Use of Advanced Hybrid Closed-Loop System in a Patient with Pancreas Cancer

To the Editor,

Treatment of diabetes is ever evolving. With advances in technology, insulin pumps have become an important component of so-called artificial pancreas systems, also known as closed-loop or automated insulin dosing systems. Advanced hybrid closed-loop (AHCL) systems have decreased burden of disease in some patients with type 1 diabetes and improved glycemic control. Fuzzy Logic Automated Insulin Regulation (FLAIR) study has shown decreased rate of hyperglycemia without the expense of hypoglycemia with these systems. ¹ Patients with type 1 diabetes are the primary targets when these systems are developed.

Patients with type 3c diabetes also suffer from diminished insulin reserve. ² Also, hypoglycemia causes a more potent risk in these patients due to loss of glucagon. ² There are scarce data regarding use of AHCL systems in these patients. In this study, we describe a patient with pancreatectomy using an AHCL system.

A 69-year-old male patient was followed for type 2 diabetes for a year when he was diagnosed with pancreas cancer. He was on metformin and gliclazide treatment, and after pancreatectomy his treatment was changed to insulin detemir and insulin aspart. He was a travel guide and after switching to insulin his major complaint was frequent hypoglycemia. His fasting glucose was 54 mg/dL at the time of admission, whereas his HbA1c was 8.5%. He was suggested MiniMed™ 780G System with Guardian™ 3 Sensor and he was switched from insulin detemir 20 U/day and insulin aspart 54 U/day to AHCL.

After initiation of AHCL, he no longer suffered from hypoglycemia and his time in range was between 74% and 96% with mild hyperglycemia (Fig. 1). His total daily basal dose ranged between 15 and 20 U, whereas his bolus dose was between 13 and 22 U. His HbA1c reduced to 7.5% after 5 months on the system. He reported that he can now perform his day job without fear of hypoglycemia and his disease burden has lessened significantly. Although we have not assessed his hypoglycemia fear with a survey before the AHCL system was implanted, after 5 months his Hypoglycemia Fear Survey Worry ³ subscale score was 18, which was relatively low.

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FIG. 1.

Change in glucose level of the patient before and after pump treatment.

AHCL systems offer convenience and improvement in daily mental burden in patients with type 1 diabetes. Patients with type 3c diabetes suffer from not only endocrine deficiency of pancreas but also from exocrine loss of pancreas. Chronic diarrhea and malabsorption are among the issues they must address lifelong, which add to their disease burden. ⁴ In this case vignette, we show that patients with pancreatectomy can benefit from an AHCL system and to the best of our knowledge this is the first report of an AHCL system in this patient group. His hypoglycemia rate and fear of hypoglycemia reduced substantially. Our patient was elderly and a traveler, he benefited from this treatment both physically and mentally. We suggest that AHCL systems can be used in patients with type 3c to maintain a life with increased quality. In the near future a system that can deliver both insulin and glucagon would be much more helpful.