Hi I'm Dr. Samina Afreen, an assistant professor of medicine at the University of Virginia and I'll be talking about digital health technology. Digital health technologies in chronic disease management help with early detection and intervention, real-time patient monitoring, personalized treatment plans, patient engagement and adherence to therapy, and care coordination among healthcare professionals. Digital health technologies that can be used for the management of patients with type 2 diabetes, chronic kidney disease and cardiovascular diseases include continuous glucose monitoring devices that can be used for real-time tracking of blood glucose trends and which also can alert for hypoglycemia and hyperglycemia. Mobile apps which can help with glucose and electrolyte tracking and help with diet and lifestyle coaching. Smart insulin delivery devices like patch pumps and closed-loop insulin pumps which can make the insulin delivery process simpler and safer. Blood ketone monitors especially in patients on SGLT2 inhibitors and those with ketosis-prone diabetes. Telemedicine and virtual care increases access to endocrinologists, nephrologists, cardiologists and helps with continuity of care for high-risk patients. The indications for continuous glucose monitor use are type 1 diabetes, type 2 diabetes mellitus on insulin, diabetes mellitus with frequent hypoglycemic episodes, diabetes mellitus with hypoglycemia unawareness and patients on insulin pump. CGMs can be ordered both by the primary care providers as well as the specialists taking care of patients with diabetes and chronic kidney disease. There are several commercially available continuous glucose monitors available. In this slide we'll talk about Dexcom. Dexcom G6. The sensor can be used for 10 days, no calibration is needed and there is a separate transmitter and disposable sensor in addition to a reader. It's integrated with various insulin pumps including Tandem, Omnipot, ILAD. Dexcom G7 sensors can also be worn for 10 days and calibration is not needed but G7 has all-in-one sensor and transmitter so you don't need separate transmitter and a separate sensor. It is supposed to have improved accuracy compared to G6 and is also integrated with insulin pumps Tandem, Omnipot and ILAD. Abbott Freestyle Libre continuous glucose monitors. Abbott Freestyle Libre 2 and 3 sensors can be worn for up to 14 days, no calibration is needed. They do not integrate with any of the available insulin pumps. Abbott Freestyle Libre 2 sensor needs to be scanned with a reader or a compatible smartphone. Each time the readings need to be seen while Abbott Freestyle Libre 3 sensor does not need to be scanned since the data is automatically pushed to the reader. Abbott Freestyle Libre 2 plus sensor can be worn for up to 15 days, no calibration is needed. It integrates with Tandem and Omnipot insulin pumps. Abbott Freestyle Libre 3 plus sensor can be worn for up to 15 days, no calibration is needed and it integrates with Beta Bionics ILAD bionic pancreas system. Next we'll talk about continuous glucose monitors from Medtronic and Eversense. Medtronic Guardian sensor is worn for 7 days, no calibration is needed and is compatible only with Medtronic pumps. Eversense E3 sensors can be worn for up to 6 months. Calibration is needed once every day after day 21. It's implantable, requires minor surgical procedures and is currently not integrated with any insulin pumps in the US. Eversense 365, the sensors can be worn up to 365 days. It needs once per week calibration after day 13. It's also implantable and requires minor surgical procedure. It's not currently integrated with any insulin pumps in the US. Utility of continuous glucose monitoring in patients with diabetes mellitus and chronic kidney diseases. Hypoglycemia prevention. Chronic kidney disease alters insulin clearance raising hypoglycemia risk. Real-time continuous glucose monitoring alerts enhance safety. Real-time feedback can also be used to adjust insulin, food and activity levels based on continuous glucose monitoring trends. Chronic kidney disease requires frequent labs. Continuous glucose monitoring reduces finger sticks. It also helps with the better assessment of glycemic control in chronic kidney diseases. Hemoglobin A1c's reliability decreases in advanced chronic kidney disease due to factors like anemia and altered red blood cell lifespan. Continuous glucose monitor derived GMI may provide a more accurate assessment of glycemic control in this population. Several mobile apps are available for use in patients with diabetes mellitus and CKD. Here we'll talk about few of these apps. Chronometer. Pros, it has extensive nutrient tracking, can be used to set highly customizable daily goals and it uses accurate food database that pulls from verified sources. It can sync with some devices and wearables and it can export or share data with healthcare providers. Cons, it can be overwhelming initially due to the level of detail. Utility in patients with CKD is that it can be used to set daily limits for potassium, phosphorus, sodium, protein. In patients with diabetes, it can help with robust carb tracking and integrate with devices and can be used to share data with healthcare providers. Next, MyNetDiary. It pulls data from large food databases. Its diabetes focus version includes blood glucose tracking. It allows for customizable nutrient targets and can export or share logs with healthcare providers. Cons, some micronutrient data may be incomplete. Utility in patients with CKD is that it can be used to set daily targets for sodium, potassium, sodium. In patients with diabetes, it can be used for carb tracking and blood glucose logging. Next, we will talk about MyFitnessPal. Pros, it uses massive food database including restaurant items. It can be used to set customized daily goals, especially in the premium version. It has a barcode scanner which can be used to scan the barcode of food items to determine their nutrients. It's very user-friendly. It syncs with fitness trackers and can log blood pressure or glucose manually. Data can be shared by exporting daily logs or screenshots. Cons, free version doesn't easily track for potassium or phosphorus unless manually added. Users submitted food items sometimes have errors and may need to verify labels. Utility in CKD patients is that it can track potassium, phosphorus, sodium, protein in the premium version. For patients with diabetes, it is great for carb counting and can manually integrate blood glucose data. Next, National Kidney Foundation MyFoodCoach. This app is endorsed by the National Kidney Foundation. It tracks main nutrients, sodium, phosphorus, potassium in many food items, provides kidney-friendly recipes and suggestions, allows for some personalization based on conditions, for example, diabetes and hypertension. Cons, database is not as large as MyFitnessPal or Chronometer. Some entries might lack full micro detail. App interface updates and availability can vary by region. Utility in CKD patients is that it's a good source for learning about kidney-friendly foods and recipes. In patients with diabetes, it allows for carb monitoring but it's not very detailed. It could be combined with glucose tracking app for full picture. Smart insulin pens. These are reusable pens with smartphone apps. They can be used to track doses, the times of administration of insulin doses. They offer calculators and reminders. Benefits, they can be used to overcome poor adherence and incorrect titration, the reduced medication errors and missed doses. Examples of smart insulin pens are Lily Tempo and Medtronic in pen. Lily Tempo components are Tempo pen which is a pre-filled disposable insulin pen with a smart button cap and Tempo smart app. Benefits, it's compatible with Lily's bolus insulin Humalog and Lumgiv and Basal Insulin Basaclar. It can be used for tracking and dosing fast-acting insulin based on carbohydrates, current blood glucose trends, activity and insulin on board. For basal insulin users, it calculates long-acting insulin adjustments for healthcare professional settings to optimize basal insulin titration. It helps prevent missed or late doses both bolus and basal with dose reminders. It can sync with Dexcom CGM and various blood glucose monitors. It has automated dose tracking which reduces manual logbooks. It has improved adherence and accuracy by causing fewer missed or missed time doses. It can be only used with Lily's insulin and has one unit dosing increments. Medtronic in pen components are in pen which is a reusable insulin pen and in pen smartphone app. It's reusable for one year. No charging is required. One year battery is in the pen which can be replaced annually. It works with rapid acting U100 insulin cartridges, Humalog, Novalog, Fiasb. Provides tracking and dosing with bolus calculator which takes into account carbs, blood glucose and insulin on board. Has half a unit dose increments and also monitors temperature. It provides dose reminders and hence prevents missed or late doses both for bolus and basal insulin. It pairs with Guardian Connect CGM and Dexcom CGMs. By providing automatic dose logging, it reduces manual record keeping. It however doesn't track basal directly. You need to have a separate pen for basal. Insulin patch pumps. These are wearable devices that deliver insulin subcutaneously. There are two main types. Bolus only, for example Secure Simplicity, basal and bolus, Wego. In CKD patients, it simplifies regimen, aids adherence, reduces injection burden which is important when multiple therapies may be required. Secure Simplicity, it provides bolus only insulin delivery. There is no continuous basal insulin delivery in Secure Simplicity. It can be worn for three days and has a built-in button for mealtime insulin. It's discrete and waterproof, can bathe, swim, exercise. However, it's not recommended for hot tubs. It's especially useful in patients who are not tech savvy and who dislike multiple shots. It is also beneficial in patients who want to avoid carrying supplies or injecting publicly. Limitations are that there is no basal insulin delivery and you need a separate pen for basal insulin doses. Wego patch pump. It can be used to administer both basal and bolus insulin. There's a preset basal which is administered over 24 hours and on-demand bolus can be administered by pressing a button. It needs to be replaced daily. No daily injections are needed while on Wego patch pump. It has a mechanical design and hence no complex programming is needed. Limitations are that the basal rate is preset and not adjustable once applied. It's not very suitable for patients with variable insulin needs or type 1 diabetes. It must be replaced daily which adds to the cost of the device. Now we will talk about the different insulin pumps. Medtronic MiniMed 780G is a tube insulin pump that adjusts basal rates using an internal algorithm and provides automatic correction boluses every five minutes. Its unique feature is the meal detection technology for missed or underestimated boluses. Tandem T slim insulin pump is a tube insulin pump. It adjusts basal rates using an internal algorithm. It provides automatic correction boluses every hour. Comprehensive software updates can enhance and modify the pumps code insulin delivery features. Omnipod 5 is a tubeless insulin pump. It adjusts basal rates and delivers automatic correction boluses as needed. It can be controlled entirely from a compatible smartphone or the provided Omnipod 5 controller. Beta bionic inut bionic pancreas is a tube insulin pump. It learns and adapts to the user's insulin needs over time. It requires only body weight for initialization. Blood ketone monitors are recommended for use in patients with type 1 diabetes at risk of DKA and type 2 diabetes mellitus on certain medications for example SGLT2 inhibitors who also have CKD. Blood ketone monitors help identify diabetic ketoacidosis or euglycemic DKA especially in SGLT2 inhibitor users allowing timely intervention. Blood ketone monitors provide more immediate and accurate readings than urine ketone strips. American Diabetes Association Consumer Guide is a comprehensive and patient-friendly resource that showcases the full range of FDA-approved diabetes technologies and insulin products available in the US. It includes up-to-date comparisons of insulin pumps, continuous glucose monitors, smart pens, glucose meters, and various types of insulin, basal, bolus, ultrarapid, and biosimilars. Below is the link that can be used to access ADA Consumer Guide. Overcoming barriers and promoting adoption. Patient resistance to technology can be overcome by providing patient education and hands-on training. Automating data integration into electronic health record and AI-driven alerts can be used to reduce healthcare professional workload and time constraints. Simplified mobile interfaces and support for low-tech users can be used for access and literacy issues. Medicare and private insurance coverage for CGMs can be used for cost concerns. Summary and key takeaways. Continuous glucose monitors, ketone monitors, and mobile apps enhance monitoring and engagement. Smart insulin delivery devices simplify insulin administration for patients and multiple daily insulin injections. Integrating digital tools into clinical workflows optimizes care. Overcoming adoption barriers ensures better utilization of available resources. Next, Myra Cantesaro is going to talk about multidisciplinary approach and referral criteria.

digital health technologies

chronic disease management

continuous glucose monitors

smart insulin pens

telemedicine

patient education