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Morrison D, Vogrin S, Zaharieva DP. Assessment of Glycemia Risk Index and Standard Continuous Glucose Monitoring Metrics in a Real-World Setting of Exercise in Adults With Type 1 Diabetes: A Post-Hoc Analysis of the Type 1 Diabetes and Exercise Initiative. J Diabetes Sci Technol 2024; 18:787-794. [PMID: 38629861 PMCID: PMC11307213 DOI: 10.1177/19322968241246458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
BACKGROUND Standardized reporting of continuous glucose monitoring (CGM) metrics does not provide extra weighting for very high or very low glucose, despite their distinct clinical significance, and thus may underestimate glycemic risk in people with type 1 diabetes (T1D) during exercise. Glycemia Risk Index (GRI) is a novel composite metric incorporating clinician-validated extra weighting for glycemic extremes, which may provide a novel summary index of glycemia risk around exercise. METHODS Adults (≥18 years) in the T1D EXercise Initiative study wore CGM and activity trackers for four weeks. For this analysis, exercise days were defined as 24 hours following ≥20 minutes of exercise, with no other exercise in the 24-hour period. Sedentary days were defined as any 24 hours with no recorded exercise within that period or the preceding 24 hours. Linear mixed-effects regression was used to evaluate exercise effects on GRI and CGM metrics within 24 hours postexercise. RESULTS In 408 adults with T1D with >70% CGM and activity data, GRI on exercise (N = 3790) versus sedentary days (N = 1865) was significantly lower (mean [SD]: 29.9 [24.0] vs 34.0 [26.1], respectively, absolute mean difference -1.70 [-2.73, -0.67], P < .001), a ~5% reduction in glycemic risk. Percent time in range (TIR; 70-180 mg/dL) increased on exercise days (absolute mean difference 2.67 [1.83, 3.50], P < .001), as did time below range (TBR; relative mean difference 1.17 [1.12, 1.22], P < .001), while time above range (TAR) decreased (relative mean difference 0.84 [0.79, 0.88], P < .001). CONCLUSIONS Glycemia Risk Index improved on exercise versus sedentary days, despite increased TBR, which is weighted most heavily in the GRI calculation, due to a robust reduction in TAR.
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Affiliation(s)
- Dale Morrison
- Department of Medicine, St Vincent’s
Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
- Department of Endocrinology and
Diabetes, St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent’s
Hospital Melbourne, The University of Melbourne, Melbourne, VIC, Australia
| | - Dessi P. Zaharieva
- Division of Pediatric Endocrinology,
Department of Pediatrics, Stanford University, Stanford, CA, USA
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Christensen MB, Ranjan AG, Rytter K, McCarthy OM, Schmidt S, Nørgaard K. Automated Insulin Delivery in Adults With Type 1 Diabetes and Suboptimal HbA 1c During Prior Use of Insulin Pump and Continuous Glucose Monitoring: A Randomized Controlled Trial. J Diabetes Sci Technol 2024:19322968241242399. [PMID: 38600822 DOI: 10.1177/19322968241242399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2024]
Abstract
BACKGROUND Automated insulin delivery (AID) systems offer promise in improving glycemic outcomes for individuals with type 1 diabetes. However, data on those who struggle with suboptimal glycemic levels despite insulin pump and continuous glucose monitoring (CGM) are limited. We conducted a randomized controlled trial to assess the effects of an AID system in this population. METHODS Participants with hemoglobin A1c (HbA1c) ≥ 58 mmol/mol (7.5%) were allocated 1:1 to 14 weeks of treatment with the MiniMed 780G system (AID) or continuation of usual care (UC). The primary endpoint was change in time in range (TIR: 3·9-10·0 mmol/L) from baseline to week 14. After this trial period, the UC group switched to AID treatment while the AID group continued using the system. Both groups were monitored for a total of 28 weeks. RESULTS Forty adults (mean ± SD: age 52 ± 11 years, HbA1c 67 ± 7 mmol/mol [8.3% ± 0.6%], diabetes duration 29 ±13 years) were included. After 14 weeks, TIR increased by 18.7% (95% confidence interval [CI] = 14.5, 22.9%) in the AID group and remained unchanged in the UC group (P < .0001). Hemoglobin A1c decreased by 10.0 mmol/mol (95% CI = 7.0, 13.0 mmol/mol) (0.9% [95% CI = 0.6%, 1.2%]) in the AID group but remained unchanged in the UC group (P < .0001). The glycemic benefits of AID treatment were reproduced after the 14-week extension phase. There were no episodes of severe hypoglycemia or diabetic ketoacidosis during the study. CONCLUSIONS For adults with type 1 diabetes not meeting glycemic targets despite use of insulin pump and CGM, transitioning to an AID system confers considerable glycemic benefits.
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Affiliation(s)
- Merete B Christensen
- Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Ajenthen G Ranjan
- Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Karen Rytter
- Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Olivia M McCarthy
- Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Applied Sports, Technology, Exercise and Medicine Research Centre, Swansea University, Swansea, UK
| | - Signe Schmidt
- Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Kirsten Nørgaard
- Copenhagen University Hospital, Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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3
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Yuan CY, Halim B, Kong YW, Lu J, Dutt-Ballerstadt R, Eckenberg P, Hillen K, Koski A, Milenkowic V, Netzer E, Obeyesekere V, Reid S, Sims C, Vogrin S, Wu HP, Seidl T, O'Neal DN. Combining an Electrochemical Continuous Glucose Sensor With an Insulin Delivery Cannula: A Feasibility Study. J Diabetes Sci Technol 2024:19322968241236771. [PMID: 38491800 DOI: 10.1177/19322968241236771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2024]
Abstract
BACKGROUND Combining a continuous glucose monitor with an insulin delivery cannula (CGM-IS) could benefit clinical outcomes. We evaluated the feasibility of a single-needle insertion electrochemical investigational CGM-IS (Pacific Diabetes Technologies, Portland, Oregon) in type 1 diabetes adults. METHODS Following 48 hours run-in using a Medtronic 780G in manual mode with a commercial insulin set, 12 participants commenced insulin delivery using the CGM-IS. A standardized test meal was eaten on the mornings of days 1 and 4. Venous samples were collected every 10 minutes one hour prior to and 15 minutes post-meal for four hours. CGM-IS glucose measurements were post-processed with a single capillary blood calibration during warm-up and benchmarked against YSI. A Dexcom G6 sensor was worn post-consent to study end. RESULTS Mean absolute relative difference (MARD) for the CGM-IS glucose measurements was 9.2% (484 paired data points). Consensus error grid revealed 88.6% within zone A and 100% in A + B. Mean (SD) % bias was -3.5 (11.7) %. There were 35 paired YSI readings <100 mg/dL cutoff and 449 ≥100 mg/dL with 81.4% within ±15 mg/dL or ±15%, and 89.9% within ±20 mg/dL or ±20%. Two cannula occlusions required discontinuation of insulin delivery: one at 70 hours post insertion and another during the day 4 meal test. Mean (SD) Dexcom glucose measurements during run-in and between meal tests was respectively 161.3 ± 27.3 mg/dL versus 158.0 ± 25.6 mg/dL; P = .39 and corresponding mean total daily insulin delivered by the pump was 58.0 ± 25.4 Units versus 57.1 ± 28.8 Units; P = .47. CONCLUSIONS Insulin delivery and glucose sensing with the investigational CGM-IS was feasible. Longer duration studies are needed.
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Affiliation(s)
- Cheng Yi Yuan
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, VIC, Australia
| | - Bella Halim
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, VIC, Australia
| | - Yee W Kong
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, VIC, Australia
| | - Jean Lu
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, VIC, Australia
| | | | | | - Ken Hillen
- Pacific Diabetes Technologies, Portland, OR, USA
| | - Anh Koski
- Pacific Diabetes Technologies, Portland, OR, USA
| | | | - Emma Netzer
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, VIC, Australia
| | - Varuni Obeyesekere
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, VIC, Australia
| | - Solomon Reid
- Pacific Diabetes Technologies, Portland, OR, USA
| | - Catriona Sims
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, VIC, Australia
| | - Sara Vogrin
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, VIC, Australia
| | - Huan-Ping Wu
- Pacific Diabetes Technologies, Portland, OR, USA
| | - Thomas Seidl
- Pacific Diabetes Technologies, Portland, OR, USA
| | - David N O'Neal
- Department of Medicine, St Vincent's Hospital Melbourne, The University of Melbourne, Fitzroy, VIC, Australia
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Åm MK, Teigen IA, Riaz M, Fougner AL, Christiansen SC, Carlsen SM. The artificial pancreas: two alternative approaches to achieve a fully closed-loop system with optimal glucose control. J Endocrinol Invest 2024; 47:513-521. [PMID: 37715091 PMCID: PMC10904408 DOI: 10.1007/s40618-023-02193-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 09/01/2023] [Indexed: 09/17/2023]
Abstract
INTRODUCTION Diabetes mellitus type 1 is a chronic disease that implies mandatory external insulin delivery. The patients must monitor their blood glucose levels and administer appropriate insulin boluses to keep their blood glucose within the desired range. It requires a lot of time and endeavour, and many patients struggle with suboptimal glucose control despite all their efforts. MATERIALS AND METHODS This narrative review combines existing knowledge with new discoveries from animal experiments. DISCUSSION In the last decade, artificial pancreas (AP) devices have been developed to improve glucose control and relieve patients of the constant burden of managing their disease. However, a feasible and fully automated AP is yet to be developed. The main challenges preventing the development of a true, subcutaneous (SC) AP system are the slow dynamics of SC glucose sensing and particularly the delay in effect on glucose levels after SC insulin infusions. We have previously published studies on using the intraperitoneal space for an AP; however, we further propose a novel and potentially disruptive way to utilize the vasodilative properties of glucagon in SC AP systems. CONCLUSION This narrative review presents two lesser-explored viable solutions for AP systems and discusses the potential for improvement toward a fully automated system: A) using the intraperitoneal approach for more rapid insulin absorption, and B) besides using glucagon to treat and prevent hypoglycemia, also administering micro-boluses of glucagon to increase the local SC blood flow, thereby accelerating SC insulin absorption and SC glucose sensor site dynamics.
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Affiliation(s)
- M K Åm
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postboks 8900, 7491, Trondheim, Norway.
| | - I A Teigen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postboks 8900, 7491, Trondheim, Norway
- Cancer Clinic, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - M Riaz
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postboks 8900, 7491, Trondheim, Norway
- Department of Endocrinology, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - A L Fougner
- Department of Engineering Cybernetics, Faculty of Information Technology and Electrical Engineering, Norwegian University of Science and Technology, Trondheim, Norway
| | - S C Christiansen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postboks 8900, 7491, Trondheim, Norway
- Department of Endocrinology, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
| | - S M Carlsen
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Health Sciences, Norwegian University of Science and Technology, Postboks 8900, 7491, Trondheim, Norway
- Department of Endocrinology, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway
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Nigi L, Iraci Sareri G, Cataldo D, Dotta F. 12-Month Efficacy of Advanced Hybrid Closed-Loop System in Adult Type 1 Diabetes Patients. Diabetes Technol Ther 2024; 26:130-135. [PMID: 37902713 DOI: 10.1089/dia.2023.0319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2023]
Abstract
Automated insulin delivery (AID) systems have improved glycemic control in individuals with type 1 diabetes (T1D). The "advanced hybrid closed loop" (AHCL) stands out as the most recent development in AID systems for T1D management. In a real-world clinical environment, we retrospectively evaluated the AHCL MiniMed™ 780G system's effectiveness to achieve and sustain glycemic control over a 12-month period in 22 adult T1D subjects. Within just 14 days of activating the automatic mode, the AHCL MiniMed 780G system showed rapid improvement in glycemic control, which persisted for 12 months. These findings underscore the effectiveness of AHCL systems in achieving and preserving optimal glycemic control in adults with T1D over a very long follow-up.
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Affiliation(s)
- Laura Nigi
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
- Diabetes and Metabolic Diseases Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Gabriele Iraci Sareri
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
| | - Dorica Cataldo
- Diabetes and Metabolic Diseases Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Francesco Dotta
- Department of Medical Sciences, Surgery and Neurosciences, University of Siena, Siena, Italy
- Diabetes and Metabolic Diseases Unit, Azienda Ospedaliera Universitaria Senese, Siena, Italy
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Akiyama T, Yamakawa T, Orime K, Ichikawa M, Harada M, Netsu T, Akamatsu R, Nakamura K, Shinoda S, Terauchi Y. Effects of hybrid closed-loop system on glycemic control and psychological aspects in persons with type 1 diabetes treated with sensor-augmented pump: A prospective single-center observational study. J Diabetes Investig 2024; 15:219-226. [PMID: 37934090 PMCID: PMC10804894 DOI: 10.1111/jdi.14103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 09/28/2023] [Accepted: 10/09/2023] [Indexed: 11/08/2023] Open
Abstract
AIMS/INTRODUCTION This study evaluated the effects of the Medtronic MiniMed 770G hybrid closed-loop system on glycemic control and psychological aspects in persons with type 1 diabetes mellitus. MATERIALS AND METHODS This 3-month prospective observational study included 22 participants with type 1 diabetes mellitus who used the Medtronic MiniMed 640G predictive low-glucose suspend system and were switched to the 770G system. Time in the range of 70-180 mg/dL and glycated hemoglobin levels were evaluated; satisfaction, emotional distress and quality of life were assessed using self-reported questionnaires, including the Diabetes Treatment Satisfaction Questionnaire Status, Problem Area in Diabetes and Diabetes Therapy-Related Quality of Life. RESULTS Time in the range of 70-180 mg/dL increased (63.5 ± 13.4 to 73.0 ± 10.9% [mean ± standard deviation], P = 0.0010), and time above the range of 181-250 mg/dL decreased (26.9 ± 8.9 to 19.6 ± 7.1%, P < 0.0005). Glycated hemoglobin levels decreased (7.7 ± 1.0 to 7.2 ± 0.8%, P = 0.0021). The percentage of participants with time below the range of 54-69 mg/dL <4% of readings increased from 91% to 100% (P < 0.0005). No significant changes were detected in the satisfaction, emotional distress and quality of life levels, but increased sensor calibration might be related to worsened emotional distress and quality of life. CONCLUSIONS The hybrid closed-loop system decreased hyperglycemia and minimized hypoglycemia, but did not improve psychological aspects compared with the predictive low-glucose suspend system, probably because sensor calibration was increased.
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Affiliation(s)
- Tomoaki Akiyama
- Department of Endocrinology and DiabetesYokohama City University Medical CenterYokohamaJapan
| | - Tadashi Yamakawa
- Department of Endocrinology and DiabetesYokohama City University Medical CenterYokohamaJapan
- Kanazawa Medical ClinicYokohamaJapan
| | - Kazuki Orime
- Department of Endocrinology and DiabetesYokohama City University Medical CenterYokohamaJapan
| | - Masahiro Ichikawa
- Department of Endocrinology and DiabetesYokohama City University Medical CenterYokohamaJapan
| | - Marina Harada
- Department of Endocrinology and DiabetesYokohama City University Medical CenterYokohamaJapan
| | - Takumi Netsu
- Department of Endocrinology and DiabetesYokohama City University Medical CenterYokohamaJapan
| | - Ryoichi Akamatsu
- Department of Endocrinology and DiabetesYokohama City University Medical CenterYokohamaJapan
| | - Keita Nakamura
- Department of Endocrinology and DiabetesYokohama City University Medical CenterYokohamaJapan
| | - Satoru Shinoda
- Department of BiostatisticsYokohama City University School of MedicineYokohamaJapan
| | - Yasuo Terauchi
- Department of Endocrinology and MetabolismYokohama City University School of MedicineYokohamaJapan
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Abstract
PURPOSE OF REVIEW Obesity is an epidemic in the United States with serious concomitant co-morbid conditions; people living with type 1 diabetes mellitus (T1D) are not immune to the risk either. Weight gain in T1D is likely multifactorial, due to genetic, environmental and treatment-related factors. FDA-approved and other adjunctive weight loss therapies may benefit people living with T1D but there are risks to consider when providing recommendations or prescribing medications. RECENT FINDINGS We performed a PubMed search of studies assessing clinical outcomes of both approved and off-label medications used in the treatment of type 1 diabetes. Search terms included 'type 1 diabetes, obesity' and the following: (1) metformin, (2) pramlintide, (3) glucagon-like peptide-1 (GLP-1) receptor agonists, (4) dual GLP-1 and gastric inhibitory polypeptide (GIP) agonists, (5) sodium-glucose cotransporter-2 (SGLT-2) inhibitors, (6) surgical treatment of obesity, (7) insulin pump, (8) insulin, (9) medical nutrition therapy, (10) diabetes self-management education, (11) exercise, (12) naltrexone-buproprion, (13) orlistat, and (14) phentermine-topiramate. SUMMARY Weight loss treatments provide a wide-range of benefits in reducing both morbidity and mortality in those who are obese. Treatments also have varying adverse effect profiles which may impact T1D treatment. In this review, we aim to summarize study outcomes in people with T1D, including risks and benefits, of on- and off-label weight loss treatments.
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Affiliation(s)
- Matthew Freeby
- David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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8
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Zeng B, Gao L, Yang Q, Jia H, Sun F. Automated Insulin Delivery Systems in Children and Adolescents With Type 1 Diabetes: A Systematic Review and Meta-analysis of Outpatient Randomized Controlled Trials. Diabetes Care 2023; 46:2300-2307. [PMID: 38011519 DOI: 10.2337/dc23-0504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 07/08/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND The glycemic control of automated insulin delivery (AID) systems in outpatient children and adolescents with type 1 diabetes (T1D) has not been systematically evaluated. PURPOSE To evaluate the efficacy and safety of AID systems in children and adolescents in outpatient settings. DATA SOURCES PubMed, Embase, the Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched until 4 May 2023. This study was registered with PROSPERO (2023, CRD42023395252). STUDY SELECTION Randomized controlled trials that compared AID systems with conventional insulin therapy in outpatient children and adolescents with T1D and reported continuous glucose monitoring outcomes were selected. DATA EXTRACTION Percent time in range (TIR) (3.9-10 mmol/L), time below range (TBR) (<3.9 mmol/L), and time above range (TAR) (>10 mmol/L) were extracted. Data were summarized as mean differences (MDs) with 95% CIs. DATA SYNTHESIS Twenty-five trials (1,345 participants) were included in the meta-analysis. AID systems were associated with an increased percentage of TIR (MD, 11.38% [95% CI 9.01-13.76], P < 0.001; high certainty). The favorable effect was consistent whether AID was used over 3 months (10.46% [8.71-12.20]) or 6 months (10.87% [7.11-14.63]). AID systems had a favorable effect on the proportion of TBR (-0.59% [-1.02 to -0.15], P = 0.008; low certainty) or TAR (-12.19% [-14.65 to -9.73], P < 0.001; high certainty) compared with control treatment. LIMITATIONS Substantial heterogeneity was observed in most analyses. CONCLUSIONS AID systems are more effective than conventional insulin therapy for children and adolescents with T1D in outpatient settings. The favorable effect is consistent both in the short term and long term.
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Affiliation(s)
- Baoqi Zeng
- Central Laboratory, Peking University Binhai Hospital, Tianjin, China
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Le Gao
- Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong, China
| | - Qingqing Yang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Hao Jia
- Drug Clinical Trial Institution, Peking University Binhai Hospital, Tianjin, China
| | - Feng Sun
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University Health Science Center, Beijing, China
- Key Laboratory of Epidemiology of Major Diseases, Peking University, Ministry of Health, Beijing, China
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Stahl-Pehe A, Schlesinger S, Kuss O, Shokri-Mashhadi N, Bächle C, Warz KD, Bürger-Büsing J, Holl R, Spörkel O, Rosenbauer J. Efficacy of automated insulin delivery (AID) systems in type 1 diabetes: protocol of a systematic review and network meta-analysis of outpatient randomised controlled trials. BMJ Open 2023; 13:e074317. [PMID: 37816564 PMCID: PMC10565260 DOI: 10.1136/bmjopen-2023-074317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 09/13/2023] [Indexed: 10/12/2023] Open
Abstract
INTRODUCTION Automated insulin delivery (AID), also known as artificial pancreas system or 'closed-loop system', represents a novel option for current treatments for type 1 diabetes (T1D). The objective of this systematic review and meta-analysis is to assess the efficacy of AID systems in comparison with current intensified insulin therapy for glycaemic control and patient-reported outcomes in individuals with T1D. METHODS AND ANALYSIS Studies will be eligible if they are randomised controlled trials (RCTs) in people with T1D of all ages, and if they compare an AID system for self-administration during the day and night period with any other type of insulin therapy for at least 3 weeks. The primary outcome will be time in the glucose target range of 70-180 mg/dL. A systematic review will be conducted in the MEDLINE, Embase, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov registries from their inception dates. Two authors will independently screen all references based on titles and abstracts against the eligibility criteria. For data extraction, standard forms will be developed and tested before extraction. All information will be assessed independently by at least two reviewers. The risk of bias of the included studies will be assessed using the Cochrane Risk of Bias 2 tool. The data synthesis will include a random-effects pairwise and network meta-analysis (NMA) in a frequentist framework. Where applicable and if sufficient RCTs are available, sensitivity analyses will be performed, and heterogeneity and publication bias will be assessed. The certainty of evidence from the NMA will be evaluated following the Grading of Recommendations Assessment, Development, and Evaluation working group guidance. ETHICS AND DISSEMINATION No ethical approval is needed. The results will be reported to the funder, presented in a peer-reviewed scientific journal and at conferences, and disseminated via press release, social media and public events. PROSPERO REGISTRATION NUMBER CRD42023395492.
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Affiliation(s)
- Anna Stahl-Pehe
- German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research, Neuherberg, Germany
| | - Sabrina Schlesinger
- German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research, Neuherberg, Germany
| | - Oliver Kuss
- German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research, Neuherberg, Germany
| | - Nafiseh Shokri-Mashhadi
- German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research, Neuherberg, Germany
| | - Christina Bächle
- German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research, Neuherberg, Germany
| | - Klaus-D Warz
- Deutsche Diabetes Föderation (DDF), Berlin, Germany
| | | | - Reinhard Holl
- German Center for Diabetes Research, Neuherberg, Germany
- Institut fur Epidemiologie und Medizinische Biometrik, Universitat Ulm, Ulm, Germany
| | - Olaf Spörkel
- German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research, Neuherberg, Germany
| | - Joachim Rosenbauer
- German Diabetes Center, Leibniz Center for Diabetes Research at the Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- German Center for Diabetes Research, Neuherberg, Germany
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Lega IC, Yale JF, Chadha A, Paty B, Roscoe R, Snider M, Steier J, Bajaj HS, Barnes T, Gilbert J, Honshorst K, Kim J, Lewis J, MacDonald B, MacKay D, Mansell K, Senior P, Rabi D, Sherifali D. Hypoglycemia in Adults. Can J Diabetes 2023; 47:548-559. [PMID: 37821214 DOI: 10.1016/j.jcjd.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
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11
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Nwokolo M, Hovorka R. The Artificial Pancreas and Type 1 Diabetes. J Clin Endocrinol Metab 2023; 108:1614-1623. [PMID: 36734145 PMCID: PMC10271231 DOI: 10.1210/clinem/dgad068] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 01/23/2023] [Accepted: 02/01/2023] [Indexed: 02/04/2023]
Abstract
Diabetes technologies represent a paradigm shift in type 1 diabetes care. Continuous subcutaneous insulin infusion (CSII) pumps and continuous glucose monitors (CGM) improve glycated hemoglobin (HbA1c) levels, enhance time in optimal glycemic range, limit severe hypoglycemia, and reduce diabetes distress. The artificial pancreas or closed-loop system connects these devices via a control algorithm programmed to maintain target glucose, partially relieving the person living with diabetes of this constant responsibility. Automating insulin delivery reduces the input required from those wearing the device, leading to better physiological and psychosocial outcomes. Hybrid closed-loop therapy systems, requiring user-initiated prandial insulin doses, are the most advanced closed-loop systems commercially available. Fully closed-loop systems, requiring no user-initiated insulin boluses, and dual hormone systems have been shown to be safe and efficacious in the research setting. Clinical adoption of closed-loop therapy remains in early stages despite recent technological advances. People living with diabetes, health care professionals, and regulatory agencies continue to navigate the complex path to equitable access. We review the available devices, evidence, clinical implications, and barriers regarding these innovatory technologies.
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Affiliation(s)
- Munachiso Nwokolo
- Wellcome Trust-MRC Institute of Metabolic Science, Box 289, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, Box 289, Addenbrooke's Hospital, Cambridge CB2 0QQ, UK
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12
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Garg SK, Grunberger G, Weinstock R, Lawson ML, Hirsch IB, DiMeglio LA, Pop-Busui R, Philis-Tsimikas A, Kipnes M, Liljenquist DR, Brazg RL, Kudva YC, Buckingham BA, McGill JB, Carlson AL, Criego AB, Christiansen MP, Kaiserman KB, Griffin KJ, Forlenza GP, Bode BW, Slover RH, Keiter A, Ling C, Marinos B, Cordero TL, Shin J, Lee SW, Rhinehart AS, Vigersky RA. Improved Glycemia with Hybrid Closed-Loop Versus Continuous Subcutaneous Insulin Infusion Therapy: Results from a Randomized Controlled Trial. Diabetes Technol Ther 2023; 25:1-12. [PMID: 36472543 PMCID: PMC10081723 DOI: 10.1089/dia.2022.0421] [Citation(s) in RCA: 19] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective: To evaluate safety and effectiveness of MiniMed™ 670G hybrid closed loop (HCL) in comparison with continuous subcutaneous insulin infusion (CSII) therapy for 6 months in persons with type 1 diabetes (T1D). Methods: Adults (aged 18-80 years), adolescents, and children (aged 2-17 years) with T1D who were using CSII therapy were enrolled and randomized (1:1) to 6 months of HCL intervention (n = 151, mean age of 39.9 ± 19.8 years) or CSII without continuous glucose monitoring (n = 151, 35.7 ± 18.4 years). Primary effectiveness endpoints included change in A1C for Group 1 (baseline A1C >8.0%), from baseline to the end of study, and difference in the end of study percentage of time spent below 70 mg/dL (%TBR <70 mg/dL) for Group 2 (baseline A1C ≤8.0%), to show superiority of HCL intervention versus control. Secondary effectiveness endpoints were change in A1C and %TBR <70 mg/dL for Group 2 and Group 1, respectively, to show noninferiority of HCL intervention versus control. Primary safety endpoints were rates of severe hypoglycemia and diabetic ketoacidosis (DKA). Results: Change in A1C and difference in %TBR <70 mg/dL for the overall group were significantly improved, in favor of HCL intervention. In addition, a significant mean (95% confidence interval) change in A1C was observed for both Group 1 (-0.8% [-1.1% to -0.4%], P < 0.0001) and Group 2 (-0.3% [-0.5% to -0.1%], P < 0.0001), in favor of HCL intervention. The same was observed for difference in %TBR <70 mg/dL for Group 1 (-2.2% [-3.6% to -0.9%]) and Group 2 (-4.9% [-6.3% to -3.6%]) (P < 0.0001 for both). There was one DKA event during run-in and six severe hypoglycemic events: two during run-in and four during study (HCL: n = 0 and CSII: n = 4 [6.08 per 100 patient-years]). Conclusions: This RCT demonstrates that the MiniMed 670G HCL safely and significantly improved A1C and %TBR <70 mg/dL compared with CSII control in persons with T1D, irrespective of baseline A1C level.
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Affiliation(s)
- Satish K. Garg
- Barbara Davis Center for Diabetes, Aurora, Colorado, USA
| | | | | | | | | | - Linda A. DiMeglio
- Indiana University—Riley Hospital for Children, Indianapolis, Indiana, USA
| | - Rodica Pop-Busui
- University of Michigan Health System—University Hospital, Ann Arbor, Michigan, USA
| | | | - Mark Kipnes
- Diabetes and Glandular Disease Clinic, San Antonio, Texas, USA
| | | | | | | | | | - Janet B. McGill
- Washington University in Saint Louis, St. Louis, Missouri, USA
| | - Anders L. Carlson
- Park Nicollet International Diabetes Center, Minneapolis, Minnesota, USA
| | - Amy B. Criego
- Park Nicollet International Diabetes Center, Minneapolis, Minnesota, USA
| | | | | | - Kurt J. Griffin
- University of South Dakota—Sanford Research, Sioux Falls, South Dakota, USA
| | - Greg P. Forlenza
- Barbara Davis Center for Childhood Diabetes, Aurora, Colorado, USA
| | | | - Robert H. Slover
- Barbara Davis Center for Childhood Diabetes, Aurora, Colorado, USA
| | | | | | | | | | - John Shin
- Medtronic, Northridge, California, USA
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13
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Zeng B, Jia H, Gao L, Yang Q, Yu K, Sun F. Dual-hormone artificial pancreas for glucose control in type 1 diabetes: A meta-analysis. Diabetes Obes Metab 2022; 24:1967-1975. [PMID: 35638377 PMCID: PMC9542047 DOI: 10.1111/dom.14781] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 05/17/2022] [Accepted: 05/26/2022] [Indexed: 12/14/2022]
Abstract
AIM To evaluate the efficacy and safety of a dual-hormone artificial pancreas (DH) in type 1 diabetes. MATERIAL AND METHODS PubMed, Embase, the Cochrane Library and ClinicalTrials.gov were searched for studies published up to February 16, 2022. We included randomized controlled trials that compared DH with single-hormone artificial pancreas (SH), continuous subcutaneous insulin infusion (CSII) or sensor-augmented pumps (SAP), and predictive low glucose suspend systems (PLGS) in type 1 diabetes. The primary outcome was percent time in target (3.9-10 mmol/L [70-180 mg/dL]). Data were summarized as mean differences (MDs) or risk differences (RDs). RESULTS A total of 17 randomized crossover trials (438 participants) were included. There were nine trials of DH versus SH, 13 trials of DH versus SAP/CSII, and two trials of DH versus PLGS. For time in target, DH showed no significant difference in time in target compared with SH (MD 2.69%, 95% confidence interval [CI] -0.38 to 5.76) but resulted in 16.05% (95% CI 12.06 to 20.05) and 6.89% (95% CI 2.63 to 11.14) more time in target range compared with SAP/CSII and PLGS, respectively. DH slightly reduced time in hypoglycaemia (MD -1.20%, 95% CI -1.85 to -0.56) but increased the risk of gastrointestinal symptoms (RD 0.18, 95% CI 0.08 to 0.27) compared with SH. CONCLUSIONS The results of this study suggest that DH has a comparable effect on time in target compared with SH, but is associated with a longer time in target range compared with SAP/CSII and PLGS. The DH slightly reduced time in hypoglycaemia but may increase the risk of gastrointestinal symptoms compared with the SH. PROSPERO registration number: CRD42022314015.
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Affiliation(s)
- Baoqi Zeng
- Department of Science and EducationPeking University Binhai HospitalTianjinChina
| | - Hao Jia
- Drug Clinical Trial InstitutionPeking University Binhai HospitalTianjinChina
| | - Le Gao
- Department of Pharmacology and PharmacyThe University of Hong KongHong KongChina
| | - Qingqing Yang
- Department of Epidemiology and Biostatistics, School of Public HealthPeking University Health Science CentreBeijingChina
| | - Kai Yu
- Department of Science and EducationPeking University Binhai HospitalTianjinChina
| | - Feng Sun
- Department of Epidemiology and Biostatistics, School of Public HealthPeking University Health Science CentreBeijingChina
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14
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Choudhary P, Kolassa R, Keuthage W, Kroeger J, Thivolet C, Evans M, Ré R, de Portu S, Vorrink L, Shin J, Habteab A, Castañeda J, da Silva J, Cohen O. Advanced hybrid closed loop therapy versus conventional treatment in adults with type 1 diabetes (ADAPT): a randomised controlled study. Lancet Diabetes Endocrinol 2022; 10:720-731. [PMID: 36058207 DOI: 10.1016/s2213-8587(22)00212-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Revised: 06/29/2022] [Accepted: 07/07/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Adults with type 1 diabetes who are treated with multiple daily injections of insulin plus intermittently scanned continuous glucose monitoring (isCGM) can have suboptimal glucose control. We aimed to assess the efficacy of an advanced hybrid closed loop (AHCL) system compared with such therapy in this population. METHODS The Advanced Hybrid Closed Loop Study in Adult Population with Type 1 Diabetes (ADAPT) trial is a prospective, multicentre, open-label, randomised controlled trial that involved 14 centres in three European countries (France, Germany, and the UK). We enrolled patients who were at least 18 years of age, had a type 1 diabetes duration of at least 2 years, HbA1c of at least 8% (64 mmol/mol), and were using multiple daily injections of insulin plus isCGM (cohort A) or real time continuous glucose monitoring (cohort B) for at least 3 months. Here, only results for cohort A are reported. Participants were randomly allocated 1:1 to AHCL therapy or continuation of multiple daily injections of insulin plus continuous glucose monitoring for 6 months with an investigator-blinded block randomisation procedure. Participants and treating clinicians could not be masked to the arm assignment. The primary endpoint was the between-group difference in mean HbA1c change from baseline to 6 months in the intention-to-treat population using AHCL therapy and those using multiple daily injections of insulin plus isCGM. The primary endpoint was analysed using a repeated measures random-effects model with the study arm and period as factors. Safety endpoints included the number of device deficiencies, severe hypoglycaemic events, diabetic ketoacidosis, and serious adverse events. This study is registered with ClinicalTrials.gov, NCT04235504. FINDINGS Between July 13, 2020, and March 12, 2021, 105 people were screened and 82 randomly assigned to treatment (41 in each arm). At 6 months, mean HbA1c had decreased by 1·54% (SD 0·73), from 9·00% to 7·32% in the AHCL group and 0·20% (0·80) in the multiple daily injections of insulin plus isCGM from 9·07% to 8·91% (model-based difference -1·42%, 95% CI -1·74 to -1·10; p<0·0001). No diabetic ketoacidosis, severe hypoglycaemia, or serious adverse events related to study devices occurred in either group; two severe hypoglycaemic events occurred in the run-in phase. 15 device-related non-serious adverse events occurred in the AHCL group, compared with three in the multiple daily injections of insulin plus isCGM group. Two serious adverse events occurred (one in each group), these were breast cancer (in one patient in the AHCL group) and intravitreous haemorrhage (in one patient in the multiple daily injections of insulin plus isCGM group). INTERPRETATION In people with type 1 diabetes using multiple daily injections of insulin plus isCGM and with HbA1c of at least 8%, the use of AHCL confers benefits in terms of glycaemic control beyond those that can be achieved with multiple daily injections of insulin plus isCGM. These data support wider access to AHCL in people with type 1 diabetes not at target glucose levels. FUNDING Medtronic International Trading Sàrl.
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Affiliation(s)
- Pratik Choudhary
- Kings College Hospital NHS Foundation Trust, London, UK; Leicester Diabetes Centre, University of Leicester, Leicester, UK
| | - Ralf Kolassa
- Diabetologische Schwerpunktpraxis, Bergheim, Germany
| | - Winfried Keuthage
- Schwerpunktpraxis für Diabetes und Ernährungsmedizin, Münster, Germany
| | - Jens Kroeger
- Zentrum für Diabetologie Bergedorf, Hamburg, Germany
| | | | - Mark Evans
- Wellcome Trust-MRC Institute of Metabolic Science and Department of Medicine, University of Cambridge, Cambridge, UK
| | - Roseline Ré
- Medtronic International Trading Sàrl, Tolochenaz, Switzerland
| | - Simona de Portu
- Medtronic International Trading Sàrl, Tolochenaz, Switzerland
| | - Linda Vorrink
- Medtronic International Trading Sàrl, Tolochenaz, Switzerland
| | - John Shin
- Medtronic, Northridge, California, USA
| | - Aklilu Habteab
- Medtronic Bakken Research Center, Maastricht, Netherlands
| | | | - Julien da Silva
- Medtronic International Trading Sàrl, Tolochenaz, Switzerland
| | - Ohad Cohen
- Medtronic International Trading Sàrl, Tolochenaz, Switzerland.
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15
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Lewis DM, Hussain S. Practical Guidance on Open Source and Commercial Automated Insulin Delivery Systems: A Guide for Healthcare Professionals Supporting People with Insulin-Requiring Diabetes. Diabetes Ther 2022; 13:1683-1699. [PMID: 35913655 PMCID: PMC9399331 DOI: 10.1007/s13300-022-01299-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 07/08/2022] [Indexed: 01/15/2023] Open
Abstract
As increasing numbers of people with insulin-managed diabetes use automated insulin delivery (AID) systems or seek such technologies, healthcare providers are faced with a steep learning curve. Healthcare providers need to understand how to support these technologies to help inform shared decision making, discussing available options, implementing them in the clinical setting, and guiding users in special situations. At the same time, there is a growing diversity of commercial and open source automated insulin delivery systems that are evolving at a rapid pace. This practical guide seeks to provide a conversational framework for healthcare providers to first understand and then jointly assess AID system options with users and caregivers. Using this framework will help HCPs in learning how to evaluate potential new commercial or open source AID systems, while also providing a guide for conversations to help HCPs to assess the readiness and understanding of users for AID systems. The choice of an AID system is not as simple as whether the system is open source or commercially developed, and indeed there are multiple criteria to assess when choosing an AID system. Most importantly, the choices and preferences of the person living with diabetes should be at the center of any decision around the ideal automated insulin delivery system or any other diabetes technology. This framework highlights issues with AID use that may lead to burnout or perceived failures or may otherwise cause users to abandon the use of AID. It discusses the troubleshooting of basic AID system operation and discusses more advanced topics regarding how to maximize the time spent on AID systems, including how to optimize settings and behaviors for the best possible outcomes with AID technology for people with insulin-requiring diabetes. This practical approach article demonstrates how healthcare providers will benefit from assessing and better understanding all available AID system options to enable them to best support each individual.
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Affiliation(s)
| | - Sufyan Hussain
- Department of Diabetes and Endocrinology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
- Department of Diabetes, King’s College London, London, UK
- Institute of Diabetes, Endocrinology and Obesity, King’s Health Partners, London, UK
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