24 Diabetes
The cost-effectiveness of HCL in Ireland: closing the loop on a revolutionary new therapy Written by Dr Jonathan Briody, Health Economist & Liam Manning, Medical Student, RCSI University of Medicine and Health Sciences
"Although HCL offers significant advantages, its cost cannot be overlooked. To conclusively assess the value of HCL therapy in Ireland, a national analysis that reflects the costs and outcomes in this setting is urgently required." Dr Jonathan Briody is a health economist conducting an economic evaluation of intervention in, and prevention of, diabetes at RCSI University of Medicine and Health Sciences. With Professor Seamus Sreenan, he was awarded the Irish Endocrine Society Student Research Bursary to encourage promising students to pursue careers in endocrinology. He is supporting Liam Manning as part of this award.
Liam Manning is a medical student in RCSI. He is also collecting and analysing information on patients with diabetes. As the Irish Endocrine Society student award recipient Liam is participating in a research project at Connolly Hospital under the guidance of Professor Seamus Sreenan and Dr Jonathan Briody. He would like to thank the Irish Endocrine Society for their support.
Type 1 Diabetes in Ireland:
such as heart disease, renal disease, blindness, and many more. This greatly affects a patient’s quality of life and can be very costly to treat (1).
Diabetes Mellitus (DM) describes a group of metabolic diseases characterised by hyperglycaemia. Once known as juvenile onset diabetes, type 1 diabetes mellitus (T1DM) involves an absolute insulin deficiency caused by the autoimmune destruction of beta cells in the pancreas. Type 2 diabetes mellitus (T2DM) involves a relative insulin deficiency caused by an acquired resistance to insulin, insufficient insulin production by beta cells or, both. While both T1DM and T2DM are characterised by hyperglycaemia, these diseases have different pathophysiology, risk factors and treatments. T1DM affects about 20,000 people in Ireland, or 0.4% of the total Irish population. T1DM is a chronic condition that will affect an individual for the rest of their life. It typically develops during childhood or adolescence so the negative impact of hyperglycaemia can compound over one’s lifetime to produce severe complications
Intervention in Type 1 Diabetes: It is essential that people with T1DM maintain their blood glucose to reduce the risk of short and long-term complications. HbA1c and time in range are the current metrics by which clinicians monitor a patients glycaemic control. It is recommended that patients achieve a HbA1c of 53mmol/mol or lower and 70%, or higher, time in range (3.9mmol/L-10mmol/L). Many factors influence how much insulin a patient needs such as emotional stress, exercise, diet, how well they sleep, and many medications. As a result, many patients fail to meet their therapeutic targets (2). T1DM is sometimes referred to as insulin-dependent diabetes because the only treatment is exogenous insulin. Before the preparation of recombinant DNA
NOVEMBER 2023 • HPN | HOSPITALPROFESSIONALNEWS.IE
human insulin in 1978 by David Goeddel and his colleagues, insulin was obtained from cows and pigs. While animal insulins still exist in clinical practice today, the recombinant form is the dominant one in today’s market. While the types of insulin that clinicians have at their disposal has changed a lot over the years, the methods of delivery have remained relatively constant. Many patients with diabetes still rely on subcutaneous insulin infusions via needles or syringes. The modern option of a continuous subcutaneous insulin infusion (CSII) uses an insulin pump to constantly administer a preprogrammed dose of insulin which can be adapted to different doses depending on the time of day or activity of the patient. These have significantly improved glycaemic control in patients using the technology. However, these devices still require the patient to monitor many factors which can affect the amount of insulin they will require such as their blood glucose, food intake, exercise, sleep, any potential illness and more. The patient must then incorporate all this information to predict how much insulin they need to maintain blood glucose within range. Unsurprisingly, this system leads to hyperglycemia, hypoglycemia, mental stress, reduced sleep, and an overall reduction in quality of life. Hybrid closed-loop insulin pumps promise
a breakthrough in diabetes care to address these issues and facilitate a reduction in the morbidity associated with T1DM. A revolution in T1DM: The hybrid closed-loop systems represent a paradigm shift in the management of T1DM. Often referred to as an artificial pancreas, such systems have an unprecedented ability to influence blood glucose levels based on real time blood glucose information. The hybrid closed loop systems involve three components: a CGM, an insulin pump and an algorithm within the pump. These work together to maintain normoglycaemia. The CGM monitors blood glucose and communicates this information to the algorithm. The algorithm notes the current blood glucose, whether it is trending upwards, downwards or remaining steady, and the target blood glucose. This informs the pump about how much insulin to deliver to the patient. These systems are referred to as “hybrid” because the patient must still count carbohydrate intake and manually enter this into the insulin pump. The closed loop system has allowed for improved glycemic control by reducing insulin infusion in anticipation of a hypoglycemic event and increasing insulin infusion to treat or prevent hyperglycemia.
