A Fool’s Paradise
It seems as if Medtronic’s announcement yesterday with the launch of the InPen connected to the Medtronic CGM has created some controversy. Now before we get into this let’s be very clear here this system is NOT yet a full-blown Tyler. It is a first step towards a Tyler, a baby step but a first step, nonetheless. Let’s also acknowledge the obvious right now there is only ONE CGM system that is approved to be used for making insulin dosing decisions, the G6 from Dexcom. Let’s further acknowledge what everyone also knows while Medtronic has worked diligently to improve the performance of their CGM it is still inferior to the G6 and Libre/Libre2.
Now onto the “controversy” many are noting that as good as the G6 is the system does not deliver “real-time” readings, a factual statement. However even if it did when it comes to insulin dosing this DOES NOT MATTER. The reason it does not matter is that the currently available short-acting insulins with the possible exception of Afrezza do not work fast enough. To put this in very simple terms even with continuous insulin delivery via an insulin pump the insulin delivered does not begin working immediately. With a Tyler where the insulin is injected there is a lag time between when the insulin is injected and when it begins to work. Hence the term “time to action.”
Anyone who’s been following the development of closed loop insulin delivery systems will tell you one of the biggest obstacles to having a truly closed loop system is not the hardware, CGM or algorithm it’s INSULIN. It’s ironic that the fastest acting insulin the one with the fastest time to action, Afrezza, cannot be used in a closed loop system. It is also the reason so many patients seeking very tight control have fallen in love with Afrezza as it works very quickly.
Now thanks to insulin dosing algorithms which thankfully are getting better and better, this time to action issue really isn’t much of an issue. Yes it would be very nice IF we had a non-inhaled short acting insulin which worked as fast as Afrezza but it’s really not necessary. It would also be nice if every CGM system delivered real time readings but again it’s really not needed.
The reality here, those pesky facts again tell us that optimal control is not about where the patient has been or where the patient is right this very moment. It’s about where the patient is going. And keep in mind that glucose values are just one of many factors that go into this complex calculation of how much insulin is delivered and when its delivered. Far too many seem to believe that glucose values dictate insulin dosing, yes it’s an important metric but it’s NOT the only metric. Again to put it very simple terms this is like baking a cake, yes flour is an important ingredient, but it is NOT the only ingredient.
The more well informed among us understand that Time in Range (TIR) is a more important metric than one or even a series of glucose measurements. Anyone who doubts this should take a look at the results patients using the Control IQ from Tandem are seeing. Frankly these results are astonishing, and they are being done with existing CGM data (the G6 from Dexcom) and currently available short-acting insulins.
The fact is this brouhaha over whether a CGM delivers readings in real time is much to do about nothing. Like so many things in our wacky world it’s more of a marketing ploy than something of real substance. What truly matters when it comes to CGM is accuracy of data and the reliability of the sensor. This is why the G6 from Dexcom remains the standard by which every other CGM system will be judged against. Abbott has closed the gap with the Libre/Libre2 and coming Libre3 but as we have seen with limitations over automated insulin dosing they have not fully closed the gap.
Medtronic to their credit has acknowledged the issues with their system and while behind they are trying to catch up. As Momma Kliff used to say the first step in solving a problem is acknowledging you have a problem.
The truly laughable part here is to the average patient, not those who are seeking ultra-tight control, these issues don’t matter. What these patients want most, other than not having diabetes at all, is diabetes management without all the hassles and drama. This day is here for patients on the Control IQ and will be here once we have a real Tyler. All this other stuff, all this chatter about real-time glucose readings is just a bunch of white noise.
All these companies who are trying to differentiate themselves are living in a fool’s paradise if they believe the informed and educated among us fall for this bullshit. But the reality is they know this but also know that investors, investors who do not understand the nuisances of diabetes management, or how insulin really works fall for this crap. To the uniformed or uneducated it’s seem logical that real-time is better than a five- or one-minute delay. Hence the reason they pony up millions of dollars.
Folks we’ve said it before and will say it again this is NOT about the toys in the toy chest or the drugs in the medicine cabinet. This is all about the talent, the ability to run a commercially viable diabetes device company. And talent unfortunately is in short supply.