Guest Post: My Take on The APP by Kim
My Take On The APP. See Also: Apprehensive Pancreas Problems.
I have been keeping up with JDRF’s Artificial Pancreas Project, and trying to wrap my head around exactly how an artificial pancreas would work. There’s a lot to know about it, and watching Dr. Aaron Kowalski’s webcast a few months back did help to clear up some of the questions I had. The Artificial Pancreas would consist of a fully integrated insulin pump (with chambers for both insulin and glucose) and a continuous glucose monitor system that can work together and autonomously, with decisions and calculations being guided by a way-over-my-head algorithm. It sounds pretty great – no more food math, no more worrying about IOB, no more overnight lows. You’d just pop the things on, and forget about it for a while. I’ve been living with type 1 for every day of 24 years, and I’m about ready for some time off. Aren’t we all?
But now that I’ve mentioned how great it could be, let me be completely honest. The artificial pancreas scares the crap out of me.
There are three main issues that I need ironed out before I’d consider adopting the Artificial Pancreas as a viable treatment option. Because, yes, I consider it a treatment, not a cure. For me, a “cure” means that my body will function on its own, the way everyone else’s does, without the use of any robot parts. (My apologies to Jim, my beloved Dexcom CGM. It’s nothing personal.)
As I mentioned, the technology components of the AP are already in existence. Insulin pumps have been widely available and ever-improving for the past two decades, and while they are great, they are not perfect. The same can be said for CGM systems, whose technology is nowhere near as mature. My issue here is that neither technology is fool-proof or absent of errors. Insulin pumps can malfunction. CGM’s are hardly 100% accurate, and can have mechanical issues as well. Knowing this, I can imagine situations where a CGM would feed incorrect data to the brain of the AP, and it would correct with insulin or glucose based on that data. How scary would that be? There are times where I personally have seen a difference of almost 100 mg/dL between a finger stick and a CGM reading. On the other side of that, what if the insulin pump portion of the AP delivers more insulin or glucose than suggested (or none at all)?
This idea of too much insulin being delivered brings me to my next point. Dr. Kowalski mentioned in his webcast the need for even faster-acting insulin, to make the artificial pancreas work as much like a functioning “real” pancreas as possible. I can see why this is needed – as the CGM detects a fast spike in blood glucose (due to food, or whatever), it needs to be able to react as quickly as possible. Here’s my problem with that: a fast-acting insulin that works almost instantly leaves very little room for error when something bad happens. If something goes haywire with the equipment and a surplus of insulin gets injected, you’ve bought an immediate trip to Troubleville. With current fast-acting insulins like Humalog or Novolog, you have about 10 – 15 minutes from the time of injection or infusion, to the time the insulin starts working. Those 10 – 15 minutes could be vital, if you discover that you’ve taken way too much. It’s enough time to down a bunch of juice, take a glucagon shot, and/or get an ambulance called. With a shorter-acting insulin, that precious pocket of time evaporates, and the risk of death increases significantly. (I know this exact scenario is a large reason why it will take a very long time for the Artificial Pancreas to gain FDA approval in the U.S., and that I shouldn’t worry about it being a factor after it’s approved for market. But it still worries me.)
My final issue is not with technology, but with the way my brain is wired. You see, for the better part of the last quarter century, I have been in charge of my diabetes. I’m making the calls on insulin doses, timing, and duration; I’m the one checking my CGM incessantly and figuring out basal rate changes; and it’s ultimately been up to me to manage my diabetes. Though I do rely on tools like my insulin pump and CGM to relay information and suggestions to me, the final word comes from me.
This is where my biggest fear lies.
I don’t really want to give up control. (There, I said it!) With as many issues as I’ve had with diabetes equipment (insulin pump dying on my wedding day; the fact that I’m on my third Dexcom receiver since starting CGM use in January), it’s hard for me to fathom a time where I can place complete trust in a “robot” to effectively manage my diabetes. It feels like there are so many ways things could go wrong when you bypass any kind of user input. Besides, what would I do with all of that free time? My life is structured with certain things always in place – carb counting, insulin boluses 15 minutes before meals, and blood sugar stalking. How many hobbies would I need to take up? How many more things could I start remembering, because my brain space is no longer bombarded with diabetes math? How much more exercise could I be getting, knowing that it would never again make my glucose level crash? And how many other things could I worry, think, and dream about it in life, with diabetes control no longer in the equation?
So far, I’m not totally sold on the idea of using an Artificial Pancreas. It might be that I need more information, but I also think that I need more reassurance. As exciting as the idea sounds, I’m going to need some mighty strong arguments in order for me to feel completely comfortable jumping on board.
Kim, Living with Diabetes Type 1 for 24 years
If you would like read more about Kim check out her blog: Texting My Pancreas
You can also follow her on Twitter: @txtngmypancreas