artificial pancreasArtificial pancreas technology has been developed to improve the day-to-day lives of people with type 1 diabetes, and is also being trialled in hospitals for some patients with type 2 diabetes. An artificial pancreas uses man-made technology to match the way a pancreas works.

The artificial pancreas device is an “all-in-one” diabetes management system that tracks blood glucose levels using a continuous glucose monitor (CGM) and automatically delivers the hormone insulin when needed using an insulin pump. The system replaces reliance on testing by ‘finger-stick’, with separate delivery of insulin by multiple daily injections.

Type 1 diabetes is an autoimmune condition where the body starts to produce antibodies that attack and destroy the insulin-producing cells in the pancreas. The body can therefore not make insulin, so the person relies on lifelong insulin injections to control their blood sugar. There are approximately 400,000 people in the UK with Type 1 diabetes.

Type 1 diabetes most commonly develops in childhood. One of the most common risks is when the blood sugar becomes very low (hypoglycaemia), which can cause varied symptoms, including agitation, confusion and altered behaviour, progressing to loss of consciousness. Hypoglycaemic episodes can often occur at night and after drinking alcohol, making it a particular risk for young people with diabetes.

Maintaining balanced blood sugar levels is crucial to the function of the brain, liver, and kidneys. Therefore, for type 1 patients, it is necessary that the levels be kept balanced when the body cannot produce insulin itself.  The endocrine functionality of the pancreas is provided by islet cells which produce the hormones insulin and glucagon.

This artificial pancreatic technology mimics the secretion of these hormones into the bloodstream in response to the body's changing blood glucose levels. This technology therefore provides substitute functionality that is normally delivered by a healthy pancreas.

 

There are three main artificial pancreas systems

  • Closed-loop artificial pancreas
  • Bionic pancreas
  • Implanted artificial pancreas

 

Closed-loop Artificial Pancreas

Closed-loop artificial pancreasThe most widely tested artificial pancreas is a ‘closed-loop insulin delivery system’, also referred to as a closed loop artificial pancreas.

The ‘closed-loop insulin pump’, is a small pumping device connected to the body. The system delivers the correct amount of hormone calculated from the glucose monitoring sensor transmitting its readings wirelessly to the pump.

The sensor continuously feeds information to the insulin pump software, thereby allowing the pump to control the amount of insulin delivered through a small tube under the skin (avoiding the need for continuous injections).


Bionic Pancreas

In 2015 the world was introduced to the iLet, a bionic pancreas that could help people with type 1 diabetes manage the condition solely through the device. The bionic pancreas, developed by Dr Edward Damiano’s Beta Bionics firm, automatically controls blood glucose levels, comprising two insulin pumps which deliver and insulin and glucagon respectively. The pumps connect with an iPhone app via Bluetooth enabling communication between the devices that helps calculate the required doses needed. Automated dosing decisions about insulin and glucagon are made every five minutes based on updated continuous glucose monitor (CGM) readings.


Implanted Artificial Pancreas

The implantable insulin delivery device features a gel that responds to changes in blood glucose levels. It is being developed by researchers from De Montfort University. When blood glucose levels are elevated, the gel enables a higher rate of insulin to be released; during lower sugar levels, the gel decreases the amount of insulin it releases. The implantable system could be refilled with insulin on a regular basis.

 

Using an 'Artificial Pancreas' in hospital patients with type 2 diabetes

Artificial pancreas technology can also improve blood glucose control among patients with type 2 diabetes admitted to hospital for non-critical care. Type 2 diabetes is where the pancreas still produces insulin, but it either cannot produce enough, or the cells of the body are no longer sensitive enough to the actions of insulin to adequately control blood sugar. Type 2 diabetes is usually controlled by diet and medication, though some people with poor control also end up needing insulin injections, similar to people with type 1 diabetes.

The number of hospitalised patients with type 2 diabetes is increasing, and glucose control often worsens during illness. According to the NIHR, those using these systems spent about six hours longer in the target range, and this could hasten their recovery and reduce staff workload.  Use of closed-loop ‘Artificial Pancreas’ pumps could benefit inpatients and decrease pressure on hospital staff. However, more cost-benefit analysis is needed.

The findings suggest that closed-loop systems could improve glucose control for hospitalised patients with type 2 diabetes. However, there are important practical considerations at this stage. A vast number of patients could potentially be eligible for this treatment. The cost of widespread use would be high, and it’s unclear whether this would translate into reduced hospital stays and reduced complications.

 

What has NICE said?

Continuous subcutaneous insulin infusion or ‘insulin pump’ therapy is recommended as a possible treatment for adults and children 12 years and over, with type 1 diabetes if:

  • attempts to reach target haemoglobin A1c (HbA1c) levels with multiple daily injections result in the person having ‘disabling hypoglycaemia’, or
  • HbA1c levels have remained high (8.5% or above) with multiple daily injections (including using long-acting insulin analogues if appropriate) despite the person and/or their carer carefully trying to manage their diabetes.

Insulin pump therapy is recommended as a possible treatment for children under 12 years with type 1 diabetes mellitus if treatment with multiple daily injections is not practical or is not considered appropriate. Children who use insulin pump therapy should have a trial of multiple daily injections when they are between the age of 12 and 18 years.

‘Disabling hypoglycaemia’ is when hypoglycaemic episodes occur frequently or without warning so that the person is constantly anxious about another episode occurring, which has a negative impact on their quality of life.

Insulin pump therapy should only be started by a trained specialist team. This team should include a doctor who specialises in insulin pump therapy, a diabetes nurse and a dietitian (someone who can give specialist advice on diet). This team should provide structured education programmes and advice on diet, lifestyle and exercise that is suitable for people using insulin pumps.

Insulin pump therapy should only be continued in adults and children 12 years and over if there has been a sustained improvement in the control of their blood glucose levels. This should be shown by a decrease in the person’s HbA1c levels or by the person having fewer hypoglycaemic episodes. Such goals should be set by the doctor through discussion with the person or their carer.

 

Sources:

https://www.nhs.uk/news/diabetes/bionic-pancreas-could-be-used-to-treat-diabetes/
https://www.nice.org.uk/guidance/ta151/resources/insulin-pump-therapy-for-diabetes-pdf-374892589
https://www.diabetes.co.uk/artificial-pancreas.html
https://www.bmj.com/content/365/bmj.l1226
https://en.wikipedia.org/wiki/Insulin_pump
https://www.nih.gov/news-events/news-releases/artificial-pancreas-system-better-controls-blood-glucose-levels-current-technology
https://discover.dc.nihr.ac.uk/content/signal-000675/type-2-diabetes-control-improves-with-artificial-pancreas