Effect of divergent continuous glucose monitoring technologies on glycaemic control in type 1 diabetes mellitus: A systematic review and meta-analysis of randomised controlled trials

Performance of a Novel Continuous Glucose Monitoring Device in People With Diabetes

BACKGROUND

In this multicenter study, performance of a novel continuous glucose monitoring (CGM) system was evaluated.

METHODS

Adult participants with diabetes were included in the study. They each wore three sensors of the CGM system on the upper arms for up to 14 days. During four in-clinic visits, frequent comparison measurements with capillary blood glucose (BG) samples were performed. The primary endpoint was the 20/20 agreement rate (AR): the percentage of CGM readings within ±20 mg/dL (at BG values <100 mg/dL) or ±20% (at BG values ≥100 mg/dL) of the comparator. Further evaluations included mean absolute relative difference (MARD) and 20/20 AR in different BG ranges and across the wear time.

RESULTS

Data from 48 participants and 139 sensors were analyzed. During in-clinic sessions the 20/20 AR was 90.5% and the MARD was 9.2%. For BG ranges <70, 70-180, and >180 mg/dL, 20/20 AR was 94.3%, 89.0%, and 92.5%, respectively. At the beginning, middle, and end of sensor wear time, 20/20 AR was 92.8%, 91.5%, and 85.9%, respectively. The 14-day survival probability was 82.4%. Pain and bleeding after sensor insertion were within the expected range. Based on the study outcome, the use of the device is regarded as safe.

CONCLUSIONS

The system showed a good performance compared to capillary BG measurements. This level of accuracy could be shown over the entire measurement range, especially in the low glycemic range, and the whole wear time of the sensors. The results of this study are supporting a non-adjunctive use of the device.

Impact in real-world of intermittent-scanned continuous glucose monitoring with alarms on hypoglycemia and its recognition in type 1 diabetes

BACKGROUND

Recent studies have demonstrated that real-time CGM use reduce the incidence severe hypoglycemic events and impaired awareness of hypoglycemia (IAH) However, there are few real-world studies evaluating the effect of intermittently scanned continuous glucose monitoring (isCGM) on hypoglycemic episodes and hypoglycemia unawareness (IAH). The present study was designed to cover this research-practice gap.

METHODS

This is a real-world, observational, prospective cohort study with 2 years of follow-up in which 60 subjects with T1D who experienced frequent hypoglycemic events were included. All the patients were invited to use isCGM type Abbott FreeStyle Libre 2® on a continuous basis for 2 years. Glucometric parameters were obtained during the initial 2 weeks using isCGM and compared with data collected for the same period at 1 year and at the end of follow-up. The IAH was evaluated using the Clarke questionnaire, and to assess psychological aspects related to hypoglycemia the Hypoglycemia Fear Survey (HFS) was used.

RESULTS

After 2-years of follow-up using isCGM, we observed a decrease in glucose variability (40.3 ± 0.8 % vs. 37.1 ± 0.9 %, p = 0.003), time in low glucose range (54-69 mg/dL) (5.2 ± 0.4 % vs. 3.6 ± 0.3 %, p = 0.001), time in very low glucose range (<54 mg/dL) (3.2 ± 0.5 % vs. 0.8 ± 0.2 %, p < 0.001), less events related to low glucose levels (10.6 ± 1.1 vs 8.0 ± 1.0, p = 0.042) and a short duration of hypoglycemia episodes (106.1 ± 5.9 min vs. 85.7 ± 5.7 min, p = 0.008). In addition, participants presented a reduction of 47 % in the frequency of IAH, assessed by the Clarke questionnaire scores (24.6 % vs. 11.6 %, p = 0.034), as well as hypoglycemia fear (77.8 ± 2.4 vs 68.2 ± 2.1, p < 0.001). Furthermore, a reduction in total insulin dose was also observed (0.64 ± 0.30 UI/Kg/day vs 0.56 ± 0.11 UI/Kg/day, p = 0.018).

CONCLUSIONS

In the real-world, long-term use of isCGM could reduce both hypoglycemic episodes and IAH in people with T1D.

Ward monitoring 4.0: real-time metabolic insights from continuous glucose monitoring into perioperative organ dysfunction

The now-routine clinical deployment of continuous glucose monitoring has demonstrated benefit in real-world settings. We make the case that continuous glucose monitoring can help re-examine, at scale, the role that (stress) hyperglycaemia plays in fuelling organ dysfunction after tissue trauma. Provided robust perioperative data do emerge, well-established continuous glucose monitoring technology could soon help transform the perioperative landscape.

Accuracy of an Off-Label Transmitter and Data Manager Paired With an Intermittent Scanned Continuous Glucose Monitor in Adults With Type 1 Diabetes

BACKGROUND

This work evaluates the accuracy and agreement between the FreeStyle Libre sensor (FSL) and an off-label converted real-time continuous glucose monitor (c-rtCGM) device consisting of the MiaoMiao transmitter and the xDrip+ application which can be coupled to the FSL.

METHODS

Four weeks of glucose data were collected from 21 participants with type 1 diabetes using the c-rtCGM and FSL: two weeks with a single initial calibration (uncalibrated) and two weeks with a daily calibration (calibrated). Accuracy and agreement evaluation included mean absolute relative difference (MARD), the %20/20 rule, Bland-Altman plots, and the Consensus Error Grid analysis.

RESULTS

Values reported by the c-rtCGM system compared with the FSL resulted in an overall MARD of 12.06% and 84.71% of the results falling within Consensus Error Grid Zone A when the device is calibrated. For uncalibrated devices, an overall MARD of 17.49% was obtained. Decreased accuracy was shown in the hypoglycemic range and for rates of change greater than 2 mg/dL/min. The between-device bias also incremented with increasing glucose values.

CONCLUSION

Measurements recorded by the c-rtCGM were found to be accurate when compared with FSL data only when performing daily c-rtCGM device calibrations. High drops in accuracy and agreement between devices occurred when the c-rtCGM was not calibrated.

Prioritizing Patient Experiences in the Management of Diabetes and Its Complications: An Endocrine Society Position Statement

Diabetes can be an arduous journey both for people with diabetes (PWD) and their caregivers. While the journey of every person with diabetes is unique, common themes emerge in managing this disease. To date, the experiences of PWD have not been fully considered to successfully implement the recommended standards of diabetes care in practice. It is critical for health-care providers (HCPs) to recognize perspectives of PWD to achieve optimal health outcomes. Further, existing tools are available to facilitate patient-centered care but are often underused. This statement summarizes findings from multistakeholder expert roundtable discussions hosted by the Endocrine Society that aimed to identify existing gaps in the management of diabetes and its complications and to identify tools needed to empower HCPs and PWD to address their many challenges. The roundtables included delegates from professional societies, governmental organizations, patient advocacy organizations, and social enterprises committed to making life better for PWD. Each section begins with a clinical scenario that serves as a framework to achieve desired health outcomes and includes a discussion of resources for HCPs to deliver patient-centered care in clinical practice. As diabetes management evolves, achieving this goal will also require the development of new tools to help guide HCPs in supporting PWD, as well as concrete strategies for the efficient uptake of these tools in clinical practice to minimize provider burden. Importantly, coordination among various stakeholders including PWD, HCPs, caregivers, policymakers, and payers is critical at all stages of the patient journey.

Comparator Data Characteristics and Testing Procedures for the Clinical Performance Evaluation of Continuous Glucose Monitoring Systems

Comparing the performance of different continuous glucose monitoring (CGM) systems is challenging due to the lack of comprehensive guidelines for clinical study design. In particular, the absence of concise requirements for the distribution of comparator (reference) blood glucose (BG) concentrations and their rate of change (RoC) that are used to evaluate CGM performance, impairs comparability. For this article, several experts in the field of CGM performance testing have collaborated to propose characteristics of the distribution of comparator measurements that should be collected during CGM performance testing. Specifically, it is proposed that at least 7.5% of comparator BG concentrations are <70 mg/dL (3.9 mmol/L) and >300 mg/dL (16.7 mmol/L), respectively, and that at least 7.5% of BG-RoC combinations indicate fast BG changes with impending hypo- or hyperglycemia, respectively. These proposed characteristics of the comparator data can facilitate the harmonization of testing conditions across different studies and CGM systems and ensure that the most relevant scenarios representing real-life situations are established during performance testing. In addition, a study protocol and testing procedure for the manipulation of glucose levels are suggested that enable the collection of comparator data with these characteristics. This work is an important step toward establishing a future standard for the performance evaluation of CGM systems.

Dynamic associations between glucose and ecological momentary cognition in Type 1 Diabetes

Type 1 diabetes (T1D) is a chronic condition characterized by glucose fluctuations. Laboratory studies suggest that cognition is reduced when glucose is very low (hypoglycemia) and very high (hyperglycemia). Until recently, technological limitations prevented researchers from understanding how naturally-occurring glucose fluctuations impact cognitive fluctuations. This study leveraged advances in continuous glucose monitoring (CGM) and cognitive ecological momentary assessment (EMA) to characterize dynamic, within-person associations between glucose and cognition in naturalistic environments. Using CGM and EMA, we obtained intensive longitudinal measurements of glucose and cognition (processing speed, sustained attention) in 200 adults with T1D. First, we used hierarchical Bayesian modeling to estimate dynamic, within-person associations between glucose and cognition. Consistent with laboratory studies, we hypothesized that cognitive performance would be reduced at low and high glucose, reflecting cognitive vulnerability to glucose fluctuations. Second, we used data-driven lasso regression to identify clinical characteristics that predicted individual differences in cognitive vulnerability to glucose fluctuations. Large glucose fluctuations were associated with slower and less accurate processing speed, although slight glucose elevations (relative to person-level means) were associated with faster processing speed. Glucose fluctuations were not related to sustained attention. Seven clinical characteristics predicted individual differences in cognitive vulnerability to glucose fluctuations: age, time in hypoglycemia, lifetime severe hypoglycemic events, microvascular complications, glucose variability, fatigue, and neck circumference. Results establish the impact of glucose on processing speed in naturalistic environments, suggest that minimizing glucose fluctuations is important for optimizing processing speed, and identify several clinical characteristics that may exacerbate cognitive vulnerability to glucose fluctuations.

Effectiveness of Continuous Glucose Monitoring on Metrics of Glycemic Control in Type 2 Diabetes Mellitus: A Systematic Review and Meta-analysis of Randomized Controlled Trials

PURPOSE

To provide a systematic review and meta-analysis synthesizing the findings of randomized controlled trials (RCTs) of continuous glucose monitors (CGMs) in the management of adults with type 2 diabetes mellitus (T2DM) on glucose control and clinical outcomes.

METHODS

MEDLINE, Embase, and Cochrane were searched for RCTs that assessed the effectiveness of real-time CGM (rt-CGM) or flash CGM (FGM) in adults (≥18 years) with T2DM that reported on at least 1 of the following outcomes: hemoglobin A1c (HbA1c), time in range, time in hyperglycemia, or time in hypoglycemia. The GRADE approach was used to assess certainty of evidence for primary outcomes.

RESULTS

Fourteen RCTs assessing CGM were included, with 825 patients in 9 RCTs using rt-CGM and 822 in 5 RCTs using FGM. Moderate certainty of evidence indicated that use of CGM had a modest but statistically significant reduction in HbA1c levels of about 0.32%. Our analyses of each device type separately showed similar reductions in HbA1c (0.34% and 0.33%, respectively, for rt-CGM and FGM), with trends for improvement in other glucose metrics favoring rt-CGM over self-monitored blood glucose.

CONCLUSION

Both rt-CGM and flash CGM led to modest but statistically significant declines in HbA1c among individuals with T2DM, with little heterogeneity in the results. However, the duration of the included RCTs was relatively short and few studies reported on important clinical outcomes, such as adverse events, emergency department use, or hospitalization. Longer term studies are needed to determine if the short-term improvements in glucose control leads to improvements in clinically important outcomes.

Real-World Evidence of Automated Insulin Delivery System Use

Objective: Pivotal trials of automated insulin delivery (AID) closed-loop systems have demonstrated a consistent picture of glycemic benefit, supporting approval of multiple systems by the Food and Drug Administration or Conformité Européenne mark receipt. To assess how pivotal trial findings translate to commercial AID use, a systematic review of retrospective real-world studies was conducted. Methods: PubMed and EMBASE were searched for articles published after 2018 with more than five nonpregnant individuals with type 1 diabetes (T1D). Data were screened/extracted in duplicate for sample size, AID system, glycemic outcomes, and time in automation. Results: Of 80 studies identified, 20 met inclusion criteria representing 171,209 individuals. Time in target range 70-180 mg/dL (3.9-10.0 mmol/L) was the primary outcome in 65% of studies, with the majority of reports (71%) demonstrating a >10% change with AID use. Change in hemoglobin A1c (HbA1c) was reported in nine studies (range 0.1%-0.9%), whereas four reported changes in glucose management indicator (GMI) with a 0.1%-0.4% reduction noted. A decrease in HbA1c or GMI of >0.2% was achieved in two-thirds of the studies describing change in HbA1c and 80% of articles where GMI was described. Time below range <70 mg/dL (<3.9 mmol/L) was reported in 16 studies, with all but 1 study showing stable or reduced levels. Most systems had >90% time in automation. Conclusion: With larger and more diverse populations, and follow-up periods of longer duration (∼9 months vs. 3-6 months for pivotal trials), real-world retrospective analyses confirm pivotal trial findings. Given the glycemic benefits demonstrated, AID is rapidly becoming the standard of care for all people living with T1D. Individuals should be informed of these systems and differences between them, have access to and coverage for these technologies, and receive support as they integrate this mode of insulin delivery into their lives.

Comparing the glycaemic outcomes between real-time continuous glucose monitoring (rt-CGM) and intermittently scanned continuous glucose monitoring (isCGM) among adults and children with type 1 diabetes: A systematic review and meta-analysis of randomized controlled trials

AIM

To conduct a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the effectiveness of real-time continuous glucose monitoring (rtCGM) versus intermittently scanned continuous glucose monitoring (isCGM) on key glycaemic metrics (co-primary outcomes HbA1c and time-in-range [TIR] 70-180 mg/dL, 3.9-10.0 mmol/L) among people with type 1 diabetes (T1D).

METHODS

Medline, PubMed, Scopus, Web of Science and Cochrane Central Register of clinical trials were searched. Inclusion criteria were RCTs; T1D populations of any age and insulin regimen; comparing any type of rtCGM with isCGM (only the first generation had been compared to date); and reporting the glycaemic outcomes. Glycaemic outcomes were extracted post-intervention and expressed as mean differences and 95% CIs between the two comparators. Results were pooled using a random-effect meta-analysis. The risk of bias was assessed using the Cochrane RoB2 tool. The quality of evidence was assessed by the GRADE approach.

RESULTS

Five RCTs met the inclusion criteria (4 parallel and 1 crossover design; 4 with CGM use <8 weeks), involving 446 participants (354 adults; 92 children and adolescents). Overall, meta-analysis showed rtCGM compared to isCGM improved absolute TIR by +7.0% (95% CI: 5.8%-8.3%, I2  = 0%, p < 0.01) accompanied by a favorable effect on time-below-range <70 mg/dL (3.9 mmol/L) - 1.7% (95%CI: -3.0% to -0.4%; p = 0.03). No differences were seen regarding HbA1c.

CONCLUSIONS

This meta-analysis highlights that for people with T1D, rtCGM confers benefits over isCGM primarily related to increased TIR, with improvements in hypo- and hyperglycaemia.

Do-it-yourself continuous glucose monitoring in people aged 16 to 69 years with type 1 diabetes: A qualitative study

AIMS

In many countries, real-time continuous glucose monitoring (rt-CGM) is not funded, and cost presents a barrier to access. A do-it-yourself conversion of intermittently scanned CGM (DIY-CGM) is a cheaper alternative. This qualitative study aimed to explore user experiences with DIY-CGM in people aged 16 to 69 years with type 1 diabetes (T1D).

METHODS

Convenience sampling was used to recruit participants for semi-structured virtual interviews exploring experiences of DIY-CGM use. Participants were recruited after completing the intervention arm of a crossover randomised controlled trial that evaluated DIY-CGM versus intermittently scanned CGM (isCGM). Participants were previously naive to DIY-CGM and rt-CGM but not isCGM. The DIY-CGM intervention consisted of a Bluetooth bridge connected to isCGM, adding rt-CGM functionality over 8 weeks. Interviews were transcribed, then thematic analysis was performed.

RESULTS

Interviews were with 12 people aged 16 to 65 years, with T1D: mean age ± SD 43 ± 14 years; baseline mean HbA1c ± SD 60 mmol/mol ± 9.9 (7.6 ± 0.9%) and time in range 59.8% ± 14.8%. Participants perceived that using DIY-CGM improved both glycaemic control and aspects of quality of life. Alarm and trend functionality allowed participants to perceive reduced glycaemic variability overnight and following meals. The addition of a smartwatch increased discrete access to glucose information. There was a high degree of trust in DIY-CGM. Challenges while using DIY-CGM included signal loss during vigorous exercise, alarm fatigue and short battery life.

CONCLUSIONS

This study suggests that for users, DIY-CGM appears to be an acceptable alternative method of rt-CGM.

Diabetes and artificial intelligence beyond the closed loop: a review of the landscape, promise and challenges

The discourse amongst diabetes specialists and academics regarding technology and artificial intelligence (AI) typically centres around the 10% of people with diabetes who have type 1 diabetes, focusing on glucose sensors, insulin pumps and, increasingly, closed-loop systems. This focus is reflected in conference topics, strategy documents, technology appraisals and funding streams. What is often overlooked is the wider application of data and AI, as demonstrated through published literature and emerging marketplace products, that offers promising avenues for enhanced clinical care, health-service efficiency and cost-effectiveness. This review provides an overview of AI techniques and explores the use and potential of AI and data-driven systems in a broad context, covering all diabetes types, encompassing: (1) patient education and self-management; (2) clinical decision support systems and predictive analytics, including diagnostic support, treatment and screening advice, complications prediction; and (3) the use of multimodal data, such as imaging or genetic data. The review provides a perspective on how data- and AI-driven systems could transform diabetes care in the coming years and how they could be integrated into daily clinical practice. We discuss evidence for benefits and potential harms, and consider existing barriers to scalable adoption, including challenges related to data availability and exchange, health inequality, clinician hesitancy and regulation. Stakeholders, including clinicians, academics, commissioners, policymakers and those with lived experience, must proactively collaborate to realise the potential benefits that AI-supported diabetes care could bring, whilst mitigating risk and navigating the challenges along the way.

Gaming the System: A Fun Continuous Glucose Monitor Interface Improves Glycemic Outcomes for Children

Achieving optimal glycemic control in children with type 1 diabetes (T1D) is challenging even when wearing a continuous glucose monitor (CGM). We measured the impact of eddii, a gamified real-time app connected to a CGM, on glycemic control. An open label, eight-week randomized controlled trial (RCT) compared glycemic control utilizing the gamified CGM app connected to Dexcom G6 with only Dexcom G6 usage. Children with T1D using Dexcom G6 were enrolled (N=92, ages 5-12 years). Time-in-range (TIR) data were collected four weeks prior to and during the study period. The gamified CGM app utilization effect was measured by difference-in-difference (D-I-D) models. The TIR and time-above-range (TAR) improved among users of the gamified CGM app; 5.38% higher and 5.80% lower than controls (P = .001 and P = .019, respectively).

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

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

More Frequent Use of Glucose Alarms Is Associated with Continuous Glucose Monitoring-Specific Diabetes Education: Findings from the Dia·Link Diabetes Panel

The associations of continuous glucose monitoring (CGM)-specific diabetes education with real-world utilization of glucose alerts and alarms were assessed in current CGM-users with type 1 or type 2 diabetes. A cross-sectional online survey was conducted in Germany assessing utilization (use and responses) of different alerts and alarms. Ordinal logistic regression analyses were conducted to analyze associations between utilization and participation in CGM-specific education. Data from 453 participants were analyzed (86.2% type 1 diabetes). Participants who received CGM-specific education were more likely to regularly use low-glucose alerts (odds ratio [OR] = 5.43, P < 0.001), low-glucose alarms (OR = 2.03, P = 0.027), and rate of change alerts (OR = 4.20, P = 0.009), and were more likely to immediately react to low-glucose alerts (OR = 5.23, P < 0.001) and rate of change alerts (OR = 3.75, P = 0.018). CGM-specific education has the potential to increase utilization of and response to alerts and alarms. This may help to implement more preventive elements regarding glucose management in everyday life.

Associations between type 1 diabetes and educational outcomes: an Aotearoa/New Zealand nationwide birth cohort study using the Integrated Data Infrastructure

AIMS/HYPOTHESIS

Type 1 diabetes is one of the most common chronic diseases of childhood. It is hypothesised that the metabolic and psychosocial consequences of type 1 diabetes may affect educational outcomes; however, existing literature presents conflicting results. This study aimed to assess whether educational outcomes differ for young people with and without type 1 diabetes in Aotearoa/New Zealand (NZ).

METHODS

This was a nationwide 9 year birth cohort study of all people born in NZ from 1993 to 2001 using linked administrative data held within the Integrated Data Infrastructure, a national research database containing linked health and non-health data. Educational outcomes of high school attainment, high school attendance and university enrolment were measured from age 13 years until 20 years. Generalised linear regression models with log link and Gaussian distributions were used to compare educational outcomes between those with and those without type 1 diabetes, adjusting for sociodemographic and maternal characteristics.

RESULTS

Of the 442,320 children in the birth cohort, type 1 diabetes was identified in 2058 (0.47%) (mean [SD] age of type 1 diabetes diagnosis 7.7 [3.4] years). Educational outcomes were significantly lower for children with type 1 diabetes than for those without type 1 diabetes, including for any high school qualification (RR 0.97 [95% CI 0.95, 0.99]), university entrance-level high school attainment (RR 0.88 [95% CI 0.84, 0.92]), regular high school attendance (RR 0.91 [95% CI 0.85, 0.97]) and university enrolment (RR 0.93 [95% CI 0.88, 0.98]), even after adjusting for sociodemographic and maternal factors. In addition, educational outcomes were substantially lower for those with post type 1 diabetes diagnosis hospitalisations for diabetic ketoacidosis and hypoglycaemia.

CONCLUSIONS/INTERPRETATION

In this whole NZ birth cohort study, type 1 diabetes was associated with lower educational outcomes spanning secondary school and into university enrolment. Ongoing efforts to support students with type 1 diabetes are needed, particularly for those with a greater risk profile.

Correlation between time on target and glycated hemoglobin in people with diabetes mellitus: systematic review

to analyze the correlation between time on target and glycated hemoglobin in people living with diabetes mellitus and carrying out continuous blood glucose monitoring or self-monitoring of capillary blood glucose.

systematic review of etiology and risk based on JBI guidelines and reported according to Preferred Reporting Items for Systematic Reviews and Meta- Analyses, covering six databases and grey literature. The sample included 16 studies and methodological quality was assessed using JBI tools. Protocol registered in the Open Science Framework, available at https://doi.org/10.17605/OSF.IO/NKMZB.

time on target (70-180 mg/dl) showed a negative correlation with glycated hemoglobin, while time above target (>180 mg/dl) showed a positive correlation. Correlation coefficients ranged between -0.310 and -0.869 for time on target, and between 0.66 and 0.934 for time above target. A study was carried out on a population that performed self-monitoring.

there is a statistically significant correlation between time on target and time above target with glycated hemoglobin. The higher the proportion in the adequate glycemic range, the closer to or less than 7% the glycated hemoglobin will be. More studies are needed to evaluate this metric with data from self-monitoring of blood glucose.

Effects of 12-Week Freestyle Libre 2.0 in Children with Type 1 Diabetes and Elevated HbA1c: A Multicenter Randomized Controlled Trial

Objective: To investigate whether intermittently scanned continuous glucose monitoring (isCGM) reduced glycated hemoglobin (HbA1c) compared with capillary self-monitored capillary blood glucose (SMBG) in children with type 1 diabetes (T1D) and elevated glycemic control. Research Design and Methods: This multicenter 12-week 1:1 randomized, controlled, parallel-arm trial included 100 participants with established T1D aged 4-13 years (mean 10.9 ± 2.3 years) naive to isCGM and with elevated HbA1c 7.5%-12.2% [58-110 mmol/mol] [mean HbA1c was 9.05 (1.3)%] [75.4 (13.9) mmol/mol]. Participants were allocated to 12-week intervention (isCGM; FreeStyle Libre 2.0; Abbott Diabetes Care, Witney, United Kingdom) (n = 49) or control (SMBG; n = 51). The primary outcome was the difference in change of HbA1c from baseline to 12 weeks. Results: There was no evidence of a difference between groups for change in HbA1c at 12 weeks (0.23 [95% confidence interval; CI: -0.21 to 0.67], P = 0.3). However, glucose-monitoring frequency increased with isCGM +4.89/day (95% CI 2.97-6.81; P < 0.001). Percent time below range (TBR) <3.9 mmol/L (70-180 mg/dL) was reduced with isCGM -6.4% (10.6 to -4.2); P < 0.001. There were no differences in within group changes for Parent or Child scores of psychosocial outcomes at 12 weeks. Conclusions: For children aged 4-13 years with elevated Hba1c isCGM led to improvements in glucose testing frequency and reduced time below range. However, isCGM did not translate into reducing Hba1c or psychosocial outcomes compared to usual care over 12-weeks. The trial is registered within the Australian New Zealand Trial Registry on February 19, 2020 (ACTRN12620000190909p; ANZCTR.org.au) and the World Health Organization International Clinical Trials Registry Platform (Universal Trial Number U1111-1237-0090).

Clinical Performance Evaluation of Continuous Glucose Monitoring Systems: A Scoping Review and Recommendations for Reporting

The use of different approaches for design and results presentation of studies for the clinical performance evaluation of continuous glucose monitoring (CGM) systems has long been recognized as a major challenge in comparing their results. However, a comprehensive characterization of the variability in study designs is currently unavailable. This article presents a scoping review of clinical CGM performance evaluations published between 2002 and 2022. Specifically, this review quantifies the prevalence of numerous options associated with various aspects of study design, including subject population, comparator (reference) method selection, testing procedures, and statistical accuracy evaluation. We found that there is a large variability in nearly all of those aspects and, in particular, in the characteristics of the comparator measurements. Furthermore, these characteristics as well as other crucial aspects of study design are often not reported in sufficient detail to allow an informed interpretation of study results. We therefore provide recommendations for reporting the general study design, CGM system use, comparator measurement approach, testing procedures, and data analysis/statistical performance evaluation. Additionally, this review aims to serve as a foundation for the development of a standardized CGM performance evaluation procedure, thereby supporting the goals and objectives of the Working Group on CGM established by the Scientific Division of the International Federation of Clinical Chemistry and Laboratory Medicine.

Efficacy of automated insulin delivery (AID) systems in type 1 diabetes: protocol of a systematic review and network meta-analysis of outpatient randomised controlled trials

INTRODUCTION

Automated insulin delivery (AID), also known as artificial pancreas system or 'closed-loop system', represents a novel option for current treatments for type 1 diabetes (T1D). The objective of this systematic review and meta-analysis is to assess the efficacy of AID systems in comparison with current intensified insulin therapy for glycaemic control and patient-reported outcomes in individuals with T1D.

METHODS AND ANALYSIS

Studies will be eligible if they are randomised controlled trials (RCTs) in people with T1D of all ages, and if they compare an AID system for self-administration during the day and night period with any other type of insulin therapy for at least 3 weeks. The primary outcome will be time in the glucose target range of 70-180 mg/dL. A systematic review will be conducted in the MEDLINE, Embase, Cochrane Central Register of Controlled Trials and ClinicalTrials.gov registries from their inception dates. Two authors will independently screen all references based on titles and abstracts against the eligibility criteria. For data extraction, standard forms will be developed and tested before extraction. All information will be assessed independently by at least two reviewers. The risk of bias of the included studies will be assessed using the Cochrane Risk of Bias 2 tool. The data synthesis will include a random-effects pairwise and network meta-analysis (NMA) in a frequentist framework. Where applicable and if sufficient RCTs are available, sensitivity analyses will be performed, and heterogeneity and publication bias will be assessed. The certainty of evidence from the NMA will be evaluated following the Grading of Recommendations Assessment, Development, and Evaluation working group guidance.

ETHICS AND DISSEMINATION

No ethical approval is needed. The results will be reported to the funder, presented in a peer-reviewed scientific journal and at conferences, and disseminated via press release, social media and public events.

PROSPERO REGISTRATION NUMBER

CRD42023395492.

The Effect of Do-It-Yourself Real-Time Continuous Glucose Monitoring on Glycemic Variables and Participant-Reported Outcomes in Adults With Type 1 Diabetes: A Randomized Crossover Trial

AIM

Real-time continuous glucose monitoring (rtCGM) has several advantages over intermittently scanned continuous glucose monitoring (isCGM) but generally comes at a higher cost. Do-it-yourself rtCGM (DIY-rtCGM) potentially has benefits similar to those of rtCGM. This study compared outcomes in adults with type 1 diabetes using DIY-rtCGM versus isCGM.

METHODS

In this crossover trial, adults with type 1 diabetes were randomized to use isCGM or DIY-rtCGM for eight weeks before crossover to use the other device for eight weeks, after a four-week washout period where participants reverted back to isCGM. The primary endpoint was time in range (TIR; 3.9-10 mmol/L). Secondary endpoints included other glycemic control measures, psychosocial outcomes, and sleep quality.

RESULTS

Sixty participants were recruited, and 52 (87%) completed follow-up. Glucose outcomes were similar in the DIY-rtCGM and isCGM groups, including TIR (53.1% vs 51.3%; mean difference -1.7% P = .593), glycosylated hemoglobin (57.0 ± 17.8 vs 61.4 ± 12.2 mmol/L; P = .593), and time in hypoglycemia <3.9 mmol/L (3.9 ± 3.8% vs 3.8 ± 4.0%; P = .947). Hypoglycemia Fear Survey total score (1.17 ± 0.52 vs 0.97 ± 0.54; P = .02) and fear of hypoglycemia score (1.18 ± 0.64 vs 0.97 ± 0.45; P = .02) were significantly higher during DIY-rtCGM versus isCGM. Diabetes Treatment Satisfaction Questionnaire status (DTSQS) score was also higher with DIY-rtCGM versus isCGM (28.7 ± 5.8 vs 26.0 ± 5.8; P = .04), whereas diabetes-related quality of life was slightly lower (DAWN2 Impact of Diabetes score: 3.11 ± 0.4 vs 3.32 ± 0.51; P = .045); sleep quality did not differ between the two groups.

CONCLUSION

Although the use of DIY-rtCGM did not improve glycemic outcomes compared with isCGM, it positively impacted several patient-reported psychosocial variables. DIY-rtCGM potentially provides an alternative, cost-effective rtCGM option.

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

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

Analytical Performance of the Factory-Calibrated Flash Glucose Monitoring System FreeStyle Libre2TM in Healthy Women

Continuous glucose monitoring (CGM) is used clinically and for research purposes to capture glycaemic profiles. The accuracy of CGM among healthy populations has not been widely assessed. This study assessed agreement between glucose concentrations obtained from venous plasma and from CGM (FreeStyle Libre2TM, Abbott Diabetes Care, Witney, UK) in healthy women. Glucose concentrations were assessed after fasting and every 15 min after a standardized breakfast over a 4-h lab period. Accuracy of CGM was determined by Bland-Altman plot, 15/15% sensor agreement analysis, Clarke error grid analysis (EGA) and mean absolute relative difference (MARD). In all, 429 valid CGM readings with paired venous plasma glucose (VPG) values were obtained from 29 healthy women. Mean CGM readings were 1.14 mmol/L (95% CI: 0.97 to 1.30 mmol/L, p < 0.001) higher than VPG concentrations. Ratio 95% limits of agreement were from 0.68 to 2.20, and a proportional bias (slope: 0.22) was reported. Additionally, 45% of the CGM readings were within ±0.83 mmol/L (±15 mg/dL) or ±15% of VPG, while 85.3% were within EGA Zones A + B (clinically acceptable). MARD was 27.5% (95% CI: 20.8, 34.2%), with higher MARD values in the hypoglycaemia range and when VPG concentrations were falling. The FreeStyle Libre2TM CGM system tends to overestimate glucose concentrations compared to venous plasma samples in healthy women, especially during hypoglycaemia and during glycaemic swings.

Patent analysis of digital sensors for continuous glucose monitoring

The high need for optimal diabetes management among an ever-increasing number of patients dictates the development and implementation of new digital sensors for continuous glucose monitoring. The purpose of this work is to systematize the global patenting trends of digital sensors for continuous glucose monitoring and analyze their effectiveness in controlling the treatment of diabetes patients of different ages and risk groups. The Lens database was used to build the patent landscape of sensors for continuous glucose monitoring. Retrospective analysis showed that the patenting of sensors for continuous glucose monitoring had positive trend over the analyzed period (2000-2022). Leading development companies are Dexcom Inc., Abbott Diabetes Care Inc., Medtronic Minimed Inc., Roche Diabetes Care Inc., Roche Diagnostics Operations Inc., Roche Diabetes Care Gmbh, and Ascensia Diabetes Care Holdings Ag, among others. Since 2006, a new approach has emerged where digital sensors are used for continuous glucose monitoring, and smartphones act as receivers for the data. Additionally, telemedicine communication is employed to facilitate this process. This opens up new opportunities for assessing the glycemic profile (glycemic curve information, quantitative assessment of the duration and amplitude of glucose fluctuations, and so on), which may contribute to improved diabetes management. A number of digital sensors for minimally invasive glucose monitoring are patented, have received FDA approval, and have been on the market for over 10 years. Their effectiveness in the clinic has been proven, and advantages and disadvantages have been clarified. Digital sensors offer a non-invasive option for monitoring blood glucose levels, providing an alternative to traditional invasive methods. This is particularly useful for patients with diabetes who require frequent monitoring, including before and after meals, during and after exercise, and in other scenarios where glucose levels can fluctuate. However, non-invasive glucose measurements can also benefit patients without diabetes, such as those following a dietary treatment plan, pregnant women, and individuals during fasting periods like Ramadan. The availability of non-invasive monitoring is especially valuable for patients in high-risk groups and across different age ranges. New world trends have been identified in the patenting of digital sensors for non-invasive glucose monitoring in interstitial skin fluid, saliva, sweat, tear fluid, and exhaled air. A number of non-invasive devices have received the CE mark approval, which confirms that the items meet European health, safety, and environmental protection standards (TensorTip Combo-Glucometer, Cnoga Medical Ltd.; SugarBEAT, Nemaura Medical; GlucoTrack, GlucoTrack Inc.), but are not FDA-approved yet. The above-mentioned sensors have characteristics that make them popular in the treatment of diabetes: they do not require implantation, do not cause an organism reaction to a foreign body, and are convenient to use. In the EU, in order to increase clinical safety and the level of transparency about medical devices, manufacturers must obtain certificates in accordance with Regulation (EU) 2017/745, taking into account the transition period. The development of systems, which include digital sensors for continuous glucose monitoring, mobile applications, and web platforms for professional analysis of glycemic control and implementation of unified glycemic assessment principles in mobile healthcare, represent promising approaches for controlling glycaemia in patients.

Heterogeneous temporal representation for diabetic blood glucose prediction

Background and aims: Blood glucose prediction (BGP) has increasingly been adopted for personalized monitoring of blood glucose levels in diabetic patients, providing valuable support for physicians in diagnosis and treatment planning. Despite the remarkable success achieved, applying BGP in multi-patient scenarios remains problematic, largely due to the inherent heterogeneity and uncertain nature of continuous glucose monitoring (CGM) data obtained from diverse patient profiles. Methodology: This study proposes the first graph-based Heterogeneous Temporal Representation (HETER) network for multi-patient Blood Glucose Prediction (BGP). Specifically, HETER employs a flexible subsequence repetition method (SSR) to align the heterogeneous input samples, in contrast to the traditional padding or truncation methods. Then, the relationships between multiple samples are constructed as a graph and learned by HETER to capture global temporal characteristics. Moreover, to address the limitations of conventional graph neural networks in capturing local temporal dependencies and providing linear representations, HETER incorporates both a temporally-enhanced mechanism and a linear residual fusion into its architecture. Results: Comprehensive experiments were conducted to validate the proposed method using real-world data from 112 patients in two hospitals, comparing it with five well-known baseline methods. The experimental results verify the robustness and accuracy of the proposed HETER, which achieves the maximal improvement of 31.42%, 27.18%, and 34.85% in terms of MAE, MAPE, and RMSE, respectively, over the second-best comparable method. Discussions: HETER integrates global and local temporal information from multi-patient samples to alleviate the impact of heterogeneity and uncertainty. This method can also be extended to other clinical tasks, thereby facilitating efficient and accurate capture of crucial pattern information in structured medical data.

Real-life 24-week changes in glycemic parameters among European users of flash glucose monitoring with type 1 and 2 diabetes and different levels of glycemic control

AIM

To evaluate real-life changes of glycemic parameters among flash glucose monitoring (FLASH) users who do not meet glycemic targets.

METHODS

De-identified data were obtained between 2014 and 2021 from patients using FLASH uninterrupted for a 24-week period. Glycemic parameters during first and last sensor use were examined in four identifiable groups: type 1 diabetes mellitus (T1DM), type 2 diabetes mellitus (T2DM) on basal-bolus insulin, T2DM on basal insulin, and T2DM without insulin treatment. Within each group, subgroup analyses were performed in persons with initial suboptimal glycemic regulation (time in range (TIR; 3.9-10 mmol/L) <70%, time above range (TAR; >10 mmol/L) >25%, or time below range (TBR; <3.9 mmol/L) >4%).

RESULTS

Data were obtained from 1,909 persons with T1DM and 1,813 persons with T2DM (1,499 basal-bolus insulin, 189 basal insulin, and 125 non-insulin users). In most of the performed analyses, both overall and in the various subgroups, significant improvements were observed in virtually all predefined primary (TIR) and secondary endpoints (eHbA1c, TAR, TBR and glucose variability).

CONCLUSIONS

24-weeks FLASH use in real life by persons with T1DM and T2DM with suboptimal glycemic regulation is associated with improvement of glycemic parameters, irrespective of pre-use regulation or treatment modality.

Initiation of Continuous Glucose Monitoring Is Linked to Improved Glycemic Control and Fewer Clinical Events in Type 1 and Type 2 Diabetes in the Veterans Health Administration

OBJECTIVE

To determine the benefit of starting continuous glucose monitoring (CGM) in adult-onset type 1 diabetes (T1D) and type 2 diabetes (T2D) with regard to longer-term glucose control and serious clinical events.

RESEARCH DESIGN AND METHODS

A retrospective observational cohort study within the Veterans Affairs Health Care System was used to compare glucose control and hypoglycemia- or hyperglycemia-related admission to an emergency room or hospital and all-cause hospitalization between propensity score overlap weighted initiators of CGM and nonusers over 12 months.

RESULTS

CGM users receiving insulin (n = 5,015 with T1D and n = 15,706 with T2D) and similar numbers of nonusers were identified from 1 January 2015 to 31 December 2020. Declines in HbA1c were significantly greater in CGM users with T1D (-0.26%; 95% CI -0.33, -0.19%) and T2D (-0.35%; 95% CI -0.40, -0.31%) than in nonusers at 12 months. Percentages of patients achieving HbA1c <8 and <9% after 12 months were greater in CGM users. In T1D, CGM initiation was associated with significantly reduced risk of hypoglycemia (hazard ratio [HR] 0.69; 95% CI 0.48, 0.98) and all-cause hospitalization (HR 0.75; 95% CI 0.63, 0.90). In patients with T2D, there was a reduction in risk of hyperglycemia in CGM users (HR 0.87; 95% CI 0.77, 0.99) and all-cause hospitalization (HR 0.89; 95% CI 0.83, 0.97). Several subgroups (based on baseline age, HbA1c, hypoglycemic risk, or follow-up CGM use) had even greater responses.

CONCLUSIONS

In a large national cohort, initiation of CGM was associated with sustained improvement in HbA1c in patients with later-onset T1D and patients with T2D using insulin. This was accompanied by a clear pattern of reduced risk of admission to an emergency room or hospital for hypoglycemia or hyperglycemia and of all-cause hospitalization.

Sustained Impact of Intermittently Scanned Continuous Glucose Monitoring on Treatment Satisfaction and Severe Hypoglycemia in Adults with Type 1 Diabetes (FUTURE): An Analysis in People with Normal and Impaired Awareness of Hypoglycemia

Objective: Nationwide reimbursement of intermittently scanned continuous glucose monitoring (isCGM) was introduced in Belgium (2016). This real-world observational study investigates the impact of isCGM over 24 months on adults with type 1 diabetes with impaired or normal awareness of hypoglycemia (IAH or NAH). Methods: We included 1905 people who started first-generation 14-day FreeStyle Libre (without alerts). Sixteen percent had IAH. Primary endpoint was evolution of quality of life (QOL); secondary endpoints were evolution of severe hypoglycemia, work absenteeism, glycated hemoglobin (HbA1c), and sensor-measured outcomes. Results: At baseline, people with IAH (n = 308) had significantly worse QOL than people with NAH (n = 1594). Only people with IAH improved on the hypoglycemia fear survey-worry subscale after 24 months (22.8 [95% confidence interval: 21.4-24.2] at baseline; 20.6 [19.0-22.1] at 24 months, P = 0.002). For both groups, Diabetes Treatment Satisfaction Scale improved over 24 months (IAH: +3.1 [2.1-4.1], P < 0.001; NAH: +2.3 [1.9-2.7], P < 0.001), whereas general QOL, diabetes distress, and HbA1c remained stable. People with IAH showed the strongest decline in work absenteeism and severe hypoglycemia (36.4% having an event 6 months before isCGM initiation; 16.0% having an event during last 6 months of follow-up, P < 0.001), with similar observations for hypoglycemia hospitalization and hypoglycemia coma. Over 24 months, people with IAH spent more time in hypoglycemia, but less time in hyperglycemia than people with NAH. Conclusion: These data show sustained improvement of severe hypoglycemia, work absenteeism, and hypoglycemia fear after isCGM reimbursement, mostly driven by people with IAH. Together with improved treatment satisfaction, irrespective of hypoglycemia awareness level, isCGM without alerts is a valuable tool under long-term real-world conditions. Clinical Trial Registration number: NCT02898714.

Interviews with Indigenous Māori with type 1 diabetes using open-source automated insulin delivery in the CREATE randomised trial

Purpose

Open-source automated insulin delivery (AID) is used by thousands of people with type 1 diabetes (T1D), but has unknown generalisability to marginalised ethnic groups. This study explored experiences of Indigenous Māori participants in the CREATE trial with use of an open-source AID system to identify enablers/barriers to health equity.

Methods

The CREATE randomised trial compared open-source AID (OpenAPS algorithm on an Android phone with a Bluetooth-connected pump) to sensor-augmented pump therapy. Kaupapa Māori Research methodology was used in this sub-study. Ten semi-structured interviews with Māori participants (5 children, 5 adults) and whānau (extended family) were completed. Interviews were recorded and transcribed, and data were analysed thematically. NVivo was used for descriptive and pattern coding.

Results

Enablers/barriers to equity aligned with four themes: access (to diabetes technologies), training/support, operation (of open-source AID), and outcomes. Participants described a sense of empowerment, and improved quality of life, wellbeing, and glycaemia. Parents felt reassured by the system’s ability to control glucose, and children were granted greater independence. Participants were able to use the open-source AID system with ease to suit whānau needs, and technical problems were manageable with healthcare professional support. All participants identified structures in the health system precluding equitable utilisation of diabetes technologies for Māori.

Conclusion

Māori experienced open-source AID positively, and aspired to use this therapy; however, structural and socio-economic barriers to equity were identified. This research proposes strength-based solutions which should be considered in the redesign of diabetes services to improve health outcomes for Māori with T1D.

Trial Registration: The CREATE trial, encompassing this qualitative sub-study, was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12620000034932p) on the 20^th January 2020.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40200-023-01215-3.

Advances in Insulin Infusion Set in the New Era of Automated Insulin Delivery: A Systematic Review

INTRODUCTION

Automated insulin delivery (AID) has become a well-known research topic devoted to achieving better glycemic outcomes. AID systems consist primarily of three components: the continuous glucose monitoring system, the insulin delivery system, either tethered or patch pump, and the control system (algorithm). A key component in the tethered pump AID system is the insulin infusion set (IIS). This Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) study was conducted to evaluate the IIS evolution in the era of AID and to provide future perspectives of IIS clinical use.

METHODS

Literature searches for articles published from January 2016 to July 2022 were performed in Embase/Medline and PubMed. Data were extracted following PRISMA guidelines. Primary meta-analysis outcomes were IIS wear duration, total daily dose of insulin, and IIS failure reasons/modes.

RESULTS

We identified 387 publications, of which 15 eligible studies compared various IISs comprising over 1400 participants and >53 000 wears. Half of the studies published in 2022 were focused on extended IISs designed for wear durations of seven days or more. Three clinical trials have demonstrated the safe use of extended IISs to seven days of wear in individuals with type 1 diabetes, and two also demonstrated good glycemic control throughout the seven-day use.

CONCLUSIONS

Research in insulin infusion technology has increased in the last six years, and extended IISs have demonstrated improved overall performance, particularly in duration of wear. Paths for future products are discussed with an emphasis on understanding the existing barriers related to both technical and nontechnical issues.

Impact of Advanced Hybrid Closed Loop on Youth With High-Risk Type 1 Diabetes Using Multiple Daily Injections

OBJECTIVE

To evaluate glycemic outcomes in youth (aged 13-25 years) with type 1 diabetes and high-risk glycemic control (HbA1c ≥8.5% [69 mmol/mol]) on multiple daily injection (MDI) therapy after transitioning to advanced hybrid closed loop (AHCL) therapy.

RESEARCH DESIGN AND METHODS

This prospective, 3-month, single-arm, dual-center study enrolled 20 participants, and all completed the study.

RESULTS

HbA1c decreased from 10.5 ± 2.1% (91.2 ± 22.8 mmol/mol) at baseline to 7.6 ± 1.1% (59.7 ± 11.9 mmol/mol), and time spent in target range 70-180 mg/dL (3.9-10.0 mmol/L) increased from 27.6 ± 13.2% at baseline to 66.5 ± 9.8% after 3 months of AHCL. Two episodes of diabetic ketoacidosis attributed to infusion set failure occurred.

CONCLUSIONS

AHCL has the potential to improve suboptimal glycemia in youth with type 1 diabetes previously on MDI therapy.

Performance Assessment of Three Continuous Glucose Monitoring Systems in Adults With Type 1 Diabetes

BACKGROUND

FIND, the global alliance for diagnostics, identified the nonmarket-approved continuous glucose monitoring (CGM) system, FiberSense system (FBS), as a potential device for use in low- and middle-income countries. Together with two market-approved, factory-calibrated CGM systems, namely, the FreeStyle Libre 2 (FL2) and the GlucoRx AiDEX (ADX), the FBS was subjected to a clinical performance evaluation.

METHODS

Thirty adult participants with type 1 diabetes were enrolled. The study was mainly conducted at home, with three in-clinic sessions conducted over the study period of 28 days. Comparator measurements were collected from capillary samples, using a high-quality blood glucose monitoring system.

RESULTS

Data from 31, 70, and 78 sensors of FBS, FL2, and ADX, respectively, were included in the performance analysis. The mean absolute relative differences between CGM and comparator data for FBS, FL2, and ADX were 14.7%, 9.2%, and 21.9%, and relative biases were -2.1%, -2.5%, and -18.5%, respectively. Analysis of individual sensor accuracy revealed low, moderate, and high sensor-to-sensor variability for FBS, FL2, and ADX, respectively. Sensor survival probabilities until the end of sensor life were 47.2% for FBS (28 days), 71.3% for FL2 (14 days), and 48.4% for ADX (14 days).

CONCLUSIONS

The results of FBS were encouraging enough to conduct further performance and usability evaluations in a low- and middle-income country. The results of FL2 mainly agreed with existing studies, whereas ADX showed substantial deviations from previously reported results.

Effects of intermittently scanned continuous glucose monitoring in adult type 1 diabetes patients with suboptimal glycaemic control: A multi-centre randomized controlled trial

AIMS

To investigate whether intermittently scanned continuous glucose monitoring without alarms (intermittently scanned CGM (isCGM)) improves glycaemic control over capillary blood glucose monitoring (BGM) among adult type 1 diabetes mellitus (T1DM) patients with suboptimal control.

MATERIALS AND METHODS

Adults with T1DM and HbA1c between 7% and 10% were 1:1 randomized to use isCGM or BGM for 24 weeks. The primary outcome was the change in HbA1c levels after intervention. The secondary outcomes were the changes in sensor-derived metrics.

RESULTS

A total of 104 adults with T1DM (34.2 ± 12.2 years; M/F, 38/66) were randomized to the isCGM group (n = 54) and the BGM group (n = 50). After 24 weeks, HbA1c significantly decreased in the isCGM group (8.1 ± 0.7% to 7.5 ± 1.0%) and the BGM group (8.0 ± 0.8% to 7.7 ± 1.0%) with between-group differences of 0.3% (95% coefficient intervals, 0.0%-0.6%; P = 0.04). The percentage of HbA1c reduction over 1.0% and 1.5% was significantly higher in the isCGM group with adjusted odds ratios of 2.5 (95% CI: 1.1-5.5; P = 0.03) and 3.2 (95% CI: 1.1-9.0; P = 0.03). Mean time-in-range 70-180 mg/dl (TIR) in the isCGM group significantly increased (from 58.5 ± 13.0% to 63.0 ± 12.6%), whereas mean TIR was similar in the BGM group (from 58.0 ± 14.6% to 57.5 ± 14.5%). Time spent in hyperglycemia reduced more in the isCGM group and time spent in hypoglycemia did not change significantly in both groups.

CONCLUSIONS

Among adult T1DM patients with suboptimal glycaemic control, compared with BGM, isCGM use resulted in a statistically significant improvement in glycaemic control after 24-week intervention.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier (NCT03522870).

Are nocturnal hypoglycemia prevention strategies influenced by diabetes technology usage? A BETTER registry analysis

AIM

To assess the association of nocturnal hypoglycemia prevention strategies (NH-PS) and diabetes technology usage (insulin pump and/or continuous glucose monitors [CGM]) in people with type 1 diabetes (PWT1D).

METHODS

Logistic regression models were used to describe associations between self-reported NH-PS and diabetes technology (pump with intermittently-scanned or real-time CGM (isCGM or rtCGM), or automated insulin delivery (AID)), hypoglycemia history, and fear of hypoglycemia (FOH).

RESULTS

Among 831 adults (65 % female, aged 44 ± 15 years, T1D duration 26 ± 15 years), 32 % reported HbA1c ≤ 7.0 %, 88 % used ≥ 1 diabetes technology, 66 % reported ≥ 1 symptomatic NH in the past month, and 64 % used ≥ 2 NH-PS. Compared to multiple daily injections (MDI) + capillary blood glucose (CBG), bedtime snack consumption was less likely among pump + isCGM (OR [95 %CI]: 0.55 [0.31, 0.98]), pump + rtCGM (0.40 [0.20, 0.81]), and AID (0.34 [0.17, 0.66]) users, while evening insulin basal reduction was associated with CSII + CBG (3.15 [1.25, 7.99]), pump + isCGM 4.00 [1.99, 8.01]), and pump + rtCGM 2.89 [1.28, 6.50] use. Elevated FOH was associated with snack consumption (1.37 [1.00, 1.89]), evening bolus insulin avoidance (1.77 [1.11, 2.83]), limiting exercise (2.50 [1.30, 4.82]), and limiting alcohol consumption (2.33 [1.15, 4.70]) as NH-PS.

CONCLUSION

Technology use and elevated FOH might influence PWT1D' choice of NH-PS.