Positioning time in range in diabetes management

Time in range in relation to amputation and all-cause mortality in hospitalised patients with diabetic foot ulcers

AIMS

The aim of this study was to evaluate the association of time in range (TIR) with amputation and all-cause mortality in hospitalised patients with diabetic foot ulcers (DFUs).

MATERIALS AND METHODS

A retrospective analysis was performed on 303 hospitalised patients with DFUs. During hospitalisation, TIR, mean blood glucose (MBG), coefficient of variation (CV), time above range (TAR) and time below range (TBR) of patients were determined from seven-point blood glucose profiles. Participants were grouped based on their clinical outcomes (i.e., amputation and death). Logistic regression was employed to analyse the association of TIR with amputation and all-cause mortality of inpatients with DFUs.

RESULTS

Among the 303 enrolled patients, 50 (16.5%) had undergone amputation whereas seven (2.3%) were deceased. Blood glucose was determined in 41,012 samples obtained from all participants. Patients who underwent amputation had significantly lower TIR and higher MBG, CV, level 2 TAR and level 1 TBR whereas deceased patients had significantly lower TIR and higher MBG and level 2 TAR. Both amputation and all-cause mortality rate declined with an increase in TIR quartiles. Logistic regression showed association of TIR with amputation (p = 0.034) and all-cause mortality (p = 0.013) after controlling for 15 confounders. This association was similarly significant in all-cause mortality after further adjustment for CV (p = 0.022) and level 1 TBR (p = 0.021), respectively.

CONCLUSIONS

TIR is inversely associated with amputation and all-cause mortality of hospitalised patients with DFUs. Further prospective studies are warranted to establish a causal relationship between TIR and clinical outcomes in patients with DFUs.

Negative association of time in range and urinary albumin excretion rate in patients with type 2 diabetes mellitus: a retrospective study of inpatients

Background:

Time in range (TIR) refers to the time an individual spends within their target glucose range, which now has been popularized as an important metric to classify glycemic management and also recognized as an important outcome of current diabetes therapies. This study aimed to investigate the association between TIR and the severity of the urinary albumin excretion rate (UAER) in patients with type 2 diabetes mellitus (T2DM).

Methods:

We retrospectively analyzed the data of 1014 inpatients with T2DM at the Department of Endocrinology and Metabolism of Peking University International Hospital, China. TIR was defined as the percentage of blood glucose within the target range of 3.90–10.00 mmol/L. Urine samples for assessment of UAER were collected for 3 consecutive days from the start of hospitalization.

Results:

The TIR values for patients with normal urine levels of albumin, microalbuminuria, and macroalbuminuria were 70% ± 20%, 50% ± 20%, and 30% ± 20%, respectively (all P < 0.001). The patients were stratified according to quartiles of TIR as follows: quartile (Q) 1, <55%; Q2, 55%–72%; Q3, 73%–83%; and Q4, >83%. The incidences of microalbuminuria in Q1, Q2, Q3, and Q4 were 41.1%, 21.6%, 7.1%, and 5.5% (all P < 0.001), respectively. The respective incidences of macroalbuminuria were 24.2%, 1.1%, 1.4%, and 0% (all P < 0.001). In multinomial logistic regression analyses, TIR was significantly correlated with microalbuminuria (odds ratio [OR] 0.58, 95% confidence interval [CI]: 0.52–0.65, P < 0.001) and macroalbuminuria (OR 0.26, 95% CI: 0.18–0.38, P < 0.001) after adjusting for age, sex, body mass index, diabetes duration, systolic blood pressure, and levels of triglycerides, glycosylated hemoglobin A1c, and creatinine.

Conclusion:

The proportion of blood glucose in TIR is closely related to the severity of UAER in patients with T2DM.

Can Faster Aspart Be Used to Optimize Glycemic Control With Insulin Pump Therapy? From Expectations to Lessons Learned After a Year of Use in the United States

Fast-acting insulin aspart (faster aspart) is an ultra-rapid-acting formulation of insulin aspart developed to more closely match the prandial endogenous insulin profile, and its accelerated absorption kinetics are expected to provide clinical benefits for patients using insulin pump therapy. A head-to-head trial versus the original insulin aspart formulation in pump therapy did not demonstrate superiority of faster aspart in terms of A1C reduction, but pump settings were not optimized for the pharmacokinetic/pharmacodynamic profile of faster aspart. Nevertheless, meal test and continuous glucose monitoring data suggest that faster aspart is beneficial for postprandial glucose control, and a case study is presented illustrating excellent results using this insulin in pump therapy. Frequent blood glucose monitoring and appropriate patient education are vital for success.

6. Glycemic Targets: Standards of Medical Care in Diabetes-2022

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc22-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc22-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Largest Amplitude of Glycemic Excursion Calculating from Self-Monitoring Blood Glucose Predicted the Episodes of Nocturnal Asymptomatic Hypoglycemia Detecting by Continuous Glucose Monitoring in Outpatients with Type 2 Diabetes

AIMS

Nocturnal asymptomatic hypoglycemia (NAH) is a serious complication of diabetes, but it is difficult to be detected clinically. This study was conducted to determine the largest amplitude of glycemic excursion (LAGE) to predict the episodes of NAH in outpatients with type 2 diabetes.

METHODS

Data were obtained from 313 outpatients with type 2 diabetes. All subjects received continuous glucose monitoring (CGM) for consecutive 72 hours. The episodes of NAH and glycemic variability indices (glucose standard deviation [SD], mean amplitude of plasma glucose excursion [MAGE], mean blood glucose [MBG]) were accessed via CGM. LAGE was calculated from self-monitoring blood glucose (SMBG).

RESULTS

A total of 76 people (24.3%) had NAH. Compared to patients without NAH, patients with NAH showed higher levels of glucose SD (2.4 ± 0.9 mmol/L vs 1.7 ± 0.9 mmol/L, p <0.001), MAGE (5.2 ± 2.1 mmol/L vs 3.7 ± 2.0, p<0.001) and LAGE (4.6 ± 2.3 mmol/L vs 3.8 ± 1.9 mmol/L, p=0.007), and lower level of MBG (7.5 ± 1.5 mmol/L vs 8.4 ± 2.2 mmol/L, p=0.002). LAGE was significantly associated with the incidence of NAH and time below rang (TBR) in model 1 [NAH: 1.189 (1.027-1.378), p=0.021; TBR: 0.008 (0.002-0.014), p=0.013] with adjustment for age, BMI, sex, work, hyperlipidemia, complication and medication, and in model 2 [NAH: 1.177 (1.013-1.367), p=0.033; TBR: 0.008 (0.002-0.014), p=0.012] after adjusting for diabetes duration based on model 1, as well as in model 3 [NAH: 1.244 (1.057-1.464), p=0.009; TBR: 0.009 (0.002-0.016), p=0.007] with further adjustment for HbA1c based on model 2. In addition, no significant interactions were found between LAGE and sex, age, HbA1c, duration of diabetes, BMI and insulin therapy on the risk of NAH. The receiver operator characteristic (ROC) curve shows the ideal cutoff value of LAGE for the prediction of NAH was 3.48 mmol/L with 66.7% sensitivity, 50% specificity and 0.587 (95% CI: 0.509-0.665) of area under the ROC curve.

CONCLUSIONS

High glycemic variability is strongly associated with the risk of NAH. The LAGE based on SMBG could be an independent predictor of NAH for outpatients with type 2 diabetes, and LAGE greater than 3.48 mmol/L could act as a warning alarm for high risk of NAH in daily life.

Glycated Hemoglobin and Risk of Arterial Stiffness in a Chinese Han Population: A Longitudinal Study

BACKGROUND AND AIMS

Glycated hemoglobin (HbA1c) associates with the risk of arterial stiffness, and such association can be found between fasting blood glucose (FBG), postprandial blood glucose (PBG), triglyceride-glucose index (TyG index), and arterial stiffness. However, the results were inconsistent, longitudinal studies were sparse, and comparison of these glycemic parameters was less conducted. We aimed to explore the longitudinal relationship between HbA1c and arterial stiffness and compare the effect of the parameters.

METHODS

Data were collected from 2011 to 2019 in Beijing Health Management Cohort (BHMC) study. Cox proportional hazard models were fitted to investigate the association between the parameters and arterial stiffness. A generalized estimation equation (GEE) analysis was conducted to investigate the effect of repeated measurements of glycemic parameters. A receiver operating characteristic (ROC) analysis was performed to compare the predictive value of glycemic parameters for arterial stiffness.

RESULTS

Among 3,048 subjects, 591 were diagnosed as arterial stiffness during the follow-up. The adjusted hazard ratio (HR) [95% confidence interval (CI)] for arterial stiffness of the highest quartile group of HbA1c was 1.63 (1.22-2.18), which was higher than those of FBG, PBG, and TyG index. The nonlinear association of arterial stiffness with HbA1c and PBG was proved. The robust results of the sensitivity analysis were obtained.

CONCLUSIONS

HbA1c is an important risk factor of arterial stiffness compared with PBG, FBG, and TyG index, and has a strong predictive ability for arterial stiffness among non-diabetics and the general population.

Glycaemic management in diabetes: old and new approaches

HbA_1c is the most used parameter to assess glycaemic control. However, evidence suggests that the concept of hyperglycaemia has profoundly changed and that different facets of hyperglycaemia must be considered. A modern approach to glycaemic control should focus not only on reaching and maintaining optimal HbA_1c concentrations as early as possible, but to also do so by reducing postprandial hyperglycaemia, glycaemic variability, and to extend as much as possible the time in range in near-normoglycaemia. These goals should be achieved while avoiding hypoglycaemia, which, should it occur, should be reverted to normoglycaemia. Modern technology, such as intermittently scanned glucose monitoring and continuous glucose monitoring, together with new drug therapies (eg, ultra-fast insulins, SGLT2 inhibitors, and GLP-1 receptor agonists), could help to change the landscape of glycaemia management based on HbA_1c in favour of a more holistic approach that considers all the different aspects of this commonly oversimplified pathophysiological feature of diabetes.

Novel Continuous Glucose Monitoring Metrics and Large-for-Gestational-Age Risk: An Exploratory Retrospective Cohort Study in Pregnancies with Type 1 Diabetes

Background: Continuous glucose monitoring (CGM) improves pregnancy outcomes in patients with type 1 diabetes (T1D). We aimed to assess the between-group differences in glycated hemoglobin (HbA1c) and the incidence of large-for-gestational-age (LGA) neonates in CGM and glucometer users and analyze the potential association of novel CGM metrics with LGA risk in T1D pregnancies. Materials and Methods: Our retrospective study cohort included 134 women with T1D treated with insulin pumps-75 of them used CGM and 59 patients measured their glucose concentrations using glucometers only. As part of our study, we matched the CGM users and patients who preferred the self-monitoring of blood glucose (SMBG) according to their baseline HbA1c and White's diabetes class at a 1:1 ratio. After the matching, both groups included 42 pregnancies. Results: We did not find any difference in changes in HbA1c and perinatal outcomes between CGM and SMBG users; however, we achieved a limited statistical power, and there were more cases of diabetic nephropathy in the SMBG group. Mothers of LGA infants had higher first-trimester HbA1c, time above target, and mean glucose concentrations in each trimester of pregnancy. Other CGM metrics reflecting glucose fluctuations attributed to hyperglycemia were associated with an increased risk of LGA. Despite optimal maternal HbA1c, 39% of neonates demonstrated LGA. Conclusions: Although participants reached the target HbA1c concentrations, mothers of LGA newborns had higher first-trimester HbA1c, as well as higher time above target range, higher mean glucose concentrations, and more glycemic fluctuations, suggesting that several CGM metrics associated with maternal hyperglycemia are associated with LGA in pregnancies with T1D.

Early Glycemic Control Assessment Based on Consensus CGM Metrics. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2021;2021:1269-1275. [PMID: 34891517 DOI: 10.1109/embc46164.2021.9631015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Continuous glucose monitoring (CGM) has revolutionized the world of diabetes and transformed the approach to diabetes care. In this context, an expert panel has reached consensus on clinical targets for CGM data interpretation based on eight CGM metrics. At least 70% of 14 consecutive CGM days (referred to as a period) are recommended to assess glycemic control based on the metrics. In clinical practice less CGM data may be available. Therefore, the primary aim of this study is to explore the ability to recover the consensus metrics utilizing less than 14 days of CGM data (intra-period). As a secondary aim, we investigate the recovery considering two consecutive periods (inter-period). The analyses are based on real-world CGM data from 484 diabetes users (4726 periods) acquired from the Cornerstones4Care® Powered by Glooko app. Using up to 14 accumulated days, the consensus metrics are calculated for each user and period, and compared to the fully 14 accumulated intra- and inter-period days. Relatively low deviations were observed for time in range (TIR) and average based metrics when using less than 14 days, however, we observed large deviations in metrics characterizing infrequent events such as time below range (TBR). Furthermore, the consensus metrics obtained in two consecutive 14 day periods have clear discrepancies (inter-period). Recovering consensus metrics using less than 14 days might still be valuable in terms of interpreting CGM data in certain clinical contexts. However, caution should be taken if treatment decisions would be made with less than 14 days of data on critical metrics such as TBR, since the metrics characterizing infrequent events deviate substantially when less data are available. Substantial deviation is also seen when comparing across two consecutive periods, which means that care should be taken not to over-generalize consensus metric based glycemic control conclusions from one period to subsequent periods.

Rethinking Carbohydrate Intake and Time in Range in Children and Adolescents with Type 1 Diabetes

The aim of this study was to evaluate the association between macronutrient intake and time in range (TIR) of 70–180 mg/dL in children and adolescents with type 1 diabetes (T1D). A multi-center study recruited patients with T1D using continuous glucose monitoring (CGM) between January 2019 and January 2020 from centers across Italy. Diet intake was recorded using three-day weighed food diaries. Nutrients were evaluated as percentages of total intake. TIR was considered at target if the percentage of readings was higher than 70%. Clinical and nutritional factors associated with TIR at target were analyzed using multiple correspondence analysis and multiple logistic regression. Data from 197 participants (53% male, median age 11.6 years, median HbA1c 55.2 mmol/mol, median TIR 60%) were analyzed. Macronutrient intake was 45.9% carbohydrates, 16.9% protein, 37.3% fat, and 13.1 g/day fiber (median values). TIR > 70% was observed in 28% of participants; their diet contained more protein (17.6%, p = 0.015) and fiber (14.4 g/day, p = 0.031) than those not at target. The probability of having a TIR > 70% was significantly higher with 40–44% consumption of carbohydrates compared with 45–50% consumption of carbohydrates and with the use of a carbohydrate counting system. Based on these results, a five percent reduction in the percentage of carbohydrate intake can help children and adolescents with T1D achieve the goal of a TIR > 70%. Both a lower and higher percentage of carbohydrate intake appears to reduce the probability of reaching the target TIR > 70%. These results require validation in other populations before being used in clinical practice.

Time in range, especially overnight time in range, is associated with sudomotor dysfunction in patients with type 1 diabetes

BACKGROUND

Time in range (TIR) is advocated as key metric of glycemic control and is reported to be associated with microvascular complications of diabetes. Sudomotor dysfunction is among the earliest detectable diabetic peripheral neuropathy (DPN). We set about to research the relationship between TIR including overnight TIR and sudomotor function detected by SUDOSCAN with the intention of exploring the correlation of TIR including overnight TIR and early DPN in type 1 diabetes (T1D).

METHODS

95 patients with T1D were enrolled. TIR including nocturnal TIR of 3.9-10.0 mmol/L was evaluated with CGM. SUDOSCAN measured feet electrochemical skin conductance (FESC) and sudomotor dysfunction was defined as average FESC < 60µS. Logistic regressions were applied to examine the independent association of TIR and overnight TIR with sudomotor function.

RESULTS

The overall prevalence of sudomotor dysfunction was 28.42%. Patients with sudomotor dysfunction had significantly lower TIR for the whole recorded phase and for nighttime. The sudomotor dysfunction prevalence progressively declined with the ascending tertiles of TIR and nocturnal TIR (P for trend < 0.05). Correlation analysis showed that the relationship between nocturnal TIR and FESC was stronger than that between TIR and FESC with correlation coefficients were respectively 0.362 and 0.356 (P < 0.001). Finally, logistic regression analysis indicated the independently negative relation between TIR and nocturnal TIR and sudomotor dysfunction (P < 0.05), and the correlation between nocturnal TIR and sudomotor dysfunction was more statistically significant.

CONCLUSIONS

TIR is negatively correlated with sudomotor dysfunction in T1D independent of HbA1c. Furthermore, decreased nocturnal TIR is more closely related to the impaired function of sudomotor nerves in sweat glands.

Achieving the HbA1c Target Requires Longer Time in Range in Pregnant Women With Type 1 Diabetes

CONTEXT

Continuous glucose monitoring (CGM) overcomes the limitations of glycated hemoglobin (HbA1c).

OBJECTIVE

This study aimed to investigate the relationship between CGM metrics and laboratory HbA1c in pregnant women with type 1 diabetes.

METHODS

An observational study enrolled pregnant women with type 1 diabetes who wore CGM devices during pregnancy and postpartum from 11 hospitals in China from January 2015 to June 2019. CGM data were collected to calculate time in range (TIR), time above range (TAR), time below range (TBR), and glycemic variability parameters. Relationships between the CGM metrics and HbA1c were explored. Linear and curvilinear regressions were conducted to investigate the best-fitting model to clarify the influence of HbA1c on the TIR-HbA1c relationship during pregnancy.

RESULTS

A total of 272 CGM data and corresponding HbA1c from 98 pregnant women with type 1 diabetes and their clinical characteristics were analyzed in this study. Mean HbA1c and TIR were 6.49 ± 1.29% and 76.16 ± 17.97% during pregnancy, respectively. HbA1c was moderately correlated with TIR3.5-7.8(R = -0.429, P = .001), mean glucose (R = 0.405, P = .001) and TAR7.8 (R = 0.435, P = .001), but was weakly correlated with TBR3.5 (R = 0.034, P = .001) during pregnancy. On average, a 1% (11 mmol/mol) decrease in HbA1c corresponded to an 8.5% increase in TIR3.5-7.8. During pregnancy, HbA1c of 6.0%, 6.5%, and 7.0% were equivalent to a TIR3.5-7.8 of 78%, 74%, and 69%, respectively.

CONCLUSION

We found there was a moderate correlation between HbA1c and TIR3.5-7.8 during pregnancy. To achieve the HbA1c target of less than 6.0%, pregnant women with type 1 diabetes should strive for a TIR3.5-7.8 of greater than 78% (18 hours 43 minutes) during pregnancy.

Benefits of the addition of continuous or flash glucose monitoring versus standard practice using self-monitored blood glucose and haemoglobin A1c in the primary care of diabetes mellitus: a systematic review protocol

INTRODUCTION

Studies demonstrate that optimal glycaemic control reduces morbidity from diabetes mellitus but remains elusive in a significant portion of patients. Although research shows that continuous glucose monitoring (CGM) and flash glucose monitoring (FGM) improves glycaemic control in selected subsets of patients with diabetes in specialty practices, we found no systematic reviews evaluating the use of CGM/FGM in primary care, where the majority of patients with diabetes are cared for.This systematic review aims to answer the questions: 'compared with usual care of self-monitoring blood glucose and haemoglobin A1c (HbA1c), does the addition of CGM/FGM use in the primary care of patients with diabetes improve glycaemic control, decrease rates of hypoglycaemia, and improve patient and physician satisfaction?' and if so, 'what subgroups of primary care patients with diabetes are most likely to benefit?'.

METHODS AND ANALYSIS

Aligning with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines, a search will be conducted in PubMed, EMBASE, Scopus, CINAHL, Cochrane Central Register of Controlled Trials and Web of Science. We will include studies investigating CGM/FGM use and reporting the primary outcome measure of HbA1c and secondary outcome measures of hypoglycaemia, time in range, time below range, time above range and patient/staff satisfaction. We will examine which patient populations appear to benefit from CGM/FGM. Three independent researchers will use the Covidence systematic review software for blinded screening and study selection. The National Heart, Lung, and Blood Institute quality assessment tool and Grading of Recommendations Assessment, Development and Evaluation will be used to assess the risk of bias and quality of evidence.

ETHICS AND DISSEMINATION

The systematic review methodology does not require ethics approval due to the nature of the study design. Study findings will be publicly available to a wide readership across disciplines and will be published in a peer-reviewed journal.

PROSPERO REGISTRATION NUMBER

CRD42021229416.

Time in range correlates glycated albumin measured immediately after 2 weeks of continuous glucose monitoring

AIMS

Time in range (TIR), an index of glycemic control and also blood glucose fluctuation, obtained from continuous glucose monitoring (CGM), has been increasing its importance along with the spread of CGM in recent years. For a while, glycated albumin (GA) has been also used as a glycemic control index during about 2-weeks in routine clinical practice. It has not yet been confirmed under optimal condition whether TIR and GA correlates. Clarification of the correlation between TIR and GA, which was measured immediately after 2-weeks of CGM, might be a finding that further supports the utility of TIR.

METHODS

GA was measured at the conclusion of 2-week CGM in 71 diabetes outpatients at our hospital, and the correlation between GA and indices such as TIR obtained from CGM was statistically analyzed.

RESULTS

It was found that TIR and time above range (TAR) were significantly correlated with GA. Upon performing multiple regression analysis, TIR, TAR and BMI. indicated a significant regression coefficient with respect to GA.

CONCLUSIONS

These findings further support the utility of TIR as a marker of glycemic control that it might also be correlated with GA, and also suggest a relation between GA and blood glucose fluctuation.

Time-in-range for monitoring glucose control: Is it time for a change?

The HbA1c value has been the gold standard for evaluating glucose control for decades. However, it has limitations such as the lack of information on glycemic variability or the risk of hypoglycemia. The increasing use of continuous glucose monitoring has provided patients and healthcare professionals with a range of useful metrics for the management of diabetes. Among them, Time in Range (TIR) is a simple and intuitive metric that gives information regarding the quality of glucose control. It is defined as the time spent in an individual's target glucose range. TIR is strongly correlated with HbA1c, and it has been linked to the risk of developing microvascular and macrovascular complications. The International Consensus on Time in Range has recently set targets for different diabetes populations. For the majority of people with type 1 or type 2 diabetes, a TIR (70-180 mg/dL or 3.9-10.0 mmol/L) of >70%, a time below range (TBR) <70 mg/dL (<3.9 mmol/L) of <4% and a TBR <54 (<3.0 mmol/L) of <1% are recommended. In this review, we address the latest evidence for the use of TIR as an essential parameter in the management of diabetes.

Diabetes Technology Meeting 2020

Diabetes Technology Society hosted its annual Diabetes Technology Meeting on November 12 to November 14, 2020. This meeting brought together speakers to cover various perspectives about the field of diabetes technology. The meeting topics included artificial intelligence, digital health, telemedicine, glucose monitoring, regulatory trends, metrics for expressing glycemia, pharmaceuticals, automated insulin delivery systems, novel insulins, metrics for diabetes monitoring, and discriminatory aspects of diabetes technology. A live demonstration was presented.

Blood pressure control measured as "time in range" during initial 24 h for inpatients with spontaneous nontraumatic intracerebral haemorrhage

BACKGROUND AND PURPOSE

Blood pressure (BP) control is an integral part in the management of spontaneous nontraumatic intracerebral haemorrhage. The aim of this study is to propose a novel concept of blood pressure control measured as 'Time in Range'(TiR) and assess its relationship to neurological deterioration.

METHOD

Retrospective study of 120 patients with Intracerebral haemorrhage who were admitted within 6 h of the symptom onset. The hourly BP readings for initial 24 h were studied in the form of time in range (TiR). TiR was defined as the percentage of readings with 'in range' systolic BP (SBP 110-140mmHG) during a unit time period. TiR was correlated with mean SBP at 6,12,18 and 24 h. It was categorized dichotomously as controlled (more than 50%) or not controlled (equal to or less than 50%) and analyzed with the change in Glasgow coma scale (drop of ≥2 units) at 24 h.

RESULTS

Correlation of TiR with mean SBP at 6 and 24 h showed significant negative correlation [r = -0.71 (at 6 h); r = -0.88 (at 24 h); p < 0.001]. The association of TiR with neurological deterioration(ND) was measured by change in GCS; with lower TiR associated with higher chances of neurological deterioration at 12 h interval [OR 4.5(1.2-16.8); p = 0.025], but not at 24 h interval [OR 1.4 (0.34-5.44); p = 0.670].

CONCLUSION

Our novel concept of 'Time in Range'(TiR) was found to be relevant in our study. Its association with mean SBP reflect its potential to be a modality of expressing control of SBP in Spontaneous Nontraumatic Intracerebral Haemorrhage.

Time in Range as a Research Outcome Measure

Time in range (TIR) is gaining ground as an outcome measure in type 1 diabetes trials. However, inclusion of TIR raises several issues for trial design. In this article, the authors begin by defining TIR and describing the current international consensus around TIR targets. They then expand on evidence for the validity of TIR as a primary clinical trial outcome before concluding with some practical, ethical, and logistical implications.

Clinical Application of Time in Range and Other Metrics

Time in range (TIR) and other continuous glucose monitoring (CGM)-derived metrics have been standardized in international consensus conferences. TIR correlates closely with A1C; a TIR of 70% correlates to an A1C of 6.7-7%. Evidence is emerging on the association of TIR with long-term diabetes complications, and each 10% increase in TIR shows a substantial decrease in risk for long-term complications. Application of TIR to clinical practice can be easily done with a stepped approach to the analysis and interpretation of CGM-derived metrics and the ambulatory glucose profile report. Clinician education and partnership with patients are crucial for successful implementation of TIR and all CGM-derived metrics in clinical practice.

Improved Estimation of Glycated Hemoglobin from Continuous Glucose Monitoring and Past Glycated Hemoglobin Data

Background: Accurate estimation of glycated hemoglobin (HbA1c) from continuous glucose monitoring (CGM) remains challenging in clinic. We propose two statistical models and validate them in real-life conditions against the current standard, glucose management indicator (GMI). Materials and Methods: Modeling utilized routinely collected data from patients with type 1 diabetes from central Poland (eligibility criteria: age >1 year, diabetes duration >3 months, and CGM use between 01/01/2015 and 12/31/2019). CGM records were extracted from dedicated Medtronic/Abbott databases and cross-referenced with HbA1c values; 28-day periods preceding HbA1c measurement with >75% of the sensor-active time were analyzed. We developed a mixed linear regression, including glycemic variability indices and patient's ID (glucose variability-based patient specific model, GV-PS) intended for closed-group use and linear regression using patient-specific error of GMI (proportional error-based patient agnostic model, PE-PA) for general use. Models were validated with either new HbA1cs from closed-group patients or separate patient-HbA1c pool. External validation was performed with data from clinical trials. Performance metrics included bias, its 95% confidence interval (95% CI), coefficient of determination (R²), and root mean square error (RMSE). Results: We included 723 HbA1c-CGM pairs from 174 patients (mean age 9.9 ± 4.4 years and diabetes duration 3.7 ± 3.6 years). GMI yielded R² = 0.58, with different bias between Medtronic and Abbott devices [0.120% vs. -0.152%, P < 0.0001], and overall 95% CI = -0.9% to +1%, RMSE = 0.47%. GV-PS successfully captured patient-specific variance (closed-group validation: R² = 0.83, bias = 0.026%, 95% CI = -0.562% to 0.591%, RMSE = 0.31%). PE-PA performed similarly on new patients (R² = 0.76, bias = -0.069%, 95% CI = -0.790% to 0.653%, RMSE = 0.37%). In external validation GMI, GV-PS, and PE-PA produced 73.8%, 87.5%, and 91.0% predictions within 0.5% (5.5 mmol/mol) from the true value. Conclusion: Constructed models performed better than GMI. PE-PA provided an accurate estimate of HbA1c with fast and straightforward implementation.

Glycemic deviation index: a novel method of integrating glycemic numerical value and variability

BACKGROUND

There are many continuous blood glucose monitoring (CGM) data-based indicators, and most of these focus on a single characteristic of abnormal blood glucose. An ideal index that integrates and evaluates multiple characteristics of blood glucose has not yet been established.

METHODS

In this study, we proposed the glycemic deviation index (GDI) as a novel integrating characteristic, which mainly incorporates the assessment of the glycemic numerical value and variability. To verify its effectiveness, GDI was applied to the simulated 24 h glycemic profiles and the CGM data of type 2 diabetes (T2D) patients (n = 30).

RESULTS

Evaluation of the GDI of the 24 h simulated glycemic profiles showed that the occurrence of hypoglycemia was numerically the same as hyperglycemia in increasing GDI. Meanwhile, glycemic variability was added as an independent factor. One-way ANOVA results showed that the application of GDI showed statistically significant differences in clinical glycemic parameters, average glycemic parameters, and glycemic variability parameters among the T2D groups with different glycemic levels.

CONCLUSIONS

In conclusion, GDI integrates the characteristics of the numerical value and the variability in blood glucose levels and may be beneficial for the glycemic management of diabetic patients undergoing CGM treatment.

Impact of Fast-Acting Insulin Aspart on Glycemic Control in Patients with Type 1 Diabetes Using Intermittent-Scanning Continuous Glucose Monitoring Within a Real-World Setting: The GoBolus Study

Background: The GoBolus study investigated the real-world effectiveness of faster aspart in patients with type 1 diabetes (T1D) using intermittent-scanning continuous glucose monitoring (iscCGM) systems. Methods: This 24-week, multicenter, single-arm, noninterventional study investigated adults with T1D (HbA_1c, 7.5%-9.5%) receiving multiple daily injections (MDI) of insulin and using iscCGM within local healthcare settings for ≥6 months before switching to faster aspart at study start (week 0; baseline). Primary endpoint was HbA_1c change from baseline to week 24. Exploratory endpoint was change in iscCGM metrics from baseline to week 24. Results: Overall, 243 patients were included (55.6% male), with mean age/diabetes duration, 49.9/18.8 years; mean HbA_1c, 8.1%. By week 24, HbA_1c had decreased by 0.19% (-2.1 mmol/mol, P < 0.0001) with no mean change in insulin doses or basal/bolus insulin ratios. For patients with sufficient available iscCGM data (n = 92): "time in range" (TIR; 3.9-10.0 mmol/L) increased from 46.9% to 50.1% (P = 0.01), corresponding to an increase of 46.1 min/day; time in hyperglycemia decreased from 49.1% to 46.1% (>10.0 mmol/L, P = 0.026) and 20.4% to 17.9% (>13.9 mmol/L, P = 0.013), corresponding to 43.5 (P = 0.024) and 35.6 (P = 0.015) fewer minutes per day on average spent in these ranges, respectively; no change for time in hypoglycemia (<3.9 and <3.0 mmol/L). Mean interstitial and postprandial glucose improved from 10.4 to 10.1 mmol/L (P = 0.035) and 11.9 to 11.0 mmol/L (P = 0.002), respectively. Conclusion: Real-world switching to faster aspart in adults with T1D on MDI improved HbA_1c, increased TIR, and decreased time in hyperglycemia without affecting time in hypoglycemia. The GoBolus study: NCT03450863.

Novel Biochemical Markers of Glycemia to Predict Pregnancy Outcomes in Women With Type 1 Diabetes

OBJECTIVE

The optimal method of monitoring glycemia in pregnant women with type 1 diabetes remains controversial. This study aimed to assess the predictive performance of HbA_1c, continuous glucose monitoring (CGM) metrics, and alternative biochemical markers of glycemia to predict obstetric and neonatal outcomes.

RESEARCH DESIGN AND METHODS

One hundred fifty-seven women from the Continuous Glucose Monitoring in Women With Type 1 Diabetes in Pregnancy Trial (CONCEPTT) were included in this prespecified secondary analysis. HbA_1c, CGM data, and alternative biochemical markers (glycated CD59, 1,5-anhydroglucitol, fructosamine, glycated albumin) were compared at ∼12, 24, and 34 weeks' gestation using logistic regression and receiver operating characteristic (ROC) curves to predict pregnancy complications (preeclampsia, preterm delivery, large for gestational age, neonatal hypoglycemia, admission to neonatal intensive care unit).

RESULTS

HbA_1c, CGM metrics, and alternative laboratory markers were all significantly associated with obstetric and neonatal outcomes at 24 weeks' gestation. More outcomes were associated with CGM metrics during the first trimester and with laboratory markers (area under the ROC curve generally <0.7) during the third trimester. Time in range (TIR) (63-140 mg/dL [3.5-7.8 mmol/L]) and time above range (TAR) (>140 mg/dL [>7.8 mmol/L]) were the most consistently predictive CGM metrics. HbA_1c was also a consistent predictor of suboptimal pregnancy outcomes. Some alternative laboratory markers showed promise, but overall, they had lower predictive ability than HbA_1c.

CONCLUSIONS

HbA_1c is still an important biomarker for obstetric and neonatal outcomes in type 1 diabetes pregnancy. Alternative biochemical markers of glycemia and other CGM metrics did not substantially increase the prediction of pregnancy outcomes compared with widely available HbA_1c and increasingly available CGM metrics (TIR and TAR).

Improved time in range and postprandial hyperglycemia with canagliflozin in combination with teneligliptin: Secondary analyses of the CALMER study

Aims/Introduction

We recently reported the beneficial effect of the combination of sodium–glucose cotransporter 2 inhibitor and dipeptidyl peptidase‐4 inhibitor on daily glycemic variability in patients with type 2 diabetes mellitus. Additional favorable effects of combination therapy were explored in this secondary analysis.

Materials and Methods

The CALMER study was a multicenter, open‐label, prospective, randomized, parallel‐group comparison trial for type 2 diabetes mellitus involving continuous glucose monitoring under meal tolerance tests. Patients were randomly assigned to switch from teneligliptin to canagliflozin (SWITCH group) or to add canagliflozin to teneligliptin (COMB group). The continuous glucose monitoring metrics, including time in target range, were investigated.

Results

All 99 participants (mean age 62.3 years; mean glycated hemoglobin 7.4%) completed the trial. The time in target range was increased in the COMB group (71.2–82.7%, P < 0.001). The extent of the reduction in time above target range was significantly larger in the COMB group compared with the SWITCH group (−14.8% vs −7.5%, P < 0.01). Area under the curve values for glucose at 120 min after all meal tolerance tests were significantly decreased in the COMB group compared with the SWITCH group (P < 0.05).

Conclusions

Sodium–glucose cotransporter 2 inhibitor combined with dipeptidyl peptidase‐4 inhibitor improved the quality of glycemic variability and reduced postprandial hyperglycemia compared with each monotherapy.

Individualizing Time-in-Range Goals in Management of Diabetes Mellitus and Role of Insulin: Clinical Insights From a Multinational Panel

Diabetes mellitus is a global health concern associated with significant morbidity and mortality. Inadequate control of diabetes leads to chronic complications and higher mortality rates, which emphasizes the importance of achieving glycemic targets. Although glycated hemoglobin (HbA_1c) is the gold standard for measuring glycemic control, it has several limitations. Therefore, in recent years, along with the emergence of continuous glucose monitoring (CGM) technology, glycemic control modalities have moved beyond HbA_1c. They encompass modern glucometrics, such as glycemic variability (GV) and time-in-range (TIR). The key advantage of these newer metrics over HbA_1c is that they allow personalized diabetes management with person-centric glycemic control. Basal insulin analogues, especially second-generation basal insulins with properties such as longer duration of action and low risk of hypoglycemia, have demonstrated clinical benefits by reducing GV and improving TIR. Therefore, for more effective and accurate diabetes management, the development of an integrated approach with second-generation basal insulin and glucometrics involving GV and TIR is the need of the hour. With this objective, a multinational group of endocrinologists and diabetologists reviewed the existing recommendations on TIR, provided their clinical insights into the individualization of TIR targets, and elucidated on the role of the second-generation basal insulin analogues in addressing TIR.

Time-in-range as a target in type 2 diabetes: An urgent need

Time-in-range emerged as a valuable blood glucose metric, 'beyond HbA1c' for a deeper insight into glycemic control in people with diabetes. It denotes the proportion of time that a person's glucose level remains within the desired target range (usually 70-180 mg/dL or 3.9-10.0 mmol/L). Though clinical targets in the current recommendations for type 1 and type 2 diabetes are close enough, their clinical profiles and prevalences are quite different. Type 2 diabetes is the commonest form of diabetes. Many clinical trials have challenged the usefulness of HbA1c as a glycemic target for Type 2 diabetes mellitus. On account of the higher prevalence and complications of type 2 diabetes, more outcomes-based studies are needed to associate time-in-range with its ongoing risk. These studies strongly support the dependability of time-in-range to identify patients with elevated risk in type 2 diabetes. We discuss the utility of time-in-range, a new metric of continuous glucose monitoring as an outcome measure to correlate with type 2 diabetes risks and complications and to analyze the effectiveness of type 2 diabetes management. This approach may support the use of time-in-range as a metric for long-term health outcomes in the type 2 diabetes population.

Choice of Continuous Glucose Monitoring Systems May Affect Metrics: Clinically Relevant Differences in Times in Ranges

Background Continuous glucose monitoring-derived parameters are becoming increasingly important in the treatment of people with diabetes. The aim of this study was to assess whether these parameters, as calculated from different continuous glucose monitoring systems worn in parallel, are comparable. In addition, clinical relevance of differences was investigated.

Methods A total of 24 subjects wore a FreeStyle Libre (A) and a Dexcom G5 (B) sensor in parallel for 7 days. Mean glucose, coefficient of variation, glucose management indicator and time spent in different glucose ranges were calculated for each system. Pairwise differences between the two different continuous glucose monitoring systems were computed for these metrics.

Results On average, the two CGM systems indicated an identical time in range (67.9±10.2 vs. 67.9±11.5%) and a similar coefficient of variation; both categorized as unstable (38.1±5.9 vs. 36.0±4.8%). In contrast, the mean time spent below and above range, as well as the individual times spent below, in and above range differed substantially. System A indicated about twice the time spent below range than system B (7.7±7.2 vs. 3.8±2.7%, p=0.003). This could have led to different therapy recommendations in approximately half of the subjects.

Discussion The differences in metrics found between the two continuous glucose monitoring systems may result in different therapy recommendations. In order to make adequate clinical decisions, measurement performance of CGM systems should be standardized and all available information, including the HbA1c, should be utilized.

A synthetic BRET-based optogenetic device for pulsatile transgene expression enabling glucose homeostasis in mice

Pulsing cellular dynamics in genetic circuits have been shown to provide critical capabilities to cells in stress response, signaling and development. Despite the fascinating discoveries made in the past few years, the mechanisms and functional capabilities of most pulsing systems remain unclear, and one of the critical challenges is the lack of a technology that allows pulsatile regulation of transgene expression both in vitro and in vivo. Here, we describe the development of a synthetic BRET-based transgene expression (LuminON) system based on a luminescent transcription factor, termed luminGAVPO, by fusing NanoLuc luciferase to the light-switchable transcription factor GAVPO. luminGAVPO allows pulsatile and quantitative activation of transgene expression via both chemogenetic and optogenetic approaches in mammalian cells and mice. Both the pulse amplitude and duration of transgene expression are highly tunable via adjustment of the amount of furimazine. We further demonstrated LuminON-mediated blood-glucose homeostasis in type 1 diabetic mice. We believe that the BRET-based LuminON system with the pulsatile dynamics of transgene expression provides a highly sensitive tool for precise manipulation in biological systems that has strong potential for application in diverse basic biological studies and gene- and cell-based precision therapies in the future.

The Diabetic Lung: Insights into Pulmonary Changes in Children and Adolescents with Type 1 Diabetes

Historically, the lung was not listed and recognized as a major target organ of diabetic injury. The first evidence of diabetic lung involvement was published fifty years ago, with a study conducted in a population of young adults affected by type 1 diabetes (T1D). In recent years, there has been mounting evidence showing that the lung is a target organ of diabetic injury since the beginning of the disease—at the pediatric age. The deeply branched vascularization of the lungs and the abundance of connective tissue, indeed, make them vulnerable to the effects of hyperglycemia, in a way similar to other organs affected by microvascular complications. In this review, we focus on pulmonary function impairment in children and adolescents affected by T1D. We also cover controversial aspects regarding available studies and future perspectives in this field.

Evaluating Glycemic Control During Basalin or Lantus Administration in Adults With Controlled Type 2 Diabetes Mellitus Using Continuous Glucose Monitoring

AIM

This study aims at evaluating glycemic control during Basalin or Lantus administration in adults with controlled type 2 diabetes mellitus using continuous glucose monitoring system (CGM).

METHODS

47 patients with well-controlled T2DM using both Basalin and oral hypoglycemic drugs were recruited. CGM were applied from day 1 to day 3 with the unchanged dose of Basalin and then removed from day 4. A washout was performed with Lantus at the same dose as Basalin from day 4 to day 10. Then patients were continued to install the CGM under Lantus administration from day 11 to day 13. Variables of CGM, such as the area under the curve (AUC) for both hyperglycemia and hypoglycemia, 24h mean blood glucose (24h MBG), 24h standard deviation of blood glucose (24h SDBG), 24h mean amplitude of glycemic excursion (24h MAGE), PT (percentage of time), and time in range (TIR), were calculated and compared between Basalin group and Lantus group.

RESULTS

The group of Lantus showed lower 24h MBG (p<0.01), 24h MAGE (p<0.05), and lower 24h SDBG (p<0.01) than the Basalin group. Lantus-treated patients had a lower PT and AUC when the cut-off point for blood glucose was 10 mmol/L (p<0.05) and 13.9 mmol/L (p<0.05), respectively. In this study, no patient developed symptomatic hypoglycemia, few hypoglycemia was observed and there was no difference of hypoglycemia between the two groups.

CONCLUSION

In patients with well-controlled T2DM who were treated with insulin glargine, Lantus group showed lower MBG, GV, and lower PT (BG > 10.0 mmol/L, BG > 13.9 mmol/L) than Basalin group. In summary, for T2DM population with HbA1c ≤ 7%, Lantus may be a better choice compared with Basalin.

6. Glycemic Targets: Standards of Medical Care in Diabetes-2021

The American Diabetes Association (ADA) "Standards of Medical Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee (https://doi.org/10.2337/dc21-SPPC), are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations, please refer to the Standards of Care Introduction (https://doi.org/10.2337/dc21-SINT). Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Ultra Rapid-Acting Inhaled Insulin Improves Glucose Control in Patients With Type 2 Diabetes Mellitus

OBJECTIVE

To determine whether the use of an inhaled insulin would improve HbA1c.

METHODS

This study was performed in 20 type 2 diabetes mellitus (T2DM) participants with HbA1c values ≥7.5 (58) to ≤11.5% (102 mmol/mol) on a variety of glucose-lowering regimens. Prandial Technosphere insulin (TI) was rapidly titrated based on a treatment algorithm using postprandial blood glucose to calculate premeal doses. A 2-week baseline period was followed by 12 weeks of active treatment with TI. The primary outcome was change in HbA1c. Secondary outcomes included glucose time in range (time in range: 70-180 mg/dL) obtained by a blinded continuous glucose monitoring during the baseline period and at the end of 12 weeks. Goals were to assess how to rapidly and safely initiate TI intensification, determine dosing requirements, and establish an effective dose range in uncontrolled T2DM.

RESULTS

Mean HbA1c decreased by -1.6% (-17 mmol/mol) from 9.0% (75 mmol/mol) at baseline to 7.4% (57 mmol/mol) at 12 weeks (P < .0001). Mean time in range increased from 42.2% to 65.7% (P < .0002). Mean prandial doses of TI were 18 or 19 units for all meals. Time below range was 1.1% baseline and 2.6% post treatment (P = .01).

CONCLUSION

Treatment with inhaled TI dosed using a simple algorithm improved glycemic control measured by both HbA1c and time in range, with low rates of hypoglycemia. These data add significantly to understanding TI in the management of T2DM patients for whom prandial insulin is a consideration.

Real-World Improvements in Hypoglycemia in an Insulin-Dependent Cohort With Diabetes Mellitus Pre/Post Tandem Basal-Iq Technology Remote Software Update

OBJECTIVE

Software updatable insulin pumps, such as the t:slim X2 pump from Tandem Diabetes Care, enable access to new technology as soon as it is commercialized. The remote software update process allows for minimal interruption in therapy compared to purchasing a new pump; however, little quantitative data exist on the software update process or on pre/post therapeutic outcomes. We examined real-world usage and impact of a remote software updatable predictive low-glucose suspend (PLGS) technology designed to reduce hypoglycemic events in people with insulin-dependent diabetes.

METHODS

Approximately 15,000 U.S. Tandem pump users remotely updated their t:slim X2 software to Basal-IQ PLGS technology since its commercial release. We performed a retrospective analysis of users who uploaded at least 21 days of pre/post PLGS update usage data to the Tandem t:connect web application between August 28, 2018, and October 21, 2019 (N = 6,170). Insulin delivery and sensor-glucose values were analyzed per recent international consensus and American Diabetes Association guidelines. Software update performance was also assessed.

RESULTS

Median software update time was 5.36 minutes. Overall glycemic outcomes for pre and post software update showed a decrease in sensor time <70 mg/dL from 2.14 to 1.18% (-1.01; 95% confidence interval [CI], -0.97, -1.05; P<.001), with overall sensor time 70 to 180 mg/dL increasing from 57.8 to 58.5% (0.64; 95% CI, 0.04, 1.24; P<.001). These improvements were sustained at 3, 6, and 9 months after the update.

CONCLUSION

Introduction of a software updatable PLGS algorithm for the Tandem t:slim X2 insulin pump resulted in sustained reductions of hypoglycemia.

ABBREVIATIONS

ADA = American Diabetes Association; CGM = continuous glucose monitoring; CI = confidence interval; PLGS = predictive low-glucose suspend; SG = sensor glucose; T1D = type 1 diabetes; T2D = type 2 diabetes; TIR = time-in-range.

Application of medium-term metrics for assessing glucose homoeostasis: Usefulness, strengths and weaknesses

This review aims to address the issue of whether or not the newer metrics, developed for continuous glucose monitoring [real-time CGM (rtCGM), intermittently scanned CGM (isCGM)], enhance assessment of the "glucose tetrad": Ambient hyperglycaemia, short-term glycaemic variability, postprandial glucose excursions and hypoglycaemia. The ever-increasing number of metrics offered with rtCGM and isCGM includes intermediate-term indicators referred to as "time in range" (TIR), the time spent in the range of 70-180mg/dL (TIR 70-180); time spent above the range of 180mg/dL (TAR>180); and time spent below the range of 70mg/dL or 54mg/dL (TBR<70 or TBR<54). The former two values are strongly correlated with HbA1c levels and can therefore serve as short- or medium-term markers of ambient hyperglycaemia, depending on whether glucose sensors are worn over periods of several days or weeks, respectively, whereas the latter indices (TBR<70 or<54) are more relevant for capturing hypoglycaemic events and quantifying their magnitude and duration, in contrast to random spot testing with self-monitoring of blood glucose. Nevertheless, although analyses of 24h glucose profiles by CGM provide a highly valuable method for quantifying postprandial glucose excursions and short-term glycaemic variability, neither of these factors can be fully represented by such TIR metrics. Thus, other metrics are clearly needed for more comprehensive assessment of glucose homoeostasis.

An emerging new concept for the management of type 2 diabetes with a paradigm shift from the glucose-centric to beta cell-centric concept of diabetes - an Asian perspective

INTRODUCTION

Recent advances in anti-diabetic medications and glucose monitoring have led to a paradigm shift in diabetes care. Newer anti-diabetic medications such as DPP-4 inhibitors, GLP-1 receptor agonists (GLP-1RAs), and SGLT2 inhibitors have enabled optimal glycemic control to be achieved without increasing the risk of hypoglycemia and weight gain. Treatment with GLP-1RAs and SGLT2 inhibitors has been demonstrated to improve cardiorenal outcomes, positioning these agents as the mainstay of treatment for patients with type 2 diabetes (T2DM). The development of these newer agents has also prompted a paradigm shift in the concept of T2DM, highlighting the importance of beta cell dysfunction in the pathophysiology of T2DM.

AREAS COVERED

Recent advances in pharmacotherapy for diabetes are summarized with a focus on the role of incretin-based drugs and SGLT2 inhibitors. The importance of a paradigm shift from a glucose-centric to a beta cell-centric concept of T2DM is also discussed, given from an Asian perspective.

EXPERT OPINION

Management of T2DM including lifestyle modification as well as pharmacotherapy should be focused on reducing beta cell workload, to preserve functional beta cell mass. A paradigm shift from a glucose-centric to a beta cell-centric concept of T2DM enhances the implementation of person-centered diabetes care.

Influence of glucometric 'dynamical' variables on duodenal-jejunal bypass liner (DJBL) anthropometric and metabolic outcomes

BACKGROUND

The endoscopically implanted duodenal-jejunal bypass liner (DJBL) is an attractive alternative to bariatric surgery for obese diabetic patients. This article aims to study dynamical aspects of the glycaemic profile that may influence DJBL effects.

METHODS

Thirty patients underwent DJBL implantation and were followed for 10 months. Continuous glucose monitoring (CGM) was performed before implantation and at month 10. Dynamical variables from CGM were measured: coefficient of variation of glycaemia, mean amplitude of glycaemic excursions (MAGE), detrended fluctuation analysis (DFA), % of time with glycaemia under 6.1 mmol/L (TU6.1), area over 7.8 mmol/L (AO7.8) and time in range. We analysed the correlation between changes in both anthropometric (body mass index, BMI and waist circumference) and metabolic (fasting blood glucose, FBG and HbA1c) variables and dynamical CGM-derived metrics and searched for variables in the basal CGM that could predict successful outcomes.

RESULTS

There was a poor correlation between anthropometric and metabolic outcomes. There was a strong correlation between anthropometric changes and changes in glycaemic tonic control (∆BMI-∆TU6.1: rho = - 0.67, P < .01) and between metabolic outcomes and glycaemic phasic control (∆FBG-∆AO7.8: r = .60, P < .01). Basal AO7.8 was a powerful predictor of successful metabolic outcome (0.85 in patients with AO7.8 above the median vs 0.31 in patients with AO7.8 below the median: Chi-squared = 5.67, P = .02).

CONCLUSIONS

In our population, anthropometric outcomes of DJBL correlate with improvement in tonic control of glycaemia, while metabolic outcomes correlate preferentially with improvement in phasic control. Assessment of basal phasic control may help in candidate profiling for DJBL implantation.

The Correlation between Time in Range and Diabetic Microvascular Complications Utilizing Information Management Platform

BACKGROUND

In recent years, the time of blood glucose within the target range is a new research hotspot in blood glucose management. TIR is expected to be a novel indicator for evaluating the efficacy of glycemic control and predicting diabetic complications. However, its relationship with diabetic complications has not been fully elucidated.

OBJECTIVE

To explore the relationship between time in range (TIR) and glycosylated hemoglobin (HbA1C) through the information big data management platform. Possible association between TIR and diabetic microvascular complications (retinopathy, nephropathy, and neuropathy) was investigated, attempting to provide theoretical basis for the clinical application of TIR and to explore the TIR control scope suitable for diabetic patients.

METHODS

A total of 5,644 type 2 diabetic patients hospitalized in the Department of Endocrinology, the Second Affiliated Hospital of Nanchang University, were selected from April 2017 to June 2020. Fingertip capillary blood glucose monitoring (FCGM) was monitored for a total of 455,664 times, and patients who are nondiabetic, pregnant, or with diabetic ketosis were excluded. Patients with 7 blood glucose points monitored for at least three consecutive days were selected as subjects in the study. 1,895 males and 1,513 females with diabetes were included, with an average age of (59.74 ± 13.40) years old and an average course of disease of 8.28 ± 7.11 years. The proportion of time in range (TIR) (70∼180 mg/dl) within the target range and the correlation between TIR and HbA1C were analyzed, as well as the relationship between TIR and the risk of diabetic complications.

RESULTS

(1) The average of TIR and HbA1C was 49.65 ± 23.36% and 8.92 ± 2.49%, respectively, and was linearly correlated. With the decrease of TIR, HbA1C increased significantly, and the difference was statistically significant (P < 0.01, R ² = 0.458). The correlation coefficient of mean TIR with mean HbA1C was -0.626. (2) There were 836 patients diagnosed with diabetic nephropathy (DN). The difference of TIR value between DN and non-DN was significant (T = 2.250, P < 0.05). Risk assessment showed the lower the TIR was, the higher the risk of DN was. TIR less than 40% was a risk factor for DN (OR = 1.249, 95% CI: 0.915-1.375). (3) There were 1,296 patients diagnosed with diabetic peripheral neuropathy (DPN). The difference of TIR value between DPN and non-DPN was significant (T = 3.844, P < 0.01). TIR value less than 70% was a risk factor for DPN (OR = 1.030, 95% CI: 0.769-1.379). (4) There were 2,077 patients diagnosed with diabetic retinopathy (DR). The difference of TIR value between DPN and non-DPN was significant (T = 3.608, P < 0.01). TIR value less than 50% was a risk factor for DR (OR = 1.092, 95% CI: 0.898-1.264). Summary. TIR may serve as a reference index for short-term blood glucose control, strongly reflecting the clinical blood glucose regulation and predicting the risk of diabetic microvascular complications.