Automated insulin delivery systems: from early research to routine care of type 1 diabetes

Characteristics of Nocturnal Hypoglycaemic Events and Their Impact on Glycaemia

BACKGROUND

Nocturnal hypoglycaemia is a burden for people with diabetes, particularly when treated with multiple daily injections (MDI) therapy. However, the characteristics of nocturnal hypoglycaemic events in this patient group are only poorly described in the literature.

METHOD

Continuous glucose monitoring (CGM) data from 185 study participants with type 1 diabetes using MDI therapy were collected under everyday conditions for up to 13 weeks. Hypoglycaemic events were identified as episodes of consecutive CGM readings <70 mg/dl or <54 mg/dl for at least 15 minutes. Subsequently, the time <54 mg/dl (TB54), time below range (TBR), time in range (TIR), time above range (TAR), glucose coefficient of variation (CV), and incidence of hypoglycaemic events were calculated for diurnal and nocturnal periods. Furthermore, the effect of nocturnal hypoglycaemic events on glucose levels the following day was assessed.

RESULTS

The incidence of hypoglycaemic events <70 mg/dl was significantly lower during the night compared to the day, with 0.8 and 3.8 events per week, respectively, while the TBR, TB54, and incidence of events with CGM readings <54 mg/dl was not significantly different. Nocturnal hypoglycaemic events <70 mg/dl were significantly longer (60 vs 35 minutes) and enveloped by less rapidly changing glucose levels. On days following nights containing hypoglycaemic events, there was a decrease in TAR, mean CGM glucose level and morning glucose levels and an increase in TB54, TBR, and CV.

CONCLUSIONS

The results showed that nocturnal hypoglycaemic events are a common occurrence in persons with type 1 diabetes using MDI with significant differences between the characteristics of nocturnal and diurnal events.

Nocturnal Hypoglycemia in the Era of Continuous Glucose Monitoring

Nocturnal hypoglycemia is a common acute complication of people with diabetes on insulin therapy. In particular, the inability to control glucose levels during sleep, the impact of external factors such as exercise, or alcohol and the influence of hormones are the main causes. Nocturnal hypoglycemia has several negative somatic, psychological, and social effects for people with diabetes, which are summarized in this article. With the advent of continuous glucose monitoring (CGM), it has been shown that the number of nocturnal hypoglycemic events was significantly underestimated when traditional blood glucose monitoring was used. The CGM can reduce the number of nocturnal hypoglycemia episodes with the help of alarms, trend arrows, and evaluation routines. In combination with CGM with an insulin pump and an algorithm, automatic glucose adjustment (AID) systems have their particular strength in nocturnal glucose regulation and the prevention of nocturnal hypoglycemia. Nevertheless, the problem of nocturnal hypoglycemia has not yet been solved completely with the technologies currently available. The CGM systems that use predictive models to warn of hypoglycemia, improved AID systems that recognize hypoglycemia patterns even better, and the increasing integration of artificial intelligence methods are promising approaches in the future to significantly minimize the risk of a side effect of insulin therapy that is burdensome for people with diabetes.

The Gene Network Correlation Analysis of Obesity to Type 1 Diabetes and Cardiovascular Disorders: An Interactome-Based Bioinformatics Approach

The current study focuses on the importance of Protein-Protein Interactions (PPIs) in biological processes and the potential of targeting PPIs as a new treatment strategy for diseases. Specifically, the study explores the cross-links of PPIs network associated with obesity, type 1 diabetes mellitus (T1DM), and cardiac disease (CD), which is an unexplored area of research. The research aimed to understand the role of highly connected proteins in the network and their potential as drug targets. The methodology for this research involves retrieving genes from the NCBI online gene database, intersecting genes among three diseases (type 1 diabetes, obesity, and cardiovascular) using Interactivenn, determining suitable drug molecules using NetworkAnalyst, and performing various bioinformatics analyses such as Generic Protein-Protein Interactions, topological properties analysis, function enrichment analysis in terms of GO, and Kyoto Encyclopedia of Genes and Genomes (KEGG), gene co-expression network, and protein drug as well as protein chemical interaction network. The study focuses on human subjects. The results of this study identified 12 genes [VEGFA (Vascular Endothelial Growth Factor A), IL6 (Interleukin 6), MTHFR (Methylenetetrahydrofolate reductase), NPPB (Natriuretic Peptide B), RAC1 (Rac Family Small GTPase 1), LMNA (Lamin A/C), UGT1A1 (UDP-glucuronosyltransferase family 1 membrane A1), RETN (Resistin), GCG (Glucagon), NPPA (Natriuretic Peptide A), RYR2 (Ryanodine receptor 2), and PRKAG2 (Protein Kinase AMP-Activated Non-Catalytic Subunit Gamma 2)] that were shared across the three diseases and could be used as key proteins for protein-drug/chemical interaction. Additionally, the study provides an in-depth understanding of the complex molecular and biological relationships between the three diseases and the cellular mechanisms that lead to their development. Potentially significant implications for the therapy and management of various disorders are highlighted by the findings of this study by improving treatment efficacy, simplifying treatment regimens, cost-effectiveness, better understanding of the underlying mechanism of these diseases, early diagnosis, and introducing personalized medicine. In conclusion, the current study provides new insights into the cross-links of PPIs network associated with obesity, T1DM, and CD, and highlights the potential of targeting PPIs as a new treatment strategy for these prevalent diseases.

Study protocol for a randomised open-label clinical trial examining the safety and efficacy of the Android Artificial Pancreas System (AAPS) with advanced bolus-free features in adults with type 1 diabetes: the 'CLOSE IT' (Closed Loop Open SourcE In Type 1 diabetes) trial

INTRODUCTION

Multiple automated insulin delivery (AID) systems have become commercially available following randomised controlled trials demonstrating benefits in people with type 1 diabetes (T1D). However, their real-world utility may be undermined by user-associated burdens, including the need to carbohydrate count and deliver manual insulin boluses. There is an important need for a 'fully automated closed loop' (FCL) AID system, without manual mealtime boluses. The (Closed Loop Open SourcE In Type 1 diabetes) trial is a randomised trial comparing an FCL AID system to the same system used as a hybrid closed loop (HCL) in people with T1D, in an outpatient setting over an extended time frame.

METHODS AND ANALYSIS

Randomised, open-label, parallel, non-inferiority trial comparing the Android Artificial Pancreas System (AAPS) AID algorithm used as FCL to the same algorithm used as HCL. Seventy-five participants aged 18-70 will be randomised (1:1) to one of two treatment arms for 12 weeks: (a) FCL-participants will be advised not to bolus for meals and (b) HCL-participants will use the AAPS AID algorithm as HCL with announced meals. The primary outcome is the percentage of time in target sensor glucose range (3.9-10.0 mmol/L). Secondary outcomes include other glycaemic metrics, safety, psychosocial factors, platform performance and user dietary factors. Twenty FCL arm participants will participate in a 4-week extension phase comparing glycaemic and dietary outcomes using NovoRapid (insulin aspart) to Fiasp (insulin aspart and niacinamide).

ETHICS AND DISSEMINATION

Approvals are by the Alfred Health Ethics Committee (615/22) (Australia) and Health and Disability Ethics Committees (2022 FULL 13832) (New Zealand). Each participant will provide written informed consent. Data protection and confidentiality will be ensured. Study results will be disseminated by publications, conferences and patient advocacy groups.

TRIAL REGISTRATION NUMBERS

ACTRN12622001400752 and ACTRN12622001401741.

Continuous glucose monitoring for automatic real-time assessment of eating events and nutrition: a scoping review

Background

Accurate dietary assessment remains a challenge, particularly in free-living settings. Continuous glucose monitoring (CGM) shows promise in optimizing the assessment and monitoring of ingestive activity (IA, i.e., consumption of calorie-containing foods/beverages), and it might enable administering dietary Just-In-Time Adaptive Interventions (JITAIs).

Objective

In a scoping review, we aimed to answer the following questions: (1) Which CGM approaches to automatically detect IA in (near-)real-time have been investigated? (2) How accurate are these approaches? (3) Can they be used in the context of JITAIs?

Methods

We systematically searched four databases until October 2023 and included publications in English or German that used CGM-based approaches for human (all ages) IA detection. Eligible publications included a ground-truth method as a comparator. We synthesized the evidence qualitatively and critically appraised publication quality.

Results

Of 1,561 potentially relevant publications identified, 19 publications (17 studies, total N = 311; for 2 studies, 2 publications each were relevant) were included. Most publications included individuals with diabetes, often using meal announcements and/or insulin boluses accompanying meals. Inpatient and free-living settings were used. CGM-only approaches and CGM combined with additional inputs were deployed. A broad range of algorithms was tested. Performance varied among the reviewed methods, ranging from unsatisfactory to excellent (e.g., 21% vs. 100% sensitivity). Detection times ranged from 9.0 to 45.0 min.

Conclusion

Several CGM-based approaches are promising for automatically detecting IA. However, response times need to be faster to enable JITAIs aimed at impacting acute IA. Methodological issues and overall heterogeneity among articles prevent recommending one single approach; specific cases will dictate the most suitable approach.

Comparison of the Sensor-Augmented Pump System with the Advanced Hybrid Closed-Loop Delivery System: Quality of Life, Diabetes Distress, and Glycaemic Outcomes in a Real-Life Context

BACKGROUND

Type 1 diabetes mellitus (T1D) is a chronic disease that requires exogenous insulin administration and intensive management to prevent any complications. Recent innovations in T1D management technologies include the Advanced Hybrid Closed-Loop delivery system (AHCL). The pioneer AHCL system provides automated basal and automated bolus corrections when needed.

OBJECTIVE

This study aimed to compare the Advanced Hybrid Closed-Loop (AHCL) system and the Sensor-Augmented Pump (SAP) with Predictive Low Glucose Management (PLGM) system, in relation to glycaemic outcomes, general and diabetes-related Quality of Life (QoL), and diabetes distress.

METHODS

General and diabetes-related QoL were assessed with the Diabetes Quality of Life Brief Clinical Inventory (DQOL-BCI) and the World Health Organization Quality of Life-BREF (WHOQOL-BREF), respectively. Diabetes distress was assessed with the Diabetes Distress Scale for Type 1 diabetes (T1-DDS).

RESULTS

Eighty-nine T1D adults participated in the study, mostly females (65.2%), with a mean age of 39.8 (± 11.5 years). They had on average 23 years of diabetes (± 10.7) and they were on continuous subcutaneous insulin infusion therapy. Significant differences favoring the AHCL over the SAP + PLGM system were demonstrated by lower mean glucose levels, less time above range, lower scores on DQOL-BCI, T1-DDS, and higher scores on WHOQOL-BREF. Finally, the linear regression models revealed the association of time in range in most of the above aspects.

CONCLUSION

This study highlighted the advantages of the AHCL system over the SAP + PLGM system in the real-world setting in relation to general and diabetes-related QoL, diabetes distress, and glycaemic outcomes.

(Hybrid) Closed-Loop Systems: From Announced to Unannounced Exercise

Physical activity and exercise have many beneficial effects on general and type 1 diabetes (T1D) specific health and are recommended for individuals with T1D. Despite these health benefits, many people with T1D still avoid exercise since glycemic management during physical activity poses substantial glycemic and psychological challenges - which hold particularly true for unannounced exercise when using an AID system. Automated insulin delivery (AID) systems have demonstrated their efficacy in improving overall glycemia and in managing announced exercise in numerous studies. They are proven to increase time in range (70-180 mg/dL) and can especially counteract nocturnal hypoglycemia, even when evening exercise was performed. AID-systems consist of a pump administering insulin as well as a CGM sensor (plus transmitter), both communicating with a control algorithm integrated into a device (insulin pump, mobile phone/smart watch). Nevertheless, without manual pre-exercise adaptions, these systems still face a significant challenge around physical activity. Automatically adapting to the rapidly changing insulin requirements during unannounced exercise and physical activity is still the Achilles' heel of current AID systems. There is an urgent need for improving current AID-systems to safely and automatically maintain glucose management without causing derailments - so that going forward, exercise announcements will not be necessary in the future. Therefore, this narrative literature review aimed to discuss technological strategies to how current AID-systems can be improved in the future and become more proficient in overcoming the hurdle of unannounced exercise. For this purpose, the current state-of-the-art therapy recommendations for AID and exercise as well as novel research approaches are presented along with potential future solutions - in order to rectify their deficiencies in the endeavor to achieve fully automated AID-systems even around unannounced exercise.

Safety and Efficacy of Sustained Automated Insulin Delivery Compared With Sensor and Pump Therapy in Adults With Type 1 Diabetes at High Risk for Hypoglycemia: A Randomized Controlled Trial

OBJECTIVE

Assess the safety and efficacy of automated insulin delivery (AID) in adults with type 1 diabetes (T1D) at high risk for hypoglycemia.

RESEARCH DESIGN AND METHODS

Participants were 72 adults with T1D who used an insulin pump with Clarke Hypoglycemia Perception Awareness scale score >3 and/or had severe hypoglycemia during the previous 6 months confirmed by time below range (TBR; defined as sensor glucose [SG] reading <70 mg/dL) of at least 5% during 2 weeks of blinded continuous glucose monitoring (CGM). Parallel-arm, randomized trial (2:1) of AID (Tandem t:slim ×2 with Control-IQ technology) versus CGM and pump therapy for 12 weeks. The primary outcome was TBR change from baseline. Secondary outcomes included time in target range (TIR; 70-180 mg/dL), time above range (TAR), mean SG reading, and time with glucose level <54 mg/dL. An optional 12-week extension with AID was offered to all participants.

RESULTS

Compared with the sensor and pump (S&P), AID resulted in significant reduction of TBR by -3.7% (95% CI -4.8, -2.6), P < 0.001; an 8.6% increase in TIR (95% CI 5.2, 12.1), P < 0.001; and a -5.3% decrease in TAR (95% CI -87.7, -1.8), P = 0.004. Mean SG reading remained similar in the AID and S&P groups. During the 12-week extension, the effects of AID were sustained in the AID group and reproduced in the S&P group. Two severe hypoglycemic episodes occurred using AID.

CONCLUSIONS

In adults with T1D at high risk for hypoglycemia, AID reduced the risk for hypoglycemia more than twofold, as quantified by TBR, while improving TIR and reducing hyperglycemia. Hence, AID is strongly recommended for this specific population.

Counting the Minutes: Perceived Diabetes Mental Load and its Associations With Technology Use and Mental Disorders

Little is known about mental load in people with diabetes and associations with demographic, clinical, and treatment characteristics, such as the use of diabetes technologies. To explore perceived mental load, 503 adults with diabetes answered the one-item survey "How much time (in minutes) would you spontaneously estimate that you spend each day thinking about your diabetes?" Mental load estimations varied widely within the sample and between subgroups. Perceived mental load was higher in type 1 diabetes than in type 2 diabetes, higher in women than in men and increased with treatment intensity (ie, insulin therapy, technology use) and the number of mental disorders. Further research may explore associations with diabetes-related distress and determine whether (perceived) mental load has relevance in technology use.

Multivariable Automated Insulin Delivery System for Handling Planned and Spontaneous Physical Activities

BACKGROUND

Hybrid closed-loop control of glucose levels in people with type 1 diabetes mellitus (T1D) is limited by the requirements on users to manually announce physical activity (PA) and meals to the artificial pancreas system. Multivariable automated insulin delivery (mvAID) systems that can handle unannounced PAs and meals without any manual announcements by the user can improve glycemic control by modulating insulin dosing in response to the occurrence and intensity of spontaneous physical activities.

METHODS

An mvAID system is developed to supplement the glucose measurements with additional physiological signals from a wristband device, with the signals analyzed using artificial intelligence algorithms to automatically detect the occurrence of PA and estimate its intensity. This additional information gained from the physiological signals enables more proactive insulin dosing adjustments in response to both planned exercise and spontaneous unanticipated physical activities.

RESULTS

In silico studies of the mvAID illustrate the safety and efficacy of the system. The mvAID is translated to pilot clinical studies to assess its performance, and the clinical experiments demonstrate an increased time in range and reduced risk of hypoglycemia following unannounced PA and meals.

CONCLUSIONS

The mvAID systems can increase the safety and efficacy of insulin delivery in the presence of unannounced physical activities and meals, leading to improved lives and less burden on people with T1D.

Key indices of glycaemic variability for application in diabetes clinical practice

Near normal glycaemic control in diabetes consists to target daily glucose fluctuations and quarterly HbA1c oscillations in addition to overall glucose exposure. Consequently, the prerequisite is to define simple, and mathematically undisputable key metrics for the short- and long-term variability in glucose homeostasis. As the standard deviations (SD) of either glucose or HbA1c are dependent on their means, the coefficient of variation (CV = SD/mean) should be applied instead as it that avoids the correlation between the SD and mean values. A CV glucose of 36% is the most appropriate threshold between those with stable versus labile glucose homeostasis. However, when near normal mean glucose concentrations are achieved a lower CV threshold of <27 % is necessary for reducing the risk for hypoglycaemia to a minimal rate. For the long-term variability in glucose homeostasis, a CVHbA1c < 5 % seems to be a relevant recommendation for preventing adverse clinical outcomes.

Implantable microfluidics: methods and applications

Implantable microfluidics involves integrating microfluidic functionalities into implantable devices, such as medical implants or bioelectronic devices, revolutionizing healthcare by enabling personalized and precise diagnostics, targeted drug delivery, and regeneration of targeted tissues or organs. The impact of implantable microfluidics depends heavily on advancements in both methods and applications. Despite significant progress in the past two decades, continuous advancements are still required in fluidic control and manipulation, device miniaturization and integration, biosafety considerations, as well as the development of various application scenarios to address a wide range of healthcare issues. In this review, we discuss advancements in implantable microfluidics, focusing on methods and applications. Regarding methods, we discuss progress made in fluid manipulation, device fabrication, and biosafety considerations in implantable microfluidics. In terms of applications, we review advancements in using implantable microfluidics for drug delivery, diagnostics, tissue engineering, and energy harvesting. The purpose of this review is to expand research ideas for the development of novel implantable microfluidic devices for various healthcare applications.

Glucose control during Ramadan in a pediatric cohort with type 1 diabetes on MiniMed standard and advanced hybrid closed‑loop systems: A pilot study

BACKGROUND

Hybrid closed-loop (HCL) systems have revolutionized the treatment of diabetes, enabling doctors to cope with challenging conditions that were previously almost impossible to manage or were very risky and difficult.

AIMS

To assess the efficacy and safety of a hybrid closed-loop (HCL) system during Ramadan fasting in a pediatric cohort with type 1 diabetes (T1D).

RESEARCH DESIGN AND METHODS

Glucose control outcomes in older children and adolescents aged 8-16 years with automated insulin delivery for T1D were analyzed during Ramadan and 1 month before Ramadan. Participants on MiniMed standard HCL (670G) or advanced HCL (780G) systems of Medtronic were categorized as fasting or nonfasting.

RESULTS

The average age of the 19 participants (8 and 11 were on standard and advanced HCL systems, respectively) was 11.35 ± 2 years. Eleven patients fasted during Ramadan. Pump setup and sensor statistics were the same during Ramadan and the month before; no significant difference was found between the two groups in terms of insulin and glucose control metrics, with practically the same coefficient of variation, time in range (TIR) and time spent in hypoglycemia, maintained within the international recommended targets. Total daily doses were paradoxically higher in patients who fasted during Ramadan (p = 0.01), without repercussions on glucose control metrics.

CONCLUSIONS

Standard and advanced HCL use during Ramadan were safe and were associated with a maintained optimum TIR (>70 %) and no significant hypoglycemia in adolescents and older children with T1D.

Determinants Related to Oxidative Stress Parameters in Pediatric Patients with Type 1 Diabetes Mellitus

Adequate glycemic management is one of the main goals in treating type 1 diabetes mellitus (T1DM) and preventing the early onset of diabetic complications. Improperly controlled diabetes mellitus (DM) will result in oxidative stress (OS) and lead to further related health issues. Therefore, the aim of this study was to evaluate the body's ability to defend against OS depending on the duration of T1DM, metabolic management, antioxidant intake and modern glycemic monitoring systems (GMS). The study included 103 adolescents with T1DM aged 10-17 years. The control group consisted of 65 healthy peers. The patients' blood was assayed for antioxidant enzymes, minerals and toxic elements. In addition, their dietary intake of antioxidant components was assessed. The T1DM group had higher total oxidant status, oxidative stress index and Cu/Zn ratio values, higher concentrations of malondialdehyde and lower total antioxidant status (TAS) and chromium, zinc, superoxide dismutase and catalase levels than their healthy peers. The comparison between GMS types revealed favorable changes in OS parameters for the flash and continuous systems. Furthermore, an effect of vitamin A and C dietary intake on serum TAS concentrations was detected. More than 82% of the patients with high TAS fulfilled the estimated average requirement norm for vitamin A, and more than 60% fulfilled the vitamin C requirement. In youths with T1DM, it is advisable to observe the antioxidant activity of the body to prevent the accelerated development of diabetic complications.

Advances in the therapeutic application and pharmacological properties of kinsenoside against inflammation and oxidative stress-induced disorders

Extensive research has implicated inflammation and oxidative stress in the development of multiple diseases, such as diabetes, hepatitis, and arthritis. Kinsenoside (KD), a bioactive glycoside component extracted from the medicinal plant Anoectochilus roxburghii, has been shown to exhibit potent anti-inflammatory and anti-oxidative abilities. In this review, we summarize multiple effects of KD, including hepatoprotection, pro-osteogenesis, anti-hyperglycemia, vascular protection, immune regulation, vision protection, and infection inhibition, which are partly responsible for suppressing inflammation signaling and oxidative stress. The protective action of KD against dysfunctional lipid metabolism is also associated with limiting inflammatory signals, due to the crosstalk between inflammation and lipid metabolism. Ferroptosis, a process involved in both inflammation and oxidative damage, is potentially regulated by KD. In addition, we discuss the physicochemical properties and pharmacokinetic profiles of KD. Advances in cultivation and artificial synthesis techniques are promising evidence that the shortage in raw materials required for KD production can be overcome. In addition, novel drug delivery systems can improve the in vivo rapid clearance and poor bioavailability of KD. In this integrated review, we aim to offer novel insights into the molecular mechanisms underlying the therapeutic role of KD and lay solid foundations for the utilization of KD in clinical practice.