let me know it had disconnected. (Also a low battery alarm as well.) On the device not on the phone. And the phone should have the same thing if the device does not respond to a heartbeat signal.
I have an AndroidAPS. This is how it works. If the phone loses contact for any reason the device just falls back to delivering insulin at a fixed rate as normal.
My buddy built Loop, the iOS app for managing this (which, thru another org just got FDA approved). I was living near him in Oakland when he was first building it and I just feel really proud of what he was able to do not only for himself but for others.
For all of you out there who are trying to use tech to solve your own problems, please keep at it, one day your work may help thousands or millions and be featured in Nature.
My spouse is also using Loop. It's a huge improvement over just the pump alone. Even just changing basal settings is easier in the app versus the pump device interface, which is no longer required using Loop on iOS with the OrangeLink device.
https://loopkit.github.io/loopdocs/
They have a new web browser build method using TestFlight, which no longer requires an up to date Mac running the latest version of Xcode. The web build mode also enables someone to update the Loop app using only their smartphone. Something which is handy for travel or long periods of time without access to a Mac. It only lasts 90 days instead of the 1 year of the Xcode build, but is easy to rebuild on TestFlight.
That's impressive as hell. The FDA is, by nature, a very conservative and slow-moving organization. They set a very high standard of evidence for anything that's actually called "medicine". (As opposed to supplements and devices that pretend not to make medical claims, in which they are largely hamstrung.)
It takes a ton of effort to get FDA approval. Navigating the process is expensive and aggravating.
I work in the space, and back in 2018 the FDA was communicating very clearly that they wanted to see someone make a closed loop artificial pancreas. They do go a little easier on companies that are developing the new stuff they want. But I suspect the bigger companies didn't want to touch it because it's inherently risky: any minor bug or glitch can literally kill children any you could lose the whole company.
It's awesome that the DIY / hacker / open source folks were able to step up to the opportunity and build this great think, but it is all very much proceed-at-your-own-risk: there's nobody with a big pile of cash to sue if you or your loved ones get hurt.
I'd love to see more of these sorts of trailblazing initiatives in the future, and it's tremendously encouraging that the FDA is apparently open to this as well.
> The DIY community and industry are not in opposition, says Lewis.
I would really like to believe that, but given how Medtronic and every CGM I have used have seemingly intentionally sabotaged open source loop compatibility with every new product, it doesn't seem like everyone's on board...
Yeah she's being diplomatic for sure. Dexcom plays ball and is also the most successful of the CGMs, so you would think that others would follow their lead and write their data to apple health. Most companies keep their data thinking its going lead to some unspecified profits down the line but then never really do anything with it.
Right, my response was more of a hope that continued research in this area would lead to possibly some solutions for earlier diagnosis and treatment. Cancer is such a cancer.
well - to be reassuring... we all have a death sentence imposed by birth. As we get older the cumulative chances of it having happened increase, eventually hitting 100%.
Cancer doesn't change that - lots of people with cancer get killed by car accidents or heart attacks. In fact a friend of mine recovered 100% from their cancer and then killed themselves on a motorbike.
The "bionic pancreas" wouldn't help with pancreatic cancer right? The problem is that nobody notices pancreatic cancer until the death warrant is signed (to use your metaphor). Using a bionic pancreas would be like putting out the fire in the kitchen only when the rest of the house is also in flames.
Definitely what is needed is better early detection but I know that's a can of worms of its own. I commented on the bionic pancreas article as I know it's not a solution to pancreatic cancer, but I'm hoping that continued research in this direction evolves into better diagnosis and cures.
I assure you: commercial players are working very hard on this.
The difficult part is actually power management. There are clearly very sophisticated algorithms that can do no meal announce closed loop management of t1d (just google scholar "closed loop type 1" -- it's a very popular problem for control systems researchers).
But they take a lot of power. Embedded convex solvers for large MPC schemes do not come cheap, especially when you want them running every 5 minutes! I have used this DIY loop system in the past. It is extremely power hungry and requires recharging daily, even when plugged in half the day. And I don't even think they are doing anything exotic like MPC. I stopped using it because of those battery issues and the implementation is gnarly -- it's basically a collection of bash scripts and relies on the operating system (armbian linux) to schedule doses. No RTOS, no watchdogs...
Power management is extremely important in a pump. If a pump dies every <24 hours without being recharged, that impacts both the patient experience and can be very dangerous. If it dies overnight you get no insulin and you will be very sick the next morning.
That said, I love that this is a thing. It pushes the tech forward and gets people excited about a machine cure, which is the only viable solution to "curing" type 1 at the moment.
I am not quite ready for a pump, but am in the market for half of the solution, a continuous blood glucose monitor. Any diabetics here have a recommendation for an affordable out of pocket continuous blood glucose monitor? (Without insurance). I have an iPhone 13.
Which is the best value for money? I am looking for something affordable. I can pay a reasonable amount monthly for consumables for it.
The best brand is Dexcom (G6 or G7). The Abbott one is cheaper but has disadvantages. Either one will be way better than nothing if you have diabetes. Without insurance dexcom will cost you like $260 a month via one of these mail order distributors: https://rapidrxusa.com/products/dexcom-g6-sensors-3-pack
Do your part as a consumer and shop around a bit to drive prices down... good luck!
I would definitetly recommend the Dexcom G7. As I come from the libre3 I have to say that the G7 overall feels more sophisticated, yet alone the overpatch they send with each sensor will help keeping the sensor on my arm. In the past the libre3 often just fell of during my swim training.
Further, libre3 is often just not supported by third party apps or pumps or other. They do not provide an official API, that might be helpful for tracking your clucose. Back in the days I used and contributed to https://github.com/timoschlueter/nightscout-librelink-up to periodically fetched my sensor data from librelink and stored it my nightscout, that runs on my server at my home. That helped a lot, but it was more than a hack.
As someone using a freestyle Libre 2, I’m also curious.
From what I know, I think the main reason is that the Libre needs NFC vs the Dexcom’s Bluetooth… except that Abbott recently updated (!!) the software and now Bluetooth works at par as the dexcom.
Some people have better sensitivity with one or the other I agree, but both are fairly solid. The Libre is smaller though, so I prefer that.
I have read a few people who say they prefer the dexcom because the freestyle is pre-calibrated and Abbott's software doesn't allow you to calibrate the device.
(I've never tried the dexcom and am very happy with my libre)
Depending on AndroidAPS for my insulin management, I'm very happy that people are working on getting this into app stores!
I'm not using most of the advanced features but just having the device regulate basal rate is life-changing. And I really don't want to be tied to one supplier here!
I've always wondered if it's possible to develop similar tech for Parkinson's patients. I don't think we're able to determine the dopamine level of an individual today. But say we can, wouldn't we be able to infuse the right amount of levodopa into a patient's body, and thus reducing their off time?
My wife is a Type 1 diabetic. Here is some interesting complexity:
She has a continuous glucose monitor on her body that tells the insulin pump how to dose her basal insulin.
Basal insulin is the background dose that you have continuously delivered.
At night, if she sleeps on the part of the body with the sensor, the blood sugar reading will be lower than actual. So the pump stops insulin and starts beeping an alarm. No big deal, she just gets up and does a finger stick blood test to check for a false positive. About half the time it will be a false low-blood sugar measure.
A related issue is that when you first insert the sensor, the blood sugar reading is way off until the body calms down at the insertion site.
So long story short, I think we need better continuous glucose monitors to prevent potential wild see-sawing when there are two opposing meds, as with the insulin-glucagon combo.
My biggest fear around this is that these solutions incentivise the biggest pharma companies to stop researching actual cures. I don’t want to have to deal with these devices, I just want it dealt with.
For me, the main thing keeping at being good at the closed loop system is delay. In the pancreas, « measure » and delivery happen at the blood level. It is instant. With CGM and pen or pomp insulin delivery, it is in the superficial higher layers of the skin for which you have 15min delay to and from blood.
Haha. You found the 'solution' for diabetes? The solution for diabetes, heart diseases, tension problems, and all thousand other components of metabolic syndrome is a complete ban on added sugar and HFCS in all goods.
I am a physician, researcher and a programmer. Any one interested in collaborating to solve similar problems feel free to contact me: https://drgo.github.io/about/
Much rather increase my manganese intake, which maintains blood sugar levels, and slows the pancreas from releasing too much amylase which further increases the blood sugar levels causing the spike.
Chromium to make my muscles sensitive to insulin also helps.
I do wonder about the PED aspect of DIY smart insulin, some bodybuilders already use insulin in this way and I wonder if elite athletes could use this to boost their performance.
Bodybuilders in particular but other elite-level athletes have always had a propensity to use PED. A thing now is to get on TRT even if they don't strictly "need" it.
Medical advances for those who do need them should not be blocked by fears (real or imagined) of abuse or misuse.
Oh, I'm not suggesting we prevent people from having this just pointing out that superphysiological results may be possible. I have ME/CFS and I'm interested in tools like this that may help me push things a bit harder, I'd prefer if a bunch of bodybuilders/athletes found the limits before I gave it a try.
Insulin, like clen, is a PED that most users are using for reasons that don't make sense. Regardless, it's already widely available, cheap in most of the world, and almost impossible to detect.
I kept looking for the identity of the minicomputer used, it has to be either a PDP-11 or a Data General system, I should think, but they provided no model numbers.
My 11/yo son is a type 1 diabetic. While this seems great...I can't trust a DIY solution. Beta Bionics has the real deal: https://www.betabionics.com/ and has been recently given the green light by the FDA.
AFAIK there is only one company, Beta Bionics [2], that is working on commercialization of such technology with dual pumps. In this case, you could be more aggressive in either direction of pushing BG, because you have a safety net.
Because this feels like a holy grail / functional cure, I'm surprised the incredible DIY teams out there haven't trained their guns on doing this. Having both "turn it up" and "turn it down" knobs seems so much more valuable than squeezing the last 5% of efficacy of AID systems. I feel like glucagon is obviously "the answer", but I don't see much talk about it.
Is the problem that there is no hardware for dual hormone pumps? I would have thought by now they'd have hacked 2 patch-pump AIDs to work simultaneously.
[1] https://www.medscape.com/viewarticle/947962 [2] https://www.thejdca.org/article/2023/06/05/fda-approves-beta...