Updates and advances

in technology for diabetes

self-management
Introduction Andrew Bzowyckyj, PharmD, BCPS, CDE,
associate professor, Pacific University Oregon
Diabetes management is constantly evolving, including new treatment options School of Pharmacy, Hillsboro
with innovative mechanisms of action, a shift toward more shared decision mak-
Correspondence: Andrew Bzowyckyj, Pacific
ing and person-centered care, and increased interest in and availability of diabe- University Oregon School of Pharmacy, 222
tes technology. Recent changes in diabetes technology have been so significant SE 8th Ave., Ste. 451, Hillsboro, OR 97123;
that the American Diabetes Association (ADA) Standards of Medical Care in Dia- bzowyckyj@pacificu.edu
betes–2019 has an entirely new section devoted to diabetes technology.1 This new
section now contains the information about self-monitoring of blood glucose (pre-
viously located within section 6, “Glycemic Targets”). It also contains new recom-
mendations on insulin delivery devices, blood glucose meters, continuous glucose
monitors, and automated insulin delivery devices.1
According to ADA, the term diabetes technology describes “the hardware, de-
vices, and software that people with diabetes use to manage blood glucose lev-
els, stave off diabetes complications, reduce the burden of living with diabetes,
and improve quality of life.”1 This article discusses how these topics relate to the
pharmacist’s role in helping people with diabetes manage their diabetes and other
chronic conditions.

Selecting the right mobile app

As of February 2018, 77% of Americans owned a smartphone, including 46% of
people aged 65 years and older.2 As these devices become more engrained in our
everyday lives, mobile applications for health care–related uses—such as help-
ing patients manage their diabetes—are a logical development. Mobile applica-
tions, or “apps,” are a type of software designed to run on a mobile device, such
as a smartphone or tablet computer.3 As of 2017, there were 325,000 mobile health
apps available for users to download, and industry projections estimated approxi-
mately 3.7 billion downloads of these apps in 2017.4

Accreditation information Learning objectives

Activity type: Knowledge based ACPE Universal Activity Number: After participating in this activity, pharmacists
Provider: APhA 0202-0000-19-152-H01-P will be able to
Target audience: Pharmacists CPE credit: 2 hours (0.2 CEUs) ■■ Identify useful diabetes-related mobile
Release date: May 1, 2019 Fee: There is no fee associated with this activ- applications based on their characteristics
Expiration date: May 1, 2022 ity for APhA members. There is a $25 fee for and functionalities.
nonmembers. ■■ Describe the role of mobile applications in
helping patients manage their diabetes.
APhA is accredited by the Accreditation Council for Pharmacy Education (ACPE) as a
■■ Discuss the criteria that should be used to
provider of continuing pharmacy education (CPE). The ACPE Universal Activity Number
evaluate a mobile application (app).
assigned to this activity by the accredited provider is 0202-0000-19-152-H01-P.
■■ Explain the importance of device accuracy
Advisory board: Jennifer Trujillo, PharmD, associate professor, Department of Clini-
when helping patients select technology for
cal Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences,
glucose monitoring.
Aurora.
■■ Describe the most useful diabetes
Disclosures: Jennifer Trujillo, PharmD, declares that she is an advisory board member for
self-management devices and support
Sanofi and BD Pharmaceuticals. Andrew Bzowyckyj, PharmD, BCPS, CDE, and APhA’s editorial
tools currently available to patients with
staff declare no conflicts of interest or financial interests in any product or service mentioned in
diabetes.
this activity, including grants, employment, gifts, stock holdings, and honoraria. For complete staff
■■ Compare the various insulin pens and
disclosures, please see www.pharmacist.com/apha-disclosures.
injectable devices that are commercially
Development: This home-study CPE activity was developed by APhA.
available.

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 CPE UPDATES AND ADVANCES IN TECHNOLOGY FOR DIABETES SELF-MANAGEMENT
Preassessment questions
Before participating in this activity, test your knowledge by an-
swering the following questions. These questions will also be part
of the CPE assessment.
1. A patient with type 2 diabetes is started on insulin glargine
U-300 at 10 units once daily. Which of the following apps can
help him titrate his basal insulin to a safe and effective dose?
a. Fooducate
b. Glooko
c. Insulia
d. Glucose Buddy
2. A patient heard from a friend about a new app that seems too
good to be true. She is thinking about purchasing the app but
is not sure if it is worth the high upfront cost. Which of the
following sources of information would be the most helpful
for her decision?
a. iTunes App Store User Ratings
b. FDA Medical Device Database
c. iMedicalApps Clearinghouse
d. National Library of Medicine Mobile Apps
3. Which of the following statements is correct about the accu-
racy of continuous glucose monitoring devices?
a. Abbott Freestyle Libre requires calibration twice daily.
b. Senseonics Eversense requires a 2-hour warm-up before
reporting data.
c. Medtronic Guardian Connect requires calibration every
12 hours.
d. Dexcom G6 sensors can be worn for only 7 days before
needing replacement.
However, many patients and health professionals alike
are easily confused by the vast array of apps available on the
market today, resulting in an inconsistent uptake of these
valuable resources. With this many apps available, it is not
possible to keep track of all of them. However, picking a few
favorites to recommend isn’t ideal, either. Each app offers a
different set of features, and recommendations should be
patient-specific. This review discusses some basic principles
for evaluating apps and highlights several of the more popu-
lar apps currently available to assist people with diabetes.
Websites featuring the top diabetes apps
■■ The best diabetes apps of 2018: www.healthline.com/health/
diabetes/top-iphone-android-apps
■■ Twelve apps for managing diabetes—blood glucose trackers, food
and exercise logs, and more: www.everydayhealth.com/hs/type-
2-diabetes-care/diabetes-apps/
■■ Top four apps for managing diabetes: www.verywellhealth.com/
top-apps-for-diabetes-management-1087237
■■ The best free diabetes apps and trackers: https://dlife.com/the-
best-free-diabetes-apps-and-trackers/
When considering health-related apps, most people typi-
cally wonder, “Where do I start?” and “What do I look for?”
Fortunately, several strategies have been proposed for evalu-
ating and selecting mobile apps: consulting the scientific lit-
erature, searching app stores, reviewing app characteristics
(e.g., descriptions, user ratings, reviews), conducting a social
44 PharmacyToday • MAY 2019
CPE_05_19_JD.indd 44
media query within professional and/or patient networks,
pilot testing the app, and eliciting feedback from patients.5
A clearinghouse website is another practical source for
verifying information about an app. iMedicalApps and
AppScript are two examples of health-related clearinghouse
websites in the United States. In addition to these general
health-related sites is a clearinghouse focused entirely on
diabetes, the Diabetes Advanced Network Access (DANA).6
Last, the United Kingdom’s (U.K.) National Health Service
has developed a clearinghouse that may be of use to indi-
viduals living outside the U.K., if the specific app of interest
is available internationally. Table 1 gives a general overview
of these app clearinghouse websites.
It is important to emphasize that most health-related apps
are not considered medical apps, which would require meet-
ing the definition and approval criteria of a medical device
and subsequent regulation by FDA. This means that many
apps are widely available to the public without formal
review or verification of the information provided.7 Before
recommending an app for patient use, therefore, practitio-
ners should consult one of these clearinghouse websites
to check the app’s validity and ensure it is of high quality.
Furthermore, when evaluating an app, there are various
other aspects to consider beyond the quality of information
provided. Table 2 provides some additional characteristics
that are important to evaluate.8
One important factor to consider is that not all apps offer
the same set of functionalities. For example, an app may pro-
vide a social outlet (e.g., chat forums, data sharing within a
network), offer a two-way communication medium between
a patient and his or her health care provider(s), or enable a
patient to log self-monitored data (e.g., meals eaten, glucose
levels, weight measurements) solely for personal use. Before
encouraging a patient to use an app, it is important to deter-
mine what the patient hopes to accomplish. Figure 1 depicts
the most common strategies mobile apps use to activate
patients. Each level of the pyramid represents an increase
in the extent to which an app enables patients to engage in
their own health care, though the exact correlation between
the two factors has not been directly researched (i.e., it is not
guaranteed that higher engagement with an app correlates
directly with an improvement in health outcomes).9
Do mobile apps work?
Several systematic reviews have evaluated the efficacy of
apps in improving diabetes-related health outcomes, with
somewhat conflicting results. Interpreting these trials is
complicated because the term app is used to describe a broad
array of communication methods that would not necessarily
be considered apps by today’s standards, such as software
programs that are desktop computer–based and two-way
text messaging. Overall, limited evidence suggests that use of
some commercially available apps, in conjunction with sup-
port from a health care provider or study staff, may improve
several short-term diabetes-related outcomes (mainly A1C),
with the long-term impact unclear.10,11
One systematic review of 21 trials (n = 1,543) evaluated the
impact of using an app to reduce A1C levels in people with
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 UPDATES AND ADVANCES IN TECHNOLOGY FOR DIABETES SELF-MANAGEMENT CPE

Table 1. Overview of app clearinghouse websites

App clearinghouse How to access Developer Content/Description
iMedicalApps ■■ Imedicalapps.com ■■ Independent online ■■ Expert reviews written by
–No login required medical publication health professionals
■■ Collaboration with
MedPageToday
AppScript ■■ Appscript.net ■■ IQVIA (formerly Quintiles & AppScript Score (0–100)
–Free, but login required IMS Health) based on six weighted
domains:
1. Professional
2. Patient
3. Functional
4. Endorsement
5. Developer
6. Clinical
Diabetes Advanced Network ■■ Danaapps.org ■■ AADE ■■ Intelligence-driven curation
Access (DANA) –Free, but login required ■■ DHX Labs ■■ Adaptive privacy and secu-
■■ Danatech.org rity (APS) scan
–Paid AADE membership ■■ Standard review
required 1. App performance
2. Privacy and security
3. Data management
■■ Enhanced review
1. Functionality
2. Usability
3. Behavior science
4. Operability
5. Privacy and security
■■ Trust score
1. Exceptional
2. Good
3. Average
National Health Service (NHS) ■■ Apps.beta.nhs.uk ■■ NHS ■■ App pricing
Apps Library –No login required ■■ Prescription requirements
■■ Description
■■ Photos
■■ Ideal candidates
■■ Overview of operating
instructions
Sources: References 5 and 6.

type 1 and type 2 diabetes. People with type 1 diabetes (n
= 516) saw an overall A1C decrease of 0.49% (95% CI [−0.94
to −0.04%]), while those with type 2 diabetes (n = 1,027) saw
a slightly higher A1C reduction of 0.57% (−0.82 to −0.32%),
though there was significant heterogeneity noted among the
trials within each study population (I2 = 84% and 77% for
type 1 and type 2 diabetes, respectively). Of interest, feed-
back from health professionals was negatively correlated
with A1C reduction in type 1 diabetes, while the opposite
held true for individuals with type 2 diabetes. In the type 2
diabetes population, low-frequency feedback (i.e., as needed
or once monthly) was associated with an A1C reduction of
0.33% (−0.59 to −0.07%, I2 = 47%), whereas high-frequency
feedback (i.e., more than once per month) was associated
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with an A1C reduction of 1.12% (−1.32 to −0.91%, I2 = 0).12
The authors did not identify a potential cause for this phe-
nomenon, although a separate study found similar results.13
Two possibilities for this difference in impact between dia-
betes types are 1) the small sample size in the studies inves-
tigating health professional feedback in type 1 diabetes, and
2) the different types of challenges faced daily by individuals
living with type 1 and type 2 diabetes.
Apps for calorie tracking and meal
planning
Numerous mobile apps are commercially available for calo-
rie tracking and meal planning. Table 3 features some of the
most common ones. The general functionalities of the apps
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 CPE UPDATES AND ADVANCES IN TECHNOLOGY FOR DIABETES SELF-MANAGEMENT

Table 2. Important factors to consider when evaluating an app

Factor
Purpose / area of focus
Device compatibility
App usability
Functionality
Cost (initial and ongoing)
User ratings
Update frequency
Privacy and security policy
HONcode principles (Health
On the Net Foundation)
Sources: References 5 and 8.
Importance
The content featured within the app should be of relevance to the patient seeking to use it.
Ensure the app is available on the platform compatible with the patient’s specific device (e.g.,
iTunes, Google Play).
The patient needs to be able to use the app, ideally with minimal instruction. The patient’s tech-
savviness may affect how critical this factor is.
In addition to being user-friendly, the app must interface with the patient’s daily routine fairly
easily to increase the likelihood of success.
Both the initial and ongoing costs are essential to evaluate to ensure the app is affordable. When
reading app descriptions, note that some app functionalities may only be available to individuals
who have a paid prescription or a premium membership.
Take a look at how many people have rated the app, in addition to reading some of the actual
comments. To get a broad perspective, one strategy is to read a few of the comments from indi-
viduals who rated the app very highly and then a few more from those who rated it very poorly.
Sometimes a low rating could be related to an experience that may be unique to that user, while a
high rating may be a paid testimonial.
This is a good measure of not only how current the app material is but also how frequently the
app developers are working on software updates that enhance the patient’s experience.
It is critical to evaluate the relevant privacy and security policies any time health information
is involved. This is especially true for apps that require information to create a profile (e.g.,
name, date of birth) or logging of health-related data (e.g., blood glucose values, laboratory test
results).
■■ Authority: State the qualifications of authors/contributors.
■■ Complementarity: Provide information to support, not replace, the patient–provider relation-
ship.
■■ Privacy: Respect the privacy and confidentiality of personal data submitted to the site by the
visitor.
■■ Attribution: Cite sources and dates of medical information being provided.
■■ Justifiability: Provide balanced and objective claims with justifications.
■■ Transparency: Provide valid contact details.
■■ Financial disclosure: Always provide details of funding sources.
■■ Advertising: Clearly distinguish advertising from editorial content.

vary, but most provide the ability to log meals, exercise,
weight, and even water intake, at a minimum.
The more mainstream apps have internal databases that
feature the nutrition information of foods from popular res-
taurants in addition to many foods and ingredients avail-
able at your local grocery store. Most also feature the abil-
ity to turn a smartphone’s camera into a barcode scanner to
instantly import the nutrition information from the product
packaging. For dishes that may not be found in a database,
such as a family recipe, MyFitnessPal also provides the abil-
ity to enter the full recipe for a specific dish on its website
(not on the smartphone app). This feature compiles the nutri-
tion information of each ingredient and translates it into a
per-serving breakdown, which in turn becomes accessible
within the user’s database on their smartphone when log-
ging that meal.
Another app that offers a unique functionality, Fooducate,
provides “grades” for specific foods (range: A–F), including
details about why the product received that specific grade
and a list of healthier alternatives (if available). Additional
functionalities include somewhat-customizable meal plans
(e.g., person-specific calorie and macronutrient goals), social
elements (e.g., ability to comment on and applaud others’
entries), and general information on health and wellness
(e.g., blog posts, articles, fitness videos).
It is important to emphasize that the customized meal plan
should not replace a dietitian’s expertise. If a patient is under
a dietitian’s care, make sure the app’s recommendations are
consistent with the dietitian’s specified clinical recommen-
dations. This will prevent confusion and enhance collabora-
tion among the care team. In addition, to maximize patient
convenience, if a patient is using a specific device or app (e.g.,
fitness tracker, running app) to track other meaningful data,
check whether it interfaces with the calorie tracking and
meal planning app of interest.
A drawback of using calorie tracking and meal planning

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 UPDATES AND ADVANCES IN TECHNOLOGY FOR DIABETES SELF-MANAGEMENT
Figure 1. Strategies to activate patients using mobile applications based on level of engagement with health care
Source: Reprinted with permission from reference 9.
apps in diabetes is that they are not diabetes-specific, so
there is no ability to log additional data that may be impor-
tant for living well with diabetes, such as glucose readings
and insulin doses. Comprehensive diabetes-specific apps do
exist, however, and will be discussed later in this article.
Apps for logging glucose and other data
It is time to say goodbye to paper glucose logbooks with tiny
boxes that are difficult to see and practically impossible to
write in or read. Like calorie tracking apps, glucose monitor-
ing apps enable users to log their glucose readings as well
as other pertinent information (e.g., mealtimes, medications
administered, symptoms). Table 3 features some common
apps used for logging glucose readings. One benefit of log-
ging electronically is the app’s ability to quickly transform
the data into a visual or graphic representation of overall
glucose patterns. These graphic renderings of data (e.g., per-
centage of readings above or below a certain goal, averages
at certain times of day, trend lines) may be easier for a patient
to understand.
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The app can also use the individual data points to provide
the patient with an estimated A1C, although this practice can
have unintended consequences. For example, if the logged-in
glucose levels are all within the goal range, but the patient’s
glucose levels are substantially elevated at other times of the
day (i.e., not captured in the log), this may create a false sense
of security for the patient and subsequent confusion when an
actual lab test measure shows a discrepant value. Therefore,
it is important to educate patients about the limitations
(mainly related to sampling bias) of calculating an estimated
A1C from a glucose log.
Other features of these apps may include feedback on the
results logged, ability to upload photos of meals and track
additional data (i.e., weight, blood pressure), and social sup-
port. In addition, many of these types of apps sync with
other apps, wearable technologies (e.g., smart watches, fit-
ness trackers), glucometers, and even continuous glucose
monitors. This feature helps automate this data collection so
users don’t have to take the extra steps of logging the data
separately.
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Table 3. Characteristics of common mobile apps

App User ratings Price General functionality
(as of December 2018) (varies by app)

Calorie tracking and meal planning

MyFitnessPal Apple: 4.7 out of 5 (494 K) Basic version is free. ■■ Ability to log
(iTunes: #5 in Health/Fitness) Android: 4.6 out of 5 (1.96 M) Premium version: – Meals
$9.99/mo – Exercise
$49.99/y
– Weight
SparkPeople Calorie Tracker Apple: 4.6 out of 5 (8 K) Basic version is free. – Water intake
(Calorie counter and diet tracker) Android: 4.5 out of 5 (33 K) Premium version: ■■ Internal nutrition lists and calorie
$4.99/mo database
My Diet Diary Calorie Counter Apple: 4.6 out of 5 (911) Free ■■ Customized meal plans
Android: 4.1 out of 5 (19 K) ■■ Sync with other apps, devices,
and wearable technology
Fooducate Nutrition Tracker Apple: 4.7 out of 5 (29 K) Basic version is free. ■■ Social element
(iTunes: #110 in Health/Fitness) Android: 4.4 out of 5 (15 K) Premium version: ■■ Articles
$0.99–$7.99/mo ■■ Fitness videos
$29.99–$99.99/y

Logging glucose and other data

mySugr Apple: 4.7 out of 5 (1.9 K) Basic version is free. ■■ Log glucose levels, meals, meds,
Android: 4.6 out of 5 (23.8 K) Premium versions: BP, weight, A1C
$2.99–19.99/mo ■■ Report estimated A1C (eA1C)
$27.99–199.99/y ■■ Motivating challenges and
feedback
Sugar Sense Diabetes App Apple: 4.6 out of 5 (4.1 K) Free
■■ Sync with other apps, devices,
Android: 4.2 out of 5 (1.2K)
and wearable technology
Health2Sync Diabetes Care Apple: 4.7 out of 5 (69) Basic version is free. ■■ Upload photos of meals
Android: 4.6 out of 5 (6.4 K) Premium versions: ■■ Social support (designated
$2.99/mo partners)
$7.99/3 mo
$14.99/6 mo

Comprehensive diabetes apps

Glucose Buddy Apple: 4.8 out of 5 (10.8 K) Basic version is free. ■■ Log glucose levels, insulin,
Android: 4.4 out of 5 (14.4 K) Premium version: meals, weight, ketones, eA1C,
$14.99/mo cholesterol, BP
$59.99/y ■■ Provide insights into daily trends
■■ Track carb intake, steps, and
MyNetDiary Diabetes Tracker Apple: 4.5 out of 5 (576) $9.99
activity
Android: 4.6 out of 5 (564)
■■ Scan food labels for carbs
Diabetes:M Apple: 4.6 out of 5 (403) Basic version is free. ■■ Sync with other apps, devices,
Android: 4.6 out of 5 (17.7 K) Premium versions: and wearable technology
$4.99/mo ■■ Import/export and reminder/
$49.99/y target capabilities
Glucosio Apple: 3 out of 5 (4) Free ■■ Receive help/motivation from
Android: 4 out of 5 (290) friends/community
■■ Calculate insulin bolus doses
Glooko Apple: 3 out of 5 (64) Free ■■ Set reminders to take meds,
Android: 4 out of 5 (928) Optional subscription: $5/mo with exercise
payment for the first year upfront ■■ Share data (either anonymously
Diabetes Connect Apple: 4.5 out of 5 (50) Free or with caregivers)
Android: 4.5 out of 5 (4.3 K) Optional in-app purchases ■■ Search food or medication
databases
PredictBGL Insulin Dose Calc Apple: 3.7 out of 5 (15) Free
■■ Insulin dose calculator with
Android: 3.5 out of 5 (47) Optional upgrade
predictive analytics
■■ Predict blood glucose levels; has
alerts warning of predictive low
■■ Coaching and just-in-time
education
Sources: References 5 and 6.

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 UPDATES AND ADVANCES IN TECHNOLOGY FOR DIABETES SELF-MANAGEMENT
Apps for titrating basal insulin doses
Clinical inertia has been a significant and common barrier
to helping patients achieve their diabetes-related goals.14
This phenomenon is especially applicable to titrating basal
insulin doses after initiation,15,16 despite previous research
leading to the development of simple treat-to-target insulin
algorithms that patients with type 2 diabetes can use on their
own—without needing to schedule a clinic appointment or
call a health professional for advice (e.g., increase two units
every 3 days until the mean fasting glucose is 100 mg/dL).17,18
Mobile apps that help patients feel more comfortable about
increasing their basal insulin doses have sought to fill this
gap. Two examples are My Dose Coach and Insulia, which
work very similarly. These apps integrate information a
patient enters about their glucose patterns and apply an algo-
rithm to recommend dose modifications. In addition to pro-
viding the patient a number, both apps explain why a spe-
cific dose was chosen. It is important to emphasize that these
apps are for basal insulin titrations only, as bolus insulin
doses are much more difficult to titrate based off a broadly
generalizable algorithm.
Apps for diabetes education and
empowerment
Recognizing that many people with diabetes have limited
time to pursue formal education in diabetes self-manage-
ment, developers have also created apps that help bridge this
gap. One such app, KingFit, features quick and convenient
videos, generally 10 minutes or less, on a variety of diabetes-
related topics. The app’s developers state on their website
that the educational information is provided by a certified
diabetes educator, which is another positive attribute.
Another app in this area is WellDoc BlueStar, an FDA-
cleared Class II medical device.19 This app provides a vari-
ety of features to enhance the patient experience, including
personalized messages analyzing glucose patterns based on
patient-derived data and computerized algorithms, diabetes
education videos, tailored coaching messages, and weekly
challenges to engage and motivate users. The app also has a
prescription version (BlueStar Rx) that has all the same func-
tionalities as the nonprescription version, in addition to an
insulin dose calculator that aids in calculating the dose of
insulin needed for a given amount of carbohydrates and/or
current blood glucose value.20
In one randomized controlled trial, this app helped
patients decrease A1C approximately 1% beyond that of the
control group within 3 months (−2.03% vs. −0.68%, P < 0.02).
In the intervention group, an additional 60% of patients had
their medications titrated or changed by their health profes-
sional, compared with the standard of care group, over the
same time period (84% vs. 23%, P = 0.002).21 A sustained A1C
reduction of a similar magnitude was seen over 1 year in a
slightly longer study.22
Comprehensive diabetes apps
This last app-related section considers apps that address
multiple facets of living with diabetes, such as meal plan-
ning, exercise habits, medication use, and blood glucose
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monitoring. These apps combine multiple aspects of the
products previously discussed (e.g., logging glucose lev-
els, meals, insulin doses; scanning food labels; socializa-
tion aspects; syncing with other apps, devices, and wear-
able technologies) as well as provide additional features for
people living with diabetes. Depending on the amount and
quality of data compiled, the apps can provide insights into
a patient’s daily trends, including use of predictive analytics
to inform treatment considerations (e.g., calculating a meal-
time insulin dose, warning of a predictive low, coaching/
just-in-time education). These apps can also facilitate sharing
of various data with family members, social networks, and
health professionals.
One particular app, mDiabetes, was evaluated in a
24-week, multicenter, randomized controlled trial in a South
Korean adult population with type 2 diabetes.23 In this study,
patients were randomized to use either the app (n = 90) or
a paper logbook (n = 82). The primary outcome was change
in A1C at 24 weeks. Use of the app resulted in an additional
0.35% reduction in A1C over the paper logbook group (0.14–
0.55%, P = 0.001), as well as a larger percentage of patients
having an A1C below 7% without hypoglycemia (odds ratio
1.82 [95% CI 1.03–3.21] P = 0.024).
Modernizing diabetes management and
patient care
As people with diabetes can attest, living with the disease
is not easy. Granted, advances in diabetes care over the last
30 years have dramatically improved patients’ ability to
manage their diabetes. Development of recombinant insu-
lins in the 1980s resulted in fewer insulin hypersensitivity
reactions, and development of insulin analogs in the 1990s
increased the likelihood of people safely achieving tighter
glucose goals. Portable glucometer technology has evolved
continually throughout the 21st century, making them more
accessible and accurate than ever before.24,25 These evolutions
in technology have substantially decreased production costs,
which over the years has generally driven down the costs
to patients for obtaining these tools and devices. However,
decreased production costs do not always translate directly
into affordability for patients.26–28
Despite all these breakthroughs and developments, there
are still many challenges and limitations in helping people
with diabetes achieve their health goals. Barriers to medica-
tion adherence will always be a problem, especially those
related to remembering when to take a medication and deter-
mining if a patient actually took their medication. It is easy
to look at a pillbox to see if the tablets that were supposed to
be taken at a specific time are still in that cube. However, it
is not possible to apply the same principle for an injectable
medication, and the result may be a patient repeating one or
more doses.
Another challenge is the accuracy of the available data.
Although health data are abundant in today’s era of por-
table glucometers and wearable technologies, the infor-
mation derived from these sources is still limited by fac-
tors that affect their accuracy (e.g., approval standards for
glucometers, limitations with A1C testing).29 Furthermore,
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 CPE UPDATES AND ADVANCES IN TECHNOLOGY FOR DIABETES SELF-MANAGEMENT
self-monitoring of blood glucose at specific time points does
not capture out-of-range values in between these checks (an
issue affecting all individuals with diabetes, but especially
those with type 1 diabetes).
Last, developments in technology do not always consider
the patient’s experience (i.e., whether these new devices and
tools are user-friendly and convenient) or accessibility to the
average patient (e.g., affordability, coverage by third-party
payers). In light of these challenges and limitations, the next
few sections of this article highlight some recent develop-
ments in technology that can help patients and clinicians
overcome these barriers to managing their diabetes.
Glucometer considerations
The accuracy of commercially available glucometers is inher-
ently at a crossroad between the accuracy of the results the
glucometer can provide and the cost associated with ensur-
ing that level of accuracy. These two variables are directly
correlated, whereby increasing one undoubtedly increases
the other. Realizing that there will likely never be a “perfect”
meter, the Diabetes Technology Society (DTS) established
the Blood Glucose Monitor Surveillance (BGMS) program
to determine the current level of accuracy of several meters
available on pharmacy shelves.30
The DTS study evaluated 18 different meters (constituting
90% of the commercially available systems used between
2013 and 2015) purchased directly off the shelves of various
consumer outlets. Study participants (n = 1,035) were adults
with type 1 diabetes, type 2 diabetes, prediabetes, or no dia-
betes. Three different clinical sites were used in a way that
ensured all 18 blood glucose meters were tested at all three
sites. Each participant was tested on six different meters in
addition to having a capillary glucose drawn (i.e., control
value). The study implemented a triple-blinded methodology,
in which the investigators, laboratory staff, and statisticians
did not have enough information to break the code until after
all the results were calculated and finalized. The investiga-
tors compared each glucometer with standards derived from
the International Organization for Standardization and FDA
2016 guidance.31,32 Glucose levels above 100 mg/dL needed to
be within 15% of a reference plasma value, whereas glucose
levels below 100 mg/dL needed to be within 15 mg/dL of a
reference plasma value.
To pass the test, at least 91% of the samples within each
study had to be within the specified standard range. A seal
of approval was awarded to any glucometer that passed the
studies performed at all three study sites. Table 4 gives an
overview of the main results. Additional details are avail-
able at the DTS website (www.diabetestechnology.org/
surveillance.shtml), including the overall variation in each
meter’s data, percentage of values within specified error lim-
its, and other information.33
It is important to note that meters that did not receive a DTS
seal of approval are not inherently “bad” meters. However,
the study represents an important step for increasing trans-
parency in glucometer accuracy. Many people do not know
that meters available for purchase today are only required to
meet the accuracy standards in place when they entered the
50 PharmacyToday • MAY 2019
CPE_05_19_JD.indd 50
market (i.e., upon initial FDA approval). The manufacturers
are not required to update their technology to meet newer
standards that take effect after their meter is approved.32
The information derived from these types of studies can
be used to inform decisions about diabetes care, includ-
ing which glucometer(s) to recommend to a patient, which
glucometer(s) a health plan should cover, and how to modify
a patient’s medication regimen on the basis of self-monitored
blood glucose data derived from a glucometer.
Although the accuracy of the results derived from a glu-
cometer is very important, practitioners must consider other
factors when determining the ideal glucometer for a patient.
Today’s meters have many more functions beyond simply
providing a glucose value. These include providing feed-
back, reminders, and alerts to the patient (and potentially to
caregivers/family members); integrating Bluetooth and USB
technology to communicate with mobile apps, and generat-
ing reports for self-evaluation and/or dissemination to the
patient’s health care provider. These functions are only ben-
eficial for patients who use them, so a discussion about the
basic functionalities a patient looks for in their meter and
whether they would actually use them is critical for evalu-
ating whether a glucometer with more advanced functions
would be helpful.
For patients with retinopathy or other forms of visual
impairment, other factors to consider include screen size,
text display size, and backlighting. Patients with diminished
manual dexterity may have difficulty with certain glucom-
eters that have small parts, vials that need to be screwed on
and off (vs. flip-tops), and complex lancet devices. Last, peo-
ple with type 1 diabetes who may need to test periodically for
ketones may benefit from a glucometer that can test for both
substances (e.g., Precision Xtra, NovaPlus Max), although test
strips designed specifically for measuring ketones will also
need to be purchased separately.34
Continuous glucose monitoring (CGM)
systems
CGM systems, a technology that is increasingly available,
addresses the challenge of not knowing specific glucose
patterns between individual glucose checks. These systems
come with three components: a wearable sensor, a transmit-
ter, and a receiver. Once the sensor is placed on the patient
and calibrated (if applicable), the CGM system automatically
and repeatedly checks the glucose levels of the interstitial
fluid surrounding the sensor at regular time intervals (usu-
ally 5–15 min).35 Depending on the device, this information
is transmitted to a receiver—often the patient’s glucometer,
insulin pump, or smartphone device—at regular intervals
(i.e., real-time CGM) or when requested by the patient (i.e.,
flash CGM).
This technology is especially beneficial for people living
with type 1 diabetes, and for anybody with diabetes of either
type who is 1) taking multiple daily injections of insulin and
has a mismatch between their A1C values and glucometer
readings, 2) at high risk for hypoglycemia (including hypo-
glycemia unawareness), and/or 3) experiencing clinically
significant glycemic variability.35–37 The first CGM systems
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 UPDATES AND ADVANCES IN TECHNOLOGY FOR DIABETES SELF-MANAGEMENT CPE

Table 4. Results of the 2018 Diabetes Technology Society (DTS) Blood Glucose Monitor System (BGMS)
Surveillance Program
Brand BGMS Test strip Study sites Compliant (N) Valid trials Compliant (%)
passed

Meters receiving a DTS seal of approval

Bayer Contour Next Contour Next 3 311 312 99.7%
Roche Accu-Chek Accu-Chek 3 306 311 98.4%
Aviva Plus Aviva Plus
Arkray Walmart ReliOn ReliOn 3 307 317 96.8%
Confirm/Micro Confirm/Micro
Agamatrix CVS Advanced CVS Advanced 3 307 318 96.5%
Abbott FreeStyle Lite FreeStyle Lite 3 298 312 95.5%
Roche Accu-Chek Accu-Chek 3 305 320 95.3%
SmartView SmartView
Meters NOT receiving a DTS seal of approval
Arkray Walmart ReliOn ReliOn Prime 2 288 312 92.3%
Prime
LifeScan OneTouch Verio OneTouch Verio 2 294 319 92.2%
Prodigy Prodigy Auto Prodigy No 2 282 312 90.4%
Code Coding
LifeScan OneTouch Ultra2 OneTouch Ultra 2 280 311 90.0%
Abbott Walmart ReliOn ReliOn Ultima 2 285 319 89.3%
Ultima
Bayer Contour Classic Contour 1 284 320 88.8%
Omnis Health Embrace Embrace No 1 282 319 88.4%
Code
HDI/Nipro TrueResult TrueResult 1 279 318 87.7%
HDI/Nipro TrueTrack TrueTrack 0 167 205 a
81.5%
BioSense SolusV2 Solus 0 244 320 76.2%
Medical
Diabetic Supply Advocate Advocate 0 241 319 75.5%
of Suncoast Redi-Code+
Philosys, Inc. Gmate Smart Gmate 0 226 320 70.6%
No study 3 data because of a test strip recall occurring during the time of this study.
a

Source: Adapted with permission from Diabetes Technology Society (DTS) Blood Glucose Monitor System Surveillance (BGMS) Program website.

approved by FDA were professional, or “blinded,” CGM sys-
tems, in which the sensor regularly recorded the patient’s
glucose levels, but the data could not be obtained until the
sensor was brought back to the clinic to be uploaded and ana-
lyzed by a health professional retrospectively. Over time, the
technology has evolved to include personal, or “unblinded,”
CGM devices that provide information about glucose trends
directly to the patient.35
Personal CGM systems can be further subdivided into
real-time and flash CGM systems. Real-time systems actively
report data at regular intervals independent of the patient’s
actions, while flash systems require the patient to request
the data at specific intervals to evaluate the information ret-
rospectively. Although both systems have inherent benefits
and drawbacks, one clear advantage of real-time systems
www.pharmacist.com
over flash CGM technology is the ability to send alerts to the
patient and caregiver(s) regarding predicted dangerous glu-
cose levels (i.e., hyperglycemia, hypoglycemia) if the current
trend is not corrected. Table 5 provides an overview of the
various FDA-approved personal CGM systems.38–42
Glucose levels in the interstitial fluid often lag 5 to 15
minutes behind blood glucose levels, especially when
blood glucose levels are changing rapidly. Because the
sensor is measuring glucose in the interstitial fluid rather
than capillary glucose, complex calibration algorithms
embedded within CGM systems translate the data derived
into a useable blood glucose value that can be reported
on the patient’s receiver and acted upon.35 To increase the
level of accuracy, some systems may require calibration
with a capillary blood glucose measurement (check using
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 CPE UPDATES AND ADVANCES IN TECHNOLOGY FOR DIABETES SELF-MANAGEMENT

Table 5. Comparisons of personal continuous glucose monitor (CGM) systems

Manufacturer FDA-approved Warm-up time Minimum Sensor Real-time vs. FDA approved
and device age calibration duration flash for treatment
model frequency decision
Dexcom G5 ≥2 y 2h Every 12 h 7d Real-time Yesa
Mobile
Dexcom G6 ≥2 y 2h Not required 10 d Real-time Yesa
Medtronic 14–75 y 2h Every 12 h 7d Real-time No
Guardian
Connect
Abbott ≥18 y 1h N/A 14 d Flash Yesa
Free-style
Libre 14-day
Senseonics ≥18 y 24 h Twice daily 90 d Real-time No
Eversense
(implant)
a
Assumes symptoms are consistent with the reading and there are no concurrent interactions.
Source: References 38 through 42.

patient’s glucometer) periodically (e.g., every 12 h).
CGM technology comes with its own set of terminology.
One important term to be aware of is warm-up time: the time
it takes for the sensor to calibrate once it is placed, before it
can start to accurately report data. This time period generally
ranges between 1 and 2 hours (Eversense implant requires
24 h). During this time, the patient must use a glucometer to
check blood glucose. This time is an essential component for
ensuring the accuracy of the sensor by allowing it to calibrate
after it is placed.
Another commonly used term with CGM systems is trend
arrows. These arrows are displayed next to the glucose level
on the patient’s receiver and are designed to help the patient
put the number into context. For example, if the patient sees
one or two upward arrows next to the current glucose read-
ing, they will know what their current glucose level is, as well
as be notified that their glucose level is rapidly increasing at
a rate greater than 2 mg/dL/min.43,44 This additional informa-
tion is especially helpful for informing treatment decisions,
particularly when compared with a glucometer, which can
only give the current glucose reading without any additional
context about the trends.
Because the cost of this technology has decreased substan-
tially over the years, access to these devices is becoming much
more mainstream, with some being sold right out of the local
community pharmacy. Since there are multiple limitations in
using a 3-month average (i.e., for A1C) to evaluate a patient’s
overall approach to diabetes management, this technology
can provide an additional objective measure: time in range.
Think of how much more useful it would be for a person
to know that their glucose levels in the last 3 months were
within the goal range approximately 80% of the time rather
than that their 3-month average (A1C) suggested they were
above goal at some point in the past 3 months. However, the
benefit on patient outcomes must be robust enough to justify
the cost, as this technology may still be more costly than tra-
ditional blood glucose monitoring with a glucometer.
In evaluating the effect of these systems on patient out-
comes, one review concluded that use of CGM in type 1 dia-
betes results in approximately 0.5% improvement in A1C and
a mild decrease in hypoglycemia.45 Another review evaluated
the literature surrounding use in several patient populations,
including patients at high risk for hypoglycemia (type 1 and
type 2 diabetes), hospitalized patients with type 2 diabetes,
and pregnant women with diabetes. These analyses generally
favored CGM use in these patient populations.46
Although these data are positive, it is important to remem-
ber that these systems are solely for monitoring and still
require the patient to act on the health information provided.
A clinical benefit will not be seen unless the patient is appro-
priately engaged in their own care and has the health literacy
and numeracy skills to interpret and act on the information.
Therefore, to get the most benefit from these systems, health
professionals will need to select the ideal patient candidates
matching the characteristics previously described, train them
on how to use the device and interpret the data derived from
it, and follow up with them periodically.
Insulin pens and injectable devices
Disposable pens may not seem like a technological advance-
ment by today’s standards, but it is safe to say they have
significantly improved diabetes care. Their convenience
and relative ease of use have increased their availability to
patients (a welcome change from vials and syringes), which
in turn has been shown to improve adherence to therapy.47
These disposable pen devices were subsequently adapted for
use in administering noninsulin injectable medications (e.g.,
glucagon-like peptide-1 agonists), as well as a safer way to
administer concentrated insulin by eliminating the need to
convert a U-100 syringe into its equivalent units.

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 UPDATES AND ADVANCES IN TECHNOLOGY FOR DIABETES SELF-MANAGEMENT
Despite these improvements in technology, patient safety
concerns abound with the use of disposable pens. Concerns
center on keeping pen needles attached to the pen and/
or reusing pen needles, not removing the inner cap prior
to injection, dialing the pen back down instead of pushing
the plunger in to administer the dose, and using a syringe
to withdraw the insulin out of the pen, among other behav-
iors.48 Therefore, it is critical that pharmacists employ the
teach-back method to educate patients on proper use of these
devices and periodically re-evaluate to determine if patients
are using good administration technique.
A further complication is that whereas insulin pens used
to be fairly standardized (i.e., 100 units/mL, 3 mL/pen, gener-
ally five pens/box, and a 28-day beyond-use dating at room
temperature), nowadays there are many different varia-
tions in product formulations and beyond-use dating. These
options are meant to accommodate the highly variable insu-
lin needs of people living with diabetes, but they increase the
potential for medication errors and prescription discrepan-
cies.49 Pharmacists should be aware of the similarities and
differences among the various pen devices so they can field
questions that patients and other health professionals will
undoubtedly have.
Needle technology has also dramatically improved, from
the original 12.7-mm needle length (suitable for an I.M. injec-
tion), to a pen needle as short as 4 mm and syringe needle of 6
mm. Because of the risk of I.M. injections and concerns about
highly variable insulin absorption and kinetics, international
consensus recommendations on insulin delivery now advise
using the 4-mm needle for all adults and children. If 4-mm
needles are not readily available, the advice is to at least avoid
needles longer than 8 mm for adults and 6 mm for children.50
Although the new pen and needle technologies are helpful
for improving adherence, they do not necessarily help people
remember if they actually administered their insulin dose. To
address this problem, Novo Nordisk developed the NovoPen
Echo, a reusable pen device that is compatible with insulin
aspart cartridges. This pen is capable of administering half-
unit doses, with a maximum of 30 units per dose. It also has
a dose memory feature on the pen cap that displays how
much insulin was injected during the most recent adminis-
tration and how many hours have passed since that dose was
administered.51
Another technological innovation to help remember
whether a dose was administered (and how much) has been
developed by Diabnext. The device, called Clipsulin C3, sim-
ply clips on to most FDA-approved insulin pens that dial in
1-unit increments. It subsequently transmits the informa-
tion related to the dose of insulin being administered to the
patient’s smartphone via Bluetooth technology. The informa-
tion is then automatically documented in a virtual logbook
that can be transmitted to others (e.g., caregiver, health care
provider) if desired.52
One final product is InPen, a reusable pen that not only
documents how much and when the last insulin dose was
administered but can also assist with calculating bolus doses
using a Bluetooth-paired smartphone app. The app can be
used to document glucose readings (either manually or
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CPE_05_19_JD.indd 53
CPE
automatically via Bluetooth and AppleHealth from a synced
glucometer or CGM device), factor in active insulin time, and
document carbohydrate intake. It offers many of the same
functionalities as an insulin pump without the high upfront
cost and requirement of having a device permanently con-
nected to the person using it. InPen is approved for use in
individuals aged 12 years and older taking multiple daily
S.C. insulin injections (i.e., not on an insulin pump). It is com-
patible with insulin lispro and insulin aspart cartridges and
administers up to a maximum of 30 units per dose in 0.5-unit
increments. Available by prescription only, the InPen requires
a health care provider to input patient-specific parameters
(e.g., glucose targets, carb-to-insulin ratio, correction factor)
into the mobile app.53
Insulin pumps and the pursuit of the
artificial pancreas
This article would be incomplete if it did not discuss recent
updates in insulin pump technology. As these devices are
often sold and managed by the pump companies themselves
and are limited to a very niche patient population, this will
not be an extensive review. However, it is important to be
aware of this technology should you come across a patient
who may be an ideal candidate or is asking about obtaining
an insulin pump.
The basic premise behind an insulin pump is the ability to
supply a continuous infusion of low-dose rapid- or short-act-
ing insulin subcutaneously to satisfy the patient’s basal insu-
lin needs. In addition, an insulin pump can provide larger
bolus doses to manage the body’s mealtime insulin needs.
The pump contains a reservoir that can store a range of 200 to
300 units of insulin. The pump is connected to the user’s body
via an infusion set that must be changed approximately every
3 days. The pump can also factor in additional information it
receives from various sources to provide a situation-specific
recommendation to the patient when determining an appro-
priate mealtime bolus dose. This information includes current
blood glucose levels, blood glucose trends (if the patient has
CGM), anticipated amount of carbohydrate intake, patient-
specific carb-to-insulin ratio and correction factor, glucose
target ranges, and active insulin time. A thorough overview
of these terms specific to insulin pumps is available online
from Medtronic.54
Currently, three major companies manufacture insu-
lin pumps: Insulet Corporation (Omnipod), MedTronic
(MiniMed), and Tandem (T:slim). In addition to these more
traditional pumps is an emerging technology: the dispos-
able insulin patch pump (e.g., V-Go), which provides a fixed
basal rate of insulin as well as customizable mealtime doses
in fixed-unit increments (e.g., up to 36 units for the V-Go in
2-unit increments). These types of insulin pumps adhere
directly to a user’s skin and therefore require no tubing. The
fixed parameters associated with these patch pumps make
them difficult to meet every patient’s needs, but they offer a
substantially lower-cost option to the right patient.55
One misconception many patients have about insulin
pumps is that the pump can “do all the work.” However, as
you can see from the list above, the pump is merely a tool
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 CPE UPDATES AND ADVANCES IN TECHNOLOGY FOR DIABETES SELF-MANAGEMENT
to help inform the patient’s clinical decision making. The
patient must still count carbohydrates, factor in the impact of
other macronutrients (fat and protein) and activity level, and
understand the patient-specific symptoms they may be expe-
riencing. If interested in learning more about the nuances of
each individual insulin pump, see the comprehensive review
published annually by ADA.55
Fortunately, ongoing research is helping to further decrease
the impediments that remain with use of insulin pump tech-
nology. The initial evolutions in this process included the
integration of CGM technology, which paved the way for the
pump to automatically initiate a low-glucose-threshold sus-
pend. This feature automatically stops the flow of insulin for
a set time period (usually up to 2 h) once a patient’s glucose
enters (or is trending toward) the patient-specific hypoglyce-
mia threshold, thereby decreasing the risk of serious hypo-
glycemic events, especially nocturnal hypoglycemia.56
From here, technology has advanced further with approval
of the Medtronic 670G system, the first hybrid closed-loop
system for people with type 1 diabetes. The pump is paired
with the Guardian CGM Sensor and is capable of a function
called “auto mode.” In auto mode, a built-in algorithm adjusts
the basal delivery of insulin every 5 minutes based on the
CGM data received and the predetermined target glucose
level. Auto mode is also able to suspend or decrease insulin
delivery to prevent an expected hypoglycemic episode. One
trial demonstrated an approximate 0.5% reduction in A1C, a
time-in-range increase of about 5%, and an approximate 40%
decrease in hypoglycemic events.57
Despite these benefits, this system is still not a panacea
for people with type 1 diabetes. The user is still required to
count carbohydrates and enter this data into the pump, know
when and how to override the system if warranted, regularly
change and rotate sites, and troubleshoot issues that may
arise (e.g., line occlusions, extreme hyperglycemia, discrep-
ancies between sensor and calibration value).58 Additional
research is ongoing to achieve an ultimate goal in this line of
study: a bionic pancreas that can autonomously administer
insulin or glucagon depending on the patient’s specific needs
and that does not require carbohydrate counting.59
Staying up to date
As mobile devices and apps become even more prevalent,
they will undoubtedly play an increasingly significant
role in helping patients live successfully with diabetes
and other chronic conditions. Therefore, it is important
to stay up to date on advances in this area. This can be
quite difficult to do. One strategy for staying up to date
is to ask patients what apps they are seeing, using, or
hearing about. This will give you an idea of which ones
might be more specific to your patient population and
therefore more beneficial to look into. Another strategy
is to check various sources online, including the app clear-
inghouses mentioned earlier (e.g., DANA at www.dan-
aapps.org), diabetes-specific blogs and websites (e.g., http://
www.diatribe.org), and general websites covering broader
health-related topics (e.g., http://www.everydayhealth.com/,
http://www.healthline.com/).
54 PharmacyToday • MAY 2019
CPE_05_19_NEW.indd 54
In addition to mobile devices and apps, the technologic
innovations related to medication administration and glu-
cose monitoring are also dramatically evolving. As the pro-
duction costs for this technology decrease, many of these
products will likely be sold at the local community phar-
macy. Therefore, pharmacists are in a critical position to
educate patients on these devices, periodically evaluate how
patients are doing with them, and collaborate with the rest of
the patient’s care team to help patients manage their diabetes
using the technology available, both now and in the future.
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endosociety/files/advocacy-and-outreach/position-statements/
all/accesstoaffordableadequatediabetessupplies.pdf?la=en. Ac-
cessed February 25, 2019.
29. American Diabetes Association. 6. Glycemic targets: Standards
of Medical Cere in Diabetes—2019. Diabetes Care. 2019;42(Sup-
pl 1):S61–S70.
30. Klonoff DC, Parkes JL, Kovatchev BP, et al. Investigation of the
accuracy of 18 marketed blood glucose monitors. Diabetes Care.
2018;41(8):1681–8.
31. International Organization for Standardization (ISO). ISO
15197:2013: in-vitro diagnostic test systems – requirements for
blood-glucose monitoring systems for self-testing in managing
diabetes mellitus. https://www.iso.org/standard/54976.html. Ac-
cessed February 25, 2019.
32. United States Food & Drug Administration. Self-monitoring blood
glucose test systems for over-the-counter use: guidance for in-
dustry and Food and Drug Administration staff. https://www.fda.
gov/downloads/ucm380327.pdf. Accessed February 25, 2019.
33. Diabetes Technology Society (DTS). Blood Glucose Monitor-
ing System (BGMS) Surveillance Program. https://www.diabe-
testechnology.org/surveillance.shtml. Accessed February 25,
2019.
34. Dolson L. How to test your blood with a home ketone meter.
https://www.verywellhealth.com/how-to-test-your-blood-for-ke-
tones-2241625. Accessed February 25, 2019.
35. Klonoff DC, Ahn D, Drincic A. Continuous glucose monitoring:
a review of the technology and clinical use. Diabetes Res Clin
Pract. 2017;133:178–92.
36. Sugawa T, Murakami T, Yabe D, et al. Hypoglycemia unaware-
ness in insulinoma revealed with flash glucose monitoring sys-
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tems. Intern Med. 2018;57(23):3407–12.
37. Lamounier RN, Geloneze B, Leite SO, et al. Hypoglycemia inci-
dence and awareness among insulin-treated patients with diabe-
tes: the HAT study in Brazil. Diabetol Metab Syndr. 2018;10:83.
38. Dexcom. The Dexcom G5 Mobile CGM System. https://www.dex-
com.com/g5-mobile-cgm. Accessed March 25, 2019.
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42. Senseonics. Eversense. https://www.eversensediabetes.com/
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43. Kudva YC, Ahmann AJ, Bergenstal RM, et al. Approach to using
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proach to using trend arrows on the Dexcom G5 CGM system to
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45. Liebl A, Henrichs HR, Heinemann L, et al. Continuous glucose
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46. Rodbard D. Continuous glucose monitoring: a review of recent
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47. Meece J. Effect of insulin pen devices on the management of dia-
betes mellitus. Am J Health Syst Pharm. 2008;65(11):1076–82.
48. Truong TH, Nguyen TT, Armor BL, et al. Errors in the adminis-
tration technique of insulin pen devices: a result of insufficient
education. Diabetes Ther. 2017;8(2):221–6.
49. Bzowyckyj AS. Embracing the insulin revolution in the ambulatory
care setting. Diabetes Spectr. 2016;29(3):140–5.
50. Frid AH, Kreugel G, Grassi G, et al. New insulin delivery recom-
mendations. Mayo Clin Proc. 2016;91(9):1231–55.
51. Novo Nordisk. NovoPen Echo User Guide. https://www.novonord-
isk.com/content/dam/Denmark/HQ/Patients/DiabetesCare/Pen-
sNeedlesInjection/novoEcho/NovoPen-Echo-IFU.pdf. Accessed
February 25, 2019.
52. Diabnext. Clipsulin C3 website. https://www.diabnext.com/insu-
lin-clipsulin/. Accessed February 25, 2019.
53. Companion Medical. InPen website. https://www.companionmed-
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54. Medtronic. The Basics of Insulin Pump Therapy. https://www.
medtronicdiabetes.com/sites/default/files/library/download-library/
workbooks/BasicsofInsulinPumpTherapy.pdf. Accessed March 27,
2019.
55. American Diabetes Association. Diabetes Forecast Consumer
Guide 2019. http://main.diabetes.org/dforg/pdfs/2019/2019-cg-
insulin-pumps.pdf. Accessed March 27, 2019.
56. Tauschmann M, Hovorka R. Insulin delivery and nocturnal glu-
cose control in children and adolescents with type 1 diabetes.
Expert Opin Drug Deliv. 2017;14(12):1367–77.
57. Garg SK, Weinzimer SA, Tamborlane WV, et al. Glucose out-
comes with the in-home use of a hybrid closed-loop insulin de-
livery system in adolescents and adults with type 1 diabetes.
Diabetes Technol Ther. 2017;19(3):155–63.
58. Scheiner G. 670G and me: Insights and incites on Medtronic’s lat-
est system. http://integrateddiabetes.com/670g-and-me-insights-
and-incites-on-medtronics-latest-system/. Accessed February
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59. El-Khatib FH, Balliro C, Hillard MA, et al. Home use of a bihor-
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 CPE UPDATES AND ADVANCES IN TECHNOLOGY FOR DIABETES SELF-MANAGEMENT

CPE assessment
This assessment must be taken online; please see “CPE information” in the sidebar below for further instructions. The
online system will present these questions in random order to help reinforce the learning opportunity. There is only one
correct answer to each question.

1. A patient with type 2 diabetes (on oral medications 4. Which of the following functionalities is only avail-
only) is looking for an app that can help her track her able in the prescription version of the WellDoc Blue-
calories and exercise. She would like something that Star app?
is easy to use and free, and she doesn’t want or need a. Diabetes education videos
extra features. Which app would be most appropriate b. Insulin dose calculator
to discuss with her? c. Tailored coaching messages
a. MyFitnessPal d. Weekly challenges to engage users
b. KingFit
c. MyNetDiary Diabetes Tracker 5. Scientific evidence suggests that use of commercially
d. Insulia available apps
a. May improve some short-term diabetes-related out-
2. A patient with type 2 diabetes is started on insulin comes such as A1C
glargine U-300 at 10 units once daily. Which of the fol- b. Are only effective when combined with frequent
lowing apps can help him titrate his basal insulin to a support from a health care provider
safe and effective dose? c. Improve quality of life but do not improve other
a. Fooducate diabetes-related outcomes
b. Glooko d. Improve A1C in patients with type 2 diabetes but not
c. Insulia in patients with type 1 diabetes
d. Glucose Buddy
6. Which one of the following patients can benefit most
3. A patient with type 1 diabetes is interested in finding from using a mobile app to help manage their
a free app that can help him log several diabetes-re- diabetes?
lated data points (i.e., glucose, insulin doses, carbohy- a. A 64-year-old woman with type 1 diabetes who does
drate intake) and also help him decide the appropriate not own a smartphone
dose to administer with meals based on his glucose b. A 43-year-old man who is in denial about his type 2
patterns. Which of the following apps is most appro- diabetes diagnosis
priate for this patient? c. A 37-year-old woman with type 2 diabetes who is
a. mySugr legally blind in both eyes
b. Health2Sync d. A 52-year-old man with type 2 diabetes who is into
c. MyNetDiary Diabetes Tracker wearable technology
d. PredictBGL Insulin Dose Calc

CPE information
To obtain the 2.0 contact hours (0.2 CEUs) of
CPE credit for this activity, you must complete
the online assessment with a passing grade
of 70% or better, complete the evaluation, and
CLAIM CREDIT at http://apha.us/CPE0519.
You will have two opportunities to successfully
complete the assessment, and the questions
will be in randomized order. The current policy
of the APhA Education Department is not to
release the correct answers to any of our CPE
tests. This policy is intended to maintain the
integrity of the CPE activity. Learners who suc-
cessfully complete this activity by the expiration
date can receive CPE credit. Please visit CPE
Monitor for your statement of credit/transcript.
To claim credit Assistance is available Monday through Friday
1. Go to http://apha.us/CPE0519. from 8:30 am to 5:00 pm ET at APhA InfoCenter
2. Log in to your APhA account or register as a at 800-237-APhA (2742) or by e-mailing info-
new user. center@aphanet.org.
3. Select “Enroll Now” or “Add to Cart” (click
“View Cart” and “Check Out”).
4. Complete the assessment and evaluation.
5. Click “Claim Credit.” You will need to provide
your NABP e-profile ID number to obtain and
print your statement of credit.

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 UPDATES AND ADVANCES IN TECHNOLOGY FOR DIABETES SELF-MANAGEMENT
7. Which of the following accurately describes the best
approach to enhancing diabetes care with use of
apps?
a. Advise patients to avoid using apps that are not ap-
proved by FDA.
b. Identify other apps that a patient may be using to
sync up with the app.
c. Recommend to patients three to four apps that are
your personal favorites.
d. Refer patients to apps that rely solely on automated
feedback from the app.
8. A patient heard from a friend about a new app that
seems too good to be true. She is thinking about pur-
chasing it but is not sure if it is worth the high upfront
cost. Which of the following sources of information
would be the most helpful for her decision?
a. iTunes App Store User Ratings
b. FDA Medical Device Database
c. iMedicalApps Clearinghouse
d. National Library of Medicine Mobile Apps
9. Which of the following characteristics describes one
of the core HONcode principles of the Health On the
Net Foundation?
a. Attribution
b. User ratings
c. Functionality
d. Update frequency
10. Which of the following is important to consider when
evaluating an app’s online user ratings?
a. Read only those reviews from people who rated the
app poorly.
b. Read only those reviews from people who rated the
app highly.
c. Read a mix of reviews from people who rated it
highly and poorly.
d. Do not read the reviews; just focus on the numerical
rating to save time.
11. Which of the following glucometers received a seal
of approval based on the results of the 2018 Diabetes
Technology Society (DTS) Blood Glucose Monitor
System (BGMS) Surveillance Program?
a. TrueTrack
b. One Touch Ultra2
c. Prodigy AutoCode
d. Accu-Chek Aviva Plus
12. Which of the following correctly describes the
standard used during the DTS BGMS Surveillance
Program?
a. Glucometer value is within 5% of a reference plasma
value for values below 150 mg/dL.
b. Glucometer value is within 15% of a reference
plasma value for all values above 100 mg/dL.
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CPE_05_19_NEW.indd 57
CPE
c. Glucometer value is within 10 mg/dL of a reference
plasma value for values below 70 mg/dL.
d. Glucometer value is within 25 mg/dL of a reference
plasma value for values above 200 mg/dL.
13. Which of the following is correct about the accuracy of
continuous glucose monitoring (CGM) devices?
a. Abbott Freestyle Libre requires calibration twice daily.
b. Senseonics Eversense requires a 2-hour warm-up
before reporting data.
c. Medtronic Guardian Connect requires calibration
every 12 hours.
d. Dexcom G6 sensors can be worn for only 7 days
before needing replacement.
14. Which of the following CGM systems is considered a
flash CGM device?
a. Dexcom G6
b. Guardian Connect
c. Eversense
d. FreeStyle Libre
15. A patient at your pharmacy has a daughter with type 1
diabetes. She heard on the news that an artificial pan-
creas was recently approved by FDA. She is excited
about the idea but has some questions. Which of the
following most correctly describes what is currently
available for patients as an artificial pancreas?
a. A fully automated insulin pump/CGM system that
allows the patient to be completely hands-off
b. A hybrid, closed-loop insulin pump/CGM system
that automatically adjusts basal insulin delivery
based on CGM data
c. A partially automated insulin pump/CGM system
that alerts the patient if CGM data indicate the pa-
tient is hypoglycemic
d. A combination system that includes an insulin
pump and a CGM, but the two devices do not inte-
grate for clinical decision-making purposes
16. Which of the following meters contains the functional-
ity to test blood samples for both glucose and ketones?
a. Precision Xtra
b. OneTouch Ultra2
c. Accu-Chek Aviva Plus
d. Bayer Contour Next EZ
17. CGM would be most beneficial for which one of the
following patients with type 2 diabetes?
a. A patient on multiple daily insulin injections and
with hypoglycemia unawareness
b. A patient taking metformin and a sulfonylurea who
occasionally experiences nocturnal hypoglycemia
c. A patient who has a glucose log that is consistent
with her or his most recent A1C
d. A patient who is legally blind in both eyes with no
permanent caregiver living with her or him
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 CPE UPDATES AND ADVANCES IN TECHNOLOGY FOR DIABETES SELF-MANAGEMENT

18. Which of the following statements is true about dis- 20. Which of the following devices is able to record the
posable insulin pen devices? times and amounts of insulin doses administered on
a. Can deliver insulin in half-unit increments a Bluetooth-paired smartphone app?
b. Can track the time of the last insulin dose to prevent a. NovoPen Echo
stacking b. Clipsulin C3
c. Should be stored without a pen needle attached c. Solostar Max
d. Can integrate with smartphone apps to deliver ac- d. FlexTouch
curate insulin doses based on carb-to-insulin ratios
and correction factors

19. Which of the following statements accurately repre-

sents the rationale for avoiding needles longer than 8
mm in adults when administering insulin injections?
a. Decreased cost associated with shorter needles
b. Higher amount of insulin wasted to prime longer
needles
c. Decreased perception of pain when administering
longer needles
d. Increased risk of variable insulin absorption with
longer needles

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