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Diabetes devices can significantly improve glycemic management and are the standard of care for people with type 1 diabetes (T1D), but the technology also creates a unique set of stresses and burdens that, if not addressed, limit their effectiveness and may cause patients to stop using them.

Over half (56%) of people with T1D who use continuous glucose monitors (CGMs), insulin pumps, automated insulin delivery (AID) systems, or other technology experience moderate-to-extreme emotional and mental burden associated with their devices, according to survey results presented during a special interest group session about “diabetes device distress” at the American Diabetes Association (ADA) 85th Scientific Sessions in Chicago.

The stresses include worry that the device might fail, distress over alarms misfiring or going off in public, and the technology’s interference in regular activities like exercise, the survey found.

“Just because something is helpful doesn’t mean that the day-to-day challenges are not still overwhelming,” said Estelle Everett, MD, an endocrinologist and health researcher at the University of California, Los Angeles (UCLA), David Geffen School of Medicine, told to Medscape Medical News.

Physicians have a lot of room for improvement in helping their patients deal with device-related distress, the survey found. Most respondents (78%) said that their diabetes provider never asked them about these burdens, and 40% did not feel they had adequate resources to address them.

“It’s important that providers inquire about the level of distress our patients are experiencing with their devices so we can better support them,” said Everett, who presented the survey data.

Physicians should listen to their patients and take their device problems seriously, session speaker David T. Ahn, MD, chief of Diabetes Services at Hoag Memorial Hospital Presbyterian, Newport Beach, California, told Medscape Medical News.

“I love diabetes technology, and this is not meant to disparage it, but I think having a more realistic understanding of the benefits and limitations allows us to build more trust with our patients and allows our patients to have a more mature relationship with their devices,” he added.

Survey: Distress Levels High, but Patients Stick With Tech

Everett and colleagues sent electronic surveys to 6700 UCLA adult patients with T1D via MyChart messages, and 1026 responded. Of 931 currently using devices, 66% used both a pump and CGM, with most having an AID system; 28% used only a CGM; 1% used pumps only; and 4% did not use those devices.

The survey was part multiple choice and part free text. In the multiple-choice section, the possibility of device failure was the most common patient concern. Over a third (37%) reported occasionally worrying that their CGM would quit, while 17% said they worry about that frequently/always. For insulin pumps, those figures were 40% and 23%, respectively.

Device alarms can be very helpful, the survey found. Over half of respondents (58%) reported that pump/CGM alerts frequently or always called attention to abnormal blood glucose levels that they weren’t aware of.

But the alerts also are a big source of stress for patients. Asked how often they felt distress from audible CGM or pump alerts/alarms occurring in public, 35% answered occasionally and 22% said frequently/always, while 44% said never/rarely.

Nearly half (47%) said that CGM or pump alerts disrupt their daily activities occasionally, 29% frequently/always, and 24% never/rarely.

In a written response, one survey participant gave an expletive-laden account of being kept up all night by multiple low blood glucose alerts.

The survey found that many patients respond to their device alarms in inappropriate ways. Nearly a third (31%) reported frequently or always ignoring or silencing the alerts. In response to high glucose alerts, 50% reported occasionally overdosing on insulin to correct the high glucose, while 17% said they frequently or always overdose.

In response to low glucose alerts, 45% reported occasionally and 31% frequently/always underdosing insulin or eating meals without bolusing insulin.

“The alarm itself can be problematic in terms of the disruptions of daily life, and then how people are responding to them also could be problematic,” Everett noted.

The quality-of-life impact varies by device type, the survey found. Patients using both a pump and CGM felt a more negative effect of diabetes on their ability to exercise and on their sex lives than those using CGM only or no devices. Everett said she plans to examine the qualitative data on those responses further. Both cases might relate to the on-body devices interfering with those activities, but other issues may play a role, she told Medscape Medical News.

On the other hand, patients using pumps with CGM felt a less negative impact on diabetes controlling their lives, feeling overwhelmed by the demands of living with diabetes, and feeling guilty or ashamed because of their diabetes.

Yet, despite the challenges of device use, 86% of respondents strongly agreed or agreed that they prefer an insulin pump over injections with a syringe or pens, and 87% strongly agree/agree that they prefer using CGMs over fingerstick glucose monitors.

Respondents using devices also scored better on the Appraisal of Diabetes Scale, a questionnaire that measures how individuals perceive and cope with the disease on a scale of 7-35 points, with lower being better. Scores were 17.79 for those using CGM only and 17.39 for those with pump and CGM use vs 19.07 with no device use. The difference between the device groups and those not using devices was significant (P = .04).

Of course, not all patients experience diabetes device distress. “I think the place to start is just figure out where your patient is in the spectrum because it is a huge spectrum,” Everett said.

Tips for Fighting Alarm Fatigue

CGM alarms and alerts vary by brand but include those denoting blood sugar changes (an urgent insulin low, a predictive low, the fall rate, high glucose, a predictive high, or rise rate) or device issues (replace sensor, check sensor, or signal loss). AID systems may have up to 30 different alerts or alarms for glycemic changes and device issues, also depending on the brand.

“It’s important to recognize the differences here so that we can provide tailored conversations with our patients,” said Gwendolyne Jack, MD, assistant professor of clinical medicine and lead of the Ambulatory Diabetes Program at Weill Cornell Medicine, New York City.

The fatigue — or distress around alerts and alarms — can arise for a variety of reasons, including false alarms (such as a so-called “compression low”), inappropriately set alarm thresholds, noisy or intrusive alarms (especially in public), alarms not referenced in the user manual, and overlapping alarms from the CGM, the pump, and their respective phone apps.

Data overload and desensitization can lead patients to dismiss the alarms/alerts or discontinue the devices altogether, harming their ability to manage their glucose levels. “Imagine all these alarms going on at the same time, about the same exact issue. And as a result of that, patients may refuse to continue on with these devices because their day is interrupted by multiple alarms and alerts,” Jack said.

The aim is to balance the alarms’ power to help patients prevent hypo- and hyperglycemia with the annoyance of disruptions. Potential approaches involve customizing the settings, such as tailoring glucose thresholds for nighttime vs daytime; adjusting the type of notification, that is, sound vs vibration; turning off some that aren’t helpful, that is, reminders and glucose rise/fall; and consolidating notifications to just one or two sources.

Certified diabetes care and education specialists (formerly called diabetes educators) and device manufacturers can provide additional training for patients, Jack noted.

CGM Troubleshooting Tricks and Hacks

Ahn discussed some common CGM problems that physicians should be aware of so they can inform their patients. One issue is the compression low — or sensor-induced pressure attenuation — a sudden, false reading of a glucose drop when the person applies pressure to the sensor, such as while sleeping. The phenomenon, which can be very alarming for patients, hasn’t been studied well, he said.

“I don’t think the topic of compression lows is really given the due diligence in the education process,” Ahn noted. “It’s a common cause of questions and phone calls.”

Another problem with CGMs is sensor variability within the first 12-24 hours of placement resulting from an inflammatory response to the foreign body. One possible solution is to “soak,” or overlap the sensors — that is, place the next sensor before the previous sensor session ends — to give the body time to adapt to the new one.

Skin reactions and sensor adhesive issues also arise frequently, sometimes leading patients to discontinue using the devices. Solutions include using barrier films, spraying a steroid such as fluticasone propionate on the skin before placing the sensor, or switching to an alternate product. Ahn recommended the Panther Program’s tips for dealing with skin-related problems as a good resource.

Patients using the Dexcom G7 might encounter a recently recognized problem nicknamed “goosenecking,” in which the filament doesn’t penetrate the skin and instead loops out of the hole on the sensor surface. Dexcom will replace those faulty sensors. In other cases, the G7 simply won’t start, and one hack is to hold a magnet over the sensor, which can sometimes give it a jump-start.

Ahn advised clinicians who prescribe any brand of CGM to patients to try wearing the devices themselves so they understand the experience. “If you wear five or six sensors, you’ll see that a lot of opportunities for challenges and errors pop up. You’ll learn so much and better empathize with your patients,” he said.

Everett and Jack reported having no disclosures. Ahn is a speaker for, advisor for, and/or recipient of research grants from Abbott, Ascensia, Insulet, Eli Lilly and Company, MannKind, Novo Nordisk, Xeris, Sequel, Eli Lilly and Company, Honey Health, Medtronic, and Tandem.

Miriam E. Tucker is a freelance journalist based in the Washington, DC, area. She is a regular contributor to Medscape Medical News, with other work appearing in the Washington Post, NPR’s Shots blog, and Diatribe. She is on X @MiriamETucker and BlueSky @miriametucker.bsky.social.