Continuous subcutaneous insulin infusion therapy is associated with reduced retinopathy progression compared with multiple daily injections of insulin

Improving equity in diabetes technology use: Voices of youth and their parents

AIMS

There are marked inequities in clinical outcomes and rates of diabetes technology use among youth with type 1 diabetes (T1D). The quantitative data from our mixed methods cohort study identified significant improvements in glycaemia and quality of life in participants. We aimed to use qualitative methods to provide further insight into our quantitative findings in the setting of underlying health disparities.

METHODS

Fifteen publicly insured, insulin pump-naïve non-Hispanic Black youth aged 6-21 years with T1D and baseline haemoglobin A1c (HbA1c) ≥86 mmol/mol (10%) and their parents participated in a mixed methods cohort study. Semi-structured interviews were conducted separately with parents and youth after completion of 6 months of HCL use. Three topic areas were explored: (1) Experience using HCL, (2) barriers to HCL and (3) facilitators to accessing HCL. Semantic content analysis and consensus coding involving two team members were used to generate themes. Thematic saturation was achieved.

RESULTS

Youth (Medianage 14.9 years, 67% female) and parents (92% female) were interviewed. Youth and their parents reported that access to HCL provides a new outlook on living with T1D, although managing T1D is still hard. They felt that diabetes technology is most helpful for those struggling with management. Participants experienced barriers to access including misconceptions of HCL systems, clinician bias and systemic racism. They suggested these barriers can be overcome by offering diabetes technology education for all people with T1D, increasing awareness of HCL in the community and providing resources to overcome barriers created by social determinants of health.

CONCLUSIONS

The voices of historically minoritised youth with suboptimal T1D control and their parents provide important, previously unreported experiences and perspectives on barriers and facilitators to using HCL that will shape interventions to improve equity in access to diabetes technology.

A cross-sectional questionnaire study: Impaired awareness of hypoglycaemia remains prevalent in adults with type 1 diabetes and is associated with the risk of severe hypoglycaemia

OBJECTIVE

Impaired awareness of hypoglycaemia (IAH) is a risk factor for severe hypoglycaemia (SH) in type 1 diabetes (T1D). Much of the IAH prevalence data comes from older studies where participants did not have the benefit of the latest insulins and technologies. This study surveyed the prevalence of IAH and SH in a tertiary adult clinic population and investigated the associated factors.

METHODS

Adults (≥18 years) attending a tertiary T1D clinic completed a questionnaire, including a Gold and Clarke score. Background information was collected from health records.

RESULTS

189 people (56.1% female) with T1D (median [IQR] disease duration 19.3 [11.5, 29.1] years and age of 41.0 [29.0, 52.0] years) participated. 17.5% had IAH and 16.0% reported ≥1 episode of SH in the previous 12 months. Those with IAH were more likely to report SH (37.5% versus 11.7%, p = 0.001) a greater number of SH episodes per person (median [IQR] 0 [0,2] versus 0 [0,0] P<0.001) and be female (72.7% versus 52.6%, p = 0.036). Socio-economic deprivation was associated with IAH (p = 0.032) and SH (p = 0.005). Use of technology was the same between IAH vs aware groups, however, participants reporting SH were more likely to use multiple daily injections (p = 0.026). Higher detectable C-peptide concentrations were associated with a reduced risk of SH (p = 0.04).

CONCLUSION

Insulin pump and continuous glucose monitor use was comparable in IAH versus aware groups. Despite this, IAH remains a risk factor for SH and is prevalent in females and in older people. Socioeconomic deprivation was associated with IAH and SH, making this an important population to target for interventions.

Dually crosslinked degradable polyionic micelles for sustained glucose-responsive insulin release

Glucose -sensitive delivery systems hold great promise as a therapeutic approach for high-incidence diabetes owing to their ability to release insulin whenever elevated glycemia is detected. However, they are unstable in a hyperglycemic environment, which leads to short-term sustained insulin release. Herein, we designed dually crosslinked insulin polyionic micelles (DCM@insulin) based on triblock polymers of o-glycol and phenylboronic acid-functionalized poly(ethylene glycol)-poly(dimethylamino carbonate)-poly(dimethylamino-trimethylene carbonate) (mPEG-P(AC-co-MPD)-PDMAC and mPEG-P(AC-co-MAPBA)-PDMATC, respectively) for sustained glucose-responsive insulin release. DCM@insulin with a phenylboronic acid ester structure (first crosslinking structure) enhanced glycemic responsiveness by regulating insulin release in a hyperglycemic environment. Additionally, the UV-crosslinking structure (second crosslinking structure) formed by the residual double bonds in AC units endowed DCM@insulin with the ability to effectively protect the loaded insulin against protease degradation and avoid burst release under multiple insulin release. The in vivo findings demonstrated that DCM@insulin effectively maintained glycemic levels (BGLs) within the normal range for 6 h in comparison to single-crosslinked micelles (SCM@insulin). Therefore, the glucose-responsive and dually crosslinked polyionic micelle system exhibits potential as a viable option for the treatment of diabetes.

RETINAL MICROVASCULOPATHY WITH DIFFERENT INSULIN INFUSION THERAPIES IN CHILDREN WITH TYPE 1 DIABETES MELLITUS WITHOUT CLINICAL DIABETIC RETINOPATHY

PURPOSE

To explore the characteristics and associated factors of retinal microvasculopathy and neurodegeneration with different insulin therapies in children with type 1 diabetes mellitus (T1DM) but without diabetic retinopathy.

METHODS

Forty-one children with T1DM with multiple daily insulin injections (MDI), 22 children with T1DM with continuous subcutaneous insulin infusion, and 62 age-matched normal control children were enrolled. SPECTRALIS Optical coherence tomography was used to scan 6×6 mm square area of posterior retina.

RESULTS

The vessel density of superficial vascular plexus, intermediate capillary plexus, and deep capillary plexus in T1DM-MDI group were all significantly lower than those in the T1DM-CSII and control groups (0.39 ± 0.05 vs. 0.44 ± 0.04 and 0.42 ± 0.06, P < 0.001; 0.26 ± 0.04 vs. 0.30 ± 0.02 and 0.28 ± 0.04, P = 0.003; 0.30 ± 0.04 vs. 0.33 ± 0.04 and 0.32 ± 0.04, P = 0.027). In T1DM-MDI group, lower vessel density of superficial vascular plexus was associated with higher hemoglobin A1c (r = -0.377, P = 0.015). Foveal avascular zone morphology index in T1DM-MDI and T1DM-CSII groups were smaller than that in the control group (0.63 ± 0.11 and 0.63 ± 0.12 vs. 0.69 ± 0.15, P = 0.040). There was no statistically significant difference in the thickness of the retina among the three groups ( P > 0.05).

CONCLUSION

The vessel density of posterior retina was lower in children with T1DM with MDI than in healthy control children and associated with higher hemoglobin A1c. There was a significant difference on vessel density betweenT1DM-MDI and T1DM-CSII, with the similar hemoglobin A1c. This study suggested that optical coherence tomography angiography could be beneficial for the detection of retinal abnormalities in children with early T1DM, and continuous subcutaneous insulin infusion may be a better choice than MDI for children with T1DM to prevent the retinal complication.

Use of Diabetes Technologies and Retinopathy in Adults With Type 1 Diabetes

Importance

Diabetic retinopathy (DR) is a complication of diabetes that can lead to vision loss. Outcomes of continuous glucose monitoring (CGM) and insulin pump use in DR are not well understood.

Objective

To assess the use of CGM, insulin pump, or both, and DR and proliferative diabetic retinopathy (PDR) in adults with type 1 diabetes (T1D).

Design, Setting, and Participants

A retrospective cohort study of adults with T1D in a tertiary diabetes center and ophthalmology center was conducted from 2013 to 2021, with data analysis performed from June 2022 to April 2023.

Exposure

Use of diabetes technologies, including insulin pump, CGM, and both CGM and insulin pump.

Main Outcomes and Measures

The primary outcome was development of DR or PDR. A secondary outcome was the progression of DR for patients in the longitudinal cohort. Multivariable logistic regression models assessed for development of DR and PDR and association with CGM and insulin pump use.

Results

A total of 550 adults with T1D were included (median age, 40 [IQR, 28-54] years; 54.4% female; 24.5% Black or African American; and 68.4% White), with a median duration of diabetes of 20 (IQR, 10-30) years, and median hemoglobin A1c (HbA1c) of 7.8% (IQR, 7.0%-8.9%). Overall, 62.7% patients used CGM, 58.2% used an insulin pump, and 47.5% used both; 44% (244 of 550) of the participants had DR at any point during the study. On univariate analysis, CGM use was associated with lower odds of DR and PDR, and CGM with pump was associated with lower odds of PDR (all P < .05), compared with no CGM use. Multivariable logistic regression adjusting for age, sex, race and ethnicity, diabetes duration, microvascular and macrovascular complications, insurance type, and mean HbA1c, showed that CGM was associated with lower odds of DR (odds ratio [OR], 0.52; 95% CI, 0.32-0.84; P = .008) and PDR (OR, 0.42; 95% CI, 0.23-0.75; P = .004), compared with no CGM use. In the longitudinal analysis of participants without baseline PDR, 79 of 363 patients (21.8%) had progression of DR during the study.

Conclusions and Relevance

In this cohort study of adults with T1D, CGM use was associated with lower odds of developing DR and PDR, even after adjusting for HbA1c. These findings suggest that CGM may be useful for diabetes management to mitigate risk for DR and PDR.

Diabetic Retinopathy - a Common Disease

Diabetic retinopathy (DR) is one of the most common complications of diabetes mellitus and one of the leading causes of visual impairment in working age individuals in the western world. The treatment of DR depends on its severity, so it is of great importance to detect patients as early as possible, in order to initiate early treatment and preserve vision. Despite currently insufficient screening participation, patients with diabetes already visit ophthalmological practices and clinics above average. Their medical care, including DR diagnostics and treatment has been making up an increasing proportion of ophthalmic activity for years. Since the prevalence of diabetes is increasing dramatically worldwide and a further increase is also predicted for Germany, the challenge for ophthalmologists is likely to grow considerably. As the same time, the diagnostic possibilities for differentiating DR and the therapeutic measures, especially with IVOM therapy, are becoming more and more complex, which increases the time burden in everyday clinical practice. The hope to avoid healthcare deficits and to further improve screening rates and visual acuity prognosis in patients with DR is based, among other things, on camera-assisted screening supported by artificial intelligence. Better diabetes management to reduce the prevalence of DR, as well as longer-acting drugs to treat DR, could also improve the care and help reduce the burden on ophthalmology practices.

Neutrophil–lymphocyte ratio as a reliable marker to predict pre-clinical retinopathy among type 2 diabetic patients

Background

Diabetic retinopathy is now recognized as a neurovascular in lieu of a microvascular complication. Visual evoked potentials (VEPs) are greatly valuable in detecting early diabetic retinal functional changes before the occurrence of structural damage. Low-grade inflammation plays a fundamental part in the development and progression of retinopathy in diabetics. Detecting diabetic patients with early retinopathy before the occurrence of clinical symptoms provides a window of opportunity to ensure the best prognosis for these eyes. Neutrophil–lymphocyte ratio (NLR) has recently been introduced as a novel marker of inflammation in various diseases. Indeed, the presence of a cheap, available, and reliable marker of inflammation that is capable to detect pre-clinical diabetic retinopathy (P-DR) is crucial for early intervention to retard the progression of ocular damage. As far as we know no previous studies investigated the role of NLR in the detection of P-DR. The aim of this study was to investigate the quality of prediction of NLR in detecting pre-clinical retinopathy in type 2 diabetic patients.

Results

In this case–control study, VEPs results showed a significant delay in P100 latencies of the patients’ group compared to the control group. According to the VEPs results, the patient group was further subdivided into two: diabetic with VEPs changes (a group with P-DR) and diabetic without VEPs changes. NLR was significantly elevated in patients with P-DR (p < 0.001). NLR cut-off point ≥ 1.97 is able to predict P-DR with 89.29% sensitivity and 84.37% specificity. Linear regression model revealed that NLR is the only independent factor that predicts P-DR. (odds ratio 3.312; 95% confidence interval 1.262–8.696, p = 0.015*.

Conclusions

Visual evoked potentials have an important role to evaluate the visual pathway in diabetics and to diagnose pre-clinical diabetic retinopathy before the occurrence of structural damage. Neutrophil–lymphocyte ratio is a reliable marker for the detection of pre-clinical diabetic retinopathy with good sensitivity (89.29%) and specificity (84.37%). Finding a reliable available laboratory test to predict P-DR could be of help to save diabetic patients from serious ocular complications.

Study protocol: a randomised controlled proof-of-concept real-world study - does maximising time in range using hybrid closed loop insulin delivery and a low carbohydrate diet restore the glucagon response to hypoglycaemia in adults with type 1 diabetes?

INTRODUCTION

People with type 1 diabetes (T1D) develop an impaired glucagon response to hypoglycaemia within 5 years of diagnosis, increasing their risk of severe hypoglycaemia. It is not known whether eliminating hypoglycaemia and hyperglycaemia allows recovery of this glucagon response. Hybrid closed loop (HCL) technologies improve glycaemic time in range (TIR). However, post-prandial glycaemic excursions are still evident. Consuming a low carbohydrate diet (LCD) may minimise these excursions.

METHODS AND ANALYSIS

This feasibility study will assess if maximising TIR (glucose ≥3.9 mmol/L≤10 mmol/L) using HCL systems plus an LCD (defined here as <130 g carbohydrate/day) for >8 months, restores the glucagon response to insulin-induced hypoglycaemia. Adults (n=24) with T1D (C-peptide <200 pmol/L), naïve to continuous glucose monitoring (CGM) and HCL systems, will be recruited and randomised to: group 1 (non-HCL) to continue their standard diabetes care with intermittent blinded CGM; or group 2 (HCL-LCD) to use the HCL system and follow a LCD. Baseline data on diet and glycaemia will be collected from all participants. The HCL-LCD group will then enter a 2-week run-in to acclimatise to their devices. Throughout, the HCL-LCD group will have their glucose closely monitored and adjusted aiming for glycaemic TIR >70%. Participants will have their glucagon response to hypoglycaemia measured at the beginning and 8 months later at the study end using a stepped hyperinsulinaemic hypoglycaemic clamp, in combination with the stable isotopes 6,6-²H₂-glucose (D2-glucose) and 1,1,2,3,3-²H₅-glycerol (D5-glycerol) to assess glucose and glycerol kinetics. The impact of hypoglycaemia on symptoms and cognitive function will be assessed during each clamp study. The primary outcome is the difference in the glucagon response to hypoglycaemia between and within groups at baseline versus study end.

ETHICS AND DISSEMINATION

Ethical (20/SS/0117)/institutional review board (2021/0001) approval has been obtained. The study will be disseminated by peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT04614168.

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.

Thirty-Year Time Trends in Diabetic Retinopathy and Macular Edema in Youth With Type 1 Diabetes

OBJECTIVE

To examine trends in diabetic retinopathy (DR) and diabetic macular edema (DME) in adolescents with type 1 diabetes between 1990 and 2019.

RESEARCH DESIGN AND METHODS

We analyzed 5,487 complication assessments for 2,404 adolescents (52.7% female, aged 12-20 years, diabetes duration >5 years), stratified by three decades (1990-1999, 2000-2009, 2010-2019). DR and DME were graded according to the modified Airlie House classification from seven-field stereoscopic fundal photography.

RESULTS

Over three decades, the prevalence of DR was 40, 21, and 20% (P < 0.001) and DME 1.4, 0.5, and 0.9% (P = 0.13), respectively, for 1990-1999, 2000-2009, and 2010-2019. Continuous subcutaneous insulin infusion (CSII) use increased (0, 12, and 55%; P < 0.001); mean HbA1c was bimodal (8.7, 8.5, and 8.7%; P < 0.001), and the proportion of adolescents meeting target HbA1c <7% did not change significantly (8.3, 7.7, and 7.1%; P = 0.63). In multivariable generalized estimating equation analysis, DR was associated with 1-2 daily injections (odds ratio 1.88, 95% CI 1.42-2.48) and multiple injections in comparison with CSII (1.38, 1.09-1.74); older age (1.11, 1.07-1.15), higher HbA1c (1.19, 1.05-1.15), longer diabetes duration (1.15, 1.12-1.18), overweight/obesity (1.27, 1.08-1.49) and higher diastolic blood pressure SDS (1.11, 1.01-1.21). DME was associated with 1-2 daily injections (3.26, 1.72-6.19), longer diabetes duration (1.26, 1.12-1.41), higher diastolic blood pressure SDS (1.66, 1.22-2.27), higher HbA1c (1.28, 1.03-1.59), and elevated cholesterol (3.78, 1.84-7.76).

CONCLUSIONS

One in five adolescents with type 1 diabetes had DR in the last decade. These findings support contemporary guidelines for lower glycemic targets, increasing CSII use, and targeting modifiable risk factors including blood pressure, cholesterol, and overweight/obesity.

Effects of intensive insulin therapy on the retinal microvasculature in patients with type 2 diabetes mellitus: a prospective observational study

Background

We examined the retinal microvascular changes and associated factors in type 2 diabetes mellitus (T2DM) before and after intensive insulin therapy.

Methods

This prospective observational study recruited patients with T2DM and divided them into intensive insulin therapy and oral hypoglycemic agent groups. All patients enrolled in this study had diabetes without retinopathy or non-proliferative diabetic retinopathy. Optical coherence tomography angiography (OCTA) was used in all patients before treatment and at 1, 3, and 6 months after treatment. Vessel density (VD) and thickness changes in the macular and optic disc areas were assessed.

Results

The study included 36 eyes in the intensive insulin therapy group and 36 in the oral hypoglycemic agent group. One month after treatment, VD in the deep capillary plexus (DCP) and peripapillary capillary VD (ppVD) were significantly decreased by intensification (P = 0.009, 0.000). At three months after treatment, decreases in VD induced by intensification were found in the superficial capillary plexus (SCP), DCP, foveal density in a 300-μm-wide region around the foveal avascular area (FD-300), and ppVD (P = 0.032, 0.000, 0.039, 0.000). Six months after treatment, decreases in VD by intensification were observed in the DCP and ppVD groups (P = 0.000, 0.000). Vessel density showed no significant change in the oral hypoglycemic agent group after treatment. The amount of DCP-VD reduction was correlated with macular thickening (r = 0.348, P = 0.038; r = 0.693, P = 0.000 and r = 0.417, P = 0.011, respectively) after intensive insulin therapy.

Conclusions

Insulin-intensive treatment caused a transient reduction in vessel density in the macular and optic disc areas. DCP-VD and ppVD were more susceptible at an earlier stage. Retinal microvasculature monitoring using OCTA is vital for patients with type 2 diabetes receiving intensive insulin therapy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12886-022-02397-9.

Delivering evidence-based interventions for type 1 diabetes in the virtual world - A review of UK practice during the SARS-CoV-2 pandemic

AIMS

This review considers the impact of the SARS-CoV-2 pandemic on access to interventions for those living with type 1 diabetes and discusses the solutions which have been considered and actioned to ensure ongoing access care.

METHODS

We performed a focussed review of the published literature, and the guidelines for changes that have been effected during the pandemic. We also drew from expert recommendations and information about local practice changes for areas where formal data have not been published.

RESULTS

Evidence based interventions which support the achievement of improved glucose levels and/or reduction in hypoglycaemia include group structured education to support self-management, insulin pump therapy and continuous glucose monitoring. The SARS-CoV-2 pandemic had impacted the ability of diabetes services to deliver these intervention. Multiple adaptations have been put in place - transition to online delivery of education and care, and usage of diabetes technology.

CONCLUSIONS

Although various adaptations have been made during the pandemic that have positively influenced uptake of services, there are many areas of delivery that need immediate improvement in the UK. We recommend a proactive approach in recognising the digital divide and inequity in distribution of these changes and we recommend introducing measures to reduce them.