Assessment of metabolic control and use of flash glucose monitoring systems in a cohort of pediatric, adolescents, and adults patients with Type 1 diabetes

Impact of Continuous Glucose Monitoring and its Glucometrics in Clinical Practice in Spain and Future Perspectives: A Narrative Review

INTRODUCTION

Continuous glucose monitoring (CGM) devices allow for 24-h real-time measurement of interstitial glucose levels and have changed the interaction between people with diabetes and their health care providers. The large amount of data generated by CGM can be analyzed and evaluated using a set of standardized parameters, collectively named glucometrics. This review aims to provide a summary of the existing evidence on the use of glucometrics data and its impact on clinical practice based on published studies involving adults and children with type 1 diabetes (T1D) in Spain.

METHODS

The PubMed and MEDES (Spanish Medical literature) databases were searched covering the years 2018-2022 and including clinical and observational studies, consensus guidelines, and meta-analyses on CGM and glucometrics conducted in Spain.

RESULTS

A total of 16 observational studies were found on the use of CGM in Spain, which have shown that cases of severe hypoglycemia in children with T1D were greatly reduced after the introduction of CGM, resulting in a significant reduction in costs. Real-world data from Spain shows that CGM is associated with improved glycemic markers (increased time in range, reduced time below and above range, and glycemic variability), and that there is a relationship between glycemic variability and hypoglycemia. Also, CGM and analysis of glucometrics proved highly useful during the COVID-19 pandemic. New glucometrics, such as the glycemic risk index, or new mathematical approaches to the analysis of CGM-derived glucose data, such as "glucodensities," could help patients to achieve better glycemic control in the future.

CONCLUSION

By using glucometrics in clinical practice, clinicians can better assess glycemic control and a patient's individual response to treatment.

Glycemic Risk Index in a Cohort of Patients with Type 1 Diabetes Mellitus Stratified by the Coefficient of Variation: A Real-Life Study

Objective: To analyze the Glycemic Risk Index (GRI) and assess their possible differences according to coefficient of variation (CV) in a cohort of real-life type 1 diabetes mellitus (DM) patient users of intermittently scanned continuous glucose monitoring (isCGM). Patients and Methods: In total, 447 adult users of isCGM with an adherence ≥70% were included in a cross-sectional study. GRI was calculated with its hypoglycemia (CHypo) and hyperglycemia (CHyper) components. Multivariate linear regression analysis was performed to evaluate the factors associated with GRI. Results: Mean age was 44.6 years (standard deviation [SD] 13.7), 57.7% being male; age of DM onset was 24.5 years (SD 14.3) and time of evolution was 20.6 years (SD 12.3). In patients with CV >36% (52.8%) versus CV ≤36% (47.2%), differences were observed in relation to GRI (18.8% [SD 1.9]; P < 0.001), CHypo (2.9% [SD 0.3]; P < 0.001), CHyper (6.3% [SD 1.4]; P < 0.001), and all classical glucometric parameters except time above range level 1. The variables that were independently associated with GRI in patient with CV >36% were time in range (TIR) (β = -1.49; confidence interval [CI:] 95% -1.63 to -1.37; P < 0.001), glucose management indicator (GMI) (β = -7.22; CI: 95% -9.53 to -4.91; P < 0.001), and CV (β = 0.85; CI: 95% 0.69 to 1.02; P < 0.001). However, in patients with CV ≤36%, the variables were age (β = 0.15; CI: 95% 0.03 to 0.28; P = 0.019), age of onset (β = -0.15; CI: 95% -0.28 to -0.02; P = 0.023), TIR (β = -1.35; CI: 95% -1.46 to -1.23; P < 0.001), GMI (β = -6.67; CI: 95% -9.18 to -4.15; P < 0.001), and CV (β = 0.33; CI: 95% 0.11 to 0.56; P = 0.004). Conclusions: In this study, the factors independently associated with metabolic control according to GRI are modified by glycemic variability.

Assessment of Patient-reported Satisfaction and Metabolic Outcomes Following Initiation of the Second Generation of Flash Glucose Monitoring in Patients with Type 1 Diabetes

BACKGROUND AND AIMS

This study aims to assess patient-reported satisfaction and metabolic outcomes following the initiation of the second generation of the Freestyle Libre 2 (FSL2) system in patients with type 1 diabetes (T1D).

METHODS

This non-randomized single-arm observation study was conducted on 86 patients with T1D living in Saudi Arabia, who were asked to wear the FSL2 for 12 weeks. The demographic data were collected at baseline, while the continuous glucose monitoring (CGM) metrics were gathered, i.e., Glucose Variability (GV) (%), mean Time in Range (TIR), Time Above Range (TAR), Time Below Range (TBR), and average duration of hypoglycemic events were collected at baseline, 6th week and 12 weeks. Further, the Continuous Glucose Monitoring Satisfaction (CGM-SAT) was collected at the end of the follow-up.

RESULTS

Compared to the 6th week, significant differences were observed in the low glucose events (p = 0.037), % TIR (p = 0.045), and % below 70 mg/dL (p = 0.047) at 12 weeks. Improvement was seen in the other glucometric variables, but no significant changes were evident (p > 0.05). On completion of the study period, the ambulatory glucose profile (AGP) metrics showed a 74.3 ± 5.01 (mg/dL) FSL2 hypoglycemia alarm threshold and a 213 ± 38.1 (mg/dL) hyperglycemia alarm threshold. A majority of the patients stated that CGM-SAT had benefits (mean score > 3.58), although they felt FSL2 had 'additional benefits. With regard to the problems with the use of FSL2 majority of the patients stated that FSL2 has minimal discomfort.

CONCLUSION

Using second-generation FSL2 in patients with T1D is positively associated with patient- reported satisfaction and metabolic outcomes.

Younger patients and low c-peptide immunoreactivity index but not nutritional states affect fasting blood ketone levels in Japanese with type 1 diabetes after sodium-glucose cotransporter 2 inhibitor administration

AIM

Sodium-glucose cotransporter 2 inhibitors (SGLT2is) are available for individuals with type 1 diabetes, but appropriate use is recommended to prevent ketosis or ketoacidosis. This study aimed to evaluate the risk of ketosis in people with type 1 diabetes, focusing on the relationship between nutritional assessment, glycaemic status, c-peptide immunoreactivity (CPR) index and body composition.

MATERIALS AND METHODS

In total, 46 Japanese patients with type 1 diabetes were included, and dietary assessment from food photographs and ketone levels were evaluated before and after taking SGLT2is. The effect of diet on morning ketone levels was also investigated.

RESULTS

All patients had an increase in mean ketone concentrations after taking SGLT2is (before 0.12 ± 0.06 mmol/L, after 0.23 ± 0.16 mmol/L). A significant negative correlation was found between average morning ketone levels and age (r = -0.514, p < .001) and the CPR index (r = -0.523, p = .038) after taking SGLT2is. Using a mixed-effects model based on the results before starting the inhibitors, it was noted that both patient-to-patient and age, or patient-to-patient and capacity of insulin secretion, influenced the ketone levels. Multiple regression analysis showed that factors associated with the risk of increasing ketone levels after taking SGLT2is were younger age (β = -0.504, p = .003) and a low ratio of basal to bolus insulin (β = -0.420, p = .005).

CONCLUSIONS

When administering SGLT2is to patients with a low CPR index or younger patients with type 1 diabetes, adequate instructions to prevent ketosis should be given.

Spanish Consensus on the Use of Intermittently Scanned Continuous Glucose Monitoring in the Management of Patients With Insulin Therapy: The MONITOR Project

BACKGROUND

Continuous glucose monitoring (CGM) systems are increasingly being adopted as an alternative or adjunct to self-monitoring of blood glucose (SMBG) by patients receiving insulin therapy. However, the available evidence on the role of intermittently scanned CGM or flash CGM (isCGM) remains limited. This consensus aims to evaluate the degree of agreement among Spanish experts on the role of isCGM in the evaluation of glycemic variability, reduction of glycosylated hemoglobin (HbA1c) levels, and selection and adjustment of insulin therapy.

METHODS

Delphi methodology was used to achieve consensus in two survey rounds. A total of 431 Spanish endocrinologists participated in the first round of a 34-item questionnaire survey on isCGM and 427 participated in the second round. Any disagreement was resolved in round 2.

RESULTS

Consensus was reached for 32 statements, and four items were ultimately agreed upon SMBG after round 2. There was a high degree of consensus that isCGM helps to evaluate glycemic variability, improves HbA1c levels, and can guide therapeutic changes in type 1 diabetes patients. However, there was no consensus on the routine use of the interquartile range to evaluate glycemic variability or the selection of HbA1c as the main parameter for monitoring glycemic control.

CONCLUSIONS

Most Spanish experts believe that the isCGM system is appropriate for: (1) identifying glycemic variability and facilitating its management, (2) evaluating hyperglycemia as a complement of HbA1c levels, and (3) guiding therapeutic decisions on insulin selection and dosing. The isCGM system is a useful tool for patients and health care professionals to improve glycemic control in insulin-dependent diabetes.

Expert Recommendations for Using Time-in-Range and Other Continuous Glucose Monitoring Metrics to Achieve Patient-Centered Glycemic Control in People With Diabetes

New metrics for assessing glycemic control beyond HbA1c have recently emerged due to the increasing use of continuous glucose monitoring (CGM) in diabetes clinical practice. Among them, time in range (TIR) has appeared as a simple and intuitive metric that correlates inversely with HbA1c and has also been newly linked to the risk of long-term diabetes complications. The International Consensus on Time in Range established a series of target glucose ranges (TIR, time below range and time above range) and recommendations for time spent within these ranges for different diabetes populations. These parameters should be evaluated together with the ambulatory glucose profile (AGP). Using standardized visual reporting may help people with diabetes and healthcare professionals in the evaluation of glucose control in frequent clinical situations. The objective of the present review is to provide practical insights to quick interpretation of patient-centered metrics based on flash glucose monitoring data, as well as showing some visual examples of common clinical situations and giving practical recommendations for their management.

Glycemia Risk Index Assessment in a Pediatric and Adult Patient Cohort With Type 1 Diabetes Mellitus

BACKGROUND

To evaluate the glycemia risk index (GRI) as a new glucometry in pediatric and adult populations with type 1 diabetes (T1D) in clinical practice.

METHODS

A cross-sectional study of 202 patients with T1D receiving intensive treatment with insulin (25.2% continuous subcutaneous insulin infusion [CSII]) and intermittent scanning (flash) glucose monitoring (isCGM). Clinical and glucometric isCGM data were collected, as well as the component of hypoglycemia (CHypo) and component of hyperglycemia (CHyper) of the GRI.

RESULTS

A total of 202 patients (53% males and 67.8% adults) with a mean age of 28.6 ± 15.7 years and 12.5 ± 10.9 years of T1D evolution were evaluated.Adult patients (>19 years) presented higher glycated hemoglobin (HbA1c) (7.4 ± 1.1 vs 6.7 ± 0.6%; P < .01) and lower time in range (TIR) (55.4 ± 17.5 vs 66.5 ± 13.1%; P < .01) values than the pediatric population, with lower coefficient of variation (CV) (38.6 ± 7.2 vs 42.4 ± 8.9%; P < .05). The GRI was significantly lower in pediatric patients (48.0 ± 22.2 vs 56.8 ± 23.4; P < .05) associated with higher CHypo (7.1 ± 5.1 vs 5.0 ± 4.5; P < .01) and lower CHyper (16.8 ± 9.8 vs 26.5 ± 15.1; P < .01) than in adults.When analyzing treatment with CSII compared with multiple doses of insulin (MDI), a nonsignificant trend to a lower GRI was observed in CSII (51.0 ± 15.3 vs 55.0 ± 25.4; P= .162), with higher levels of CHypo (6.5 ± 4.1 vs 5.4 ± 5.0; P < .01) and lower CHyper (19.6 ± 10.6 vs 24.6 ± 15.2; P < .05) compared with MDI.

CONCLUSIONS

In pediatric patients and in those with CSII treatment, despite a better control by classical and GRI parameters, higher overall CHypo was observed than in adults and MDI, respectively. The present study supports the usefulness of the GRI as a new glucometric parameter to evaluate the global risk of hypoglycemia-hyperglycemia in both pediatric and adult patients with T1D.

Flash Glucose Monitoring System facilitates sustainable improvements in glycemic control in patients with type 1 diabetes: A 12-month follow-up study in real life

BACKGROUND AND AIMS

Examine the glycemic control on Type 1 Diabetes (T1D) wearing the Flash Glucose Monitoring (FGM) system for a one-year period of time.

METHODS

This prospective study done using 187 patients with T1D (14-40yrs) who self-tested their glucose levels by FGM. Continuous glucose monitoring (CGM) metrics were gathered i.e., Glucose Variability (GV) (%), mean Time in Range (TIR), Time Above Range (TAR), Time Below Range (TBR), and average duration of hypoglycemic events at the 3, 6, and 12 month time periods.

RESULTS

At 6th, 9th and 12th months, for values of GV, % in target, TAR and %>250 mg/dL, no significant changes (p > 0.05) were noted compared to 3 months. However, significant changes from the baseline were evident for the values of the mean glucose level at the 3rd (p = 0.028), 9th (p = 0.048) and 12th months (p = 0.022). When the mean glucose value at 3 months was compared to the same at 6, 9, and 12 month period, no significant changes (p > 0.05) were seen. When compared with baseline values, low glucose events at 3 months (p = 0.028), 6 months (p = 0.048), 9 months (p = 0.022) and 12 months (p = 0.038) showed significant changes. However, the percentage below 70 mg/dL (barring the value at 12 months, p = 0.046), no significant changes were observed. The HbA1c revealed significant drop in 3, 6, 9 and 12 months compared to baseline values.

CONCLUSION

Significant improvement was noted in CGM metrics when patients switched from conventional finger pricking method over to FGM system, and the effect was observed during the entire study period.

Study protocol: Safety and efficacy of smart watch integrated do-it-yourself continuous glucose monitoring in adults with Type 1 diabetes, a randomised controlled trial

PURPOSE

Type 1 diabetes (T1D) management requires regular monitoring of glucose levels and judicious therapeutic administration of insulin to prevent both microvascular and macrovascular complications. Few people with diabetes are able to sustain the self-monitored blood glucose measurements needed for optimal care, and those that do, typically experience significant diabetes-related distress. Both intermittently scanned continuous glucose monitoring (isCGM) and continuous glucose monitoring (CGM) offer alternatives to reduce the overall burden, but both still have limitations. Given the expense of CGM, smart watch integrated do-it-yourself (DIY)-CGM has been developed as an alternative to commercial isCGM and CGM technologies. This study has been designed to evaluate the clinical efficacy of smart watch integrated DIY-CGM compared with isCGM in adults with T1D.

METHODS

This multicentre, randomised, crossover study will be conducted in New Zealand and aims to recruit 60 adults with established T1D who currently use isCGM. DIY-CGM will be compared to usual care with isCGM. Participants will be randomised to either arm of the study for 8 weeks followed by a 4-week washout period before crossing over to the other study arm for a further 8 weeks. The primary endpoint is glucose time in range (TIR) defined as percentage of time interstitial glucose is spent between 3.9 to 10 mmol/L for the entire intervention period. Secondary endpoints include diabetes-related quality of life, distress, and sleep quality in participants and their partners.

DISCUSSION

The results of this study will provide clinical trial data regarding smart watch integrated DIY-CGM versus isCGM for improving glycaemic control in adults with T1D, and also report a variety of key secondary outcomes, including changes in subjective outcome measures for both people with diabetes and their partners.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12621000648820,31 May 2021); World Health Organisation International Clinical Trial Registry Platform (U1111-1262-2784, 3rd December 2020).

Effectiveness of the freestyle libre 2 flash glucose monitoring system on diabetes-self-management practices and glycemic parameters among patients with type 1 diabetes using insulin pump

AIMS

To determine the effectiveness of Freestyle Libre 2 (FSL2) on diabetes-self-management (DSM) practices and glycemic parameters among patients with type 1 diabetes (T1D) using insulin pump.

METHODS

This prospective study was performed among 47 patients with T1D (13-21yrs) who self-tested their glucose levels by the conventional finger-prick method using blood glucose meters (BGM). Data related to glycemic profile i.e., mean time in range (TIR), mean time above range (TAR) mean time below range (TBR), mean glucose level, hemoglobin A1c (HbA1c), total daily dose of insulin (TDDI), frequency of glucose monitoring and DSM responses were collected at baseline and 12 weeks.

RESULTS

The mean TIR was 59.8 ± 12.6%, TAR 32.7 ± 11.6%, TBR 7.5 ± 4.3%, mean glycemic variability, standard deviation 63.2 ± 12.5 mg/dL, and the coefficient of variation 41.3 ± 11.4% at 12 weeks. At baseline, the HbA1c level was 8.3%, and at 12 weeks, it dropped to 7.9% (p = 0.064). Baseline glucose monitoring frequency through BGM was 2.4/day; however, after the patients employed the FSL2, a higher degree of frequency of glucose monitoring was evident at 12 weeks as 8.2/day (p < 0.001). Significant improvements were observed in all the DSM subscales at 12 weeks.

CONCLUSION

Using FSL2 was found to raise the patients' DSM levels and improved metabolic control.