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Fuchs S, Caserto JS, Liu Q, Wang K, Shariati K, Hartquist CM, Zhao X, Ma M. A Glucose-Responsive Cannula for Automated and Electronics-Free Insulin Delivery. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2024; 36:e2403594. [PMID: 38639424 PMCID: PMC11223976 DOI: 10.1002/adma.202403594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 04/12/2024] [Indexed: 04/20/2024]
Abstract
Automated delivery of insulin based on continuous glucose monitoring is revolutionizing the way insulin-dependent diabetes is treated. However, challenges remain for the widespread adoption of these systems, including the requirement of a separate glucose sensor, sophisticated electronics and algorithms, and the need for significant user input to operate these costly therapies. Herein, a user-centric glucose-responsive cannula is reported for electronics-free insulin delivery. The cannula-made from a tough, elastomer-hydrogel hybrid membrane formed through a one-pot solvent exchange method-changes permeability to release insulin rapidly upon physiologically relevant varying glucose levels, providing simple and automated insulin delivery with no additional hardware or software. Two prototypes of the cannula are evaluated in insulin-deficient diabetic mice. The first cannula-an ends-sealed, subcutaneously inserted prototype-normalizes blood glucose levels for 3 d and controls postprandial glucose levels. The second, more translational version-a cannula with the distal end sealed and the proximal end connected to a transcutaneous injection port-likewise demonstrates tight, 3-d regulation of blood glucose levels when refilled twice daily. This proof-of-concept study may aid in the development of "smart" cannulas and next-generation insulin therapies at a reduced burden-of-care toll and cost to end-users.
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Affiliation(s)
- Stephanie Fuchs
- Biological and Environmental Engineering, Cornell University, Ithaca, NY, 14853, USA
| | - Julia S. Caserto
- Robert Frederick Smith School of Chemical and Biomolecular Engineering, Cornell University, Ithaca NY, 14853, USA
| | - Qingsheng Liu
- Biological and Environmental Engineering, Cornell University, Ithaca, NY, 14853, USA
| | - Kecheng Wang
- Biological and Environmental Engineering, Cornell University, Ithaca, NY, 14853, USA
| | - Kaavian Shariati
- Biological and Environmental Engineering, Cornell University, Ithaca, NY, 14853, USA
| | - Chase M. Hartquist
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Xuanhe Zhao
- Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Minglin Ma
- Biological and Environmental Engineering, Cornell University, Ithaca, NY, 14853, USA
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2
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Yu J, Wang H, Zhu M, Zhou M, Xu J. Patient-Centered Positive Factors Influencing Glycemic Control in Adolescents with Type 1 Diabetes Mellitus in China: A Cross-Sectional and Longitudinal Study. Patient Prefer Adherence 2024; 18:1039-1046. [PMID: 38826503 PMCID: PMC11141705 DOI: 10.2147/ppa.s460104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/08/2024] [Indexed: 06/04/2024] Open
Abstract
Objective This study aimed to explore the stable longitudinal patient-centered self-protective factors of glycosylated hemoglobin (HbA1c) in adolescents with type 1 diabetes mellitus (T1DM). Methods We used both cross-sectional and longitudinal datasets at the Diabetes Education Center and National Endocrine and Metabolism Centre of a university hospital in China from April 2020 to July 2022. Participants were assessed using the Adolescent Diabetic Behavior Rating Scale (DBRS), Diabetes Strengths and Resilience Measure for Adolescents (DSTAR-Teen). HbA1c and other clinical variables were obtained from the medical record at the same time. 266 adolescents (131 male, age 14.1±3.9 years) completed the cross-sectional assessments and 131 (62 male, age 14.6±3.3 years) participated in a follow-up at a 1-year visit interval. Results Logistic regression analysis of cross-sectional data of 266 cases showed that there were significant positive effects between pump treatment (β=0.090, OR 2.460, P=0.005), DBRS scores (β=2.593, OR 13.366, P=0.002) and the meeting of standard HbA1c (<7.5%, 58 mmol/mol). Disease duration (β=-0.071, OR 0.932, P=0.033) was negatively correlated with it. The longitudinal multivariate generalized estimation equation model showed that DBRS scores (β=3.165, OR 23.681, P=0.009) and DSTAR-Teen scores (β=0.050, OR 1.051, P=0.012) had a positive influence on the meeting of standard HbA1c over one year time of 131 cases. Conclusion Self-care and resilience had higher cross-temporal stability in influencing glycemic control over time. To reach a better glycemic control and improve long-term health outcomes, attention should be paid to the detection and enhancement of these patient-centered promoters.
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Affiliation(s)
- Jian Yu
- Department of Endocrinology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing, LA, 210029, People’s Republic of China
| | - Hong Wang
- Department of Endocrinology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing, LA, 210029, People’s Republic of China
| | - Min Zhu
- Department of Endocrinology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing, LA, 210029, People’s Republic of China
| | - Meijing Zhou
- Department of Endocrinology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing, LA, 210029, People’s Republic of China
| | - Jingjing Xu
- Department of Endocrinology, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing, LA, 210029, People’s Republic of China
- Department of Nursing, The First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital), Nanjing, LA, 210036, People’s Republic of China
- School of Public Health, Nanjing Medical University, Nanjing, LA, 210036, People’s Republic of China
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Folk S, Zappe J, Wyne K, Dungan KM. Comparative Effectiveness of Hybrid Closed-Loop Automated Insulin Delivery Systems Among Patients with Type 1 Diabetes. J Diabetes Sci Technol 2024:19322968241234948. [PMID: 38557128 DOI: 10.1177/19322968241234948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
BACKGROUND Clinical trials have demonstrated the efficacy and safety of hybrid closed-loop (HCL) systems, yet few studies have compared outcomes in the real-world setting. METHOD This retrospective study analyzed patients from an academic endocrinology practice between January 1, 2018, and November 18, 2022. The inclusion criteria were diagnosis code for type I diabetes (T1D), >18 years of age, new to any HCL system [Medtronic 670G/770G (MT), Tandem Control IQ (CIQ), or Omnipod 5 (OP5)], and availability of a pump download within three months. The outcomes included %time in range (TIR) of 70 to 180 mg/dL, %time below range (TBR) <70 mg/dL at 90 days, and HbA1c for 91 to 180 days. RESULT Of the 176 participants, 47 were MT, 74 CIQ, and 55 OP5. Median (25%, 75%) change in HbA1c was -0.1 (-0.8, 0.3), -0.6 (-1.1, -0.15), and -0.55 (-0.98, 0)% for MT, CIQ, and OP5, respectively, (P = .04). TIR was 70 (57, 76), 67 (59, 75), and 68 (60, 76)% (P = .95) at 90 days while TBR was 2 (1, 3), 1 (0, 2), and 1 (0, 1)%, respectively, (P = .002). The %time in automated delivery was associated with TIR and change in HbA1c. After controlling other factors including %time in automated delivery, HCL type was not an independent predictor of change in HbA1c nor TIR but remained a significant predictor of TBR. CONCLUSION There were significant reductions in HbA1c in CIQ and OP5. TIR was similar across pumps, but TBR was highest with MT. The %time in automated delivery likely explains differences in change in HbA1c but not TBR between HCL systems.
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Affiliation(s)
- Sara Folk
- The Ohio State University College of Medicine, Columbus, OH, USA
| | - Janet Zappe
- Division of Endocrinology, Diabetes and Metabolism, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kathleen Wyne
- Division of Endocrinology, Diabetes and Metabolism, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Kathleen M Dungan
- Division of Endocrinology, Diabetes and Metabolism, The Ohio State University College of Medicine, Columbus, OH, USA
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Bai H, He N, Zhang Y, Ahmad A, Yang XX, Ma Y, Liang LJ. Quality of Life and Glucose Regulation in Pediatric Patients with Type 1 Diabetes: A Study in the Ningxia Hui Autonomous Region. Diabetes Metab Syndr Obes 2024; 17:1267-1278. [PMID: 38496005 PMCID: PMC10944302 DOI: 10.2147/dmso.s446387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 02/24/2024] [Indexed: 03/19/2024] Open
Abstract
Objective In this study, we aimed to evaluate the current status of the quality of life (QOL) of pediatric patients and plasma glucose concentration regulation in children with type 1 diabetes (T1DM) in the Ningxia Hui autonomous region. Methods The study involved children with T1DM admitted to the General Hospital of Ningxia Medical University between October 2011 and October 2021. The children and their parents completed general information and quality of life (QOL) questionnaires. The regulation of plasma glucose concentration was assessed based on HbA1c levels, and plasma glucose and QOL-influencing components were investigated. Results Among the 136 pediatric patients diagnosed with T1DM, the mean glycated hemoglobin (HbA1c) level was recorded at 8.7% (7.2%, 10.5%). A breakdown of the patient cohort revealed that 44 patients (32.4%) demonstrated good regulation of plasma glucose, 33 patients (24.3%) exhibited acceptable glycemic control, and 59 patients (43.3%) displayed poor regulation of plasma glucose. The control of plasma glucose in pediatric patients diagnosed with T1DM was affected by the duration of the disease, the patient's age, the frequency of daily plasma glucose measurements, the use of CGM, diabetic ketoacidosis (DKA), and the education level of the mother. The control of plasma glucose, dietary management, DKA, the ability to learn, and health education are interfering factors of quality of life in children diagnosed with T1DM. Effective control of plasma glucose may ensure the QOL in children with T1DM, and DKA was the risk factor for QOL. Conclusion In Ningxia, the regulation of plasma glucose in pediatric and adolescent patients with T1DM remains suboptimal, leading to poor QOL. There is a pressing need to enhance glucose regulation and QOL through comprehensive strategies, which include reinforced dietary management, rigorous monitoring of plasma glucose levels, and heightened health education levels.
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Affiliation(s)
- Hua Bai
- Department of Pediatrics, General Hospital of Ningxia Medical University, Yinchuan, 750004, People’s Republic of China
| | - Na He
- PKUFH-NINGXIA Women Children’s Hospital, Yinchuan, 750001, People’s Republic of China
| | - Yan Zhang
- The First Clinical Medical College of Ningxia Medical University General Hospital, Yinchuan, 750004, People’s Republic of China
| | - Aqsa Ahmad
- The First Clinical Medical College of Ningxia Medical University General Hospital, Yinchuan, 750004, People’s Republic of China
| | - Xing-Xing Yang
- The First Clinical Medical College of Ningxia Medical University General Hospital, Yinchuan, 750004, People’s Republic of China
| | - Yan Ma
- The First Clinical Medical College of Ningxia Medical University General Hospital, Yinchuan, 750004, People’s Republic of China
| | - Li-Jun Liang
- Department of Pediatrics, General Hospital of Ningxia Medical University, Yinchuan, 750004, People’s Republic of China
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Barnard-Kelly K, Thienel F, Mader JK, Oliver N, Franek E, Vesper I, Dagenbach N, Vogt G, Etter T, Künsting T. A Three-Arm Randomized Controlled Study Comparing Patient-Reported Outcomes in People With Type 1 Diabetes Using Continuous Subcutaneous Insulin Infusion or Multiple Daily Injections. J Diabetes Sci Technol 2024:19322968241234055. [PMID: 38456441 DOI: 10.1177/19322968241234055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Abstract
BACKGROUND The aim of this study was to compare patient-reported outcomes (PROs) in people with type 1 diabetes using either continuous subcutaneous insulin infusion (CSII) with two different insulin patch pumps or multiple daily injections (MDIs). MATERIALS AND METHODS In this randomized three-arm study, people with type 1 diabetes on MDI therapy were included and used either MDI, the Accu-Chek Solo micropump system (Solo) or Omnipod for 26 weeks. From weeks 26 to 39, all participants used CSII with Solo. Patient-reported outcomes were assessed using the diabetes technology questionnaire (DTQ); in addition, HbA1c values were measured. RESULTS Overall, 181 participants were randomized (61 MDI arm, 62 Solo arm, 58 Omnipod arm) and 142 completed the study. After 26 weeks in the study, the DTQ "change" score in the Solo group (105.9 [100.6-111.2]; baseline-adjusted mean [95% confidence interval]) was significantly higher than in the MDI group (94.8 [89.6-100.0]) (P = .001). The comparison between the Solo group (105.1 [99.1-111.1]) and the Omnipod group (108.7 [103.1-114.4]) showed no significant differences (P = .382). HbA1c increased by 0.2% ± 0.7% in the MDI group and decreased in both pump groups (Solo group -0.2% ± 0.8% and Omnipod group -0.1% ± 0.8%). Differences in HbA1c between the Solo group and the MDI group were significant (P = .009), but not between the Solo group and the Omnipod group (P = .896). CONCLUSIONS This study showed that switching from MDI to CSII improves both psychosocial well-being and physiological outcomes. Furthermore, there were no substantial differences between the established and the recently released patch pump. Trial registration at www.clinicaltrials.gov is NCT03478969.
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Affiliation(s)
| | - Florian Thienel
- Christliches Krankenhaus Quakenbrück GmbH, Quakenbrück, Germany
| | - Julia K Mader
- Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Nick Oliver
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Edward Franek
- Central Clinical Hospital of the MSWiA in Warsaw, Warsaw, Poland
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Wang W, Wang S, Zhang Y, Geng Y, Li D, Liu S. Multivariable identification based MPC for closed-loop glucose regulation subject to individual variability. Comput Methods Biomech Biomed Engin 2023:1-14. [PMID: 37982220 DOI: 10.1080/10255842.2023.2282952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 11/02/2023] [Indexed: 11/21/2023]
Abstract
The controller is important for the artificial pancreas to guide insulin infusion in diabetic therapy. However, the inter- and intra-individual variability and time delay of glucose metabolism bring challenges to control glucose within a normal range. In this study, a multivariable identification based model predictive control (mi-MPC) is developed to overcome the above challenges. Firstly, an integrated glucose-insulin model is established to describe insulin absorption, glucose-insulin interaction under meal disturbance, and glucose transport. On this basis, an observable glucose-insulin dynamic model is formed, in which the individual parameters and disturbances can be identified by designing a particle filtering estimator. Next, embedded with the identified glucose-insulin dynamic model, a mi-MPC method is proposed. In this controller, plasma glucose concentration (PGC), an important variable and indicator of glucose regulation, is estimated and controlled directly. Finally, the method was tested on 30 in-silico subjects produced by the UVa/Padova simulator. The results show that the mi-MPC method including the model, individual identification, and the controller can regulate glucose with the mean value of 7.45 mmol/L without meal announcement.
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Affiliation(s)
- Weijie Wang
- College of Mechanical and Vehicle Engineering, Taiyuan University of Technology, Shanxi, China
- Department of Endocrinology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Shanxi, China
| | - Shaoping Wang
- School of Automation Science and Electrical Engineering, Beihang University, Beijing, China
- Beijing Advanced Innovation Center for Big Data-based Precision Medicine, Beijing, China
| | - Yuwei Zhang
- School of Automation Science and Electrical Engineering, Beihang University, Beijing, China
| | - Yixuan Geng
- School of Automation Science and Electrical Engineering, Beihang University, Beijing, China
| | - Deng'ao Li
- College of Data Science, Taiyuan University of Technology, Shanxi, China
| | - Shiwei Liu
- Department of Endocrinology, Shanxi Bethune Hospital, Shanxi Academy of Medical Sciences, Shanxi, China
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7
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Zhang E, Shi Y, Han X, Zhu H, Song B, Yang C, Cao Z. An injectable and biodegradable zwitterionic gel for extending the longevity and performance of insulin infusion catheters. Nat Biomed Eng 2023:10.1038/s41551-023-01108-z. [PMID: 37884794 DOI: 10.1038/s41551-023-01108-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Accepted: 09/18/2023] [Indexed: 10/28/2023]
Abstract
Continuous subcutaneous insulin infusion (CSII) is an essential insulin replacement therapy in the management of diabetes. However, the longevity of clinical CSII is limited by skin complications, by impaired insulin absorption and by occlusions associated with the subcutaneous insertion of CSII catheters, which require replacement and rotation of the insertion site every few days. Here we show that a biodegradable zwitterionic gel covering the tip end of commercial off-the-shelf CSII catheters fully resolves early skin irritations, extends the longevity of catheters and improves the rate of insulin absorption (also with respect to conventional syringe-based subcutaneous injection) for longer than 6 months in diabetic mice, and by 11 days in diabetic minipigs (from 2 to 13 days, under standard CSII-wearing conditions of insulin pump therapy and in a continuous basal-plus-bolus-infusion setting). The implanted gel displayed anti-inflammatory and anti-foreign-body-reaction properties and promoted the local formation of new blood vessels. The gel is subcutaneously injected before the tip of catheter is inserted into it, and should be generally applicable to CSII catheters and other implantable devices.
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Affiliation(s)
- Ershuai Zhang
- Department of Chemical Engineering and Materials Science, Wayne State University, Detroit, MI, USA
| | - Yuanjie Shi
- Department of Chemical Engineering and Materials Science, Wayne State University, Detroit, MI, USA
| | - Xiangfei Han
- Department of Chemical Engineering and Materials Science, Wayne State University, Detroit, MI, USA
| | - Hui Zhu
- Department of Chemical Engineering and Materials Science, Wayne State University, Detroit, MI, USA
| | - Boyi Song
- Department of Chemical Engineering and Materials Science, Wayne State University, Detroit, MI, USA
| | - Chengbiao Yang
- Department of Chemical Engineering and Materials Science, Wayne State University, Detroit, MI, USA
| | - Zhiqiang Cao
- Department of Chemical Engineering and Materials Science, Wayne State University, Detroit, MI, USA.
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8
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Foran J, Egan A, Somers E, O'Connell SM. Close intervention sessions complement intensive insulin therapy in paediatric diabetes: a longitudinal study. Arch Dis Child 2023; 108:818-823. [PMID: 37402632 PMCID: PMC10511970 DOI: 10.1136/archdischild-2023-325436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 06/19/2023] [Indexed: 07/06/2023]
Abstract
OBJECTIVE To examine the impact of multidisciplinary team input and intensive insulin therapy on glycaemic control in children and adolescents with diabetes over a 13-year period. DESIGN Two statistical approaches were used to interrogate the dataset. First a matched pair analysis to compare insulin treatment-type effect (pump vs multiple daily injections (MDIs)), followed by panel data regression to assess the impact of intensive re-education on glycated haemoglobin (HbA1c), in addition to treatment type. SETTING A large tertiary paediatric diabetes centre using a prospectively maintained database of clinical encounters from 2007 to 2020. MAIN OUTCOME MEASURES Difference in HbA1c between treatment types (matching methodology) and expected change in HbA1c with treatment type and re-education (panel data). RESULTS Compared with MDI, matched pump patients had a lower HbA1c 6 months after pump commencement (ΔHbA1c=-0.53%, CI -0.34% to -0.72%; n=106). This effect was robust in controlling for socioeconomic deprivation (ΔHbA1c=-0.74%, CI -0.40% to -1.08%; n=29). Panel data analysis demonstrated a -0.55% reduction in HbA1c with pump therapy compared with MDI therapy (CI -0.43% to -0.67%). Patients who had intensive re-education had recorded an HbA1c of 0.95% (CI 0.85% to 1.05%) greater than otherwise identical patients prior to re-education. Following these sessions, HbA1c dropped by a mean -0.81% (CI -0.68% to -0.95%) within 6 months. These were also robust in controlling for socioeconomic factors. CONCLUSIONS Compared with matched peers on MDI regimens, patients on pump therapy have lower expected HbA1c, an effect sustained for up to 8 years. Intensive re-education is associated with a significant drop in previously elevated HbA1c levels.
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Affiliation(s)
- Jason Foran
- Department of Diabetes and Endocrinology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Aisling Egan
- Department of Diabetes and Endocrinology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Eric Somers
- Department of Diabetes and Endocrinology, Children's Health Ireland at Crumlin, Dublin, Ireland
| | - Susan M O'Connell
- Department of Diabetes and Endocrinology, Children's Health Ireland at Crumlin, Dublin, Ireland
- Paediatrics and Child Health, Royal College of Surgeons Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Ireland
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Schmidt S, Madsen KP, Pedersen-Bjergaard U, Rytter K, Hommel E, Cleal B, Willaing I, Andersen HU, Nørgaard K. Associations between clinical and psychosocial factors and HbA1c in adult insulin pump users with type 1 diabetes. Acta Diabetol 2023:10.1007/s00592-023-02081-4. [PMID: 37160785 DOI: 10.1007/s00592-023-02081-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 03/28/2023] [Indexed: 05/11/2023]
Abstract
AIMS Many adults with type 1 diabetes do not achieve recommended glycemic goals despite intensive insulin therapy using insulin pumps. The aim of this study was to explore associations between clinical and psychosocial factors and HbA1c in insulin pump users to identify and prioritize areas for potential intervention. METHODS A questionnaire-based survey covering clinical and psychosocial aspects of life with type 1 diabetes was distributed to all adult (≥ 18 years) insulin pump users in the Capital Region of Denmark. Responses were combined with data from medical records and national registries. Associations with HbA1c were modeled using regression-based machine learning. RESULTS Of 1,591 invited individuals, 770 (48.4%) responded to the survey. Mean HbA1c among responders was 7.3% (56 mmol/mmol), and 35.6% had an HbA1c < 7.0% (53 mmol/mol). Six factors were significantly associated with HbA1c: diabetes duration (0.006% (0.1 mmol/mol) lower HbA1c per 1-year increase in diabetes duration); education (0.4% (4.3 mmol/mol) lower HbA1c with long higher education vs. primary school); insulin type (0.2% (2.2 mmol/mol) lower HbA1c with ultra-rapid-acting insulin vs. rapid-acting insulin); hypoglycemia awareness status (0.2% (2.2 mmol/mol) lower HbA1c with complete unawareness vs. full awareness); insulin device satisfaction (0.2% (2.7 mmol/mol) lower HbA1c per 1-point increase in Insulin Device Satisfaction Survey score); and diabetes distress (0.3% (3.1 mmol/mol) higher HbA1c per 1-point increase in Type 1 Diabetes Distress Scale score). CONCLUSIONS This study identified several associations between clinical and psychosocial factors and HbA1c that may be considered when developing interventions targeted people with type 1 diabetes.
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Affiliation(s)
- Signe Schmidt
- Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Borgmester Ib Juuls Vej 83, 2730, Herlev, Denmark
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Kristoffer Panduro Madsen
- Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Borgmester Ib Juuls Vej 83, 2730, Herlev, Denmark
- Danish Centre for Health Economics, University of Southern Denmark, Odense, Denmark
| | - Ulrik Pedersen-Bjergaard
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Karen Rytter
- Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Borgmester Ib Juuls Vej 83, 2730, Herlev, Denmark
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark
| | - Eva Hommel
- Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Borgmester Ib Juuls Vej 83, 2730, Herlev, Denmark
| | - Bryan Cleal
- Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Borgmester Ib Juuls Vej 83, 2730, Herlev, Denmark
| | - Ingrid Willaing
- Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Borgmester Ib Juuls Vej 83, 2730, Herlev, Denmark
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Henrik Ullits Andersen
- Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Borgmester Ib Juuls Vej 83, 2730, Herlev, Denmark
| | - Kirsten Nørgaard
- Copenhagen University Hospital - Steno Diabetes Center Copenhagen, Borgmester Ib Juuls Vej 83, 2730, Herlev, Denmark.
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
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10
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Khadem H, Nemat H, Elliott J, Benaissa M. Blood Glucose Level Time Series Forecasting: Nested Deep Ensemble Learning Lag Fusion. Bioengineering (Basel) 2023; 10:bioengineering10040487. [PMID: 37106674 PMCID: PMC10135844 DOI: 10.3390/bioengineering10040487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 04/29/2023] Open
Abstract
Blood glucose level prediction is a critical aspect of diabetes management. It enables individuals to make informed decisions about their insulin dosing, diet, and physical activity. This, in turn, improves their quality of life and reduces the risk of chronic and acute complications. One conundrum in developing time-series forecasting models for blood glucose level prediction is to determine an appropriate length for look-back windows. On the one hand, studying short histories foists the risk of information incompletion. On the other hand, analysing long histories might induce information redundancy due to the data shift phenomenon. Additionally, optimal lag lengths are inconsistent across individuals because of the domain shift occurrence. Therefore, in bespoke analysis, either optimal lag values should be found for each individual separately or a globally suboptimal lag value should be used for all. The former approach degenerates the analysis's congruency and imposes extra perplexity. With the latter, the fine-tunned lag is not necessarily the optimum option for all individuals. To cope with this challenge, this work suggests an interconnected lag fusion framework based on nested meta-learning analysis that improves the accuracy and precision of predictions for personalised blood glucose level forecasting. The proposed framework is leveraged to generate blood glucose prediction models for patients with type 1 diabetes by scrutinising two well-established publicly available Ohio type 1 diabetes datasets. The models developed undergo vigorous evaluation and statistical analysis from mathematical and clinical perspectives. The results achieved underpin the efficacy of the proposed method in blood glucose level time-series prediction analysis.
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Affiliation(s)
- Heydar Khadem
- Department of Electronic and Electrical Engineering, University of Sheffield, Sheffield S10 2TN, UK
| | - Hoda Nemat
- Department of Electronic and Electrical Engineering, University of Sheffield, Sheffield S10 2TN, UK
| | - Jackie Elliott
- Department of Oncology and Metabolism, University of Sheffield, Sheffield S10 2TN, UK
- Department of Diabetes and Endocrinology, Sheffield Teaching Hospitals, Sheffield S5 7AU, UK
| | - Mohammed Benaissa
- Department of Electronic and Electrical Engineering, University of Sheffield, Sheffield S10 2TN, UK
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Lumb A, Misra S, Rayman G, Avari P, Flanagan D, Choudhary P, Dhatariya K. Variation in the Current Use of Technology to Support Diabetes Management in UK Hospitals: Results of a Survey of Health Care Professionals. J Diabetes Sci Technol 2023; 17:733-741. [PMID: 36949718 DOI: 10.1177/19322968231161076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
BACKGROUND There has been a significant increase in the use of wearable diabetes technologies in the outpatient setting over recent years, but this has not consistently translated into inpatient use. METHODS An online survey was undertaken to understand the current use of technology to support inpatient diabetes care in the United Kingdom. RESULTS Responses were received from 42 different organizations representing 104 hospitals across the United Kingdom. Significant variation was found between organizations in the use of technology to support safe, effective inpatient diabetes care. Benefits of the use of technology were reported, and areas of good practice identified. CONCLUSION Technology supports good inpatient diabetes care, but there is currently variation in its use. Guidance has been developed which should drive improvements in the use of technology and hence improvements in the safety and effectiveness of inpatient diabetes care. Key recommendations include implementation of this guidance (especially for continuous glucose monitoring), ensuring specialist support is available for the use of wearable diabetes technology in hospital, optimizing information sharing across the health care system, and making full use of data from networked glucose and ketone meters.
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Affiliation(s)
- Alistair Lumb
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Shivani Misra
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Gerry Rayman
- Ipswich Diabetes Centre, East Suffolk and North Essex NHS Foundation Trust, Ipswich, UK
| | - Parizad Avari
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, London, UK
| | - Daniel Flanagan
- Department of Endocrinology, University Hospital Plymouth, Plymouth, UK
| | - Pratik Choudhary
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
- Norwich Medical School, University of East Anglia, Norwich, UK
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12
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Avari P, Lumb A, Flanagan D, Rayman G, Misra S, Choudhary P, Dhatariya K. Insulin Pumps and Hybrid Close Loop Systems Within Hospital: A Scoping Review and Practical Guidance From the Joint British Diabetes Societies for Inpatient Care. J Diabetes Sci Technol 2022; 17:625-634. [PMID: 36458697 DOI: 10.1177/19322968221137335] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
This article is the second of a two-part series providing a scoping review and summary of the Joint British Diabetes Societies for Inpatient Care (JBDS-IP) guidelines on the use of diabetes technology in people with diabetes admitted to hospital. The first part reviewed the use of continuous glucose monitoring (CGM) in hospital. In this article, we focus on the use of continuous subcutaneous insulin infusion (CSII; insulin pumps) and hybrid closed-loop systems in hospital. JBDS-IP advocates enabling people who can self-manage and are willing and capable of using CSII to continue doing so as they would do out of hospital. CSII should be discontinued if the individual is critically ill or hemodynamically unstable. For individuals on hybrid closed-loop systems, the system should be discontinued from auto-mode, and may be used individually (as CGM only or CSII only, if criteria are met). Continuing in closed-loop mode may only be done so under specialist guidance from the Diabetes Team, where the diabetes teams are comfortable and knowledgeable about the specific devices used. Health care organizations need to have clear local policies and guidance to support individuals using these wearable technologies, and ensure the relevant workforce is capable and skilled enough to ensure their safe use within the hospital setting.
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Affiliation(s)
- Parizad Avari
- Department of Diabetes and Endocrinology, Imperial College Healthcare NHS Trust, London, UK
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Alistair Lumb
- Oxford Centre for Diabetes, Endocrinology and Metabolism, Churchill Hospital, Oxford, UK
| | - Daniel Flanagan
- Department of Endocrinology, University Hospital Plymouth, Plymouth, UK
| | - Gerry Rayman
- Ipswich Diabetes Centre, East Suffolk and North East Essex Foundation Trust, Ipswich, UK
| | - Shivani Misra
- Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Pratik Choudhary
- Diabetes Research Centre, University of Leicester, Leicester, UK
| | - Ketan Dhatariya
- Elsie Bertram Diabetes Centre, Norfolk and Norwich University Hospitals NHS Foundation Trust, Norwich, UK
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13
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Melnychuk J, Wyne K, Dungan K. Predictors of change in hypoglycemia unawareness among patients with type 1 diabetes. Diabetes Metab Res Rev 2022; 38:e3582. [PMID: 36254715 DOI: 10.1002/dmrr.3582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 07/20/2022] [Accepted: 08/12/2022] [Indexed: 11/11/2022]
Abstract
AIMS To analyse predictors of hypoglycemia unawareness (HU) and improvement in Clarke score in clinical practice. MATERIALS AND METHODS We retrospectively identified patients with type 1 diabetes (T1D) at an academic T1D clinic who completed HU surveys 6-12 months apart. HU (Clarke score ≥4) and improvement in Clarke score (decrease by ≥1 point or more clinically relevant ≥2 point) were assessed in univariable relationships and using multivariable logistic regression. RESULTS Of the 300 participants, median diabetes duration was 19 years, 47 had HU at baseline, and 91 had an improvement by 1 point while 21 had an improvement by 2 points. Patients with baseline Clarke score ≥4 who had ≥1 or ≥2 point improvement had lower filtration rate (eGFR) than those who did not. After adjustment for other variables, gender (male OR 0.33, 95% CI 0.15, 0.74), log diabetes duration (OR 6.40, 95% CI 2.84, 14.5), and eGFR <60 ml/min/1.73 m2 (5.56, 95% CI 1.98, 15.6) were independent predictors of baseline HU. Continuous glucose monitoring use (OR 2.04, 95% CI 1.20, 3.48) and log diabetes duration (OR 1.78, 95% CI 1.22, 2.60) were independent predictors of 1 point improvement and eGFR <60 ml/min/1.73 m2 (OR 10.5, 95% CI 3.64, 30.0) and an education visit (OR 2.64, 95% CI 1.01, 6.89) were independent predictors of 2 point improvement in Clarke score. CONCLUSIONS Diabetes duration, gender, and eGFR were independent predictors of HU. Improvement in Clarke score is possible in patients with long-standing T1D, underscoring the need for additional study.
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Affiliation(s)
- Jared Melnychuk
- The Ohio State University College of Medicine, Columbus, Ohio, USA
| | - Kathleen Wyne
- Division of Endocrinology, Diabetes and Metabolism, The Ohio State University, Columbus, Ohio, USA
| | - Kathleen Dungan
- Division of Endocrinology, Diabetes and Metabolism, The Ohio State University, Columbus, Ohio, USA
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14
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Ware J, Hovorka R. Closed-loop insulin delivery: update on the state of the field and emerging technologies. Expert Rev Med Devices 2022; 19:859-875. [PMID: 36331211 PMCID: PMC9780196 DOI: 10.1080/17434440.2022.2142556] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/28/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Over the last five years, closed-loop insulin delivery systems have transitioned from research-only to real-life use. A number of systems have been commercialized and are increasingly used in clinical practice. Given the rapidity of new developments in the field, understanding the capabilities and key similarities and differences of current systems can be challenging. This review aims to provide an update on the state of the field of closed-loop insulin delivery systems, including emerging technologies. AREAS COVERED We summarize key clinical safety and efficacy evidence of commercial and emerging insulin-only hybrid closed-loop systems for type 1 diabetes. A literature search was conducted and clinical trials using closed-loop systems during free-living conditions were identified to report on safety and efficacy data. We comment on emerging technologies and adjuncts for closed-loop systems, as well as non-technological priorities in closed-loop insulin delivery. EXPERT OPINION Commercial hybrid closed-loop insulin delivery systems are efficacious, consistently improving glycemic control when compared to standard therapy. Challenges remain in widespread adoption due to clinical inertia and the lack of resources to embrace technological developments by health care professionals.
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Affiliation(s)
- Julia Ware
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Pediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Pediatrics, University of Cambridge, Cambridge, United Kingdom
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15
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Continuous subcutaneous insulin infusion is associated with a better glycemic control than multiple daily insulin injections without difference in diabetic ketoacidosis and hypoglycemia admissions among Emiratis with Type 1 diabetes. PLoS One 2022; 17:e0264545. [PMID: 36136973 PMCID: PMC9498969 DOI: 10.1371/journal.pone.0264545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 02/12/2022] [Indexed: 11/19/2022] Open
Abstract
Aims
To characterizes Emiratis patients with Type 1 diabetes (T1D) and compares outcomes between continuous subcutaneous insulin infusion (CSII) versus multiple daily insulin injections (MDI) users. The WHO-Five Well-Being Index (WHO-5) score was used to screen for depression.
Methods
In this cross-sectional study; sociodemographic, clinical characteristics and insulin replacement regimens were collected on patients with T1D between 2015–2018.
Results
134 patients with mean age of 20.9±7.5 years were included. Females constitute 56.7% and 50.7% had diabetes duration of >10 years. Diabetic ketoacidosis (DKA) at presentation was reported in 46.3%. Average glycemic control over preceding 12months was satisfactory (less than 7.5%), suboptimal (7.5–9%), and poor (more than 9%) in 26.6%, 42.7% & 30.6% of the patients, respectively. Higher proportion of patients using CSII achieved satisfactory or suboptimal glycemic control compared to patients with MDI (P = 0.003). The latest median /IQR HbA1c was significantly lower (P = 0.041) in patients using CSII (8.2 /1.93%) compared to MDI (8.5/2.45%). There was no significant difference between two groups in DKA, severe hypoglycemia or total WHO-5 score.
Conclusions
CSII usage was associated with better glycemic control than MDI, although no difference in DKA and severe hypoglycemia. The overall glycemic control among Emiratis subjects with T1D is unsatisfactory and needs more rigorous patient counseling and education.
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16
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Jones J, James S, Brown F, O'Neal D, I Ekinci E. Dead in bed - A systematic review of overnight deaths in type 1 diabetes. Diabetes Res Clin Pract 2022; 191:110042. [PMID: 36007797 DOI: 10.1016/j.diabres.2022.110042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 05/18/2022] [Accepted: 08/11/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Type 1 diabetes is a significant, life-long condition which affects many people worldwide. One of the most feared causes of type 1 diabetes mortality, overnight mortality, often caused by the dead in bed syndrome, is largely underreported. A systematic literature search was undertaken to understand the frequency, risk factors, causes and impact that diabetes-related technologies have on overnight mortality, in this population. METHODS MEDLINE (Ovid), Embase (Ovid) and Cochrane were searched to June 2021, using defined inclusion and exclusion criteria. Quality appraisal was undertaken. RESULTS Overall, 26 records met the inclusion criteria. Large-scale cohort studies examined data up to 2013, and there were no studies published after 2018. The proportion of deaths attributable to the dead in bed syndrome was between 2 and 5% of deaths in children, adolescents, and young adults, with a slight decrease in proportion of dead in bed syndrome since 1991. CONCLUSION Overnight mortality is occurring for people with type 1 diabetes, reported as recently as in 2018. Living alone, alcohol and illicit substances consistently appear as risk factors, and the impact of technology on overnight mortality is not fully understood, with more recent data, from larger cohort studies being required.
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Affiliation(s)
- Jessica Jones
- Department of Medicine, University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia; Department of Endocrinology, Austin Health, 145 Studley Road, Heidelberg, Victoria 3084, Australia; Australian Centre of Accelerating Diabetes Innovations (ACADI), University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia
| | - Steven James
- Department of Medicine, University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia; Australian Centre of Accelerating Diabetes Innovations (ACADI), University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia; School of Nursing, Midwifery and Paramedicine, University of the Sunshine Coast, 1 Moreton Parade, Petrie, Queensland 4502, Australia
| | - Fran Brown
- Melbourne Diabetes Education & Support, 76 Edwin St, Heidelberg Heights, Victoria 3081, Australia
| | - David O'Neal
- Department of Medicine, University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia; Australian Centre of Accelerating Diabetes Innovations (ACADI), University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia; Department of Endocrinology, St Vincent's Hospital, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia
| | - Elif I Ekinci
- Department of Medicine, University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia; Department of Endocrinology, Austin Health, 145 Studley Road, Heidelberg, Victoria 3084, Australia; Australian Centre of Accelerating Diabetes Innovations (ACADI), University of Melbourne, Grattan Street, Parkville, Victoria 3010, Australia.
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17
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Tzivian L, Sokolovska J, Grike AE, Kalcenaua A, Seidmann A, Benis A, Mednis M, Danovska I, Berzins U, Bogdanovs A, Syundyukov E. Quantitative and qualitative analysis of the quality of life of Type 1 diabetes patients using insulin pumps and of those receiving multiple daily insulin injections. Health Qual Life Outcomes 2022; 20:120. [PMID: 35915454 PMCID: PMC9344781 DOI: 10.1186/s12955-022-02029-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 07/18/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Insulin pump therapy represents an alternative to multiple daily injections and can improve glycemic control and quality of life (QoL) in Type 1 diabetes mellitus (T1DM) patients. We aimed to explore the differences and factors related to the T1DM-specific QoL of such patients in Latvia. Design and methods A mixed-method cross-sectional study on 87 adult T1DM patients included 20 pump users and 67 users of injections who participated in the quantitative part of the study; 8 pump users and 13 injection users participated in the qualitative part. Patients were invited to participate using a dedicated digital platform. Their QoL and self-management habits were assessed using specially developed questionnaires adapted to Latvian conditions. Multiple logistic regression models were built to investigate the association between social and self-management factors and patients’ QoL. In addition, qualitative analysis of answers was performed. Results Insulin pump users were younger, had higher incomes, and reported higher T1DM expenses than users of multiple daily injections. There were no differences in self-management between the groups; Total QoL differed at the 0.1 significance level. In fully adjusted multiple logistic regression models, the most important factor that increased Total QoL was lower T1DM-related expenses (odds ratio, OR 7.02 [95% confidence interval 1.29; 38.0]). Men and those with more years of living with T1DM had better QoL (OR 9.62 [2.20; 42.1] and OR 1.16 [1.05; 1.29], respectively), but the method of administration was not significantly associated with QoL (OR 7.38 [0.87; 62.9]). Qualitative data supported the results of quantitative analysis. Conclusions QoL was the main reason to use an insulin pump, while the expense was the main reason to avoid the use of it or to stop using it. Reimbursement policies thus should be considered to enable patients to choose the more convenient method for themselves. Supplementary Information The online version contains supplementary material available at 10.1186/s12955-022-02029-2.
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Affiliation(s)
- Lilian Tzivian
- Faculty of Medicine, University of Latvia, Jelgavas Str. 3, Riga, Latvia.
| | | | - Anna E Grike
- Faculty of Humanities, University of Latvia, Riga, Latvia
| | - Agate Kalcenaua
- Faculty of Medicine, Riga Stardins University, Riga, Latvia.,Longenesis Ltd, Riga, Latvia
| | - Abraham Seidmann
- Questrom Business School, Boston University, Boston, MA, 02215, USA.,Digital Business Institute, Health Analytics and Digital Health, Boston University, Boston, MA, 02215, USA
| | - Arriel Benis
- Faculty of Industrial Engineering and Technology Management, Holon Institute of Technology, 5810201, Holon, Israel.,Faculty of Digital Technologies in Medicine, Holon Institute of Technology, 5810201, Holon, Israel
| | | | | | | | | | - Emil Syundyukov
- Longenesis Ltd, Riga, Latvia.,Faculty of Computing, University of Latvia, Raina boulevard 19, Riga, 1050, Latvia
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18
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Lal R, Leelarathna L. Insulin Delivery Hardware: Pumps and Pens. Diabetes Technol Ther 2022; 24:S21-S34. [PMID: 35475688 PMCID: PMC9206467 DOI: 10.1089/dia.2022.2502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Rayhan Lal
- Division of Endocrinology, Department of Medicine & Pediatrics, Stanford University School of Medicine, Stanford, CA
- Stanford Diabetes Research Center, Stanford University School of Medicine, Stanford, CA
| | - Lalantha Leelarathna
- Manchester Diabetes Centre, Manchester University NHS Foundation Trust, Manchester, UK and Division of Diabetes, Endocrinology and Gastroenterology, University of Manchester, Manchester, UK
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19
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Ware J, Hovorka R. Recent advances in closed-loop insulin delivery. Metabolism 2022; 127:154953. [PMID: 34890648 PMCID: PMC8792215 DOI: 10.1016/j.metabol.2021.154953] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 11/05/2021] [Accepted: 11/24/2021] [Indexed: 02/03/2023]
Abstract
Since the discovery of insulin 100 years ago, we have seen considerable advances across diabetes therapies. The more recent advent of glucose-responsive automated insulin delivery has started to revolutionise the management of type 1 diabetes in children and adults. Evolution of closed-loop insulin delivery from research to clinical practice has been rapid, and multiple systems are now commercially available. In this review, we summarise key evidence on currently available closed-loop systems and those in development. We comment on dual-hormone and do-it-yourself systems, as well as reviewing clinical evidence in special populations such as very young children, older adults and in pregnancy. We identify future directions for research and barriers to closed-loop adoption, including how these might be addressed to ensure equitable access to this novel therapy.
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Affiliation(s)
- Julia Ware
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom; Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom; Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom.
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20
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Rytter K, Madsen KP, Andersen HU, Cleal B, Hommel E, Nexø MA, Pedersen-Bjergaard U, Skinner T, Willaing I, Nørgaard K, Schmidt S. Insulin Pump Treatment in Adults with Type 1 Diabetes in the Capital Region of Denmark: Design and Cohort Characteristics of the Steno Tech Survey. Diabetes Ther 2022; 13:113-129. [PMID: 34807407 PMCID: PMC8607214 DOI: 10.1007/s13300-021-01181-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 11/03/2021] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Insulin pump therapy can improve quality of life and glycaemic outcomes for many people with type 1 diabetes (T1D). The multidimensional Steno Tech Survey study aims to investigate why some insulin pump users do not achieve treatment goals. In this article, we present the study design and analyse differences in population characteristics between responders and non-responders. METHODS In June 2020, all 1591 insulin pump users (≥ 18 years) in the Capital Region of Denmark were invited to participate in an online questionnaire that evaluated several dimensions of insulin pump self-management and psychosocial health. Demographic, socioeconomic and clinical characteristics, including age, sex and HbA1c, of the cohort were identified via national registries. Predictors of questionnaire response/non-response were explored with logistic regression analysis. RESULTS In the full study population, 58% were female, median age was 42 years and median HbA1c was 58 mmol/mol (7.5%); 30% had HbA1c < 53 mmol/mol (7.0%). In total, 770 individuals (48%) responded to the questionnaire. Logistic regression analysis showed that 50+ years of age (odds ratio [OR] = 2.3, 95% confidence interval [CI]: 1.4-3.8), female sex (OR = 1.3, CI: 1.02-1.6), being married (OR = 1.8, CI: 1.3-2.4) and having long higher education (OR = 1.6, CI: 1.004-2.5) were significantly associated with a higher likelihood of responding to the survey; the opposite was found for HbA1c from 64 to < 75 mmol (8.0-9.0%) (OR = 0.6, CI: 0.4-0.8) and HbA1c ≥ 75 mmol/mol (≥ 9.0%) (OR = 0.2, CI: 0.1-0.3). CONCLUSIONS The established Steno Tech cohort enables future analysis of a range of psychosocial and behavioural aspects of insulin pump self-management. Interpretation and generalization of findings should consider observed differences between responders and non-responders.
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Affiliation(s)
- Karen Rytter
- Clinical Research, Copenhagen University Hospital – Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Kristoffer P. Madsen
- Health Promotion Research, Copenhagen University Hospital – Steno Diabetes Center Copenhagen, Herlev, Denmark
- Danish Centre for Health Economics, University of Southern Denmark, Odense, Denmark
| | - Henrik U. Andersen
- Clinical Research, Copenhagen University Hospital – Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Bryan Cleal
- Health Promotion Research, Copenhagen University Hospital – Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Eva Hommel
- Clinical Research, Copenhagen University Hospital – Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Mette A. Nexø
- Health Promotion Research, Copenhagen University Hospital – Steno Diabetes Center Copenhagen, Herlev, Denmark
| | - Ulrik Pedersen-Bjergaard
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Endocrinology and Nephrology, Nordsjællands Hospital, Hillerød, Denmark
| | - Timothy Skinner
- Department of Psychology, University of Copenhagen, Copenhagen, Denmark
| | - Ingrid Willaing
- Health Promotion Research, Copenhagen University Hospital – Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Kirsten Nørgaard
- Clinical Research, Copenhagen University Hospital – Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Signe Schmidt
- Clinical Research, Copenhagen University Hospital – Steno Diabetes Center Copenhagen, Herlev, Denmark
- Department of Clinical Pharmacology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
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21
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Bratke H, Margeirsdottir HD, Assmus J, Njølstad PR, Skrivarhaug T. Does Current Diabetes Technology Improve Metabolic Control? A Cross-Sectional Study on the Use of Insulin Pumps and Continuous Glucose Monitoring Devices in a Nationwide Pediatric Population. Diabetes Ther 2021; 12:2571-2583. [PMID: 34389930 PMCID: PMC8385028 DOI: 10.1007/s13300-021-01127-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/21/2021] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE To examine the use of multiple daily injections (MDI), insulin pumps, self-measured blood glucose (SMBG), and continuous glucose monitoring (CGM) systems, and their association with glycated hemoglobin (HbA1c), diabetic ketoacidosis (DKA), and severe hypoglycemia. METHODS In a pediatric population-based nationwide cross-sectional study, we analyzed data from 2623 participants up to 18 years of age with type 1 diabetes, using 2017 annual data from the Norwegian Childhood Diabetes Registry. HbA1c was adjusted for age, gender, and diabetes duration. Using a linear mixed-effects model, we assessed HbA1c and the incidence of DKA and severe hypoglycemia according to the use of MDI, insulin pumps, SMBG, and CGM. RESULTS We observed that 74.7% of participants were using an insulin pump and 52.6% were using a CGM system. Mean HbA1c was 7.8% (62 mmol/mol). The HbA1c of pump users was 0.14 percentage points (pp) higher than that of MDI users. Fewer pump users than MDI users achieved an HbA1c of < 7.5% (38.3 vs. 41.6%). CGM users had a 0.18 pp lower HbA1c than SMBG users, with 40.5 and 38.0%, respectively, achieving an HbA1c of < 7.5%. The incidence of severe hypoglycemia or hospitalization due to DKA was not different in pump and CGM users compared with nonusers. Compared with other insulin pumps, patch pump use was associated with a significantly lower odds ratio for DKA. CONCLUSIONS Despite the broad use of diabetes technology, as many as 61% of our pediatric cohort did not reach the HbA1c target recommended by the International Society for Pediatric and Adolescent Diabetes (ISPAD). Lower HbA1c was associated with CGM use but not with insulin pump use. Acute complications were not less frequent in the groups using insulin pumps or CGM compared with those using MDI and SMBG. Further research is required to explore the lower incidence of DKA among patch pump users. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT04201171.
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Affiliation(s)
- Heiko Bratke
- Department of Pediatrics, Haugesund Hospital, Fonna Health Trust, Postbox 2170, 5504, Haugesund, Norway.
- Department of Clinical Science, Center for Diabetes Research, University of Bergen, Bergen, Norway.
- Oslo Diabetes Research Centre, Oslo, Norway.
| | - Hanna D Margeirsdottir
- Oslo Diabetes Research Centre, Oslo, Norway
- Division of Childhood and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
| | - Jörg Assmus
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
| | - Pål R Njølstad
- Department of Clinical Science, Center for Diabetes Research, University of Bergen, Bergen, Norway
- Children and Adolescent Clinic, Haukeland University Hospital, Bergen, Norway
| | - Torild Skrivarhaug
- Oslo Diabetes Research Centre, Oslo, Norway
- Division of Childhood and Adolescent Medicine, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Division of Childhood and Adolescent Medicine, The Norwegian Childhood Diabetes Registry, Oslo University Hospital, Oslo, Norway
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22
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Antich-Isern P, Caro-Barri J, Aparicio-Blanco J. The combination of medical devices and medicinal products revisited from the new European legal framework. Int J Pharm 2021; 607:120992. [PMID: 34390808 DOI: 10.1016/j.ijpharm.2021.120992] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Revised: 07/20/2021] [Accepted: 08/08/2021] [Indexed: 02/06/2023]
Abstract
Medical devices and medicinal products have many similarities in their nature, scope or specific medical purposes, and despite the differences in their principal means of action, they are often used in combination. Indeed, many medicinal products depend on medical devices for their administration, and it is increasingly common for medical devices to contain medicinal substances to support their action. Therefore, the combination of medicinal products and medical devices provides additional benefits for patients. However, their higher technical complexity requires a strengthening of their authorisation and certification requirements. In this regard, more comprehensive requirements and classification rules are introduced by a new European regulation on medical devices that fully applies from May 26th 2021. On account of their therapeutic significance, this review aims at gaining insight into the borderline between medical devices and medicinal products in this new 2021 regulatory framework. For the first time, any item containing a medical device and a medicinal product will have both parts evaluated. Through exemplification of both marketed and investigational devices incorporating medicinal substances and drug-device combinations, the new European requirements and their implications are thoroughly illustrated herein.
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Affiliation(s)
- Pau Antich-Isern
- Department of Pharmaceutics and Food Technology, Faculty of Pharmacy, Complutense University of Madrid, Madrid, Spain
| | - Julia Caro-Barri
- Notified Body 0318, Spanish Agency of Medicines and Medical Devices (AEMPS), Madrid, Spain
| | - Juan Aparicio-Blanco
- Department of Pharmaceutics and Food Technology, Faculty of Pharmacy, Complutense University of Madrid, Madrid, Spain; Institute of Industrial Pharmacy, Complutense University of Madrid, Madrid, Spain.
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23
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Lavens A, Nobels F, De Block C, Oriot P, Verhaegen A, Chao S, Casteels K, Mouraux T, Doggen K, Mathieu C. Effect of an Integrated, Multidisciplinary Nationwide Approach to Type 1 Diabetes Care on Metabolic Outcomes: An Observational Real-World Study. Diabetes Technol Ther 2021; 23:565-576. [PMID: 33780640 DOI: 10.1089/dia.2021.0003] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Objective: Achieving good metabolic control in people with type 1 diabetes (T1D) remains a challenge, despite the evolutions in diabetes technologies over the past decade. Here we investigate the evolution of metabolic control in people with T1D, where care is provided by specialized centers with access to technology, diabetes education, and regular follow-up. Methods: Data were cross-sectionally collected between 2010 and 2018 from more than 100 centers in Belgium. The evolutions over time of hemoglobin A1C (HbA1c), low-density lipoprotein (LDL) cholesterol, and systolic blood pressure (SBP) were investigated, together with the evolutions of use of insulin pump (continuous subcutaneous insulin infusion [CSII]), continuous glucose monitoring (CGM), and lipid-lowering and antihypertensive drugs. Association of HbA1c with gender, age, diabetes duration, and technology use was analyzed on the most recent cohort. Results: The study population contained data from 89,834 people with T1D (age 1-80 years). Mean HbA1c decreased from 65 mmol/mol (8.1%) in 2010-2011 to 61 mmol/mol (7.7%) in 2017-2018 (P < 0.0001, adjusted for gender, age, diabetes duration, and technology use). Respectively, mean LDL cholesterol decreased from 2.45 mmol/L (94.6 mg/dL) to 2.29 mmol/L (88.5 mg/dL) (P < 0.0001, adjusted for gender, age, and diabetes duration), and mean SBP remained stable. CGM usage increased, whereas the use of CSII and lipid-lowering and antihypertensive drugs remained stable. Gender, age, diabetes duration, and technology use were independently associated with HbA1c. Conclusions: Our real-world data show that metabolic and lipid control improved over time in a system where T1D care is organized through specialized multidisciplinary centers with emphasis on linking education to provision of technology, and its quality is monitored.
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Affiliation(s)
- Astrid Lavens
- Health Services Research, Sciensano, Brussels, Belgium
| | - Frank Nobels
- Department of Endocrinology, Onze-Lieve-Vrouw Hospital Aalst, Aalst, Belgium
| | - Christophe De Block
- Department of Endocrinology, Diabetology and Metabolism, University of Antwerp-Antwerp University Hospital, Antwerp, Belgium
| | - Philippe Oriot
- Department of Endocrinology and Diabetes, Mouscron Hospital Centre, Mouscron, Belgium
| | - Ann Verhaegen
- Department of Endocrinology, Diabetology and Metabolism, University of Antwerp-Antwerp University Hospital, Antwerp, Belgium
| | - Suchsia Chao
- Health Services Research, Sciensano, Brussels, Belgium
| | - Kristina Casteels
- Department of Pediatrics, University Hospitals Leuven-KU Leuven, Leuven, Belgium
- Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Thierry Mouraux
- Department of Pediatric Endocronology, University Hospitals de Namur-UC Louvain, Yvoir, Belgium
| | - Kris Doggen
- Health Services Research, Sciensano, Brussels, Belgium
| | - Chantal Mathieu
- Department of Endocrinology, University Hospitals Leuven-KU Leuven, Leuven, Belgium
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24
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Priesterroth L, Grammes J, Clauter M, Kubiak T. Diabetes technologies in people with type 1 diabetes mellitus and disordered eating: A systematic review on continuous subcutaneous insulin infusion, continuous glucose monitoring and automated insulin delivery. Diabet Med 2021; 38:e14581. [PMID: 33826771 DOI: 10.1111/dme.14581] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 03/26/2021] [Accepted: 03/31/2021] [Indexed: 02/06/2023]
Abstract
AIMS In this systematic review, we aimed (1) to identify and describe research investigating the use of advanced diabetes technologies (continuous subcutaneous insulin infusion, CSII; continuous glucose monitoring, CGM; automated insulin delivery, AID) in people with type 1 diabetes (T1DM) and disordered eating and (2) to discuss potential (dis)advantages of diabetes technology use in this population, derived from previous research. METHODS We conducted a systematic literature search in two electronic databases for English articles published between 2000 and 2020 addressing eating disorders and/or dysfunctional eating behaviours and diabetes technology use in children, adolescents and adults with T1DM (PROSPERO ID CRD42020160244). RESULTS Of 70 publications initially identified, 17 were included. Overall, evidence on the use of diabetes technologies in people with T1DM and disordered eating is scarce. The majority of the studies reports findings on CSII in people with T1DM and dysfunctional eating behaviours or eating disorders. Findings predominantly stem from observational data and are, in most cases, secondary findings of the respective studies. Providing the greatest flexibility in diabetes management, CSII may have benefits in disordered eating. CGM data may complement the diagnostic process of disordered eating with a physiological indicator of insulin restriction (i.e. time spent in hyperglycaemia). CONCLUSIONS Results on possible (dis)advantages of diabetes technology use in people with T1DM and disordered eating are based on observational data, small pilot trials and anecdotical evidence from case reports. Prospective data from larger samples are needed to reliably determine potential effects of diabetes technology on disordered eating in T1DM.
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Affiliation(s)
- Lilli Priesterroth
- Health Psychology, Institute of Psychology, Johannes Gutenberg University, Mainz, Germany
| | - Jennifer Grammes
- Health Psychology, Institute of Psychology, Johannes Gutenberg University, Mainz, Germany
| | - Mona Clauter
- Health Psychology, Institute of Psychology, Johannes Gutenberg University, Mainz, Germany
| | - Thomas Kubiak
- Health Psychology, Institute of Psychology, Johannes Gutenberg University, Mainz, Germany
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25
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Freckmann G, Buck S, Waldenmaier D, Kulzer B, Schnell O, Gelchsheimer U, Ziegler R, Heinemann L. Insulin Pump Therapy for Patients With Type 2 Diabetes Mellitus: Evidence, Current Barriers, and New Technologies. J Diabetes Sci Technol 2021; 15:901-915. [PMID: 32476471 PMCID: PMC8258526 DOI: 10.1177/1932296820928100] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Guido Freckmann
- Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
| | - Sina Buck
- Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
- Sina Buck, MSc, Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Lise-Meitner-Straße 8/2, Ulm 89081, Germany.
| | - Delia Waldenmaier
- Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
| | - Bernhard Kulzer
- Forschungsinstitut Diabetes Akademie Bad Mergentheim, Germany
| | - Oliver Schnell
- Forschergruppe Diabetes e.V., Helmholtz Zentrum, Munich, Germany
| | | | - Ralph Ziegler
- Diabetes Clinic for Children and Adolescents, Münster, Germany
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26
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Jeyam A, Gibb FW, McKnight JA, Kennon B, O'Reilly JE, Caparrotta TM, Höhn A, McGurnaghan SJ, Blackbourn LAK, Hatam S, McCrimmon RJ, Leese G, Lindsay RS, Petrie J, Chalmers J, Philip S, Wild SH, Sattar N, McKeigue PM, Colhoun HM. Marked improvements in glycaemic outcomes following insulin pump therapy initiation in people with type 1 diabetes: a nationwide observational study in Scotland. Diabetologia 2021; 64:1320-1331. [PMID: 33686483 PMCID: PMC8099793 DOI: 10.1007/s00125-021-05413-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 12/21/2020] [Indexed: 11/06/2022]
Abstract
AIMS/HYPOTHESIS Our aim was to assess the use of continuous subcutaneous insulin infusion (CSII) in people with type 1 diabetes in Scotland and its association with glycaemic control, as measured by HbA1c levels, frequency of diabetic ketoacidosis (DKA) and severe hospitalised hypoglycaemia (SHH), overall and stratified by baseline HbA1c. METHODS We included 4684 individuals with type 1 diabetes from the national Scottish register, who commenced CSII between 2004 and 2019. We presented crude within-person differences from baseline HbA1c over time since initiation, crude DKA and SHH event-rates pre-/post-CSII exposure. We then used mixed models to assess the significance of CSII exposure, taking into account: (1) the diffuse nature of the intervention (i.e. structured education often precedes initiation); (2) repeated within-person measurements; and (3) background time-trends occurring pre-intervention. RESULTS HbA1c decreased after CSII initiation, with a median within-person change of -5.5 mmol/mol (IQR -12.0, 0.0) (-0.5% [IQR -1.1, 0.0]). Within-person changes were most substantial in those with the highest baseline HbA1c, with median -21.0 mmol/mol (-30.0, -11.0) (-1.9% [-2.7, -1.0]) change in those with a baseline >84 mmol/mol (9.8%) within a year of exposure, that was sustained: -19.0 mmol/mol (-27.6, -6.5) (-1.7% [-2.5, -0.6]) at ≥5 years. Statistical significance and magnitude of change were supported by the mixed models results. The crude DKA event-rate was significantly lower in post-CSII person-time compared with pre-CSII person-time: 49.6 events (95% CI 46.3, 53.1) per 1000 person-years vs 67.9 (64.1, 71.9); rate ratio from Bayesian mixed models adjusting for pre-exposure trend: 0.61 (95% credible interval [CrI] 0.47, 0.77; posterior probability of reduction pp = 1.00). The crude overall SHH event-rate in post-CSII vs pre-CSII person-time was also lower: 17.8 events (95% CI 15.8, 19.9) per 1000 person-years post-exposure vs 25.8 (23.5, 28.3) pre-exposure; rate ratio from Bayesian mixed models adjusting for pre-exposure trend: 0.67 (95% CrI 0.45, 1.01; pp = 0.97). CONCLUSIONS/INTERPRETATION CSII therapy was associated with marked falls in HbA1c especially in those with high baseline HbA1c. CSII was independently associated with reduced DKA and SHH rates. CSII appears to be an effective option for intensive insulin therapy in people with diabetes for improving suboptimal glycaemic control.
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Affiliation(s)
- Anita Jeyam
- MRC Institute of Genetic and Molecular Medicine, University of Edinburgh, Edinburgh, UK.
| | - Fraser W Gibb
- Royal Infirmary of Edinburgh, Edinburgh Centre for Endocrinology and Diabetes, Edinburgh, UK
| | | | - Brian Kennon
- Queen Elizabeth University Hospital, Glasgow, UK
| | - Joseph E O'Reilly
- MRC Institute of Genetic and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Thomas M Caparrotta
- MRC Institute of Genetic and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Andreas Höhn
- MRC Institute of Genetic and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Stuart J McGurnaghan
- MRC Institute of Genetic and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Luke A K Blackbourn
- MRC Institute of Genetic and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Sara Hatam
- MRC Institute of Genetic and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | - Rory J McCrimmon
- Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | | | - Robert S Lindsay
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - John Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Sam Philip
- Grampian Diabetes Research Unit, Diabetes Centre, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Sarah H Wild
- Usher Institute of Population Health Sciences and Informatics, Centre for Population Health Sciences, School of Molecular, Genetic and Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Paul M McKeigue
- Usher Institute of Population Health Sciences and Informatics, Centre for Population Health Sciences, School of Molecular, Genetic and Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Helen M Colhoun
- MRC Institute of Genetic and Molecular Medicine, University of Edinburgh, Edinburgh, UK
- Public Health, NHS Fife, Kirkcaldy, UK
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27
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Haak T, Herrmann E, Lippmann-Grob B, Tombek A, Hermanns N, Krichbaum M. The Effect of Prandial Insulin Applied for Fat Protein Units on Postprandial Glucose Excursions in Type 1 Diabetes Patients with Insulin Pump Therapy: Results of a Randomized, Controlled, Cross-Over Study. Exp Clin Endocrinol Diabetes 2021; 130:262-267. [PMID: 33878763 DOI: 10.1055/a-1474-8193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE This randomized cross-over study aimed to compare different algorithms for calculating prandial insulin considering the fat and protein content of a standardized meal in type 1 diabetes patients using insulin pump therapy (CSII). METHODS Twenty-six patients received a standardized evening meal for three consecutive days using different algorithms for insulin dose adjustment: A) exclusive consideration of carbohydrate content without considering fat-protein content, B) high-dose algorithm considering additional insulin for fat protein units (FPUs) with the same factor as for carbohydrates, and C) low-dose algorithm considering additional insulin for FPUs with half the factor as for carbohydrates. The primary outcome was the proportion of interstitial glucose values in the target range (≥ 70 to ≤ 180 mg/dl) during the post-prandial 12-hour follow-up period. Secondary outcomes were the occurrence of hypo- and hyperglycemic episodes and the coverage with carbohydrates for treatment of hypoglycemia. RESULTS The percentage of glucose values in the target range was significantly higher when fat-protein content was not considered, whereas, in the hyperglycemic range, it did not differ significantly among the three groups. The percentage of hypoglycemic glucose values were the highest in the groups considering fat-protein content and lowest in the group not considering FPUs with no significant difference between the two groups in terms of FPUs. CONCLUSIONS In adult type 1 diabetes patients using CSII, it is not recommended to consider a high fat and protein content in the diet when calculating prandial insulin dosage with the selected algorithms, as this increases the risk of hypoglycemia disproportionately.
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Affiliation(s)
- Thomas Haak
- Diabetes Clinic, Bad Mergentheim, Gemany.,FIDAM - Research Institute Diabetes Academy, Mergentheim, Gemany
| | | | - Bernhard Lippmann-Grob
- Diabetes Clinic, Bad Mergentheim, Gemany.,FIDAM - Research Institute Diabetes Academy, Mergentheim, Gemany
| | | | - Norbert Hermanns
- Diabetes Clinic, Bad Mergentheim, Gemany.,FIDAM - Research Institute Diabetes Academy, Mergentheim, Gemany
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28
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Lind N, Lindqvist Hansen D, Sætre Rasmussen S, Nørgaard K. Real-time continuous glucose monitoring versus self-monitoring of blood glucose in adults with insulin-treated type 2 diabetes: a protocol for a randomised controlled single-centre trial. BMJ Open 2021; 11:e040648. [PMID: 33452188 PMCID: PMC7813336 DOI: 10.1136/bmjopen-2020-040648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Medical treatment options for type 2 diabetes (T2D) have increased over the last decade and enhance the possibility of individualised treatment strategies where insulin is still one of them. In spite of the advancements in treatment options, less than one-third of the population with T2D obtain their optimal glycaemic goal. In persons with type 1 diabetes, continuous glucose monitoring (CGM) has shown to be the most important driver for improvement in glycaemic control, even more than insulin-pump therapy. The use of technology in T2D has only been investigated in few studies.The overall objective of the research study is to examine the effectiveness of the use of CGM versus self-monitoring of blood glucose (SMBG) in persons with insulin-treated T2D on glycaemic variables and patient-reported outcomes on treatment satisfaction, health behaviour and well-being. The independent effect of peer support will also be studied. METHODS AND ANALYSIS The study is a single centre, prospective, randomised, open-labelled, three-armed study with the randomisation 2:1:2 in group A with CGM, group B with CGM and peer support, and group C as a control group with SMBG. The participants receive a training course unique for the allocation group. The study runs for 12 months and includes 100 adult participants with insulin-treated T2D, treated at the outpatient clinic at Steno Diabetes Center Copenhagen. Primary outcome is difference in change in time in range. Recruitment begins in August 2020 and ends in July 2021. Final 12-month follow-up is anticipated to be in August 2022. ETHICS AND DISSEMINATION The study will be carried out in accordance with the Helsinki Declaration and is approved by the Scientific Ethics Committee of the Capital Region (H-20000843). Data collection and handling will be performed in accordance with the General Data Protection Regulation and is approved by the Danish Data Protection Agency (J-2020-100). Dissemination will be in international peer-reviewed journals, conferences and a plain-language summary for participants. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Registry (NCT04331444). PROTOCOL VERSION V.3, 11 December 2020.
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Affiliation(s)
- Nanna Lind
- Clinical Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark
| | | | | | - Kirsten Nørgaard
- Clinical Research, Steno Diabetes Center Copenhagen, Gentofte, Denmark
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29
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Kwa T, Zhang G, Shepard K, Wherry K, Chattaraj S. The improved survival rate and cost-effectiveness of a 7-day continuous subcutaneous insulin infusion set. J Med Econ 2021; 24:837-845. [PMID: 34154504 DOI: 10.1080/13696998.2021.1945784] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
AIMS The purpose of this article is to compare the insulin cost-savings of the Medtronic Extended Infusion Set (or EIS, a.k.a. Extended Wear Infusion Set) designed and labeled for up to 7-day use with rapid-acting insulins to the current standard of care, 2- to 3-day infusion sets. METHODS There are three major improvements (reducing insulin waste, plastic waste, and adverse events) with the extended duration of infusion set wear. This analysis focuses on cost savings from reduced insulin wastage during set changes. Studies published on insulin infusion set survival and EIS clinical trial data (NCT04113694) were used to estimate device lifetime performance using a Markov chain Monte Carlo model, including the assessment of adverse effects and device failure. Total costs associated with infusion set change or failure were systematically found in published literature or estimated based on physical usage, and the direct impact on insulin costs was calculated. RESULTS Based on the model and clinical data, EIS users can expect to change their infusion sets about 75 fewer times than standard set users each year. The costs related to unrecoverable insulin during an infusion set and reservoir change in the US were estimated to range from $19.79 to $22.48, resulting in approximately $1324 to $1677 in annual cost-savings for the typical user from minimizing insulin wastage. LIMITATIONS The study only assessed devices used within a monitored setting, that is, clinical trials. In addition, the variability associated with healthcare standards and costs and individual treatment variability including insulin dosages, contribute to the uncertainties with the calculations. CONCLUSIONS Our analysis demonstrates that by extending the duration of infusion set wear, there may be substantial cost savings by reducing insulin wastage.
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30
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Hu S, Yang H, Chen Z, Leng X, Li C, Qiao L, Lv W, Li T. Clinical Outcome and Cost-Effectiveness Analysis of CSII Versus MDI in Children and Adolescent With Type 1 Diabetes Mellitus in a Public Health Care System of China. Front Endocrinol (Lausanne) 2021; 12:604028. [PMID: 33859614 PMCID: PMC8043415 DOI: 10.3389/fendo.2021.604028] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 01/20/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES To evaluate the clinical and economic consequences of continuous subcutaneous insulin infusion (CSII) vs. multiple daily injections (MDI) in children and adolescents with type 1 diabetes mellitus (T1DM) from a public health care system in developed areas of developing country, considering changes in glycemic Control, daily insulin requirements, lipid profile, body mass index (BMI), frequency of severe hypoglycemia and Diabetic Ketoacidosis (DKA) and diabetic complications. METHODS This was a retrospective cohort study of children and adolescents with T1DM. Data were collected at baseline and the end of every year including glycated hemoglobin (HbA1c), insulin dose, lipid profile, blood pressure, and adverse events (severe hypoglycemia and DKA). The Cost-effectiveness analysis was performed using the IQVIA CORE Diabetes Model (CDM) to simulate diabetes progression by utilizing the clinical data obtained from the two groups. The main outcome measures were Life Expectancy, Quality adjusted life years (QALYs), Total Costs and Incremental Costs and Effectiveness Ratio (ICER) of CSII compared with MDI in Chinese pediatric patients with T1DM in Qingdao City (60 years). RESULTS Mean HbA1c values and daily insulin doses were significantly lower in those receiving CSII therapy throughout follow-up. Mean direct lifetime costs were ¥ 67,137 higher with CSII treatment than with MDI for pediatric patients. Treatment with CSII was associated with an improvement in life expectancy of 0.41 years for pediatric patients compared with MDI based on CORE diabetes model simulation. The corresponding gains in QALYs were 0.42. These data produced corresponding ICER is ¥ 161,815 per QALY for pediatric T1DM patients in Qingdao. Sensitivity analyses suggested that our base-case assumptions were mostly robust. CONCLUSIONS CSII is associated with improved long-term clinical outcomes compared with MDI. Based on this model analysis, CSII appears to be more cost-effective for the Qingdao TIDM pediatric population and health care system.
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Affiliation(s)
- Sicui Hu
- Paediatric Endocrinology and Metabolism Department, Qingdao Women and Children’s Hospital, Qingdao, China
| | - Hongxiu Yang
- Paediatric Endocrinology and Metabolism Department, Qingdao Women and Children’s Hospital, Qingdao, China
| | - Zhihong Chen
- Neuroendocrine Pediatric Department, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Xuefei Leng
- Neuroendocrine Pediatric Department, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Cheng Li
- Paediatric Endocrinology and Metabolism Department, Qingdao Women and Children’s Hospital, Qingdao, China
| | - Lingyan Qiao
- Paediatric Endocrinology and Metabolism Department, Qingdao Women and Children’s Hospital, Qingdao, China
| | - Weiqing Lv
- Research and Development Department, Medtronic (Shanghai) Management Co, Ltd, Shanghai, China
| | - Tang Li
- Paediatric Endocrinology and Metabolism Department, Qingdao Women and Children’s Hospital, Qingdao, China
- *Correspondence: Tang Li,
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31
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Waldenmaier D, Zschornack E, Buhr A, Pleus S, Haug C, Freckmann G. A Prospective Study of Insulin Infusion Set Use for up to 7 Days: Early Replacement Reasons and Impact on Glycemic Control. Diabetes Technol Ther 2020; 22:734-741. [PMID: 32167382 DOI: 10.1089/dia.2019.0445] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background: There is limited evidence supporting a replacement interval of infusion sets for continuous subcutaneous insulin infusion (CSII). The aim of this study was to investigate if steel and soft cannula infusion sets can be used in CSII therapy for up to 7 days without negative impact on infusion sites or glycemic control. Methods: The insulin infusion sets YpsoPump® Orbit®micro (steel needle) and YpsoPump® Orbit®soft (soft cannula) were each used for up to 7 days by 40 adult subjects with CSII. Each subject used both infusion set types twice. Early replacement reasons were documented and glycemic control was monitored. Results: Of 160 inserted insulin infusion sets, 66% were used for 7 days with no obvious difference between steel and soft infusion sets. The mean wearing time was 6.2 ± 1.5 days. Main reasons for early infusion set replacements were occlusions (19%), plaster issues (4%), and accidental pull-out (4%). Comparing glycemic control during day 1-3 and 1-7, mean glucose was 146 ± 21 mg/dL versus 148 ± 18 mg/dL, coefficient of variation was 34% ± 7% versus 33% ± 5%, and insulin dose was 40 ± 11 U versus 41 ± 11 U. Only mild and nonserious infusion site reactions occurred. Conclusions: In this study, 7 days indwelling time of insulin infusion sets did not show a clinically relevant impact on glycemic control or insulin requirements and the infectious risk appeared to be low. The replacement interval of infusion sets may be individualized beyond the currently labeled maximum use duration.
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Affiliation(s)
- Delia Waldenmaier
- Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
| | - Eva Zschornack
- Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
| | | | - Stefan Pleus
- Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
| | - Cornelia Haug
- Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
| | - Guido Freckmann
- Institut für Diabetes-Technologie, Forschungs- und Entwicklungsgesellschaft mbH an der Universität Ulm, Ulm, Germany
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Schmidt S, Andersen Nexø M, Norgaard O, Willaing I, Pedersen-Bjergaard U, Skinner TC, Nørgaard K. Psychosocial factors associated with HbA 1c in adults with insulin pump-treated type 1 diabetes: a systematic review. Diabet Med 2020; 37:1454-1462. [PMID: 32579748 DOI: 10.1111/dme.14347] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2020] [Revised: 05/16/2020] [Accepted: 06/18/2020] [Indexed: 01/31/2023]
Abstract
AIMS To identify currently available studies on the association between psychosocial factors and HbA1c in adults with insulin pump-treated type 1 diabetes, by performing a systematic review of the literature. METHODS MEDLINE, Embase, CINAHL and PsycINFO were searched for original studies on the association between psychosocial factors and HbA1c in ≥ 50 adult, non-pregnant, insulin pump users with type 1 diabetes. RESULTS The search resulted in 1777 unique records, of which eight were eligible for inclusion. All identified studies were observational, with sample sizes ranging from 51 to 214. Seven different psychosocial factors were investigated in the eight studies. Study analysis suggested that HbA1c may be associated with diabetes numeracy and quality of life. There were no indications of associations between HbA1c and fear of hypoglycaemia or self-efficacy. Results regarding associations between HbA1c and coping style, diabetes distress and locus of control were inconsistent. CONCLUSIONS This systematic review summarizes the currently limited information on the association between psychosocial factors and HbA1c during insulin pump therapy. The evidence base of the included studies was weak, and this review highlights the need for more research in these areas, with improved methodological and theoretical frameworks, including exploration of a broader spectrum of psychosocial variables and their potential association with HbA1c and other metabolic outcomes. (PROSPERO International prospective register of systematic reviews registration no: CRD42020145705).
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Affiliation(s)
- S Schmidt
- Steno Diabetes Centre Copenhagen, Gentofte, Denmark
| | | | - O Norgaard
- Steno Diabetes Centre Copenhagen, Gentofte, Denmark
| | - I Willaing
- Steno Diabetes Centre Copenhagen, Gentofte, Denmark
| | - U Pedersen-Bjergaard
- Nordsjaellands Hospital, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - T C Skinner
- Institute of Psychology, University of Copenhagen, Copenhagen, Denmark
- La Trobe Rural Health School, La Trobe University, Bendigo, Australia
| | - K Nørgaard
- Steno Diabetes Centre Copenhagen, Gentofte, Denmark
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Fuchs J, Hovorka R. Closed-loop control in insulin pumps for type-1 diabetes mellitus: safety and efficacy. Expert Rev Med Devices 2020; 17:707-720. [PMID: 32569476 PMCID: PMC7441745 DOI: 10.1080/17434440.2020.1784724] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 06/16/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Type 1 diabetes is a lifelong disease with high management burden. The majority of people with type 1 diabetes fail to achieve glycemic targets. Algorithm-driven automated insulin delivery (closed-loop) systems aim to address these challenges. This review provides an overview of commercial and emerging closed-loop systems. AREAS COVERED We review safety and efficacy of commercial and emerging hybrid closed-loop systems. A literature search was conducted and clinical trials using day-and-night closed-loop systems during free-living conditions were used to report on safety data. We comment on efficacy where robust randomized controlled trial data for a particular system are available. We highlight similarities and differences between commercial systems. EXPERT OPINION Study data shows that hybrid closed-loop systems are safe and effective, consistently improving glycemic control when compared to standard therapy. While a fully closed-loop system with minimal burden remains the end-goal, these hybrid closed-loop systems have transformative potential in diabetes care.
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Affiliation(s)
- Julia Fuchs
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
| | - Roman Hovorka
- Wellcome Trust-MRC Institute of Metabolic Science, University of Cambridge, Cambridge, United Kingdom
- Department of Paediatrics, University of Cambridge, Cambridge, United Kingdom
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Grammes J, Küstner E, Dapp A, Hummel M, Kämmer JC, Kubiak T, Schütz-Fuhrmann I, Zimny S, Bollow E, Holl RW. Comparative characteristics of older people with type 1 diabetes treated with continuous subcutaneous insulin infusion or insulin injection therapy: data from the German/Austrian DPV registry. Diabet Med 2020; 37:856-862. [PMID: 31853984 DOI: 10.1111/dme.14218] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2019] [Indexed: 01/30/2023]
Abstract
AIM To compare clinical characteristics and outcomes in adults with type 1 diabetes aged ≥ 60 years using continuous subcutaneous insulin infusion (CSII) vs. insulin injection therapy. Further, to determine the percentage of older adults with type 1 diabetes using CSII. RESEARCH DESIGN AND METHODS Retrospective study using data of the Diabetes Prospective Follow-up Registry (DPV). Including percentage CSII use from 2008 to 2018, and the characteristics of 9547 individuals extracted from the DPV in March 2019 (N = 1404 CSII; N = 8143 insulin injection therapy). Wilcoxon rank sum tests were used for continuous variables and chi-square tests for categorical variables to compare clinical characteristics of people using CSII vs. insulin injection therapy. Adjusted analyses used generalized linear models to compare diabetes-related outcomes. RESULTS CSII usage has increased in older adults (from 12% in 2008 to 23% in 2018). After adjustment, CSII was associated with lower HbA1c [60.7 mmol/mol (7.7 ± 0.1%) vs. 62.8% (7.9 ± 0.1%)], lower daily insulin dose (0.49 ± 0.02 vs. 0.61 ± 0.01 IU/kg), fewer days in hospital (8.1 ± 0.12 vs. 11.2 ± 0.11 days/person-year), fewer severe hypoglycaemic events (0.16 ± 0.02 vs. 0.21 ± 0.03 events/person-year) and fewer diabetic ketoacidosis (0.06 ± 0.01 vs. 0.08 ± 0.01 events/person-year). Individuals on CSII showed lower rates of microalbuminuria and also have a diagnosis of depression and neuropathy. CONCLUSIONS A growing number of older adults are using insulin pumps. Older age in itself should not be seen as a contraindication for CSII.
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Affiliation(s)
- J Grammes
- Health Psychology, Institute of Psychology, Johannes Gutenberg University, Mainz, Germany
- Diabetes Technology Working Group, Ulm, Germany
| | - E Küstner
- Diabetes Technology Working Group, Ulm, Germany
| | - A Dapp
- Diabetes Center, Hospital District Tuttlingen, Medical Clinic Spaichingen, Spaichingen, Germany
| | - M Hummel
- Diabetology Outpatient Clinic, Rosenheim, Germany
| | - J-C Kämmer
- Department of Gastroenterology, Cardiology, Diabetology and Geriatrics, Vivantes Klinikum, Berlin, Germany
| | - T Kubiak
- Health Psychology, Institute of Psychology, Johannes Gutenberg University, Mainz, Germany
- Diabetes Technology Working Group, Ulm, Germany
| | - I Schütz-Fuhrmann
- Department of Internal Medicine, Krankenhaus Hietzing, Vienna, Austria
| | - S Zimny
- Department of Internal Medicine, Endocrinology and Diabetology, Helios Kliniken, Schwerin, Germany
| | - E Bollow
- ZIBMT, Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich, Germany
| | - R W Holl
- ZIBMT, Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
- German Center for Diabetes Research (DZD), Munich, Germany
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Abstract
The success of diabetes technologies depends on the attitudes and behavior of the individuals who choose to adopt them. Real-time continuous glucose monitoring, continuous subcutaneous insulin infusion, and sensor-augmented pump systems may positively affect diabetes-related quality of life (QOL), although the influence on QOL outcomes seems to be modest and the results from randomized controlled trials are limited and controversial. In contrast, more consistently positive QOL-related responses are apparent from observational data. The newer generations of devices hold the promise for more strongly enhancing diabetes-related QOL. Appropriate training and ongoing support are likely to be the key to successful uptake.
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Affiliation(s)
- William H Polonsky
- Behavioral Diabetes Institute, 5405 Oberlin Drive, Suite 100, San Diego, CA 92121, USA; University of California, San Diego, San Diego, CA, USA.
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36
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Thunander M, Lindgren A, Petersson C, Landin-Olsson M, Holmberg S. Standard mortality rates and years of life lost for serologically defined adult-onset type 1 and type 2 diabetes - A fifteen year follow-up. Diabetes Res Clin Pract 2020; 160:107943. [PMID: 31765685 DOI: 10.1016/j.diabres.2019.107943] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 11/08/2019] [Accepted: 11/19/2019] [Indexed: 10/25/2022]
Abstract
AIMS The Diabetes Incidence in Kronoberg (DIK) study of adult-onset diabetes used serological classification. Standard Mortality Rates (SMR) and Years of Life Lost (YLL) 15 years after adult-onset (18-100 years) of diabetes were compared to the population of Kronoberg. METHODS Of 1609/1660 (97%) patients, 112 (7%) had type 1 (T1D) (GADA+ and/or ICA+, and/or C-peptide < 0.25 nmol/l), and 1497 (93%) had type 2 diabetes (T2D) (antibody- and C-peptide ≥ 0.25 nmol/l). The National Swedish Mortality Register provided time of death. RESULTS For T1D SMR did not differ from the Kronoberg population in any age group. In T2D SMR was 1.20 (1.12-1.29). After 15 years 26% (29/112) T1D and 52% (785/1497) T2D patients had died, p < 0.0001. In T2D SMR was 5.6 (30-39 years), 2 (40-59 years), 1.4 (60-69 years), and thereafter no difference. There were no significant sex differences in mortality, and no YLL to adult-onset T1D, but five YLL to T2D for onset at ages 20-60 years. CONCLUSIONS For adult-onset T1D SMR did not differ from the general population, in contrast to previous findings in childhood-onset (< 30 years of age) T1D. The difference in mortality between persons with diabetes and the general population was due to higher mortality in T2D.
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Affiliation(s)
- Maria Thunander
- Department of Clinical Sciences, Diabetes and Endocrinology, Lund University, Lund, Sweden; Department of Research and Development, Region Kronoberg, Växjö, Sweden; Department of Internal Medicine, Endocrinology and Diabetes, Central Hospital, Växjö, Sweden.
| | - Anna Lindgren
- Centre for Mathematical Sciences, Lund University, Lund, Sweden
| | - Christer Petersson
- Department of Research and Development, Region Kronoberg, Växjö, Sweden; Primary Care, Region Kronoberg, Växjö, Sweden
| | - Mona Landin-Olsson
- Department of Clinical Sciences, Diabetes and Endocrinology, Lund University, Lund, Sweden; Department of Endocrinology and Diabetes, Skane University Hospital, Lund, Sweden
| | - Sara Holmberg
- Department of Research and Development, Region Kronoberg, Växjö, Sweden; Division of Occupational and Environmental Medicine, Lund University, Lund, Sweden
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Puckett C, Wong JC, Daley TC, Cossen K. How organizations shape medical technology allocation: Insulin pumps and pediatric patients with type 1 diabetes. Soc Sci Med 2020; 249:112825. [PMID: 32088512 PMCID: PMC8063485 DOI: 10.1016/j.socscimed.2020.112825] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 01/18/2020] [Accepted: 01/28/2020] [Indexed: 10/25/2022]
Abstract
Although guidelines for prescribing insulin pumps to patients with type 1 diabetes (T1D) focus on patient assessment, sociological research shows decision-making is influenced by the organizations within which actors are embedded. However, how organizational context shapes unequal resource allocation by race and class is less well understood. To investigate this, we compare two pediatric endocrinology centers differing in racial and socio-economic equity in pump use. Using over 400 h of observations and 16 provider interviews, we find allocation is shaped by how organizations use patient cultural health capital to determine pump eligibility, frame technology use, and structure decision-making processes. Overall, findings extend health inequalities research by describing how organizations shape technology resource allocation by race and class.
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Affiliation(s)
- Cassidy Puckett
- Department of Sociology, Emory University, 1555 Tarbutton Hall, Room 225, Atlanta, GA 30322, USA.
| | - Jenise C Wong
- Department of Pediatrics, Division of Endocrinology, University of California, San Francisco, USA
| | - Tanicia C Daley
- Department of Pediatrics, Division of Endocrinology, Emory University School of Medicine, USA
| | - Kristina Cossen
- Department of Pediatrics, Division of Endocrinology, Emory University School of Medicine, USA
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Gupta J, Fuchs GS, Jenkins M, van Geel B, Jensen ML, Sparre T. User Satisfaction and Insulin Pump Handling With a Prefilled Insulin Cartridge in Adults and Adolescents With Type 1 Diabetes. J Diabetes Sci Technol 2020; 14:97-104. [PMID: 31113250 PMCID: PMC7189155 DOI: 10.1177/1932296819848700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND This comparative handling study investigated user satisfaction and insulin pump handling with a prefilled insulin cartridge versus a self-filled insulin reservoir in insulin pump users with type 1 diabetes (T1D). METHODS Adult (n = 105) and adolescent (n = 25) participants performed insulin pump preparations using a prefilled insulin cartridge and self-filled insulin reservoir. User satisfaction, insulin pump preparation time, and residual air in infusion set tubing were assessed for each insulin filling method. Post hoc analysis evaluated training time. RESULTS User satisfaction scores were statistically significantly different in favor of the prefilled insulin cartridge versus the self-filled insulin reservoir (mean [SD]: overall, 4.0 [0.5] vs 3.3 [0.9]; burden on the user, 1.8 [0.6] vs 2.9 [1.0]; user inconvenience, 2.0 [0.7] vs 2.8 [1.1]; device effectiveness, 3.9 [0.7] vs 3.6 [0.9]; all P < .001). Insulin pump preparation time and residual air measurements were significantly different and numerically lower for the prefilled insulin cartridge versus the self-filled insulin reservoir (mean [SD]: preparation time, 124.4 [30.3] vs 237.8 [64.2] seconds, P < .001; residual air, 2.3 [26.3] vs 10.0 [63.3] mm, P = .007). Training time was shorter with the prefilled insulin cartridge versus the self-filled insulin reservoir (mean [min; max]: 193.1 [36; 453] vs 535.8 [124; 992] seconds). CONCLUSIONS Adult and adolescent insulin pump users were more satisfied with the prefilled insulin cartridge versus the self-filled insulin reservoir when preparing an insulin pump. The prefilled insulin cartridge was associated with reduced insulin pump preparation time and reduced training time versus the self-filled insulin reservoir.
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Affiliation(s)
- Jitendra Gupta
- Novo Nordisk A/S, Søborg, Denmark
- Jitendra Gupta, Novo Nordisk A/S,
Vandtårnsvej 114, 2860 Søborg, Denmark.
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Beck RW, Bergenstal RM, Laffel LM, Pickup JC. Advances in technology for management of type 1 diabetes. Lancet 2019; 394:1265-1273. [PMID: 31533908 DOI: 10.1016/s0140-6736(19)31142-0] [Citation(s) in RCA: 132] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 04/26/2019] [Accepted: 05/01/2019] [Indexed: 01/07/2023]
Abstract
Technological advances have had a major effect on the management of type 1 diabetes. In addition to blood glucose meters, devices used by people with type 1 diabetes include insulin pumps, continuous glucose monitors, and, most recently, systems that combine both a pump and a monitor for algorithm-driven automation of insulin delivery. In the next 5 years, as many advances are expected in technology for the management of diabetes as there have been in the past 5 years, with improvements in continuous glucose monitoring and more available choices of systems that automate insulin delivery. Expansion of the use of technology will be needed beyond endocrinology practices to primary-care settings and broader populations of patients. Tools to support decision making will also need to be developed to help patients and health-care providers to use the output of these devices to optimise diabetes management.
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Affiliation(s)
- Roy W Beck
- Jaeb Center for Health Research, Tampa, FL, USA.
| | - Richard M Bergenstal
- International Diabetes Center, Park Nicollet and Health Partners, Minneapolis, MN, USA
| | - Lori M Laffel
- Joslin Diabetes Center, Harvard Medical School, Boston, MA, USA
| | - John C Pickup
- King's College London, Faculty of Life Sciences and Medicine, Guy's Hospital, London, UK
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40
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Galindo RJ, Migdal AL, Umpierrez GE. Are We Ready to Move Beyond Capillary Glucose Testing and Insulin Injections? Am J Med Sci 2019; 358:315-316. [PMID: 31655712 DOI: 10.1016/j.amjms.2019.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Indexed: 01/22/2023]
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Postprandial Glucose Control in Type 1 Diabetes: Importance of the Gastric Emptying Rate. Nutrients 2019; 11:nu11071559. [PMID: 31295897 PMCID: PMC6683017 DOI: 10.3390/nu11071559] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 07/05/2019] [Accepted: 07/08/2019] [Indexed: 12/14/2022] Open
Abstract
The achievement of optimal post-prandial (PP) glucose control in patients with type 1 diabetes (T1DM) remains a great challenge. This review summarizes the main factors contributing to PP glucose response and discusses the likely reasons why PP glucose control is rarely achieved in T1DM patients. The macronutrient composition of the meal, the rate of gastric emptying and premeal insulin administration are key factors affecting the PP glucose response in T1DM. Although the use of continuous insulin infusion systems has improved PP glucose control compared to conventional insulin therapy, there is still need for further ameliorations. T1DM patients frequently present a delayed gastric emptying (GE) that produces a lower but more prolonged PP hyperglycemia. In addition, delayed GE is associated with a longer time to reach the glycemic peak, with a consequent mismatch between PP glucose elevation and the timing of premeal insulin action. On this basis, including GE time and meal composition in the algorithms for insulin bolus calculation of the insulin delivery systems could be an important step forward for optimization of PP glucose control in T1DM.
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42
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Senn JD, Fischli S, Slahor L, Schelbert S, Henzen C. Long-Term Effects of Initiating Continuous Subcutaneous Insulin Infusion (CSII) and Continuous Glucose Monitoring (CGM) in People with Type 1 Diabetes and Unsatisfactory Diabetes Control. J Clin Med 2019; 8:jcm8030394. [PMID: 30901914 PMCID: PMC6463068 DOI: 10.3390/jcm8030394] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Revised: 03/13/2019] [Accepted: 03/19/2019] [Indexed: 12/01/2022] Open
Abstract
Background: We aimed to assess the long-term effects of the introduction of continuous subcutaneous insulin infusion (CSII) and continuous glucose monitoring (CGM) in people with type 1 diabetes (T1D). Methods: A prospective single-centre cohort study including participants with T1D and HbA1c > 7.5%. After completing a course in flexible intensified insulin treatment (FIT), participants were offered treatment change to CSII/CGM. FIT participants with HbA1c ≤ 7.5% who remained on multiple daily injections (MDI) and without CGM were monitored as a separate cohort to compare the cumulative incidence of diabetic complications. Results: The study cohort included 41 participants with T1D (21 male/20 female). The mean age (±SD) at inclusion was 24.2 ± 10.9 years, the mean follow-up was 8.9 ± 2.8 years, and the mean diabetes duration at the end of the study was 15.9 ± 10.1 years. The mean HbA1c level before the introduction of CSII was 8.8 ± 1.3% (73 ± 8 mmol/mol), and decreased significantly thereafter to 8.0 ± 1.1% (63 ± 7 mmol/mol) (p = 0.0001), and further to 7.6 ± 1.1% (59 ± 11 mmol/mol) after the initiation of CGM (p = 0.051). In the MDI group the HbA1c levels did not change significantly during a mean follow-up of 6.8 ± 3.2 years. The frequency of severe hypoglycaemia after the introduction of CSII/CGM declined significantly (from 9.7 to 2.2 per 100 patient-years, p = 0.03), and the cumulative incidence of newly diagnosed diabetic microvascular complications were comparable between the study group and the observational cohort. Conclusion: In people with T1D and unsatisfactory diabetes control the introduction of CSII and CGM results in a substantial and long-term improvement.
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Affiliation(s)
- Jon-Duri Senn
- Division of Endocrinology, Diabetology, and Clinical Nutrition, Department of Medicine, Lucerne Cantonal Hospital, CH-6000 Lucerne 16, Switzerland.
| | - Stefan Fischli
- Division of Endocrinology, Diabetology, and Clinical Nutrition, Department of Medicine, Lucerne Cantonal Hospital, CH-6000 Lucerne 16, Switzerland.
| | - Lea Slahor
- Division of Endocrinology, Diabetology, and Clinical Nutrition, Department of Medicine, Lucerne Cantonal Hospital, CH-6000 Lucerne 16, Switzerland.
| | - Susanne Schelbert
- Division of Endocrinology, Diabetology, and Clinical Nutrition, Department of Medicine, Lucerne Cantonal Hospital, CH-6000 Lucerne 16, Switzerland.
| | - Christoph Henzen
- Division of Endocrinology, Diabetology, and Clinical Nutrition, Department of Medicine, Lucerne Cantonal Hospital, CH-6000 Lucerne 16, Switzerland.
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Abstract
Objective: Clinical trial data demonstrates improved glycemic control with hybrid close loop (HCL) insulin delivery systems, yet limited real-world data exists. Data from the inaugural cohort of patients initiating a HCL system (Medtronic MiniMed™ 670G, Medtronic Canada, Brampton, ON) at a university medical center was used to examine real-world utilization and glycemic control following a standardized implementation process. Methods: Data from 34 adult patients with type 1 diabetes were obtained from pump downloads at 4 time points: (1) previous insulin pump, (2) HCL in manual-mode, (3) 2 weeks after HCL auto-mode transition, and (4) 6 to 12 weeks after initiation of HCL. In-person training by certified diabetes educators was performed across 3 sessions with phone and electronic messaging following auto-mode start. Results: Mean self-monitored blood glucose (SMBG) per day increased from 5.15 baseline to 6.49 at 6 to 12 weeks (P<.05) with 3.26 sensor calibrations per day. Time-in-auto-mode was 79.3% at 2 weeks and 72.3% at final follow-up, with 82% of patients spending >50% of time in auto-mode. There were 8.2 auto-mode exits over the final 14-day download. Time-in-target was 67.3% in manual-mode, 73.4% at 2 weeks (P = .09), and 71.7% by 6 to 12 weeks (P = .06). Hemoglobin A1c (HbA1c) decreased by 0.51% (P = .02), while total daily dose and % basal did not change. Patients with HbA1c <7.0% (53 mmol/mol) at baseline spent more time-in-target than those with HbA1c ≥7.0% (53 mmol/mol; 78.0% versus 67.5%) despite spending less time-in-auto-mode (66.5% versus 74.8%). Conclusion: These data illustrate real-world implementation of HCL technology using a structured education program within a major medical center. Overall benefit may vary based on baseline characteristics such as HbA1c. Abbreviations: CDE = certified diabetes educator; HbA1c = hemoglobin A1c; HCL = hybrid closed loop; SMBG = self-monitored blood glucose.
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Oliver N, Holt RIG. The James Lind Alliance research priorities for diabetes. Diabet Med 2019; 36:267-268. [PMID: 30770611 DOI: 10.1111/dme.13917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- N Oliver
- Diabetic Medicine, London, UK
- Division of Diabetes and Endocrinology, Imperial College, London, UK
| | - R I G Holt
- Diabetic Medicine, University of Southampton, Southampton, UK
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
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MacIsaac RJ, Lee MH, McAuley SA, Ward GM, O’Neal DN. Empagliflozin as an adjunctive therapy for type 1 diabetes. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:S134. [PMID: 30740455 PMCID: PMC6330613 DOI: 10.21037/atm.2018.12.52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Accepted: 12/18/2018] [Indexed: 11/06/2022]
Affiliation(s)
- Richard J. MacIsaac
- Department of Endocrinology & Diabetes, St Vincent’s Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Victoria, Australia
| | - Melissa H. Lee
- Department of Endocrinology & Diabetes, St Vincent’s Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Victoria, Australia
| | - Sybil A. McAuley
- Department of Endocrinology & Diabetes, St Vincent’s Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Victoria, Australia
| | - Glenn M. Ward
- Department of Endocrinology & Diabetes, St Vincent’s Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Victoria, Australia
| | - David N. O’Neal
- Department of Endocrinology & Diabetes, St Vincent’s Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Victoria, Australia
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