Automated frequent insulin dosage titrations to enhance therapy effectiveness; lessons from the d-Nav® insulin guidance

Background and aims: Insulin therapy is used by a quarter of type 2 diabetes patients, yet most do not achieve glycemic goals. Unless dosage is frequently adjusted, variations in insulin requirements hamper its effectiveness. In reality, dosage adjustments are done sporadically due to providers\u27 workload in caring for a large number of patients. d-Nav® has been developed to overcome this barrier by bridging the titration gap. d-Nav is a handheld device that automatically analyzes stored glucose patterns and titrates insulin at least weekly, based on individual needs. Previous experience has underscored the role of care specialists\u27 in supporting effective use of d-Nav. We equipped a diabetes specialty team with d-Nav to assess its impact on insulin management of patients with type 2 diabetes compared to close patient support without automatic dosage titration. Materials and methods: We conducted a 6-month, multicenter, randomized-controlled trial with 181 sub-optimally controlled patients with type 2 diabetes. Standard care, which was delivered by a diabetes specialist team who contacted patients 7 times (control group), was compared to the same with the addition of d-Nav (d- Nav group). Results: In the d-Nav group, A1c decreased by 1% from 8.7±0.8% (mean±standard deviation or SD) to 7.7±1.0%, while in the control group A1c decreased by 0.3% from 8.5±0.8% to 8.2±0.9% (p\u3c0.0001)(See Figure). In the d-Nav group, clinically significant improvement in A1c (≥0.3%) was seen in 80.7% of subjects and 52.3% achieved A1c≤7.5%. Conversely, in the control group 44.4% improved A1c≥0.3% and 21.0% achieved A1c≤7.5%. In nearly half of the control patients (43.2%), A1c worsened or was unchanged during the study compared to 14.8% in the d- Nav group (see Figure). Conclusion: When equipped with automated insulin titration capabilities, a diabetes specialist team can deliver an effective insulin therapy to the majority of patients. Automated insulin titration along with provider support can significantly advance the standard of care in insulin users with type 2 diabetes. (Figure Presented)