The App Avalanche

The App Avalanche

Yesterday per a company issued press release;

“Hygieia, a digital insulin enhancement company dedicated to making insulin therapy easier and more effective for everyone involved, announced that the company has received 510(k) clearance from the U.S. Food and Drug Administration (FDA) for a phone app that will further enhance the company’s d-Nav® Insulin Guidance Service. The app is cleared for use as an aid in optimizing insulin management among people with Type 2 diabetes.”

Hygieia now joins a large and growing list of companies who offer apps that help a patient more effectively dose insulin. That poor dead cat cannot be swung these days without hitting an insulin dosing app. Which makes us wonder with this avalanche of apps how will these independent companies make any money. Yes, they are way cool and whiz bang and yes, they will help the patient when used as designed but just how these companies plan to make any money remains a mystery.

The app model for Lilly, Novo Nordisk and Sanofi is simple as the goal is to sell more insulin, these apps will be free to the patient. In this new area of mix and match there will also be plenty of “free” apps with the app makers attempting to make money from data gathering, selling ads or both. We suspect at some point now that Dexcom owns TypeZero and Abbott has an association with Bigfoot and now Novo they will have free apps which help patients more effectively dose insulin, their goal is also simple sell more sensors.

The more pressing question perhaps is will the patients who really need these apps actually use them. Keep in mind we are not talking about the 10% of patients who are already actively engaged with their diabetes management nor are we talking the 20% who are completely disengaged; we’re talking the 70% which are passively engaged.

For years physicians have dumbed down insulin dosing as they knew most patients would not do all the heavy lifting when it came to calculating how much insulin they should take. They knew most patients were not monitoring their glucose regularly and few understood the complexities of counting carbs. Adjustments to dosing were made retrospectively based on HbA1c results.

Thanks to all these apps and patient friendly CGM all this has changed. Still one has to wonder will the patient use this technology on a regular basis, or will they fall back to their old habits. Even the apps that come with virtual coaching may not change this as the patient still must respond to the advice they are being given. The app may take away most of the heavy lifting, but it still has to be interacted with. As we say often the app can provide the what to do but it cannot make the patient do it.

We hate to burst everyone’s buddle but there is no hard evidence to suggest that any advancement in diabetes technology has had a significant impact where it counts; outcomes. There is no question this is NOT true with actively engaged patients. Yet it is true with the 70% of patients who are passively engaged. We heard this song and dance before with glucose monitoring when everyone said alternate site testing and no coding would increase testing frequency, it didn’t. We heard this same song when “smart” insulin pumps arrived yet only 30% or so of Type 1’s use a pump. As much as we believe CGM is the most transformative diabetes technology ever invented the jury is still out as to whether this technology will have an impact beyond actively engaged patients.

Unlike an actively engaged patient the passively engaged patient is not living their life thinking about their diabetes management. They have real lives to live and to most diabetes management is one big pain in the ass. Worse there are few tangible benefits even when they take the time. These people aren’t thinking about time in range, insulin to carb ratios or correction factors. They are thinking about their jobs, their family and all the stuff people without diabetes think about every day.

Want more proof of this let’s do some simple math, there are approximately 30 million people in the US with diabetes. Based on publicly available information between them Dexcom, Abbott and Medtronic have less than 2 million patients using a CGM and that’s globally. Add up the numbers for Medtronic, Tandem and Insulet and maybe there are 1.5 million patients globally using an insulin pump. This isn’t a fly on an elephant’s ass this is bacteria on an elephant’s ass.

A disproportionate amount of attention is given to all these way cool whiz bang toys and this avalanche of apps. Yet no one bothers to ask whether any of these way cool whiz bang toys and this avalanche of apps will be embraced by the masses, not just the few. As Spook said the needs of the many should outweigh the needs of the few or the one. Yet in the upside-down world of diabetes the needs of the few garner more attention than the needs of the many.

Just by way of example this is one reason we believe so strongly in the exenatide micropump from Intarcia as once inserted diabetes management becomes STUPID. We suspect this stupidity is one of the reasons GLP-1 therapy continues to gain traction. No glucose monitoring, little fear of hypoglycemia, perhaps some weight loss and the patient takes it just once a day or once a week. Patients want stupid and so do their physicians, remember the physician isn’t paid to teach diabetes management.

The harsh reality here and no one talks about this either is all this way cool whiz bang technology and avalanche of apps has the POTENTIAL to be transformative IF and only IF the masses use it.