Skin Problems Associated with Insulin Pumps and Sensors in Adults with Type 1 Diabetes: A Cross-Sectional Study

Prevalence of dermatitis including allergic contact dermatitis from medical devices used by children and adults with Type 1 diabetes mellitus: A systematic review and questionnaire study

Use of medical devices (MDs), that is, glucose sensors and insulin pumps, in patients with Type 1 diabetes mellitus (T1D) has proven an enormous advantage for disease control. Adverse skin reactions from these MDs may however hamper compliance. The objective of this study was to systematically review and analyse studies assessing the prevalence and incidence of dermatitis, including allergic contact dermatitis (ACD) related to MDs used in patients with T1D and to compare referral routes and the clinical investigation routines between clinics being part of the European Environmental and Contact Dermatitis Research Group (EECDRG). A systematic search of PubMed, EMBASE, CINAHL and Cochrane databases of full-text studies reporting incidence and prevalence of dermatitis in persons with T1D using MDs was conducted until December 2021. The Newcastle-Ottawa Scale was used to assess study quality. The inventory performed at EECRDG clinics focused on referral routes, patient numbers and the diagnostic process. Among the 3145 screened abstracts, 39 studies fulfilled the inclusion criteria. Sixteen studies included data on children only, 14 studies were on adults and nine studies reported data on both children and adults. Participants were exposed to a broad range of devices. Skin reactions were rarely specified. It was found that both the diagnostic process and referral routes differ in different centres. Further data on the prevalence of skin reactions related to MDs in individuals with T1D is needed and particularly studies where the skin reactions are correctly diagnosed. A correct diagnosis is delayed or hampered by the fact that, at present, the actual substances within the MDs are not declared, are changed without notice and the commercially available test materials are not adequately updated. Within Europe, routines for referral should be made more standardized to improve the diagnostic procedure when investigating patients with possible ACD from MDs.

Insertable Biosensors: Combining Implanted Sensing Materials with Wearable Monitors

Insertable biosensor systems are medical diagnostic devices with two primary components: an implantable biosensor within the body and a wearable monitor that can remotely interrogate the biosensor from outside the body. Because the biosensor does not require a physical connection to the electronic monitor, insertable biosensor systems promise improved patient comfort, reduced inflammation and infection risk, and extended operational lifetimes relative to established percutaneous biosensor systems. However, the lack of physical connection also presents technical challenges that have necessitated new innovations in developing sensing chemistries, transduction methods, and communication modalities. In this review, we discuss the key developments that have made insertables a promising option for longitudinal biometric monitoring and highlight the essential needs and existing development challenges to realizing the next generation of insertables for extended-use diagnostic and prognostic devices.

Long-Term Evaluation of Inserted Nanocomposite Hydrogel-Based Phosphorescent Oxygen Biosensors: Evolution of Local Tissue Oxygen Levels and Foreign Body Response

Phosphorescence-based oxygen-sensing hydrogels are a promising platform technology for an upcoming generation of insertable biosensors that are smaller, softer, and potentially more biocompatible than earlier designs. However, much remains unknown about their long-term performance and biocompatibility in vivo. In this paper, we design and evaluate a range of hydrogel sensors that contain oxygen-sensitive phosphors stabilized by micro- and nanocarrier systems. These devices demonstrated consistently good performance and biocompatibility in young adult rats for over three months. This study thoroughly establishes the biocompatibility and long-term suitability of phosphorescence lifetime sensors in vivo, providing the groundwork for expansion of this platform technology into a family of small, unobtrusive biosensors for a range of clinically relevant metabolites.

Skin Reactions in Children with Type 1 Diabetes Associated with the Use of New Diabetes Technologies-An Observational Study from a Regional Polish Pediatric Diabetes Center

The study aimed to estimate the prevalence of skin problems in children and adolescents with type 1 diabetes (T1D) using insulin pumps (IPs) and/or continuous glucose monitoring (CGM) in our center and analyze their association with various factors. As part of the international ISPAD JENIOUS-initiated SKIN-PEDIC project, we interviewed and examined patients who visited the regional pediatric diabetes center in Opole (Poland) for four weeks regarding the use of IP and/or CGM and the presence of skin problems. Body mass index (BMI) and glycemic parameters were obtained retrospectively from medical records. Among 115 individuals (45.2% girls, 83.5% IP users, 96.5% CGM users), old scars were the most common skin problem (IP users 53.1%; CGM users 66.4%), while ≥2 types of skin problems co-occurred (IP users 40.6%; CGM users 27.3%). Longer IP use was associated with a higher prevalence of skin problems (50% for IP < 1 year, 98.1%-IP 1-3 years, 100% for IP > 3 years; p < 0.001), pointing out extra attention with IP use > 1 year. No significant associations were found between skin problems and gender, age, BMI centile and glycemic parameters. Dermatological complications were common among children using IP and CGM in our center, highlighting the need for vigilant monitoring and early intervention to manage these skin-related issues effectively.

Insulin Pump Therapy and Adverse Skin Reactions With Focus on Allergic Contact Dermatitis in Individuals Living With Diabetes Mellitus: A Systematic Review and Clinical-Based Update

BACKGROUND

The use of insulin pumps (continuous subcutaneous insulin infusion [CSII]) in individuals living with type 1 diabetes (T1D) improves disease control. However, adverse skin reactions may hamper compliance. We aimed to assess the relationship of insulin pumps, particularly that of infusion set therapy, used in children and adults with T1D and dermatitis including allergic contact dermatitis (ACD).

METHODS

A systematic search of PubMed, and EMBASE, of full-text studies reporting dermatitis in persons with diabetes using a CSII was conducted from 2020 to 2023. The Newcastle-Ottawa Scale was used to assess study quality. The inventory performed at the Department of Occupational and Environmental Dermatology, Malmö, Sweden (YMDA) was also performed highlighting the diagnostic process.

RESULTS

Among the 391 screened abstracts, 21 studies fulfilled the inclusion criteria. Seven studies included data on children only, four studies were on adults, and nine studies reported data on both children and adults. Participants were exposed to a broad range of pumps. Dermatitis was rarely specified. Up to 60% of those referred to a university hospital due to skin reactions possibly related to insulin pumps had an ACD.

CONCLUSIONS

The review and our findings indicate that there is not sufficient focus on contact allergy in the primary toxicological evaluations of substances used also for insulin pump therapy products and that possible adverse skin reactions are not correctly followed up in the clinical setting.

Device-Related Skin Reactions Increase Emotional Burden in Youths With Type 1 Diabetes and Their Parents

BACKGROUND

Skin reactions due to technological devices pose a significant concern in the management of type 1 diabetes (T1D). This multicentric, comparative cross-sectional study aimed to assess the psychological impact of device-related skin issues on youths with T1D and their parents.

METHODS

Participants with skin reactions were matched in a 1:1 ratio with a control group. Diabetes-related emotional distress was evaluated using the Problem Areas in Diabetes-Teen version (PAID-T) for participants aged 11 to 19 years and the Problem Areas in Diabetes-Parent Revised version (PAID-PR) completed by parents. In addition, glucose control was assessed through glycated hemoglobin (HbA1c) values and continuous glucose monitoring (CGM) metrics.

RESULTS

A total of 102 children and adolescents were consecutively recruited. Adolescents with skin issues had higher PAID-T scores compared to those without (79.6 ± 21.1 vs 62 ± 16.8; P = .004). Parents of youths with skin reactions also reported higher PAID-PR scores than the control group (34.0 ± 11.0 vs 26.9 ± 12.3; P = .015). No differences were observed in HbA1c levels (6.9 ± 0.8% vs 6.8 ± 0.8%, P = .555) or CGM glucose metrics between the two groups. Remarkably, 25.5% were forced to discontinue insulin pumps and/or glucose sensors (21.5% and 5.9%, respectively).

CONCLUSIONS

Our study highlighted the increased emotional burden experienced by youths with T1D and their parents due to device-related skin reactions, emphasizing the need for further research and interventions in this crucial aspect of diabetes management.

Introducing the Pi-CON Methodology to Overcome Usability Deficits during Remote Patient Monitoring

The adoption of telehealth has soared, and with that the acceptance of Remote Patient Monitoring (RPM) and virtual care. A review of the literature illustrates, however, that poor device usability can impact the generated data when using Patient-Generated Health Data (PGHD) devices, such as wearables or home use medical devices, when used outside a health facility. The Pi-CON methodology is introduced to overcome these challenges and guide the definition of user-friendly and intuitive devices in the future. Pi-CON stands for passive, continuous, and non-contact, and describes the ability to acquire health data, such as vital signs, continuously and passively with limited user interaction and without attaching any sensors to the patient. The paper highlights the advantages of Pi-CON by leveraging various sensors and techniques, such as radar, remote photoplethysmography, and infrared. It illustrates potential concerns and discusses future applications Pi-CON could be used for, including gait and fall monitoring by installing an omnipresent sensor based on the Pi-CON methodology. This would allow automatic data collection once a person is recognized, and could be extended with an integrated gateway so multiple cameras could be installed to enable data feeds to a cloud-based interface, allowing clinicians and family members to monitor patient health status remotely at any time.

Lipohypertrophy and Insulin: An Update From the Diabetes Technology Society

Lipohypertrophy is a common skin complication associated with insulin-treated diabetes. The impact of lipohypertrophy as a contributing factor to suboptimal glycemic control, glucose variability, and hypoglycemia is often under-recognized by health care professionals. In a recent Webinar on April 26, 2023, Diabetes Technology Society asked international experts to provide updates on the latest knowledge related to lipohypertrophy for practicing clinicians and educators, researchers, and industries involved in insulin delivery. A recording of the Webinar is freely available on the Diabetes Technology Society Web site (https://www.diabetestechnology.org/).

Ultrasound Detected Subcutaneous Changes in a Pediatric Cohort After Initiation of a New Insulin Pump or Glucose Sensor

Objective: This study examined subcutaneous tissue changes at sites used by continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM), and tested whether these changes, if any, were associated with glycated hemoglobin (HbA1c). Research Design and Methods: This prospective study investigated recently used CSII or CGM sites in 161 children and adolescents during the first year after initiation of a new diabetes device. Subcutaneous changes such as echogenicity, vascularization, and the distance from the skin surface to the muscle at CSII and CGM sites were assessed by ultrasound. Results: The distance from skin surface to muscle fascia at both the upper arm and abdomen was influenced by age, body mass index z-score, and sex. Especially in boys and the youngest, the depth of many devices outreached the mean distance. The mean distance for boys at the abdomen and upper arm ranged from 4.5-6.5 mm and 5-6.9 mm for all ages, respectively. Hyperechogenicity at CGM sites was 4.3% after 12 months. The frequency of subcutaneous hyperechogenicity and vascularization at CSII sites increased significantly over time (41.2% to 69.3% and 2% to 16% respectively, P < 0.001 and P = 0.009). Hyperechogenicity in the subcutis was not a predictor of elevated HbA1c (P = 0.11). Conclusion: There is large variation in the distance from the skin surface to the muscle fascia and many diabetes devices reach even deeper. Hyperechogenicity and vascularization increased significantly over time at CSII sites, but not CGM sites. The importance of hyperechogenicity for insulin absorption is unclear and further investigations are needed. Clinical Trial Registration number: NCT04258904.

Continuous subcutaneous insulin infusions: Closing the loop

CONTEXT

Continuous subcutaneous insulin infusions (CSIIs) and continuous glucose monitors (CGMs) have revolutionized the management of diabetes mellitus (DM). Over the last two decades the development of advanced, small, and user-friendly technology has progressed substantially, essentially closing the loop in the fasting and post-absorptive state, nearing the promise of an artificial pancreas. The momentum was mostly driven by the diabetes community itself, to improve its health and quality of life.

EVIDENCE ACQUISITION

Literature regarding CSII and CGM was reviewed.

EVIDENCE SYNTHESIS

Management of DM aims to regulate blood glucose to prevent long term micro and macrovascular complications. CSIIs combined with CGMs provide an integrated system to maintain tight glycemic control in a safe and uninterrupted fashion, while minimizing hypoglycemic events. Recent advances have allowed to 'close the loop' by better mimicking endogenous insulin secretion and glucose level regulation. Evidence supports sustained improvement in glycemic control with reduced episodes of hypoglycemia using these systems, while improving quality of life. Ongoing work in delivery algorithms with or without counterregulatory hormones will allow for further layers of regulation of the artificial pancreas.

CONCLUSION

Ongoing efforts to develop an artificial pancreas have created effective tools to improve the management of DM. CSIIs and CGMs are useful in diverse populations ranging from children to the elderly, as well as in various clinical contexts. Individually and more so together, these have had a tremendous impact in the management of DM, while avoiding treatment fatigue. However, cost and accessibility are still a hindrance to its wider application.

Translational gaps and opportunities for medical wearables in digital health

A confluence of advances in biosensor technologies, enhancements in health care delivery mechanisms, and improvements in machine learning, together with an increased awareness of remote patient monitoring, has accelerated the impact of digital health across nearly every medical discipline. Medical grade wearables-noninvasive, on-body sensors operating with clinical accuracy-will play an increasingly central role in medicine by providing continuous, cost-effective measurement and interpretation of physiological data relevant to patient status and disease trajectory, both inside and outside of established health care settings. Here, we review current digital health technologies and highlight critical gaps to clinical translation and adoption.

Evaluation of Extended Infusion Set Performance in Adults with Type 1 Diabetes: Infusion Set Survival Rate and Glycemic Outcomes from a Pivotal Trial

Background: Standard insulin infusion sets (IISs) are to be replaced every 2 to 3 days to avoid complications and diabetic ketosis due to set failure. This pivotal trial evaluated the safety and performance of a new extended-wear infusion set (EIS) when used for 7 days by adults with type 1 diabetes (T1D). Methods: This single-arm, nonrandomized trial enrolled adults (18-80 years of age) with T1D, who used their own MiniMed™ 670G system with insulin lispro or insulin aspart and the EIS for up to 7 days, across 12 consecutive wears. Safety endpoints included incidence of serious adverse events (SAEs), serious adverse device effects (SADEs), unanticipated adverse device effects (UADEs), severe hypoglycemia (SevHypo), severe hyperglycemia (SevHyper), diabetic ketoacidosis (DKA), and skin infection. The EIS failure rate due to unexplained hyperglycemia (i.e., suspected occlusion), the overall EIS survival rate, glycemic control outcomes (i.e., A1C, mean sensor glucose and time spent in established glucose ranges), total daily insulin delivered, and satisfaction with the EIS were determined. Results: The intention to treat population (n = 259, 48% men, 45.0 ± 14.1 years) wore a total of 3041 EIS devices. No SADE, UADE, or DKA events was reported. Overall rates of SAEs, SevHypo, SevHyper, and skin infection were 3.8, 2.5, 104.1, and 20.1 events per 100 participant-years. The rate of EIS failure due to unexplained hyperglycemia at the end of day 7 was 0.1% (95% confidence interval [CI]: 0.03-0.51) and 0.4% (95% CI: 0.16-1.00) for insulin lispro and aspart use, respectively. Overall EIS survival rate at the end of day 7 was 77.8% (95% CI: 76.2-79.3), glycemic control did not change, and participants reported greater satisfaction with the EIS compared with standard IISs worn before the study (P < 0.001). Conclusions: This investigation demonstrates that the EIS, when worn for up to 7 days, was safe and rated with high satisfaction, without adversely affecting glycemic control in adults with T1D. Clinical Trial Registration number: NCT04113694 (https://clinicaltrials.gov/ct2/show/NCT04113694).

Diabetes Technology Meeting 2021

Diabetes Technology Society hosted its annual Diabetes Technology Meeting on November 4 to November 6, 2021. This meeting brought together speakers to discuss various developments within the field of diabetes technology. Meeting topics included blood glucose monitoring, continuous glucose monitoring, novel sensors, direct-to-consumer telehealth, metrics for glycemia, software for diabetes, regulation of diabetes technology, diabetes data science, artificial pancreas, novel insulins, insulin delivery, skin trauma, metabesity, precision diabetes, diversity in diabetes technology, use of diabetes technology in pregnancy, and green diabetes. A live demonstration on a mobile app to monitor diabetic foot wounds was presented.

Correlation in Dose-Response to Rapid- and Long-Acting Insulin for People with Type 1 Diabetes

In diabetes, it can become necessary to switch between pump- and pen-based insulin treatment. This switch involves a translation between rapid- and long-acting insulin analogues. In standard-of-care translation algorithms, a unit-to-unit conversion is applied. However, this simplification may not fit all individuals. In this paper, we investigate the correlation between dose-response to rapid- and long-acting insulin in the same individual, and compare the correlation across individuals. As a measure of dose-response, we estimate the insulin sensitivity in clinical data from 25 subjects with type 1 diabetes. For parameter estimation, we use maximum likelihood with a continuous-discrete extended Kalman filter and Bergman's minimal model. The results show a weak correlation between insulin sensitivity to rapid- and long-acting insulin across individuals. On this sparse data set, the analysis suggests that the standardized unit-to-unit translation between insulin analogues may not benefit all subjects.

Evaluation of the FreeStyle Libre, a flash glucose monitoring system, in client-owned cats with diabetes mellitus

Objectives

Home blood glucose monitoring using a portable blood glucose meter is important in the management of feline diabetes mellitus, but taking blood samples may be stressful for owners and cats. A flash glucose monitoring system measuring interstitial glucose, such as the FreeStyle Libre, overcomes some of these drawbacks. The aim of this study was to evaluate the practical use and analytical and clinical accuracy of the FreeStyle Libre in 41 client-owned diabetic cats.

Methods

In this prospective study, interstitial glucose concentrations were measured with the FreeStyle Libre and compared with blood glucose concentrations measured with a portable blood glucose meter (AlphaTRAK) on days 1, 7 or 8 and 14 after application of the device. Cat behaviour during application, location, skin reaction at the attachment site and owner satisfaction were assessed. Accuracy was determined by fulfilment of ISO 15197:2013 criteria, including Bland–Altman plotting and error grid analysis.

Results

Placing the device was easy, with 70% of cats showing no reaction. Most sensors were placed on the thoracic wall. Skin reactions at the attachment site were not present or mild in almost all cats. Owners were very satisfied with the use of the FreeStyle Libre. Median functional life of the sensor was 10 days (range 1–14). Good correlation was found between interstitial and blood glucose measurements (rho[r] = 0.88, P <0.0001). Fifty-three percent of interstitial glucose concentrations were within a maximum deviation of 15% from blood glucose concentrations and 92.7% were within the safe risk zones 0 and 1 of the surveillance error grid.

Conclusions and relevance

The flash glucose monitoring system was easy to use and owners of diabetic cats were satisfied with its use. Although the device did not completely fulfil ISO requirements, it is sufficiently accurate for glucose monitoring in diabetic cats.

Insulin Pump-related Inpatient Admissions in a National Sample of Youth With Type 1 Diabetes

BACKGROUND

Insulin pump use in type 1 diabetes management has significantly increased in recent years, but we have few data on its impact on inpatient admissions for acute diabetes complications.

METHODS

We used the 2006, 2009, 2012, and 2019 Kids' Inpatient Database to identify all-cause type 1 diabetes hospital admissions in those with and without documented insulin pump use and insulin pump failure. We described differences in (1) prevalence of acute diabetes complications, (2) severity of illness during hospitalization and disposition after discharge, and (3) length of stay (LOS) and inpatient costs.

RESULTS

We identified 228 474 all-cause admissions. Insulin pump use was documented in 7% of admissions, of which 20% were due to pump failure. The prevalence of diabetic ketoacidosis (DKA) was 47% in pump nonusers, 39% in pump users, and 60% in those with pump failure. Admissions for hyperglycemia without DKA, hypoglycemia, sepsis, and soft tissue infections were rare and similar across all groups. Admissions with pump failure had a higher proportion of admissions classified as major severity of illness (14.7%) but had the lowest LOS (1.60 days, 95% CI 1.55-1.65) and healthcare costs ($13 078, 95% CI $12 549-$13 608).

CONCLUSIONS

Despite the increased prevalence of insulin pump in the United States, a minority of pediatric admissions documented insulin pump use, which may represent undercoding. DKA admission rates were lower among insulin pump users compared to pump nonusers. Improved accuracy in coding practices and other approaches to identify insulin pump users in administrative data are needed, as are interventions to mitigate risk for DKA.

Reduction of clinically important low glucose excursions with a long-term implantable continuous glucose monitoring system in adults with type 1 diabetes prone to hypoglycaemia: the France Adoption Randomized Clinical Trial

AIM

To assess the glucose control outcomes of the implantable Eversense real-time continuous glucose monitoring (CGM) system compared to self-monitoring of blood glucose or intermittently scanned CGM in patients with type 1 (T1D) or type 2 diabetes (T2D).

PATIENTS AND METHODS

This was a randomized (2:1), prospective, national, multicentre study. All participants, aged >18 years and on multiple daily insulin injections or insulin pump treatment, had a sensor inserted, which was activated only in the "enabled" group. Included patients had T1D or T2D with a glycated haemoglobin (HbA1c) level > 8% (64 mmol/mol) (Cohort 1) or T1D with a time spent with glucose values below 70 mg/dL (3.8 mmol/l) (TBR^<70 ) for >1.5 h/d during the previous 28 days (Cohort 2). The primary outcomes were HbA1c change at D180 (Cohort 1) or change in time spent with glucose values below 54 mg/dL (TBR^<54 ) during the period of Day (D)90 to D120 (Cohort 2). A covariance model (analyses of covariance) was used for endpoint analyses.

RESULTS

Overall, 149 patients were included in Cohort 1 and 90 in Cohort 2. In Cohort 1, the adjusted mean difference (enabled - control) in HbA1c at D180 was -0.1% (95% confidence interval [CI] -0.4; 0.1; P = 0.341). No significant difference in time with values in the range 70 to 180 mg/dL or time with values above range (>180 mg/dL) was observed. In Cohort 2, the mean adjusted difference in TBR^<54 was -1.6% (95% CI -3.1; -0.1; P = 0.039) during D90 to D120 and remained at -2.6% (95% CI -4.5; -0.6; P = 0.011) during D150 to D180 (prespecified secondary outcome). The CGM system was found to be safe.

CONCLUSION

This study shows that the Eversense CGM system can significantly decrease TBR^<54 in patients with T1D prone to hypoglycaemia.

Allergic Contact Dermatitis, an Important Skin Reaction in Diabetes Device Users: A Systematic Review

ABSTRACT

Diabetes management has undergone many advances over the years, including the introduction of devices that allow patients to monitor blood glucose and administer insulin. Although these devices have improved patients' quality of life, they are associated with adverse reactions.A systematic literature search was performed up to May 2020 in PubMed, Cochrane, and Embase databases, with no temporal restrictions. Articles were screened by title, abstract, and full text as needed. A manual search among the references of the included articles was also performed.Two hundred sixty-five articles were identified, and 50 studies met inclusion criteria. Several cases of allergic contact dermatitis due to the use of insulin infusion systems and blood glucose monitoring have been reported. Acrylates, methacrylates, and colophonium, as well as, in particular, isobornyl acrylate, represent the main allergens responsible.Skin reactions, in particular allergic contact dermatitis, are a very common adverse event caused by insulin pumps and glucose sensors, which may lead to discontinue the usage of these devices with serious consequences for the patients. Collaboration between specialists, specifically between dermatologists and diabetologists, with patients and manufacturers is essential for the correct management of diabetes devices and potential related skin reactions.

Insulin Pump Therapy for Patients With Type 2 Diabetes Mellitus: Evidence, Current Barriers, and New Technologies

An increasing number of patients with type 2 diabetes mellitus (T2DM) use insulin pumps. The first insulin pumps especially designed for patients with T2DM have recently become available. However, national guidelines do not primarily recommend the use of continuous subcutaneous insulin infusion (CSII) for this patient group. The effectiveness of CSII in T2DM has not yet been convincingly demonstrated, despite some positive evidence. An overview and an assessment of various studies to date will be given. T2DM is a heterogeneous disease with a substantial phenotypic variability; therefore, it is difficult to provide general conclusions about the effectiveness of CSII in T2DM therapy. The pump types, characteristics, and associated barriers may play a relevant role for therapy outcome. Most advanced functions like various bolus dosages offered by conventional insulin pumps are not needed for T2DM treatment and complicate the device handling for this subject group. Additionally, new technologies like increased connectivity, advanced software features, and interoperability are currently becoming available representing further barriers. The implementation of this technological progress might be a benefit for pumps for T2DM as well. However, these have not been sufficiently examined either and increased security challenges due to integrated peripheral components should not be neglected in terms of a sound cybersecurity. Pump features and handling for patients with T2DM should be as easy as possible, indicating a need for insulin pumps specially designed for patients with T2DM. However, it has to be investigated if pumps designed for T2DM are more effective than other intensified insulin regimens.

Skin Reaction Report Form: Development and Design of a Standardized Report Form for Skin Reactions Due to Medical Devices for Diabetes Management

BACKGROUND

Skin reactions due to medical devices for diabetes management have become a common problem in diabetes technology. There is a varying degree in how detailed skin reactions are described in scientific literature and diabetes practice, and no uniform structured documentation is given. Whereas most articles only describe findings, some others already document final diagnoses, such as contact dermatitis. Furthermore, inconsistent wordings for comparable issues were used.

METHODS

A more detailed and standardized documentation, possibly facilitated by a generally accepted guideline for structured descriptions, of skin reactions could be helpful to enable better differentiations between the described skin reactions. Therefore, a report form to assess skin reactions due to medical devices in diabetes therapy was developed and will be presented in this article.

RESULTS

The one-page report form is divided into four categories and a separate instruction paper. Beside general information the form includes the location, size, severity and duration of skin appearances, the grading of itching, and suspected diagnoses.

CONCLUSION

A consistent use of the form in daily practice and clinical trials could facilitate a fast and standardized documentation and help to evaluate the occurrence and severity of different skin reactions due to medical devices in diabetes management.

Cutaneous Reactions to Continuous Glucose Monitoring and Continuous Subcutaneous Insulin Infusion Devices in Type 1 Diabetes Mellitus

BACKGROUND

Continuous glucose monitoring (CGM) and continuous subcutaneous insulin infusion (CSII) are the standard of care for type 1 diabetes in children. There is little reported on device-related skin complications and treatment options. This study documents cutaneous reactions to CGM and CSII devices in children and young adults with type 1 diabetes.

METHODS

One hundred and twenty-one subjects (3-25 years) with type 1 diabetes and CGM and/or CSII use were recruited over a three-month period from the Naomi Berrie Diabetes Center at Columbia University Irving Medical Center. A five-question survey was completed for each subject detailing demographic data, diabetes management, and device-related skin complications.

RESULTS

Sixty percent of subjects reported skin complications related to CGM and/or CSII use. Terms most frequently used to describe cutaneous reactions were "red," "itchy," "painful," and "rash." Subjects who used both CGM and CSII were more likely to report skin problems than those who used only CSII (odds ratio 2.9, [95% confidence interval: 1.2-6.7]; P = .015). There were no associations between skin complications and sex or race/ethnicity. Twenty-two percent of subjects with adverse skin event(s) discontinued use of a device due to their skin problem. Seven percent were evaluated by a dermatologist. Eighty-one percent used a range of products to treat their symptoms, with variable perceived clinical outcomes.

CONCLUSIONS

Skin complications related to CSII or CGM devices are commonly reported in pediatric patients with type 1 diabetes and may lead to interruption or discontinuation of device use. Future studies are needed to elucidate the causes of these reactions and determine the best methods for prevention.

Further Evidence of Allergic Contact Dermatitis Caused by 2,2'-Methylenebis(6-tert-Butyl-4-Methylphenol) Monoacrylate, a New Sensitizer in the Dexcom G6 Glucose Sensor

BACKGROUND

Since the spring of 2020, we have seen several patients experiencing severe allergic contact dermatitis (ACD) from the Dexcom G6 glucose sensor after the composition of the sensor's adhesive patch had been changed. We have previously reported the finding of a new sensitizer, 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate, in the Dexcom G6 adhesive patch. Three patients with ACD from Dexcom G6 tested positive to this sensitizer. They were also allergic to isobornyl acrylate, a sensitizer present both in Dexcom G6 and in other medical devices previously used by these patients.

OBJECTIVE

The aim of the study was to report the first 4 cases sensitized to 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate without a simultaneous allergy to isobornyl acrylate.

METHODS

The cases were patch tested their own materials, a medical device series, and 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate in several concentrations.

RESULTS

All 4 cases tested positive to 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate at either 1.0% or 1.5% in petrolatum, whereas 20 controls tested negative to both concentrations.

CONCLUSIONS

The cases reported here provide further evidence of 2,2'-methylenebis(6-tert-butyl-4-methylphenol) monoacrylate as a relevant culprit sensitizer in patients with ACD from Dexcom G6. However, the initially used patch test concentration (0.3%) did not suffice to elicit positive reactions in these cases, which is why patch testing at 1.5% is recommended.

Complications associated with a flash glucose monitoring system in diabetic cats

OBJECTIVES

Glucose monitoring is an integral part of diabetes management. Interstitial glucose monitoring systems are increasingly commonly being used for this purpose in dogs and cats, including the use of a flash glucose monitoring system (FGMS). The aim of this study was to describe the incidence and nature of complications associated with the use of an FGMS in diabetic cats.

METHODS

The medical records of all cats that had placement of a 14-day FGMS during a 1-year period were retrospectively reviewed. Data retrieved included the number of days the sensor remained attached and functional, location of sensor placement and complications associated with the sensor. Complications were defined as early sensor detachment, sensor failure prior to the end of the 14-day monitoring period and dermatologic changes at the sensor site. Descriptive statistics were used to characterize the data.

RESULTS

Twenty cats had a total of 33 FGMSs placed. The majority (30/33 [91%]) of sensors were placed over the dorsolateral aspect of the thorax just caudal to the scapula. Twenty (61%) FGMSs remained attached and functional for the full 14 days. The overall incidence of complications associated with FGMS use was 10/33 (30%). The most frequent complication was early sensor detachment (n = 5/33 [15%]). Mild dermatologic changes (erythema, crusts) were noted with 4/33 (12%) FGMSs. More serious complications (skin erosions, abscess formation) were noted with 2/33 (6%) FGMSs.

CONCLUSIONS AND RELEVANCE

The use of the FGMS is relatively safe in cats, although there are potential complications that owners should be made aware of.

A Light Activated Glucagon Trimer with Resistance to Fibrillation

In this work, we have brought the release of glucagon under the control of light. The aim of this approach is to allow minimally invasive, two-hormone control of blood glucose. Glucagon has two major challenges associated with its therapeutic application: (1) the required amount and timing of glucagon release is highly variable, and (2) glucagon rapidly fibrillates in solution, forming aggregates that are inactive. We have developed a light activated glucagon trimer, in which we have joined three glucagon molecules via light cleaved linkers. We demonstrated that this material can be stimulated by light to release glucagon in a predictable manner. In addition, we demonstrated that in the absence of light, the trimer does not form fibrils and thus releases normal unfibrillated glucagon upon irradiation. These qualities make this material ideal for incorporation into a two hormone light-activated artificial pancreas system.

Five-Month Follow-up Shows No Improvement in Dermatological Complications in Children With Type 1 Diabetes Using Continuous Glucose Monitoring Systems and Insulin Pumps

BACKGROUND

A Danish study showed that 90% of the pediatric patients who participated had some time experienced dermatological complications due to treatment with continuous subcutaneous insulin infusion (CSII). This follow-up study describes dermatological complications due to CSII and/or continuous glucose monitoring (CGM) between the two study periods and includes health-related quality of life (HrQoL) measurements.

METHODS

A total of 138 patients (95%) out of 145 patients from the initial study answered an online questionnaire regarding dermatological complications related to CSII and/or CGM, five months later. A second questionnaire (DISABKIDS) regarding HrQoL was sent out to those 138 of which 111 patients completed it. The patients were aged from 2 to 20 years. Descriptive statistics, χ² tests, and univariate and multivariate analyses were used to analyze the data.

RESULTS

In total, 81% of the 138 patients continued to have dermatological complications at follow-up. Itching was the most frequently reported complication. Patients using Enlite reported more dermatological complications than those using Libre. In total, 79% of the patients who used barrier cream in the initial study still had dermatological complications five months later. Age, gender, Body Mass Index (BMI), or HbA1c levels showed no significant association with dermatological complications. Patients who perceived dermatological complications as a greater problem had lower HrQoL scores.

CONCLUSION

Once dermatological complications start to appear, they become chronic, indicating that the treatments currently available are inadequate. Patients perceiving dermatological complications as a greater problem were associated with lower HrQoL. These findings highlight the need for additional preventive studies.

The Influence of Skin Thickness on Flash Glucose Monitoring System Accuracy in Dogs with Diabetes Mellitus

Simple Summary

A flash glucose monitoring system (FGMS) has been validated for use in dogs with diabetes mellitus and diabetic ketoacidosis. It continuously measures the glucose in the interstitial fluid through a small filament (5 mm long) inserted under the skin. Interstitial glucose concentrations are reportedly comparable to whole blood glucose concentrations. However, several factors can influence the performance of interstitial sensors, including the proportion of interstitial fluid in a tissue. The influence of skin thickness on flash glucose monitoring system accuracy has not been investigated in previous studies; therefore, the aim of this study was to evaluate whether FGMS accuracy is affected by skin thickness. On the basis of our results, skin thickness seems to affect FGMS measurements; the mean bias was significantly inversely correlated (p = 0.02; r = −0.6) with the mean skin thickness, and clinical accuracy according to ISO 15197:2013 criteria was observed only in dogs with skin thickness > 5 mm, with 99% of the results falling in zone A + B of the Parkes consensus error grid analysis. In dogs with thin skin (<5 mm), the clinical accuracy was low, and the results should be interpreted with caution.

Abstract

A flash glucose monitoring system (FGMS) has been validated for use in diabetic dogs. However, it is unknown whether skin thickness affects FGMS measurements. The aim of this study was to evaluate whether FGMS accuracy is affected by skin thickness. Fourteen client-owned diabetic dogs on insulin treatment were prospectively enrolled in the study. The dogs were divided into two groups according to their ultrasound-measured skin thickness: dogs with skin thickness < 5 mm (Group 1) and dogs with skin thickness > 5 mm (Group 2). On days 1, 7 and 14, glucose curves were obtained simultaneously using the FGMS and a validated portable blood glucose meter. Paired measurements were used to calculate the mean bias and to determine accuracy according to ISO 15197:2013 criteria. The mean bias was significantly inversely correlated (p = 0.02; r = −0.6) with the mean skin thickness. Clinical accuracy was observed only in Group 2, with 99% of the results in zone A + B of the Parkes consensus error grid analysis. In conclusion, skin thickness seems to affect FGMS measurements, and the device is accurate in dogs with thicker skin (>5 mm); in dogs with thin skin (<5 mm), the clinical accuracy is low, and the results should be interpreted with caution.

Contact dermatitis caused by glucose sensors, insulin pumps, and tapes: Results from a 5-year period

BACKGROUND

The number of patients with contact dermatitis from glucose sensors and insulin infusion sets is increasing. Patch testing is challenging because of a lack of information concerning the constituent materials of medical devices.

OBJECTIVES

To report on products and causes of allergic reactions to glucose sensors or insulin infusion sets over a 5-year period and suggest a short screening series.

METHODS

Analysis of patch test data from consecutive patients suspected of allergic contact dermatitis (ACD) to glucose sensors and/or insulin infusion sets from 2015-2019.

RESULTS

Patient numbers increased from 4 to 15 per year; 30/38 (78.9%) were children. In 29 (76.3%), a diagnosis of allergic/probable ACD was established, mostly due to the tapes of the device or allergens in these tapes (n = 23) followed by allergens in the device housing (n = 10). Isobornyl acrylate, abitol, and colophonium were the most common allergens. Information from manufacturers was often difficult to obtain and, if accessible, inadequate. For this reason, the diagnosis was delayed for more than 1.5 years in 12 (31%) patients.

CONCLUSIONS

The increasing number of patients, mostly children, with ACD from devices used in treatment of type 1 diabetes demonstrates the importance of this problem. Allergies can easily be overlooked, due to the lack of mandatory labeling of the constituent materials of the devices.

Cost of Treating Skin Problems in Patients with Diabetes Who Use Insulin Pumps and/or Glucose Sensors

Background: The use of insulin pump and glucose sensor is advantageous, but unfortunately many experience skin problems. To reduce or overcome skin problems, patients use additional products or change their sets preterm. Therefore, the aim was to investigate costs related to skin problems. Materials and Methods: Two hundred sixty-three patients from four different hospitals in Denmark participated in a cross-sectional survey about skin problems related to insulin pump and/or glucose sensor use. Additional costs aside technology and diabetes treatment were calculated based on adhesives, patches, lotion, and preterm shifts of infusion or sensor sets due to skin problems. Descriptive statistics and linear regression were used. Results: The total costs for all these expenses were 11493.9 U.S. dollars (USD) in 145 pediatric patients and 4843 USD in 118 adult patients. The costs were higher in patients with, than without, skin problems and for skin problems due to the glucose sensor compared with insulin pump. Pediatric patients with eczema and/or wound due to the glucose sensor did cost 154.3 USD more, than patients without these skin problems (P < 0.01). We found a clear dose/response relationship between costs and severity of skin problems, especially in pediatric patients. Conclusions: Our data show that skin problems due to use of insulin pump and/or glucose sensor have significant costs on the Danish welfare system. This leaves an economic incentive for developing more skin-sensitive adhesive for the infusion set and sensors, at least for a certain subgroup of patients.

Contact dermatitis caused by glucose sensors-15 adult patients tested with a medical device patch test series

BACKGROUND

Several cases of allergic contact dermatitis (ACD) to the glucose sensor FreeStyle Libre have been reported. Isobornyl acrylate (IBOA) and N,N-dimethylacrylamide (DMAA) are known culprit allergens.

OBJECTIVES

To evaluate patients with suspected ACD to FreeStyle Libre in a standardized manner, present causative allergens, and assess patient-reported implications.

METHODS

A total of 15 patients with suspected ACD to FreeStyle Libre were patch tested with the Swedish baseline series and a new medical device series. IBOA and DMAA were tested at 0.1% and 0.3% in petrolatum (pet.). Readings were performed on day (D) 3 and D7. Background data, details on skin reactions, and associated implications were assessed using a questionnaire.

RESULTS

Thirteen patients were sensitized to IBOA and four to DMAA. Two positive reactions to IBOA and one to DMAA were seen only at 0.3% concentration on D7. Median duration of sensor use before dermatitis onset was 6 months. Half the number of the patients took precautions in everyday life due to sensor-related skin reactions. Six patients discontinued sensor usage.

CONCLUSIONS

Patients with suspected ACD to glucose sensors should be evaluated with a relevant patch test series containing IBOA and DMAA. Adding the 0.3% pet. concentration is recommended. The reading on D7 is necessary.

Allergic Contact Dermatitis to Components of Wearable Adhesive Health Devices

Consumer use of wearable health devices has been rapidly increasing. Because of prolonged skin contact required, allergic contact dermatitis to components has been reported. Eczematous rash is the most common dermatologic adverse reaction to continuous glucose monitors, and rash from wearable activity trackers is commonly reported by consumers, suggesting that allergic contact dermatitis to wearable health devices may be vastly underreported. Acrylates, methacrylates, and colophonium are the most common allergens found on patch testing. Isobornyl acrylate has been identified as the primary allergen in many cases of allergic contact dermatitis to continuous glucose monitors. These chemicals are found in either the adhesives or the units themselves. Awareness of the presence of these chemicals in wearable devices may provide assistance for diagnostic patch testing in users who have dermatological reactions to the devices and hopefully guide dermatotoxicological evaluation guidance by government and industry.

Cutaneous Complications With Continuous or Flash Glucose Monitoring Use: Systematic Review of Trials and Observational Studies

BACKGROUND

Continuous glucose monitoring (CGM)/flash glucose monitoring (FGM) use in diabetes management is increasing. Cutaneous complications associated with these devices were reported. We conducted a systematic review to provide an overview of cutaneous complications with CGM/FGM use.

METHODS

We identified observational studies and intervention trials that report on cutaneous complications with CGM/FGM use up to January 14, 2019. Studies were identified through Medline, Embase, and PubMed, or with hand searching of the previous publications. Screening was duplicated and data extracted to consider four main themes: incidence rate and severity, participant perspectives of cutaneous complications, potential solutions, and future directions in diabetic technology relevant to reducing cutaneous complications.

RESULTS

A total of 54 eligible studies were identified. The overall event rate of cutaneous complications reported from 19 trials was one event per eight weeks of sensor wear-time of which 1.5% were considered severe. The most common cutaneous complications were wear-related erythema, itching, and induration. Although skin irritations were the most common cause of CGM/FGM discontinuation, most users experienced less pain or discomfort with CGM/FGM than capillary blood glucose testing. Future technological advances may reduce, but not eliminate cutaneous complications.

CONCLUSION

The incidence rate of reported cutaneous complications with CGM/FGM use from the available literature is low, with one event per eight weeks of sensor wear-time. Reported complication severity was also low, leading to low rates of CGM/FGM discontinuation. However, there appear to be discrepancies between reporting in trial and observational data. Greater constancy in reporting is necessary to understand the frequency of this issue.

Benefits and limitations of continuous glucose monitoring in type 1 diabetes

Introduction: Type 1 diabetes (T1D) is a chronic condition characterized by a complete deficiency in insulin production. Optimal management requires constant knowledge of glucose levels for safe and effective insulin administration. Self-monitoring of blood glucose (SMBG) using capillary blood glucose meters is cumbersome and provides limited information to guide management. Continuous glucose monitoring (CGM) technology addresses many of these gaps, but itself has limitations which have prevented people with diabetes and their clinicians from fully embracing this technology. This review covers the benefits and limitations of CGM use, and looks toward future application of this technology in the management of T1D.Areas covered: Impact of CGM on physical and psychosocial outcomes in people with T1D. Barriers to CGM uptake. Integration with insulin pumps and other technologies. Opportunities for future application.Expert opinion: CGM technology will be utilized by the majority of people with T1D and increasing numbers of people with type 2 diabetes due to improved insurance coverage and easier-to-use systems. Its use as part of artificial pancreas systems will add further utility, as it will help to protect from both hypoglycemia and hyperglycemia. People with diabetes will spend more time in range and experience fewer acute and chronic complications.

High Prevalence of Skin Reactions Among Pediatric Patients with Type 1 Diabetes Using New Technologies: The Alarming Role of Colophonium

In the past few years, the increasing use of devices for diabetes treatment, such as continuous subcutaneous insulin infusion pumps, flash glucose monitoring, continuous glucose monitoring systems, sensor-augmented pumps, and automated insulin delivery devices, has resulted in important improvements in disease management. Meanwhile, the longer a patient uses a device, the greater the likelihood of developing a skin reaction. Allergic contact dermatitis is the most frequently described skin side effect caused by adhesive tapes contained in the insulin infusion sets or glucose sensor sets and used to connect these devices to the body. We describe 18 patients, followed up at our Pediatric Diabetes Centre, who experienced dermatological complications due to diabetes device use from January 2018 to December 2018. All the patients were patch tested with allergens from a "standard" series and from a "plastics and glues" series. Patch tests resulted positive in 66.7% of patients. Colophonium was the most frequently isolated sensitizing allergen (41.1% of cases). It is a complex mixture of >100 compounds derived from pine trees. Colophonium is commonly used, in both unmodified and modified forms, as a fast-acting adhesive for industrial, medical, or other commercial uses. Its presence in the adhesive of the insulin sets and glucose sensors was confirmed by the manufacturer of some devices brand. On the basis of our results, we stress the importance of contacting manufacturers for product information. We also highlight that there should be stricter legal restrictions to label medical adhesives, even if only small amounts of colophonium are used.

Evaluation of Isobornyl Acrylate Content in Medical Devices for Diabetes Treatment

Background: Along with increased usage of continuous glucose monitors, flash glucose monitors, and patch pumps by patients with diabetes, the frequency of skin reactions has also increased. Skin irritation and itching can be annoying to users. However, more serious contact allergies to one or more components of the adhesives or plastic material of the housing of the devices can become lifelong. Redness and itchiness are so strong that patients can no longer use a particular system. In August 2017, a major culprit allergen, isobornyl acrylate (IBOA), was identified for these more serious reactions. Objectives: Our objective was to evaluate IBOA content in different medical products. Methods: The plastic material used for the housing of the Freestyle Libre (n = 3), Dexcom G6 (n = 3), and Enlite (n = 4) was analyzed for IBOA content by gas chromatography-mass spectrometry. Adhesives of the different systems were also analyzed. Results: IBOA was found in the housings of Freestyle Libre and Enlite sensor, but not in the Dexcom G6. Conclusions: Patients with an IBOA allergy should consider switching to a medical product without IBOA. Furthermore, removal of IBOA from devices that contact the skin is encouraged.

Documentation of Skin-Related Issues Associated with Continuous Glucose Monitoring Use in the Scientific Literature

Background: The average wear time of continuous glucose monitoring (CGM) systems steadily increased over the last years. Increased wear times are likely achieved by using adhesives with a longer adherence time, which may have a more pronounced effect on the skin than adhesives with shorter adherence time. Methods: In this project, a structured literature search was performed to assess how potential skin-related issues with CGM usage have been reported in scientific literature in the last 5 years. The literature search was performed with four search terms in the PubMed database. Results: In sum, 279 articles were analyzed. Skin-related issues were mentioned in 19.0% of articles (53 out of 279). With respect to articles mentioning skin-related issues, CGM performance or efficacy was the study's main topic of most of these studies, whereas the minority used CGM as "add-on" to assess other objectives. There was a varying degree in how detailed skin-related issues were described and no uniform structured documentation was given. While some articles only described findings, other articles already documented final diagnoses, such as contact dermatitis. Furthermore, inconsistent wordings for comparable issues were used. The most frequent issues were pain, itching, erythema, bleeding, bruising, and allergic reactions. Conclusion: To draw possible conclusions about the occurrence of skin-related issues during CGM use, more reports about skin-related issues in scientific literature are needed. A more detailed and uniformly structured documentation, possibly facilitated by a generally accepted guideline for structured descriptions, of skin-related issues could be helpful to enable clear differentiations between the described skin reactions.

Skin Problems Due to Treatment with Technology Are Associated with Increased Disease Burden Among Adults with Type 1 Diabetes

BACKGROUND

In a 4-month follow-up survey, we examined whether treatment with continuous subcutaneous insulin infusion (CSII) and/or continuous glucose monitoring (CGM) in adults with type 1 diabetes was associated with sustained skin problems and whether skin problems were associated with diabetes-related emotional distress.

RESEARCH DESIGN AND METHODS

A total of 111 adult patients completed a follow-up questionnaire concerning skin problems as a result of CSII and/or CGM use. The questionnaire included a patient-reported outcome measure, the Problem Areas in Diabetes (PAID) scale.

RESULTS

Current visible skin problems caused by CSII or CGM use were reported by 51 (46.0%) participants, in 34 (66.7%) of whom skin problems had been reported more than 4 months earlier. Seventy-two (64.9%) participants reported skin problems as a result of CSII use, whereas 38 (74.5%) reported skin problems owing to CGM use at some time. Itching was the most prevalent complaint. CSII-related itching was associated with a mean PAID score >20 (P = 0.01), and patients with more than one skin problem had an increased PAID score compared with those with one or no skin problems (P = 0.006).

CONCLUSIONS

More than half patients treated with CSII, CGM, or both had experienced skin problems during 4 months of follow-up that were associated with increased diabetes burden. Skin problems represent a persistent health issue affecting diabetes-specific emotional distress.