Early and sustained increase in time in range 1 year after initiation of hybrid close loop therapy via telemedicine in type 1 diabetes patients

An automated insulin delivery system from pregestational care to postpartum in women with type 1 diabetes. Preliminary experience with telemedicine in 6 patients

INTRODUCTION

The use of most commercially available automated insulin delivery (AID) systems is off-label in pregnancy. However, an increasing number of women with type 1 diabetes (T1D) use such devices throughout pregnancy and delivery. We analysed the data of six women with T1D from a single centre (Diabetology Outpatient Clinic of District-63/Asl Salerno, Italy) who were able to start and maintain AID therapy with the MiniMed™ 780G (Medtronic, Minneapolis, MN, USA) throughout the pregestational care period, pregnancy, delivery, and postpartum.

METHODS

We retrospectively collected data from six patients with T1D who received training and initiation on use of the MiniMed™ 780G and attended follow-up visits throughout pregnancy (these visits were virtual because of the COVID-19 pandemic). All patients maintained their devices in the closed-loop setting throughout pregnancy and during labour and delivery. We analysed data from the pregestational phase to the first 30 days postpartum.

RESULTS

All patients achieved the recommended metabolic goals before conception [median time in range (TIR) of 88% for 70-180 mg/dL; median pregnancy-specific TIR 63-140 mg/dL (ps-TIR) of 66% and maintained the ps-TIR until delivery (median ps-TIR 83%). All patients had slightly better metrics during the night than during the day, with a very low time below range of < 63 mg/dL. Optimal glycaemic values were also maintained on the day of labour and delivery (median ps-TIR 92.5%) and in the first 30 days postpartum, with no severe hypoglycaemia. The only neonatal complications were jaundice in one child and an interatrial defect in another child.

CONCLUSION

In our well-selected and trained patients, use of the MiniMed™ 780G helped to achieve and maintain ps-metrics from the pregestational period to delivery despite the fact that the algorithm is not set to achieve the ambitious glycaemic values recommended for pregnancy.

Two Cases With Type 1 Diabetes Treated With Insulin Pump Therapy Using a Telemedicine Approach During the COVID-19 Pandemic

Type 1 diabetes mellitus (T1D) is an autoimmune-related disease resulting in insulin dependency, treated with insulin injection via pen devices or continuous subcutaneous insulin infusion (CSII). Face-to-face instruction for managing insulin injection and dosing and machine-to-device troubleshooting are required early to initiate CSII from insulin injections. Thus, T1D individuals may encounter significant barriers to pen devices or CSII introduction if they live in remote rural areas. In this regard, intermittently scanned continuous glucose monitoring (isCGM) can share visualized glucose profiles via a cloud-platform-based system, offering the potential as an effective tool in telemedicine. Herewith, we report two cases of subjects with T1D living in remote rural areas whose CSII was safely introduced in outpatient settings with the aid of cloud-platform-based isCGM and a video-meeting tool. They showed improved glucose profiles after CSII initiation. Even under the coronavirus disease 2019 (COVID-19) pandemic, the telemedicine system enabled healthcare providers to monitor glucose profiles and confirm device procedures of CSII. We emphasize the usefulness of online instruction with cloud-platform-based isCGM for introducing CSII in cases with barriers to healthcare access, particularly during the COVID-19 pandemic.

Precision Medicine in Type 2 Diabetes Mellitus: Utility and Limitations

Type 2 diabetes mellitus (T2DM) is one of the most widespread diseases in Western countries, and its incidence is constantly increasing. Epidemiological studies have shown that in the next 20 years. The number of subjects affected by T2DM will double. In recent years, owing to the development and improvement in methods for studying the genome, several authors have evaluated the association between monogenic or polygenic genetic alterations and the development of metabolic diseases and complications. In addition, sedentary lifestyle and socio-economic and pandemic factors have a great impact on the habits of the population and have significantly contributed to the increase in the incidence of metabolic disorders, obesity, T2DM, metabolic syndrome, and liver steatosis. Moreover, patients with type 2 diabetes appear to respond to antihyperglycemic drugs. Only a minority of patients could be considered true non-responders. Thus, it appears clear that the main aim of precision medicine in T2DM is to identify patients who can benefit most from a specific drug class more than from the others. Precision medicine is a discipline that evaluates the applicability of genetic, lifestyle, and environmental factors to disease development. In particular, it evaluated whether these factors could affect the development of diseases and their complications, response to diet, lifestyle, and use of drugs. Thus, the objective is to find prevention models aimed at reducing the incidence of pathology and mortality and therapeutic personalized approaches, to obtain a greater probability of response and efficacy. This review aims to evaluate the applicability of precision medicine for T2DM, a healthcare burden in many countries.

Results From a Virtual Clinic for the Follow-up of Patients Using the Advanced Hybrid Closed-Loop System

BACKGROUND

Evidence regarding the implementation of medium-term strategies in advanced hybrid closed-loop (AHCL) system users is limited. Therefore, this study aimed to describe the efficacy and safety of the AHCL system in patients with type 1 diabetes (T1D) on a six-month follow-up in a virtual diabetes clinic (VDC).

METHOD

A prospective cohort of adult patients with T1D treated using the AHCL system (Mini Med 780G; Medtronic, Northridge, California) in a VDC follow-up. Standardized training and follow-up were conducted virtually. Clinical data and metabolic control outcomes were reported at baseline, and at three and six months.

RESULTS

Sixty-four patients (mean age = 42 ± 14.6 years, 65% men, 54% with graduate education) were included. Percentage time in range (%TIR) increased significantly regardless of prior therapy with intermittently scanned continuous glucose monitoring + multiple daily injections and sensor-augmented pump therapy with predictive low-glucose management after starting AHCL and persisted during the follow-up period with no hypoglycemic events. The %TIR 70 to 180 mg/dL according to socioeconomic strata was 73.4% ± 5.3%, 78.1% ± 8.1%, and 84.2% ± 7.5% for the lower, middle, and upper strata, respectively. The sensor was used more frequently in the population with a higher education level. Adherence to sensor use and SmartGuard retention were higher in patients who underwent the VDC follow-up.

CONCLUSIONS

Medium-term follow-up of users of AHCL systems in a VDC contributes to safely achieving %TIR goals. Virtual diabetes clinic follow-up favored adherence to sensor use and continuous SmartGuard use. Socioeconomic strata were associated with a better glycemic profile and education level was associated with better adherence to sensor use.