Closed-Loop Control During Intense Prolonged Outdoor Exercise in Adolescents With Type 1 Diabetes: The Artificial Pancreas Ski Study

Artificial pancreas treatment for outpatients with type 1 diabetes: systematic review and meta-analysis

OBJECTIVE

To evaluate the efficacy and safety of artificial pancreas treatment in non-pregnant outpatients with type 1 diabetes.

DESIGN

Systematic review and meta-analysis of randomised controlled trials.

DATA SOURCES

Medline, Embase, Cochrane Library, and grey literature up to 2 February 2018.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Randomised controlled trials in non-pregnant outpatients with type 1 diabetes that compared the use of any artificial pancreas system with any type of insulin based treatment. Primary outcome was proportion (%) of time that sensor glucose level was within the near normoglycaemic range (3.9-10 mmol/L). Secondary outcomes included proportion (%) of time that sensor glucose level was above 10 mmol/L or below 3.9 mmol/L, low blood glucose index overnight, mean sensor glucose level, total daily insulin needs, and glycated haemoglobin. The Cochrane Collaboration risk of bias tool was used to assess study quality.

RESULTS

40 studies (1027 participants with data for 44 comparisons) were included in the meta-analysis. 35 comparisons assessed a single hormone artificial pancreas system, whereas nine comparisons assessed a dual hormone system. Only nine studies were at low risk of bias. Proportion of time in the near normoglycaemic range (3.9-10.0 mmol/L) was significantly higher with artificial pancreas use, both overnight (weighted mean difference 15.15%, 95% confidence interval 12.21% to 18.09%) and over a 24 hour period (9.62%, 7.54% to 11.7%). Artificial pancreas systems had a favourable effect on the proportion of time with sensor glucose level above 10 mmol/L (-8.52%, -11.14% to -5.9%) or below 3.9 mmol/L (-1.49%, -1.86% to -1.11%) over 24 hours, compared with control treatment. Robustness of findings for the primary outcome was verified in sensitivity analyses, by including only trials at low risk of bias (11.64%, 9.1% to 14.18%) or trials under unsupervised, normal living conditions (10.42%, 8.63% to 12.2%). Results were consistent in a subgroup analysis both for single hormone and dual hormone artificial pancreas systems.

CONCLUSIONS

Artificial pancreas systems are an efficacious and safe approach for treating outpatients with type 1 diabetes. The main limitations of current research evidence on artificial pancreas systems are related to inconsistency in outcome reporting, small sample size, and short follow-up duration of individual trials.

The Benefits and Limits of Technological Advances in Glucose Management Around Physical Activity in Patients Type 1 Diabetes

Physical activity is highly recommended for patients living with type 1 diabetes (T1D) due to its varied health benefits. Nevertheless, glucose management, during and in the hours following exercise, represents a great challenge for these patients who most often end up leading a sedentary life style. Important technological advances in insulin delivery devices and glucose monitoring are now available and continue to progress. These technologies could be used to alleviate glucose management related to physical activity in T1D. Continuous glucose monitoring (CGM) helps patients observe the trends of glycemic fluctuations when exercising and in the following night to deal pre-emptively with hypoglycemic risks and treat hypoglycemic episodes in a timely manner. Insulin pumps offer the flexibility of adjusting insulin basal rates and boluses according to patient's specific needs around exercise. The artificial pancreas links CGM to pump through an intelligent hormone dosing algorithm to close the loop of glucose control and has thus the potential to ease the burden of exercise in T1D. This review will examine and discuss the literature related to physical activity practice using each of these technologies. The aim is to discuss their benefits as well as their limitations and finally the additional research needed in the future to optimize their use in T1D.