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Abstract
The pancreas is a complex organ with exocrine and endocrine components. Many pathologies impair exocrine function, including chronic pancreatitis, cystic fibrosis and pancreatic ductal adenocarcinoma. Conversely, when the endocrine pancreas fails to secrete sufficient insulin, patients develop diabetes mellitus. Pathology in either the endocrine or exocrine pancreas results in devastating economic and personal consequences. The current standard therapy for treating patients with type 1 diabetes mellitus is daily exogenous insulin injections, but cell sources of insulin provide superior glycaemic regulation and research is now focused on the goal of regenerating or replacing β cells. Stem-cell-based models might be useful to study exocrine pancreatic disorders, and mesenchymal stem cells or secreted factors might delay disease progression. Although the standards that bioengineered cells must meet before being considered as a viable therapy are not yet established, any potential therapy must be acceptably safe and functionally superior to current therapies. Here, we describe progress and challenges in cell-based methods to restore pancreatic function, with a focus on optimizing the site for cell delivery and decreasing requirements for immunosuppression through encapsulation. We also discuss the tools and strategies being used to generate exocrine pancreas and insulin-producing β-cell surrogates in situ and highlight obstacles to clinical application.
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202
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Herrero P, Bondia J, Oliver N, Georgiou P. A coordinated control strategy for insulin and glucagon delivery in type 1 diabetes. Comput Methods Biomech Biomed Engin 2017; 20:1474-1482. [PMID: 28929796 DOI: 10.1080/10255842.2017.1378352] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Type 1 diabetes is an autoimmune condition characterised by a pancreatic insulin secretion deficit, resulting in high blood glucose concentrations, which can lead to micro- and macrovascular complications. Type 1 diabetes also leads to impaired glucagon production by the pancreatic α-cells, which acts as a counter-regulatory hormone to insulin. A closed-loop system for automatic insulin and glucagon delivery, also referred to as an artificial pancreas, has the potential to reduce the self-management burden of type 1 diabetes and reduce the risk of hypo- and hyperglycemia. To date, bihormonal closed-loop systems for glucagon and insulin delivery have been based on two independent controllers. However, in physiology, the secretion of insulin and glucagon in the body is closely interconnected by paracrine and endocrine associations. In this work, we present a novel biologically-inspired glucose control strategy that accounts for such coordination. An in silico study using an FDA-accepted type 1 simulator was performed to evaluate the proposed coordinated control strategy compared to its non-coordinated counterpart, as well as an insulin-only version of the controller. The proposed coordinated strategy achieves a reduction of hyperglycemia without increasing hypoglycemia, when compared to its non-coordinated counterpart.
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Affiliation(s)
- Pau Herrero
- a Centre for Bio-Inspired Technology, Institute of Biomedical Engineering , Imperial College London , London , UK
| | - Jorge Bondia
- b Institut Universitari d'Automàtica i Informàtica Industrial , Universitat Politècnica de València , València , Spain
| | - Nick Oliver
- c Charing Cross Hospital, Imperial College Healthcare NHS Trust , London , UK
| | - Pantelis Georgiou
- a Centre for Bio-Inspired Technology, Institute of Biomedical Engineering , Imperial College London , London , UK
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203
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Weisman A, Kramer CK, Perkins BA. Meta-analysis of artificial pancreas trials: methodological considerations - Authors' reply. Lancet Diabetes Endocrinol 2017; 5:685-686. [PMID: 28842160 DOI: 10.1016/s2213-8587(17)30237-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 06/28/2017] [Indexed: 11/30/2022]
Affiliation(s)
- Alanna Weisman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada; Leadership Sinai Centre for Diabetes, Toronto, ON M5T 3L9, Canada; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Caroline K Kramer
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada
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204
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Tauschmann M, Hovorka R. Insulin delivery and nocturnal glucose control in children and adolescents with type 1 diabetes. Expert Opin Drug Deliv 2017; 14:1367-1377. [PMID: 28819992 PMCID: PMC5942151 DOI: 10.1080/17425247.2017.1360866] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Introduction: Nocturnal glucose control remains challenging in children and adolescents with type 1 diabetes due to highly variable overnight insulin requirements. The issue may be addressed by glucose responsive insulin delivery based on real-time continuous glucose measurements. Areas covered: This review outlines recent developments of glucose responsive insulin delivery systems from a paediatric perspective. We cover threshold-based suspend application, predictive low glucose suspend, and more advanced single hormone and dual-hormone closed-loop systems. Approaches are evaluated in relation to nocturnal glucose control particularly during outpatient randomised controlled trials. Expert opinion: Significant progress translating research from controlled clinical centre settings to free-living unsupervised home studies have been achieved over the past decade. Nocturnal glycaemic control can be improved whilst reducing the risk of hypoglycaemia with closed-loop systems. Following the US regulatory approval of the first hybrid closed-loop system in non-paediatric population, large multinational closed-loop clinical trials and pivotal studies including paediatric populations are underway or in preparation to facilitate the use of closed-loop systems in clinical practice.
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Affiliation(s)
- Martin Tauschmann
- a Wellcome Trust-MRC Institute of Metabolic Science , University of Cambridge , Cambridge , UK.,b Department of Paediatrics , University of Cambridge , Cambridge , UK
| | - Roman Hovorka
- a Wellcome Trust-MRC Institute of Metabolic Science , University of Cambridge , Cambridge , UK.,b Department of Paediatrics , University of Cambridge , Cambridge , UK
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205
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Abstract
PURPOSE OF REVIEW The review summarizes the current state of the artificial pancreas (AP) systems and introduces various new modules that should be included in future AP systems. RECENT FINDINGS A fully automated AP must be able to detect and mitigate the effects of meals, exercise, stress and sleep on blood glucose concentrations. This can only be achieved by using a multivariable approach that leverages information from wearable devices that provide real-time streaming data about various physiological variables that indicate imminent changes in blood glucose concentrations caused by meals, exercise, stress and sleep. The development of a fully automated AP will necessitate the design of multivariable and adaptive systems that use information from wearable devices in addition to glucose sensors and modify the models used in their model-predictive alarm and control systems to adapt to the changes in the metabolic state of the user. These AP systems will also integrate modules for controller performance assessment, fault detection and diagnosis, machine learning and classification to interpret various signals and achieve fault-tolerant control. Advances in wearable devices, computational power, and safe and secure communications are enabling the development of fully automated multivariable AP systems.
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Affiliation(s)
- Ali Cinar
- Department of Chemical and Biological Engineering and Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL, USA.
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206
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Ang KH, Sherr JL. Moving beyond subcutaneous insulin: the application of adjunctive therapies to the treatment of type 1 diabetes. Expert Opin Drug Deliv 2017; 14:1113-1131. [DOI: 10.1080/17425247.2017.1360862] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Kathleen H. Ang
- Yale Children’s Diabetes Program, Yale University School of Medicine, New Haven, CT, USA
| | - Jennifer L. Sherr
- Yale Children’s Diabetes Program, Yale University School of Medicine, New Haven, CT, USA
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207
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Ly TT, Weinzimer SA, Maahs DM, Sherr JL, Roy A, Grosman B, Cantwell M, Kurtz N, Carria L, Messer L, von Eyben R, Buckingham BA. Automated hybrid closed-loop control with a proportional-integral-derivative based system in adolescents and adults with type 1 diabetes: individualizing settings for optimal performance. Pediatr Diabetes 2017; 18:348-355. [PMID: 27191182 DOI: 10.1111/pedi.12399] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2016] [Revised: 04/06/2016] [Accepted: 04/22/2016] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Automated insulin delivery systems, utilizing a control algorithm to dose insulin based upon subcutaneous continuous glucose sensor values and insulin pump therapy, will soon be available for commercial use. The objective of this study was to determine the preliminary safety and efficacy of initialization parameters with the Medtronic hybrid closed-loop controller by comparing percentage of time in range, 70-180 mg/dL (3.9-10 mmol/L), mean glucose values, as well as percentage of time above and below target range between sensor-augmented pump therapy and hybrid closed-loop, in adults and adolescents with type 1 diabetes. METHODS We studied an initial cohort of 9 adults followed by a second cohort of 15 adolescents, using the Medtronic hybrid closed-loop system with the proportional-integral-derivative with insulin feed-back (PID-IFB) algorithm. Hybrid closed-loop was tested in supervised hotel-based studies over 4-5 days. RESULTS The overall mean percentage of time in range (70-180 mg/dL, 3.9-10 mmol/L) during hybrid closed-loop was 71.8% in the adult cohort and 69.8% in the adolescent cohort. The overall percentage of time spent under 70 mg/dL (3.9 mmol/L) was 2.0% in the adult cohort and 2.5% in the adolescent cohort. Mean glucose values were 152 mg/dL (8.4 mmol/L) in the adult cohort and 153 mg/dL (8.5 mmol/L) in the adolescent cohort. CONCLUSIONS Closed-loop control using the Medtronic hybrid closed-loop system enables adaptive, real-time basal rate modulation. Initializing hybrid closed-loop in clinical practice will involve individualizing initiation parameters to optimize overall glucose control.
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Affiliation(s)
- Trang T Ly
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA, USA.,School of Paediatrics and Child Health, The University of Western Australia, Perth, Western Australia, Australia
| | - Stuart A Weinzimer
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - David M Maahs
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO, USA
| | - Jennifer L Sherr
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | | | | | | | | | - Lori Carria
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Laurel Messer
- Barbara Davis Center for Childhood Diabetes, University of Colorado Denver, Aurora, CO, USA
| | - Rie von Eyben
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA, USA
| | - Bruce A Buckingham
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA, USA
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208
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Abstract
PURPOSE OF REVIEW Type 1 diabetes (T1D) and type 2 diabetes (T2D) are frequent conditions during childhood and adolescence. The present review offers an update on current available treatment strategies for T1D and T2D approved for use in children and adolescents. RECENT FINDINGS Insulin remains the main and essential therapeutic strategy in youth with T1D. A second generation of insulin analogues is being evaluated and could help in improving glycemic control. Over the last decades advances in technology have allowed the implementation of insulin pump therapy and continuous glucose monitoring, and are now leading the way towards the development of an artificial pancreas or closed loop system.Treatment of T2D is based on lifestyle interventions and metformin as the first-line drug to be used. Little evidence is available for other oral hypoglycemic drugs, currently used in adults. SUMMARY Although much progress has been made in the field of diabetes management, there are still several unmet goals. One of the main issues is to develop a system allowing more physiological insulin coverage. For both T1D and T2D, there is a strong need of new drugs to be used alone or in combination, mainly in patients struggling to achieve good glycemic control.
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209
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Weisman A, Bai JW, Cardinez M, Kramer CK, Perkins BA. Effect of artificial pancreas systems on glycaemic control in patients with type 1 diabetes: a systematic review and meta-analysis of outpatient randomised controlled trials. Lancet Diabetes Endocrinol 2017; 5:501-512. [PMID: 28533136 DOI: 10.1016/s2213-8587(17)30167-5] [Citation(s) in RCA: 304] [Impact Index Per Article: 43.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 04/11/2017] [Accepted: 04/11/2017] [Indexed: 12/27/2022]
Abstract
BACKGROUND Closed-loop artificial pancreas systems have been in development for several years, including assessment in numerous varied outpatient clinical trials. We aimed to summarise the efficacy and safety of artificial pancreas systems in outpatient settings and explore the clinical and technical factors that can affect their performance. METHODS We did a systematic review and meta-analysis of randomised controlled trials comparing artificial pancreas systems (insulin only or insulin plus glucagon) with conventional pump therapy (continuous subcutaneous insulin infusion [CSII] with blinded continuous glucose monitoring [CGM] or unblinded sensor-augmented pump [SAP] therapy) in adults and children with type 1 diabetes. We searched Medline, Embase, and the Cochrane Central Register of Controlled Trials for studies published from 1946, to Jan 1, 2017. We excluded studies not published in English, those involving pregnant women or participants who were in hospital, and those testing adjunct medications other than glucagon. The primary outcome was the mean difference in percentage of time blood glucose concentration remained in target range (3·9-10 mmol/L or 3·9-8 mmol/L, depending on the study), assessed by random-effects meta-analysis. This study is registered with PROSPERO, number 2015:CRD42015026854. FINDINGS We identified 984 reports; after exclusions, 27 comparisons from 24 studies (23 crossover and one parallel design) including a total of 585 participants (219 in adult studies, 265 in paediatric studies, and 101 in combined studies) were eligible for analysis. Five comparisons assessed dual-hormone (insulin and glucagon), two comparisons assessed both dual-hormone and single-hormone (insulin only), and 20 comparisons assessed single-hormone artificial pancreas systems. Time in target was 12·59% higher with artificial pancreas systems (95% CI 9·02-16·16; p<0·0001), from a weighted mean of 58·21% for conventional pump therapy (I2=84%). Dual-hormone artificial pancreas systems were associated with a greater improvement in time in target range compared with single-hormone systems (19·52% [95% CI 15·12-23·91] vs 11·06% [6·94 to 15·18]; p=0·006), although six of seven comparisons compared dual-hormone systems to CSII with blinded CGM, whereas 21 of 22 single-hormone comparisons had SAP as the comparator. Single-hormone studies had higher heterogeneity than dual-hormone studies (I2 79% vs 66%). Bias assessment characteristics were incompletely reported in 12 of 24 studies, no studies masked participants to the intervention assignment, and masking of outcome assessment was not done in 12 studies and was unclear in 12 studies. INTERPRETATION Artificial pancreas systems uniformly improved glucose control in outpatient settings, despite heterogeneous clinical and technical factors. FUNDING None.
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Affiliation(s)
- Alanna Weisman
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada.
| | - Johnny-Wei Bai
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Marina Cardinez
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada
| | - Caroline K Kramer
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Bruce A Perkins
- Lunenfeld-Tanenbaum Research Institute, Mount Sinai Hospital, Toronto, ON, Canada; Division of Endocrinology and Metabolism, Department of Medicine, University of Toronto, Toronto, ON, Canada
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210
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Turksoy K, Frantz N, Quinn L, Dumin M, Kilkus J, Hibner B, Cinar A, Littlejohn E. Automated Insulin Delivery-The Light at the End of the Tunnel. J Pediatr 2017; 186:17-28.e9. [PMID: 28396030 DOI: 10.1016/j.jpeds.2017.02.055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 02/13/2017] [Accepted: 02/20/2017] [Indexed: 12/28/2022]
Affiliation(s)
- Kamuran Turksoy
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL
| | - Nicole Frantz
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL
| | - Laurie Quinn
- College of Nursing, University of Illinois at Chicago, Chicago, IL
| | - Magdalena Dumin
- Biological Sciences Division, University of Chicago, Chicago, IL
| | - Jennifer Kilkus
- Biological Sciences Division, University of Chicago, Chicago, IL
| | - Brooks Hibner
- Biological Sciences Division, University of Chicago, Chicago, IL
| | - Ali Cinar
- Department of Biomedical Engineering, Illinois Institute of Technology, Chicago, IL; Biological Sciences Division, University of Chicago, Chicago, IL; Department of Chemical and Biological Engineering, Illinois Institute of Technology, Chicago, IL
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211
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Shanker K, Daley T, Semple R, Rouster-Stevens K, Ham JN. Intractable Hypoglycemia in the Setting of Autoimmune Overlap Syndrome. Pediatrics 2017; 139:peds.2016-0866. [PMID: 28562254 DOI: 10.1542/peds.2016-0866] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/29/2016] [Indexed: 11/24/2022] Open
Abstract
Evaluation of hypoglycemia in a patient with known diabetes mellitus, although usually straightforward, can at times be challenging. We present the case of an 8 year-old Latina girl initially diagnosed with type 1 diabetes mellitus in the setting of multiple autoimmune disorders, including dermatomyositis and lupus nephritis. She subsequently developed signs of insulin resistance and severe hypoglycemia, which was found to be due to insulin-receptor autoantibodies. This condition, known as type B insulin resistance, is a rare, heterogeneous metabolic disease that may feature hypoglycemia in the setting of extreme insulin resistance and hyperinsulinemia and, in this case, masqueraded as type 1 diabetes mellitus. The presence of hypoglycemia in the setting of multiple autoimmune disorders should prompt consideration of autoimmune-mediated hypoglycemia. In addition to immunologic modifying therapies, advances in diabetes care in the form of continuous glucose monitoring have provided an additional tool to manage recurrent hypoglycemia.
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Affiliation(s)
| | | | - Robert Semple
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom; and
| | - Kelly Rouster-Stevens
- Division of Pediatric Rheumatology, Department of Pediatrics, Emory University, Atlanta, Georgia
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212
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Christiansen SC, Fougner AL, Stavdahl Ø, Kölle K, Ellingsen R, Carlsen SM. A Review of the Current Challenges Associated with the Development of an Artificial Pancreas by a Double Subcutaneous Approach. Diabetes Ther 2017; 8:489-506. [PMID: 28503717 PMCID: PMC5446388 DOI: 10.1007/s13300-017-0263-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Indexed: 01/01/2023] Open
Abstract
INTRODUCTION Patients with diabetes type 1 (DM1) struggle daily to achieve good glucose control. The last decade has seen a rush of research groups working towards an artificial pancreas (AP) through the application of a double subcutaneous approach, i.e., subcutaneous (SC) continuous glucose monitoring (CGM) and continuous subcutaneous insulin infusion. Few have focused on the fundamental limitations of this approach, especially regarding outcome measures beyond time in range. METHODS Based on insulin physiology, the limitations of CGM, SC insulin absorption, meal challenge, and physical activity in DM1 patients, we discuss the limitations of the double SC approach. Finally, we discuss safety measures and the achievements reported in some recent AP studies that have utilized the double SC approach. RESULTS Most studies show that a double SC AP increases the time in range compared to a sensor-augmented insulin pump and shortens the time in hypoglycemia. Despite these achievements, the proportion of time spent in hyperglycemia is still roughly 20-40%, and hypoglycemia is still present 1-4% of the time. The main factors limiting further progress are the latency of SC CGM (at least 5-10 min) and the slow pharmacokinetics of SC-delivered fast-acting insulin. The maximum blood insulin level is reached after 45 min and the maximum glucose-lowering effect is observed after 1.5-2 h, while the glucose-lowering effect lasts for at least 5 h. CONCLUSIONS Although using a double SC AP leads to significant improvements in glucose control, the SC approach has severe limitations that hamper further progress towards a robust AP.
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Affiliation(s)
- Sverre Christian Christiansen
- Department of Endocrinology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway.
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway.
| | - Anders Lyngvi Fougner
- Department of Engineering Cybernetics, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Central Norway Regional Health Authority, Stjørdal, Norway
| | - Øyvind Stavdahl
- Department of Engineering Cybernetics, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Konstanze Kölle
- Department of Engineering Cybernetics, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
- Central Norway Regional Health Authority, Stjørdal, Norway
| | - Reinold Ellingsen
- Department of Electronic Systems, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
| | - Sven Magnus Carlsen
- Department of Endocrinology, St Olavs Hospital, Trondheim University Hospital, Trondheim, Norway
- Department of Cancer Research and Molecular Medicine, Norwegian University of Science and Technology (NTNU), Trondheim, Norway
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213
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Rodbard D. Continuous Glucose Monitoring: A Review of Recent Studies Demonstrating Improved Glycemic Outcomes. Diabetes Technol Ther 2017; 19:S25-S37. [PMID: 28585879 PMCID: PMC5467105 DOI: 10.1089/dia.2017.0035] [Citation(s) in RCA: 243] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Continuous Glucose Monitoring (CGM) has been demonstrated to be clinically valuable, reducing risks of hypoglycemia and hyperglycemia, glycemic variability (GV), and improving patient quality of life for a wide range of patient populations and clinical indications. Use of CGM can help reduce HbA1c and mean glucose. One CGM device, with accuracy (%MARD) of approximately 10%, has recently been approved for self-adjustment of insulin dosages (nonadjuvant use) and approved for reimbursement for therapeutic use in the United States. CGM had previously been used off-label for that purpose. CGM has been demonstrated to be clinically useful in both type 1 and type 2 diabetes for patients receiving a wide variety of treatment regimens. CGM is beneficial for people using either multiple daily injections (MDI) or continuous subcutaneous insulin infusion (CSII). CGM is used both in retrospective (professional, masked) and real-time (personal, unmasked) modes: both approaches can be beneficial. When CGM is used to suspend insulin infusion when hypoglycemia is detected until glucose returns to a safe level (low-glucose suspend), there are benefits beyond sensor-augmented pump (SAP), with greater reduction in the risk of hypoglycemia. Predictive low-glucose suspend provides greater benefits in this regard. Closed-loop control with insulin provides further improvement in quality of glycemic control. A hybrid closed-loop system has recently been approved by the U.S. FDA. Closed-loop control using both insulin and glucagon can reduce risk of hypoglycemia even more. CGM facilitates rigorous evaluation of new forms of therapy, characterizing pharmacodynamics, assessing frequency and severity of hypo- and hyperglycemia, and characterizing several aspects of GV.
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Affiliation(s)
- David Rodbard
- Biomedical Informatics Consultants LLC , Potomac, Maryland
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214
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Fox LA, Balkman E, Englert K, Hossain J, Mauras N. Safety of using real-time sensor glucose values for treatment decisions in adolescents with poorly controlled type 1 diabetes mellitus: a pilot study. Pediatr Diabetes 2017; 18:271-276. [PMID: 27435145 PMCID: PMC5250611 DOI: 10.1111/pedi.12404] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2016] [Revised: 04/15/2016] [Accepted: 05/30/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND This study explored the safety of using real-time sensor glucose (SG) data for treatment decisions in adolescents with poorly controlled type 1 diabetes. METHODS Ten adolescents with type 1 diabetes, HbA1c ≥9% on insulin pumps were admitted to the clinical research center and a continuous glucose sensor was inserted. Plasma glucose was measured at least hourly using Yellow Springs Instrument's (YSI) glucose analyzer. Starting at dinner, SG rather than YSI was used for treatment decisions unless YSI was <70 mg/dL (<3.9 mmol/L) or specific criteria indicating SG and YSI were very discordant were met. Participants were discharged after lunch the next day. RESULTS Ten participants (seven males; 15.2-17.8 year old) completed the study. The range of differences between high glucose correction doses using SG vs YSI for calculations was -2 (SG < YSI dose) to +1 (SG > YSI dose); this difference was two units in only 2 of 23 correction doses given (all SG < YSI dose). There were five episodes of mild hypoglycemia in two patients, two of which occurred after using SG for dose calculations. There was no severe hypoglycemia and no YSI glucose >350 mg/dL (19.4 mmol/L). Mean (±SE) pre- and postmeal YSI glucose were 163 ± 11 and 183 ± 12 mg/dL (9.1 ± 0.6 and 10.2 ± 0.7 mmol/L), respectively. CONCLUSION Use of real-time continuous glucose monitoring for treatment decisions was safe and did not result in significant over- or undertreatment. Use of SG for treatment decisions under supervised inpatient conditions is a suitable alternative to repeated fingerstick glucose monitoring. Outpatient studies using SG in real-time are needed.
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Affiliation(s)
- Larry A. Fox
- Nemours Children’s Health System, Jacksonville, FL
| | | | - Kim Englert
- Nemours Children’s Health System, Jacksonville, FL
| | - Jobayer Hossain
- Biostatistics Core, Alfred I. duPont Hospital for Children, Wilmington, DE
| | - Nelly Mauras
- Nemours Children’s Health System, Jacksonville, FL
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215
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Abstract
Advances in continuous glucose monitoring (CGM) have brought on a paradigm shift in the management of type 1 diabetes. These advances have enabled the automation of insulin delivery, where an algorithm determines the insulin delivery rate in response to the CGM values. There are multiple automated insulin delivery (AID) systems in development. A system that automates basal insulin delivery has already received Food and Drug Administration approval, and more systems are likely to follow. As the field of AID matures, future systems may incorporate additional hormones and/or multiple inputs, such as activity level. All AID systems are impacted by CGM accuracy and future CGM devices must be shown to be sufficiently accurate to be safely incorporated into AID. In this article, we summarize recent achievements in AID development, with a special emphasis on CGM sensor performance, and discuss the future of AID systems from the point of view of their input-output characteristics, form factor, and adaptability.
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Affiliation(s)
- Jessica R. Castle
- Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health & Science University, Portland, Oregon
| | - J. Hans DeVries
- Department of Endocrinology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Boris Kovatchev
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
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216
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Affiliation(s)
- Marc D Breton
- Center for Diabetes Technology; University of Virginia School of Medicine, University of Virginia , Charlottesville, Virginia
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217
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Hirsch IB, Balo AK, Sayer K, Garcia A, Buckingham BA, Peyser TA. A Simple Composite Metric for the Assessment of Glycemic Status from Continuous Glucose Monitoring Data: Implications for Clinical Practice and the Artificial Pancreas. Diabetes Technol Ther 2017; 19:S38-S48. [PMID: 28585873 PMCID: PMC5467104 DOI: 10.1089/dia.2017.0080] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND The potential clinical benefits of continuous glucose monitoring (CGM) have been recognized for many years, but CGM is used by a small fraction of patients with diabetes. One obstacle to greater use of the technology is the lack of simplified tools for assessing glycemic control from CGM data without complicated visual displays of data. METHODS We developed a simple new metric, the personal glycemic state (PGS), to assess glycemic control solely from continuous glucose monitoring data. PGS is a composite index that assesses four domains of glycemic control: mean glucose, glycemic variability, time in range and frequency and severity of hypoglycemia. The metric was applied to data from six clinical studies for the G4 Platinum continuous glucose monitoring system (Dexcom, San Diego, CA). The PGS was also applied to data from a study of artificial pancreas comparing results from open loop and closed loop in adolescents and in adults. RESULTS The new metric for glycemic control, PGS, was able to characterize the quality of glycemic control in a wide range of study subjects with various mean glucose, minimal, moderate, and excessive glycemic variability and subjects on open loop versus closed loop control. CONCLUSION A new composite metric for the assessment of glycemic control based on CGM data has been defined for use in assessing glycemic control in clinical practice and research settings. The new metric may help rapidly identify problems in glycemic control and may assist with optimizing diabetes therapy during time-constrained physician office visits.
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218
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MohammadRidha T, Ait-Ahmed M, Chaillous L, Krempf M, Guilhem I, Poirier JY, Moog CH. Model Free iPID Control for Glycemia Regulation of Type-1 Diabetes. IEEE Trans Biomed Eng 2017; 65:199-206. [PMID: 28459682 DOI: 10.1109/tbme.2017.2698036] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVE The objective is to design a fully automated glycemia controller of Type-1 Diabetes (T1D) in both fasting and postprandial phases on a large number of virtual patients. METHODS A model-free intelligent proportional-integral-derivative (iPID) is used to infuse insulin. The feasibility of iPID is tested in silico on two simulators with and without measurement noise. The first simulator is derived from a long-term linear time-invariant model. The controller is also validated on the UVa/Padova metabolic simulator on 10 adults under 25 runs/subject for noise robustness test. RESULTS It was shown that without measurement noise, iPID mimicked the normal pancreatic secretion with a relatively fast reaction to meals as compared to a standard PID. With the UVa/Padova simulator, the robustness against CGM noise was tested. A higher percentage of time in target was obtained with iPID as compared to standard PID with reduced time spent in hyperglycemia. CONCLUSION Two different T1D simulators tests showed that iPID detects meals and reacts faster to meal perturbations as compared to a classic PID. The intelligent part turns the controller to be more aggressive immediately after meals without neglecting safety. Further research is suggested to improve the computation of the intelligent part of iPID for such systems under actuator constraints. Any improvement can impact the overall performance of the model-free controller. SIGNIFICANCE The simple structure iPID is a step for PID-like controllers since it combines the classic PID nice properties with new adaptive features.
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Yu J, Zhang Y, Sun W, Kahkoska AR, Wang J, Buse JB, Gu Z. Insulin-Responsive Glucagon Delivery for Prevention of Hypoglycemia. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2017; 13:10.1002/smll.201603028. [PMID: 28318091 PMCID: PMC5769873 DOI: 10.1002/smll.201603028] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2016] [Revised: 01/01/2017] [Indexed: 05/17/2023]
Abstract
Hypoglycemia, the state of abnormally low blood glucose level, is an acute complication of insulin and sulfonylurea therapy in diabetes management. Frequent insulin dosing and boluses during daily diabetes care leads to an increased risk of dangerously low glucose levels, which can cause behavioral and cognitive disturbance, seizure, coma, and even death. This study reports an insulin-responsive glucagon delivery method based on a microneedle (MN)-array patch for the prevention of hypoglycemia. The controlled release of glucagon is achieved in response to elevated insulin concentration by taking advantage of the specific interaction between insulin aptamer and target insulin. Integrating a painless MN-array patch, it is demonstrated that this insulin-triggered glucagon delivery device is able to prevent hypoglycemia following a high-dose insulin injection in a chemically induced type 1 diabetic mouse model.
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Affiliation(s)
- Jicheng Yu
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC, 27695, USA
- Center for Nanotechnology in Drug Delivery and Division of Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Yuqi Zhang
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC, 27695, USA
- Center for Nanotechnology in Drug Delivery and Division of Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Wujin Sun
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC, 27695, USA
- Center for Nanotechnology in Drug Delivery and Division of Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - Anna R Kahkoska
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, 27599, USA
| | - Jinqiang Wang
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC, 27695, USA
- Center for Nanotechnology in Drug Delivery and Division of Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
| | - John B Buse
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, 27599, USA
| | - Zhen Gu
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, NC, 27695, USA
- Center for Nanotechnology in Drug Delivery and Division of Molecular Pharmaceutics, UNC Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, 27599, USA
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, 27599, USA
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Haidar A, Messier V, Legault L, Ladouceur M, Rabasa-Lhoret R. Outpatient 60-hour day-and-night glucose control with dual-hormone artificial pancreas, single-hormone artificial pancreas, or sensor-augmented pump therapy in adults with type 1 diabetes: An open-label, randomised, crossover, controlled trial. Diabetes Obes Metab 2017; 19:713-720. [PMID: 28094472 DOI: 10.1111/dom.12880] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Revised: 01/03/2017] [Accepted: 01/12/2017] [Indexed: 01/17/2023]
Abstract
AIMS To assess whether the dual-hormone (insulin and glucagon) artificial pancreas reduces hypoglycaemia compared to the single-hormone (insulin alone) artificial pancreas in outpatient settings during the day and night. MATERIAL AND METHODS In a randomized, three-way, crossover trial we compared the dual-hormone artificial pancreas, the single-hormone artificial pancreas and sensor-augmented pump therapy (control) in 23 adults with type 1 diabetes. Each intervention was applied from 8 AM Day 1 to 8 PM Day 3 (60 hours) in outpatient free-living conditions. The primary outcome was time spent with sensor glucose levels below 4.0 mmol/L. A P value of less than .017 was regarded as significant. RESULTS The median difference between the dual-hormone system and the single-hormone system was -2.3% (P = .072) for time spent below 4.0 mmol/L, -1.3% (P = .017) for time below 3.5 mmol/L, and -0.7% (P = .031) for time below 3.3 mmol/L. Both systems reduced (P < .017) hypoglycaemia below 4.0, 3.5 and 3.3 mmol/L compared to control therapy, but reductions were larger with the dual-hormone system than with the single-hormone system (medians -4.0% vs -3.4% for 4.0 mmol/L; -2.7% vs -2.2% for 3.5 mmol/L; and -2.2% vs -1.2% for 3.3 mmol/L). There were 34 hypoglycaemic events (<3.0 mmol/L for 20 minutes) with control therapy, 14 with the single-hormone system and 6 with the dual-hormone system. These differences in hypoglycaemia were observed while mean glucose level was low and comparable in all interventions (P = NS). CONCLUSIONS The dual-hormone artificial pancreas had the lowest risk of hypoglycaemia, but the differences were not statistically significant. Larger studies are needed.
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Affiliation(s)
- Ahmad Haidar
- Faculty of Medicine, Department of Biomedical Engineering, McGill University, Montréal, Québec, Canada
- Faculty of Medicine, Division of Endocrinology and Metabolism, McGill University, Montréal, Québec, Canada
| | - Virginie Messier
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
| | - Laurent Legault
- Montreal Children's Hospital, McGill University Health Centre, Montréal, Québec, Canada
| | - Martin Ladouceur
- The Research Center of the Université de Montréal Hospital Center, Montréal, Québec, Canada
- Département de Médecine Sociale et Préventive, School of Public Health, Université de Montréal, Montréal, Québec, Canada
| | - Rémi Rabasa-Lhoret
- Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
- The Research Center of the Université de Montréal Hospital Center, Montréal, Québec, Canada
- Faculty of Medicine, Nutrition Department, Université de Montréal, Montréal, Québec, Canada
- Montreal Diabetes Research Center, Montréal, Québec, Canada
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Tauschmann M, Allen JM, Wilinska ME, Ruan Y, Thabit H, Acerini CL, Dunger DB, Hovorka R. Sensor Life and Overnight Closed Loop: A Randomized Clinical Trial. J Diabetes Sci Technol 2017; 11:513-521. [PMID: 27837162 PMCID: PMC5505426 DOI: 10.1177/1932296816678631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Closed-loop (CL) systems direct insulin delivery based on continuous glucose monitor (CGM) sensor values. CGM accuracy varies with sensor life, being least accurate on day 1 of sensor insertion. We evaluated the effect of sensor life (enhanced Enlite, Medtronic MiniMed, Northridge, CA) on overnight CL. METHODS In an open-label, randomized, 2-period, inpatient crossover pilot study, 12 adolescents on insulin pump (age 16.7 ± 1.9 years; HbA1c 66 ± 10 mmol/mol) attended a clinical research facility on 2 overnight occasions. In random order, participants received CL on day 1 or on day 3-4 after sensor insertion. During both periods, glucose was automatically controlled by a model predictive control algorithm informed by sensor glucose. Plasma glucose was measured every 30 to 60 min. RESULTS During overnight CL (22:30 to 07:30), the proportion of time with plasma glucose readings in the target range (3.9-8.0 mmol/l, primary endpoint) when initiated on day 1 of sensor insertion vs day 3-4 were comparable (58 ± 32% day 1 vs 56 ± 36% day 3-4; P = .34), and there were no significant differences between interventions in terms of mean plasma glucose ( P = .26), percentage time above 8.0 mmol/l ( P = .49), and time spent below 3.9 mmol/l ( P = .93). Sensor accuracy varied with sensor life (mean absolute relative difference 19.8 ± 15.0% on day 1 and 13.7 ± 10.2% on day 3 to 4). Sensor glucose tended to under-read plasma glucose inflating benefits of CL on glucose control. CONCLUSIONS In spite of differences in sensor accuracy, overnight CL glucose control informed by sensor glucose on day 1 or day 3-4 after sensor insertion was comparable. The model predictive controller appears to mitigate against sensor inaccuracies.
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Affiliation(s)
- Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Janet M. Allen
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Malgorzata E. Wilinska
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Yue Ruan
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Hood Thabit
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Carlo L. Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - David B. Dunger
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK
- Department of Paediatrics, University of Cambridge, Cambridge, UK
- Roman Hovorka, University of Cambridge Metabolic Research Laboratories, Level 4, Institute of Metabolic Science, Box 289, Addenbrooke’s Hospital, Hills Rd, Cambridge CB2 0QQ, UK.
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DeBoer MD, Breton MD, Wakeman C, Schertz EM, Emory EG, Robic JL, Kollar LL, Kovatchev BP, Cherñavvsky DR. Performance of an Artificial Pancreas System for Young Children with Type 1 Diabetes. Diabetes Technol Ther 2017; 19:293-298. [PMID: 28426239 DOI: 10.1089/dia.2016.0424] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Young children 5-8 years old with type 1 diabetes (T1D) exhibit clear needs for improved glycemic control but may be limited in their ability to safely interact with an artificial pancreas system. Our goal was to evaluate the safety and performance of an artificial pancreas (AP) system among young children with T1D. RESEARCH DESIGN AND METHODS In a randomized, crossover trial, children with T1D age 5-8 years were enrolled to receive on separate study periods (in random order) either the UVa AP using the DiAs Control Platform software with child-resistant lock-out screens (followed as an out-patient admission) or their usual insulin pump+continuous glucose monitor (CGM) care at home. Hypoglycemic events and CGM tracings were compared between the two 68-h study periods. All analyses were adjusted for level of physical activity as tracked using Fitbit devices. RESULTS Twelve participants (median age 7 years, n = 6 males) completed the trial. Compared to home care, the AP admission resulted in increased time with blood glucose (BG) 70-180 mg/dL (73% vs. 47%) and lower mean BG (152 mg/dL vs. 190 mg/dL), both P < 0.001 after adjustment for activity. Occurrence of hypoglycemia was similar between sessions without differences in time <70 mg/dL (AP 1.1% ± 1.1%; home 1.6% ± 1.2%). There were no adverse events during the AP or home study periods. CONCLUSIONS Use of an AP in young children was safe and resulted in improved mean BG without increased hypoglycemia. This suggests that AP use in young children is safe and improves overall diabetes control. ClinicalTrials.gov registration number: NCT02750267.
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Affiliation(s)
- Mark D DeBoer
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
- 2 Division of Pediatric Endocrinology, Department of Pediatrics, University of Virginia , Charlottesville, Virginia
| | - Marc D Breton
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Christian Wakeman
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Elaine M Schertz
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Emma G Emory
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Jessica L Robic
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Laura L Kollar
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Boris P Kovatchev
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
| | - Daniel R Cherñavvsky
- 1 Center for Diabetes Technology, University of Virginia , Charlottesville, Virginia
- 3 TypeZero Technologies, Inc., Charlottesville, Virginia
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Shao J, Xue S, Yu G, Yu Y, Yang X, Bai Y, Zhu S, Yang L, Yin J, Wang Y, Liao S, Guo S, Xie M, Fussenegger M, Ye H. Smartphone-controlled optogenetically engineered cells enable semiautomatic glucose homeostasis in diabetic mice. Sci Transl Med 2017; 9:9/387/eaal2298. [DOI: 10.1126/scitranslmed.aal2298] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2016] [Accepted: 04/03/2017] [Indexed: 12/16/2022]
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Bally L, Thabit H, Kojzar H, Mader JK, Qerimi-Hyseni J, Hartnell S, Tauschmann M, Allen JM, Wilinska ME, Pieber TR, Evans ML, Hovorka R. Day-and-night glycaemic control with closed-loop insulin delivery versus conventional insulin pump therapy in free-living adults with well controlled type 1 diabetes: an open-label, randomised, crossover study. Lancet Diabetes Endocrinol 2017; 5:261-270. [PMID: 28094136 PMCID: PMC5379244 DOI: 10.1016/s2213-8587(17)30001-3] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Revised: 12/08/2016] [Accepted: 12/09/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Tight control of blood glucose concentration in people with type 1 diabetes predisposes to hypoglycaemia. We aimed to investigate whether day-and-night hybrid closed-loop insulin delivery can improve glucose control while alleviating the risk of hypoglycaemia in adults with HbA1c below 7·5% (58 mmol/mol). METHODS In this open-label, randomised, crossover study, we recruited adults (aged ≥18 years) with type 1 diabetes and HbA1c below 7·5% from Addenbrooke's Hospital (Cambridge, UK) and Medical University of Graz (Graz, Austria). After a 2-4 week run-in period, participants were randomly assigned (1:1), using web-based randomly permuted blocks of four, to receive insulin via the day-and-night hybrid closed-loop system or usual pump therapy for 4 weeks, followed by a 2-4 week washout period and then the other intervention for 4 weeks. Treatment interventions were unsupervised and done under free-living conditions. During the closed-loop period, a model-predictive control algorithm directed insulin delivery, and prandial insulin delivery was calculated with a standard bolus wizard. The primary outcome was the proportion of time when sensor glucose concentration was in target range (3·9-10·0 mmol/L) over the 4 week study period. Analyses were by intention to treat. This study is registered with ClinicalTrials.gov, number NCT02727231, and is completed. FINDINGS Between March 21 and June 24, 2016, we recruited 31 participants, of whom 29 were randomised. One participant withdrew during the first closed-loop period because of dissatisfaction with study devices and glucose control. The proportion of time when sensor glucose concentration was in target range was 10·5 percentage points higher (95% CI 7·6-13·4; p<0·0001) during closed-loop delivery compared with usual pump therapy (65·6% [SD 8·1] when participants used usual pump therapy vs 76·2% [6·4] when they used closed-loop). Compared with usual pump therapy, closed-loop delivery also reduced the proportion of time spent in hypoglycaemia: the proportion of time with glucose concentration below 3·5 mmol/L was reduced by 65% (53-74, p<0·0001) and below 2·8 mmol/L by 76% (59-86, p<0·0001). No episodes of serious hypoglycaemia or other serious adverse events occurred. INTERPRETATION Use of day-and-night hybrid closed-loop insulin delivery under unsupervised, free-living conditions for 4 weeks in adults with type 1 diabetes and HbA1c below 7·5% is safe and well tolerated, improves glucose control, and reduces hypoglycaemia burden. Larger and longer studies are warranted. FUNDING Swiss National Science Foundation (P1BEP3_165297), JDRF, UK National Institute for Health Research Cambridge Biomedical Research Centre, and Wellcome Strategic Award (100574/Z/12/Z).
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Affiliation(s)
- Lia Bally
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Diabetes & Endocrinology, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK; Department of Diabetes, Endocrinology, Clinical Nutrition & Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hood Thabit
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Diabetes & Endocrinology, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
| | - Harald Kojzar
- Department of Internal Medicine, Division of Endocrinology & Diabetology, Medical University of Graz, Graz, Austria
| | - Julia K Mader
- Department of Internal Medicine, Division of Endocrinology & Diabetology, Medical University of Graz, Graz, Austria
| | - Jehona Qerimi-Hyseni
- Department of Internal Medicine, Division of Endocrinology & Diabetology, Medical University of Graz, Graz, Austria
| | - Sara Hartnell
- Department of Diabetes & Endocrinology, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
| | - Martin Tauschmann
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Janet M Allen
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Malgorzata E Wilinska
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Thomas R Pieber
- Department of Internal Medicine, Division of Endocrinology & Diabetology, Medical University of Graz, Graz, Austria
| | - Mark L Evans
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Diabetes & Endocrinology, Cambridge University Hospitals National Health Service Foundation Trust, Cambridge, UK
| | - Roman Hovorka
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, UK; Department of Paediatrics, University of Cambridge, Cambridge, UK.
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Nimri R, Bratina N, Kordonouri O, Avbelj Stefanija M, Fath M, Biester T, Muller I, Atlas E, Miller S, Fogel A, Phillip M, Danne T, Battelino T. MD-Logic overnight type 1 diabetes control in home settings: A multicentre, multinational, single blind randomized trial. Diabetes Obes Metab 2017; 19:553-561. [PMID: 27981804 DOI: 10.1111/dom.12852] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Revised: 11/25/2016] [Accepted: 12/08/2016] [Indexed: 01/17/2023]
Abstract
AIMS To evaluate the safety, efficacy and need for remote monitoring of the MD-Logic closed-loop system during short-term overnight use at home. METHODS Seventy-five patients (38 male; aged 10-54 years; average A1c, 7.8% ± 0.7%, 61.8 ± 7.2 mmol/mol) were enrolled from 3 clinical sites. Patients were randomly assigned to participate in 2 overnight crossover periods, each including 4 consecutive nights, 1 under closed-loop control and 1 under sensor-augmented pump (SAP) therapy in the patient's home. Both study arms were supervised using a remote-monitoring system in a blinded manner. Primary endpoints were time spent with glucose levels below 70 mg/dL and percentage of nights in which mean overnight glucose levels were within 90 to 140 mg/dL. RESULTS The median [interquartile range] percentage of time spent in hypoglycaemia was significantly lower on nights when MD-Logic was used, compared to SAP therapy (2.07 [0, 4.78] and 2.6 [0, 10.34], respectively; P = .004) and the percentage of individual nights with a mean overnight glucose level in target was significantly greater (75 [42, 75] and 50 [25,75], respectively; P = .008). The time spent in target range was increased by a median of 28% (P = .001), with the same amount of insulin (10.69 [7.28, 13.94] and 10.41[6.9, 14.07], respectively; P = .087). The remote monitoring triggered calls for hypoglycaemia at twice the rate during SAP therapy compared to closed-loop control (62 and 29, respectively; P = .002). CONCLUSIONS The MD-Logic system demonstrated a safe and efficient profile during overnight use by children, adolescents and adults with type 1 diabetes and, therefore, provides an effective means of mitigating the risk of nocturnal hypoglycaemia.
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Affiliation(s)
- Revital Nimri
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Natasa Bratina
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Children's Hospital, Ljubljana, Slovenia
| | - Olga Kordonouri
- Diabetes Centre for Children and Adolescents, AUF DER BULT, Kinder- und Jugendkrankenhaus, Hannover, Germany
| | - Magdalena Avbelj Stefanija
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Children's Hospital, Ljubljana, Slovenia
| | - Maryam Fath
- Diabetes Centre for Children and Adolescents, AUF DER BULT, Kinder- und Jugendkrankenhaus, Hannover, Germany
| | - Torben Biester
- Diabetes Centre for Children and Adolescents, AUF DER BULT, Kinder- und Jugendkrankenhaus, Hannover, Germany
| | - Ido Muller
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Eran Atlas
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Shahar Miller
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Aviel Fogel
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
| | - Moshe Phillip
- The Jesse Z and Sara Lea Shafer Institute for Endocrinology and Diabetes, National Center for Childhood Diabetes, Schneider Children's Medical Center of Israel, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Thomas Danne
- Diabetes Centre for Children and Adolescents, AUF DER BULT, Kinder- und Jugendkrankenhaus, Hannover, Germany
| | - Tadej Battelino
- Department of Pediatric Endocrinology, Diabetes and Metabolism, University Children's Hospital, Ljubljana, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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Use of Wearable Sensors and Biometric Variables in an Artificial Pancreas System. SENSORS 2017; 17:s17030532. [PMID: 28272368 PMCID: PMC5375818 DOI: 10.3390/s17030532] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 03/02/2017] [Accepted: 03/03/2017] [Indexed: 01/26/2023]
Abstract
An artificial pancreas (AP) computes the optimal insulin dose to be infused through an insulin pump in people with Type 1 Diabetes (T1D) based on information received from a continuous glucose monitoring (CGM) sensor. It has been recognized that exercise is a major challenge in the development of an AP system. The use of biometric physiological variables in an AP system may be beneficial for prevention of exercise-induced challenges and better glucose regulation. The goal of the present study is to find a correlation between biometric variables such as heart rate (HR), heat flux (HF), skin temperature (ST), near-body temperature (NBT), galvanic skin response (GSR), and energy expenditure (EE), 2D acceleration-mean of absolute difference (MAD) and changes in glucose concentrations during exercise via partial least squares (PLS) regression and variable importance in projection (VIP) in order to determine which variables would be most useful to include in a future artificial pancreas. PLS and VIP analyses were performed on data sets that included seven different types of exercises. Data were collected from 26 clinical experiments. Clinical results indicate ST to be the most consistently important (important for six out of seven tested exercises) variable over all different exercises tested. EE and HR are also found to be important variables over several types of exercise. We also found that the importance of GSR and NBT observed in our experiments might be related to stress and the effect of changes in environmental temperature on glucose concentrations. The use of the biometric measurements in an AP system may provide better control of glucose concentration.
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Abstract
Type 1 diabetes is a disease in which autoimmune destruction of pancreatic β-cells leads to insulin deficiency. Controlling blood glucose with an acceptable range is a major goal of therapy. Measurements of hemoglobin A1c and blood glucose levels are used for both the diagnosis and the long-term management of the disease. This chapter briefly describes the pathophysiology, diagnosis, and management of type 1 diabetes.
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Affiliation(s)
- Lindy Kahanovitz
- Department of Biotechnology Engineering, Ben Gurion University of the Negev, Beersheva, Israel
- Diabetes Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Patrick M. Sluss
- Pathology Department, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02114, USA
| | - Steven J. Russell
- Diabetes Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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228
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Spaic T, Driscoll M, Raghinaru D, Buckingham BA, Wilson DM, Clinton P, Chase HP, Maahs DM, Forlenza GP, Jost E, Hramiak I, Paul T, Bequette BW, Cameron F, Beck RW, Kollman C, Lum JW, Ly TT. Predictive Hyperglycemia and Hypoglycemia Minimization: In-Home Evaluation of Safety, Feasibility, and Efficacy in Overnight Glucose Control in Type 1 Diabetes. Diabetes Care 2017; 40:359-366. [PMID: 28100606 PMCID: PMC5319476 DOI: 10.2337/dc16-1794] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 12/22/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE The objective of this study was to determine the safety, feasibility, and efficacy of a predictive hyperglycemia and hypoglycemia minimization (PHHM) system compared with predictive low-glucose insulin suspension (PLGS) alone in overnight glucose control. RESEARCH DESIGN AND METHODS A 42-night trial was conducted in 30 individuals with type 1 diabetes in the age range 15-45 years. Participants were randomly assigned each night to either PHHM or PLGS and were blinded to the assignment. The system suspended the insulin pump on both the PHHM and PLGS nights for predicted hypoglycemia but delivered correction boluses for predicted hyperglycemia on PHHM nights only. The primary outcome was the percentage of time spent in a sensor glucose range of 70-180 mg/dL during the overnight period. RESULTS The addition of automated insulin delivery with PHHM increased the time spent in the target range (70-180 mg/dL) from 71 ± 10% during PLGS nights to 78 ± 10% during PHHM nights (P < 0.001). The average morning blood glucose concentration improved from 163 ± 23 mg/dL after PLGS nights to 142 ± 18 mg/dL after PHHM nights (P < 0.001). Various sensor-measured hypoglycemic outcomes were similar on PLGS and PHHM nights. All participants completed 42 nights with no episodes of severe hypoglycemia, diabetic ketoacidosis, or other study- or device-related adverse events. CONCLUSIONS The addition of a predictive hyperglycemia minimization component to our existing PLGS system was shown to be safe, feasible, and effective in overnight glucose control.
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Affiliation(s)
- Tamara Spaic
- St. Joseph's Health Care London, London, Ontario, Canada
| | | | | | - Bruce A Buckingham
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA
| | - Darrell M Wilson
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA
| | - Paula Clinton
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA
| | - H Peter Chase
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - David M Maahs
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA.,Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Gregory P Forlenza
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Emily Jost
- Barbara Davis Center for Childhood Diabetes, University of Colorado School of Medicine, Aurora, CO
| | - Irene Hramiak
- St. Joseph's Health Care London, London, Ontario, Canada
| | - Terri Paul
- St. Joseph's Health Care London, London, Ontario, Canada
| | | | | | - Roy W Beck
- Jaeb Center for Health Research, Tampa, FL
| | | | - John W Lum
- Jaeb Center for Health Research, Tampa, FL
| | - Trang T Ly
- Department of Pediatrics, Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Stanford, CA
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Graf A, McAuley SA, Sims C, Ulloa J, Jenkins AJ, Voskanyan G, O’Neal DN. Moving Toward a Unified Platform for Insulin Delivery and Sensing of Inputs Relevant to an Artificial Pancreas. J Diabetes Sci Technol 2017; 11:308-314. [PMID: 28264192 PMCID: PMC5478040 DOI: 10.1177/1932296816682762] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Advances in insulin pump and continuous glucose monitoring technology have primarily focused on optimizing glycemic control for people with type 1 diabetes. There remains a need to identify ways to minimize the physical burden of this technology. A unified platform with closely positioned or colocalized interstitial fluid glucose sensing and hormone delivery components is a potential solution. Present challenges to combining these components are interference of glucose sensing from proximate insulin delivery and the large discrepancy between the life span of current insulin infusion sets and glucose sensors. Addressing these concerns is of importance given that the future physical burden of this technology is likely to be even greater with the ongoing development of the artificial pancreas, potentially incorporating multiple hormone delivery, glucose sensing redundancy, and sensing of other clinically relevant nonglucose biochemical inputs.
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Affiliation(s)
- Anneke Graf
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Sybil A. McAuley
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Catriona Sims
- Department of Medicine, University of Melbourne, Melbourne, Australia
| | | | - Alicia J. Jenkins
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
- NHMRC Clinical Trials Centre, Sydney, Australia
| | | | - David N. O’Neal
- Department of Endocrinology & Diabetes, St Vincent’s Hospital Melbourne, Melbourne, Australia
- Department of Medicine, University of Melbourne, Melbourne, Australia
- David N. O’Neal, MBBS, MD, Department of Medicine, University of Melbourne, 29 Regent St, Fitzroy, Melbourne, VIC 3065, Australia.
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Garg SK, Weinzimer SA, Tamborlane WV, Buckingham BA, Bode BW, Bailey TS, Brazg RL, Ilany J, Slover RH, Anderson SM, Bergenstal RM, Grosman B, Roy A, Cordero TL, Shin J, Lee SW, Kaufman FR. Glucose Outcomes with the In-Home Use of a Hybrid Closed-Loop Insulin Delivery System in Adolescents and Adults with Type 1 Diabetes. Diabetes Technol Ther 2017; 19:155-163. [PMID: 28134564 PMCID: PMC5359676 DOI: 10.1089/dia.2016.0421] [Citation(s) in RCA: 410] [Impact Index Per Article: 58.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The safety and effectiveness of the in-home use of a hybrid closed-loop (HCL) system that automatically increases, decreases, and suspends insulin delivery in response to continuous glucose monitoring were investigated. METHODS Adolescents (n = 30, ages 14-21 years) and adults (n = 94, ages 22-75 years) with type 1 diabetes participated in a multicenter (nine sites in the United States, one site in Israel) pivotal trial. The Medtronic MiniMed® 670G system was used during a 2-week run-in phase without HCL control, or Auto Mode, enabled (Manual Mode) and, thereafter, with Auto Mode enabled during a 3-month study phase. A supervised hotel stay (6 days/5 nights) that included a 24-h frequent blood sample testing with a reference measurement (i-STAT) occurred during the study phase. RESULTS Adolescents (mean ± standard deviation [SD] 16.5 ± 2.29 years of age and 7.7 ± 4.15 years of diabetes) used the system for a median 75.8% (interquartile range [IQR] 68.0%-88.4%) of the time (2977 patient-days). Adults (mean ± SD 44.6 ± 12.79 years of age and 26.4 ± 12.43 years of diabetes) used the system for a median 88.0% (IQR 77.6%-92.7%) of the time (9412 patient-days). From baseline run-in to the end of study phase, adolescent and adult HbA1c levels decreased from 7.7% ± 0.8% to 7.1% ± 0.6% (P < 0.001) and from 7.3% ± 0.9% to 6.8% ± 0.6% (P < 0.001, Wilcoxon signed-rank test), respectively. The proportion of overall in-target (71-180 mg/dL) sensor glucose (SG) values increased from 60.4% ± 10.9% to 67.2% ± 8.2% (P < 0.001) in adolescents and from 68.8% ± 11.9% to 73.8% ± 8.4% (P < 0.001) in adults. During the hotel stay, the proportion of in-target i-STAT® blood glucose values was 67.4% ± 27.7% compared to SG values of 72.0% ± 11.6% for adolescents and 74.2% ± 17.5% compared to 76.9% ± 8.3% for adults. There were no severe hypoglycemic or diabetic ketoacidosis events in either cohort. CONCLUSIONS HCL therapy was safe during in-home use by adolescents and adults and the study phase demonstrated increased time in target, and reductions in HbA1c, hyperglycemia and hypoglycemia, compared to baseline. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT02463097.
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Affiliation(s)
- Satish K. Garg
- Barbara Davis Center for Diabetes, University of Colorado Denver, Aurora, Colorado
| | | | | | | | | | | | | | | | - Robert H. Slover
- Barbara Davis Center for Diabetes, University of Colorado Denver, Aurora, Colorado
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El-Khatib FH, Balliro C, Hillard MA, Magyar KL, Ekhlaspour L, Sinha M, Mondesir D, Esmaeili A, Hartigan C, Thompson MJ, Malkani S, Lock JP, Harlan DM, Clinton P, Frank E, Wilson DM, DeSalvo D, Norlander L, Ly T, Buckingham BA, Diner J, Dezube M, Young LA, Goley A, Kirkman MS, Buse JB, Zheng H, Selagamsetty RR, Damiano ER, Russell SJ. Home use of a bihormonal bionic pancreas versus insulin pump therapy in adults with type 1 diabetes: a multicentre randomised crossover trial. Lancet 2017; 389:369-380. [PMID: 28007348 PMCID: PMC5358809 DOI: 10.1016/s0140-6736(16)32567-3] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Revised: 11/29/2016] [Accepted: 12/05/2016] [Indexed: 12/16/2022]
Abstract
BACKGROUND The safety and effectiveness of a continuous, day-and-night automated glycaemic control system using insulin and glucagon has not been shown in a free-living, home-use setting. We aimed to assess whether bihormonal bionic pancreas initialised only with body mass can safely reduce mean glycaemia and hypoglycaemia in adults with type 1 diabetes who were living at home and participating in their normal daily routines without restrictions on diet or physical activity. METHODS We did a random-order crossover study in volunteers at least 18 years old who had type 1 diabetes and lived within a 30 min drive of four sites in the USA. Participants were randomly assigned (1:1) in blocks of two using sequentially numbered sealed envelopes to glycaemic regulation with a bihormonal bionic pancreas or usual care (conventional or sensor-augmented insulin pump therapy) first, followed by the opposite intervention. Both study periods were 11 days in length, during which time participants continued all normal activities, including athletics and driving. The bionic pancreas was initialised with only the participant's body mass. Autonomously adaptive dosing algorithms used data from a continuous glucose monitor to control subcutaneous delivery of insulin and glucagon. The coprimary outcomes were the mean glucose concentration and time with continuous glucose monitoring (CGM) glucose concentration less than 3·3 mmol/L, analysed over days 2-11 in participants who completed both periods of the study. This trial is registered with ClinicalTrials.gov, number NCT02092220. FINDINGS We randomly assigned 43 participants between May 6, 2014, and July 3, 2015, 39 of whom completed the study: 20 who were assigned to bionic pancreas first and 19 who were assigned to the comparator first. The mean CGM glucose concentration was 7·8 mmol/L (SD 0·6) in the bionic pancreas period versus 9·0 mmol/L (1·6) in the comparator period (difference 1·1 mmol/L, 95% CI 0·7-1·6; p<0·0001), and the mean time with CGM glucose concentration less than 3·3 mmol/L was 0·6% (0·6) in the bionic pancreas period versus 1·9% (1·7) in the comparator period (difference 1·3%, 95% CI 0·8-1·8; p<0·0001). The mean nausea score on the Visual Analogue Scale (score 0-10) was greater during the bionic pancreas period (0·52 [SD 0·83]) than in the comparator period (0·05 [0·17]; difference 0·47, 95% CI 0·21-0·73; p=0·0024). Body mass and laboratory parameters did not differ between periods. There were no serious or unexpected adverse events in the bionic pancreas period of the study. INTERPRETATION Relative to conventional and sensor-augmented insulin pump therapy, the bihormonal bionic pancreas, initialised only with participant weight, was able to achieve superior glycaemic regulation without the need for carbohydrate counting. Larger and longer studies are needed to establish the long-term benefits and risks of automated glycaemic management with a bihormonal bionic pancreas. FUNDING National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health, and National Center for Advancing Translational Sciences.
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Affiliation(s)
- Firas H El-Khatib
- Department of Biomedical Engineering, Boston University, Boston, MA, USA
| | - Courtney Balliro
- Diabetes Unit and Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Mallory A Hillard
- Diabetes Unit and Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Kendra L Magyar
- Diabetes Unit and Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Laya Ekhlaspour
- Diabetes Unit and Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Manasi Sinha
- Diabetes Unit and Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Debbie Mondesir
- Diabetes Unit and Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Aryan Esmaeili
- Diabetes Unit and Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Celia Hartigan
- Center for Clinical and Translational Science and the Diabetes Center of Excellence, University of Massachusetts Medical School, Worcester, MA, USA
| | - Michael J Thompson
- Center for Clinical and Translational Science and the Diabetes Center of Excellence, University of Massachusetts Medical School, Worcester, MA, USA
| | - Samir Malkani
- Center for Clinical and Translational Science and the Diabetes Center of Excellence, University of Massachusetts Medical School, Worcester, MA, USA
| | - J Paul Lock
- Center for Clinical and Translational Science and the Diabetes Center of Excellence, University of Massachusetts Medical School, Worcester, MA, USA
| | - David M Harlan
- Center for Clinical and Translational Science and the Diabetes Center of Excellence, University of Massachusetts Medical School, Worcester, MA, USA
| | - Paula Clinton
- Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Eliana Frank
- Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Darrell M Wilson
- Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Daniel DeSalvo
- Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Lisa Norlander
- Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Trang Ly
- Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Bruce A Buckingham
- Division of Pediatric Endocrinology and Diabetes, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Jamie Diner
- Diabetes Care Center, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Milana Dezube
- Diabetes Care Center, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Laura A Young
- Diabetes Care Center, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - April Goley
- Diabetes Care Center, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - M Sue Kirkman
- Diabetes Care Center, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - John B Buse
- Diabetes Care Center, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, Boston, MA, USA
| | | | - Edward R Damiano
- Department of Biomedical Engineering, Boston University, Boston, MA, USA
| | - Steven J Russell
- Diabetes Unit and Department of Medicine, Massachusetts General Hospital, Boston, MA, USA.
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Murphy HR, Stewart ZA. Automated insulin delivery: what's new, needed, and next? Lancet 2017; 389:333-334. [PMID: 28007347 DOI: 10.1016/s0140-6736(16)32591-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 12/14/2016] [Indexed: 12/22/2022]
Affiliation(s)
- Helen R Murphy
- Norwich Medical School, University of East Anglia, Norwich NR4 7UQ, UK.
| | - Zoe A Stewart
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge CB2 0QQ, UK
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Hu X, Yu J, Qian C, Lu Y, Kahkoska AR, Xie Z, Jing X, Buse JB, Gu Z. H 2O 2-Responsive Vesicles Integrated with Transcutaneous Patches for Glucose-Mediated Insulin Delivery. ACS NANO 2017; 11:613-620. [PMID: 28051306 PMCID: PMC5568789 DOI: 10.1021/acsnano.6b06892] [Citation(s) in RCA: 196] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
A self-regulated "smart" insulin administration system would be highly desirable for diabetes management. Here, a glucose-responsive insulin delivery device, which integrates H2O2-responsive polymeric vesicles (PVs) with a transcutaneous microneedle-array patch was prepared to achieve a fast response, excellent biocompatibility, and painless administration. The PVs are self-assembled from block copolymer incorporated with polyethylene glycol (PEG) and phenylboronic ester (PBE)-conjugated polyserine (designated mPEG-b-P(Ser-PBE)) and loaded with glucose oxidase (GOx) and insulin. The polymeric vesicles function as both moieties of the glucose sensing element (GOx) and the insulin release actuator to provide basal insulin release as well as promote insulin release in response to hyperglycemic states. In the current study, insulin release responds quickly to elevated glucose and its kinetics can be modulated by adjusting the concentration of GOx loaded into the microneedles. In vivo testing indicates that a single patch can regulate glucose levels effectively with reduced risk of hypoglycemia.
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Affiliation(s)
- Xiuli Hu
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, North Carolina 27695, United States
- State Key Laboratory of Polymer Chemistry and Physics, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Jilin, 130022, People’s Republic of China
| | - Jicheng Yu
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, North Carolina 27695, United States
| | - Chenggen Qian
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, North Carolina 27695, United States
| | - Yue Lu
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, North Carolina 27695, United States
| | - Anna R. Kahkoska
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina 27599, United States
| | - Zhigang Xie
- State Key Laboratory of Polymer Chemistry and Physics, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Jilin, 130022, People’s Republic of China
| | - Xiabin Jing
- State Key Laboratory of Polymer Chemistry and Physics, Changchun Institute of Applied Chemistry, Chinese Academy of Sciences, Jilin, 130022, People’s Republic of China
| | - John B. Buse
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina 27599, United States
| | - Zhen Gu
- Joint Department of Biomedical Engineering, University of North Carolina at Chapel Hill and North Carolina State University, Raleigh, North Carolina 27695, United States
- Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, North Carolina 27599, United States
- Corresponding Author:
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Bally L, Thabit H, Hovorka R. Closed-loop for type 1 diabetes - an introduction and appraisal for the generalist. BMC Med 2017; 15:14. [PMID: 28114938 PMCID: PMC5260117 DOI: 10.1186/s12916-017-0794-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 01/12/2017] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Rapid progress over the past decade has been made with the development of the 'Artificial Pancreas', also known as the closed-loop system, which emulates the feedback glucose-responsive functionality of the pancreatic beta cell. The recent FDA approval of the first hybrid closed-loop system makes the Artificial Pancreas a realistic therapeutic option for people with type 1 diabetes. In anticipation of its advent into clinical care, we provide a primer and appraisal of this novel therapeutic approach in type 1 diabetes for healthcare professionals and non-specialists in the field. DISCUSSION Randomised clinical studies in outpatient and home settings have shown improved glycaemic outcomes, reduced risk of hypoglycaemia and positive user attitudes. User input and interaction with existing closed-loop systems, however, are still required. Therefore, management of user expectations, as well as training and support by healthcare providers are key to ensure optimal uptake, satisfaction and acceptance of the technology. An overview of closed-loop technology and its clinical implications are discussed, complemented by our extensive hands-on experience with closed-loop system use during free daily living. CONCLUSIONS The introduction of the artificial pancreas into clinical practice represents a milestone towards the goal of improving the care of people with type 1 diabetes. There remains a need to understand the impact of user interaction with the technology, and its implication on current diabetes management and care.
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Affiliation(s)
- Lia Bally
- University of Cambridge Metabolic Research Laboratories and NIHR Cambridge Biomedical Research Centre, Wellcome Trust-MRC Institute of Metabolic Science, Box 289, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
- Department of Diabetes & Endocrinology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Diabetes, Endocrinology, Clinical Nutrition & Metabolism, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Hood Thabit
- University of Cambridge Metabolic Research Laboratories and NIHR Cambridge Biomedical Research Centre, Wellcome Trust-MRC Institute of Metabolic Science, Box 289, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK
- Department of Diabetes & Endocrinology, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Roman Hovorka
- University of Cambridge Metabolic Research Laboratories and NIHR Cambridge Biomedical Research Centre, Wellcome Trust-MRC Institute of Metabolic Science, Box 289, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK.
- Department of Paediatrics, University of Cambridge, Cambridge, UK.
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235
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Love B. Artificial Organs. Biomaterials 2017. [DOI: 10.1016/b978-0-12-809478-5.00014-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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236
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de Bock M, Dart J, Roy A, Davey R, Soon W, Berthold C, Retterath A, Grosman B, Kurtz N, Davis E, Jones T. Exploration of the Performance of a Hybrid Closed Loop Insulin Delivery Algorithm That Includes Insulin Delivery Limits Designed to Protect Against Hypoglycemia. J Diabetes Sci Technol 2017; 11:68-73. [PMID: 27621143 PMCID: PMC5375079 DOI: 10.1177/1932296816668876] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Hypoglycemia remains a risk for closed loop insulin delivery particularly following exercise or if the glucose sensor is inaccurate. The aim of this study was to test whether an algorithm that includes a limit to insulin delivery is effective at protecting against hypoglycemia under those circumstances. METHODS An observational study on 8 participants with type 1 diabetes was conducted, where a hybrid closed loop system (HCL) (Medtronic™ 670G) was challenged with hypoglycemic stimuli: exercise and an overreading glucose sensor. RESULTS There was no overnight or exercise-induced hypoglycemia during HCL insulin delivery. All daytime hypoglycemia was attributable to postmeal bolused insulin in those participants with a more aggressive carbohydrate factor. CONCLUSION HCL systems rely on accurate carbohydrate ratios and carbohydrate counting to avoid hypoglycemia. The algorithm that was tested against moderate exercise and an overreading glucose sensor performed well in terms of hypoglycemia avoidance. Algorithm refinement continues in preparation for long-term outpatient trials.
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Affiliation(s)
- Martin de Bock
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, WA, Australia
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
- School of Paediatrics and Child Health, The University of Western Australia, Perth, WA, Australia
| | - Julie Dart
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | | | - Raymond Davey
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - Wayne Soon
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - Carolyn Berthold
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | - Adam Retterath
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
| | | | | | - Elizabeth Davis
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, WA, Australia
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
- School of Paediatrics and Child Health, The University of Western Australia, Perth, WA, Australia
| | - Timothy Jones
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, WA, Australia
- Telethon Kids Institute, The University of Western Australia, Perth, WA, Australia
- School of Paediatrics and Child Health, The University of Western Australia, Perth, WA, Australia
- Timothy Jones, MD, Princess Margaret Hospital for Children, Department of Endocrinology and Diabetes, GPO Box D184, Perth, WA 6840, Australia. Email
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Kovatchev B, Cheng P, Anderson SM, Pinsker JE, Boscari F, Buckingham BA, Doyle FJ, Hood KK, Brown SA, Breton MD, Chernavvsky D, Bevier WC, Bradley PK, Bruttomesso D, Del Favero S, Calore R, Cobelli C, Avogaro A, Ly TT, Shanmugham S, Dassau E, Kollman C, Lum JW, Beck RW. Feasibility of Long-Term Closed-Loop Control: A Multicenter 6-Month Trial of 24/7 Automated Insulin Delivery. Diabetes Technol Ther 2017; 19:18-24. [PMID: 27982707 DOI: 10.1089/dia.2016.0333] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND In the past few years, the artificial pancreas-the commonly accepted term for closed-loop control (CLC) of blood glucose in diabetes-has become a hot topic in research and technology development. In the summer of 2014, we initiated a 6-month trial evaluating the safety of 24/7 CLC during free-living conditions. RESEARCH DESIGN AND METHODS Following an initial 1-month Phase 1, 14 individuals (10 males/4 females) with type 1 diabetes at three clinical centers in the United States and one in Italy continued with a 5-month Phase 2, which included 24/7 CLC using the wireless portable Diabetes Assistant (DiAs) developed at the University of Virginia Center for Diabetes Technology. Median subject characteristics were age 45 years, duration of diabetes 27 years, total daily insulin 0.53 U/kg/day, and baseline HbA1c 7.2% (55 mmol/mol). RESULTS Compared with the baseline observation period, the frequency of hypoglycemia below 3.9 mmol/L during the last 3 months of CLC was lower: 4.1% versus 1.3%, P < 0.001. This was accompanied by a downward trend in HbA1c from 7.2% (55 mmol/mol) to 7.0% (53 mmol/mol) at 6 months. HbA1c improvement was correlated with system use (Spearman r = 0.55). The user experience was favorable with identified benefit particularly at night and overall trust in the system. There were no serious adverse events, severe hypoglycemia, or diabetic ketoacidosis. CONCLUSION We conclude that CLC technology has matured and is safe for prolonged use in patients' natural environment. Based on these promising results, a large randomized trial is warranted to assess long-term CLC efficacy and safety.
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Affiliation(s)
- Boris Kovatchev
- 1 University of Virginia Center for Diabetes Technology, Charlottesville, Virginia
| | - Peiyao Cheng
- 2 Jaeb Center for Health Research , Tampa, Florida
| | - Stacey M Anderson
- 1 University of Virginia Center for Diabetes Technology, Charlottesville, Virginia
| | | | | | - Bruce A Buckingham
- 5 Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine , Stanford, California
| | - Francis J Doyle
- 6 Department of Chemical Engineering, University of California , Santa Barbara, Santa Barbara, California
- 7 Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University , Cambridge, Massachusetts
| | - Korey K Hood
- 5 Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine , Stanford, California
| | - Sue A Brown
- 1 University of Virginia Center for Diabetes Technology, Charlottesville, Virginia
| | - Marc D Breton
- 1 University of Virginia Center for Diabetes Technology, Charlottesville, Virginia
| | - Daniel Chernavvsky
- 1 University of Virginia Center for Diabetes Technology, Charlottesville, Virginia
| | - Wendy C Bevier
- 3 William Sansum Diabetes Center , Santa Barbara, California
| | - Paige K Bradley
- 3 William Sansum Diabetes Center , Santa Barbara, California
| | | | | | | | | | | | - Trang T Ly
- 5 Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine , Stanford, California
| | - Satya Shanmugham
- 5 Division of Pediatric Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine , Stanford, California
| | - Eyal Dassau
- 6 Department of Chemical Engineering, University of California , Santa Barbara, Santa Barbara, California
- 7 Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University , Cambridge, Massachusetts
| | | | - John W Lum
- 2 Jaeb Center for Health Research , Tampa, Florida
| | - Roy W Beck
- 2 Jaeb Center for Health Research , Tampa, Florida
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Taleb N, Haidar A, Messier V, Gingras V, Legault L, Rabasa-Lhoret R. Glucagon in artificial pancreas systems: Potential benefits and safety profile of future chronic use. Diabetes Obes Metab 2017; 19:13-23. [PMID: 27629286 DOI: 10.1111/dom.12789] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 09/09/2016] [Accepted: 09/11/2016] [Indexed: 12/17/2022]
Abstract
The role of glucagon in the pathophysiology of diabetes has long been recognized, although its approved clinical use has so far been limited to the emergency treatment of severe hypoglycaemia. A novel use of glucagon as intermittent mini-boluses is proposed in the dual-hormone version (insulin and glucagon) of the external artificial pancreas. Short-term studies suggest that the incorporation of glucagon into artificial pancreas systems has the potential to further decrease hypoglycaemic risk and improve overall glucose control; however, the potential long-term safety and benefits also need to be investigated given the recognized systemic effects of glucagon. In the present report, we review the available animal and human data on the physiological functions of glucagon, as well as its pharmacological use, according to dosing and duration (acute and chronic). Along with its main role in hepatic glucose metabolism, glucagon affects the cardiovascular, renal, pulmonary and gastrointestinal systems. It has a potential role in weight reduction through its central satiety function and its role in increasing energy expenditure. Most of the pharmacological studies investigating the effects of glucagon have used doses exceeding 1 mg, in contrast to the mini-boluses used in the artificial pancreas. The available data are reassuring but comprehensive human studies using small but chronic glucagon doses that are close to the physiological ranges are lacking. We propose a list of variables that could be monitored during long-term trials of the artificial pancreas. Such trials should address the questions about the risk-benefit ratio of chronic glucagon use.
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Affiliation(s)
- Nadine Taleb
- Metabolic diseases unit, Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
- Department of Biomedical Sciences, Faculty of Medicine, Édouard-Montpetit, Université de Montréal, Montréal, Québec, Canada
| | - Ahmad Haidar
- Department of Biomedical Engineering, Faculty of Medicine, McGill University, Montréal, Québec, Canada
- Division of Endocrinology, Department of Medicine, Faculty of Medicine, McGill University, Montréal, Québec, Canada
| | - Virginie Messier
- Metabolic diseases unit, Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
| | - Véronique Gingras
- Metabolic diseases unit, Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
- Nutrition Department, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
| | - Laurent Legault
- Montreal Children's Hospital, Department of Pediatrics, McGill University Health Centre, Montréal, Québec, Canada
| | - Rémi Rabasa-Lhoret
- Metabolic diseases unit, Institut de recherches cliniques de Montréal, Montréal, Québec, Canada
- Montreal Diabetes Research Center, Montréal, Québec, Canada
- Nutrition Department, Faculty of Medicine, Université de Montréal, Montréal, Québec, Canada
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240
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Ramkissoon CM, Aufderheide B, Bequette BW, Vehi J. A Review of Safety and Hazards Associated With the Artificial Pancreas. IEEE Rev Biomed Eng 2017; 10:44-62. [DOI: 10.1109/rbme.2017.2749038] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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241
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Ekhlaspour L, Maahs DM. In-Home Closed Loop Control for Artificial Pancreas: Patient and Provider Perspective. Diabetes Technol Ther 2017; 19:4-6. [PMID: 28055224 PMCID: PMC6435341 DOI: 10.1089/dia.2016.0432] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Laya Ekhlaspour
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine , Stanford, California
| | - David M Maahs
- Division of Endocrinology and Diabetes, Department of Pediatrics, Stanford University School of Medicine , Stanford, California
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242
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Xie M, Ye H, Wang H, Charpin-El Hamri G, Lormeau C, Saxena P, Stelling J, Fussenegger M. -cell-mimetic designer cells provide closed-loop glycemic control. Science 2016; 354:1296-1301. [DOI: 10.1126/science.aaf4006] [Citation(s) in RCA: 140] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 11/10/2016] [Indexed: 12/12/2022]
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243
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Toschi E, Wolpert H. Utility of Continuous Glucose Monitoring in Type 1 and Type 2 Diabetes. Endocrinol Metab Clin North Am 2016; 45:895-904. [PMID: 27823610 DOI: 10.1016/j.ecl.2016.06.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A consensus conference of the American Association of Clinical Endocrinologists and American College of Endocrinology held in February 2016 advocated expanding the use of continuous glucose monitoring (CGM) in the management of diabetes. Based on the data described in this paper, CGM use is shown to improve glucose control and reduce hypoglycemic events, and therefore has the potential to reduce the risk of acute and chronic complications of diabetes. Likely, all of the above would not only improve the quality of life and life expectancy of people with diabetes, but would also have a positive impact on health-related cost.
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Affiliation(s)
- Elena Toschi
- Joslin Diabetes Center, Adult Section, One Joslin Place, Boston, MA 02215, USA.
| | - Howard Wolpert
- Joslin Diabetes Center, Adult Section, One Joslin Place, Boston, MA 02215, USA
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Sharifi A, De Bock MI, Jayawardene D, Loh MM, Horsburgh JC, Berthold CL, Paramalingam N, Bach LA, Colman PG, Davis EA, Grosman B, Hendrieckx C, Jenkins AJ, Kumareswaran K, Kurtz N, Kyoong A, MacIsaac RJ, Speight J, Trawley S, Ward GM, Roy A, Jones TW, O'Neal DN. Glycemia, Treatment Satisfaction, Cognition, and Sleep Quality in Adults and Adolescents with Type 1 Diabetes When Using a Closed-Loop System Overnight Versus Sensor-Augmented Pump with Low-Glucose Suspend Function: A Randomized Crossover Study. Diabetes Technol Ther 2016; 18:772-783. [PMID: 27835037 DOI: 10.1089/dia.2016.0288] [Citation(s) in RCA: 64] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND We compared glycemia, treatment satisfaction, sleep quality, and cognition using a nighttime Android-based hybrid closed-loop system (Android-HCLS) with sensor-augmented pump with low-glucose suspend function (SAP-LGS) in people with type 1 diabetes. MATERIALS AND METHODS An open-label, prospective, randomized crossover study of 16 adults (mean [SD] age 42.1 [9.6] years) and 12 adolescents (15.2 [1.6] years) was conducted. All participants completed four consecutive nights at home with Android-HCLS (proportional integral derivative with insulin feedback algorithm; Medtronic) and SAP-LGS. PRIMARY OUTCOME percent continuous glucose monitoring (CGM) time (00:00-08:00 h) within target range (72-144 mg/dL). Secondary endpoints: percent CGM time above target (>144 mg/dL); below target (<72 mg/dL); glycemic variability (SD); symptomatic hypoglycemia; adult treatment satisfaction; sleep quality; and cognitive function. RESULTS The primary outcome for all participants was not statistically different between Android-HCLS and SAP-LGS (mean [SD] 59.4 [17.9]% vs. 53.1 [18]%; p = 0.14). Adults had greater percent time within target range (57.7 [18.6]% vs. 44.5 [14.5]%; p < 0.006); less time above target (42.0 [18.7]% vs. 52.6 [16.5]%; p = 0.034); lower glycemic variability (35 [10.7] mg/dL vs. 46 [10.7] mg/dL; p = 0.003); and less (median [IQR]) time below target (0.0 [0.0-0.4]% vs. 0.80 [0.0-3.9]%; p = 0.025). In adolescents, time below target was lower with Android-HCLS vs. SAP-LGS (0.0 [0.0-0.0]% vs. 1.8 [0.1-7.9]%; p = 0.011). Nocturnal symptomatic hypoglycemia was less (1 vs. 10; p = 0.007) in adolescents, but not adults (5 vs. 13; p = 0.059). In adults, treatment satisfaction increased by 10 points (p < 0.02). Sleep quality and cognition did not differ. CONCLUSIONS Android-HCLS in both adults and adolescents reduced nocturnal hypoglycemia and, in adults, improved overnight time in target range and treatment satisfaction compared with SAP-LGS.
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Affiliation(s)
- Amin Sharifi
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
| | - Martin I De Bock
- 2 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
| | - Dilshani Jayawardene
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
| | - Margaret M Loh
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
| | - Jodie C Horsburgh
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
| | - Carolyn L Berthold
- 2 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
| | - Nirubasini Paramalingam
- 2 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
| | - Leon A Bach
- 3 Department of Endocrinology and Diabetes, Alfred Hospital , Melbourne, Australia
| | - Peter G Colman
- 4 Department of Diabetes and Endocrinology, Royal Melbourne Hospital , Melbourne, Australia
| | - Elizabeth A Davis
- 2 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
| | | | - Christel Hendrieckx
- 6 The Australian Centre for Behavioural Research in Diabetes , Diabetes Victoria, Australia
- 7 School of Psychology, Deakin University , Geelong, Australia
| | - Alicia J Jenkins
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
- 8 Department of Medicine, University of Melbourne , St. Vincent's Hospital Melbourne, Melbourne, Australia
- 9 University of Sydney , NHMRC Clinical Trials Centre, Australia
| | - Kavita Kumareswaran
- 3 Department of Endocrinology and Diabetes, Alfred Hospital , Melbourne, Australia
| | | | - Andrew Kyoong
- 10 Department of Respiratory and Sleep Medicine, St. Vincent's Hospital Melbourne , Melbourne, Australia
| | - Richard J MacIsaac
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
- 8 Department of Medicine, University of Melbourne , St. Vincent's Hospital Melbourne, Melbourne, Australia
| | - Jane Speight
- 6 The Australian Centre for Behavioural Research in Diabetes , Diabetes Victoria, Australia
- 7 School of Psychology, Deakin University , Geelong, Australia
- 11 AHP Research , Hornchurch, Essex, United Kingdom
| | - Steven Trawley
- 6 The Australian Centre for Behavioural Research in Diabetes , Diabetes Victoria, Australia
- 7 School of Psychology, Deakin University , Geelong, Australia
| | - Glenn M Ward
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
- 8 Department of Medicine, University of Melbourne , St. Vincent's Hospital Melbourne, Melbourne, Australia
| | - Anirban Roy
- 5 Medtronic Diabetes , Northridge, California
| | - Timothy W Jones
- 2 Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children , Perth, Australia
| | - David N O'Neal
- 1 Department of Endocrinology and Diabetes, St. Vincent's Hospital Melbourne , Melbourne, Australia
- 8 Department of Medicine, University of Melbourne , St. Vincent's Hospital Melbourne, Melbourne, Australia
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245
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Sharples EJ, Mittal SM, Friend PJ. Challenges in pancreas transplantation. Acta Diabetol 2016; 53:871-878. [PMID: 27283012 DOI: 10.1007/s00592-016-0865-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2015] [Accepted: 02/22/2016] [Indexed: 01/26/2023]
Abstract
Whole-organ pancreas transplantation, either alone or combined with a kidney transplant, is the only definitive treatment for many patients with type 1 diabetes that restores normal glucose homoeostasis and insulin independence. Pancreas transplantation delays, or potentially prevents, secondary diabetes complications and is associated with improvement in patient survival when compared with either patients remaining on the waiting list or those receiving kidney transplant alone. Pancreas transplantation is safe and effective, with 1-year patient survival >97 % and graft survival rates of 85 % at 1 year and 76 % at 5 years in recent UK data. This review focuses on some current areas of interest in pancreas transplantation.
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Affiliation(s)
- E J Sharples
- Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals, Old Road, Headington, Oxford, OX3 7LE, UK.
| | - S M Mittal
- Oxford Transplant Centre, Churchill Hospital, Oxford University Hospitals, Old Road, Headington, Oxford, OX3 7LE, UK
| | - P J Friend
- Nuffield Department of Surgery, Oxford University, Oxford, UK
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246
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Marchetti L, Reali F, Dauriz M, Brangani C, Boselli L, Ceradini G, Bonora E, Bonadonna RC, Priami C. A Novel Insulin/Glucose Model after a Mixed-Meal Test in Patients with Type 1 Diabetes on Insulin Pump Therapy. Sci Rep 2016; 6:36029. [PMID: 27824066 PMCID: PMC5099899 DOI: 10.1038/srep36029] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2016] [Accepted: 10/10/2016] [Indexed: 11/30/2022] Open
Abstract
Current closed-loop insulin delivery methods stem from sophisticated models of the glucose-insulin (G/I) system, mostly based on complex studies employing glucose tracer technology. We tested the performance of a new minimal model (GLUKINSLOOP 2.0) of the G/I system to characterize the glucose and insulin dynamics during multiple mixed meal tests (MMT) of different sizes in patients with type 1 diabetes (T1D) on insulin pump therapy (continuous subcutaneous insulin infusion, CSII). The GLUKINSLOOP 2.0 identified the G/I system, provided a close fit of the G/I time-courses and showed acceptable reproducibility of the G/I system parameters in repeated studies of identical and double-sized MMTs. This model can provide a fairly good and reproducible description of the G/I system in T1D patients on CSII, and it may be applied to create a bank of “virtual” patients. Our results might be relevant at improving the architecture of upcoming closed-loop CSII systems.
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Affiliation(s)
- Luca Marchetti
- The Microsoft Research - University of Trento Centre for Computational and Systems Biology (COSBI), Rovereto (TN), Italy
| | - Federico Reali
- The Microsoft Research - University of Trento Centre for Computational and Systems Biology (COSBI), Rovereto (TN), Italy.,Department of Mathematics, University of Trento, Trento, Italy
| | - Marco Dauriz
- Department of Medicine, Section of Endocrinology, University of Verona School of Medicine, Verona, Italy
| | - Corinna Brangani
- Department of Medicine, Section of Endocrinology, University of Verona School of Medicine, Verona, Italy
| | - Linda Boselli
- Department of Medicine, Section of Endocrinology, University of Verona School of Medicine, Verona, Italy
| | - Giulia Ceradini
- Department of Medicine, Section of Endocrinology, University of Verona School of Medicine, Verona, Italy
| | - Enzo Bonora
- Department of Medicine, Section of Endocrinology, University of Verona School of Medicine, Verona, Italy.,Division of Endocrinology and Metabolic Diseases, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Riccardo C Bonadonna
- Department of Clinical and Experimental Medicine, University of Parma, Parma, Italy.,Division of Endocrinology, Azienda Ospedaliera Universitaria of Parma, Italy
| | - Corrado Priami
- The Microsoft Research - University of Trento Centre for Computational and Systems Biology (COSBI), Rovereto (TN), Italy.,Department of Mathematics, University of Trento, Trento, Italy
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247
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Jacobs PG, El Youssef J, Reddy R, Resalat N, Branigan D, Condon J, Preiser N, Ramsey K, Jones M, Edwards C, Kuehl K, Leitschuh J, Rajhbeharrysingh U, Castle JR. Randomized trial of a dual-hormone artificial pancreas with dosing adjustment during exercise compared with no adjustment and sensor-augmented pump therapy. Diabetes Obes Metab 2016; 18:1110-1119. [PMID: 27333970 PMCID: PMC5056819 DOI: 10.1111/dom.12707] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 06/08/2016] [Accepted: 06/12/2016] [Indexed: 11/30/2022]
Abstract
AIMS To test whether adjusting insulin and glucagon in response to exercise within a dual-hormone artificial pancreas (AP) reduces exercise-related hypoglycaemia. MATERIALS AND METHODS In random order, 21 adults with type 1 diabetes (T1D) underwent three 22-hour experimental sessions: AP with exercise dosing adjustment (APX); AP with no exercise dosing adjustment (APN); and sensor-augmented pump (SAP) therapy. After an overnight stay and 2 hours after breakfast, participants exercised for 45 minutes at 60% of their maximum heart rate, with no snack given before exercise. During APX, insulin was decreased and glucagon was increased at exercise onset, while during SAP therapy, subjects could adjust dosing before exercise. The two primary outcomes were percentage of time spent in hypoglycaemia (<3.9 mmol/L) and percentage of time spent in euglycaemia (3.9-10 mmol/L) from the start of exercise to the end of the study. RESULTS The mean (95% confidence interval) times spent in hypoglycaemia (<3.9 mmol/L) after the start of exercise were 0.3% (-0.1, 0.7) for APX, 3.1% (0.8, 5.3) for APN, and 0.8% (0.1, 1.4) for SAP therapy. There was an absolute difference of 2.8% less time spent in hypoglycaemia for APX versus APN (p = .001) and 0.5% less time spent in hypoglycaemia for APX versus SAP therapy (p = .16). Mean time spent in euglycaemia was similar across the different sessions. CONCLUSIONS Adjusting insulin and glucagon delivery at exercise onset within a dual-hormone AP significantly reduces hypoglycaemia compared with no adjustment and performs similarly to SAP therapy when insulin is adjusted before exercise.
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Affiliation(s)
- P G Jacobs
- Department of Biomedical Engineering, Oregon Health and Science University, Portland.
| | - J El Youssef
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland
| | - R Reddy
- Department of Biomedical Engineering, Oregon Health and Science University, Portland
| | - N Resalat
- Department of Biomedical Engineering, Oregon Health and Science University, Portland
| | - D Branigan
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland
| | - J Condon
- Department of Biomedical Engineering, Oregon Health and Science University, Portland
| | - N Preiser
- Department of Biomedical Engineering, Oregon Health and Science University, Portland
| | - K Ramsey
- Oregon Clinical and Translational Research Institute Biostatistics and Design Program, Oregon Health and Science University, Portland
| | - M Jones
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland
| | - C Edwards
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland
| | - K Kuehl
- Department of Medicine, Division of Health Promotion and Sports Medicine, Human Performance Laboratory, Oregon Health and Science University, Portland
| | - J Leitschuh
- Department of Biomedical Engineering, Oregon Health and Science University, Portland
| | - U Rajhbeharrysingh
- Department of Biomedical Engineering, Oregon Health and Science University, Portland
| | - J R Castle
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center, Oregon Health and Science University, Portland
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Tauschmann M, Allen JM, Wilinska ME, Thabit H, Acerini CL, Dunger DB, Hovorka R. Home Use of Day-and-Night Hybrid Closed-Loop Insulin Delivery in Suboptimally Controlled Adolescents With Type 1 Diabetes: A 3-Week, Free-Living, Randomized Crossover Trial. Diabetes Care 2016; 39:2019-2025. [PMID: 27612500 PMCID: PMC5079605 DOI: 10.2337/dc16-1094] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 08/18/2016] [Indexed: 02/03/2023]
Abstract
OBJECTIVE This study evaluated the feasibility, safety, and efficacy of day-and-night hybrid closed-loop insulin delivery in adolescents with type 1 diabetes under free-living conditions. RESEARCH DESIGN AND METHODS In an open-label randomized crossover study, 12 suboptimally controlled adolescents on insulin pump therapy (mean ± SD age 14.6 ± 3.1 years; HbA1c 69 ± 8 mmol/mol [8.5 ± 0.7%]; duration of diabetes 7.8 ± 3.5 years) underwent two 21-day periods in which hybrid closed-loop insulin delivery was compared with sensor-augmented insulin pump therapy in random order. During the closed-loop intervention, a model predictive algorithm automatically directed insulin delivery between meals and overnight. Participants used a bolus calculator to administer prandial boluses. RESULTS The proportion of time that sensor glucose was in the target range (3.9-10 mmol/L; primary end point) was increased during the closed-loop intervention compared with sensor-augmented insulin pump therapy by 18.8 ± 9.8 percentage points (mean ± SD; P < 0.001), the mean sensor glucose level was reduced by 1.8 ± 1.3 mmol/L (P = 0.001), and the time spent above target was reduced by 19.3 ± 11.3 percentage points (P < 0.001). The time spent with sensor glucose levels below 3.9 mmol/L was low and comparable between interventions (median difference 0.4 [interquartile range -2.2 to 1.3] percentage points; P = 0.33). Improved glucose control during closed-loop was associated with increased variability of basal insulin delivery (P < 0.001) and an increase in the total daily insulin dose (53.5 [39.5-72.1] vs. 51.5 [37.6-64.3] units/day; P = 0.006). Participants expressed positive attitudes and experience with the closed-loop system. CONCLUSIONS Free-living home use of day-and-night closed-loop in suboptimally controlled adolescents with type 1 diabetes is safe, feasible, and improves glucose control without increasing the risk of hypoglycemia. Larger and longer studies are warranted.
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Affiliation(s)
- Martin Tauschmann
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K.,Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Janet M Allen
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K.,Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Malgorzata E Wilinska
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K.,Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Hood Thabit
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K
| | - Carlo L Acerini
- Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - David B Dunger
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K.,Department of Paediatrics, University of Cambridge, Cambridge, U.K
| | - Roman Hovorka
- Wellcome Trust-Medical Research Council Institute of Metabolic Science, University of Cambridge, Cambridge, U.K. .,Department of Paediatrics, University of Cambridge, Cambridge, U.K
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Lee JB, Dassau E, Gondhalekar R, Seborg DE, Pinsker JE, Doyle FJ. Enhanced Model Predictive Control (eMPC) Strategy for Automated Glucose Control. Ind Eng Chem Res 2016; 55:11857-11868. [PMID: 27942106 DOI: 10.1021/acs.iecr.6b02718] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Development of an effective artificial pancreas (AP) controller to deliver insulin autonomously to people with type 1 diabetes mellitus is a difficult task. In this paper, three enhancements to a clinically validated AP model predictive controller (MPC) are proposed that address major challenges facing automated blood glucose control, and are then evaluated by both in silico tests and clinical trials. First, the core model of insulin-blood glucose dynamics utilized in the MPC is expanded with a medically inspired personalization scheme to improve controller responses in the face of inter- and intra-individual variations in insulin sensitivity. Next, the asymmetric nature of the short-term consequences of hypoglycemia versus hyperglycemia is incorporated in an asymmetric weighting of the MPC cost function. Finally, an enhanced dynamic insulin-on-board algorithm is proposed to minimize the likelihood of controller-induced hypoglycemia following a rapid rise of blood glucose due to rescue carbohydrate load with accompanying insulin suspension. Each advancement is evaluated separately and in unison through in silico trials based on a new clinical protocol, which incorporates induced hyper- and hypoglycemia to test robustness. The advancements are also evaluated in an advisory mode (simulated) testing of clinical data. The combination of the three proposed advancements show statistically significantly improved performance over the nonpersonalized controller without any enhancements across all metrics, displaying increased time in the 70-180 mg/dL safe glycemic range (76.9 versus 68.8%) and the 80-140 mg/dL euglycemic range (48.1 versus 44.5%), without a statistically significant increase in instances of hypoglycemia. The proposed advancements provide safe control action for AP applications, personalizing and improving controller performance without the need for extensive model identification processes.
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Affiliation(s)
- Joon Bok Lee
- Department of Chemical Engineering, University of California, Santa Barbara, CA 93106, USA; Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, 29 Oxford Street, Cambridge, MA 02138, USA; William Sansum Diabetes Center, 2219 Bath Street, Santa Barbara, CA 93105
| | - Eyal Dassau
- Department of Chemical Engineering, University of California, Santa Barbara, CA 93106, USA; Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, 29 Oxford Street, Cambridge, MA 02138, USA; William Sansum Diabetes Center, 2219 Bath Street, Santa Barbara, CA 93105
| | - Ravi Gondhalekar
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, 29 Oxford Street, Cambridge, MA 02138, USA; William Sansum Diabetes Center, 2219 Bath Street, Santa Barbara, CA 93105
| | - Dale E Seborg
- Department of Chemical Engineering, University of California, Santa Barbara, CA 93106, USA
| | - Jordan E Pinsker
- William Sansum Diabetes Center, 2219 Bath Street, Santa Barbara, CA 93105
| | - Francis J Doyle
- Department of Chemical Engineering, University of California, Santa Barbara, CA 93106, USA; Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, 29 Oxford Street, Cambridge, MA 02138, USA; William Sansum Diabetes Center, 2219 Bath Street, Santa Barbara, CA 93105
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Castle JR, Youssef JE, Branigan D, Newswanger B, Strange P, Cummins M, Shi L, Prestrelski S. Comparative Pharmacokinetic/Pharmacodynamic Study of Liquid Stable Glucagon Versus Lyophilized Glucagon in Type 1 Diabetes Subjects. J Diabetes Sci Technol 2016; 10:1101-7. [PMID: 27325390 PMCID: PMC5032962 DOI: 10.1177/1932296816653141] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
BACKGROUND There is currently no stable liquid form of glucagon commercially available. The aim of this study is to assess the speed of absorption and onset of action of G-Pump™ glucagon at 3 doses as compared to GlucaGen®, all delivered subcutaneously via an OmniPod®. METHODS Nineteen adult subjects with type 1 diabetes participated in this Phase 2, randomized, double-blind, cross-over, pharmacokinetic/pharmacodynamic study. Subjects were given 0.3, 1.2, and 2.0 µg/kg each of G-Pump glucagon and GlucaGen via an OmniPod. RESULTS G-Pump glucagon effectively increased blood glucose levels in a dose-dependent fashion with a glucose Cmax of 183, 200, and 210 mg/dL at doses of 0.3, 1.2, and 2.0 µg/kg, respectively (P = ns vs GlucaGen). Mean increases in blood glucose from baseline were 29.2, 52.9, and 77.7 mg/dL for G-Pump doses of 0.3, 1.2, and 2.0 µg/kg, respectively. There were no statistically significant differences between treatments in the glucose T50%-early or glucagon T50%-early with one exception. The glucagon T50%-early was greater following G-Pump treatment at the 2.0 μg/kg dose (13.9 ± 4.7 min) compared with GlucaGen treatment at the 2.0 μg/kg dose (11.0 ± 3.1 min, P = .018). There was more pain and erythema at the infusion site with G-Pump as compared to GlucaGen. No serious adverse events were reported, and no unexpected safety issues were observed. CONCLUSIONS G-Pump glucagon is a novel, stable glucagon formulation with similar PK/PD properties as GlucaGen, but was associated with more pain and infusion site reactions as the dose increased, as compared to GlucaGen.
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Affiliation(s)
- Jessica R Castle
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR, USA
| | - Joseph El Youssef
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR, USA
| | - Deborah Branigan
- Department of Medicine, Division of Endocrinology, Harold Schnitzer Diabetes Health Center Oregon Health & Science University, Portland, OR, USA
| | | | - Poul Strange
- Xeris Pharmaceuticals, Inc, Austin, TX, USA Integrated Medical Development, Princeton Junction, NJ, USA
| | | | - Leon Shi
- Integrated Medical Development, Princeton Junction, NJ, USA
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