Closed-Loop Insulin Therapy Improves Glycemic Control in Adolescents and Young Adults: Outcomes from the International Diabetes Closed-Loop Trial

Closed-loop systems: recent advancements and lived experiences

INTRODUCTION

Hybrid closed loop systems are now commercially available for people with type 1 diabetes and are increasingly being adopted into clinical practice. Real-world data reflect both the glycemic and quality of life benefits reported in trials.

AREAS COVERED

In this review, we summarize the key clinical efficacy and safety evidence for hybrid closed-loop systems, and the lived experience of users with type 1 diabetes across different age groups and during pregnancy. We comment on recent and emerging advancements addressing performance limitations and user experience, as well as the use of closed-loop systems in other types of diabetes.

EXPERT OPINION

Emerging technological developments in closed-loop systems focus on improving performance and increasing automation to further optimize glycemic outcomes and improve quality of life for users. Workforce developments are now urgently required to ensure widespread equitable access to this life-changing technology. Future applications of closed-loop technology are expected to expand into other types of diabetes including type 2 diabetes.

Psychological and Clinical Challenges in the Management of Type 1 Diabetes during Adolescence: A Narrative Review

Adolescence, a critical period of physical and psychological development, presents unique challenges in type 1 diabetes (T1D) management due to endocrinological changes, reduced therapeutic adherence, and elevated susceptibility to psychological issues such as depression, anxiety, and eating disorders. This narrative review explores the impact of psychological and behavioral factors on glycemic control in adolescents with T1D. We examine the prevalence and influence of mental health disorders, lifestyle factors, harmful behaviors, and social dynamics on diabetes management and glycemic outcomes. Strategies for improving metabolic control are also reviewed, including cognitive behavioral therapy, technological devices, and educational interventions. The importance of tailored psychological support, family involvement, and targeted interventions to improve adherence to treatment and glycemic control in adolescents with T1D should be emphasized.

Simplified Meal Management in Adults Using an Advanced Hybrid Closed-Loop System

Background: The advanced hybrid closed-loop (AHCL) algorithm combines automated basal rates and corrections yet requires meal announcement for optimal performance, which poses a challenge for some. We aimed to compare glucose control in adults with type 1 diabetes (T1D) using the MiniMedTM 780G AHCL system, utilizing simplified meal announcement versus precise carbohydrate (CHO) counting. Methods: In a study involving 14 adults with T1D, we evaluated glycemic control during a 13-week "precise phase," followed by two 3- to 4-week simplified meal announcement phases: "fixed one-step" (preset of one personalized fixed CHO amount) and "multistep" (entry of multiples of one, two, or three of these presets depending on meal size estimate). Results: The mean age was 45.7 ± 12.4, and 10 participants were male (71%). Mean baseline HbA1c was 6.8% ± 1.2% and time in range (TIR) was 67.5% ± 16.7%. Comparing the fixed one-step to the precise study phase, TIR was similar (75.4 ± 13% vs. 77.7 ± 9%, P = 0.12), and glucose management indicator (GMI) was slightly higher (6.8 ± 0.4 vs. 6.6 ± 0, P = 0.01). Furthermore, there was less level 1 and 2 hypoglycemia (1.6 ± 1% vs. 2.8 ± 2%, P = 0.03 and 0.3 ± 5% vs. 0.65 ± 1%, P = 0.08) but slightly more level 1 and 2 hyperglycemia (17.1 ± 8% vs. 15.0 ± 7%, P = 0.05 and 5.5 ± 5% vs. 3.6 ± 3%, P = 0.04). When comparing the multistep with the precise phase, GMI was identical (6.6%) and TIR superior (80.5 ± 10% vs. 77.7 ± 9%, P = 0.02). Additionally, there was less level 1 hypoglycemia (1.9 ± 1% vs. 2.8 ± 2%, P = 0.01) and a trend for less level 2 hypoglycemia (0.4 ± 0.7% vs. 0.65 ± 1%, P = 0.08). Conclusions: A simplified meal announcement strategy for adults using the MiniMed 780G system, relying on three increments of a fixed one-step CHO amount, may offer a way to improve glycemic control and ease self-care. For patients with more limitations, using one fixed one-step CHO amount could be a safe alternative to meeting most consensus glycemic targets.

Three months use of Hybrid Closed Loop Systems improves glycated hemoglobin levels in adolescents and children with type 1 diabetes: A meta-analysis

BACKGROUND

Longer outpatient studies have demonstrated that hybrid closed loop (HCL) use has led to a concomitant reduction in glycated hemoglobin(HbA1c) by 0.3%-0.7%. However, reports have also indicated that HbA1c levels are not declined in the long-term use of HCL. Therefore, we wonder that 3 months use of HCL could improve glycated hemoglobin levels in adolescents and children with T1D.

METHODS

Relevant studies were searched electronically in the Cochrane Library, PubMed, and Embase utilizing the key words "Pediatrics or Child or Adolescent", "Insulin Infusion Systems" and "Diabetes Mellitus" from inception to 17th March 2024 to evaluate the performance of HCL on HbA1c in adolescents, and children with T1D.

RESULTS

Nine studies involving 927 patients were identified. Three months use of HCL show a beneficial effect on HbA1c management (p <0.001) as compared to standard of care in adolescents and children with T1D, without evidence of heterogeneity between articles (I2 = 40%, p = 0.10). HCL did significantly increase the overall average percentage of hypoglycemic time between 70 and 180 mg/dL (TIR) (p <0.001; I2 = 51%). HCL did not show a beneficial effect on hypoglycemic time <70 mg/dL and <54 mg/dL (p >0.05). The overall percentage of hyperglycemic time was significantly decreased in HCL group compared to the control group when it was defined as >180 mg/dL (p <0.001; I2 = 83%), >250 mg/dL (p = 0.007, I2 = 86%) and >300 mg/dL (p = 0.005; I2 = 76%). The mean glucose level was significantly decreased by HCL (p <0.001; I2 = 58%), however, no significant difference was found in coefficient of variation of sensor glucose (p = 0.82; I2 = 71%) and daily insulin dose (p = 0.94; I2 <0.001) between the HCL group and the control group.

CONCLUSIONS

HCL had a beneficial effect on HbA1c management and TIR without increased hypoglycemic time as compared to standard of care in adolescents and children with T1D when therapy duration of HCL was not less than three months.

TRIAL NUMBER AND REGISTRY URL

CRD42022367493; https://www.crd.york.ac.uk/PROSPERO, Principal investigator: Zhen-feng Zhou, Date of registration: October 30, 2022.

Artificial intelligence for diabetes care: current and future prospects

Artificial intelligence (AI) use in diabetes care is increasingly being explored to personalise care for people with diabetes and adapt treatments for complex presentations. However, the rapid advancement of AI also introduces challenges such as potential biases, ethical considerations, and implementation challenges in ensuring that its deployment is equitable. Ensuring inclusive and ethical developments of AI technology can empower both health-care providers and people with diabetes in managing the condition. In this Review, we explore and summarise the current and future prospects of AI across the diabetes care continuum, from enhancing screening and diagnosis to optimising treatment and predicting and managing complications.

The psychosocial outcomes of advanced hybrid closed-loop system in children and adolescents with type 1 diabetes

The study was carried out to determine the psychosocial outcomes of advanced hybrid closed-loop (AHCL) systems in children and adolescents with type 1 diabetes (T1D). Single-center and cohort study with a duration 6 months consisted of 60 children and adolescents with T1D. Standard clinical procedures, including both glycemic indicators, e.g., sensor-measured time within the 70-180 mg/dL range and glycated hemoglobin (HbA1c) levels, and psychosocial metrics were used for data collection. The psychosocial metrics included the Pediatric Quality of Life Inventory (PedsQL) 3.0 Diabetes Module for both children (8-12 years) and parents; the Quality of Life for Youth scale for adolescents (13-18 years); the Strengths and Difficulties Questionnaire (SDQ); the Hypoglycemia Fear Survey for Children (HFS-C); the Revised Child Anxiety and Depression Scale (R-CADS); and AHCLS-specific DTSEQ satisfaction and expectation survey. These metrics were evaluated at the baseline and after 6 months of AHCL use. Of the 60 children and adolescents with T1D for whom the AHCL system was utilized, 41 of them, 23 female and 18 male, completed the surveys. The mean age of the 41 children and adolescents was 12.5 ± 3.2 (min. 6.7, max. 18) years. The time spent within the target glycemic range, i.e., time-in-range (TIR), improved from 76.9 ± 9% at the baseline to 80.4 ± 5% after 6 months of AHCL system use (p = 0.03). Additionally, HbA1c levels reduced from 7.1% ± 0.7% at the baseline to 6.8% ± 0.8% after 6 months of AHCL system use (p = 0.03). The most notable decline in HbA1c was observed in participants with higher baseline HbA1c levels. All patients' HFS-C and AHCL system-specific DTSEQ satisfaction and expectation survey scores were within the normal range at the baseline and remained unchanged during the follow-up period. No significant difference was found in the R-CADS scores of children and adolescents between baseline and after 6 months of AHCL system use. However, there was a significant decrease in the R-CADS scores of the parents. Patients' PedsQL scores were high both at the baseline and after 6 months. The SDQ scores were high at baseline, and there was no significant improvement at the end of 6 months.  Conclusion: This is the first study to investigate in detail the psychosocial outcomes of AHCL system use in T1D patients and their parents. Although state-of-the-art technologies such as AHCL provide patients with more flexibility in their daily lives and information about glucose fluctuations, the AHCL resulted in a TIR above the recommended target range without a change in QOL, HFS-C, SDQ, and R-CADS scores. The scores obtained from the R-CADS conducted by the parents of the children indicated that the use of pumps caused a psychological improvement in the long term, with a significant decrease in the R-CADS scores of the children and adolescents with T1D. What is Known: • Previous studies focused on clinical outcomes of AHCL systems in pediatric T1D patients, showing glycemic control improvements. • Limited attention given to psychosocial outcomes of AHCL systems in children and adolescents with T1D. • Crucial psychosocial factors like quality of life, emotional well-being, and fear of hypoglycemia underexplored in AHCL system context. What is New: • First study to comprehensively examine psychosocial outcomes of AHCL systems in pediatric T1D patients. • Study's robust methodology sets new standard for diabetes technology research and its impact on qualiy of life.

Increase Access, Reduce Disparities: Recommendations for Modifying Medicaid CGM Coverage Eligibility Criteria

Numerous studies have demonstrated the clinical value of continuous glucose monitoring (CGM) in type 1 diabetes (T1D) and type 2 diabetes (T2D) populations. However, the eligibility criteria for CGM coverage required by the Centers for Medicare & Medicaid Services (CMS) ignore the conclusive evidence that supports CGM use in various diabetes populations that are currently deemed ineligible. In an earlier article, we discussed the limitations and inconsistencies of the agency's CGM eligibility criteria relative to current scientific evidence and proposed practice solutions to address this issue and improve the safety and care of Medicare beneficiaries with diabetes. Although Medicaid is administered through CMS, there is no consistent Medicaid policy for CGM coverage in the United States. This article presents a rationale for modifying and standardizing Medicaid CGM coverage eligibility across the United States.

Automated Insulin Delivery Systems in Pediatric Type 1 Diabetes: A Narrative Review

This narrative review assesses the use of automated insulin delivery (AID) systems in managing persons with type 1 diabetes (PWD) in the pediatric population. It outlines current research, the differences between various AID systems currently on the market and the challenges faced, and discusses potential opportunities for further advancements within this field. Furthermore, the narrative review includes various expert opinions on how different AID systems can be used in the event of challenges with rapidly changing insulin requirements. These include examples, such as during illness with increased or decreased insulin requirements and during physical activity of different intensities or durations. Case descriptions give examples of scenarios with added user-initiated actions depending on the type of AID system used. The authors also discuss how another AID system could have been used in these situations.

A Real-World Prospective Study of the Effectiveness and Safety of Automated Insulin Delivery Compared With Other Modalities of Type 1 Diabetes Treatment During Ramadan Intermittent Fasting

OBJECTIVE

To compare the fasting experience and glycemic control during Ramadan among people with type 1 diabetes (PWT1D) who use automated insulin delivery (AID) versus other modalities of treatment.

RESEARCH DESIGN AND METHODS

A total of 294 PWT1D who attempted fasting during Ramadan in 2022 were categorized on the basis of treatment modality into one of five groups: 1) AID (n = 62); 2) conventional pump + continuous glucose monitoring (CGM; n = 37); 3) pump + self-monitoring of blood glucose (SMBG; n = 8); 4) multiple daily injections (MDI) + CGM (n = 155); and 5) MDI + SMBG (n = 32). Predictors of fasting most days of Ramadan (i.e., breaking fast ≤2 days because of diabetes) were analyzed using uni- and multivariable logistic regression.

RESULTS

The median numbers of days when fasting was broken because of diabetes were 2, 5, 3, 3.5, and 2.5 for AID, conventional pump + CGM, MDI + CGM, pump + SMBG, and MDI + SMBG users, respectively (P = 0.047). Users of AID had a significantly greater time in range (TIR) and lower glycemia risk index, time below range, and time above range compared with users of conventional pumps and MDI (both P < 0.05). Likewise, 53% of AID users attained the double target of 1) breaking fast ≤2 days because of diabetes and 2) maintaining TIR ≥70% during Ramadan compared with only 3% of the conventional pump users and 44% of the MDI + CGM users (both P < 0.05). Compared with MDI + CGM users, AID users were twice as likely to complete fasting most days of Ramadan.

CONCLUSIONS

Use of AID is associated with the highest rates of fasting and best glycemic control during Ramadan fasting.

Twelve-Month Follow-up from a Randomized Controlled Trial of Simplified Meal Announcement Versus Precise Carbohydrate Counting in Adolescents with Type 1 Diabetes Using the MiniMed™ 780G Advanced Hybrid Closed-Loop System

Background and Aims: Carbohydrate counting is a well-established tool for self-management of type 1 diabetes (T1D) and can improve glycemic control and potentially reduce long-term complication risk. However, it can also be burdensome, error-prone, and complicated for the patient. A randomized controlled trial was conducted to investigate glycemic control with carbohydrate counting ("flex") versus simplified meal announcement ("fix") in adolescents with T1D using the MiniMed™ 780G system. The present study reports follow-up data to 12 months. Methods: Adolescents with T1D were randomly assigned 1:1 to use the MiniMed™ 780G system alongside the flex versus fix approaches. Participants were followed for 12 months with outcomes recorded at 3, 6, 9, and 12 months. The primary endpoint was the difference in time-in-range (TIR), and secondary endpoints included glycated hemoglobin (HbA1c) and other glucose and insulin metrics. Results: At 12 months, TIR (proportion of time with sensor glucose 70-180 mg/dL) was significantly lower in the fix versus flex group (72.9% vs. 80.1%, respectively; P = 0.001). There was no significant difference in HbA1c between the fix (6.8% ± 0.5%) and flex groups (6.5% ± 0.5%) at 12 months (P = 0.092), and mean HbA1c was below 7% at all time points in both arms. Conclusions: Glycemic control with simplified meal announcement was maintained over 12 months. On average, the international consensus targets were met in both arms for all time points. The simplified approach represents a viable alternative to carbohydrate counting, particularly in people who find the latter burdensome; however, carbohydrate counting resulted in superior TIR. This study is registered with ClinicalTrials.gov, number NCT05069727.

Updating Our Understanding of Device Use in Adolescents: Demographic Factors and Preferences in a Group of Adolescents With Type 1 Diabetes

PURPOSE

The purpose of the study was to identify demographic factors associated with continuous glucose monitor (CGM) and automated insulin delivery (AID) use among adolescents with type 1 diabetes and to explore why adolescents may start and stop using CGMs.

METHODS

Adolescents ages 13 to 17 and caregivers completed demographic and device use surveys at baseline for a randomized trial of a behavioral intervention conducted at 2 large medical centers in the United States. This study is a secondary analysis of the demographic and device use data.

RESULTS

The study sample consisted of 198 participants ages 13 to 17, 58% female, 57% non-Hispanic White, 24% non-Hispanic Black, 19% other race and ethnicity. Eighty-one percent of adolescents were using CGM, and 10% reported past use. Forty percent of adolescents reported taking CGM breaks ranging hours to weeks. Higher CGM use was found in higher income families (>$90 000). No difference in CGM use was observed related to race or ethnicity.

CONCLUSIONS

These findings suggest CGM use is increasing even among adolescents, a group that historically has had the lowest device use. However, adolescents often take CGM breaks, and it is not clear if they adjust their diabetes management during these times. It is important for providers to understand when and why patients may take CGM breaks so education about diabetes management while off CGM can occur. Further investigation into management during CGM breaks, particularly in those using an AID system, is needed.

Patient reported outcomes (PROs) and user experiences of young children with type 1 diabetes using t:slim X2 insulin pump with control-IQ technology

OBJECTIVE

Examine patient-reported outcomes (PROs) after the use of t:slim X2 insulin pump with Control-IQ technology (CIQ) in young children with type 1 diabetes.

METHODS

Children with type 1 diabetes, ages 2 to < 6 years (n = 102), were randomly assigned 2:1 to either CIQ or standard care (SC) with pump or multiple daily injections (MDI) plus continuous glucose monitoring (CGM) for 13 weeks. Both groups were offered to use CIQ for an additional 13 weeks after the randomized control trial's (RCT) completion. Guardians completed PRO questionnaires at baseline, 13-, and 26-weeks examining hypoglycemia concerns, quality of life, parenting stress, and sleep. At 26 weeks, 28 families participated in user-experience interviews. Repeated measures analyses compared PRO scores between systems used.

RESULT

Comparing CIQ vs SC, responses on all 5 PRO surveys favored the CIQ group, showing that CIQ was superior to SC at 26 weeks (p values < 0.05). User-experience interviews indicated significant benefits in optimized glycemic control overall and nighttime control (28 of 28 families endorsed). All but 2/28 families noted substantial reduction in management burden resulting in less mental burden and all but 4 stated that they wanted their children to continue using CIQ.

CONCLUSIONS

Families utilizing CIQ experienced glycemic benefits coupled with substantial benefits in PROs, documented in surveys and interviews. Families utilizing CIQ had reduced hypoglycemia concerns and parenting stress, and improved quality of life and sleep. These findings demonstrate the benefit of CIQ in young children with type 1 diabetes that goes beyond documented glycemic benefit.

9. Pharmacologic Approaches to Glycemic Treatment: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Real-world glycaemic outcomes in patients with type 1 diabetes using glucose sensors-Experience from a single centre in Dublin

AIMS

To evaluate changes in glycated haemoglobin (HbA1 c) and sensor-based glycaemic metrics after glucose sensor commencement in adults with T1D.

METHODS

We performed a retrospective observational single-centre study on HbA1 c, and sensor-based glycaemic data following the initiation of continuous glucose monitoring (CGM) in adults with T1D (n = 209).

RESULTS

We observed an overall improvement in HbA1 c from 66 (59-78) mmol/mol [8.2 (7.5-9.3)%] pre-sensor to 60 (53-71) mmol/mol [7.6 (7.0-8.6)%] on-sensor (p < .001). The pre-sensor HbA1 c improved from 66 (57-74) mmol/mol [8.2 (7.4-8.9)%] to 62 (54-71) mmol/mol [7.8 (7.1-8.7)%] within the first year of usage to 60 (53-69) mmol/mol [7.6 (7.0-8.4)%] in the following year (n = 121, p < .001). RT-CGM-user had a significant improvement in HbA1 c (Dexcom G6; p < .001, r = 0.33 and Guardian 3; p < .001, r = 0.59) while a non-significant reduction was seen in FGM-user (Libre 1; p = .279). Both MDI (p < .001, r = 0.33) and CSII group (p < .001, r = 0.41) also demonstrated significant HbA1 c improvement. Patients with pre-sensor HbA1 c of ≥64 mmol/mol [8.0%] (n = 125), had attenuation of pre-sensor HbA1 c from 75 (68-83) mmol/mol [9.0 (8.4-9.7)%] to 67 (59-75) mmol/mol [8.2 (7.6-9.0)%] (p < .001, r = 0.44). Altogether, 25.8% of patients achieved the recommended HbA1 c goal of ≤53 mmol/mol and 16.7% attained the recommended ≥70% time in range (3.9-10.0 mmol/L).

CONCLUSIONS

Our study demonstrated that minimally invasive glucose sensor technology in adults with T1D is associated with improvement in glycaemic outcomes. However, despite significant improvements in HbA1 c, achieving the recommended goals for all glycaemic metrics remained challenging.

14. Children and Adolescents: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

The Hybrid Closed-Loop System Tandem t:slim X2™ with Control-IQ Technology: Expert Recommendations for Better Management and Optimization

Technological advances in the management of diabetes, especially type 1 diabetes (T1D), have played a main role in significantly improving glycemic control of these patients in recent years. Undoubtedly, the most important advance has been the commercialization of hybrid closed-loop systems (HCL). Their effectiveness places them in the different guidelines from scientific societies as the gold standard for the treatment of people with T1D. However, obtaining the maximum performance from these systems requires a degree of expertise from the professionals who care for these patients. Specifically, the Tandem X2:slim with Control-IQ technology system, due to its features and configuration options and adjustments, allows T1D patients to better adapt the management of diabetes to multiple circumstances in their day-to-day life. It is necessary, however, to follow a systematic process to start the system and also for the subsequent follow-up, which allows its optimization in the shortest possible time. This expert recommendation reviews the main features of this HCL system, suggesting how to implement it and optimize its use after gaining experience treating many patients.

Automated Insulin Delivery Systems in Children and Adolescents With Type 1 Diabetes: A Systematic Review and Meta-analysis of Outpatient Randomized Controlled Trials

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.

Real-world outcomes of continuous glucose monitoring in adults with diabetes mellitus attending an Irish tertiary hospital

BACKGROUNDS AND AIMS

The American Diabetes Association/European Association for the Study of Diabetes recently recommend the preferential use of continuous glucose monitoring(CGM) over self-monitoring of blood glucose for the management of type 1 diabetes (T1DM). For most adults with T1DM, the recommended target time in range is > 70% with < 4% time below range. In Ireland, CGM use has become increasingly popular since 2021. We aimed to audit adult CGM use and analyse CGM metrics in our cohort of adults with diabetes attending a tertiary diabetes centre.

METHODS

People with diabetes who were using DEXCOM G6 CGM devices, and sharing their data with the healthcare team on the DEXCOM CLARITY for healthcare professionals platform were included in the audit. Clinical information, glycated haemoglobin (HbA1c) and CGM metrics were gathered retrospectively from medical records and the DEXCOM CLARITY platform.

RESULTS

Data were available for 119 CGM users, 96.9% with T1DM, median age 36 years (IQR = 20) and median diabetes duration 17 years (IQR = 20). Fifty-three per cent of the cohort was male. Mean time in range was 56.2% (SD = 19.2) and mean time below range was 2.3% (SD = 2.6). Mean HbA1c in CGM users was 56.7 mmol/mol (SD = 13.1). This represented a decrease of 6.7 mmol/mol compared to the last HbA1c measurements available pre-commencement of CGM (p ≤ 0.0001, CI 4.4-8.9). The percentage of people in this cohort with a HbA1c < 53 mmol/mol was 40.6% (n = 39/96), compared to 17.5% (n = 18/103) pre-commencement of CGM.

CONCLUSIONS

Our study highlights the challenges in optimising the use of CGM. Our team aims to focus on providing additional education to CGM users, more frequent touch-base virtual reviews and increasing access to hybrid closed-loop insulin pump therapy.

Glucose Monitoring Metrics in Individuals With Type 1 Diabetes Using Different Treatment Modalities: A Real-World Observational Study

OBJECTIVE

This study aimed to investigate the association between continuous glucose monitoring (CGM)-derived glycemic metrics and different insulin treatment modalities using real-world data.

RESEARCH DESIGN AND METHODS

A cross-sectional study at Steno Diabetes Center Copenhagen, Denmark, included individuals with type 1 diabetes using CGM. Data from September 2021 to August 2022 were analyzed if CGM was used for at least 20% of a 4-week period. Individuals were divided into four groups: multiple daily injection (MDI) therapy, insulin pumps with unintegrated CGM (SUP), sensor-augmented pumps with low glucose management (SAP), and automated insulin delivery (AID). The MDI and SUP groups were further subdivided based on CGM alarm features. The primary outcome was percentage of time in range (TIR: 3.9-10.0 mmol/L) for each treatment group. Secondary outcomes included other glucose metrics and HbA1c.

RESULTS

Out of 6,314 attendees, 3,184 CGM users were included in the analysis. Among them, 1,622 used MDI, 504 used SUP, 354 used SAP, and 561 used AID. Median TIR was 54.0% for MDI, 54.9% for SUP, 62,9% for SAP, and 72,1% for AID users. The proportion of individuals achieving all recommended glycemic targets (TIR >70%, time above range <25%, and time below range <4%) was significantly higher in SAP (odds ratio [OR] 2.4 [95% CI 1.6-3.5]) and AID (OR 9.4 [95% CI 6.7-13.0]) compared with MDI without alarm features.

CONCLUSIONS

AID appears superior to other insulin treatment modalities with CGM. Although bias may be present because of indications, AID should be considered the preferred choice for insulin pump therapy.

Safety and Glycemic Outcomes During the MiniMedTM Advanced Hybrid Closed-Loop System Pivotal Trial in Children and Adolescents with Type 1 Diabetes

Background: During MiniMed™ advanced hybrid closed-loop (AHCL) use by adolescents and adults in the pivotal trial, glycated hemoglobin (A1C) was significantly reduced, time spent in range (TIR) was significantly increased, and there were no episodes of severe hypoglycemia or diabetic ketoacidosis (DKA). The present study investigated the same primary safety and effectiveness endpoints during AHCL use by a younger cohort with type 1 diabetes (T1D). Methods: An intention-to-treat population (N = 160, aged 7-17 years) with T1D was enrolled in a single-arm study at 13 investigational centers. There was a run-in period (∼25 days) using HCL or sensor-augmented pump with/without predictive low-glucose management, followed by a 3-month study period with AHCL activated at two glucose targets (GTs; 100 and 120 mg/dL) for ∼45 days each. The mean ± standard deviation values of A1C, TIR, mean sensor glucose (SG), coefficient of variation (CV) of SG, time at SG ranges, and insulin delivered between run-in and study were analyzed (Wilcoxon signed-rank test or t-test). Results: Compared with baseline, AHCL use was associated with reduced A1C from 7.9 ± 0.9% (N = 160) to 7.4 ± 0.7% (N = 136) (P < 0.001) and overall TIR increased from the run-in 59.4 ± 11.8% to 70.3 ± 6.5% by end of study (P < 0.001), without change in CV, time spent below range (TBR) <70 mg/dL, or TBR <54 mg/dL. Relative to longer active insulin time (AIT) settings (N = 52), an AIT of 2 h (N = 19) with the 100 mg/dL GT increased mean TIR to 73.4%, reduced TBR <70 mg/dL from 3.5% to 2.2%, and reduced time spent above range (TAR) >180 mg/dL from 28.7% to 24.4%. During AHCL use, there was no severe hypoglycemia or DKA. Conclusions: In children and adolescents with T1D, MiniMed AHCL system use was safe, A1C was lower, and TIR was increased. The lowest GT and shortest AIT were associated with the highest TIR and lowest TBR and TAR, all of which met consensus-recommended glycemic targets. ClinicalTrials.gov ID: NCT03959423.

Combining Glucose Monitoring and Insulin Infusion in an Integrated Device: A Narrative Review of Challenges and Proposed Solutions

The introduction of automated insulin delivery (AID) systems has enabled increasing numbers of individuals with type 1 diabetes (T1D) to improve their glycemic control largely. However, use of AID systems is limited due to their complexity and costs associated. The user must wear both a continuously monitoring glucose system and an insulin infusion pump. The glucose sensor and the insulin catheter must be inserted at two different body sites using different insertion devices. In addition, the user must pair and manage the different systems. These communicate with the AID software implemented on the pump or on a third device such as a dedicated display device or smart phone application. These components might be developed and commercialized by different manufacturers, which in turn can cause difficulties for patients seeking technical support. A possible solution to these challenges would be to integrate the glucose sensor and insulin catheter into a single device. This would allow the glucose sensor and insulin catheter to be inserted simultaneously, eliminating the need for pairing, and simplifying system management. In recent years, different technologies have been developed and evaluated in clinical investigations that combine the glucose sensor and the insulin catheter in one platform. The consistent finding of all these studies is that integration has no adverse effect on insulin infusion and glucose measurements provided that certain conditions are met. In this review, we discuss the perceived challenges of such an approach and discuss possible solutions that have been proposed.

Blood glucose monitoring devices: current considerations

Measuring blood glucose concentrations via capillary (fingerprick) blood glucose monitoring or continuous (interstitial) glucose monitoring is an important aspect of management for many people with diabetes. Blood glucose monitoring informs patient self-management strategies, which can improve the patient's engagement in their own care and reduce barriers to achieving recommended blood glucose targets. Blood glucose monitoring also informs clinician-guided management plans. Compared to capillary blood glucose monitoring, continuous glucose monitoring in people using insulin significantly improves glycaemic metrics and is associated with improved patient-reported outcomes. Even with good glycaemic metrics, patients using continuous glucose monitoring should still have access to capillary blood glucose monitoring for correlation of hypoglycaemic readings when accuracy may be compromised or if there is a malfunction with the continuous blood glucose monitor.

New therapies towards a better glycemic control in youths with type 1 diabetes

Type 1 diabetes (T1D) is the most frequent form of diabetes in pediatric age, affecting more than 1.5 million people younger than age 20 years worldwide. Early and intensive control of diabetes provides continued protection against both microvascular and macrovascular complications, enhances growth, and ensures normal pubertal development. In the absence of definitive reversal therapy for this disease, achieving and maintaining the recommended glycemic targets is crucial. In the last 30 years, enormous progress has been made using technology to better treat T1D. In spite of this progress, the majority of children, adolescents and young adults do not reach the recommended targets for glycemic control and assume a considerable burden each day. The development of promising new therapeutic advances, such as more physiologic insulin analogues, pioneering diabetes technology including continuous glucose monitoring and closed loop systems as well as new adjuvant drugs, anticipate a new paradigm in T1D management over the next few years. This review presents insights into current management of T1D in youths.

Glycemic Outcomes During Early Use of the MiniMed™ 780G Advanced Hybrid Closed-Loop System with Guardian™ 4 Sensor

Background: Safety and significant improvement in overall glycated hemoglobin (A1C) and percentage of time spent in (TIR), below (TBR), and above (TAR) glucose range were demonstrated in the pivotal trial of adolescents and adults using the MiniMed™ advanced hybrid closed-loop (AHCL) system with the adjunctive, calibration-required Guardian™ Sensor 3. The present study evaluated early outcomes of continued access study (CAS) participants who transitioned from the pivotal trial investigational system to the approved MiniMed™ 780G system with the non-adjunctive, calibration-free Guardian™ 4 Sensor (MM780G+G4S). Study data were presented alongside those of real-world MM780G+G4S users from Europe, the Middle East, and Africa. Methods: The CAS participants (N = 109, aged 7-17 years and N = 67, aged >17 years) used the MM780G+G4S for 3 months and data of real-world MM780G+G4S system users (N = 10,204 aged ≤15 years and N = 26,099 aged >15 years) were uploaded from September 22, 2021 to December 02, 2022. At least 10 days of real-world continuous glucose monitoring (CGM) data were required for analyses. Glycemic metrics, delivered insulin and system use/interactions underwent descriptive analyses. Results: Time in AHCL and CGM use were >90% for all groups. AHCL exits averaged 0.1/day and there were few blood glucose measurements (BGMs) (0.8/day-1.0/day). Adults in both cohorts met most consensus recommendations for glycemic targets. Pediatric groups met recommendations for %TIR and %TBR, although not those for mean glucose variability and %TAR, possibly due to low use of recommended glucose target (100 mg/dL) and active insulin time (2 h) settings (28.4% in the CAS cohort and 9.4% in the real-world cohort). The CAS pediatric and adult A1C were 7.2% ± 0.7% and 6.8% ± 0.7%, respectively, and there were no serious adverse events. Conclusions: Early clinical use of the MM780G+G4S was safe and involved minimal BGMs and AHCL exits. Consistent with real-world pediatric and adult use, outcomes were associated with achievement of recommended glycemic targets. Clinical Trial Registration number: NCT03959423.

Intelligent Insulin vs. Artificial Intelligence for Type 1 Diabetes: Will the Real Winner Please Stand Up?

Research in the treatment of type 1 diabetes has been addressed into two main areas: the development of "intelligent insulins" capable of auto-regulating their own levels according to glucose concentrations, or the exploitation of artificial intelligence (AI) and its learning capacity, to provide decision support systems to improve automated insulin therapy. This review aims to provide a synthetic overview of the current state of these two research areas, providing an outline of the latest development in the search for "intelligent insulins," and the results of new and promising advances in the use of artificial intelligence to regulate automated insulin infusion and glucose control. The future of insulin treatment in type 1 diabetes appears promising with AI, with research nearly reaching the possibility of finally having a "closed-loop" artificial pancreas.

Efficacy and safety of closed-loop control system for type one diabetes in adolescents a meta analysis

This meta-analysis compares the efficacy and safety of Closed-Loop Control (CLC) to Sensor-Augmented Insulin Pump (SAP) for adolescent patients with Type 1 Diabetes Mellitus (T1DM). Eleven randomized-controlled trials were included with a total of 570 patients, from a total of 869 articles found adhering to PRISMA guidelines. The efficacy of the therapies were evaluated from the day, night and during physical activities monitoring of the of the mean blood glucose (BG), Time In Range (TIR), and Standard Deviation (SD) of the glucose variability. The safety measure of the therapies, was assessed from the day and night recording of the hypoglycemic and hyperglycemic events occurred. Pooled results of comparison of mean BG values for day, night and physical activities, - 4.33 [- 6.70, - 1.96] (P = 0.0003), - 16.61 [- 31.68, - 1.54] (P = 0.03) and - 8.27 [- 19.52, 2.99] (P = 0.15). The monitoring for day, night and physical activities for TIR - 13.18 [- 19.18, - 7.17] (P < 0.0001), - 15.36 [- 26.81, - 3.92] (P = 0.009) and - 7.39 [- 17.65, 2.87] (P = 0.16). The day and night results of SD of glucose variability was - 0.40 [- 0.79, - 0.00] (P = 0.05) and - 0.86 [- 2.67, 0.95] (P = 0.35). These values shows the superiority of CLC system in terms of efficacy. The safety evaluation, of the day, night and physical activities observations of average blood glucose goal hypoglycemic events - 0.54 [- 1.86, 0.79] (P = 0.43), 0.04 [- 0.20, 0.27] (P = 0.77) and 0.00 [- 0.25, 0.25] (P = 1.00) and hyperglycemic events - 0.04 [- 0.20, 0.27] (P = 0.77), - 7.11 [- 12.77, - 1.45] (P = 0.01) and - 0.00 [- 0.10, 0.10] (P = 0.97), highlights the commendable safety factor of CLC. The CLC systems can be considered as an ideal preference in the management of adolescents with type 1 diabetes to be used during a 24 h basis.

Metabolic Outcomes in Pediatric Patients One-Year Post-Total Pancreatectomy with Islet Autotransplantation after Early Pump Initiation

We previously published that insulin pump initiation immediately after IV insulin therapy was associated with improved post-surgical glycemic outcomes compared to multiple daily injections (MDI) in pediatric patients following a total pancreatectomy with islet autotransplantation (TPIAT). We investigated metabolic outcomes of this population at one-year post-TPIAT to assess if the improved outcomes in the early pump group were sustained over time. We retrospectively reviewed 40 patients post-TPIAT previously studied at 10-days post-surgery (15 used MDI and 25 used pump therapy immediately post-ICU, and all were discharged on pump therapy). Data analyzed included: demographics, islet equivalents per kilogram (IEQ/kg) transplanted, exogenous insulin use, and baseline vs. one-year (via mixed meal testing) HbA1c, fasting glucose, insulinogenic index, and the area under the curve (AUC) for insulin and c-peptide. More patients were off insulin at one year in the early pump group compared to the MDI group (45% vs. 13%, p = 0.07). Of all patients off insulin, 100% of the early pump users weaned off by six months post-TPIAT compared to 30% of the MDI users. Two known variables associated with favorable insulin outcomes, lower age and higher IEQ/kg, were not significantly different between groups. Fasting glucose was lower in the early pump group compared to the MDI group (median 97 vs. 122 mg/dL, p = 0.003), while AUC c-peptide was greater in early pump users at one-year post-TPIAT but did not reach significance (median 57.0 vs. 50.3 ng/mL × minutes, p = 0.14). Other metabolic outcomes did not differ between groups. Despite lower median age and higher IEQ/kg in the MDI group, the early pump group had a lower fasting glucose. Younger TPIAT age (p = 0.02) and early pump users (p = 0.04) were significantly associated with insulin independence at one year. This study was limited by sample size. Early pump use may have long-term benefits in post-TPIAT endogenous insulin secretion.

A Systematic Review of Commercial Hybrid Closed-Loop Automated Insulin Delivery Systems

INTRODUCTION

Several different forms of automated insulin delivery systems (AID systems) have recently been developed and are now licensed for type 1 diabetes (T1D). We undertook a systematic review of reported trials and real-world studies for commercial hybrid closed-loop (HCL) systems.

METHODS

Pivotal, phase III and real-world studies using commercial HCL systems that are currently approved for use in type 1 diabetes were reviewed with a devised protocol using the Medline database.

RESULTS

Fifty-nine studies were included in the systematic review (19 for 670G; 8 for 780G; 11 for Control-IQ; 14 for CamAPS FX; 4 for Diabeloop; and 3 for Omnipod 5). Twenty were real-world studies, and 39 were trials or sub-analyses. Twenty-three studies, including 17 additional studies, related to psychosocial outcomes and were analysed separately.

CONCLUSIONS

These studies highlighted that HCL systems improve time In range (TIR) and arouse minimal concerns around severe hypoglycaemia. HCL systems are an effective and safe option for improving diabetes care. Real-world comparisons between systems and their effects on psychological outcomes require further study.

Switching to an advanced hybrid closed-loop system in real-world practice improves hypoglycemia awareness and metabolic control in adults with type 1 diabetes, particularly in those with impaired perception of hypoglycemia symptoms

AIMS

To evaluate the efficacy of an advance closed-loop (AHCL) system in restoring awareness of hypoglycemia in patients with type 1 diabetes (T1D).

METHODS

We conducted a prospective study including 46 subjects with T1D flash glucose monitoring (FGM) or continuous glucose monitoring (CGM) switching to a Minimed 780G® system. Patients were classified in three groups according to the therapy used before switching to Minimed® 780G: multiple dose insulin (MDI) therapy + FGM (n = 6), continuous subcutaneous insulin infusion + FGM (n = 21), and sensor-augmented pump with predictive low-glucose suspend (n = 19). FGM/CGM data were analyzed at baseline, after 2 and 6 months on AHCL. Clarke's score of hypoglycemia awareness was compared at baseline and 6 months recordings. We also compared the efficacy of the AHCL system in improving A_1c among patients with appropriate perception of symptoms of hypoglycemia compared to those presenting with impaired awareness of hypoglycemia (IAH).

RESULTS

Participants had a mean age of 37 ± 15 and a diabetes duration of 20 ± 10 years. At baseline, 12 patients (27%) showed IAH as defined by a Clarke's score ≥ 3. Patients with IAH were older and had lower estimated glomerular filtration rate (eGFR) compared with those who did not have IAH; with no differences in baseline CGM metrics or A_1c. An overall decrease in A_1c was observed after 6 months on AHCL system (from 6.9 ± 0.5% to 6.7 ± 0.6%, P < 0.001), regardless of prior insulin therapy. The improvement in metabolic control was greater in patients with IAH, showing a reduction in A_1c from 6.9 ± 0.5 to 6.4 ± 0.4% vs 6.9 ± 0.5 to 6.8 ± 0.6% (P = 0.003), showing a parallel increase in total daily boluses of insulin and automatic bolus correction administered by the AHCL system. In patients with IAH Clarke's score decreased from 3.6 ± 0.8 at baseline to 1.9 ± 1.6 after 6 months (P < 0.001). After 6 months on AHCL system, only 3 patients (7%) presented with a Clarke's score ≥ 3, resulting in an absolute risk reduction of 20% (95% confidence interval: 7-32) of having IAH.

CONCLUSIONS

Switching from any type of insulin administration to AHCL system improves restoration of hypoglycemia awareness and metabolic control in patients with T1D, particularly in adults with impaired perception of hypoglycemia symptoms.

TRIAL REGISTRATION

ClinicalTrial.gov ID NCT04900636.

Consensus Recommendations for the Use of Automated Insulin Delivery Technologies in Clinical Practice

The significant and growing global prevalence of diabetes continues to challenge people with diabetes (PwD), healthcare providers, and payers. While maintaining near-normal glucose levels has been shown to prevent or delay the progression of the long-term complications of diabetes, a significant proportion of PwD are not attaining their glycemic goals. During the past 6 years, we have seen tremendous advances in automated insulin delivery (AID) technologies. Numerous randomized controlled trials and real-world studies have shown that the use of AID systems is safe and effective in helping PwD achieve their long-term glycemic goals while reducing hypoglycemia risk. Thus, AID systems have recently become an integral part of diabetes management. However, recommendations for using AID systems in clinical settings have been lacking. Such guided recommendations are critical for AID success and acceptance. All clinicians working with PwD need to become familiar with the available systems in order to eliminate disparities in diabetes quality of care. This report provides much-needed guidance for clinicians who are interested in utilizing AIDs and presents a comprehensive listing of the evidence payers should consider when determining eligibility criteria for AID insurance coverage.

Simplified Meal Announcement Versus Precise Carbohydrate Counting in Adolescents With Type 1 Diabetes Using the MiniMed 780G Advanced Hybrid Closed Loop System: A Randomized Controlled Trial Comparing Glucose Control

OBJECTIVE

We aimed to compare glucose control in adolescents with type 1 diabetes (T1D) using the MiniMed 780G system who used simplified meal announcement with those who used precise carbohydrate counting.

RESEARCH DESIGN AND METHODS

This randomized controlled trial included 34 participants (age 12-18 years) with T1D who were on multiple daily injections or insulin pump and were scheduled to start using the MiniMed 780G system at Sidra Medicine in Qatar. After a 7-day run-in period, participants were randomly assigned to the fix group (simplified meal announcement by preset of three personalized fixed carbohydrate amounts) or the flex group (precise carbohydrate counting) and followed for 12 weeks. Between-group difference in time in range (TIR) was the primary end point. Secondary end points included HbA1c and other glycometrics.

RESULTS

During the 12-week study phase, TIR was 73.5 ± 6.7% in the fix and 80.3 ± 7.4% in the flex group, with a between-group difference of 6.8% in favor of flex (P = 0.043). Time >250 mg/dL was better in the flex group (P = 0.012), whereas HbA1c (P = 0.168), time below range (P = 0.283), and time between 180 and 250 mg/dL (P = 0.114) did not differ.

CONCLUSIONS

Adolescents using the MiniMed 780G system with a preset of three personalized fixed carbohydrate amounts can reach international targets of glycemic control. Therefore, it may be a valuable alternative to precise carbohydrate counting in users who are challenged by precise carbohydrate counting. Because carbohydrate counting further improves outcomes, these skills remain important for MiniMed 780G users.

Automated insulin delivery systems: from early research to routine care of type 1 diabetes

Automated insulin delivery (AID) systems, so-called closed-loop systems or artificial pancreas, are based upon the concept of insulin supply driven by blood glucose levels and their variations according to body glucose needs, glucose intakes and insulin action. They include a continuous glucose monitoring device which provides a signal to a control algorithm tuning insulin delivery from an infusion pump. The control algorithm is the key of the system since it commands insulin administration in order to maintain blood glucose in a predefined target range and close to a near-normal glucose level. The last two decades have shown dramatic advances toward the use in free life of AID systems for routine care of type 1 diabetes through step-by-step demonstrations of feasibility, safety and efficacy in successive hospital, transitional and outpatient trials. Because of the constraints of pharmacokinetics and dynamics of subcutaneous insulin delivery, the currently available AID systems are all 'hybrid' or 'semi-automated' insulin delivery systems with a need of meal and exercise announcements in order to anticipate rapid glucose variations through pre-meal bolus or pre-exercise reduction of infusion rate. Nevertheless, these AID systems significantly improve time spent in a near-normal range with a reduction of the risk of hypoglycemia and the mental load of managing diabetes in everyday life, representing a milestone in insulin therapy. Expected progression toward fully automated, further miniaturized and integrated, possibly implantable on long-term and more physiological closed-loop systems paves the way for a functional cure of type 1 diabetes.

14. Children and Adolescents: Standards of Care in Diabetes-2023

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, a multidisciplinary expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Automated insulin delivery: benefits, challenges, and recommendations. A Consensus Report of the Joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association

A technological solution for the management of diabetes in people who require intensive insulin therapy has been sought for decades. The last 10 years have seen substantial growth in devices that can be integrated into clinical care. Driven by the availability of reliable systems for continuous glucose monitoring, we have entered an era in which insulin delivery through insulin pumps can be modulated based on sensor glucose data. Over the past few years, regulatory approval of the first automated insulin delivery (AID) systems has been granted, and these systems have been adopted into clinical care. Additionally, a community of people living with type 1 diabetes has created its own systems using a do-it-yourself approach by using products commercialised for independent use. With several AID systems in development, some of which are anticipated to be granted regulatory approval in the near future, the joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association has created this consensus report. We provide a review of the current landscape of AID systems, with a particular focus on their safety. We conclude with a series of recommended targeted actions. This is the fourth in a series of reports issued by this working group. The working group was jointly commissioned by the executives of both organisations to write the first statement on insulin pumps, which was published in 2015. The original authoring group was comprised by three nominated members of the American Diabetes Association and three nominated members of the European Association for the Study of Diabetes. Additional authors have been added to the group to increase diversity and range of expertise. Each organisation has provided a similar internal review process for each manuscript prior to submission for editorial review by the two journals. Harmonisation of editorial and substantial modifications has occurred at both levels. The members of the group have selected the subject of each statement and submitted the selection to both organisations for confirmation.

[Diabetes mellitus and road traffic-a position paper of the Austrian Diabetes Association (update 2023)]

Public safety (prevention of accidents) is the primary objective in assessing fitness to drive a motor vehicle. However, general access to mobility should not be restricted if there is no particular risk to public safety. For people with diabetes mellitus, the Führerscheingesetz (Driving Licence Legislation) and the Führerscheingesetz-Gesundheitsverordnung (Driving Licence Legislation Health enactment) regulate important aspects of driving safety in connection with acute and chronic complications of the disease. Critical complications that may be relevant to road safety include severe hypoglycemia, pronounced hyperglycemia and hypoglycemia perception disorder as well as severe retinopathy and neuropathy, endstage renal disease and certain cardiovascular manifestations. If there is a suspicion of the presence of one of these complications, a detailed evaluation is required.In addition, the individual antihyperglycemic medication should be checked for existing potential for hypoglycemia. Sulfonylureas, glinides and insulin belong to this group and are therefore associated with the requirement of a 5-year limitation of the driver's license. Other antihyperglycemic drugs without potential for hypoglycemia such as Metformin, SGLT‑2 inhibitors (Sodium-dependent-glucose-transporter‑2 inhibitors, gliflozins), DPP-4-inhibitors (Dipeptidyl-Peptidase inhibitors, gliptins), and GLP‑1 analogues (GLP‑1 rezeptor agonists) are not associated with such a time limitation.The relevant laws which regulate driving safety give room for interpretation, so that specific topics on driving safety for people with diabetes mellitus are elaborated from a medical and traffic-relevant point of view. This position paper is intended to support people involved in this challenging matter.

Transition From Pediatric to Adult Care for Individuals With Type 1 Diabetes: Opportunities and Challenges

OBJECTIVES

Type 1 diabetes (T1D) is a chronic disease with patients across the age spectrum that has high potential for morbidity and mortality. Unfortunately, patients transitioning from pediatric to adult care continue to demonstrate worsened glycemic control in part due to lack of understanding of transition of care best practices.

METHODS

This review highlights the impact of existing transition of care interventions, assessment tools, and other recently published strategies for providers to consider to improve care of adolescent and young adult (AYA) patients with T1D in both hospital- and clinic-based settings.

RESULTS

Many barriers impact patients with T1D during the transition period and disparities by race, sex, insurance status, and comorbid illness persist. As diabetic care continues to evolve and the prevalence of adolescents and young adults living with T1D increases, an intentional approach to transition of care is more pressing than ever. While current literature on transition of care models is limited, many show promise in improving clinic attendance and decreasing hospitalization. There are critical discussions that providers should lead with AYA patients to improve their outcomes and increase diabetes self-management, such as re-addressing carbohydrate counseling, sleep hygiene, and reproductive planning.

CONCLUSION

While further research on transition of care is needed, many care models offer the promise of improved T1D outcomes, enhancements in our approach to care, and increased value for our health care system at large.

Automated Insulin Delivery: Benefits, Challenges, and Recommendations. A Consensus Report of the Joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association

A technological solution for the management of diabetes in people who require intensive insulin therapy has been sought for decades. The last 10 years have seen substantial growth in devices that can be integrated into clinical care. Driven by the availability of reliable systems for continuous glucose monitoring, we have entered an era in which insulin delivery through insulin pumps can be modulated based on sensor glucose data. Over the past few years, regulatory approval of the first automated insulin delivery (AID) systems has been granted, and these systems have been adopted into clinical care. Additionally, a community of people living with type 1 diabetes has created its own systems using a do-it-yourself approach by using products commercialized for independent use. With several AID systems in development, some of which are anticipated to be granted regulatory approval in the near future, the joint Diabetes Technology Working Group of the European Association for the Study of Diabetes and the American Diabetes Association has created this consensus report. We provide a review of the current landscape of AID systems, with a particular focus on their safety. We conclude with a series of recommended targeted actions. This is the fourth in a series of reports issued by this working group. The working group was jointly commissioned by the executives of both organizations to write the first statement on insulin pumps, which was published in 2015. The original authoring group was comprised by three nominated members of the American Diabetes Association and three nominated members of the European Association for the Study of Diabetes. Additional authors have been added to the group to increase diversity and range of expertise. Each organization has provided a similar internal review process for each manuscript prior to submission for editorial review by the two journals. Harmonization of editorial and substantial modifications has occurred at both levels. The members of the group have selected the subject of each statement and submitted the selection to both organizations for confirmation.

Long-term effectiveness of advanced hybrid closed loop in children and adolescents with type 1 diabetes

BACKGROUND

Advanced hybrid closed loop (AHCL) systems are the newest tool to improve metabolic control in type 1 diabetes (T1D). Long-term glycemic control of children and adolescents with T1D switching to MiniMed™ 780G in a real clinical setting was evaluated.

METHODS

Time in range (TIR) and in different glucose ranges, glycemic variability indexes, HbA1c and basal-bolus insulin distribution were evaluated in 44 subjects (mean age 14.2 ± 4.0 years, 22 males) during manual mode period, first 14 days (A14d) and first month after auto-mode activation (A1M), first 14 days after 3 months (A3M) and 6 months (A6M) in auto-mode.

RESULTS

Mean TIR at A14d was 76.3 ± 9.6% versus 69.3 ± 12.6% in manual mode (p < 0.001), and this improvement was maintained over 6 months. Subjects with TIR >70% and >80% in manual mode were 45% and 23%, respectively, and increased to 80% (p = 0.041) and 41% (p = 0.007) at A14d. Basal-bolus distribution changed in favor of bolus, and auto-correction boluses inversely correlated with TIR. HbA1c was 7.2 ± 0.7% (55 mmol/mol) at baseline and significantly improved after 3 months (6.7 ± 0.5%, 50 mmol/mol, p < 0.001) and 6 months (6.6 ± 0.5%, 49 mmol/mol, p < 0.001). TIR was higher in individuals >13 years at all time periods (p < 0.001). Glycemic target <120 mg/dl was associated with better TIR.

CONCLUSIONS

AHCL MiniMed™ 780G allowed rapid and sustained improvement of glycemic control in young T1D patients, reaching recommended TIR. Teenagers showed good technology adherence with optimal TIR, maintained better over time compared to younger children. Stricter settings were associated with better metabolic control, without increase in severe hypoglycemia occurrence.

Improved CGM Glucometrics and More Visits for Pediatric Type 1 Diabetes Using Telemedicine During 1 Year of COVID-19

PURPOSE

The COVID-19 pandemic led to rapid adoption of telemedicine for the care of youth with type 1 diabetes (T1D). We assessed the utility of a primarily virtual care model by comparing glucometrics from a pediatric sample with T1D using continuous glucose monitoring (CGM) both before and during the pandemic.

METHODS

Pediatric patients aged 1 to 17 years with T1D duration ≥ 1 year if ≥ 6 years old or ≥ 6 months if < 6 years old, with ≥ 1 visit with recorded CGM data both prepandemic (April 1, 2019-March 15, 2020) and during the pandemic (April 1, 2020-March 15, 2021) were included. Data were extracted from the electronic health record.

RESULTS

Our sample comprised 555 young people (46% male, 87% White, 79% pump-treated), mean age 12.3 ± 3.4 years, T1D duration 5.9 ± 3.5 years, baseline glycated hemoglobin A1c 8.0 ± 1.0% (64 ± 10.9 mmol/mol). Diabetes visit frequency increased from 3.8 ± 1.7 visits/prepandemic period to 4.3 ± 2.2 visits/pandemic period (P < 0.001); during pandemic period, 92% of visits were virtual. Glucose management indicator (GMI) improved slightly from 7.9% (63 mmol/mol) prepandemic to 7.8% (62 mmol/mol) during the pandemic (P < 0.001). Those with equal or greater visit frequency (n = 437 [79% of sample]) had significant improvement in GMI (8.0% to 7.8% [64 to 62 mmol/mol], P < 0.001), whereas those with lower visit frequency did not (7.8 [62 mmol/mol], P = 0.86).

CONCLUSIONS

Children and adolescents with T1D using CGM before and during the pandemic showed an overall increase in visit frequency using primarily telemedicine-based care and improved CGM glucometrics. Further research is needed to understand factors associated with successful use of telemedicine for pediatric T1D.

Advancements and future directions in the teamwork, targets, technology, and tight control-the 4T study: improving clinical outcomes in newly diagnosed pediatric type 1 diabetes

PURPOSE OF REVIEW

The benefits of intensive diabetes management have been established by the Diabetes Control and Complications Trial. However, challenges with optimizing glycemic management in youth with type 1 diabetes (T1D) remain across pediatric clinics in the United States. This article will review our Teamwork, Targets, Technology, and Tight Control (4T) study that implements emerging diabetes technology into clinical practice with a team approach to sustain tight glycemic control from the onset of T1D and beyond to optimize clinical outcomes.

RECENT FINDINGS

During the 4T Pilot study and study 1, our team-based approach to intensive target setting, education, and remote data review has led to significant improvements in hemoglobin A1c throughout the first year of T1D diagnosis in youth, as well as family and provider satisfaction.

SUMMARY

The next steps include refinement of the current 4T study 1, developing a business case, and broader implementation of the 4T study. In study 2, we are including a more pragmatic cadence of remote data review and disseminating exercise education and activity tracking to both English- and Spanish-speaking families. The overall goal is to create and implement a translatable program that can facilitate better outcomes for pediatric clinics across the USA.

Use of intermittently scanned continuous glucose monitoring in young people with high-risk type 1 diabetes-Extension phase outcomes following a 6-month randomized control trial

AIMS

To describe the impact of a 12-month intervention using intermittently scanned continuous glucose monitoring (isCGM) on glycaemic control and glucose test frequency in adolescents and young adults with type 1 diabetes (T1D) and high-risk glycaemic control (HbA_1c ≥75 mmol/mol [≥9.0%]).

METHODS

In total, 64 young people (aged 13-20 years, 16.6 ± 2.1 years; 48% female; 41% Māori or Pacific ethnicity; mean diabetes duration 7.5 ± 3.8 years) with T1D were enrolled in a 6-month, randomized, parallel-group study comparing glycaemic outcomes from the isCGM intervention (n = 33) to self monitoring blood glucose (SMBG) controls (n = 31). In this 6-month extension phase, both groups received isCGM; HbA_1c , glucose time-in-range (TIR), and combined glucose test frequency were assessed at 9 and 12 months.

RESULTS

At 12 months, the mean difference in HbA_1c from baseline was -4 mmol/mol [-0.4%] (95% confidence interval, CI: -8, 1 mmol/mol [-0.8, 0.1%]; p = 0.14) in the isCGM intervention group, and -7 mmol/mol [-0.7%] (95% CI: -16, 1 mmol/mol [-1.5, 0.1%]; p = 0.08) in the SMBG control group. No participants achieved ≥70% glucose TIR (3.9-10.0 mmol/L). The isCGM intervention group mean rate of daily glucose testing was highest at 9 months, 2.4 times baseline rates (p < 0.001), then returned to baseline by 12 months (incidence rate ratio = 1.4; 95% CI: 0.9, 2.1; p = 0.091).

CONCLUSIONS

The use of isCGM in young people with high-risk T1D resulted in transient improvements in HbA_1c and glucose monitoring over a 9-month time frame; however, benefits were not sustained to 12 months.

Cambridge hybrid closed-loop algorithm in children and adolescents with type 1 diabetes: a multicentre 6-month randomised controlled trial

BACKGROUND

Closed-loop insulin delivery systems have the potential to address suboptimal glucose control in children and adolescents with type 1 diabetes. We compared safety and efficacy of the Cambridge hybrid closed-loop algorithm with usual care over 6 months in this population.

METHODS

In a multicentre, multinational, parallel randomised controlled trial, participants aged 6-18 years using insulin pump therapy were recruited at seven UK and five US paediatric diabetes centres. Key inclusion criteria were diagnosis of type 1 diabetes for at least 12 months, insulin pump therapy for at least 3 months, and screening HbA1c levels between 53 and 86 mmol/mol (7·0-10·0%). Using block randomisation and central randomisation software, we randomly assigned participants to either closed-loop insulin delivery (closed-loop group) or to usual care with insulin pump therapy (control group) for 6 months. Randomisation was stratified at each centre by local baseline HbA1c. The Cambridge closed-loop algorithm running on a smartphone was used with either (1) a modified Medtronic 640G pump, Medtronic Guardian 3 sensor, and Medtronic prototype phone enclosure (FlorenceM configuration), or (2) a Sooil Dana RS pump and Dexcom G6 sensor (CamAPS FX configuration). The primary endpoint was change in HbA1c at 6 months combining data from both configurations. The primary analysis was done in all randomised patients (intention to treat). Trial registration ClinicalTrials.gov, NCT02925299.

FINDINGS

Of 147 people initially screened, 133 participants (mean age 13·0 years [SD 2·8]; 57% female, 43% male) were randomly assigned to either the closed-loop group (n=65) or the control group (n=68). Mean baseline HbA1c was 8·2% (SD 0·7) in the closed-loop group and 8·3% (0·7) in the control group. At 6 months, HbA1c was lower in the closed-loop group than in the control group (between-group difference -3·5 mmol/mol (95% CI -6·5 to -0·5 [-0·32 percentage points, -0·59 to -0·04]; p=0·023). Closed-loop usage was low with FlorenceM due to failing phone enclosures (median 40% [IQR 26-53]), but consistently high with CamAPS FX (93% [88-96]), impacting efficacy. A total of 155 adverse events occurred after randomisation (67 in the closed-loop group, 88 in the control group), including seven severe hypoglycaemia events (four in the closed-loop group, three in the control group), two diabetic ketoacidosis events (both in the closed-loop group), and two non-treatment-related serious adverse events. There were 23 reportable hyperglycaemia events (11 in the closed-loop group, 12 in the control group), which did not meet criteria for diabetic ketoacidosis.

INTERPRETATION

The Cambridge hybrid closed-loop algorithm had an acceptable safety profile, and improved glycaemic control in children and adolescents with type 1 diabetes. To ensure optimal efficacy of the closed-loop system, usage needs to be consistently high, as demonstrated with CamAPS FX.

FUNDING

National Institute of Diabetes and Digestive and Kidney Diseases.

Glycemic outcomes of Advanced Hybrid Closed Loop system in children and adolescents with Type 1 Diabetes, previously treated with Multiple Daily Injections (MiniMed 780G system in T1D individuals, previously treated with MDI)

BACKGROUND

The objective of this study was to evaluate the glycemic outcomes in children and adolescents with Type 1 Diabetes (T1D) previously treated with Multiple Daily Injections (MDI) using a structured initiation protocol for the Advanced Hybrid Closed Loop (AHCL) Minimed 780G insulin pump system.

METHODS

In this prospective open label single-arm, single-center, clinical investigation, we recruited children and adolescents (aged 7-17 years) with T1D on MDI therapy and HbA1c below 12.5%. All participants followed a 10-day structured initiation protocol which included 4 steps: step 1: AHCL system assessment; step 2: AHCL system training; step 3: Sensor augmented pump therapy (SAP) for 3 days; step 4: AHCL system use for 12 weeks, successfully completing the training from MDI to AHCL in 10 days. The primary outcome of the study was the change in the time spent in the target in range (TIR) of 70-180 mg/dl and HbA1c from baseline (MDI + CGM, 1 week) to study phase (AHCL, 12 weeks). The paired student t-test was used for statistical analysis and a value < 0.05 was considered statistically significant.

RESULTS

Thirty-four participants were recruited and all completed the 12 weeks study. TIR increased from 42.1 ± 18.7% at baseline to 78.8 ± 6.1% in the study phase (p < 0.001). HbA1c decreased from 8.6 ± 1.7% (70 ± 18.6 mmol/mol) at baseline, to 6.5 ± 0.7% (48 ± 7.7 mmol/mol) at the end of the study (p = 0.001). No episodes of severe hypoglycemia or DKA were reported.

CONCLUSION

Children and adolescents with T1D on MDI therapy who initiated the AHCL system following a 10-days structured protocol achieved the internationally recommended goals of glycemic control with TIR > 70% and a HbA1c of < 7%.

Clinical Evaluation of a Novel Insulin Immunosensor

BACKGROUND

The estimation of available active insulin remains a limitation of automated insulin delivery systems. Currently, insulin pumps calculate active insulin using mathematical decay curves, while quantitative measurements of insulin would explicitly provide person-specific PK insulin dynamics to assess remaining active insulin more accurately, permitting more effective glucose control.

METHODS

We performed the first clinical evaluation of an insulin immunosensor chip, providing near real-time measurements of insulin levels. In this study, we sought to determine the accuracy of the novel insulin sensor and assess its therapeutic risk and benefit by presenting a new tool developed to indicate the potential therapeutic consequences arising from inaccurate insulin measurements.

RESULTS

Nine adult participants with type-1 diabetes completed the study. The change from baseline in immunosensor-measured insulin levels was compared with values obtained by standard enzyme-linked immunosorbant assay (ELISA) after preprandial injection of insulin. The point-of-care quantification of insulin levels revealed similar temporal trends as those from the laboratory insulin ELISA. The results showed that 70% of the paired immunosensor-reference values were concordant, which suggests that the patient could take action safely based on insulin concentration obtained by the novel sensor.

CONCLUSIONS

This proposed technology and preliminary feasibility evaluation show encouraging results for near real-time evaluation of insulin levels, with the potential to improve diabetes management. Real-time measurements of insulin provide person-specific insulin dynamics that could be used to make more informed decisions regarding insulin dosing, thus helping to prevent hypoglycemia and improve diabetes outcomes.

Closed-Loop Insulin Therapy in Older Adults with Type 1 Diabetes: Real-World Data

Objective: To assess the impact of initiation of closed-loop control (CLC) on glycemic metrics in older adults with type 1 diabetes (T1D) in the real world. Methods: Retrospective analysis of electronic health records from a single tertiary diabetes center of older adults prescribed CLC between January and December 2020. Results: Forty-eight patients (mean age 70 ± 4 years, T1D duration 42 ± 14 years) were prescribed CLC and 39/48 started on the CLC. Among the CLC starters, 97.5% and 95% were prior pump and continuous glucose monitoring (CGM) users, respectively. CGM metrics showed an increase in time-in-range (62% ± 13% to 76% ± 9%; P < 0.001), a reduction in both time spent <70 mg/dL [2% (1%-3%) to 1% (1%-2%); P = 0.03] and >180 mg/dL (30% ± 11% to 20% ± 9%; P < 0.001) at 3 months. Conclusion: In this real-world data most of the older patients with T1D initiating CLC were prior pump and CGM users. Initiation of CLC improved glycemic control and reduced time spent in hypoglycemia compared with prior therapy.

Real-World Performance of the MiniMed™ 780G System: First Report of Outcomes from 4120 Users

Background: The MiniMed™ 780G system includes an advanced hybrid closed loop (AHCL) algorithm that provides both automated basal and correction bolus insulin delivery. The preliminary performance of the system in real-world settings was evaluated. Methods: Data uploaded from August 2020 to March 2021 by individuals living in Belgium, Finland, Italy, the Netherlands, Qatar, South Africa, Sweden, Switzerland, and the United Kingdom were aggregated and retrospectively analyzed to determine the mean glucose management indicator (GMI), percentage of time spent within (TIR), below (TBR), and above (TAR) glycemic ranges, system use, and insulin consumption in users having ≥10 days of sensor glucose (SG) data after initiating AHCL. The impact of initiating AHCL was evaluated in a subgroup of users also having ≥10 days of SG data, before AHCL initiation. Results: Users (N = 4120) were observed for a mean of 54 ± 32 days. During this time, they spent a mean of 94.1% ± 11.4% of the time in AHCL and achieved a mean GMI of 6.8% ± 0.3%, TIR of 76.2% ± 9.1%, TBR <70 of 2.5% ± 2.1%, and TAR >180 of 21.3% ± 9.4%, after initiating AHCL. There were 77.3% and 79.0% of users who achieved a TIR >70% and a GMI of <7.0%, respectively. Users for whom comparison with pre-AHCL was possible (N = 812) reduced their GMI by 0.4% ± 0.4% (P = 0.005) and increased their TIR by 12.1% ± 10.5% (P < 0.0001), post-AHCL initiation. More users achieved the glycemic treatment goals of GMI <7.0% (37.6% vs. 75.2%, P < 0.0001) and TIR >70% (34.6% vs. 74.9%, P < 0.0001) when compared with pre-AHCL initiation. Conclusion: Most MiniMed 780G system users achieved TIR >70% and GMI <7%, while minimizing hypoglycemia, in a real-world condition.

Improvement in Mean CGM Glucose in Young People with Type 1 Diabetes During 1 Year of the COVID-19 Pandemic

The coronavirus disease 2019 (COVID-19) pandemic likely affected youth with type 1 diabetes (T1D). We used electronic health record-extracted data to compare continuous glucose monitoring (CGM) metrics during 1 year of the pandemic with those of the previous year. The sample comprised CGM users, aged 1 to <18 years, with T1D duration ≥6 months (age <6 years) or ≥1 year (age ≥6 years). The prepandemic sample comprised 641 youth (52% female, aged 12.3 ± 3.5, T1D duration 6.0 ± 3.5 years). The pandemic sample comprised 648 youth (52% female, age 13.3 ± 3.5, duration 6.7 ± 3.8 years), with care delivered primarily through telemedicine. Mean CGM glucose was 6.3 mg/dL lower during the pandemic (187.3 ± 35.6) versus prepandemic (193.6 ± 33.0) (P < 0.001). A higher percentage of youth achieved glucose management indicator <7% during the pandemic than the prior year (P < 0.001). Lower CGM glucose values were observed during the COVID-19 pandemic. Future studies are needed to assess how changes in health care delivery, including telemedicine, and lifestyle during this time may have supported this improvement.

Effect of nationwide reimbursement of real-time continuous glucose monitoring on HbA1c, hypoglycemia and quality of life in a pediatric type 1 diabetes population: The RESCUE-pediatrics study

OBJECTIVE

Real-time continuous glucose monitoring (RT-CGM) can improve metabolic control and quality of life (QoL), but long-term real-world data in children with type 1 diabetes (T1D) are scarce. Over a period of 24 months, we assessed the impact of RT-CGM reimbursement on glycemic control and QoL in children/adolescents with T1D treated with insulin pumps.

RESEARCH DESIGN AND METHODS

We conducted a multicenter prospective observational study. Primary endpoint was the change in HbA1c. Secondary endpoints included change in time in hypoglycemia, QoL, hospitalizations for hypoglycemia and/or ketoacidosis and absenteeism (school for children, work for parents).

RESULTS

Between December 2014 and February 2019, 75 children/adolescents were followed for 12 (n = 62) and 24 months (n = 50). Baseline HbA1c was 7.2 ± 0.7% (55 ± 8mmol/mol) compared to 7.1 ± 0.8% (54 ± 9mmol/mol) at 24 months (p = 1.0). Participants with a baseline HbA1c ≥ 7.5% (n = 27, mean 8.0 ± 0.3%; 64 ± 3mmol/mol) showed an improvement at 4 months (7.6 ± 0.7%; 60 ± 8mmol/mol; p = 0.009) and at 8 months (7.5 ± 0.6%; 58 ± 7mmol/mol; p = 0.006), but not anymore thereafter (endpoint 24 months: 7.7 ± 0.9%; 61 ± 10mmol/mol; p = 0.2). Time in hypoglycemia did not change over time. QoL for parents and children remained stable. Need for assistance by ambulance due to hypoglycemia reduced from 8 to zero times per 100 patient-years (p = 0.02) and work absenteeism for parents decreased from 411 to 214 days per 100 patient-years (p = 0.03), after 24 months.

CONCLUSION

RT-CGM in pump-treated children/adolescents with T1D showed a temporary improvement in HbA1c in participants with a baseline HbA1c ≥ 7.5%, without increasing time in hypoglycemia. QoL was not affected. Importantly, RT-CGM reduced the need for assistance by ambulance due to hypoglycemia and reduced work absenteeism for parents after 24 months.

CLINICAL TRIAL REGISTRATION

[ClinicalTrials.gov], identifier [NCT02601729].