A clinical review of the t:slim X2 insulin pump

Insulin pumps are commonly used for intensive insulin therapy to treat type 1 diabetes in adults and youth. Insulin pump technologies have advanced dramatically in the last several years to integrate with continuous glucose monitors (CGM) and incorporate control algorithms. These control algorithms automate some insulin delivery in response to the glucose information received from the CGM to reduce the occurrence of hypoglycemia and hyperglycemia and improve overall glycemic control. The t:slim X2 insulin pump system became commercially available in 2016. It is an innovative insulin pump technology that can be updated remotely by the user to install new software onto the pump device as new technologies become available. Currently, the t:slim X2 pairs with the Dexcom G6 CGM and there are two advanced software options available: Basal-IQ, which is a predictive low glucose suspend (PLGS) technology, and Control-IQ, which is a Hybrid Closed Loop (HCL) technology. This paper will describe the different types of advanced insulin pump technologies, review how the t:slim X2 insulin pump works, and summarize the clinical studies leading to FDA approval and commercialization of the Basal-IQ and Control-IQ technologies.

Do-It-Yourself Automated Insulin Delivery: A Leading Example of the Democratization of Medicine

Digital innovations have led to an explosion of data in healthcare, driving processes of democratization and foreshadowing the end of the paternalistic era of medicine and the inception of a new epoch characterized by patient-centered care. We illustrate that the "do it yourself" (DIY) automated insulin delivery (AID) innovation of diabetes is a leading example of democratization of medicine as evidenced by its application to the three pillars of democratization in healthcare (intelligent computing; sharing of information; and privacy, security, and safety) outlined by Stanford but also within a broader context of democratization. The heuristic algorithms integral to DIY AID have been developed and refined by human intelligence and demonstrate intelligent computing. We deliver examples of research in artificial pancreas technology which actively pursues the use of machine learning representative of artificial intelligence (AI) and also explore alternate approaches to AI within the DIY AID example. Sharing of information symbolizes the core philosophy behind the success of the DIY AID evolution. We examine data sharing for algorithm development and refinement, for sharing of the open-source algorithm codes online, for peer to peer support, and sharing with medical and scientific communities. Do it yourself AID systems have no regulatory approval raising safety concerns as well as medico-legal and ethical implications for healthcare professionals. Other privacy and security factors are also discussed. Democratization of healthcare promises better health access for all and we recognize the limitations of DIY AID as it exists presently, however, we believe it has great potential.

Review of the Omnipod® 5 Automated Glucose Control System Powered by Horizon™ for the treatment of Type 1 diabetes

Type 1 diabetes (T1D) is a medical condition that requires constant management, including monitoring of blood glucose levels and administration of insulin. Advancements in diabetes technology have offered methods to reduce the burden on people with T1D. Several hybrid closed-loop systems are commercially available or in clinical trials, each with unique features to improve care for patients with T1D. This article reviews the Omnipod® 5 Automated Glucose Control System Powered by Horizon™ and the safety and efficacy data to support its use in the management of T1D.

Closed-loop control in insulin pumps for type-1 diabetes mellitus: safety and efficacy

INTRODUCTION

Type 1 diabetes is a lifelong disease with high management burden. The majority of people with type 1 diabetes fail to achieve glycemic targets. Algorithm-driven automated insulin delivery (closed-loop) systems aim to address these challenges. This review provides an overview of commercial and emerging closed-loop systems.

AREAS COVERED

We review safety and efficacy of commercial and emerging hybrid closed-loop systems. A literature search was conducted and clinical trials using day-and-night closed-loop systems during free-living conditions were used to report on safety data. We comment on efficacy where robust randomized controlled trial data for a particular system are available. We highlight similarities and differences between commercial systems.

EXPERT OPINION

Study data shows that hybrid closed-loop systems are safe and effective, consistently improving glycemic control when compared to standard therapy. While a fully closed-loop system with minimal burden remains the end-goal, these hybrid closed-loop systems have transformative potential in diabetes care.

The Use of Technology in Managing Diabetes in Youth Part 2-Insulin Pump Technologies: Information and Tips for the School Nurse

Insulin pump technologies are commonly used by youth with type 1 diabetes (T1D) for intensive insulin therapy, the gold standard for T1D care. Insulin pump technologies are advancing rapidly, with new insulin pumps becoming available every year offering improvements in glycemic control. School nurses must understand the basics of insulin pump therapy and distinguish between advanced pump technologies to best support their students with T1D. This is the second article in a three-part series on the use of technology in managing diabetes in youth. The first article described continuous glucose monitoring (CGM) devices and provided tips for the school nurses in incorporating CGM into the student's individualized healthcare plan. The purpose of this article is to summarize insulin pump technologies, from conventional insulin pump therapy to advanced automated insulin delivery systems and to describe keys to success with insulin pump technologies. Part 3 will focus on special considerations and problem solving related to technology use in the school setting.

Six months of hybrid closed loop in the real-world: An evaluation of children and young adults using the 670G system

OBJECTIVE

To describe glycemic and psychosocial outcomes in youth with type 1 diabetes using a hybrid closed loop (HCL) system.

SUBJECTS

Youth with type 1 diabetes (2-25 years) starting the 670G HCL system for their diabetes care were enrolled in an observational study.

METHODS

Prospective data collection occurred during routine clinical care and included glycemic variables (sensor time in range [70-180 mg/dL], HbA1c), and psychosocial variables (Hypoglycemia Fear Survey [HFS]; Problem Areas in Diabetes [PAID]). Mixed models were used to analyze change across time.

RESULTS

Ninety-two youth (mean age 15.7 ± 3.6 years, 50% female, HbA1c 8.8% ± 1.8%) started HCL for their diabetes care. Youth used Auto Mode 65.5% ± 3.0% of the time at month 1, which decreased to 51.2% ± 3.4% at month 6 (P = .001). Sensor time in range increased from 50.7% ± 1.8% at baseline to 56.9% ± 2.1% at 6 months (P = .007). HbA1c decreased from 8.7% ± 0.2% at baseline to 8.4% ± 0.2% after 6 months of use (P ≤ .0001), with the greatest HbA1c decline in participants with high baseline HbA1c. Increased percent time in auto mode was associated with lower HbA1c (P = .02). Thirty percent of youth discontinued HCL in the first 6 months of use. There were no changes in the HFS or PAID scores across time.

CONCLUSIONS

HCL use is associated with improved glycemic control and no change in psychosocial outcomes in this clinical sample. The decline in HCL use across time suggests that youth experience barriers in sustaining use of HCL. Further research is needed to understand reasons for HCL discontinuation and determine intervention strategies.

The Development and Psychometric Validation of the Diabetes Impact and Device Satisfaction Scale for Individuals with Type 1 Diabetes

BACKGROUND

With the rapid development of new insulin delivery technology, measuring patient experience has become especially pertinent. The current study reports on item development, psychometric validation, and intended use of the newly developed Diabetes Impact and Device Satisfaction (DIDS) Scale.

METHOD

The DIDS Scale was informed by a comprehensive literature review, and field tested as part of two focus groups. The finalized measure was used at baseline and 6 months post-assessment with a large US cohort. Exploratory factor analyses (EFAs) were conducted to determine and confirm factor structure and item selection. Internal reliability, test-retest reliability, and convergent/divergent validity of the emerged factors were tested with demographics, diabetes-specific information, and diabetes behavioral and satisfaction measures.

RESULTS

In all, 778 participants with type 1 diabetes (66% female, mean age 47.13 ± 17.76 years, 74% insulin pump users) completed surveys at both baseline and post-assessment. EFA highlighted two factors-Device Satisfaction (seven items, Cronbach's α = 0.85-0.90) and Diabetes Impact (four items, Cronbach's α = 0.71-0.75). DIDS Scale demonstrated good concurrent validity and test-retest reliability.

CONCLUSION

The DIDS Scale is a novel and a brief assessment tool with robust psychometric properties. It is recommended for use across all insulin delivery devices and is considered appropriate for use in longitudinal studies. Future studies are recommended to evaluate the performance of DIDS Scale in diverse populations with diabetes.

MiniMed 670G hybrid closed loop artificial pancreas system for the treatment of type 1 diabetes mellitus: overview of its safety and efficacy

Introduction: Automated insulin delivery for people with type 1 diabetes has been a major goal in the diabetes technology field for many years. While a fully automated system has not yet been accomplished, the MiniMed™ 670G artificial pancreas (AP) system is the first commercially available insulin pump that automates basal insulin delivery, while still requiring user input for insulin boluses. Determining the safety and efficacy of this system is essential to the development of future devices striving for more automation. Areas Covered: This review will provide an overview of how the MiniMed 670G system works including its safety and efficacy, how it compares to similar devices, and anticipated future advances in diabetes technology currently under development. Expert Opinion: The ultimate goal of advanced diabetes technologies is to reduce the burden and amount of management required of patients with diabetes. In addition to reducing patient workload, achieving better glucose control and improving hemoglobin A1c (HbA1c) values are essential for reducing the threat of diabetes-related complications further down the road. Current devices come close to reaching these goals, but understanding the unmet needs of patients with diabetes will allow future technologies to achieve these goals more quickly.

Real-World Use of Do-It-Yourself Artificial Pancreas Systems in Children and Adolescents With Type 1 Diabetes: Online Survey and Analysis of Self-Reported Clinical Outcomes

Background

Patient-driven initiatives have made uptake of Do-it-Yourself Artificial Pancreas Systems (DIYAPS) increasingly popular among people with diabetes of all ages. Observational studies have shown improvements in glycemic control and quality of life among adults with diabetes. However, there is a lack of research examining outcomes of children and adolescents with DIYAPS in everyday life and their social context.

Objective

This survey assesses the self-reported clinical outcomes of a pediatric population using DIYAPS in the real world.

Methods

An online survey was distributed to caregivers to assess the hemoglobin A_1c levels and time in range (TIR) before and after DIYAPS initiation and problems during DIYAPS use.

Results

A total of 209 caregivers of children from 21 countries responded to the survey. Of the children, 47.4% were female, with a median age of 10 years, and 99.4% had type 1 diabetes, with a median duration of 4.3 years (SD 3.9). The median duration of DIYAPS use was 7.5 (SD 10.0) months. Clinical outcomes improved significantly, including the hemoglobin A_1c levels (from 6.91% [SD 0.88%] to 6.27% [SD 0.67]; P<.001) and TIR (from 64.2% [SD 15.94] to 80.68% [SD 9.26]; P<.001).

Conclusions

Improved glycemic outcomes were found across all pediatric age groups, including adolescents and very young children. These findings are in line with clinical trial results from commercially developed closed-loop systems.

Navigating Two Roads to Glucose Normalization in Diabetes: Automated Insulin Delivery Devices and Cell Therapy

Incredible strides have been made since the discovery of insulin almost 100 years ago. Insulin formulations have improved dramatically, glucose levels can be measured continuously, and recently first-generation biomechanical "artificial pancreas" systems have been approved by regulators around the globe. However, still only a small fraction of patients with diabetes achieve glycemic goals. Replacement of insulin-producing cells via transplantation shows significant promise, but is limited in application due to supply constraints (cadaver-based) and the need for chronic immunosuppression. Over the past decade, significant progress has been made to address these barriers to widespread implementation of a cell therapy. Can glucose levels in people with diabetes be normalized with artificial pancreas systems or via cell replacement approaches? Here we review the road ahead, including the challenges and opportunities of both approaches.

Capabilities of Next-Generation Patch Pump: Improved Precision, Instant Occlusion Detection, and Dual-Hormone Therapy

Insulin pumps allow patients to attain better blood glucose control with more lifestyle flexibility. Their size and cost, however, limit their usefulness. Current CSII pumps are bulky, intrusive, and expensive. SFC Fluidics is addressing these problems by developing a new type of wearable patch pump based on the patented electro-chemiosmotic (ECO) microfluidic pumping technology. This nonmechanical pumping technology allows accurate and precise delivery of very small amounts of insulin and/or other drugs, including concentrated insulin. The pump engine is small and can be made inexpensively from injection molded parts, allowing its use in a disposable or semidisposable pod format. In addition, a single ECO pump engine can be used to deliver two drugs through independent pathways. Other features of SFC Fluidics' pod include latching safety valves that prevent accidental overdosing of insulin due to pressure changes and an instantaneous occlusion sensor that can immediately detect delivery failure at the first missed dose. These features allow for the development of a series of patch pumps that will offer users the benefit of CSII therapy in a more discreet and reliable patch pump form.

Predictive hyperglycemia and hypoglycemia minimization: In-home double-blind randomized controlled evaluation in children and young adolescents

OBJECTIVE

The primary objective of this trial was to evaluate the feasibility, safety, and efficacy of a predictive hyperglycemia and hypoglycemia minimization (PHHM) system vs predictive low glucose suspension (PLGS) alone in optimizing overnight glucose control in children 6 to 14 years old.

RESEARCH DESIGN AND METHODS

Twenty-eight participants 6 to 14 years old with T1D duration ≥1 year with daily insulin therapy ≥12 months and on insulin pump therapy for ≥6 months were randomized per night into PHHM mode or PLGS-only mode for 42 nights. The primary outcome was percentage of time in sensor-measured range 70 to 180 mg/dL in the overnight period.

RESULTS

The addition of automated insulin delivery with PHHM increased time in target range (70-180 mg/dL) from 66 ± 11% during PLGS nights to 76 ± 9% during PHHM nights (P<.001), without increasing hypoglycemia as measured by time below various thresholds. Average morning blood glucose improved from 176 ± 28 mg/dL following PLGS nights to 154 ± 19 mg/dL following PHHM nights (P<.001).

CONCLUSIONS

The PHHM system was effective in optimizing overnight glycemic control, significantly increasing time in range, lowering mean glucose, and decreasing glycemic variability compared to PLGS alone in children 6 to 14 years old.

Review of a commercially available hybrid closed-loop insulin-delivery system in the treatment of Type 1 diabetes

Type 1 diabetes is an important medical condition causing significant burden and morbidity to those persons affected by it. Improvements in insulin products, insulin delivery and glucose monitoring technology have all contributed to reductions in long-term complications and hypoglycemia. This article reviews the Medtronic 670G device and summarizes the data supporting how this product reduces the burden and increases the safety of insulin dosing in Type 1 diabetes.

Psychosocial Impact of the Bionic Pancreas During Summer Camp

BACKGROUND

The psychosocial impact of the bionic pancreas (BP) was assessed among children attending diabetes camp.

METHODS

Nineteen children were randomly assigned for 5 days to the BP condition and 5 days to the control condition in a crossover design.

RESULTS

Significant reductions in hypoglycemic fear and regimen burden were found. Children felt less burdened or worried about diabetes and felt freer to do things they enjoyed while using the BP. Children wished the BP responded to out of range numbers faster and expressed annoyance about carrying around the necessary equipment.

CONCLUSIONS

Children may experience improved psychosocial outcomes following use of BP while expressing key areas of user concern. Future studies in less controlled environments with larger sample sizes can determine if these findings are generalizable to other groups.

Toward Development of Psychosocial Measures for Automated Insulin Delivery

The INSPIRE study working group launched its initial workshop in February 2015 to facilitate collaboration among key stakeholders interested in automated insulin delivery (AID) systems and the psychosocial outcomes of individuals who may use these new technologies. Specifically, the INSPIRE team's goal is to facilitate measure development assessing the psychosocial factors associated with AID systems. A second working group was held to foster exchange among key stakeholders in AID system development. Patient, health care provider, engineering, industry, academic, regulatory and payer perspectives were presented. The INSPIRE working group will continue to serve as a platform to encourage open dialogue among all stakeholders with the aim of facilitating technology that offers minimal user burden and maximum benefit from both a psychological and physiologic perspective.

Periodic-zone model predictive control for diurnal closed-loop operation of an artificial pancreas

BACKGROUND

The objective of this research is an artificial pancreas (AP) that performs automatic regulation of blood glucose levels in people with type 1 diabetes mellitus. This article describes a control strategy that performs algorithmic insulin dosing for maintaining safe blood glucose levels over prolonged, overnight periods of time and furthermore was designed with outpatient, multiday deployment in mind. Of particular concern is the prevention of nocturnal hypoglycemia, because during sleep, subjects cannot monitor themselves and may not respond to alarms. An AP intended for prolonged and unsupervised outpatient deployment must strategically reduce the risk of hypoglycemia during times of sleep, without requiring user interaction.

METHODS

A diurnal insulin delivery strategy based on predictive control methods is proposed. The so-called "periodic-zone model predictive control" (PZMPC) strategy employs periodically time-dependent blood glucose output target zones and furthermore enforces periodically time-dependent insulin input constraints to modulate its behavior based on the time of day.

RESULTS

The proposed strategy was evaluated through an extensive simulation-based study and a preliminary clinical trial. Results indicate that the proposed method delivers insulin more conservatively during nighttime than during daytime while maintaining safe blood glucose levels at all times. In clinical trials, the proposed strategy delivered 77% of the amount of insulin delivered by a time-invariant control strategy; specifically, it delivered on average 1.23 U below, compared with 0.31 U above, the nominal basal rate overnight while maintaining comparable, and safe, blood glucose values.

CONCLUSIONS

The proposed PZMPC algorithm strategically prevents nocturnal hypoglycemia and is considered a significant step toward deploying APs into outpatient environments for extended periods of time in full closed-loop operation.