December 12, 2006

The Artificial Pancreas Project

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CHAT TRANSCRIPT – The Artificial Pancreas Project with Dr. Aaron Kowalski (December, 12, 2006)

Want to be a guest speaker contact: Gina

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Gina says (17:55): Hello Aaron!

periwinkle says to (17:55): Good evening, Dr. Kowalski

Jon says to (17:55): Hi Aaron!

Aaron Kowalski says to (17:56): Hello Everyone!

Aaron Kowalski says to (17:57): I have my diet coke and my CGM by my side – life is good

periwinkle says to (17:57): I am most excited about the development of the continuous glucose sensor. My question to you is this: I often take baths as opposed to showers and am wondering if this will be possible with the sensor, especially if I bathe in very shallow water?

periwinkle says to (17:58): Has my question been received by Dr. Kowalski?

Julie says to (17:58): So, let’s cut to the chase – when will we have a completely closed loop pump?

Aaron Kowalski says to (17:59): I’m wearing the STS and the Paradigm Real Time right now. The Paradigm is waterproof and I believe FDA approved as such. While the DexCom STS is not FDA approved as waterproof, I’ve shower with it on and uncovered and I’ve gone swimming with it w/o issue

christine says to (17:59): julie, do you think anyone knows that?

christine says to (17:59): it seems like there are a lot of issues to overcome

Aaron Kowalski says to (17:59): I believe a closed-loop is sooner than we expect

Gina says (17:59): how soon

Gina says (17:59): like tomorrow

Allieb2 says to (17:59): really?? sooner!??

Gina says (17:59): haha

Gina says (18:00): Jk

Aaron Kowalski says to (18:00): There are obstacles, but we’ve (JDRF) funded research in real people that shows it can be done now with today’s tools

Aaron Kowalski says to (18:00): Not tomorrow

Gina says to (18:00): i know im just kidding! Haha

christine says to (18:00): how will the issue of insulina ction time be overcome?

Rmhb1126 says to (18:00): Hi Aaron – it’s Renee….any updates on insurance covering the CGMS? I know lots of families who would like to access this technology but can’t afford the out-of-pocket costs

christine says to (18:00): will it require some form of access to the portal vein/artery?

Julie says to (18:00): Is there a sensor that’s measuring blood glucose instead of interstitial fluid glucose? Is JDRF also working with Animas and their technology for a sensor?

Aaron Kowalski says to (18:01): That is an issue – but I like to say (got this from Dr. Buckingham at Stanford) don’t let perfection be the enemy of the good

Aaron Kowalski says to (18:01): Even with today’s insulin’s there is so much room for improvement

Gina says (18:01): PLEASE GIVE AARON A CHANCE TO ANSWER AFTER EACH QUESTION… THANKS

Aaron Kowalski says to (18:01): It can be done sub-q – with very good results

Johnboy says to (18:02): cool

periwinkle says to (18:02): Well, Dr. Kowalski — it remains an issue with me with regard to the baths vs. showers — I’d sure like to have a positive answer about that !!!!

Aaron Kowalski says to (18:02): Right now most sensors are measuring interstitial fluid

Aaron Kowalski says to (18:02): Medtronic has an implanted IV sensor – but I think that is a while away

periwinkle says to (18:02): That would be great for me for sure —- bathe away !!!!

Aaron Kowalski says to (18:02): We are working with most all of the companies -to different degrees to try to close the loop.

Aaron Kowalski says to (18:03): I was excited to see Lifescan join with animas

Gina says (18:03): Can you give us a little background on The Artificial pancreas, in case some people dont know.

Kit says to parrotletzoo (18:03): yes please!

parrotletzoo says to (18:03): will systems with closed loops incorporate glucagon into the pumps?

periwinkle says to (18:03): I am so very very hopeful that I’ll be able to enjoy the sensor and still bathe as I have been accustomed to !

Aaron Kowalski says to (18:04): I oversee research that the JDRF funds on the Artificial Pancreas

Aaron Kowalski says to (18:04): We just launched a major – multi-million dollar initiative to try to make this a reality – Sooner!

Julie says to (18:04): What part is JDRF funding in this research and how many $$ are going from the donations towards this?

Aaron Kowalski says to (18:05): We’re using a variety of different approaches to do this – including glucagon as counterregulation – partnering great diabetes docs with world class engineers

parrotletzoo says to (18:05): nice

Julie says to (18:05): Is Symlin being used too?

Aaron Kowalski says to (18:05): Right now we’re about to launch a large CGM trial – over 500 people and we just announced six sites working on closed loop

christine says to (18:05): how does one apply for this trial?

periwinkle says to (18:06): Truthfully, Dr. Kowalski, do you believe that I should even consider the sensor in as much as I continue to bathe instead of showering??

Gina says (18:06): how can people be 1 of the 500

Aaron Kowalski says to (18:06): Symlin is going to be plugged in at some of the sites and is a logical approach to the post meal highs we face

christine says to (18:06): interesting approach

Aaron Kowalski says to (18:06): We have info about enrollment on our website – also a clinicaltrials.gov

Aaron Kowalski says to (18:07): meant to say clinicaltrials.gov

Julie says to (18:07): Respectfully, shouldn’t the meter, cgms, pump…companies be funding these trials rather than JDRF?

Aaron Kowalski says to (18:07): This is a common question I get

Aaron Kowalski says to (18:07): What we want to do is fill in the gaps

Aaron Kowalski says to (18:07): Will there be an artifical pancreas without JDRF funding – probably yes

sstrumello says to (18:07): Exactly how much of a “gap” is JDRF funding?

Aaron Kowalski says to (18:08): will it happen SOONER with JDRF – I think certainly yes!

Aaron Kowalski says to (18:08): We’re funding about $11 million over the next two years

sstrumello says to (18:08): thanks!

Aaron Kowalski says to (18:09): There are many obstacles that an independent foundation like the JDRF can address

Aaron Kowalski says to (18:09): FDA, health insurance, etc…

Kit says to (18:09): Is this a worldwide thing, or the US atm???

Julie says to (18:09): Is JDRF moving in a different direction now, and not focusing on cure-focus research? I still see the closed loop pump as a mechanical device that can fail. …not a cure.

Aaron Kowalski says to (18:09): We need all people with diabetes to have access to these tools. Right now I have to pay out of pocket to get my cgm sensors

Gina says (18:09): dont you think that the artificial pancreas closed loop system is just another way for companies to make money instead of putting money toward a cure.

Aaron Kowalski says to (18:10): Both my brother and I have type 1 (many years), the closed loop is not a cure (in my mind) but an important step forward

Aaron Kowalski says to (18:10): We need to prevent complications, ease the burden of diabetes, while we get to a cure

christine says to (18:10): will any trials include people with type 2?

Aaron Kowalski says to (18:11): This is US based and we have a site in England

Kit says to (18:11): thanks

Aaron Kowalski says to (18:11): Right now we don’t have any type 2 patients – but we’re working with NIH to include people with type 2 in such studies

Aaron Kowalski says to (18:12): I want to make a comment about the thought about companies – profits – etc…

Gina says (18:12): why focus on 11 million toward another mechanical device just to make life easier… even with these devices we can still get complications

Johnboy says to (18:13): i used to say that i would wait to start pumping when the pump got smarter…it’s smarter, but still not smart enough…i finally have in and started…but now i can’t wait for improvements… a closed loop, if it works, would be a quantum leap forward imo

Aaron Kowalski says to (18:13): Ultimately, the JDRF, the NIH, ADA, etc.. are not going to be able to deliver a cure – whether it’s an AP, islets, regenterated beta cells, etc… we need companies to pick this up at some point – we need to partner with companies

Aaron Kowalski says to (18:14): Most every company i interact with has tons of committed people with direct connections to type 1

Julie says to (18:14): Will the companies give back to JDRF a share of their profits if they indeed do profit from this partnership?

Aaron Kowalski says to (18:14): I believe a robust AP could eliminate complications!!

sstrumello says to Gina (18:14): Dr. Kowalski, as JDRF research has revealed, hypoglycemia unawareness is due in large part to faulty counterregulation, something which a closed-loop “artificial pancreas” will not correct. What is JDRF’s position on this?

Aaron Kowalski says to (18:15): Right now we’re not funding the companies – we’re funding the academics at Universities, but when we do fund companies, we include language that if they profit, monies come back to fund more research to push forward

Aaron Kowalski says to (18:15): My brother has suffered terribly from Hypo unawareness – I’m all too familiar with this and oversee our hypo program

parrotletzoo says to (18:16): hypo unawareness is where glucagon would come into play in a closed loop system right?

Aaron Kowalski says to (18:16): I’ve given many glucagon injections and we nearly lost him more than once

Aaron Kowalski says to (18:16): Two points – the research suggests by reducing hypo you can regain some awareness – very strong evidence

Kassie says to (18:16): I arrived late, but did I read you correctly that there will be no cure? “Ultimately, the JDRF, the NIH, ADA, etc.. are not going to be able to deliver a cure – whether it’s an AP, islets, regenterated beta cells, etc”

Aaron Kowalski says to (18:17): And, with a robust AP, I think we could eliminate the VAST majority of hyop – even in those with unawareness

Aaron Kowalski says to (18:18): NO NO NO – I’m convince there will be a cure, but what I meant was that we may have a perfect cure in a lab but for us – people with diabetes – to benefit, we need to deliver them

Kassie says to Aaron Kowalski (18:18): thank you for clarifying that! {smile_smiley}

Aaron Kowalski says to (18:18): And – the JDRF, NIH, ADA, etc.. just are not set up to make devices, drugs, cells, etc.. put them through FDA, market them, etc..

Aaron Kowalski says to (18:19): We need companies to pick up the research and run with it

Kassie says to Aaron Kowalski (18:19): got it, thanks

Julie says to (18:19): Who exactly will get the $11 million from JDRF for this?

Aaron Kowalski says to (18:19): I’m more optimistic than ever there will be a cure

christine says to (18:19): can you comment any on the higher potency insulins, and what their involvment in the AP will be?

Aaron Kowalski says to (18:20): You can check out the research sites on our website – <a href=”http://www.jdrf.org/artificialpancreas”>www.jdrf.org/artificialpancreas</a> – hope I spelled that right

Aaron Kowalski says to (18:20): Joslin, Stanford, Yale, U.Wash, U.VIrginia, Cambridge, Sansum, Iowa, etc…

sstrumello says to (18:20): Can you tell us about the selection of clinical trial participants? Many studies focus on newly diagnosed patients or as your website noted, young patients, rather than a complete cross-section of patients with the condition.

Aaron Kowalski says to (18:21): The CGM study will be for people over the age of 8 years on shots or pumps

Aaron Kowalski says to (18:21): Not newly diagnosed

Aaron Kowalski says to (18:21): All types of people with diabetes

Rmhb1126 says to (18:22): Aaaron – any progress on getting insurance to cover the CGMS?

christine says to (18:22): so insulin dependant type 2s or 1.5s also?

jshirsch says to (18:22): Hi, Aaron.

Aaron Kowalski says to (18:22): Insurance coverage is a big issue – we have a great team of people working in Washington on this

sstrumello says to Aaron Kowalski (18:23): Thanks

LLL says to (18:23): Why over the age of 8 years? How is the age of participants determined for studies like this?

Aaron Kowalski says to (18:23): A tremendous advocate for people with diabetes is my colleague in DC – Cynthia Rice – she heads up the team that is driving this and she is fantastic – I’m confident we’ll get it done

Aaron Kowalski says to (18:24): We worked with the docs to make the protocol.

jshirsch says to (18:24): I’ve heard anecdotally that some patients using DexCom are struggling with the device, and sales are apparently soft. Is there any concern about whether CGM itself will work — let alone the artificial pancreas?

Aaron Kowalski says to (18:24): Over 8 was a tradeoff that we made based on some of the other clinical work going on in CGM – particularly DirecNet

Aaron Kowalski says to (18:25): I’ve been wearing a DexCom for nearly 8 months- I think it’s awesome!!

Aaron Kowalski says to (18:25): My brother is wearing one as well and its helped tremendously with his lows

Aaron Kowalski says to (18:25): THere is no doubt in my mind that this works

Julie says to (18:25): Wouldn’t encapsulated porcine islets that function well be an artificial pancreas we could all live with?

Aaron Kowalski says to (18:25): I’m also wearing the Medtronic Paradigm Real Time – also great

Gina says (18:26): Aaron lets be real here, do you really want to have another device in or on you… i mean arent you as a type 1 sick of feeling like a robot. I know i am as well as many others…im sick of all these freaking devices that come out TO MAKE MY LIFE EASIER

Aaron Kowalski says to (18:26): We’re supporting Xeno and Encapsulation research – likely down the road however

Gina says (18:26): im sick of the stupid commericials that say a blood montior is virtually pain free come on we know it hurts

Gina says (18:26): no matter how fine the needle

Gina says (18:26): get me a cure not another device

Aaron Kowalski says to (18:27): Wearing the CGM has made my life so much easier I cann’t even tell you. I do less fingersticks – wearing it has been no big deal – SO MUCH more peace of mind

Aaron Kowalski says to (18:28): Ultimately, I think we’ll see things easier to wear and smaller and that will be in the near future

LLL says to (18:28): I am the parent of a child with type 1 and changing sites on one device is hard enough….I’m not sure my child would go for two devices

parrotletzoo says to (18:28): peronally, i didnt mind the pump, i wouldnt have minded a cgms, I’ll take what I can get to give me optimal health until a cure is available.

Julie says to (18:28): Are you making dose decisions based on the output even though it’s not approved to do so?

Aaron Kowalski says to (18:28): Many kids are wearing the both and have similar reaction to me

Aaron Kowalski says to (18:29): the benefit far outweights the cost

Aaron Kowalski says to (18:29): I can not lie hear – I’m using my STS to make most of my decisions – and my A1c is way down – with no lows!

LLL says to (18:29): No doubt MY first concern is the best possible health for my child, but she has social issues to deal with

Jon says to (18:29): I am a parent also, and I would love having a device monitor my kid so that I don’t have to

LLL says to (18:30): One kid already called her a robot and she’s only in first grade

Kit says to (18:30): thats way harsh

Gina says (18:30): LLL that is what i feel like

Gina says (18:30): a robot

THE KAKSTER says to (18:30): can some one come to teen room

Aaron Kowalski says to (18:30): THe issue with the size of the devices agains speaks to why we need companies involved here – and the more the better

Gina says (18:30): i cant stand summer because of my pump… but i do horrible on lantus

Gina says (18:31): so when i switch to shots i sky rocket

LLL says to (18:31): Yep, first week of first grade – even after it was all explained to the kids – the nurse read them Taking Diabetes to School

Aaron Kowalski says to (18:31): The more competition, the better the devices … look at Insulet and how they have pushed the field forward for pumps

Aaron Kowalski says to (18:31): And dexcom has done the same on cgm

LLL says to (18:31): What companies are in the best position and the most motivated to back this type of research?

Rmhb1126 says to christine (18:31): what’s happening with the Navigator?

Aaron Kowalski says to (18:32): I hope the Navigator will be out soon – it seems like any day, but we’ve been hoping that for a while

Aaron Kowalski says to (18:33): I work with the direcnet group that has been testing the Navigator and it looks great

Julie says to (18:33): How long is the warm up period for the Navigator?

Aaron Kowalski says to (18:33): This is an issue – right now it looks like it will be 10 hours

Aaron Kowalski says to (18:34): The STS and the Medtronic devices are two each

jshirsch says to (18:34): aaron, many people have love/hate relationships with their pumps — powerful tools, but a pain when they break down. do you fear similar experiences with cgm, or is the technology appreciably better?

Kassie says to Aaron Kowalski (18:34): can you have one set warming up while you finish out another set? or do you go 10 hours without feedback?

LLL says to (18:34): Why doesn’t JDRF partner with other non-profits like the Lee
Iacocca foundation or even ADA for funding research?

Aaron Kowalski says to (18:34): So far, it’s been a pretty good experience for me with my CGM’s

Aaron Kowalski says to (18:34): I do think there are some features that can be made easier to deal with – particularly the alarms

Aaron Kowalski says to (18:35): What can be frustrating when using the CGM is the feeling that even with all the information in the world, it’s still tough to stay in target

Aaron Kowalski says to (18:35): Initially, the alarms seem to be going off all of the time
*** (18:36):basketballchich2011 quit the room

Aaron Kowalski says to (18:36): We need faster acting insulin – which is a priority for me on the research side

parrotletzoo says to (18:36): i had issues with my pump alarms not being loud enough, are the alarms on your cgm’s audable enough under clothing, or say burried in bedding at night?

LLL says to (18:36): I have issues with alarm volumes too

Aaron Kowalski says to (18:36): Interstitial glucose – 159 and steady {smile_smiley}

sstrumello says to (18:36): According to the October 24, 2006 JAMA, insulin remains the #1 medicine on file for the FDA for “adverse effects” requiring hospitalization, largely due to hypoglycemia. Might JDRF consider funding gaps for startup companies such as SmartCells, Inc.?

Gina says (18:36): i have issues period lol

Aaron Kowalski says to (18:37): The issue with the StS for many people is the alarms are too loud. I find them more than adequate to catch my attention

Aaron Kowalski says to (18:37): if not – my wife certainly hears them at night! 🙁

parrotletzoo says to (18:37): that is good to know, thanks

sstrumello says to (18:37): SmartCells’ key advantages would be reducing/eliminating the incidence of hypoglycemia, requiring fewer injections and less glucose monitoring, and control of both fasting and mealtime glucose levels. Their website is <a href=”http://www.smartinsulin.com/”>http://www.smartinsulin.com/</a>

Aaron Kowalski says to (18:38): There are many technologies – device, drug, and cell based that hold tremendous potential.

Julie says to (18:39): I’m more interested in vibrating alarms for adults/teens – they don’t want to call attention to themselves with audio alarms…but this is really a minor point IMHO, I think we need to know how we can count on such a device when we know all devices fail

Julie says to (18:39): at some point in time

LLL says to (18:39): Frankly I find it frustrating when non-profits compete with each other. If there is a clear direction that will help – why don’t the non-profits join forces?

Aaron Kowalski says to (18:39): I think we – as people with diabetes – need to understand that the regulatory challenges for cell-based therapies are considerable. This is a major focus of the JDRF

LLL says to (18:39): But maybe that’s naive.

Aaron Kowalski says to (18:40): I don’t care who discovers the cure – I want everyone to work together and I try to do just that every day at the JDRF

Aaron Kowalski says to (18:40): Not naive – this is how it should be and I’ve seen much better synergy between organizations of late.

Julie says to (18:40): What percent of the JDRF annual budget is now going towards research for complications and research towards the AP?

LLL says to (18:41): Good because the for-profit companies will follow suit if they see a clear direction I think

Aaron Kowalski says to (18:41): Complications – about 22% AP – about 5%

Aaron Kowalski says to (18:41): The AP budget is relatively small

Julie says to (18:41): Thanks.

Aaron Kowalski says to (18:41): Again – trying to leverage – not duplicate

Julie says to (18:42): What have been some of the frustrations you’ve experienced with the cgms?

christine says to (18:43): this may be a bit off topic, so correct me if i am wrong to ask

christine says to (18:43): but what is the jdrf funding in terms of islet transplant trials?

Aaron Kowalski says to (18:43): I think the main frustration I’ve had is what I’ve mentioned before – despite having all of this information it’s still so tough

Aaron Kowalski says to (18:43): But, I’ve learned quickly and it’s so helpful

Aaron Kowalski says to (18:44): I don’t have many really negative experiences – BUT I think that’s because I had the right expectations

Kassie says to Aaron Kowalski (18:44): how will the AP address that aspect – do you think it will be better at staying in range, better at using the CGM information?

Aaron Kowalski says to (18:44): CGM is different than blood glucose monitoring – and if you get the hang of dealing with interstitial fluid – it’s great

Kassie says to Aaron Kowalski (18:44): that aspect =&gt; tough to stay in range, despite the good info

LLL says to (18:44): How do you keep up with expanding technology, such as the explosion of Bluetooth, when only a few years ago everything was I/R?

Julie says to (18:44): You’ve had no negative experiences whatsoever? Usually there are some in any learning curve. How long are you using each sensor?

Aaron Kowalski says to (18:44): The power of the CGM is the trends

Aaron Kowalski says to (18:45): But, you need to look at the device to do something

Aaron Kowalski says to (18:45): You simply can’t look all of the time – we need automation

Aaron Kowalski says to (18:45): The approach the researchers we fund at Yale are taking is a “hybrid”

Kassie says to Aaron Kowalski (18:45): how will the AP account for things like stress/exercise/carb intake? or will it just respond to blood sugar automatically, and quick enough to account for those variables?

LLL says to (18:46): Hybrid?

Aaron Kowalski says to (18:46): The closed loop runs all of the time but the kids do a mini-bolus before meals – tremendously effective

Kassie says to Aaron Kowalski (18:46): so there’s still room for error (carb counting, estimating, ratios)?

Aaron Kowalski says to (18:46): This way the basal is essentially on autopilot and then you can get some insulin on board to compensate for the slow sub-q delivery issues

Aaron Kowalski says to (18:47): They get near perfect control overnight – not eating and not moving around – very exciting

Aaron Kowalski says to (18:47): During the day it’s significantly better than what they record the prior days open loop – and the subjects generally have A1c’s in the 6’s

LLL says to (18:48): How long does it take to figure out the best basal rates? With my daughter’s pump, we still haven’t figured it out? And how are the basals adjusted for growth, etc?

sstrumello says to Aaron Kowalski (18:48): What about those of us who, after 30 years with T1DM, still have a high c-peptide level? I use almost no basal insulin at all, only a small dose of N overnight covers my basal needs all day.

Aaron Kowalski says to (18:49): The alogrithm is developed by hardcore engineers and looks and many differrent factors – much more reactive than a person can be

parrotletzoo says to (18:49): will the AP address alpha cell exhaustion that some people with diabetes have?

Aaron Kowalski says to (18:49): Even for those with low insulin requirments – should be better – can also turn off insulin if you’re getting low

Kassie says to Aaron Kowalski (18:50): so the AP won’t adjust based on low blood sugars? you’d have to turn it off?

Aaron Kowalski says to (18:50): The alpha cell function may be improved in theory – much closer to “normal” insulin on board

Kassie says to Aaron Kowalski (18:50): and how the heck are you going to explain this to all us non engineers! {smile_smiley}

Aaron Kowalski says to (18:50): The AP will titer down or turn off if you are getting low

parrotletzoo says to (18:50): nice

Julie says to (18:51): IMHO it’s going to be a long time to work as a true closed loop pump – especially measuring interstitial glucose fluid with an approx. lag time of 20 minutes behind bg, and insulin that takes time to peak and varies per individual.

Aaron Kowalski says to (18:51): Don’t need to be an engineer really – as Dr. Tamborlane at Yale says “If the blood sugar is going up give more insulin, if it’s going down, give less”

Aaron Kowalski says to (18:51): Julie – I disagree – and the data really supports this.

Aaron Kowalski says to (18:52): We may not get to 100% closed righ away – but we can do much better than we as people with diabetes are doing “open loop”

Kassie says to Aaron Kowalski (18:52): hey if it were that simple, my current set up would work 😉

Aaron Kowalski says to (18:53): With even a “semi-closed” loop, there should be no more A1c’s of 8’s or likely even 7’s – and if we can do this, without lows, we could put a huge dent in complications

Julie says to (18:53): I’m concerned that parents are already using the CGMS data to bolus their kids…rather than confirm with bg checks. I’m all for pushing the technology forward…just more concerned about relying on the technology at this stage.

Aaron Kowalski says to (18:53): AND ease so much of the burden of diabetes

LLL says to (18:54): tough crowd lol. But seriously, you’re not saying that everyone responds to insulin in the same amount of time?

Gina says (18:54): i havent had an a1c below 8 in over a year

Aaron Kowalski says to (18:54): I agree – it absolutely needs to be safe – and that’s our main focus. I have no doubt we can be more effective than open loop, but it needs to be safe

Gina says (18:54): safety first

sstrumello says to (18:55): What are the key safety measures you’re examining?

Aaron Kowalski says to (18:55): That said, personally, I think with the data I’ve seen we could close the loop tomorrow – eliminate most complications and PREVENT way more hypo then would ever be caused

Aaron Kowalski says to (18:55): The key is that the sensor doesn’t allow for overdosing of insulin

Aaron Kowalski says to (18:55): No hypo

Kassie says to Aaron Kowalski (18:56): which means no over treating and rebounding

Aaron Kowalski says to (18:56): There are many checks and balances that may be used to do this. This is the research the JDRF is funding right now

Gina says (18:56): even with the pump I have a fear of going low in the middle of the night

Julie says to (18:56): The sensor doesn’t allow you to overeat when you feel low? {flower_smiley}

Gina says (18:56): lol

Aaron Kowalski says to (18:56): Gina -that is what is amazing to me

Aaron Kowalski says to (18:57): Even with a pump – and even with a CGM alarming – if you don’t react – you can get very low

Aaron Kowalski says to (18:57): Right now, we should have pumps that turn off if people are getting low and not reacting – they shouldn’t continue to pump insulin into you

Gina says (18:58): I know this sounds nuts but I will eat a little something before I go to sleep… I am always afraid

LLL says to (18:58): not nuts

Aaron Kowalski says to (18:58): This is – in my opinion – the first step to the closed loop and we have great researchers working on this right now

LLL says to (18:58): We have a strict nighttime snack policy in our house

Gina says (18:59): I carry so much stuff in case I go low on the subway or the railroad… or some natural disaster o r terrorist attack

Aaron Kowalski says to (18:59): Not nuts at all – with fingersticks you never know – I use a slide in all of my talks that shows someone who went to bed at 120 – may have had a bed time snack – and was really dropping like a rock but didn’t know it – went into a seizure

Julie says to (18:59): How will the AP adjust to the sudden post exercise lows that come many hours after exercise?

sstrumello says to (18:59): or lows that come after drinking sometimes?

Gina says (19:00): ahh the after drinking lows lol

Aaron Kowalski says to (19:00): Julie- the algorithms are very sophisticated in picking up patterns of trending down glucose – will titer insulin down or off

Aaron Kowalski says to (19:00): We have two AP researchers who show glucagon can also be included – may be great protection

Aaron Kowalski says to (19:01): Another click – 166 – may need a unit before bed!

Julie says to (19:01): But if Glucagon is forcing the little bit of reserve left in the liver, will the person be left without any counter-regulatory mechanism for the next low if they exercise again in 24 hours?

LLL says to (19:01): And how does AP deal with carbs like Pizza – we do a combo bolus on my daughter but we’ve never gotten it right – we always miss the peak and end up with multiple corrections

Gina says (19:01): is having a closed loop system lets say going to save my life if I am stuck under some rubble for three days because of an attack on new york or what.

Aaron Kowalski says to (19:02): Pretty much the same as the going down idea – looking at trends, rates of change, and past experiences to compensate

parrotletzoo says to (19:02): forgive me if this has already been addressed I came in late, but are any of the research studies on AP using implanted pumps and cgms? Or are they all external?

LLL says to (19:02): There’s nothing that detects the peak and gradually compensates for it?

Aaron Kowalski says to (19:02): Gina – don’t know about that!!

sstrumello says to (19:02): Tough crowd … LOL

Gina says (19:03): hey we live in a crazy world, didnt hurt to ask lol

Julie says to (19:03): Gina, the closed loop pump won’t allow attacks on NY

Gina says (19:03): lol

Aaron Kowalski says to (19:03): Right now, they are all external – I think this is first. Medtronic has an implanted pump and sensor, but I think what’s first is what we call SC-SC — sub-cutaneous sensor and pump

rickinwacotx says to (19:03): I am confused by my MD……he says I am insulin resistant does that mean I have to take more than other folks

Gina says (19:03): now that is a machine I want lol

parrotletzoo says to (19:04): ah

Aaron Kowalski says to (19:04): Many people with type 1 also become insulin resistant – this may increase your insulin requirements

sstrumello says to Aaron Kowalski (19:04): What about reducing the size … and especially reducing all the tubes and wires required? Any ideas on timeframes for an integrated sensor/infusion set?

LLL says to (19:04): The SC-SC – that has to be changed like an external site?

Julie says to (19:05): Aaron we really do appreciate your time tonight. We just have to find a bit of humor. Are you working with the Omnipod too?

rickinwacotx says to (19:05): I take lantus 2 times a day 30 in am &amp; 50pm

Aaron Kowalski says to (19:05): I’ve been fortunate to see some of the high tech stuff coming down the pike – smaller will be hear soon

Aaron Kowalski says to (19:05): LLL – yes – just like today’s pump and CGM

rickinwacotx says to (19:05): plus novalog pre meals 30u

Aaron Kowalski says to (19:05): Julie – Omnipod is participating in some of the AP studies

Aaron Kowalski says to (19:06): I’m happy to stay on if people have more questions

LLL says to (19:06): owie – if changing a site externally hurts – internal must be a bummer!!

rickinwacotx says to (19:06): I can’t seem to get control

sstrumello says to rickinwacotx (19:06): Thats comparatively high … I’m a 37 year old man, and my total daily dose is usually less than your evening dose of Lantus.

Julie says to (19:06): Is Omnipod working on one insertion device that combines a sensor and the pump?

rickinwacotx says to (19:06): A1C 10,7

parrotletzoo says to (19:07): LLl I imagine that internal pump refills would be done under local anesthesia 😉

Julie says to (19:07): I thought the AP you’re working on now is external.

Aaron Kowalski says to (19:07): I think everyone want to have the sensor and pump together – we may be limited a bit by just how close you can get the two, but it is likely possible.

LLL says to (19:07): Are there any concerns over long-term use of some of the wireless technology? I didn’t understand if AP was using bluetooth, I/R, or ?

bina says to (19:07): Aaron, when do you think it is coming on the market?

Julie says to (19:08): Is Abbott’s Aviator pump involved in the AP project?

sstrumello says to (19:08): I’d rather get a full pancreas transplant than go into surgery for an internal pump which has potential of failure

Aaron Kowalski says to (19:08): Julie – right nearly all of the JDRF funded AP work is external – we have one great researcher – Dr. Ken Ward – who’s working on small implanted approaches

Gina says (19:08): they both do scott

parrotletzoo says to (19:08): I’d take an islet transplant over either but transplants have their issues too

Aaron Kowalski says to (19:09): Right now the technologies are radio

rickinwacotx says to (19:09): I wanna say thanks for inviting me but your talkin’ way above me here………….the VA won’t even look into those

Aaron Kowalski says to (19:09): Abbott is a very active participant in the project and has been very supportive

LLL says to (19:10): I wondered why Minimed was sticking with radio when the world is going bluetooth….

rickinwacotx says to (19:10): so I will sadly say goodbye {shrug_smiley}

Aaron Kowalski says to (19:10): I’ll stay on, but if others need to leave – I’d ask you to check out the JDRF web site for more AP info and sign up to be diabetes advocates for the JDRF!! This makes a tremendous difference and ensures diabetes is a priority in this country!

sstrumello says to (19:11): Don’t leave on my account … just a personal opinion on internal pumps

Aaron Kowalski says to (19:11): Rick – email me if you have more questions!

Julie says to (19:11): I’m still hopeful for encapsulated porcine islets. Islets are the perfect AP. We need those without immunosuppression. We need islets that are glucose responsive and not rejected

rickinwacotx says to sstrumello (19:11): I would but I don’t have your e-mail

Aaron Kowalski says to (19:11): [email protected]

rickinwacotx says to (19:12): dang this is differante than yahoo LOL

Julie says to (19:12): You’ve been terrific about answering our questions Aaron. Thank you so much.

christine says to Dan (19:12): thank you Aaron

LLL says to (19:12): Yes, thanks for your time

Aaron Kowalski says to (19:12): Julie – we continue to fund lots of research in this area and this is certainly our goal – to walk away completely!

periwinkle says to (19:12): very informative session, thanks so much !

sstrumello says to (19:12): Thanks Aaron … I’m not convinced yet, but much closer than I was at the beginning of this program!!

rickinwacotx says to (19:12): yeah from me too

Gina says (19:13): haha me too scott

Aaron Kowalski says to (19:13): Great – I’m always available to answer questions if I can

Julie says to Jon (19:13): Gina/Jon will this chat be available in transcripts?

Gina says (19:13): of course

rickinwacotx says to (19:13): what can I do any dif than I am already?

B and M says to (19:13): Hope you come to JDRF in Bergen County.

Gina says (19:13): this chat will be available tomorrow sometime

rickinwacotx says to (19:14): I get so down and my wife gets ticked off at me

Aaron Kowalski says to (19:14): Rick – in my opinion it’s all about the glucose level – that needs to be priority number 1

rickinwacotx says to (19:14): I feel like I am on a roller coaster

Julie says to (19:14): Wishing you good health too Aaron.. Looking forward to hearing more in the future. Give everyone on your staff a raise this holiday season LOL.

Aaron Kowalski says to (19:14): B and M – I think I’m coming to the JDRF in Bergen in the spring – I live in Central NJ!

sstrumello says to (19:14): Thanks, goodnight everyone!

Gina says (19:14): NITE SCOTT

Gina says (19:15): Aaron, I am always on the diabetes rollercoaster as well, mentally a closed loop system would help me i think.

Gina says (19:15): anything to take the thinking out of it
Aaron Kowalski says to (19:16): I think that’s going to be the main benefit – relieve some of the mental burden

LLL says to (19:16): I’d love to see you in Bergen also. Keep us posted!

rickinwacotx says to (19:16): aaron I got your addy and thanks alot for your time……..VA won’t put me on a pump

Aaron Kowalski says to (19:17): I’m on a pump now – but did shots until recently – we’re working with the VA to try to help. But, in the meantime, do your best to go after those high sugars

Gina says (19:17): my worst time of the day is during the day

rickinwacotx says to (19:17): I am and I seem to have a lot of lows at nite

Aaron Kowalski says to (19:18): On the cgm I’ve found breakfast to be very very difficult

Gina says (19:18): i will forget to bolus, and check or correct while at work

Aaron Kowalski says to (19:18): I’ve used that information to modify my ratios and my basal in the AM which has helped

rickinwacotx says to (19:18): ya’ll are makin’ me feel like a real dummy

rickinwacotx says to (19:18): dummy opps

parrotletzoo says to (19:19): gah! i want cgms! lol

Aaron Kowalski says to (19:19): The CGM is great for pumpers – immediately see if you missed a bolus – or last week a picked up a kinked cannula very quickly

Julie says to (19:19): Aaron are you using the smaller sensors?

Aaron Kowalski says to (19:19): I’m using the currently available DexCom and Medtronic sensors

rickinwacotx says to (19:19): cya’ll God Bless

Gina says (19:20): wait, you are on two cgms ?

Gina says (19:20): nite rick

Gina says (19:20): thanks for coming

Julie says to (19:20): I assume you’ve tested the Navigator also?

Aaron Kowalski says to (19:20): I’ve been trying both lately – the STS and the Medtronic – haven’t had a go with the Navigator yet

Aaron Kowalski says to (19:20): But, I’ve seen it quite a bit and the data looks fantastic

Gina says (19:20): its like you have a tool belt of cgms lol

parrotletzoo says to (19:21): can i ask which you prefer?

Julie says to (19:21): I agree the data looks terrific. The 10 hour warm up is a “bummer”

Gina says (19:21): Aaron the diabetic tool man lol

parrotletzoo says to (19:21): sts or medtronic

Aaron Kowalski says to (19:21): My wife thinks I’m crazy – but I like to be able to have experience with what I talk about and its been super interesting

parrotletzoo says to (19:21): of course, makes sense

Gina says (19:21): yea

parrotletzoo says to (19:21): job research 😉

Gina says (19:21): id say

Julie says to (19:22): So how close are the Dexcom and MM when you look at them both?

Aaron Kowalski says to (19:22): We’re hopeful the 10 hour piece will be addressed quickly

Gina says (19:22): which one has the 10 hr problem

Gina says (19:22): dex

Aaron Kowalski says to (19:22): the navigator has a 10 hour warm-up –

Gina says (19:22): oh oh

Gina says (19:22): we had a chat with Phil Southerland about the navigator

Aaron Kowalski says to (19:22): The STS and the MM both have been great – trend along very similarly

Julie says to (19:23): Have you had more problems with one brand sensor over the other?

Aaron Kowalski says to (19:23): Just say Phil in Atlanta a few weeks back – had on his Navigator

Gina says (19:23): maybe when you are done you can lend me yours lol…haha

Gina says (19:24): i have to tell you i struggle big time

Aaron Kowalski says to (19:24): I think they are both great – different

Julie says to (19:24): If you can convince Gina to use it, she’ll be living proof even the nay sayers can be swayed.

Gina says (19:24): lol

Aaron Kowalski says to (19:24): Gina – you’ll be on a CGM – I’m sure of it!

Gina says (19:24): if you are paying sure!

Gina says (19:24): lol

Aaron Kowalski says to (19:25): My brother will not wear a pump – but he loves the CGM

parrotletzoo says to (19:25): i loved my pump!

Julie says to (19:25): Does the cgm from MM have a vibrating alarm instead of an audible one?

Aaron Kowalski says to (19:26): The MM has a variety of alarms – which is nice – I keep mine on vibrate

Gina says (19:26): i have my pump on vibrate

Aaron Kowalski says to (19:26): The STS vibrates first – then beeps if you don’t react to it

parrotletzoo says to (19:26): that’s a nice feature

parrotletzoo says to (19:26): I work in a loud environment and don’t always hear pump alarms

Aaron Kowalski says to (19:27): Any other science questions?

Gina says (19:27): Hmm

Aaron Kowalski says to (19:27): Almost my bed time!

parrotletzoo says to (19:27): thank you for you time

Julie says to (19:27): How many fingersticks do you do now per day?

Gina says (19:28): oh yea do you have to calibrate

Aaron Kowalski says to (19:28): Truthfully – two – the two required for calibration

Gina says (19:28): lucky

Aaron Kowalski says to (19:28): And, as I said before, my A1c is way down and I have had significantly less lows

Julie says to Aaron Kowalski (19:28): Good night.

Julie says to Aaron Kowalski (19:28): Thanks again.

Gina says (19:28): I need to get my blood sugars down big time

Gina says (19:29): I am getting married and eventually would like to have children and that’s something that worries me

Gina says (19:29): that I won’t be able to be in better control

Aaron Kowalski says to (19:30): There was a great letter to the editor in the Journal Diabetes Care this month describing the power of CGM in a women who had struggled with her control and then was pregnant –

Aaron Kowalski says to (19:30): helped tremendously

Gina says (19:30): I don’t think I will be able to do it unless i have something like that

Aaron Kowalski says to (19:30): Will likely become the gold standard

bigainge says to (19:31): Thank you for your time Aaron, you have been most helpful. I bid you goodnite.

Gina says (19:31): Aaron, thank you so much for coming tonite

Aaron Kowalski says to (19:31): Good night bigainge !

Gina says (19:32): I will send you the transcript once we edit

Aaron Kowalski says to (19:32): Gina – everyone thanks – it was a lot of fun!

periwinkle says to (19:32): Goodnight and thanks again !

Aaron Kowalski says to (19:32): Again – sign up to be diabetes advocates at <a href=”http://www.jdrf.org”>www.jdrf.org</a>

Aaron Kowalski says to (19:33): And reach out to me if you think of any other questions at any point – I’m very optimistic = the future is bright!!

Aaron Kowalski says to (19:34): Good night everyone – I’m going to sign off

Gina says to Aaron Kowalski (19:34): Nite!