This year marks the centenary of one of the biggest medical breakthroughs in history - the discovery of insulin.

It began a century of innovation in which the lives of millions of people with type 1 diabetes have been saved.

With recent figures showing nearly half a billion people worldwide have diabetes, innovators are designing new ways of providing care.

One radical paradigm shift is the possibility of providing insulin orally rather than via injections.

“No person with diabetes should die because they cannot access insulin and that still happens sadly across the world,” says Professor Andrew Boulton, consultant physician at the University of Manchester and president of the International Diabetes Federation. “People with type 1 diabetes require insulin to survive and many people with type 2 diabetes also need it to manage their condition,” he continued.

One innovator in this field is clinical stage biopharmaceutical company Diabetology Limited. The firm has completed phase 2b trials of an oral insulin replacement, which could provide an alternative to injected insulin for people with type 1 or late-stage type 2 diabetes.

Diabetology cofounders Glen Travers and Dr Roger New have been working for 30 years to develop the Axcess oral delivery system, which increases the absorption of peptides, proteins and other macromolecules across the intestinal wall.

New believes that insulin is the perfect target for oral administration. “When you administer it by the oral route, as soon as it’s goes across the gut wall it goes directly to the liver and interacts with the receptors in the liver, which is what happens in a healthy individual. This is very good because it’s the liver that controls the glucose levels in the bloodstream,” he tells MobiHealthNews.

Travers adds that Diabetology hopes to change the paradigm for people with diabetes. “It looked to me like we could not only achieve something in terms of compliance – an easier way to take a drug which was otherwise injectable, but much more importantly see the benefit of allowing the liver control sugar levels rather than having injected insulin into the outer circulation,” he says.

Remote care

Throughout the COVID-19 pandemic innovators have focused on enabling diabetes patients to self-manage their condition, as attendance at hospital diabetes clinics has dramatically fallen. People with diabetes are more vulnerable to developing severe illness if they catch the virus and an NHS report showed that one in three hospital deaths in England were of diabetes patients.  

“Telemedicine has taken a step forward and many consultations between health professionals and people with diabetes have been using smart technology, teleconferencing and video conferencing - sharing the screen so they can look at their blood sugars and what they had to eat,” says Boulton. “They can have a discussion without having to come to the hospital.”

Smart technology has also been a game changer in Boulton’s specialist area of diabetes complications affecting a lower limb. People with diabetes are at risk of suffering neuropathy, which can lead to ulcers or sores on the feet. If left untreated, infections can develop and potentially lead to amputation.

“Now we’re using smart wireless bathmats to help patients remotely monitor skin temperature of their feet, because it’s been shown that the foot warms up before an ulcer develops. Patients self-monitor their foot temperature and the results are sent back to the physician,” explains Boulton.

Researchers at Manchester Metropolitan University (MMU) in collaboration with Boulton's group have also tested a smart pressure-sensing insole that reduced diabetic foot ulcers in high-risk patients by 71%.

“High pressure plus loss of feeling leads to breakdown. The insole can alert the patient so they can alter their walking or rest to reduce the risk of high pressure,” continues Boulton.

Meanwhile another MMU study is examining the use of vibrating smart insoles to improve balance for patients with diabetic neuropathy.

Digital health explosion

One of the most significant technologies is continuous glucose monitoring (CGM), which allows people to automatically track their blood sugar with a smartphone.

Liz Perraudin, senior policy officer at Diabetes UK, says there has been “an explosion” in the number of people using such digital health products to help manage their diabetes. Orcha estimates that between 2019 and 2020 the downloads of diabetes-related apps grew by 400% in the UK.

“More recent advances in diabetes technology include the emergence of hybrid closed-loop systems and we are thrilled that the NHS recently announced a pilot project that will see up to 1,000 people with type 1 diabetes getting access to the life-changing tech as part of this pilot,” says Perraudin.

Other recent technologies being adopted across Europe include smart insulin pens, which give people with diabetes the opportunity to get more data about the insulin they are using and share it directly with their healthcare teams.

Platforms like Diasend and Tidepool also allow people to share their data directly with their clinicians.

In the UK, NHSX supported the testing and adoption of the healthy.io smartphone urinalysis technology, which turns people’s smartphones into an at-home kidney function test.

“At a time when the ability to conduct tests face-to-face has been limited, this has been a great step forward in areas using the technology,” says Perraudin.

Accessibility issues

Unfortunately, not everyone with diabetes is able to access technology. Many people worldwide do not have smartphones, and there is huge variation in the accessibility of insulin pumps.

Although there is strong evidence that flash glucose monitors can be hugely beneficial for people with type 2 diabetes who use insulin, they are not routinely available on the NHS in England.

In the future Perraudin hopes to see the use of hybrid closed-loop technology expanding. “We’d also like to see innovators and tech manufacturers ensuring that they better understand and address the needs of people living with diabetes. No one person is the same and we would like to see more technologies emerging that are usable and helpful for all people living with diabetes, no matter their background,” concludes Perraudin.