Impact of flash glucose monitoring on hypoglycaemia in adults with type 1 diabetes managed with multiple daily injection therapy: a pre-specified subgroup analysis of the IMPACT randomised controlled trial

Initiating GLP-1 Therapy in Combination with FreeStyle Libre Provides Greater Benefit Compared with GLP-1 Therapy Alone

Background and Aim: Glucagon-like peptide-1 receptor agonists (GLP-1 RA) therapy provides glycemic benefits to individuals with type 2 diabetes (T2D). However, the effects of GLP-1 RA therapy in combination with FreeStyle Libre systems (FSL) are unknown. This study aimed to compare changes in hemoglobin A1c (HbA1c) between people acquiring GLP-1 with FSL (GLP-1+FSL) versus GLP-1 without FSL (GLP-1). Methods: This real-world study used Optum's de-identified Market Clarity Data, a linked electronic health records (EHR)-claims database, and included adults with T2D and HbA1c ≥8% who acquired their first GLP-1 RA medication between 2018 and 2022. GLP-1+FSL subjects acquired their first FSL within ±30 days of their first GLP-1 acquisition. Cohorts were matched 1:5 on baseline insulin therapy, age, sex, baseline HbA1c, and GLP-1 type. Paired changes in HbA1c were compared between unmatched and matched groups at 6 months. Results: The study included 24,724 adults in the unmatched cohort (GLP-1+FSL, n = 478; GLP-1, n = 24,246). The matched cohort included 478 GLP-1+FSL users and 2,390 GLP-1 users: mean age 53.5 ± 11.8 and 53.5 ± 11.3 years, HbA1c 10.25 ± 1.68% and 10.22 ± 1.69%, respectively. HbA1c reduction was greater in the GLP-1+FSL group compared with the GLP-1 group in the unmatched cohort (-2.43% vs. -1.73%, difference 0.70%, P < 0.001, respectively) and in the matched cohort (-2.43% vs. -2.06%, difference 0.37%, P < 0.001). GLP-1+FSL vs. GLP-1 treatment was associated with greater HbA1c reduction in the intensive insulin (-2.32% vs. -1.50%), nonintensive insulin (-2.50% vs. -1.74%), and noninsulin group (-2.46% vs. -1.78%), as well as in patients using semaglutide (-2.73% vs. -1.92%) and dulaglutide (-2.45% vs. -1.71%) GLP-1 RA, all P < 0.001. Conclusions: Adults with suboptimally controlled T2D, initiating GLP-1 RA with FreeStyle Libre, had greater improvement in HbA1c compared with those treated with GLP-1 RA only. These results suggest an additional glycemic benefit of FSL when used with a GLP-1 RA in T2D treatment.

Quality of life, diabetes-related stress and treatment satisfaction are correlated with glycemia risk index (GRI), time in range and hypoglycemia/hyperglycemia components in type 1 diabetes

INTRODUCTION

To evaluate the relationship between the GRI -component of hypoglycemia (CHypo) and hyperglycemia (CHyper)- with diabetes quality of life (DQoL), diabetes-related stress (DDS), perception of hypoglycemia (Clarke Test), visual analogic scale (VAS) and diabetes-knowledge (DKQ2) in T1D.

METHODS

Cross-sectional study in 92 patients with T1D under intensive insulin treatment (21.7% CSII) and flash glucose monitoring (isCGM). Clinical, metabolic and glycometric parameters and quality of life/satisfaction questionnaires were analyzed.

RESULTS

92 patients (54.3% male, BMI 25.4 ± 4.5 kg/m2, HbA1c 7.5 ± 1.0%, TIR 53.9 ± 15.9%) with mean age 36.1 ± 12.6years and 17.8 ± 11.3 T1D duration. The mean GRI was 60.6 ± 22.2 with a CHypo and CHyper of 5.9 ± 4.8 and 27.3 ± 14.4, respectively. 19.1% presented a pathological Clarke's test. Patients with TIR > 70% and GRI < 40 showed better VAS (8.8 ± 1.3 vs 9.3 ± 0.9, p < 0.05) and DDS (46.4 ± 22.1 vs 36.7 ± 16.6, p < 0.05) scores, showing no differences between groups. CHyper > 15 and Chypo > 3.4 were related to worse levels of DQoL (91.1 ± 23.9 vs 76.6 ± 18.6 and 94.6 ± 24.8 vs 79.8 ± 20.1, p < 0.01), DDS(49.8 ± 22.4 vs 35.7 ± 16.5 and 49.8 ± 22.4 vs 35.7 ± 16.5, p < 0.01),and DKQ2 (24.4 ± 4.3 vs 26.8 ± 5.2 and 24.1 ± 4.8 vs 26.0 ± 4.6, p < 0.05), respectively. Worse metabolic control defined by GRI correlated with worse scores in VAS (r = -0.209, p < 0.05), DQoL (r = 0.205, p < 0.05), and DDS (r = 0.205, p < 0.05). No difference was observed in knowledge´s scale. CHyper correlated with worse scores in VAS (r = -0.231, p < 0.05), DQoL (r = 0.422, p < 0.01), and DDS (r = 0.341, p < 0.01) and lower degree of knowledge DKQ2 (r = -0.231, p < 0.05). When analyzing DQoL as a dependent variable in a multiple lineal regression, only age (β = 0.747; p < 0.001) and CHyper (β = 0.717; p < 0.001) maintained statistical significance.

CONCLUSIONS

Higher GRI was related to worse quality of life, diabetes-related stress and satisfaction with treatment, analogous to the TIR results.CHyper an Chypo were related to a greater decline in quality of life, diabetes-related stress, and lower satisfaction with treatment.However, in a multiple linear regression, only CHyper maintained statistical significance.

Glycemic metrics in Japanese isCGM users - Analysis by diabetes type and therapy

AIMS/INTRODUCTION

The FreeStyle Libre (FSL) intermittently scanned continuous glucose monitoring (isCGM) system continually measures interstitial glucose levels and provides the data to users in numerical and graphical formats that guide users in their daily diabetes self-management. Although numerous studies have demonstrated the glycemic benefits of FSL in pediatric and adult populations, few studies have characterized FSL use specifically by Japanese adults with type 1 or 2 diabetes. We utilized established CGM metrics to assess glycemic control in a large cohort of Japanese adults with type 1 and 2 diabetes.

MATERIALS AND METHODS

A total of 3,463 anonymized FSL users provided categorization into one of four therapy groups of interest: type 1 diabetes (n = 1,768), type 2 diabetes-multiple daily injections (MDI) (n = 612), type 2 diabetes-basal (BOI) (n = 343), and type 2 diabetes-non-insulin (NIT) (n = 740). Established CGM metrics were used to assess glycemic control.

RESULTS

All study groups showed relatively good glycemic control. Type 1 diabetes users showed the highest glucose variability (SD, 61 mg/dL; and %CV, 40%), above the established target level (%CV ≤ 36%). type 2 diabetes-MDI and type 2 diabetes-BOI users had similar levels of glucose variability (both within target). Type 2 diabetes-NIT users had the highest mean % time in range (TIR) (84.3%) and largest percentage of users that met the target of %TIR > 70% (87.4%). In contrast, type 1 diabetes users had the lowest mean %TIR (62.6%) and the lowest percentage meeting the established %TIR target (30.5%).

CONCLUSIONS

By utilizing CGM devices in daily diabetes care, both healthcare professionals and patients can monitor glycemic excursions and gain insights into their historical glucose control patterns.

Effectiveness of the flash glucose monitoring system in preventing severe hypoglycemic episodes and in improving glucose metrics and quality of life in subjects with type 1 diabetes at high risk of acute diabetes complications

AIMS

To assess the effectiveness of the intermittent-scanned continuous glucose monitoring (isCGM) system in preventing severe hypoglycemic episodes and in improving glucose parameters and quality of life.

METHODS

Four hundred T1D individuals were enrolled in a prospective real-word study with an intermittently scanned continuous glucose monitoring device during the 12-months follow-up. The primary endpoint was the incidence of severe hypoglycemic events.

RESULTS

82% of subjects were naïve to the use of the device (group A) and 18% were already wearing the system (group B). The cumulative incidence of severe hypoglycemia (SH) at 12 months was 12.06 per 100 person-year (95% CI: 8.35-16.85) in group A and 10.14 (95% CI: 4.08-20.90) in group B without inter-group differences. In group A there was a significant decrease in SH at 12 months compared to 3 months period (p = 0.005). Time in glucose range significantly increased in both groups accompanied with a significant decrease in glucose variability. HbA1c showed a progressive significant time-dependent decrease in group A. The use of the device significantly improved the perceived quality of life.

CONCLUSION

This study confirmed the effectiveness of the isCGM in reducing hypoglycemic risk without glucose deterioration, with potential benefits on adverse outcomes in T1D individuals.

TRIAL REGISTRATION

ClinicalTrials.gov registration no. NCT04060732.

Association of Changes in A1C Following Continuous Glucose Monitoring Acquisition in People with Sub-Optimally Treated Type 2 Diabetes Taking GLP-1 RA Therapy

INTRODUCTION

Both glucagon-like peptide-1 receptor agonists (GLP-1 RA) and continuous glucose monitoring (CGM) improve glycemia in patients with type 2 diabetes (T2D). However, it is unknown whether adding CGM to GLP-1 RA therapy further improves A1c. We evaluated changes in A1c levels 6 months after initiation of FreeStyle Libre (FSL) in adults with sub-optimally controlled T2D already on GLP-1 RA therapy.

METHODS

This retrospective, observational study used Optum's de-identified Market Clarity Data, a linked electronic health record-claims database to assess changes in A1c after FSL acquisition. Inclusion criteria were T2D diagnosis, ≥ 18 years, baseline A1c ≥ 8%, with the first FSL acquisition between 2018 and 2022. Patients were required to be on GLP-1 RA prior to FSL with at least one GLP-1 RA prescription within 90 days of FSL acquisition. GLP-1 RA initiation was defined as the earliest GLP-1 RA prescription from 2017 onwards. Paired changes in A1c were assessed at 6 months after initial FSL acquisition.

RESULTS

The study cohort included 1454 adults with T2D (age 55 ± 10 years, 52% male, 38% with intensive insulin therapy, median 471 days from GLP-1 RA initiation to FSL, and baseline A1c 9.8 ± 1.5%). After FSL acquisition, patients experienced an A1c decrease of 1.5 ± 1.9% (p < 0.001). Patients with a baseline A1c > 10% had the largest reduction (n = 497, - 2.7 ± 2.2%, p < 0.001). Significant improvements were observed in subgroups based on insulin therapy and GLP-1 RA formulation. Those initiating GLP-1 RA therapy > 24 months before FSL acquisition also showed improvements in A1c (n = 478; - 1.3 ± 1.7%, p < 0.001).

CONCLUSIONS

In a large, real-world study of adults with T2D, those on prior GLP-1 RA therapy experienced significant A1c improvements after acquiring FSL, irrespective of GLP-1 RA duration, GLP-1 RA formulation, or insulin therapy type. These findings support the use of FSL in adults with T2D treated with GLP-1 RA.

Glycaemic outcomes in people living with diabetes under 65 and over 65 years old using an intermittently scanned continuous glucose monitoring system

Objective

Intermittently scanned continuous glucose monitoring (isCGM) has revolutionised the care of people with diabetes but its uptake and benefits in older adults are not well known. We examined the impact of isCGM (Freestyle Libre, FSL) on glycaemic outcomes in younger (⩽65 years) and older adults (>65 years) with diabetes.

Design and methods

In total, 2260 adult patients registered on the Libreview account at University Hospitals Birmingham NHS Foundation Trust, UK, were included. Inclusion criteria: all patients with type 1 and type 2 diabetes aged >18 years, use of isCGM >6 months, scanning at least 6 times/day. Demographics, diabetes history and glycaemic outcomes (time in range (TIR), time above range and time below range (TBR), estimated HbA1c, HbA1c at start and at end of study) were collected by accessing electronic patient records and Libreview. Outcomes were compared between age groups ⩽65 or >65 years old.

Results

Most patients were of Caucasian ethnicity (⩽65 years 68%, >65 years 73%) and had type 1 diabetes. Mean duration of diabetes was 19.5 years (range 0-65 years) and 34.5 years (range 0-79 years) for ⩽65 and >65 years, respectively. Only a quarter of those ⩽65 years achieved (219/943; 23.2%) their age specific TIR target compared to 69% (78/113) of those >65 years cohort, while 70.1% (663/946) of ⩽65 years and 40.7% (46/113) of >65 years achieved their age-specific TBR target. When the less strict ⩽65 years TBR target was applied, 75% (85/113) of >65 years cohort achieved this.

Conclusion

FSL use was associated with improved glycaemic outcomes across all age groups. Individualised targets may be needed to improve TBR in those aged >65 years.

Prevalence of dermatitis including allergic contact dermatitis from medical devices used by children and adults with Type 1 diabetes mellitus: A systematic review and questionnaire study

Use of medical devices (MDs), that is, glucose sensors and insulin pumps, in patients with Type 1 diabetes mellitus (T1D) has proven an enormous advantage for disease control. Adverse skin reactions from these MDs may however hamper compliance. The objective of this study was to systematically review and analyse studies assessing the prevalence and incidence of dermatitis, including allergic contact dermatitis (ACD) related to MDs used in patients with T1D and to compare referral routes and the clinical investigation routines between clinics being part of the European Environmental and Contact Dermatitis Research Group (EECDRG). A systematic search of PubMed, EMBASE, CINAHL and Cochrane databases of full-text studies reporting incidence and prevalence of dermatitis in persons with T1D using MDs was conducted until December 2021. The Newcastle-Ottawa Scale was used to assess study quality. The inventory performed at EECRDG clinics focused on referral routes, patient numbers and the diagnostic process. Among the 3145 screened abstracts, 39 studies fulfilled the inclusion criteria. Sixteen studies included data on children only, 14 studies were on adults and nine studies reported data on both children and adults. Participants were exposed to a broad range of devices. Skin reactions were rarely specified. It was found that both the diagnostic process and referral routes differ in different centres. Further data on the prevalence of skin reactions related to MDs in individuals with T1D is needed and particularly studies where the skin reactions are correctly diagnosed. A correct diagnosis is delayed or hampered by the fact that, at present, the actual substances within the MDs are not declared, are changed without notice and the commercially available test materials are not adequately updated. Within Europe, routines for referral should be made more standardized to improve the diagnostic procedure when investigating patients with possible ACD from MDs.

Increase Access, Reduce Disparities: Recommendations for Modifying Medicaid CGM Coverage Eligibility Criteria

Numerous studies have demonstrated the clinical value of continuous glucose monitoring (CGM) in type 1 diabetes (T1D) and type 2 diabetes (T2D) populations. However, the eligibility criteria for CGM coverage required by the Centers for Medicare & Medicaid Services (CMS) ignore the conclusive evidence that supports CGM use in various diabetes populations that are currently deemed ineligible. In an earlier article, we discussed the limitations and inconsistencies of the agency's CGM eligibility criteria relative to current scientific evidence and proposed practice solutions to address this issue and improve the safety and care of Medicare beneficiaries with diabetes. Although Medicaid is administered through CMS, there is no consistent Medicaid policy for CGM coverage in the United States. This article presents a rationale for modifying and standardizing Medicaid CGM coverage eligibility across the United States.

Accuracy and Functionality of Select Continuous Glucose Monitoring Systems Are Not Impacted by Implantable Cardioverter Defibrillator Devices

BACKGROUND

Increasing numbers of individuals with diabetes are adopting use of continuous glucose monitoring (CGM) in their daily self-management. Many of these individuals have advanced heart disease. Implantable cardioverter defibrillator (ICD) devices can effectively reduce arrhythmic death and all-cause mortality in individuals with advanced heart disease. However, the potential impact of ICD devices on CGM system accuracy and functionality has not been well studied.

METHODS

This evaluation assessed whether FreeStyle Libre (FL) CGM systems can coexist and function within the same patient in the presence of wireless interference devices, including current ICD devices. Interferer sources included Wi-Fi devices, Bluetooth devices, cellular mobile devices, implantable medical devices, Bluetooth Low-Energy (BLE) devices, BLE accessory devices and BLE mobile devices, and ICD-programmer interferers. Five testing methodologies were used to evaluate the accuracy and functionality of the CGM systems when exposed to ICD functions: high-energy emergency shocking, pacing modes, anti-tachycardia pacing mode (ATP), and DC Fibber mode.

RESULTS

All acceptance criteria and testing requirements were met for the CGM and ICD system for wireless coexistence evaluation.

CONCLUSIONS

Our findings demonstrated that coexisting ICD devices and FL CGM systems provide safe and effective wireless communications with functional and accurate transfer of data during scenarios expected in clinical use.

Effect of switch from flash glucose monitoring to flash glucose monitoring with real-time alarms on hypoglycaemia in people with type 1 diabetes mellitus

We aimed to evaluate the utility of the FreeStyle Libre 2 device for reducing time below range level 1 and level 2 compared with the Freestyle Libre device (without alarms) in people with type 1 diabetes mellitus. We conducted longitudinal observational follow-up study of a cohort of 100 people with type 1 diabetes mellitus who had switched from FreeStyle Libre to FreeStyle Libre 2 as part of routine clinical practice. Three months after switching to FreeStyle Libre 2, compared with results with FreeStyle Libre, there were a significant improvements in time below range level 1 (p = 0.02) and level 2 (p <0.001), time in range (p <0.001), time above range level 1 (p = 0.002), glucose management indicator (p= 0.04) and mean glucose (p= 0.04) during follow-up. Furthermore there was a significant direct association between age and change in TIR with a coefficient of 0.23, and a significant inverse association between age and change in TAR-1 with a coefficient of 0.11. Switching to a flash glucose monitoring system with alarms improves time below range, time in range and coefficient of variation in people with type 1 diabetes mellitus.

Continuous Glucose Monitoring Alarms in Adults with Type 1 Diabetes: User Characteristics and the Impact of Hypoglycemia and Hyperglycemia Alarm Thresholds on Glycemic Control

Background: Few studies have evaluated the implications of the alarm thresholds of continuous glucose monitoring (CGM) systems for individuals with diabetes. The present study aimed to investigate the influence of hypoglycemia and hyperglycemia alarm thresholds on glycemic control in adults with type 1 diabetes (T1DM) and the characteristics of patients who use these alarms more frequently. Methods: This observational cross-sectional study included 873 users of the FreeStyle Libre 2 system (501 men, median age 48 years, range 18-90 years) with T1DM from a single center. We investigated the role of demographic and metabolic factors on the use of alarms and the impact of hypoglycemia and hyperglycemia alarms and their thresholds on glycemic control. Results: Alarm users were older than nonusers (median age 49 vs. 43 years, respectively; P < 0.001). The hypoglycemia alarms were set by 76.1% of women and by 69.1% of men (P = 0.022). The hypoglycemia alarms reduced hypoglycemia features and glucose variability, although at the expense of shorter time in range. The higher the hypoglycemia alarm threshold, the greater these effects. The hyperglycemia alarms were effective in reducing hyperglycemia and lowering the glucose management indicator, although at the expense of a greater tendency to hypoglycemia. The lower the hyperglycemia alarm threshold, the greater these effects. Conclusions: CGM alarms contribute to better glycemic control. However, hypoglycemia and hyperglycemia alarms have advantages and disadvantages. Adults with T1DM should explore, under medical supervision, which alarm thresholds will best help them achieve their individual glycemic goals.

Optimal Coefficient of Variance Threshold to Minimize Hypoglycemia Risk in Individuals with Well-Controlled Type 1 Diabetes Mellitus

BACKGRUOUND

This study investigated the optimal coefficient of variance (%CV) for preventing hypoglycemia based on real-time continuous glucose monitoring (rt-CGM) data in people with type 1 diabetes mellitus (T1DM) already achieving their mean glucose (MG) target.

METHODS

Data from 172 subjects who underwent rt-CGM for at least 90 days and for whom 439 90-day glycemic profiles were available were analyzed. Receiver operator characteristic analysis was conducted to determine the cut-off value of %CV to achieve time below range (%TBR)<54 mg/dL <1 and =0.

RESULTS

Overall mean glycosylated hemoglobin was 6.8% and median %TBR<54 mg/dL was 0.2%. MG was significantly higher and %CV significantly lower in profiles achieving %TBR<54 mg/dL <1 compared to %TBR<54 mg/dL ≥1 (all P<0.001). The cut-off value of %CV for achieving %TBR<54 mg/dL <1 was 37.5%, 37.3%, and 31.0%, in the whole population, MG >135 mg/dL, and ≤135 mg/dL, respectively. The cut-off value for %TBR<54 mg/dL=0% was 29.2% in MG ≤135 mg/dL. In profiles with MG ≤135 mg/dL, 94.2% of profiles with a %CV <31 achieved the target of %TBR<54 mg/dL <1, and 97.3% with a %CV <29.2 achieved the target of %TBR<54 mg/ dL=0%. When MG was >135 mg/dL, 99.4% of profiles with a %CV <37.3 achieved %TBR<54 mg/dL <1.

CONCLUSION

In well-controlled T1DM with MG ≤135 mg/dL, we suggest a %CV <31% to achieve the %TBR<54 mg/dL <1 target. Furthermore, we suggest a %CV <29.2% to achieve the target of %TBR<54 mg/dL =0 for people at high risk of hypoglycemia.

Detection and Intervention: Use of Continuous Glucose Monitoring in the Early Stages of Type 2 Diabetes

The term "prediabetes" has been used to identify the state of abnormal glucose homeostasis (dysglycemia) that often leads to the development of clinical type 2 diabetes. However, this term does not describe the cellular changes that are already taking place in individuals with elevated glucose levels. This article describes our approach to detecting early dysglycemia using continuous glucose monitoring and explains how this approach can be integrated into clinical practice settings.

Flash glucose monitoring system in gestational diabetes: a study of accuracy and usability

PURPOSE

Studies of flash glucose monitoring systems (FGMSs) in pregnancy are insufficient, especially in gestational diabetes (GD). Our aim was to evaluate Freestyle Libre's usability and accuracy (compared to self-monitoring of blood glucose [SMBG]) for GD patients in real-life conditions.

METHODS

This is a prospective study with pregnant women diagnosed with GD (n = 24 for the usability analysis; n = 19 for the accuracy analysis). The study duration was up to 28 days (lifetime of two sensors). Participants executed a minimum of four daily FGMS readings obtained immediately after capillary SMBG. Analytical accuracy was assessed with mean absolute relative difference (MARD) and mean absolute difference (MAD); clinical accuracy was assessed with Surveillance Error Grid (SEG). Usability was evaluated with a user acceptability questionnaire.

RESULTS

The mean pregestational BMI was 25.21 ± 5.15 kg/m2 (mean ± SD), the mean gestational age was 30.31 ± 2.02 weeks, and the mean glucose values were 76.63 ± 7.49 mg/dL. A total of 1339 SMBG-FGMS pairs of values were obtained. Analytical accuracy was good with an overall MARD of 14.07% and an in-target MARD of 13.79%. The number of SMBG-FMGS pairs for above-target values was low (122 of 1339) with an associated MARD of 17.95%. Clinical accuracy of the FGMS was demonstrated, with 94.4% of values in the no-risk or slight, lower risk zones of the SEG. FGMS accuracy was unaffected by pregestational BMI or gestational age. The user acceptability questionnaire showed high levels of satisfaction, with 95.8-100% preferring FGMS to SMBG. No unexpected or severe adverse effects occurred.

CONCLUSION

FGMS showed good performance in GD regarding accuracy and usability. Larger studies are needed to corroborate our results, verify the analytical accuracy of above-target values as this glucose range might lead to initiation or adjustment of pharmacological therapy, and ultimately establish definitive recommendations regarding prescription of FGMS for GD patients.

Effects of 12-Week Freestyle Libre 2.0 in Children with Type 1 Diabetes and Elevated HbA1c: A Multicenter Randomized Controlled Trial

Objective: To investigate whether intermittently scanned continuous glucose monitoring (isCGM) reduced glycated hemoglobin (HbA1c) compared with capillary self-monitored capillary blood glucose (SMBG) in children with type 1 diabetes (T1D) and elevated glycemic control. Research Design and Methods: This multicenter 12-week 1:1 randomized, controlled, parallel-arm trial included 100 participants with established T1D aged 4-13 years (mean 10.9 ± 2.3 years) naive to isCGM and with elevated HbA1c 7.5%-12.2% [58-110 mmol/mol] [mean HbA1c was 9.05 (1.3)%] [75.4 (13.9) mmol/mol]. Participants were allocated to 12-week intervention (isCGM; FreeStyle Libre 2.0; Abbott Diabetes Care, Witney, United Kingdom) (n = 49) or control (SMBG; n = 51). The primary outcome was the difference in change of HbA1c from baseline to 12 weeks. Results: There was no evidence of a difference between groups for change in HbA1c at 12 weeks (0.23 [95% confidence interval; CI: -0.21 to 0.67], P = 0.3). However, glucose-monitoring frequency increased with isCGM +4.89/day (95% CI 2.97-6.81; P < 0.001). Percent time below range (TBR) <3.9 mmol/L (70-180 mg/dL) was reduced with isCGM -6.4% (10.6 to -4.2); P < 0.001. There were no differences in within group changes for Parent or Child scores of psychosocial outcomes at 12 weeks. Conclusions: For children aged 4-13 years with elevated Hba1c isCGM led to improvements in glucose testing frequency and reduced time below range. However, isCGM did not translate into reducing Hba1c or psychosocial outcomes compared to usual care over 12-weeks. The trial is registered within the Australian New Zealand Trial Registry on February 19, 2020 (ACTRN12620000190909p; ANZCTR.org.au) and the World Health Organization International Clinical Trials Registry Platform (Universal Trial Number U1111-1237-0090).

Guideline Development for Medical Device Technology: Issues for Consideration

Advances in the development of innovative medical devices and telehealth technologies create the potential to improve the quality and efficiency of diabetes care through collecting, aggregating, and interpreting relevant health data in ways that facilitate more informed decisions among all stakeholder groups. Although many medical societies publish guidelines for utilizing these technologies in clinical practice, we believe that the methodologies used for the selection and grading of the evidence should be revised. In this article, we discuss the strengths and limitations of the various types of research commonly used for evidence selection and grading and present recommendations for modifying the process to more effectively address the rapid pace of device and technology innovation and new product development.

Utility and precision evidence of technology in the treatment of type 1 diabetes: a systematic review

BACKGROUND

The greatest change in the treatment of people living with type 1 diabetes in the last decade has been the explosion of technology assisting in all aspects of diabetes therapy, from glucose monitoring to insulin delivery and decision making. As such, the aim of our systematic review was to assess the utility of these technologies as well as identify any precision medicine-directed findings to personalize care.

METHODS

Screening of 835 peer-reviewed articles was followed by systematic review of 70 of them (focusing on randomized trials and extension studies with ≥50 participants from the past 10 years).

RESULTS

We find that novel technologies, ranging from continuous glucose monitoring systems, insulin pumps and decision support tools to the most advanced hybrid closed loop systems, improve important measures like HbA1c, time in range, and glycemic variability, while reducing hypoglycemia risk. Several studies included person-reported outcomes, allowing assessment of the burden or benefit of the technology in the lives of those with type 1 diabetes, demonstrating positive results or, at a minimum, no increase in self-care burden compared with standard care. Important limitations of the trials to date are their small size, the scarcity of pre-planned or powered analyses in sub-populations such as children, racial/ethnic minorities, people with advanced complications, and variations in baseline glycemic levels. In addition, confounders including education with device initiation, concomitant behavioral modifications, and frequent contact with the healthcare team are rarely described in enough detail to assess their impact.

CONCLUSIONS

Our review highlights the potential of technology in the treatment of people living with type 1 diabetes and provides suggestions for optimization of outcomes and areas of further study for precision medicine-directed technology use in type 1 diabetes.

Coverage for Continuous Glucose Monitoring for Individuals with Type 2 Diabetes Treated with Nonintensive Therapies: An Evidence-Based Approach to Policymaking

Numerous studies have demonstrated the clinical benefits of continuous glucose monitoring (CGM) in individuals with type 1 diabetes (T1D) and type 2 diabetes (T2D) who are treated with intensive insulin regimens. Based on this evidence, CGM is now a standard of care for individuals within these diabetes populations and widely covered by commercial and public insurers. Moreover, recent clinical guidelines from the American Diabetes Association and American Association of Clinical Endocrinology now endorse CGM use in individuals treated with nonintensive insulin regimens. However, despite increasing evidence supporting CGM use for individuals treated with less-intensive insulin therapy or noninsulin medications, insurance coverage is limited or nonexistent. This narrative review reports key findings from recent randomized, observational, and retrospective studies investigating use of CGM in T2D individuals treated with basal insulin only and/or noninsulin therapies and presents an evidence-based rationale for expanding access to CGM within this population.

Real-life data of hypoglycemic events in children and adolescents with type 1 diabetes

INTRODUCTION

Hypoglycemia composes an always present risk in the treatment of type 1 diabetes (T1D) and can be a fatal complication. Many studies on hypoglycemic events are based on self-reported data or focused on the aggregated time below range. We have processed continuous glucose monitoring (CGM) data in children and adolescents with T1D in order to examine all occurring hypoglycemic events.

RESEARCH DESIGN AND METHODS

CGM data (mean 168±3 days) from 214 children and adolescents with T1D were analyzed using computer-based algorithms. Patients were divided into three groups based on estimated HbA1c (eHbA1c): (1) ≤48 mmol/mol (n=58); (2) 49-64 mmol/mol (n=113); (3) ≥65 mmol/mol (n=43). The groups were compared concerning descriptive data and CGM metrics with emphasis on the frequency of hypoglycemic events.

RESULTS

Only one self-reported event of severe hypoglycemia was registered, while 54 390 hypoglycemic events (<3.9 mmol/L (<70 mg/dL)) were identified from CGM data out of which 11 740 were serious (<3.0 mmol/L (<54 mg/dL)). On average there were 1.5±0.1 hypoglycemic events per 24 hours out of which 1.2±0.1 were mild (3.0-3.9 mmol/L) and 0.3±0.02 serious. Group 1 had a higher frequency of both total and mild hypoglycemic events compared with both groups 2 and 3. However, the frequency of serious hypoglycemic events was similar in all groups. A negative correlation was observed for eHbA1c and total daily and mild hypoglycemic events (r=-0.57 and r=-0.66, respectively, p<0.0001), whereas for serious hypoglycemic events there was only a borderline significance (r=-0.13, p=0.05).

CONCLUSIONS

This study shows that hypoglycemic events are a frequent phenomenon in children and adolescents with T1D, occurring regardless of overall metabolic control. Although patients with an HbA1c ≤48 mmol/mol had a higher frequency of mild hypoglycemic events there was no increase in serious hypoglycemic events.

Effect of diabetes technologies on the fear of hypoglycaemia among people living with type 1 diabetes: a systematic review and meta-analysis

Background

Fear of hypoglycaemia (FOH) significantly disrupts the daily management of type 1 diabetes (T1D) and increases the risk of complications. Recent technological advances can improve glucose metrics and reduce hypoglycaemia frequency, yet their impact on FOH is unclear. This systematic review and meta-analysis (SRMA) aimed to synthesize the current literature to understand the impact of diabetes technologies on FOH in T1D.

Methods

In this SRMA, we searched PubMed, Medline, Scopus, and Web of Science from inception up to May 21st, 2023 for studies assessing the effect of using real-time or intermittently scanned continuous glucose monitors (rtCGM or isCGM); insulin pumps (CSII); and their combinations on FOH as the primary outcome, measured using the Hypoglycaemia Fear Survey (HFS; including total, worries [HFS-W], and behaviours [HFS-B] scores), in non-pregnant adults with T1D. Data was extracted by the first and second authors. Results were pooled using a random-effects model based on study design (RCT and non-RCT), with subgroup analysis based on the type of technology, reported change in hypoglycaemia frequency, and duration of use. Risk of bias was evaluated with Cochrane and Joanna Briggs Institute tools. This study is registered with PROSPERO, CRD42021253618.

Findings

A total of 51 studies (n = 8966) were included, 22 of which were RCTs. Studies on rtCGM and CSII reported lower FOH levels with ≥8 weeks of use. Studies on CSII and rtCGM combinations reported lower FOH levels after ≥13 weeks of automated insulin delivery (AID) use or 26 weeks of sensor-augmented pump (SAP) use. The meta-analysis showed an overall lower FOH with technologies, specifically for the HFS-W subscale. The RCT meta-analysis showed lower HFS-W scores with rtCGM use (standard mean difference [95%CI]: -0.14 [-0.23, -0.05], I2 = 0%) and AID (-0.17 [-0.33, -0.01], I2 = 0%). Results from non-RCT studies show that SAP users (-0.33 [-0.38, -0.27], I2 = 0%) and rtCGM users (-0.38 [-0.61, -0.14], I2 = 0%) had lower HFS-W.

Interpretation

We found consistent, yet small to moderate, effects supporting that diabetes technologies (specifically rtCGM, SAP, and AID) may reduce hypoglycaemia-related worries in adults with T1D. Current literature, however, has limitations including discrepancies in baseline characteristics and limited, mainly descriptive, statistical analysis. Thus, future studies should assess FOH as a primary outcome, use validated surveys, and appropriate statistical analysis to evaluate the clinical impacts of technology use beyond just glucose metrics.

Funding

Canadian Institutes of Health Research, Juvenile Diabetes Research Foundation Ltd.

Budget Impact Analysis of the FreeStyle Libre Flash Continuous Glucose Monitoring System® in Patients with Type 1 Diabetes Mellitus and Type 2 Diabetes Mellitus with Multiple Daily Insulin Injections in Argentina

OBJECTIVE

To estimate the budget impact of the potential coverage of FreeStyle Libre Flash Continuous Glucose Monitoring System (FSL) for glycemia monitoring in all type 1 diabetes mellitus (T1DM) patients and in those with type 2 diabetes mellitus (T2DM) with multiple daily insulin injections, from the social security and the private third-party payer's perspective in Argentina.

METHODS

A budget impact model was developed to estimate the cost difference between the self-monitoring of blood glucose (standard of care) and FSL over 5 years. Input parameters were retrieved from local literature complemented by expert opinion. Health care costs were estimated by a micro-costing approach and reported in USD as of April 2022 (1 USD = 113.34 Argentine pesos). One-way sensitivity and scenario analyses were conducted.

RESULTS

From a social security third-party payer perspective, the incorporation of FSL was associated with net savings per member per month (PMPM) of $0.026 (Year 1) to $0.097 (Year 5) and net savings PMPM of $0.002 (Year 1) to $0.008 (Year 5) for T1DM and T2DM patients, respectively. Similar findings are reported from the private third-party payer perspective. The budget impact results were more sensitive to the acquisition costs of the FSL and test strips.

CONCLUSION

The potential coverage of FSL in patients with T1DM and T2DM with multiple daily insulin injections could be associated with small financial savings considering current technology acquisition costs (FSL and test strips) for social security and the private sector third-party payers in Argentina.

Comparing clinical outcomes between two continuous glucose monitors: similar diabetes-related events, all-cause hospitalizations and HbA1c reductions in type 1 and type 2 diabetes

Objectives

We compared clinical outcomes after acquiring a FreeStyle Libre© Flash Continuous Glucose Monitoring System (FSL) or Dexcom (DEX) continuous glucose monitoring (CGM) device in individuals with type 1 diabetes (T1D) and type 2 diabetes (T2D) treated with intensive insulin therapy.

Design and Methods

This retrospective analysis of the IBM® MarketScan® Research Databases and IBM® Explorys® Electronic Health Records Database assessed differences in acute diabetes-related events (ADE), all-cause hospitalizations (ACH) and glycated hemoglobin (HbA1c) in T1D and T2D populations 6 months post CGM acquisition. Analyses were conducted in two study cohorts (Cohort 1, n = 7,494; Cohort 2, n = 678). Participants were T1D or T2D, age ≥ 18 years, treated with short or rapid-acting insulin and naïve to CGM, who acquired a CGM system. Users were propensity score matched on demographics and clinical factors.

Results

Cohort 1: Post-CGM ADE-free rates at 6 months ranged from 94.8 to 96.7% and ACH-free rates ranged from 90.4 to 95.4%, for both T1D and T2D groups, with no significant differences between CGM systems. Cohort 2: Significant HbA1c reductions were associated with use of the DEX and FSL devices in the T1D (-0.35% and -0.37%, respectively) and T2D (-0.73% and -0.79%, respectively) cohorts, both p < 0.001, with no significant differences in the magnitude of reduction between systems (T1D p = 0.99 and T2D p = 0.84).

Conclusions

Acquisition of the FSL and DEX systems was associated with similar rates of acute diabetes-related events and all-cause hospitalizations and similar HbA1c reductions in adults with T1D and T2D.

Pharmacy benefit considerations for continuous glucose monitoring acquisition: Vermont Medicaid experience

Many individuals with diabetes are not achieving their glycemic goals. Use of continuous glucose monitoring (CGM) improves diabetes management. Access to CGM is often hindered when individuals must acquire their supplies through the traditional durable medical device channel. Vermont Medicaid transitioned CGM coverage from a medical/durable medical equipment benefit to a pharmacy benefit. This improved access and lessened the burden on prescribing health care providers. We describe the process the Vermont Medicaid program implemented to make this transition. DISCLOSURES: Funding for editorial assistance in the development of this manuscript was provided by Abbott Diabetes Care. The funder had no input in the manuscript content. The authors received no compensation.

Budget impact analysis of the freestyle libre flash continuous glucose monitoring system® in patients with diabetes mellitus type 1 in Chile

OBJECTIVE

To estimate the budget impact of covering the FreeStyle Libre Flash Continuous Glucose Monitoring System (FSL) for type 1 Diabetes Mellitus patients (T1DM), compared to self-monitoring of blood glucose (SMBG), from the perspective of public and private third-party payers in Chile.

METHODS

A budget impact model was developed to estimate the cost difference between SMBG and FSL over five years. Two FSL coverage schemes were assessed. Input parameters were retrieved from the literature review and complemented by expert opinion. Healthcare costs were estimated by a micro-costing approach and reported in USD.

RESULTS

For a public sector third-party payer, incorporating FSL implied a cost increase up to USD 0.013 per member per month (PMPM) for the fifth year under the broad coverage scheme and a net saving of 0.0001 PMPM (all years) under the restricted coverage scheme. From a private sector third-party payer, incorporating FSL implied savings up to USD 0.028 PMPM (fifth year) for the broad coverage scheme and up to USD 0.012 PMPM (fifth year) for the restricted scheme.

CONCLUSION

Incorporating the FSL for T1DM patients was associated with a marginal incremental cost for the public sector third-party payer and cost savings in Chile's private healthcare sector.

Management of Individuals With Diabetes at High Risk for Hypoglycemia: An Endocrine Society Clinical Practice Guideline

CONTEXT

Hypoglycemia in people with diabetes is common, especially in those taking medications such as insulin and sulfonylureas (SU) that place them at higher risk. Hypoglycemia is associated with distress in those with diabetes and their families, medication nonadherence, and disruption of life and work, and it leads to costly emergency department visits and hospitalizations, morbidity, and mortality.

OBJECTIVE

To review and update the diabetes-specific parts of the 2009 Evaluation and Management of Adult Hypoglycemic Disorders: Endocrine Society Clinical Practice Guideline and to address developing issues surrounding hypoglycemia in both adults and children living with diabetes. The overriding objectives are to reduce and prevent hypoglycemia.

METHODS

A multidisciplinary panel of clinician experts, together with a patient representative, and methodologists with expertise in evidence synthesis and guideline development, identified and prioritized 10 clinical questions related to hypoglycemia in people living with diabetes. Systematic reviews were conducted to address all the questions. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess the certainty of evidence and make recommendations.

RESULTS

The panel agreed on 10 questions specific to hypoglycemia risk and prevention in people with diabetes for which 10 recommendations were made. The guideline includes conditional recommendations for use of real-time continuous glucose monitoring (CGM) and algorithm-driven insulin pumps in people with type 1 diabetes (T1D), use of CGM for outpatients with type 2 diabetes at high risk for hypoglycemia, use of long-acting and rapid-acting insulin analogs, and initiation of and continuation of CGM for select inpatient populations at high risk for hypoglycemia. Strong recommendations were made for structured diabetes education programs for those at high risk for hypoglycemia, use of glucagon preparations that do not require reconstitution vs those that do for managing severe outpatient hypoglycemia for adults and children, use of real-time CGM for individuals with T1D receiving multiple daily injections, and the use of inpatient glycemic management programs leveraging electronic health record data to reduce the risk of hypoglycemia.

CONCLUSION

The recommendations are based on the consideration of critical outcomes as well as implementation factors such as feasibility and values and preferences of people with diabetes. These recommendations can be used to inform clinical practice and health care system improvement for this important complication for people living with diabetes.

A Systematic Review Supporting the Endocrine Society Guidelines: Management of Diabetes and High Risk of Hypoglycemia

CONTEXT

Interventions targeting hypoglycemia in people with diabetes are important for improving quality of life and reducing morbidity and mortality.

OBJECTIVE

To support development of the Endocrine Society Clinical Practice Guideline for management of individuals with diabetes at high risk for hypoglycemia.

METHODS

We searched several databases for studies addressing 10 questions provided by a guideline panel from the Endocrine Society. Meta-analysis was conducted when feasible. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology was used to assess certainty of evidence.

RESULTS

We included 149 studies reporting on 43 344 patients. Continuous glucose monitoring (CGM) reduced episodes of severe hypoglycemia in patients with type 1 diabetes (T1D) and reduced the proportion of patients with hypoglycemia (blood glucose [BG] levels <54 mg/dL). There were no data on use of real-time CGM with algorithm-driven insulin pumps vs multiple daily injections with BG testing in people with T1D. CGM in outpatients with type 2 diabetes taking insulin and/or sulfonylureas reduced time spent with BG levels under 70 mg/dL. Initiation of CGM in hospitalized patients at high risk for hypoglycemia reduced episodes of hypoglycemia with BG levels lower than 54 mg/dL and time spent under 54 mg/dL. The proportion of patients with hypoglycemia with BG levels lower than 70 mg/dL and lower than 54 mg/dL detected by CGM was significantly higher than point-of-care BG testing. We found no data evaluating continuation of personal CGM in the hospital. Use of an inpatient computerized glycemic management program utilizing electronic health record data was associated with fewer patients with and episodes of hypoglycemia with BG levels lower than 70 mg/dL and fewer patients with severe hypoglycemia compared with standard care. Long-acting basal insulin analogs were associated with less hypoglycemia. Rapid-acting insulin analogs were associated with reduced severe hypoglycemia, though there were more patients with mild to moderate hypoglycemia. Structured diabetes education programs reduced episodes of severe hypoglycemia and time below 54 mg/dL in outpatients taking insulin. Glucagon formulations not requiring reconstitution were associated with longer times to recovery from hypoglycemia, although the proportion of patients who recovered completely from hypoglycemia was not different between the 2 groups.

CONCLUSION

This systematic review summarized the best available evidence about several interventions addressing hypoglycemia in people with diabetes. This evidence base will facilitate development of clinical practice guidelines by the Endocrine Society.

Status of continuous glucose monitoring use and management in tertiary hospitals of China: a cross-sectional study

OBJECTIVE

This study aims to reveal the use and management status of continuous glucose monitoring (CGM) in tertiary hospitals in China and to determine the potential factors affecting the application of CGM, based on which more effective solutions would be produced and implemented.

DESIGN

An online, cross-sectional study was conducted from October 2021 to December 2021.

SETTING

Eighty-three tertiary hospitals in China were involved.

PARTICIPANTS

Eighty-three head nurses and 281 clinical nurses were obtained.

OUTCOME

Current condition of CGM use and management, the factors that hinder the use and management of CGM, scores of current CGM use and management, as well as their influencing factors, were collected.

RESULTS

Among the 83 hospitals surveyed, 57 (68.7%) hospitals used CGM for no more than 10 patients per month. Seventy-three (88.0%) hospitals had developed CGM standard operating procedures, but only 29 (34.9%) hospitals devised emergency plans to deal with adverse effects related to CGM. Comparably, maternal and children's hospitals were more likely to have a dedicated person to assign install CGM than general hospitals (52.2% vs 26.7%). As for the potential causes that hinder the use and management of CGM, head nurses' and nurses' perceptions differed. Head nurses perceived patients' limited knowledge about CGM (60.2%), the high costs of CGM and inaccessibility to medical insurance (59.0%), and imperfect CGM management systems (44.6%) as the top three factors. Different from head nurses, CGM operation nurses considered the age of CGM operators, the type of hospital nurses worked in, the number of patients using CGM per month and the number of CGM training sessions as potential factors (p<0.05).

CONCLUSIONS

The study provides a broad view of the development status of CGM in China. Generally speaking, the use and management of CGM in China are not yet satisfactory, and more efforts are wanted for improvement.

The Advanced Diabetes Technologies for Reduction of the Frequency of Hypoglycemia and Minimizing the Occurrence of Severe Hypoglycemia in Children and Adolescents with Type 1 Diabetes

Hypoglycemia is an often-observed acute complication in the management of children and adolescents with type 1 diabetes. It causes inappropriate glycemic outcomes and may impair the quality of life in the patients. Severe hypoglycemia with cognitive impairment, such as a convulsion and coma, is a lethal condition and is associated with later-onset cognitive impairment and brain-structural abnormalities, especially in young children. Therefore, reducing the frequency of hypoglycemia and minimizing the occurrence of severe hypoglycemia are critical issues in the management of children and adolescents with type 1 diabetes. Advanced diabetes technologies, including continuous glucose monitoring and sensor-augmented insulin pumps with low-glucose suspension systems, can reduce the frequency of hypoglycemia and the occurrence of severe hypoglycemia without aggravating glycemic control. The hybrid closed-loop system, an automated insulin delivery system, must be the most promising means to achieve appropriate glycemic control with preventing severe hypoglycemia. The use of these advanced diabetes technologies could improve glycemic outcomes and the quality of life in children and adolescents with type 1 diabetes.

Advances in Continuous Glucose Monitoring and Integrated Devices for Management of Diabetes with Insulin-Based Therapy: Improvement in Glycemic Control

Continuous glucose monitoring (CGM) technology has evolved over the past decade with the integration of various devices including insulin pumps, connected insulin pens (CIPs), automated insulin delivery (AID) systems, and virtual platforms. CGM has shown consistent benefits in glycemic outcomes in type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) treated with insulin. Moreover, the combined effect of CGM and education have been shown to improve glycemic outcomes more than CGM alone. Now a CIP is the expected future technology that does not need to be worn all day like insulin pumps and helps to calculate insulin doses with a built-in bolus calculator. Although only a few clinical trials have assessed the effectiveness of CIPs, they consistently show benefits in glycemic outcomes by reducing missed doses of insulin and improving problematic adherence. AID systems and virtual platforms made it possible to achieve target glycosylated hemoglobin in diabetes while minimizing hypoglycemia, which has always been challenging in T1DM. Now fully automatic AID systems and tools for diabetes decisions based on artificial intelligence are in development. These advances in technology could reduce the burden associated with insulin treatment for diabetes.

Efficacy of unblinded and blinded intermittently scanned continuous glucose monitoring for glycemic control in adults with type 1 diabetes

OBJECTIVE

Intermittently scanned continuous glucose monitoring (isCGM) is used for unblinded or blinded monitoring of interstitial glucose. We aimed to compare the efficacy of blinded and unblinded isCGM with the FreeStyle Libre system for glycemic control in adults with type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

This randomized clinical trial conducted between October 2018 and September 2019 across four endocrinology practices in China included 273 adults aged ≥18 years with T1D, who were randomly divided in a 2:1 ratio into the unblinded (n = 199) or blinded isCGM group (n = 78). In the blinded group, the clinician used FreeStyle Libre Pro system for monitoring, but self-monitoring was also performed by the patients.

RESULTS

Two hundred sixteen (78%) participants completed the study (152 [75%] in the unblinded and 64 [82%] in the blinded group). At 12 weeks, a significant increase in TIR (3.9-10.0 mmol/L) was only observed in the unblinded group, along with a significant decrease in hyperglycemia (>13.9 mmol/L), hypoglycemia (<3.0 mmol/L), glycemic variability. Further, the mean HbA1c reduction from baseline to 12 weeks was 0.5% in the unblinded isCGM group and 0.4% in the blinded isCGM group respectively (P < 0.001), but the significance did not remain after adjustment for between-group differences. Finally, 99.5% of the blinded isCGM values and 93.8% the of unblinded isCGM values were obtained at the final visit.

CONCLUSIONS

The unblinded isCGM system was associated with benefits for glucose management, but nearly 100% of the attempted profiles were obtained successfully with the blinded isCGM system. Thus, combining real-time and retrospective data with isCGM might be the most impactful way to utilize flash glycemic monitoring devices.

[Insulin pump therapy and continuous glucose monitoring]

This Guideline represents the recommendations of the Austrian Diabetes Association (ÖDG) on the use of diabetes technology (insulin pump therapy; continuous glucose monitoring, CGM; hybrid closed-loop systems, HCL; diabetes apps) and access to these technological innovations for people with diabetes mellitus based on current scientific evidence.

Flash glucose monitoring system in patients with type 1 diabetes in healthcare center in Brazil: real world data from a short-term prospective study

Objective

To evaluate the alternate use of flash glucose monitoring (FGM) with self-monitoring blood glucose (SMBG), in patients with type 1 diabetes (T1D).

Materials and methods

Two weeks of open FGM (P2), both preceded (P1) and followed by 2 weeks (P3) of SMBG with a blinded FGM system. Mean absolute relative difference (MARD) was calculated by (|FGMi - SMBGi|) / SMBGi, where it was a paired data sample.

Results

In total, 34 patients were evaluated. Time in range (TIR) did not change between P1 and P2. In 12 patients (35.3%), TIR increased from 40% at P1 to 52% at P2 (p = 0.002) and in 22 (64.7%), TIR decreased or did not change. FGM use resulted in decreased % time spent in hypoglycemia (<70 mg/dL) (6.5% vs. 5.0%; p = 0.005), increased % time spent in hyperglycemia (>180 mg/dL) (44.5% to 51%; p = 0.046) with no significant change in % TIR. The proportion of patients who reached sensor-estimated glycated hemoglobin (eA1c) < 7% decreased from 23.5% at P1 to 12.9% at P2, p = 0.028. For the whole sample, the MARD between the two methods was 15.5% (95% CI 14.5-16.6%). For normal glucose range, hyperglycemic levels and hypoglycemic levels MARD were 16.0% (95% CI 15.0-17.0%), 13.3% (95% CI 11.5-15.2%) and 23.4% [95% CI 20.5-26.3%)], respectively.

Conclusion

FGM after usual SMBG decreased the % time spent in hypoglycemia concomitant with an undesired increase in % time spent in hyperglycemia. Lower accuracy of FGM regarding hypoglycemia levels could result in overcorrection of hypoglycemia.

Continuous Glucose Monitor, Insulin Pump, and Automated Insulin Delivery Therapies for Type 1 Diabetes: An Update on Potential for Cardiovascular Benefits

PURPOSE OF REVIEW

The incidence of type 1 diabetes (T1D) is rising in all age groups. T1D is associated with chronic microvascular and macrovascular complications but improving glycemic trends can delay the onset and slow the progression of these complications. Utilization of technological devices for diabetes management, such as continuous glucose monitors (CGM) and insulin pumps, is increasing, and these devices are associated with improvements in glycemic trends. Thus, device use may be associated with long-term prevention of T1D complications, yet few studies have investigated the direct impacts of devices on chronic complications in T1D. This review will describe common diabetes devices and combination systems, as well as review relationships between device use and cardiovascular outcomes in T1D.

RECENT FINDINGS

Findings from existing cohort and national registry studies suggest that pump use may aid in improving cardiovascular risk factors such as hypertension and dyslipidemia. Furthermore, pump users have been shown to have lower arterial stiffness and better measures of myocardial function. In registry and case-control longitudinal data, pump use has been associated with fewer cardiovascular events and reduction of cardiovascular disease (CVD) and all-cause mortality. CVD is the leading cause of morbidity and mortality in T1D. Consistent use of diabetes devices may protect against the development and progression of macrovascular complications such as CVD through improvement in glycemic trends. Existing literature is limited, but findings suggest that pump use may reduce acute cardiovascular risk factors as well as chronic cardiovascular complications and overall mortality in T1D.

Metabolic control and satisfaction in a diabetes education programme in flash glucose monitoring through telemedicine in type 1 diabetes

OBJECTIVE

To evaluate metabolic control and satisfaction with a telemedicine diabetes education programme for the initiation of flash glucose monitoring (FGM) in type 1 diabetes.

MATERIAL AND METHODS

Prospective study in 48 patients (52.1% women, 22.9% on insulin pump) who started FGM. They were analysed at baseline and 3 months after the beginning of the FGM. The results were compared with an on-site learning cohort matched by age, sex and HbA1c.

RESULTS

At the beginning and 3 months after the MFG, HbA1c improvement was observed (7.9±1.4 vs 7.3±1.1%), p<0.01; with a decrease in time below range - TBR - (4.7±4.9 vs 3.5±3.5%), p<0.05 and number of hypoglycaemic events (9.4±8.7 vs 6.9±5.7/15 days), p<0.05, associated with a worsening in time above range - TAR - (33.5±19.9 vs 37.0±20.9%), p<0.05. No significant differences were observed in the TIR 70-180mg/dl (61.7±18.6 vs 59.4±20.0%), glycemic variability or the use of FGM. Patient satisfaction with telemedicine training was 4.8±0.3 out of 5. No significant differences were observed in the follow-up, either in HbA1c or other glucometer parameters between on-site and online training. In a multivariate analysis adopting the HbA1c at follow-up as the dependent variable, only the TIR (β=-0.034; p<0.001) and the initial HbA1c (β=0.303; p<0.001) maintained statistical significance, unrelated to the on-site or online training (β=0.136; p=ns).

CONCLUSIONS

A telemedicine programme is an adequate tool for training in FGM, with results similar to on-site training, and it was associated with a high degree of satisfaction.

Effects of flash glucose monitoring on glycemic control in participants with diabetes mellitus: A meta-analysis of randomized controlled trials

BACKGROUND

With the introduction of flash glucose monitoring (FGM) into the international market in 2014, academics worldwide are exploring whether this device improves glycemic control in participants with diabetes mellitus.

OBJECTIVE

A study was conducted in which participants were evaluated to determine the effect of FGM on glycemic control.

METHODS

From inception to April 9, 2022, we searched the Cochrane Library, PubMed, SinoMed, Embase, Web of Science, MEDLINE, CNKI, Wan Fang Data, and VIP databases to collect randomized controlled trials (RCTs) related to the effect of FGM on glycemic control in participants with diabetes mellitus. Outcomes included glycated hemoglobin, the occurrence of hypoglycemic events, fasting plasma glucose (FPG), and 2-h postprandial glucose (2hPG) levels. The statistical analysis was performed using R 4.1.3 software.

RESULTS

We included 19 studies involving 2013 participants, all of which were RCTs. Meta-analysis results revealed that compared to self-monitoring of blood glucose (SMBG), FGM significantly reduced glycated hemoglobin levels in participants with type 2 diabetes mellitus [mean difference = -0.74 [95 % CI-1.16, -0.32], P < 0.01] and type 1 diabetes mellitus combined with type 2 diabetes mellitus [mean difference = -1.14 [95 % CI-3.14, 0.87], P < 0.01], with a greater effect in participants aged ≤65 years with type 2 diabetes mellitus (mean difference = -1.38 [95 % CI-2.05, -0.72], P < 0.01). However, there was no effect of FGM on the improvement of glycated hemoglobin levels in patients with type 1 diabetes mellitus [P = 0.45]. Furthermore, fasting plasma glucose levels and 2-h postprandial glucose levels were significantly lower in FGM than SMBG, and the number of hypoglycemic events was also significantly lower.

CONCLUSION

Comparing SMBG with FGM indicated that FGM improves fasting plasma glucose levels, 2-h postprandial glucose levels, and glycated hemoglobin levels, and it reduces the number of hypoglycemic events.

Significance of the CGM metric of time in range in children and adolescents with type 1 diabetes

Continuous glucose monitoring (CGM) has been widely used in children and adolescents as well as adults with type 1 diabetes. CGM metrics include three key measurements of target glucose: time in range (TIR: 70-180 mg/dL), time below range (TBR: <70 mg/dL), and time above range (TAR: >180 mg/dL). The primary goal of optimal glycemic control is to increase TIR to more than 70%, while simultaneously reducing TBR to less than 4%, while minimizing severe hypoglycemia to less than 1%, as proposed by the Advanced Technologies and Treatments for Diabetes (ATTD) panel. However, several studies have indicated that the TIR goal is quite difficult to achieve in pediatric patients who have remarkable interindividual and day-to-day glycemic variation due to their irregular lifestyles. Previous studies have demonstrated that patients without an automated insulin delivery system are unlikely to attain the recommended glycemic goals. On the other hand, reduction of hypoglycemia, particularly minimizing severe hypoglycemia, is a critical issue in the effective management of children with type 1 diabetes. Frequent episodes of severe hypoglycemia and hypoglycemia can cause lasting neurological damage. Accordingly, we propose reducing the TBR to less than 5%, rather than just targeting the TIR to more than 70%. In CGM metrics this should be the cardinal glycemic goal for pediatric patients who are either being treated with multiple daily injections of insulin or a conventional insulin pump, but who are not using an automated insulin delivery system.

Experiences of Using Wearable Continuous Glucose Monitors in Adults With Diabetes: A Qualitative Descriptive Study

PURPOSE

The purpose of the study was to understand the experiences of adults with diabetes wearing a continuous glucose monitor (CGM).

METHODS

This qualitative, descriptive study included 19 adults with type 1 diabetes or type 2 diabetes, who had used the FreeStyle Libre CGM for at least 4 weeks, from an outpatient clinic at a university-affiliated hospital in Korea. Data were collected through in-depth interviews and analyzed using an inductive content analysis approach.

RESULTS

The content analysis revealed 3 major themes-navigating glucose level fluctuations, reframing diabetes self-care and improving quality of life, and device improvement and service quality. Participants reported that CGMs offered convenient glucose level monitoring, allowed early response to rapid glucose changes, and facilitated effective patient-clinician communication. Participants expressed concerns about the financial burden and limited services, recommending improvements for devices, consumer services, and health insurance coverage.

CONCLUSIONS

Study findings indicated that using wearable CGMs could improve self-care and quality of life in adults with diabetes. Using CGMs could improve patients' understanding of how diabetes self-care management affects real-time glucose levels. Health care providers could support patients' self-care by using device data. Improvements in quality, services, and insurance coverage could increase user satisfaction and promote self-care.

Effect of divergent continuous glucose monitoring technologies on glycaemic control in type 1 diabetes mellitus: A systematic review and meta-analysis of randomised controlled trials

AIMS

We aimed to conduct a systematic review and meta-analysis of randomised controlled clinical trials (RCTs) assessing separately and together the effect of the three distinct categories of continuous glucose monitoring (CGM) systems (adjunctive, non-adjunctive and intermittently-scanned CGM [isCGM]), compared with traditional capillary glucose monitoring, on HbA1c and CGM metrics.

METHODS

PubMed, Web of Science, Scopus and Cochrane Central register of clinical trials were searched. Inclusion criteria were as follows: randomised controlled trials; participants with type 1 diabetes of any age and insulin regimen; investigating CGM and isCGM compared with traditional capillary glucose monitoring; and reporting glycaemic outcomes of HbA1c and/or time-in-range (TIR). Glycaemic outcomes were extracted post-intervention and expressed as mean differences and 95%CIs between treatment and comparator groups. Results were pooled using a random-effects meta-analysis. Risk of bias was assessed using the Cochrane Rob2 tool.

RESULTS

This systematic review was conducted between January and April 2021; it included 22 RCTs (15 adjunctive, 5 non-adjunctive, and 2 isCGM)). The overall analysis of the pooled three categories showed a statistically significant absolute improvement in HbA1c percentage points (mean difference (95% CI): -0.22% [-0.31 to -0.14], I²  = 79%) for intervention compared with comparator and was strongest for adjunctive CGM (-0.26% [-0.36, -0.16]). Overall TIR (absolute change) increased by 5.4% (3.5 to 7.2), I²  = 71% for CGM intervention compared with comparator and was strongest with non-adjunctive CGM (6.0% [2.3, 9.7]).

CONCLUSIONS

For individuals with T1D, use of CGM was beneficial for impacting glycaemic outcomes including HbA1c, TIR and time-below-range (TBR). Glycaemic improvement appeared greater for TIR for newer non-adjunctive CGM technology.

Hypoglycemia unawareness in type 1 diabetes patients using intermittent continuous glucose monitoring: Identification of risk factors and glycemic patterns

BACKGROUND

Hypoglycemia unawareness designates failure to detect eminent hypoglycemia. Clarke's questionnaire is one of the most used systems to evaluate this problem.

AIMS

To relate Clarke's questionnaire (QQ) results with continuous glucose monitoring data.

METHODS

Application of the questionnaire in a sample of type 1 diabetes mellitus (T1DM) patients using intermittent continuous glucose monitoring (iCGM).

RESULTS

111 T1DM patients were evaluated, 56.8% female, mean age 35.0 ± 12.4 years and mean disease duration 18.8 ± 10.5 years. According to CQ, 13.5% had unawareness, 76.6% awareness and 9.9% indeterminate awareness to hypoglycemia. Those with unawareness had longer disease duration (25.1 ± 10.4 vs 18.2 ± 10.3 for awareness and 14.9 ± 9.9 for indeterminate awareness, p = 0.047), more time below range (10.3 ± 4.9% vs 6.3 ± 5.1 and 6.3 ± 4.8; p = 0.009) and higher mean duration of hypoglycemia (131.7 ± 38.6 vs 116.6 ± 49.6 and 131.7 ± 38.6; p = 0.008). In multivariate analysis, mean duration of hypoglycemia was an independent predictor of CQ results. In a receiver operating curve (AUC 0.746; p = 0.004) a mean duration of hypoglycemia ≥106.5 min showed 84.6% sensitivity/64.4% specificity for unawareness.

CONCLUSIONS

Our sample had a significative prevalence of hypoglycemia unawareness which increased with longer diabetes duration. iCGM data can be indicative of this problem, with a mean hypoglycemia duration ≥106.5 min being suggestive, albeit unspecific.

Safety and effectiveness of do-it-yourself artificial pancreas system compared with continuous subcutaneous insulin infusions in combination with free style libre in people with type 1 diabetes

AIMS

The use of do-it-yourself artificial pancreas systems (DIYAPS) among people with type 1 diabetes is increasing. At present, it is unclear how DIYAPS compares with other technologies such as FreeStyle Libre (FSL) and continuous subcutaneous insulin infusion (CSII). The aim of this analysis is to compare safety, effectiveness and quality-of-life outcomes of DIYAPS use with the addition of FSL to CSII.

METHOD

Data from two large UK hospitals were extracted from the Association of British Clinical Diabetologists (ABCD) DIYAPS and FSL audits. Outcomes included HbA_1c , glucose TBR (time-below-range), TIR (time-in-range), Diabetes Distress Score (DDS), and Gold hypoglycaemia score. Any adverse events were noted. Changes at follow-up were assessed using paired t-tests and ANOVA in Stata; TIR/TBR at follow-up assessed using unpaired t-tests; chi-square tests assessed the change in frequency of health utilisation (e.g. hospital admissions).

RESULTS

DIYAPS (n = 35) and FSL+CSII (n = 149) users, with median follow-up duration of 1.4 (IQR 0.8-2.1) and 1.3 (IQR 0.7-1.8) years, respectively, were included. HbA_1c with DIYAPS use changed by -10 mmol/mol [0.9%] (p < 0.001, 95% CI 5, 14 [0.5, 1.3%]) significantly lower (p < 0.001) than in the FSL+CSII group -3 mmol/mol [0.25%] (p < 0.001, 95% CI 1, 4 [0.1, 0.4%]). TIR was higher and TBR was lower in the DIYAPS group. Adverse events were rare in both groups and no significant differences were observed in the frequency of healthcare utilisation.

CONCLUSION

DIYAPS use was associated with a lower HbA_1c levels, higher TIR and lower TBR compared with FSL+CSII. There was no significant increase in adverse events, although this should be interpreted cautiously given the low numbers of users. Full results from the ABCD DIYAPS audit are awaited.

Impact of flash glucose monitoring on quality of life and glycaemic control parameters in adults with type 1 diabetes mellitus⋆

INTRODUCTION

Flash glucose monitoring (FGM) improves some glycaemic control variables and quality of life parameters.

OBJECTIVE

Our aim was to evaluate the quality of life and glycaemic control parameters after initiating FGM in patients with type 1 diabetes (DM1) in clinical practice.

MATERIAL AND METHODS

A prospective observational study in DM1 patients that started using FGM between June 2019 and April 2020. We analysed their scores on the Diabetes Quality of Life (DQOL) questionnaire, Diabetes Distress Scale (DDS), Diabetes Treatment Satisfaction Questionnaire (DTSQ) and glycaemic control parameters at baseline and 3 months after the FGM onset.

RESULTS

We recruited 114 patients, 56% male, mean age 37.2 (standard deviation, SD 12.4), with 18.7 (SD 11.5) years of DM1, 24.6% of which used continuous subcutaneous insulin infusion. Differences were observed (baseline vs. 3 months) in the DTSQ score (22 [15.5-27] vs. 25 [22-28], P < 0.001) and in the DQOL score (88 [74-104] vs. 84 [70-101], P = 0.017) but not in the DDS score. HbA1c was 7.8% (SD 1.3) vs. 7.4% (SD 1.1) (P < 0.001), without improvement in other glycaemic control variables, except for the mean number of hypoglycaemic events/14 days: 14 (SD 9) at baseline vs. 11.5 (SD 7) at 3 months (P < 0.001).

CONCLUSIONS

The initiation of FGM, combined with a structured educational programme, was associated with improvement in quality of life and patient satisfaction in DM1 patients. An improvement in HbA1c and a reduction in the number of hypoglycaemia events was observed, but not in the rest of glycaemic control parameters.

Flash glucose monitoring and glycemic control in type 1 diabetes with subcutaneous insulin infusion

AIMS

To analyze the association between scan frequency and glycemic measures in continuous subcutaneous insulin infusion (CSII) treated type 1 diabetes (T1DM) adults.

METHODS

This retrospective study included 140 patients (> 18 years) with T1DM who used flash glucose monitoring (FGM). For each patient, we analyzed the Ambulatory Glucose Profile data over a period of 90 days. Data regarding glucose management indicator (GMI), time above, below and within range (TIR) and coefficient of variation (CV) were correlated with the number of daily scans. The effect of each additional test on glucose parameters was also evaluated.

RESULTS

Users performed a mean of 8.6 ± 4.4 scans per day. There was an inverse correlation between scanning frequency and GMI (r = - 0.431, p < 0.001), CV (r = - 0.440, p < 0.001), time above and below range (r = - 0.446, p < 0.001 and r = - 0.200, p = 0.018, respectively). The number of daily scans correlated positively with TIR (r = 0.554, p < 0.001). For each additional scan per day, the mean GMI decreased 0.09% and TIR increased 1.60%.

CONCLUSIONS

In patients with T1DM and CSII, higher rates of scanning correlated with improved glycemic markers, including reduced GMI and CV and increased TIR. For each test performed, there was a significant effect on the improvement of all glucose parameters.

Clinical and economic outcomes of continuous glucose monitoring system (CGMS) in patients with diabetes mellitus: A systematic literature review

OBJECTIVE

Poor glycemic management increases the risk of cardiac, microvascular, and other complications. Therefore, timely assessment and control of glycemic levels is paramount in diabetes. Recent advancements in automated management methods is the use of a continuous glucose monitoring system (CGMS). The objective was to study its clinical and economic impact in the glucose level monitoring and how it can be effectively used or reimbursed for wider population.

METHODS

Comprehensive search was done using multiple databases to capture relevant and most recent evidence. All steps were conducted by two independent researchers and discrepancies resolved by a third reviewer. Quality appraisal was performed by relevant scale depending on study design.

RESULTS

Twenty-six and 12 studies were included for clinical and economic outcomes, respectively. Clinical outcomes like HbA1c and glucose variation, time in range, accuracy, etc. were captured. Comparison of different CGMS types was also reported. Major economic outcomes were direct cost, healthcare resource utilization, and work absenteeism.

CONCLUSIONS

CGMS in patients with diabetes is associated with a valuable clinical implications in reducing hypoglycemic events, glucose and HbA1c level. Additionally, it has an impact on direct and indirect costs of management. Further, quantitative analysis would be required to produce concrete evidence.

Virtual visits and the use of continuous glucose monitoring for diabetes care in the era of COVID-19

ABSTRACT

The coronavirus disease 2019 (COVID-19) pandemic has led to an increase in virtual care utilization for patients with diabetes mellitus (DM). Virtual DM care requires both providers and patients to become familiar with new technology that supports home health monitoring. Continuous glucose monitoring (CGM) is a DM technology that provides 24-hr glucose monitoring and is associated with improved clinical outcomes, including decreased rates of hypoglycemia and lower hemoglobin A1c (A1c). Continuous glucose monitoring use has increased due to ease of use and its ability to allow patients to share data with providers during virtual visits. Although the clinical benefits of CGM use are clear, many providers are overwhelmed by the various options available and large influx of data received. The purpose of this clinical case review is to provide an overview of CGM use in the virtual care setting. Various types of CGMs will be defined and an overview of the patient characteristics shown to benefit most from CGM use will be provided. Further, recommendations for improving clinic workflow when using CGM will be outlined, including strategies to handle the influx of large datasets, outlining the role of the nurse practitioner (NP) and other providers in the clinic, and organizing data for efficient and improved clinical decision making. Continuous glucose monitoring use is hallmarked to revolutionize DM care for many patients, particularly during and after the COVID-19 pandemic. It is important that clinicians understand the nuances of CGM use and organize their virtual clinics to efficiently manage CGM users, leading to improved clinical decisions and patient outcomes.

Impact of flash glucose monitoring on glycemic control varies with the age and residual β-cell function of patients with type 1 diabetes mellitus

AIMS/INTRODUCTION

We aimed to explore the clinical factors associated with glycemic variability (GV) assessed with flash glucose monitoring (FGM), and investigate the impact of FGM on glycemic control among Chinese type 1 diabetes mellitus patients in a real-life clinical setting.

MATERIALS AND METHODS

A total of 171 patients were included. GV was assessed from FGM data. A total of 110 patients wore FGM continuously for 6 months (longitudinal cohort). Hemoglobin A1c (HbA1c), fasting and 2-h postprandial C-peptide, and glucose profiles were collected. Changes in HbA1c and glycemic parameters were assessed during a 6-month FGM period.

RESULTS

Individuals with high residual C-peptide (HRCP; 2-h postprandial C-peptide >200 pmol/L) had less GV than patients with low residual C-peptide ( 2-h postprandial C-peptide ≤200 pmol/L; P < 0.001). In the longitudinal cohort (n = 110), HbA1c and mean glucose decreased, time in range (TIR) increased during the follow-up period (P < 0.05). The 110 patients were further divided into age and residual C-peptide subgroups: (i) HbA1c and mean glucose were reduced significantly only in the subgroup aged ≤14 years during the follow-up period, whereas time below range also increased in this subgroup at 3 months (P = 0.047); and (ii) HbA1c improved in the HRCP subgroup at 3 and 6 months (P < 0.05). The mean glucose decreased and TIR improved significantly in the low residual C-peptide subgroup; however, TIR was still lower and time below range was higher than those of the HRCP subgroup at all time points (P < 0.05).

CONCLUSIONS

HRCP was associated with less GV. FGM wearing significantly reduced HbA1c, especially in pediatric patients and those with HRCP. Additionally, the mean glucose and TIR were also found to improve.