Automated Insulin Delivery in Children with Type 1 Diabetes

Automated insulin dosing systems: Advances after a century of insulin

The daily complexities of insulin therapy and glucose variability in type 1 diabetes still pose significant challenges, despite advancements in modern insulin analogues. Minimising hypoglycaemia and optimising time spent within target glucose range are recommended to reduce the risk of diabetes-related complications and distress. Access to structured education and adjuvant diabetes technologies, such as insulin pumps and glucose sensors, are recommended by National Institute for Health and Care Excellence (NICE) to enable people with type 1 diabetes achieve their glycaemic goals. One hundred years after the discovery of insulin, automated insulin dosing (AID, a.k.a. closed loop or artificial pancreas) systems are a reality with a number of systems available and being used in usual clinical practice. Evidence from randomised clinical trials and real-world prospective studies support efficacy, effectiveness and safety of AID systems. Qualitative evaluations reveal treatment satisfaction and positive effects on quality of life. Current insulin-only AID systems still require carbohydrate and activity announcement (hybrid closed loop) due to the inherent pharmacokinetic limitations of rapid-acting insulin analogies. Ultra-rapid acting insulin and adjunctive use of other therapies (e.g. glucagon, pramlitide) are being evaluated to achieve full closed loop. Open-source AID (OS-AID) systems have been developed by the diabetes community, driven by a desire for safety and to accelerate technological advancement. In addition to effectiveness and safety, real-world prospective studies suggest that OS-AID systems fulfil unmet needs of commercially approved systems. The development, ongoing challenges and expectations of AID are outlined in this review.

A clinical review of the t:slim X2 insulin pump

Insulin pumps are commonly used for intensive insulin therapy to treat type 1 diabetes in adults and youth. Insulin pump technologies have advanced dramatically in the last several years to integrate with continuous glucose monitors (CGM) and incorporate control algorithms. These control algorithms automate some insulin delivery in response to the glucose information received from the CGM to reduce the occurrence of hypoglycemia and hyperglycemia and improve overall glycemic control. The t:slim X2 insulin pump system became commercially available in 2016. It is an innovative insulin pump technology that can be updated remotely by the user to install new software onto the pump device as new technologies become available. Currently, the t:slim X2 pairs with the Dexcom G6 CGM and there are two advanced software options available: Basal-IQ, which is a predictive low glucose suspend (PLGS) technology, and Control-IQ, which is a Hybrid Closed Loop (HCL) technology. This paper will describe the different types of advanced insulin pump technologies, review how the t:slim X2 insulin pump works, and summarize the clinical studies leading to FDA approval and commercialization of the Basal-IQ and Control-IQ technologies.

Use of a do-it-yourself artificial pancreas system is associated with better glucose management and higher quality of life among adults with type 1 diabetes

BACKGROUND

Previous studies show that the use of do-it-yourself artificial pancreas system (DIYAPS) may be associated with better glycemic control characterized by improved estimated hemoglobin A1c (eHbA1c) and time in range among adults with type 1 diabetes (T1D). However, few studies have demonstrated the changes in laboratory-measured HbA1c, which is a more accepted index for glycemic control, after using a DIYAPS.

METHODS

This is a retrospective before-after study approaching patients who reported self-use of AndroidAPS. The main inclusion criteria included: T1D; aged ⩾18 years; having complete record of ⩾3 months of continuous AndroidAPS use; with laboratory-measured HbA1c and quality of life scale data before and after 3 months of AndroidAPS use; and not pregnant. The primary outcome was the change in HbA1c between baseline and 3 months after initiation of AndroidAPS use.

RESULTS

Overall, 15 patients (10 females) were included; the median age was 32.2 years (range: 19.2-69.4), median diabetes duration was 9.7 years (range: 1.8-23.7) and median baseline HbA1c was 7.3% (range: 6.4-10.1). The 3 months of AndroidAPS use was associated with substantial reductions in HbA1c [6.79% (SD: 1.29) versus 7.63% (SD: 1.06), p = 0.002] and glycemic variability when compared with sensor-augmented pump therapy. A lower level of fear of hypoglycemia [22.13 points (SD: 6.87) versus 26.27 points (SD: 5.82), p = 0.010] was also observed after using AndroidAPS.

CONCLUSIONS

The 3 months of AndroidAPS use was associated with significant improvements in glucose management and quality of life among adults with T1D.