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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. J Clin Med 2023; 12:jcm12030781. [PMID: 36769430 PMCID: PMC9917934 DOI: 10.3390/jcm12030781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2022] [Revised: 01/09/2023] [Accepted: 01/17/2023] [Indexed: 01/20/2023] Open
Abstract
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.
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2
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Abraham MB, Karges B, Dovc K, Naranjo D, Arbelaez AM, Mbogo J, Javelikar G, Jones TW, Mahmud FH. ISPAD Clinical Practice Consensus Guidelines 2022: Assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes 2022; 23:1322-1340. [PMID: 36537534 PMCID: PMC10107518 DOI: 10.1111/pedi.13443] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 10/27/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Mary B Abraham
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia.,Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia.,Discipline of Pediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - Beate Karges
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Klemen Dovc
- Department of Pediatric Endocrinology, Diabetes and Metabolic Diseases, UMC - University Children's Hospital, Ljubljana, Slovenia, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Diana Naranjo
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California, USA
| | - Ana Maria Arbelaez
- Division of Endocrinology and Diabetes, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Joyce Mbogo
- Department of Pediatric and Child Health, Aga Khan University Hospital, Nairobi, Kenya
| | - Ganesh Javelikar
- Department of Endocrinology and Diabetes, Max Super Speciality Hospital, New Delhi, India
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia.,Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia.,Discipline of Pediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - Farid H Mahmud
- Division of Endocrinology, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Canada
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3
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Real-world outcomes of insulin pump compared to multiple daily injection therapy in adult type 1 diabetes mellitus patients in a Mediterranean scenario. Int J Diabetes Dev Ctries 2020. [DOI: 10.1007/s13410-020-00887-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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4
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Chen E, King F, Kohn MA, Spanakis EK, Breton M, Klonoff DC. A Review of Predictive Low Glucose Suspend and Its Effectiveness in Preventing Nocturnal Hypoglycemia. Diabetes Technol Ther 2019; 21:602-609. [PMID: 31335193 DOI: 10.1089/dia.2019.0119] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
To evaluate the effectiveness of predictive low glucose suspend (PLGS) systems within sensor-augmented insulin infusion pumps at preventing nocturnal hypoglycemia in patients with type 1 diabetes (DM1), we performed a systematic review and meta-analysis of randomized crossover trials. Pubmed and Google Scholar were searched for randomized crossover trials, published between January 2013 and July 2018, in nonpregnant outpatients with DM1, which compared event rates during PLGS overnight periods and non-PLGS overnight periods. The primary outcome was the proportion of overnight periods with one or more hypoglycemic measurement. When available, individual patient data were used to assess the effect of clustering measurements within patients. Four studies (272 patients, 10,735 patient-nights: 5422 PLGS and 5313 non-PLGS) were included in the meta-analysis. Two studies reported patient-level data that permitted assessment of the effect of clustering measurements within patients. The effect on the risk difference was minimal. The proportion of overnight periods with one or more episodes of hypoglycemia was 19.6% for the PLGS periods and 27.8% for the non-PLGS periods. Based on the pooled estimate, PLGS overnight periods were associated with an 8.8% lower risk of hypoglycemia (risk difference -0.088; 95% CI -0.119 to -0.056, I2 = 67.4%, τ2 = 0.0006, 4 studies). PLGS systems can reduce nocturnal hypoglycemic events in patients with DM1.
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Affiliation(s)
- Ethan Chen
- Diabetes Research Institute at Mills-Peninsula Medical Center, San Mateo, California
| | - Fraya King
- Diabetes Research Institute at Mills-Peninsula Medical Center, San Mateo, California
| | - Michael A Kohn
- Department of Epidemiology and Biostatistics, University of California, San Francisco School of Medicine, San Francisco, California
| | - Elias K Spanakis
- Division of Endocrinology, Baltimore Veterans Affairs Medical Center, Baltimore, Maryland
- Division of Endocrinology, Diabetes, and Nutrition, University of Maryland School of Medicine, Baltimore, Maryland
| | - Marc Breton
- Center for Diabetes Technology, University of Virginia, Charlottesville, Virginia
| | - David C Klonoff
- Diabetes Research Institute at Mills-Peninsula Medical Center, San Mateo, California
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5
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Gómez AM, Henao DC, Taboada LB, Leguizamón G, Rondón MA, Muñoz OM, García-Jaramillo MA, León Vargas FM. Impact of sensor-augmented pump therapy with predictive low-glucose management on hypoglycemia and glycemic control in patients with type 1 diabetes mellitus: 1-year follow-up. Diabetes Metab Syndr 2019; 13:2625-2631. [PMID: 31405686 DOI: 10.1016/j.dsx.2019.07.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 07/10/2019] [Indexed: 10/26/2022]
Abstract
AIMS To describe real-life experience with sensor-augmented pump therapy with predictive low-glucose management (SAPT-PLGM), in terms of hypoglycemia and glycemic control after one year of follow-up in T1D patients with hypoglycemia as the main indication of therapy. METHODS Retrospective cohort study under real life conditions. Baseline and one-year follow-up variables of glycemic control, hypoglycemia and glycemic variability were compared. RESULTS Fifty patients were included, 31 on prior treatment with SAPT with low-glucose suspend (LGS) feature and 19 on multiple dose insulin injections (MDI). Mean HbA1c decreased in the MDI group (8.24%-7.08%; p = 0.0001). HbA1c change was not significant in the SAPT-LGS group. Area under the curve (AUC) below 70 mg/dl improved in both SAPT-LGS and MDI groups while AUC, %time and events below 54 mg/dl decreased in SAPT-LGS group. Glycemic variability improved in the MDI group. Less patients presented severe hypoglycemia with SAPT-PLGM in both groups, however the change was non-significant. CONCLUSIONS Under real life conditions, SAPT-PLGM reduced metrics of hypoglycemia in patients previously treaded with MDI and SAPT-LGS without deteriorating glycemic control in SAPT-LGS patients, while improving it in patients treated with MDI.
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Affiliation(s)
- Ana M Gómez
- Pontificia Universidad Javeriana, Bogotá, Colombia; Hospital Universitario San Ignacio, Division of Endocrinology, Bogotá, Colombia.
| | - Diana C Henao
- Pontificia Universidad Javeriana, Bogotá, Colombia; Hospital Universitario San Ignacio, Division of Endocrinology, Bogotá, Colombia
| | - Lucía B Taboada
- Pontificia Universidad Javeriana, Bogotá, Colombia; Hospital Universitario San Ignacio, Division of Endocrinology, Bogotá, Colombia
| | | | - Martín A Rondón
- Department of Clinical Epidemiology and Biostatistics, Pontificia Universidad Javeriana, Bogotá, Colombia
| | - Oscar M Muñoz
- Hospital Universitario San Ignacio, Department of Internal Medicine, Bogotá, Colombia
| | | | - Fabián M León Vargas
- Faculty of Mechanical, Electronic and Biomedical Engineering, Universidad Antonio Nariño, Bogotá, Colombia
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Viñals C, Quirós C, Giménez M, Conget I. Real-Life Management and Effectiveness of Insulin Pump with or Without Continuous Glucose Monitoring in Adults with Type 1 Diabetes. Diabetes Ther 2019; 10:929-936. [PMID: 30900146 PMCID: PMC6531534 DOI: 10.1007/s13300-019-0599-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION To describe and compare the routine use of continuous subcutaneous insulin infusion (CSII) in type 1 diabetes (T1D) patients with and without continuous glucose monitoring (CGM) in routine clinical practice and its relationship with glycemic outcomes. METHODS Retrospective observational case-control study collecting routine use of CSII and CGM in T1D patients between January 2016 and December 2016. Patients with T1D using sensor augmented pump (SAP) were matched by sex and disease duration in a 1:3 ratio with those treated only with CSII. Patients used a Paradigm Veo or 640G Medtronic-Minimed® insulin pump with or without a glucose sensor (Enlite, Medtronic-Minimed®) for at least 12 months. RESULTS A total of 160 subjects with T1D were included, 40 using SAP and 120 on CSII (age 47 ± 12 years, 88 women, diabetes duration 29 ± 9.0 years, 10 ± 4.7 years on CSII, HbA1C 7.6 ± 0.8%). Those in SAP therapy used the sensor 63% of time, performed less self-monitored blood glucose (SMBG)/day (3.3 ± 1.9 vs. 4.5 ± 2.0; p < 0.01), more bolus/day (6.2 ± 3.6 vs. 4.8 ± 1.6; p < 0.05), more basal insulin segment/day (6.5 ± 2.1 vs. 5.9 ± 1.5; p < 0.05), and more suspension time of the pump (97 ± 93 vs. 9.6 ± 20 min/day; p < 0.0001). Regarding metabolic control, SAP therapy patients had lower HbA1c (7.4 ± 0.7 vs. 7.7 ± 0.9%; p = 0.068), lower average SMBG value (151 ± 32 vs. 163 ± 30 mg/dL; p < 0.05), a lower percentage of SMBG values greater than 180 mg/dL (30 ± 19 vs. 37 ± 16%; p < 0.05) with no differences in SMBG values less than 70 mg/dL (12 ± 8.0 vs. 9.8 ± 9.8%; p = 0.33) compared with patients on CSII. There were no differences in bolus wizard targets or in insulin/carbohydrate ratios per day. CONCLUSION In a real-world setting, SAP therapy is associated with more self-adjustments of insulin therapy when compared to CSII alone. This could result in an improvement in glucose control.
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Affiliation(s)
- Clara Viñals
- Diabetes Unit, Endocrinology and Nutrition Department, Hospital Clínic, Barcelona, Spain
| | - Carmen Quirós
- Diabetes Unit, Endocrinology and Nutrition Department, Hospital Clínic, Barcelona, Spain
- Endocrinology and Nutrition Department, Hospital Universitari Mútua de Tarrasa, Tarrasa, Spain
| | - Marga Giménez
- Diabetes Unit, Endocrinology and Nutrition Department, Hospital Clínic, Barcelona, Spain
- IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), Barcelona, Spain
- CIBERDEM (CIBER in Diabetes and Associated Metabolic Disorders), Barcelona, Spain
| | - Ignacio Conget
- Diabetes Unit, Endocrinology and Nutrition Department, Hospital Clínic, Barcelona, Spain.
- IDIBAPS (Institut d'Investigacions Biomèdiques August Pi i Sunyer), Barcelona, Spain.
- CIBERDEM (CIBER in Diabetes and Associated Metabolic Disorders), Barcelona, Spain.
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Thomakos P, Mitrakou A, Kepaptsoglou O, Taraoune I, Barreto C, Zoupas CS. The Predictive Low Glucose Management System in Prevention of Clinically Significant Hypoglycemia in Type 1 Diabetes. A Preliminary Study Identifying the Most Common Events Leading Up to Hypoglycemia During Insulin Pump Therapy. Exp Clin Endocrinol Diabetes 2019; 129:385-389. [PMID: 30986882 DOI: 10.1055/a-0889-7598] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND/AIM Prevention of hypoglycemia remains a major challenge in diabetic management, despite the introduction of modern insulin pumps in daily clinical practice. The Low Glucose Suspend (LGS) and the newer Predictive Low Glucose Management (PLGM) systems incorporated in the Medtronic insulin pumps have shown promising results in prevention of hypoglycemia. Our aim was to evaluate the effect of the 2 systems relative to the frequency of clinically significant hypoglycemia in Type 1 diabetes (T1DM). In addition, we investigated the events preceding clinically significant hypoglycemia episodes. METHODS A cross-sectional study was conducted in 30 T1DM patients using the MiniMed 640G vs. 30 using the MiniMed Veo sensor-augmented insulin pump. All data was recorded during patients' normal daily activity and living conditions. The patients were matched for age and duration of diabetes. RESULTS PLGM use was associated with lower incidence of clinically significant hypoglycemia (1.9±1.4 vs. 3.6±1.9 episodes per week), along with reduced exposure to hypoglycemia. The data indicated that both pump systems are effective in preventing severe hypoglycemic episodes. In both groups the most common events preceding hypoglycemic episodes included adjustment of hyperglycemia, basal rate increase and miscalculation of carbohydrates. CONCLUSIONS The results indicated that the use of the Minimed 640G pump system can help reduce the frequency of clinically significant hypoglycemia. Management of hyperglycemia must be addressed in diabetes education programs in order to encourage proper adjustment of high blood glucose levels. Future studies would be useful in exploring the details of the events preceding hypoglycemia episodes in insulin pump users.
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Affiliation(s)
- Petros Thomakos
- Diabetes Center and Clinic, Hygeia General Hospital, Marousi, Athens, Greece.,Department of Clinical Therapeutics, National and Kapodistrian University of Athens Alexandra Hospital, Athens, Greece
| | - Asimina Mitrakou
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens Alexandra Hospital, Athens, Greece
| | - Olga Kepaptsoglou
- Diabetes Center and Clinic, Hygeia General Hospital, Marousi, Athens, Greece
| | - Ibrahim Taraoune
- Diabetes Center and Clinic, Hygeia General Hospital, Marousi, Athens, Greece
| | - Carol Barreto
- Diabetes Center and Clinic, Hygeia General Hospital, Marousi, Athens, Greece
| | - Christos Sp Zoupas
- Diabetes Center and Clinic, Hygeia General Hospital, Marousi, Athens, Greece
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Cherubini V, Gesuita R, Skrami E, Rabbone I, Bonfanti R, Arnaldi C, D'Annunzio G, Frongia A, Lombardo F, Piccinno E, Schiaffini R, Toni S, Tumini S, Tinti D, Cipriano P, Minuto N, Lenzi L, Ferrito L, Ventrici C, Ortolani F, Cohen O, Scaramuzza A. Optimal predictive low glucose management settings during physical exercise in adolescents with type 1 diabetes. Pediatr Diabetes 2019; 20:107-112. [PMID: 30378759 DOI: 10.1111/pedi.12792] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 07/24/2018] [Accepted: 10/18/2018] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES To assess the optimal setting of the predictive low glucose management (PLGM) algorithm for preventing exercise-induced hypoglycemia in adolescents with type 1 diabetes. METHODS Thirty-four adolescents, 15 to 20 years, wearing PLGM system, were followed during 3 days exercise during a diabetes camp. PLGM threshold was set at 70 mg/dL between 8 am and 10 pm and 90 mg/dL during 10 pm and 8 am Adolescents were divided into group A and B, with PLGM threshold at 90 and 70 mg/dL, respectively, during exercise. Time spent in hypoglycemia and AUC for time slots 8 am to 1 pm, 1 to 4 pm, 4 to 11 pm, 11 pm to 3 am, 3 to 8 am, in 3 days were compared between groups by Wilcoxon rank sum test. RESULTS We analyzed 31 patients (median age 15.0 years, 58.1% males, median diabetes duration 7.0 years, hemoglobin A1c [HbA1c] 7.1%). No significant difference has been observed in time spent in hypoglycemia between groups using threshold 70 or 90. Time spent in target was similar in both groups, as well as time spent in hypo or hyperglycemia. The trends of blood glucose over the 3 days in the 2 groups over-lapped without significant differences. CONCLUSIONS A PLGM threshold of 90 mg/dL during the night was associated with reduced time in hypoglycemia in adolescents doing frequent physical exercise, while maintaining 65.1% time in range during the day. However, a threshold of 70 mg/dL seems to be safe in the duration of the physical exercise. PLGM system in adolescents with type 1 diabetes was effective to prevent hypoglycemia during and after exercise, irrespective of the PLGM thresholds used.
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Affiliation(s)
- Valentino Cherubini
- Division of Pediatric and Adolescent Diabetes, Department of Women's and Children's Health, AOU Salesi Hospital, Ancona, Italy
| | - Rosaria Gesuita
- Centre of Epidemiology and Biostatistics, Polytechnic University of Marche, Ancona, Italy
| | - Edlira Skrami
- Centre of Epidemiology and Biostatistics, Polytechnic University of Marche, Ancona, Italy
| | - Ivana Rabbone
- Department of Pediatrics, University of Turin, Turin, Italy
| | - Riccardo Bonfanti
- Pediatric Diabetes and Diabetes Research Institute, San Raffaele Hospital, Milan, Italy
| | | | - Giuseppe D'Annunzio
- Department of Pediatrics, Istituto "G. Gaslini" Children's Hospital, Genoa, Italy
| | | | | | - Elvira Piccinno
- Metabolic Diseases and Diabetology, Pediatric Hospital Giovanni XXIII, Bari, Italy
| | | | - Sonia Toni
- Juvenile Diabetes Center, Anna Meyer Children's Hospital, Florence, Italy
| | - Stefano Tumini
- Center of Pediatric Diabetology, University of Chieti, Chieti, Italy
| | - Davide Tinti
- Department of Pediatrics, University of Turin, Turin, Italy
| | - Paola Cipriano
- Center of Pediatric Diabetology, University of Chieti, Chieti, Italy
| | - Nicola Minuto
- Institute of Endocrinology, Sheba Medical Center, Ramat Gan, Israel
| | - Lorenzo Lenzi
- Juvenile Diabetes Center, Anna Meyer Children's Hospital, Florence, Italy
| | - Lucia Ferrito
- Division of Pediatric and Adolescent Diabetes, Department of Women's and Children's Health, AOU Salesi Hospital, Ancona, Italy
| | | | - Federica Ortolani
- Metabolic Diseases and Diabetology, Pediatric Hospital Giovanni XXIII, Bari, Italy
| | - Ohad Cohen
- Institute of Endocrinology, Sheba Medical Center, Ramat Gan, Israel.,Medtronic, Tolochenaz, Switzerland
| | - Andrea Scaramuzza
- Division of Pediatrics, ASST Cremona, "Ospedale Maggiore di Cremona", Cremona, Italy
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9
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Abraham MB, Smith GJ, Nicholas JA, Fairchild JM, King BR, Ambler GR, Cameron FJ, Davis EA, Jones TW. Characteristics of Automated Insulin Suspension and Glucose Responses with the Predictive Low-Glucose Management System. Diabetes Technol Ther 2019; 21:28-34. [PMID: 30585769 DOI: 10.1089/dia.2018.0205] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The Predictive Low-Glucose Management (PLGM) system suspends basal insulin when hypoglycemia is predicted and reduces hypoglycemia. The aim of this analysis was to explore the characteristics of automated insulin suspension and sensor glucose (SG) responses following PLGM-initiated pump suspension. RESEARCH DESIGN AND METHODS Children and adolescents with type 1 diabetes used the Medtronic MiniMed™ 640G pump as part of a randomized controlled trial. Data collected on a subgroup of participants on PLGM (suspend before low enabled) from CareLink® Therapy Management Software were analyzed to explore the time and duration of PLGM-initiated pump suspension. Day and nighttime were defined as 06:00 am to 10:00 pm and 10:00 pm to 6:00 am, respectively. RESULTS There were 20,183 suspend before low events in 8523 days (2.37 events/day). The mean suspend duration was 55.0 ± 32.7 min (day 50.0 ± 30.1, night 71.7 ± 35.1; P < 0.001). Although a 2-h pump suspension was more frequent at night (day 5%, night 18%), a patient-initiated resumption occurred more during day (day 34%, night 12%). SG values did not reach <3.5 and <3 mmol/L in 79% and 91% of the events, respectively. The 2-h SG following pump resumption was higher following autoresumption during the day (day vs. night 9.3 mmol/L vs. 8.4 mmol/L; P < 0.001). CONCLUSIONS Longer suspends and fewer glycemic excursions occur at night compared with day. The higher glycemic daytime excursions could be due to carbohydrate consumption to increase glucose levels and highlights the need for health care professionals to educate patients about carbohydrate intake around pump suspension.
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Affiliation(s)
- Mary B Abraham
- 1 Children's Diabetes Center, Telethon Kids Institute, The University of Western Australia, Perth, Australia
- 2 Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- 3 Division of Pediatrics, Within the Medical School, The University of Western Australia, Perth, Australia
| | - Grant J Smith
- 1 Children's Diabetes Center, Telethon Kids Institute, The University of Western Australia, Perth, Australia
| | - Jennifer A Nicholas
- 1 Children's Diabetes Center, Telethon Kids Institute, The University of Western Australia, Perth, Australia
- 2 Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
| | - Janice M Fairchild
- 4 Department of Endocrinology and Diabetes, Women's and Children's Hospital, Adelaide, Australia
| | - Bruce R King
- 5 Department of Endocrinology and Diabetes, John Hunter Children's Hospital, Newcastle, Australia
| | - Geoffrey R Ambler
- 6 Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, The University of Sydney, Sydney, Australia
| | - Fergus J Cameron
- 7 Department of Endocrinology and Diabetes, Royal Children's Hospital, Melbourne, Australia
| | - Elizabeth A Davis
- 1 Children's Diabetes Center, Telethon Kids Institute, The University of Western Australia, Perth, Australia
- 2 Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- 3 Division of Pediatrics, Within the Medical School, The University of Western Australia, Perth, Australia
| | - Timothy W Jones
- 1 Children's Diabetes Center, Telethon Kids Institute, The University of Western Australia, Perth, Australia
- 2 Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia
- 3 Division of Pediatrics, Within the Medical School, The University of Western Australia, Perth, Australia
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10
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Vigersky RA. Going beyond HbA1c to understand the benefits of advanced diabetes therapies. J Diabetes 2019; 11:23-31. [PMID: 30151979 DOI: 10.1111/1753-0407.12846] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 08/14/2018] [Accepted: 08/21/2018] [Indexed: 11/27/2022] Open
Abstract
The gold standard for monitoring overall glycemia is HbA1c. However, HbA1c has several important limitations, giving more weight to the prior 2 to 3 months rather than short-term glycemic control. In addition, the level of the HbA1c does not reflect the important interpersonal differences in its relationship with mean glucose, and HbA1c is affected by many common clinical conditions (anemia, uremia) that can interfere with the accuracy of its measurement in the laboratory. The development and refinement of continuous glucose monitoring (CGM), a glucose- and patient-centric technology, over the past two decades have permitted the creation of new single and composite metrics, such as the percentage of time in range and the glucose pentagon, respectively, which provide clinically relevant insights into short-term glycemic control. In addition, CGM creates new outcome metrics for clinical management and investigational studies (percentage of time in hypoglycemia, percentage of time in target range) that can accurately and meaningfully report the effects of an intervention, whether that is a drug, a device, or a psychosocial program, and CGM provides the key input to drive algorithm-based insulin delivery. Finally, CGM linked with artificial intelligence permits real-time feedback to patients about modifiable patterns of glycemic excursions.
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Affiliation(s)
- Robert A Vigersky
- Uniformed Services University of the Health Sciences, Bethesda, Maryland
- Medtronic Diabetes, Northridge, California
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11
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Beato-Víbora PI, Quirós-López C, Lázaro-Martín L, Martín-Frías M, Barrio-Castellanos R, Gil-Poch E, Arroyo-Díez FJ, Giménez-Álvarez M. Impact of Sensor-Augmented Pump Therapy with Predictive Low-Glucose Suspend Function on Glycemic Control and Patient Satisfaction in Adults and Children with Type 1 Diabetes. Diabetes Technol Ther 2018; 20:738-743. [PMID: 30256132 DOI: 10.1089/dia.2018.0199] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIMS The aim was to evaluate the effectiveness of sensor-augmented pump therapy with predictive low-glucose suspend function (SAP-PLGS) in real-world use in children and adults with type 1 diabetes (T1D). METHODS Patients with T1D treated with the MiniMed 640G® pump with PLGS function at three referral hospitals were retrospectively evaluated. HbA1c at baseline and at 6, 12, 18, and 24 months was analyzed. Two weeks of data from pumps, sensors, and/or glucose meters were downloaded. Patients completed satisfaction questionnaires at the last follow-up visit. RESULTS A total of 162 patients were included. Mean age was 32 ± 17 years, 28% were (n = 46) children, and 29% (n = 47) were with a history of severe hypoglycemia. Median follow-up was 12 months (6-18). HbA1c was reduced from 55 ± 9 to 54 ± 8 mmol/mol (7.2% ± 0.8% to 7.1% ± 0.7%) at 12 months (P < 0.03, n = 100). In patients with suboptimal control, there was a reduction in HbA1c from 66% ± 7% to 61 ± 10 mmol/mol (8.2% ± 0.6% to 7.7% ± 0.9%) at the end of follow-up (n = 26, P < 0.01). Three percent (n = 5) of the patients experienced severe hypoglycemia during follow-up. A reduction in the percentage of self-monitoring of blood glucose values <70 mg/dL was achieved (10% ± 7% to 6% ± 5%, P = 0.001, n = 144). Time in range 70-180 mg/dL was 67% ± 13% at the end of follow-up and predictors of a higher time in range were identified. The use of sensors was high (86%) and 73% of the patients showed high satisfaction. In patients using sensors at baseline (n = 54), the time spent at <54 and <70 mg/dL was reduced. CONCLUSION SAP-PLGS reduces hypoglycemia frequency while maintaining glycemic control in adults and children under real-life conditions.
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Affiliation(s)
| | | | | | - María Martín-Frías
- 3 Paediatric Diabetes Unit, Ramón y Cajal University Hospital , Madrid, Spain
| | | | - Estela Gil-Poch
- 4 Department of Paediatrics, Badajoz University Hospital , Badajoz, Spain
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12
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Abraham MB, Jones TW, Naranjo D, Karges B, Oduwole A, Tauschmann M, Maahs DM. ISPAD Clinical Practice Consensus Guidelines 2018: Assessment and management of hypoglycemia in children and adolescents with diabetes. Pediatr Diabetes 2018; 19 Suppl 27:178-192. [PMID: 29869358 DOI: 10.1111/pedi.12698] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 05/28/2018] [Indexed: 12/23/2022] Open
Affiliation(s)
- Mary B Abraham
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia.,Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia.,Division of Paediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - Timothy W Jones
- Department of Endocrinology and Diabetes, Perth Children's Hospital, Perth, Australia.,Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia.,Division of Paediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - Diana Naranjo
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
| | - Beate Karges
- Division of Endocrinology and Diabetes, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | | | - Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - David M Maahs
- Division of Endocrinology, Department of Pediatrics, Stanford University School of Medicine, Stanford, California
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Sherr JL, Tauschmann M, Battelino T, de Bock M, Forlenza G, Roman R, Hood KK, Maahs DM. ISPAD Clinical Practice Consensus Guidelines 2018: Diabetes technologies. Pediatr Diabetes 2018; 19 Suppl 27:302-325. [PMID: 30039513 DOI: 10.1111/pedi.12731] [Citation(s) in RCA: 128] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2018] [Accepted: 07/10/2018] [Indexed: 12/12/2022] Open
Affiliation(s)
- Jennifer L Sherr
- Department of Pediatrics, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Martin Tauschmann
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, UK.,Department of Paediatrics, University of Cambridge, Cambridge, UK
| | - Tadej Battelino
- UMC-University Children's Hospital, Ljubljana, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Martin de Bock
- Department of Paediatrics, University of Otago, Christchurch, New Zealand
| | - Gregory Forlenza
- University of Colorado Denver, Barbara Davis Center, Aurora, Colorado
| | - Rossana Roman
- Medical Sciences Department, University of Antofagasta and Antofagasta Regional Hospital, Antofagasta, Chile
| | - Korey K Hood
- Department of Psychiatry & Behavioral Sciences, Stanford University School of Medicine, Palo Alto, California
| | - David M Maahs
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California
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Petrovski G, Al Khalaf F, Hussain K, Campbell J, El Awwa A. Continuous Subcutaneous Insulin Infusion Characteristics in Type 1 Diabetes Children and Adolescents in Qatar. Diabetes Ther 2018; 9:2091-2098. [PMID: 30220038 PMCID: PMC6167275 DOI: 10.1007/s13300-018-0510-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Indexed: 11/26/2022] Open
Abstract
AIM To describe continuous subcutaneous insulin infusion (CSII) characteristics in type 1 diabetes mellitus (T1DM) children and adolescents using a standardized protocol in routine clinical settings in Qatar. METHODS A total of 138 T1DM patients (62 males; 76 females; mean age 9.8 ± 3.4 years) with a mean diabetes duration of 2.4 ± 1.9 years initiated CSII (MiniMed® Veo®™ and MiniMed® 640 G insulin pumps; Medtronic, Northridge, CA, USA) in 2016 and 2017. CSII characteristics and glycated hemoglobin (HbA1c) were evaluated 1 year after treatment initiation. RESULTS At 1 year after treatment initiation, the insulin dose had significantly increased (from 0.59 ± 0.23 to 0.74 ± 0.26 U/kg body weight per 24; P < 0.05), and the HbA1c level had significantly decreased (from 9.7 ± 1.3 to 8.1 ± 0.6%; P < 0.05). More than 92% of patients used the Bolus Wizard feature of the insulin pump at the following settings: insulin-to-carbohydrate ratio 19.2 ± 9.3 g; insulin sensitivity factor 131 ± 68 mg/dl; target range 91 ± 9.3-135 ± 14.2 mg/dl; active insulin time 3.8 ± 0.8 h. CONCLUSION Our results show that CSII may significantly improve glucose control in T1D children and adolescents who use a standardized protocol. A reduction of HbA1c by - 1.6% was achieved at 1 year after CSII initiation. These results need to be confirmed in a study with a longer duration.
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Affiliation(s)
- Goran Petrovski
- Pediatrics, Endocrine and Diabetes Division, Sidra Medicine, Doha, Qatar.
| | - Fawziya Al Khalaf
- Pediatrics, Endocrine and Diabetes Division, Sidra Medicine, Doha, Qatar
| | - Khalid Hussain
- Pediatrics, Endocrine and Diabetes Division, Sidra Medicine, Doha, Qatar
| | - Judith Campbell
- Pediatrics, Endocrine and Diabetes Division, Sidra Medicine, Doha, Qatar
| | - Ahmed El Awwa
- Pediatrics, Endocrine and Diabetes Division, Sidra Medicine, Doha, Qatar
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Lucidi P, Porcellati F, Bolli GB, Fanelli CG. Prevention and Management of Severe Hypoglycemia and Hypoglycemia Unawareness: Incorporating Sensor Technology. Curr Diab Rep 2018; 18:83. [PMID: 30121746 DOI: 10.1007/s11892-018-1065-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE OF REVIEW In addition to assisting in achieving improved glucose control, continuous glucose monitoring (CGM) sensor technology may also aid in detection and prevention of hypoglycemia. In this paper, we report on the current scientific evidence on the effectiveness of this technology in the prevention of severe hypoglycemia and hypoglycemia unawareness. RECENT FINDINGS Recent studies have found that the integration of CGM with continuous subcutaneous insulin infusion (CSII) therapy, a system known as sensor-augmented pump (SAP) therapy, very significantly reduces the occurrence of these conditions by providing real-time glucose readings/trends and automatically suspending insulin infusion when glucose is low (LGS) or, even, before glucose is low but is predicted to soon be low (PLGS). Initial data indicate that even for patients with type 1 diabetes treated with multiple daily injections, real-time CGM alone has been found to reduce both severe hypoglycemia and hypoglycemia unawareness. Closed loop systems (artificial pancreas) comprised of CGM and CSII without patient intervention to adjust basal insulin, which automatically reduce, increase, and suspend insulin delivery, represent a potential new option that is moving toward becoming a reality in the near future. Sensor technology promises to continue to improve patients' lives not only by attaining glycemic control but also by reducing hypoglycemia, a goal best achieved in conjunction with structured individualized patient education.
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Affiliation(s)
- Paola Lucidi
- Department of Medicine, Section of Endocrinology and Metabolic Diseases, University di Perugia, Piazzale Gambuli, 1, 06132, Perugia, Italy
| | - Francesca Porcellati
- Department of Medicine, Section of Endocrinology and Metabolic Diseases, University di Perugia, Piazzale Gambuli, 1, 06132, Perugia, Italy
| | - Geremia B Bolli
- Department of Medicine, Section of Endocrinology and Metabolic Diseases, University di Perugia, Piazzale Gambuli, 1, 06132, Perugia, Italy
| | - Carmine G Fanelli
- Department of Medicine, Section of Endocrinology and Metabolic Diseases, University di Perugia, Piazzale Gambuli, 1, 06132, Perugia, Italy.
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16
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Affiliation(s)
- Tadej Battelino
- 1 UMC-University Children's Hospital Ljubljana
- 2 Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Bruce W Bode
- 3 Atlanta Diabetes Associates, Atlanta, Georgia
- 4 Emory University School of Medicine, Atlanta, Georgia
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Abraham MB, Nicholas JA, Smith GJ, Fairchild JM, King BR, Ambler GR, Cameron FJ, Davis EA, Jones TW. Reduction in Hypoglycemia With the Predictive Low-Glucose Management System: A Long-term Randomized Controlled Trial in Adolescents With Type 1 Diabetes. Diabetes Care 2018; 41:303-310. [PMID: 29191844 DOI: 10.2337/dc17-1604] [Citation(s) in RCA: 79] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 10/31/2017] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Short-term studies with automated systems that suspend basal insulin when hypoglycemia is predicted have shown a reduction in hypoglycemia; however, efficacy and safety have not been established in long-term trials. RESEARCH DESIGN AND METHODS We conducted a 6-month, multicenter, randomized controlled trial in children and adolescents with type 1 diabetes using the Medtronic MiniMed 640G pump with Suspend before low (predictive low-glucose management [PLGM]) compared with sensor-augmented pump therapy (SAPT) alone. The primary outcome was percentage time in hypoglycemia with sensor glucose (SG) <3.5 mmol/L (63 mg/dL). RESULTS In an intent-to-treat analysis of 154 subjects, 74 subjects were randomized to SAPT and 80 subjects to PLGM. At baseline, the time with SG <3.5 mmol/L was 3.0% and 2.8% in the SAPT and PLGM groups, respectively. During the study, PLGM was associated with a reduction in hypoglycemia compared with SAPT (% time SG <3.5 mmol/L: SAPT vs. PLGM, 2.6 vs. 1.5, P < 0.0001). A similar effect was also noted in time with SG <3 mmol/L (P < 0.0001). This reduction was seen both during day and night (P < 0.0001). Hypoglycemic events (SG <3.5 mmol/L for >20 min) also declined with PLGM (SAPT vs. PLGM: events/patient-year 227 vs. 139, P < 0.001). There was no difference in glycated hemoglobin (HbA1c) at 6 months (SAPT 7.6 ± 1.0% vs. PLGM 7.8 ± 0.8%, P = 0.35). No change in quality of life measures was reported by participants/parents in either group. There were no PLGM-related serious adverse events. CONCLUSIONS In children and adolescents with type 1 diabetes, PLGM reduced hypoglycemia without deterioration in glycemic control.
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Affiliation(s)
- Mary B Abraham
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia.,Division of Paediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - Jennifer A Nicholas
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia.,Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, Australia
| | - Grant J Smith
- Department of Endocrinology and Diabetes, Princess Margaret Hospital for Children, Perth, Australia
| | - Janice M Fairchild
- Department of Endocrinology and Diabetes, Women's and Children's Hospital, Adelaide, Australia
| | - Bruce R King
- Department of Endocrinology and Diabetes, John Hunter Children's Hospital, Newcastle, Australia
| | - Geoffrey R Ambler
- Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead and Clinical School, The University of Sydney, Sydney, Australia
| | - Fergus J Cameron
- Department of Endocrinology and Diabetes, The Royal Children's Hospital, Melbourne, Australia
| | - Elizabeth A Davis
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia.,Division of Paediatrics, Medical School, The University of Western Australia, Perth, Australia
| | - Timothy W Jones
- Children's Diabetes Centre, Telethon Kids Institute, The University of Western Australia, Perth, Australia .,Division of Paediatrics, Medical School, The University of Western Australia, Perth, Australia
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Affiliation(s)
| | - Eyal Dassau
- 1 William Sansum Diabetes Center , Santa Barbara, California
- 2 Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University , Cambridge, Massachusetts
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