In 1999 we were seeing the first reports of a new protocol for pancreatic islet cell transplantation coming from Canada. These reports were suggesting that individuals who were disabled by type 1 diabetes and associated hypoglycaemia could be rendered free of hypoglycaemia and potentially free of insulin injections. At roughly the same time we were also seeing the first clinical use of wearable technology to continuously monitor glucose concentrations in the body. Instead of a few brief glimpses each day, we had the prospect of a detailed analysis of what was happening to glucose all the time. The prospect was that we could use insulin therapy in a much more refined way – leading to better glucose control with a lower risk of unwanted hypoglycaemia.
This was an exciting time for those involved in diabetes research. The two parallel streams of work both offered the potential for a large step forward in diabetes care. For the person with type 1 diabetes, a lot of thought and planning is required each day to maintain glucose in an optimal range. There was the potential for both of these treatments to significantly reduce the day-to-day burden of living with diabetes. We had a technological approach and a biological approach, and there was talk at the time about a race to see which approach would have the greatest impact the soonest.
By chance, this last month we have had four papers that demonstrate how far we have progressed in the past 20 years. Two provide an update on current best practice and results of pancreatic islet transplantation, while the others tell us about the impact of wearable glucose monitoring technology: what it can achieve and how to use it.
Focusing on the technological approach, Leelarathna and colleagues performed a randomised controlled trial of intermittently scanned continuous glucose monitoring for people with type 1 diabetes. The FLASH-UK study was difficult to perform, and the investigators are to be particularly congratulated as the first study participants were recruited in early 2020, as we were first learning about COVID-19. The fact that they persisted despite the challenges in obtaining robust results at such a difficult time reflects how significant the potential results were felt to be. The use of cloud-based technology to allow remote monitoring of results was adopted in the study and has now become a standard tool in diabetes care. It is an important study and the gold-standard design shows us, with some confidence, that wearable glucose monitoring technology can improve glucose control by reducing the frequency of both high and low glucose levels.
All those working clinically in type 1 diabetes will be aware of the revolution in glucose measurement in recent years: both continuous and flash monitoring systems. Real-world data have shown an exponential rise in uptake of this technology. Individuals with type 1 diabetes are voting with their feet as there is a clear benefit, not only in lowered glucose levels but also in reduced frequency and anxiety associated with hypoglycaemia. The authors comment that their findings match with data gathered outside of the clinical research environment, and they mention the important ABCD Nationwide FreeStyle Libre Audit (Deshmukh et al, 2020).
Although the authors do not discuss the potential for combining this tool with insulin pump therapy, this is clearly the very exciting next step to be taken. In 1999, we perhaps would have expected to get to this point sooner. However, it finally feels as if we are doing something very different for people with type 1 diabetes, and there is potential for further big steps forward, hopefully over a much shorter period.